QUESTIONNAIRE DESIGNED TO ANALYZE “IMPACTS ON WOMEN’S HEALTH DURING CLIMACTERIUM FOR VICTIMS OF DOMESTIC OR SEXUAL VIOLENCE”
BY MORAES & FONSECA, 2009
1 - When you began to suffer violence, you lived: on a farm
□,
in the city□.
With your biological parents
□,
With adoptive parents□,
With husband/partner□,
With youremployers
□,
With another relative□.
2 – When?
During childhood (0-10 years old)
□
, adolescence (11-19 years old)□,
adulthood (over 20 years old)□.
2.1 – During childhood, did you suffer violence?
Never
□,
A few times□,
Sometimes□,
Many times□,
Always□.
2.2 – During adolescence, did you suffer violence?
Never
□,
A few times□,
Sometimes□,
Many times□,
Always□.
3 – During childhood, did you suffer (You can check more than one alternative):
Physical violence
□,
Sexual violence□,
Psychological abuse□,
Physical neglect
□
, Emotional neglect□,
All types of violence□.
3.1 During adolescence, did you suffer:
Physical violence
□,
Sexual violence□
, Psychological abuse□
, Physical neglect□
, Emotional neglect□
, All types of violence□
.3.2 – During childhood/adolescence, who perpetrated violence against you?
Father
□,
Mother□,
Brother□,
Other relatives□,
Stepfather or stepmother□,
Boyfriend□,
Others.
__________________
4 – Did you begin to suffer violence during adulthood (after 20 years old)?
Yes
□,
No□.
4.1 – At what age did you begin to suffer traumas/violence during adulthood? (You can check more than one alternative)
Between 20 and 24 years
□,
25-29□,
30-34□,
35-39□,
40-44□,
45-49□,
50-54□,
55,-59□,
60-64□,
65 or older□.
4.3 – During adulthood (after 20 years old), what kind of violence did you suffer? Physical violence
□,
Sexual violence□,
Psychological abuse□,
Physical neglect□,
Emotional neglect□,
All of them□
.4.4 - During adulthood, did you suffer violence?
Never
□,
A few times□,
Sometimes□,
Many times□,
Always□.
4.5 - Who abused you?
Husband/partner
□,
Boyfriend□,
Lover□,
Employer□,
Other□
.5 - When you suffered or suffer violence, did/do you look for health services?
Never
□,
A few times□,
Sometimes□,
Many times□,
Always□.
5.1 – If you look(ed) for help, where did/do you go?
Health unit
□,
Hospital□,
Private office□,
NGO□,
Church□
.5.2- If you did/do not look for help, why not?
Fear
□,
Shame□,
Thought it was useless□,
Access to health services was difficult□,
Other□.
6 – When you suffered violence, did you tell or seek help from someone?
Never
□,
A few times□,
Sometimes□,
Many times□,
Always□.
6.1 If you did tell someone, who did you tell or ask for help?
Family
□,
Neighbors□,
Friends□,
Priest/pastor□.
6.2 – If you did not tell anyone, why not?
Fear
□,
Shame□,
Guilt□,
Thought it was useless□,
Other□
.7 – When you suffered violence, did you or someone you know go to a police district?
Never
□,
A few times□,
Sometimes□,
Many times□,
Always□.
7.1 – When you suffered violence, did you or someone you know call the police?
Never
□,
A few times□,
Sometimes□,
Many times□,
Always□.
7.2 – If not, why?
Fear
□,
Shame□,
Thought it was useless□,
Was economically dependent on the aggressor□,
Because of the children
□,
Did not want to harm the aggressor□,
All of the above□,
Other□
.8 – Which of these diseases do you currently have (occurring up to twelve months prior to this interview):
Hypertension
□,
Diabetes□,
Depression□,
Osteoporosis□,
Labyrinthitis□,
Tenosynovitis□,
Fibromyalgia□,
Rheumatic disease□,
Breast cancer□,
Ovarian cancer□,
Uterine cancer□,
Other cancers
□,
Systemic lupus erythematosus□,
Herniated disk□,
Allergies□,
Bronchitis□,
Varicose veins in the legs
□,
Venous thrombosis□,
Illicit drug abuse□,
Uterine fibroids□,
Liverproblems
□,
Renal problems□,
Obesity□,
Gastritis□,
Other diseases□.
Which? _____________________
9 – Do you think your health problems are somehow related to the violence you experienced?
Totally agree
□,
Partially agree□,
Not sure□,
Partially disagree□,
Completely disagree□.
9.1 Do you think your health problems could have been reduced if a health professional had inquired about the violence you suffered?
Totally agree
□,
Partially agree□,
Not sure□,
Partially disagree□,
Completely disagree□.
10 – Do you have an active sexual life?
Never
□,
Occasionally□,
Some of the time□,
Most of the time□,
All of the time□.
10.1 – If you do have an active sexual life, is it satisfactory?
Never
□,
Occasionally□,
Some of the time□,
Most of the time□,
All of the time□.
10.2 – If your sexual life is unsatisfactory, why?
No libido
□,
Husband is sick, impotent□,
Resentment of partner□,
You are sick□,
You do not want to have anything to do with men because of your previous suffering□,
You do not want to have anything to do with men for other reasons□.
10.3 – If you do not have an active sexual life, why?
You have no partner
□,
Husband is sick, impotent□,
You do not want to have anything to do with men□,
You do not feel like it□,
You do not feel good about your body□,
Other□.
11 – How do you feel now? What is your mood now?
I am sad/depressed
□,
I am somewhat sad/depressed□,
I am neither happy nor sad□,
I amhappy/joyful
□,
I am very happy/joyful□.
11.1 Did the violence that you suffered negatively influence your way of living, acting, or feeling?
12 – Among the diverse violence episodes you have suffered, check the one that had the greatest impact on your physical and psychological health:
(you may check more than one alternative)
1- Suffering many traumas/violence from my biological and/or adoptive parents □
2- Suffering many traumas/violence from siblings or other family members □
3- Suffering many traumas/violence from someone who was raising me or adopted me □
4- Suffering abuse/rape by an unknown person □
5- Suffering physical violence or other trauma from someone who was close or was an acquaintance and/or relative □
6- Suffering physical violence or other trauma from someone with whom I was not familiar □
7- Being beaten/hurt by someone I loved dearly or still love □
8- Being beaten/hurt by the father of my children □
9- Being the victim of humiliation, cursing, calumnies □
10- Being forced to have sexual intercourse with my husband/partner against my will □
11- Being forced to have sexual intercourse with my boyfriend/husband/partner in a way I did not like □
12- Suffering any kind of trauma/violence from a person from an institution (shelter, hospital, workplace, school/college, another place I lived or was cared for) □
13 – If health professionals had asked you, in a sheltering and discreet way, if you had suffered or were suffering some type of violence, would you have told them or asked for help?
Totally agree
□,
Partially agree□,
Not sure□
, Partially disagree□,
Completely disagree□.
13.1 Many people suffering violence feel intimidated about telling health professionals that they are victims of violence. What do you think health professionals could do to help these persons to talk about this subject?
(You may check more than one alternative)
1. They must always ask the woman if she was a victim of violence at some point of her life □. 2. Professionals must be more open, allowing people to talk; they must look at their faces, be more patient when listening □.
3. Professionals must help patients feel more secure to allow them to talk about their conflicts □. 4. They need to have another view of the problem, believing that violence exists and is harmful to people’s health □.
5. I am unable to talk about this problem with male professionals because I have experienced trauma from men. It would be nice if the professional was a woman who inspired my confidence □. 6. Professionals must encourage women to report the violence they suffer. They must encourage them to not accept violence □.
7. Professionals must refer them to a psychologist, social worker or other professional □. 8. They must understand that our diseases are not only of the body □.
9. I do not think talking will solve anything. Physicians can do nothing □. 10. I do not know □.
Annex II – Epidemiological data
Age: ______ Race:__________ Weight:_______ Height:_______ PA:___________
Age at first period: ______ Age at first sexual intercourse: ______
Date of last period: ___/___/_____ Menopause:____Years:
Births: G___ P___ A ___ Normal births
□
Caesarean Section□
Medications you currently use (you may check more than one option):
For arterial hypertension
□,
rheumatism□
, diabetes□
, osteoporosis□
, high cholesterol□
,depression
□
, fibromyalgia□
, your heart□
, gastritis□
, labyrinthitis□
, I do not know what my medication is for□,
For other diseases□
.Active sexual life?
Yes
□
No□
For how long? (____ years)If yes, is it satisfactory? Yes
□
No□
For how long (___ years)Smoker? Yes
□
No□
Quit smoking□
For how long? (___ years) Alcohol use: Yes□
No□
Quit drinking□
For how long? (___ years) Menopausal Kupperman IndexVasomotor - 04; 08; 12 Paresthesia - 02; 04; 06 Insomnia - 02; 04; 06 Nervousness - 02; 04; 06 Melancholy - 01; 02; 03 Vertigo - 01; 02; 03 Weakness - 01; 02; 03
Arthralgia/Myalgia - 01; 02; 03 Headaches - 01; 02; 03
Arrhythmia - 01; 02; 03 Tingling - 01; 02; 03
TOTAL______
Personal history: Arterial hypertension
□
, diabetes□
, depression□,
osteoporosis□
, labyrinthitis□
, tenosynovitis□,
fibromyalgia□
, rheumatic disease□
, breast cancer□
, ovarian cancer□
,uterine cancer
□
, other cancers□
, systemic lupus erythematosus□
, herniated disk□
, allergies□
,Family history: Arterial hypertension
□
, diabetes□
, depression□,
osteoporosis□
, labyrinthitis□
, tenosynovitis□,
fibromyalgia□
, rheumatic disease□
, breast cancer□
, ovarian cancer□
,uterine cancer
□
, other cancers□
, systemic lupus erythematosus□
, herniated disk□
, allergies□
,bronchitis
□
, varicose veins in the legs□
, thrombosis□
, gastritis□
, liver problems□,
uterinefibroids
□
, illicit drug abuse□
, transplants□
, other diseases□
Which? ___________________