Onsline Survey - Patient 18 yr 12-month Follow-Up Englis

Attachment Q-3. Online follow-up survey for Z-CAN patients (12-month survey version b – for non-respondents to the 6-month survey)

No.	Question	Coding	Skip
1	What is your current relationship status?	Single/never married 1 Partner (not cohabiting) 2 Cohabiting (not married) 3 Married 4 Separated/Divorced 5 Widowed 6
2	During the past 12 months, have you had trouble paying for any of the following? (check all that apply)	Transportation 1 Housing 2 Medical care or medicine 3 Food 4 None of the above 5
3	Do you want to prevent pregnancy now?	No 1 Yes 2	15
4	What is the main reason you want to prevent pregnancy now? (Select one)	I cannot afford to have a baby (or another baby) now 1 I don’t want to have a baby now 2 I don’t want to get pregnant now because I am worried about Zika virus 3 Other___________________ 4
5	In the past 12 months, have you been pregnant?	No 1 Yes 2 Don’t know 3	111 311
6	How many times in the past 12 months have you been pregnant?	----- times
7	Are you pregnant right now?	No 1 Yes 2 Don’t know 3
	The next few questions ask about pregnancies you have had in the past 12 months. If you were pregnant more than once in the past 12 months, please respond about your most recent pregnancy.
8	Thinking back to just before you got pregnant, how did you feel about becoming pregnant?	I wanted to be pregnant later 1 I wanted to be pregnant sooner 2 I wanted to be pregnant then 3 I didn’t want to be pregnant then or at any time in the future 4 I wasn’t sure what I wanted 5
9	When you got pregnant, were you or your husband or partner doing anything to keep from getting pregnant? Some things people do to keep from getting pregnant include having their using birth control pills, implants, condoms, withdrawal, or natural family planning.	No 1 Yes 2	111
10	What method of birth control were you using when you got pregnant? Check ALL that apply	IUD (Mirena, ParaGard, Liletta, or Skyla ) 1 Contraceptive implant (Nexplanon) 2 Shots or injections (Depo-Provera) 3 Birth control pills 4 Contraceptive patch (Xulane) or vaginal ring (NuvaRing) 5 Condoms 6 Natural family planning (including rhythm method) 7 Withdrawal (pulling out) 8 Other______________________ 9
11	In the next 6 months, how would you feel if you got pregnant?	Very upset 1 Somewhat upset 2 Indifferent or don’t care 3 Somewhat pleased 4 Very pleased 5 Don’t know 6
The next questions ask about birth control methods you are using now or used in the past 12 months, even if it was for a short time.
12	Are you using any of these methods of birth control now? (Select one) Note-survey will skip to appropriate ‘current’ section for methods marked ‘yes’	Hormonal IUD (Mirena, Skyla, Liletta) No 1 Yes 2 Copper IUD (ParaGard) No 1 Yes 2 Implant (Nexplanon) No 1 Yes 2 Contraceptive shot (DepoProvera) No 1 Yes 2 Birth control pills No 1 Yes 2 Contraceptive ring (Nuvaring) No 1 Yes 2 Contraceptive patch (Xulane) No 1 Yes 2	2LNG-IUD current 2Cu-IUD current 2Implant current 2Depo current 2Pills current 2Ring current 2Patch current
13	Did you use any of these methods of birth control during the past 12 months, but you are not using it now? (select all that apply) Note- Survey will skip to section for each methods marked ‘yes’. After those sections are completed, will skip to ‘Condom’ section Note- if no to all methods, will skip to ‘Condom’ section.	Hormonal IUD (Mirena, Skyla, Liletta) No 1 Yes 2 Copper IUD (ParaGard) No 1 Yes 2 Implant (Nexplanon) No 1 Yes 2 Contraceptive shot (DepoProvera) No 1 Yes 2 Birth control pills No 1 Yes 2 Contraceptive ring (Nuvaring) No 1 Yes 2 Contraceptive patch (Xulane) No 1 Yes 2	2LNG-IUD past 2Cu-IUD past 2Implant past 2Depo past 2Pills past 2Ring past 2Patch past If 1 to ALL Condom
LNG-IUD--Current (Note- These headings will not be visible to the participant)
14	When did you start using the hormonal IUD (Mirena, Skyla, Liletta)?	MM / YYYY
15	In the past 12 months, how satisfied have you been with your hormonal IUD?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	117
16	What are the main reasons you have not been very satisfied with your hormonal IUD? (check all that apply)	I experienced bleeding changes 1 I experienced side effects 2 It caused me pain 3 It was too expensive for me 4 My partner does not want me to use it 5 I want to get pregnant 6 I do not believe it is effective for birth control 7 Other reason (specify): ­­____ 8
17	In the past 12 months, did your hormonal IUD ever completely fall out?	No 1 Yes 2	221
18	In the past 12 months, was your hormonal IUD removed?	No 1 Yes 2	1next applicable section
19	Did you pay a Z-CAN provider to have your IUD removed?	No 1 Yes 2 if yes, show pop-up screen: You should not have been asked to pay for your IUD removal. If you were asked to pay for a Z-CAN service, you may contact the Z-CAN program at [email protected]
20	Why did you have your hormonal IUD removed? (check all that apply)	It was in the wrong place 1 It was falling out 2 I had an infection (e.g. chlamydia, gonorrhea, pelvic inflammatory disease (PID)) 3 I experienced bleeding changes………..4 I experienced side effects……………….5 It caused me pain..……………………..6 I wanted to get pregnant………………...7 Other____________________ 8
21	When did you have a new hormonal IUD inserted?	MM / YYYY	next applicable section
LNG-IUD Past
22	When did you start using the hormonal IUD (Mirena, Skyla, Liletta)?	MM / YYYY
23	In the past 12 months, how satisfied were you with your hormonal IUD (Mirena, Skyla, Liletta)?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	125
24	What are the main reasons you were not very satisfied with your hormonal IUD? (check all that apply)	I experienced bleeding changes 1 I experienced side effects 2 It caused me pain 3 It was too expensive for me 4 My partner did not want me to use it 5 I wanted to get pregnant 6 I do not believe it is effective for birth control 7 Other reason (specify): ­­____ 8
25	In the past 12 months, did your hormonal IUD ever completely fall out?	No 1 Yes 2	2next applicable section
26	In the past 12 months, was your hormonal IUD removed?	No 1 Yes 2
27	Did you pay a Z-CAN provider to have your IUD removed?	No 1 Yes 2 if yes, show pop-up screen: You should not have been asked to pay for your IUD removal. If you were asked to pay for a Z-CAN service, you may contact the Z-CAN program at [email protected]
28	Did you talk with a Z-CAN provider before you stopped using your hormonal IUD (or had it removed)?	No 1 Yes 2
29	Why did you stop using your hormonal IUD (or have it removed)? (check all that apply)	It was in the wrong place………………..1 It was falling out…………………………..2 I had an infection (e.g. chlamydia, gonorrhea, pelvic inflammatory disease (PID)) 3 I experienced bleeding changes 4 I experienced side effects 5 It caused me pain 6 It was too expensive for me 7 My partner did not want me to use it 8 I wanted to get pregnant 9 I do not believe it is effective for birth control 10 Healthcare provider recommended I stop using it 11 Other reason (specify): ­­_______ 12	next applicable section
Cu-IUD Current
30	When did you start using the copper IUD (ParaGard)?	MM / YYYY
31	In the past 12 months, how satisfied have you been with your copper IUD?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	133
32	What are the main reasons you have not been very satisfied with your copper IUD? (check all that apply)	I experienced bleeding changes 1 I experienced side effects 2 It caused me pain 3 It was too expensive for me 4 My partner does not want me to use it 5 I want to get pregnant 6 I do not believe it is effective for birth control 7 Other reason (specify): ­­____ 8
33	In the past 12 months, did your copper IUD ever completely fall out?	No 1 Yes 2	237
34	In the past 12 months, was your copper IUD removed?	No 1 Yes 2	1next applicable section
35	Did you pay a Z-CAN provider to have your IUD removed?	No 1 Yes 2 if yes, show pop-up screen: You should not have been asked to pay for your IUD removal. If you were asked to pay for a Z-CAN service, you may contact the Z-CAN program at [email protected]
36	Why did you have your copper IUD removed? (check all that apply)	It was in the wrong place 1 It was falling out 2 I had an infection (e.g. chlamydia, gonorrhea, pelvic inflammatory disease (PID)) 3 I experienced bleeding changes ………..4 I experienced side effects……………….5 It caused me pain…………………………6 I wanted to get pregnant………………..7 Other____________ 8
37	When did you have a new copper IUD inserted?	MM / YYYY	next applicable section
CU-IUD Past
38	When did you start using the copper IUD (ParaGard)?	MM / YYYY
39	In the past 12 months, how satisfied were you with your copper IUD?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	138
40	What are the main reasons you were not very satisfied with your copper IUD? (check all that apply)	I experienced bleeding changes 1 I experienced side effects 2 It caused me pain 3 It was too expensive for me 4 My partner did not want me to use it 5 I wanted to get pregnant 6 I do not believe it is effective for birth control 7 Other reason (specify): ­­____ 8
41	In the past 12 months, did your copper IUD ever completely fall out?	No 1 Yes 2	2next applicable section
42	In the past 12 months, was your copper IUD removed?	No 1 Yes 2
43	Did you pay a Z-CAN provider to have your IUD removed?	No 1 Yes 2 if yes, show pop-up screen: You should not have been asked to pay for your IUD removal. If you were asked to pay for a Z-CAN service, you may contact the Z-CAN program at [email protected]
44	Did you talk with a Z-CAN provider before you stopped using your copper IUD (or had it removed)?	No 1 Yes 2
45	Why did you stop using your copper IUD (or have it removed)? (check all that apply)	It was in the wrong place………………..1 It was falling out………………………….2 I had an infection (e.g. chlamydia, gonorrhea, pelvic inflammatory disease (PID)) 3 I experienced bleeding changes 4 I experienced side effects 5 It caused me pain 6 It was too expensive for me 7 My partner did not want me to use it 8 I want to get pregnant 9 I do not believe it is effective for birth control 10 Healthcare provider recommended I stop using it 11 Other reason (specify): ­­_______ 12	next applicable section
Implant-current
46	When did you start using the implant (Nexplanon)?	MM / YYYY
47	In the past 12 months, how satisfied have you been with your implant? Note- 1,2 will skip to either other methods (past use) or condom section	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	1,2next appropriate section
48	What are the main reasons you have not been very satisfied with your implant? (check all that apply)	I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner does not want me to use it 6 I want to get pregnant 7 I do not believe it is effective for birth control 8 Other reason (specify): ­­____ 9	next applicable section
Implant-past
49	When did you start using the implant (Nexplanon)?	MM / YYYY
50	In the past 12 months, how satisfied were you with the implant?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	152
51	What are the main reasons you were not very satisfied with your implant? (check all that apply)	I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner did not want me to use it 6 I wanted to get pregnant 7 I do not believe it is effective for birth control 8 Other reason (specify): ­­____ 9
52	Did you pay a Z-CAN provider to have your implant removed?	No 1 Yes 2 if yes, show pop-up screen: You should not have been asked to pay for your implant removal. If you were asked to pay for a Z-CAN service, you may contact the Z-CAN program at [email protected]
53	Did you talk with a Z-CAN provider before you had your implant removed?	No 1 Yes 2
54	Why did you have your implant removed? (check all that apply)	I experienced bleeding changes 1 I experienced side effects 2 It caused me pain 3 It was too expensive for me 4 My partner did not want me to use it 5 I wanted to get pregnant 6 I do not believe it is effective for birth control 7 Healthcare provider recommended I stop using it 8 Other reason (specify): ­­_________ 9	next applicable section
Depo-Current
55	When did you start using the contraceptive shot (Depo Provera)?	MM / YYYY
56	What was the date of your most recent shot? If you do not know the exact date, please provide month and year.	MM / DD / YYYY
57	In the past 12 months, how satisfied have you been with the contraceptive shot? Note- 1,2 will skip to either other methods (past use) or condom section	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	1,2next appropriate section
58	What are the main reasons you have not been very satisfied with contraceptive shot? (check all that apply)	It is not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner does not want me to use it 6 I want to get pregnant 7 I do not believe it is effective for birth control 8 Other reason (specify): ­­____ 9	next applicable section
Depo-past
59	When did you start using the contraceptive shot (Depo Provera)?	MM / YYYY
60	In the past 12 months, how satisfied were you with the contraceptive shot (Depo Provera)?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	162
61	What are the main reasons you were not very satisfied with the contraceptive shot? (check all that apply)	It was not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner did not want me to use it 6 I wanted to get pregnant 7 I do not believe it is effective for birth control 8 Other reason (specify): ­­____ 9
62	Did you talk with a Z-CAN provider before you stopped using the contraceptive shot?	No 1 Yes 2
63	Why did you stop using the contraceptive shot? (check all that apply)	It was not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner did not want me to use it 6 I wanted to get pregnant 7 I do not believe it is effective for birth control 8 Healthcare provider recommended I stop using it 9 I had trouble getting to a Z-CAN clinic for shots 10 Other reason (specify): ­­_______ 11	next applicable section
Pill-Current
64	When did you start using the birth control pill?	MM / YYYY
65	In the past 12 months, how satisfied have you been with the using the birth control pill?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	167
66	What are the main reasons you have not been very satisfied using the birth control pill? (check all that apply)	It is not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner does not want me to use it 6 I want to get pregnant 7 I do not believe it is effective for birth control 8 Other reason (specify): ­­____ 9
67	The last time that you got birth control pills from a Z-CAN provider, how many packs of pills did you receive?	1 pack 1 2 packs 2 3 packs 3 4-6 packs 4 7-9 packs 5 10-12 packs 6 13 packs 7
68	During the past 12 months, how difficult has it been for you to get more pills when you need them?	Not difficult 1 Somewhat difficult 2 Very difficult 3	1next applicable section
69	Why was it was difficult for you to get more pills when you needed them? Select all that apply	Distance to the Z-CAN clinic 1 Hard to get to the Z-CAN clinic 2 Remembering to go to the Z-CAN clinic 3 Finding the time to go to the Z-CAN clinic 4 Pills were too expensive 5 Other reason____________ 6	next applicable section
Pill-Past
70	When did you start using the birth control pill?	MM / YYYY
71	In the past 12 months, how satisfied were you with the using the birth control pill?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	173
72	What are the main reasons you were not very satisfied using the birth control pill? (check all that apply)	It was not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner did not want me to use it 6 I wanted to get pregnant 7 I do not believe it is effective for birth control 8 Other reason (specify): ­­____ 10
73	The last time that you got birth control pills from a Z-CAN provider, how many packs of pills did you receive?	1 pack 1 2 packs 2 3 packs 3 4-6 packs 4 7-9 packs 5 10-12 packs 6 13 packs 7
74	During the past 12 months, how difficult was it for you to get more pills when you need them?	Not difficult 1 Somewhat difficult 2 Very difficult 3	176
75	Why was it was difficult for you to get more pills when you needed them? Select all that apply	Distance to the Z-CAN clinic 1 Hard to get to the Z-CAN clinic 2 Remembering to go to the Z-CAN clinic 3 Finding the time to go to the Z-CAN clinic 4 Pills were too expensive 5 Other reason____________ 6
76	Did you talk with a Z-CAN provider before you stopped using the pill?	No 1 Yes 2
77	Why did you stop using the birth control pill? (check all that apply)	It was not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner did not want me to use it 6 I wanted to get pregnant 7 I do not believe it is effective for birth control 8 Healthcare provider recommended I stop using it 9 Too hard to remember to take a pill every day 10 Too hard to get pills from Z-CAN clinic 11 Other reason (specify): ____ 12	next applicable section
Ring-Current
78	When did you start using the ring (Nuvaring)?	MM / YYYY
79	In the past 12 months, how satisfied have you been with the ring?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	181
80	What are the main reasons you have not been very satisfied with the ring? (check all that apply)	It is not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner does not want me to use it 6 I want to get pregnant 7 I do not believe it is effective for birth control 8 Other reason (specify): ­­____ 9
81	During the past 12 months, how hard has it been for you to get more rings when you need them? Note- 1 will skip to either other methods (past use) or condom section	Not difficult 1 Somewhat difficult 2 Very difficult 3	1next appropriate section
82	Why has it been was difficult for you to get more rings when you needed them? Select all that apply	Distance to the Z-CAN clinic 1 Hard to get to the Z-CAN clinic 2 Remembering to go to the Z-CAN clinic 3 Finding the time to go to the Z-CAN clinic 4 The ring is too expensive 5 Other reason____________ 6	next applicable section
Ring-Past
83	When did you start using the ring (Nuvaring)?	MM / YYYY
84	In the past 12 months, how satisfied were you with the ring?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	186
85	What are the main reasons you were not very satisfied with the ring? (check all that apply)	It was not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner did not want me to use it 6 I wanted to get pregnant 7 I do not believe it is effective for birth control 8 Other reason (specify): ­­____ 9
86	During the past 12 months, how hard was it for you to get more rings when you need them?	Not difficult 1 Somewhat difficult 2 Very difficult 3	188
87	Why was it difficult for you to get more rings when you needed them? Select all that apply	Distance to the Z-CAN clinic 1 Hard to get to the Z-CAN clinic 2 Remembering to go to the Z-CAN clinic 3 Finding the time to go to the Z-CAN clinic 4 The ring is too expensive 5 Other reason____________ 6
88	Did you talk with a Z-CAN provider before you stopped using the ring?	No 1 Yes 2
89	Why did you stop using the ring? (check all that apply)	It was not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner did not want me to use it 6 I wanted to get pregnant 7 I do not believe it is effective for birth control 8 Healthcare provider recommended I stop using it 9 It was difficult to use/insert 10 Too hard to get rings from Z-CAN clinic 11 Other reason (specify): ____ 12	next applicable section
Patch-Current
90	When did you start using the patch?	MM / YYYY
91	In the past 12 months, how satisfied have you been with the patch?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	193
92	What are the main reasons you have not been very satisfied with the patch? (check all that apply)	It is not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner does not want me to use it 6 I want to get pregnant 7 I do not believe it is effective for birth control 8 Other reason (specify): ­­____ 9
93	During the past 12 months, how hard has it been for you to get more patches when you need them? Note- 1 will skip to either other methods (past use) or condom section	Not difficult 1 Somewhat difficult 2 Very difficult 3	1next appropriate section
94	Why has it been difficult for you to get more patches when you needed them? Select all that apply	Distance to the Z-CAN clinic 1 Hard to get to the Z-CAN clinic 2 Remembering to go to the Z-CAN clinic 3 Finding the time to go to the Z-CAN clinic 4 The patch is too expensive 5 Other reason____________ 6	next applicable section
Patch-Past
95	When did you start using the patch?	MM / YYYY
96	In the past 12 months, how satisfied were you with the patch?	Very satisfied 1 Somewhat satisfied 2 Not satisfied 3	198
97	What are the main reasons you were not very satisfied with the patch? (check all that apply)	It was not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner did not want me to use it 6 I wanted to get pregnant 7 I do not believe it is effective for birth control 8 Other reason (specify): ­­____ 9
98	During the past 12 months, how hard was it for you to get more patches when you need them?	Not difficult 1 Somewhat difficult 2 Very difficult 3
99	Why was it was difficult for you to get more patches when you needed them? Select all that apply	Distance to the Z-CAN clinic 1 Hard to get to the Z-CAN clinic 2 Remembering to go to the Z-CAN clinic 3 Finding the time to go to the Z-CAN clinic 4 The patch is too expensive 5 Other reason____________ 6
100	Did you talk with a Z-CAN provider before you stopped using the patch?	No 1 Yes 2
101	Why did you stop using the patch? (check all that apply)	It was not convenient for me 1 I experienced bleeding changes 2 I experienced side effects 3 It caused me pain 4 It was too expensive for me 5 My partner did not want me to use it 6 I wanted to get pregnant 7 I do not believe it is effective for birth control 8 Healthcare provider recommended I stop using it 9 It was difficult to use 10 Too hard to get patches from Z-CAN clinic 11 Other reason (specify): ____ 12	next applicable section
Condoms
102	During the past 12 months, how often do you and your partner(s) use condoms?	Never 1 Sometimes 2 Most of the time 3 Always 4	1104
103	Why do you and your partner(s) use condoms? (select all that apply )	To prevent sexually transmitted infections (Chlamydia, gonorrhea, HIV, etc) 1 To prevent pregnancy 2 To prevent Zika virus infection 3 Other__________________ 4
Other
104	During the past 12 months, did you use any of these other birth control methods?	Withdrawal (pulling out) No 1 Yes 2 Tubal sterilization (female) No 1 Yes 2 Vasectomy (male sterilization) No 1 Yes 2 Rhythm method or fertility awareness No 1 Yes 2 Other_________________ No 1 Yes 2
Thank you very much for participating in this survey. The information you provide will help the Z-CAN program improve contraception services in Puerto Rico.