WACC Survey "Voice of Women"
1. Your background:
Age:
Country:
Marital status:
Married, living with partner
Single
Divorced
Widowed
Number of children
2. Please state the diagnosis given by your doctor:
Only one answer possible
Nothing serious but requires monitoring
Cervical lesion (CIN1)
Cervical lesion (CIN2 / CIN3)
Cervical cancer
Other
Don’t remember
3. How did you find out about the results of your “abnormal” smear test?
Only one answer possible
You were sent a letter from your doctor asking you to make an appointment to see him regarding the results of your smear test
You were sent a letter with the results from the laboratory and an additional note from your doctor
Your doctor called to inform you of the results of your smear test
The doctor’s secretary called to arrange an appointment for you to discuss the results of your smear test with your doctor
Other
4. When you received the results of your abnormal smear, what was the first thing you felt?
Please, select no more than 3 answers
Anxiety
Guilty
Panic
Injustice
Anger
Shame
Alone
Didn’t know what it meant (need for further information)
Stress
Nothing special
Incredulity
Other
5. After your doctor had explained what the diagnosis meant and what the next steps will be, how did you feel? Did you feel…
Please, select no more than 3 answers
Reassured
Relieved
Worried
Helpless
Optimistic
Disorientated
Aggressive
Ashamed
Confident
Other
Depressed
6. On a scale of 1 to 10 with regard to your relationship with your doctor how would you rate the psychological support that you received from your doctor throughout this examination? (where 1 means that you felt extremely alone and 10 that you felt completely supported by your doctor)
Please, circle the most appropriate number for you
Extremely alone
1
2
3
4
5
6
7
8
9
10
Completely supported
7. After you were given the results by your doctor and / or your treatment, did you talk about your disease with somebody else?
No
Yes (precise):
my partner
my friend
my mother
another member of my family
my daughter
Other
8. What treatment did you receive?
Multiple answers possible
Check-up smears for 6 months
Check-up smears for 1 year
HPV test
Colposcopy
Biopsy
Cervical conisation
Hysterectomy
Don’t know
Other
9. How did you manage the treatment or wait?
Please, select no more than 3 answers
I was very worried
I was disoriented
I was confident (reassured)
I was ashamed
I was depressed
I felt alone
I felt that my physical integrity
was under threat
10. Has your illness had any impact on: (where 1 means that you felt not at all affected and 10 that you felt severely affected)
On each line please ckeck the most appropriate number for you
not at all affected
severely affected
1
2
3
4
5
6
7
8
9
10
Your family life?
Your relationship with your partner?
Your daily life?
Your professional life?
11. On a scale of 1 to 10 with regard to your relationship with your partner how would you rate the psychological support that you received from your partner throughout this examination? (where 1 means that you felt extremely alone and 10 that you felt completely supported by your partner)
Please, circle the most appropriate number for you
Extremely alone
1
2
3
4
5
6
7
8
9
10
Completely supported
12. More precisely, on a scale from 1 to 10, would you say that you were well informed on (where 1 means not informed at all and 10 means very well informed)
On each line please circle the most appropriate number for you
not at all informed
very well informed
1
2
3
4
5
6
7
8
9
10
The illness
The treatments
The emotional consequences
The consequences on your relationship
The consequences on your family life
The consequences
on your future as a mother (fertility)
13. Where did you get the information from?
Multiple answers possible
Media
Friends
Family
Doctor
On line
Other
14. Would you like more information on cervical cancer and other genital diseases linked to papillomavirus and on the way to prevent them?
Only one answer possible
Yes, absolutely
Yes, maybe
Not really
Definitely not
15. What would be the most useful sources of information for you?
Please select 2 answers
Website
Newsletter
My doctor
Women’s groups
Media / TV
Other
