Assessment of psychological distress in patients with cervical dysplasia according to age, education, information acquisition and information level

Assessment of psychological distress in patients with cervical dysplasia according to age, education, information acquisition and information level | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of psychological distress in patients with cervical dysplasia according to age, education, information acquisition and information level Anne Cathrine Scherer-Quenzer, Saskia Laureen Herbert, Tanja Schlaiss, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4185892/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Aug, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted 4 You are reading this latest preprint version Abstract Purpose: This study aims to investigate the psychological distress experienced by patients with initial diagnosis of abnormal Pap smears or dysplastic changes of the cervix uteri. It is investigated whether patients' age, education, information level and approach to information acquisition have an impact on their psychological distress. Methods: A total of 364 female patients, aged 20-80 years, referred to the special dysplasia consultation hour at the Department of Obstetrics and Gynecology, Wuerzburg, completed a questionnaire containing validated items to assess information level, information acquisition, information needs and psychological distress, including a distress thermometer. Data from questionnaires and medical reports were used for analysis. Results: The study found that 56.9% of patients experienced psychological distress before their first visit. Patients under 44 years of age, especially those with concerns about fertility and sexuality, and those with lower levels of education showed higher levels of distress (p-value=0.018 and p-value=0.037). 40.9% of patients felt poorly informed and 53.7% of patients wanted more information before their visit. Correlational analysis showed that the method of obtaining information correlated with the desire for more information (p-value <0.001). Those who received information via the Internet felt less informed, wanted more information and experienced more anxiety. Conclusion: These findings highlight the need for improved patient education strategies and effective doctor-patient communication to address the knowledge gap and reduce patient distress. In addition, healthcare providers should ensure that patients have access to reliable online resources for accurate information. psychological burden abnormal Pap smear risk factors What does this study adds to the clinical work This study highlights the prevalence of psychological distress among patients with cervical dysplasia and investigates the extent to which factors such as age, information acquisition, level of information, desire for more information and educational level have an influence on patients' psychological distress. These findings can help tailor patient education strategies and improve doctor-patient communication and overall quality of care for patients undergoing cervical screening and diagnosis. Introduction In 2022 cancer was diagnosed in 19.98 million people worldwide [1]. It is well known that cancer diagnosis is associated with psychological distress [2]. The extent of psychological comorbidity in cancer patients was first scientifically investigated in the 1970s and 1980s. Since then, the scientific focus on this topic has increased [3]. A comparative study of oncology patients, chronically ill patients and healthy people showed that 20% of oncology patients described themselves as psychologically distressed, compared with 10.6% of healthy people and 14.8% of chronically ill people. The risk of subsequent mental disorders is particularly high in young long-term survivors [4]. One type of cancer that particularly affects young women is cervical cancer. According to recent data, it is the 14th most common cancer and the 4th most common cancer in women worldwide [5]. In a study conducted in the USA in 2005, patients with an average age of 45 years who were being followed for 5-10 years after treatment for cervical cancer were asked about their diagnosis. The patients were healthy at the time of the survey and reported a good quality of life. However, 69% said they would have attended a support group if it had been offered at the time of diagnosis [6]. A study conducted in Germany in 2015 with 595 patients found that after being informed of an abnormal Pap smear, 68.8% of women reacted with anxiety and 26.3% reacted with panic. For 63.9% of patients, talking to their doctor was the most important source of information. But even after the discussion, 51.4% were still worried and only 24.4% were reassured [7]. The aim and interest of this study is, firstly, to investigate the psychological distress experienced by patients with abnormal Pap smears or dysplastic changes of the cervix. The second aim is to determine whether age, education and the way in which information is obtained have an influence on the psychological distress of patients, in order to optimise and support patient care, patient education and patient information in the future. The main questions, which are to be answered in this work, are the following: Does the age of patients with abnormal Pap smears have an effect on the psychological burden? Does information level and information acquisition have an effect on the psychological burden? Is there a correlation between the psychological burden of patients with dysplasia or precancerous lesions of the cervix and their level of education? Methods Human Patient Data This retrospective study was registered with the Institutional Review Board (Ref. No. 20210628 01) The female patients were referred to the special dysplasia consultation hour at the Department of Obstetrics and Gynecology (University of Wuerzburg) by their respective gynecologists in case of abnormal Pap smears or HPV positivity for further diagnostics and treatment. During their initial visit, the patients were given the questionnaire found in the appendix. In addition, information was extracted from each patient’s medical report. The questions are based on a validated questionnaire for assessing psychological distress in patients with cervical dysplasia (Cervical Dysplasia Distress Questionnaire = CDDQ), which was validated by Shinn et al. in a study involving 661 participants [8]. The CDDQ was supplemented with four questions addressing background information of the affected individual and the Distress Thermometer. The Distress Thermometer is a developed screening instrument from the National Comprehensive Cancer Network to measure psychosocial distress in oncologically ill patients. The thermometer allows patients to indicate their psychological burden on a numerical scale from 0 to 10. „0“ represents "no burden" and „10“ represents "very burdened." Over the years, the thermometer has been validated through numerous studies [9]. The four additional questions related to the level of education, the subjective level of information, the desire for further information, the method of obtaining information about dysplasia, and the adequacy of prior information provided by the personal gynecologist. These four questions were chosen to specifically assess the patients' level of knowledge and then to discuss possible ways of optimising education and information in the future. Each patient could choose up to five answers. Pap smears were interpreted by two experienced gynecological cytologists with more than 20 years of experience at the Department of Obstetrics and Gynecology (University of Wuerzburg). HPV testing was evaluated by polymerase chain reaction (PCR) amplification followed by genotyping at the Institute of Virology and Immunology (University of Wuerzburg). The genotypes were categorised as 'high risk' and 'low risk'. Statistical analysis All variables were documented in an Excel file (Microsoft Office Excel 2013, Washington, USA). The data was analyzed using the statistical software SPSS (Version 24) from IBM (SPSS Inc., Chicago, IL. USA) and the following statistical test procedures: - Descriptive Data Analysis - Correlation analysis using Spearman's rank correlation coefficient (rho) - Mann-Whitney U test - Chi squared test - Kruskal-Walis test p-values of <0.05 were considered statistically significant. Use of Large Language Models ChatGPT Version 4.0 (OpenAI Inc., San Francisco) was used for language quality check. Results Patient cohort The patient cohort consisted of a total of 364 female patients aged between 20 and 80 years, with a mean age of 43.3 years (SD = 11.3). Of the Pap tests performed, Pap IVa-p was the most common (25.5%), followed by Pap IIID2 (21.4%) and IIp (21.2%). In addition, 70.3% of patients had a high-risk HPV subtype. Patients' overall psychological distress was assessed using the Distress Thermometer [ 9 ]. For analysis, responses from 1 to 5 were grouped as "not distressed" and responses from 6 to 10 were grouped as "distressed". 56.9% of patients reported psychological distress. (Table 1 ). Table 1 Patient characteristics. SD = standard deviation. HPV high risk = 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, HPV low risk = 40, 42, 43, 44, 54, 61, 72, 81, low distress level measured from 1 to 5 (according to Distress Thermometer), high distress level measured from 6 to 10 (according to Distress Thermometer) Mean (SD) or number (percentage) Age in years 43,3 (11,3) Pap IVa-p 93 (25,5) Pap IIID2 78 (21,4) Pap IIp 77 (21,2) Others 116 (31,9) HPV high risk 256 (70,3) HPV low risk 13 (3,6) HPV negativ 32 (8,8) No Data 63 (17,3) Low Distress Level 157 (43,1) High Distress Level 207 (56,9) Psychological burden and information acquisition based on patients' age The following results aim to illustrate how the patients' age influences their psychological burden and concerns. The cohort was divided into a group of younger and older women according to the mean age of the group of 43.3 years, which was used as a threshold between "young" and "old". While 57.3% of the younger women reported psychological distress, only 42.8% of the older patients reported the same (p-value = 0.018). There was also a statistically significant difference in information seeking between younger and older patients (p-value = 0.028). Among younger patients, 62.1% sought information from their gynecologist, compared to 74.8% of older patients. 27.2% of younger patients obtained information only from the internet, compared to 14.8% of older patients. Although most patients in both groups were generally informed by the attending gynecologist (67.6%), statistical analysis shows that younger women were significantly more likely than older women to obtain their information only from the internet, and older women were significantly more likely than younger women to obtain their information only from their gynecologist (Table 2 ). Table 2 Information acquisition based on patients' age. Cross tabulation and Chi-square test. R = Standardized residual. Age Young (< 43.3 year) Old (≥ 43.3 year) Sum No information acquisition Observed count 19 12 31 Expected count 17,7 13,3 31 Proportion within the group (in%) 9,2 7,7 8,6 R 0,3 -0,4 Information through gynecologist Observed count 128 116 244 Expected count 139,2 104,8 244,0 Proportion within the group (in%) 62,1% 74,8% 67,6% R -1 1,1 Information through internet (solely) Observed count 56 23 79 Expected count 45,1 33,9 79,0 Proportion within the group (in%) 27,2% 14,8% 21,9% R 1,6 -1,9 Information through family/friends Observed count 3 4 7 Expected count 4,0 3,0 7,0 Proportion within the group (in%) 1,5% 2,6% 1,9% R -0,5 0,6 Psychological burden based on information level Question 1 assessed the patients' level of information during their initial visit. Patients could select their answers on a numerical scale from 1 to 10. For the analysis of Question 1 responses from 1 to 5 were grouped as "poorly informed“, and responses from 6 to 10 were grouped as "well informed." The distribution of Question 1 revealed that 40.9% of the patients felt poorly informed. These patients also reported a higher psychological burden (based on the Distress Thermometer) compared to others (p-value = 0.048). Psychological burden based on information acquisition Question 2 examined where patients had obtained information prior to their first visit. The response options for question 2 were 'not at all', 'from the gynecologist', 'from the internet' or 'from friends/acquaintances'. Multiple answers were possible for this question. Overall, 67.6% of patients obtained information from their gynecologist. The second most common source was the internet with 21.9%. Only 8.6% of patients had received no information before their first visit (Table 2 ). While 62.3% of the women who had obtained information from the internet were psychologically distressed, 57.8% of those who had been informed by their gynecologist reported the same (Table 3 ). Correlation analysis shows that the level of psychological distress does not depend on the way in which the information was obtained (p-value = 0.971). Table 3 Cross table concerning information acquisition and measured distress level. Distress level measured from 1 to 10. Low distress level = 1–5. High distress level = 6–10. Distress-Level 1 2 3 4 5 6 7 8 9 10 No information acquisition Observed count 1 4 4 4 3 0 3 3 1 2 Percentage 4 16 16 16 12 0 12 12 4 8 Information through gynecologist Observed count 14 16 15 11 19 8 28 24 25 18 Percentage 7,9 9,0 8,4 6,2 10,7 4,5 15,7 13,5 14 10,1 Information through internet (solely) Observed count 8 10 5 9 11 8 13 17 19 14 Percentage 7,0 8,8 4,4 7,9 9,6 7,0 11,4 14,9 16,7 12,3 Information through family/friends Observed count 1 1 0 0 3 2 2 5 3 1 Percentage 5,6 5,6 0 0 16,7 11,1 11,1 27,8 16,7 5,6 Sum 20 26 22 20 28 14 40 36 33 27 Correlation between information acquisition, wish for information and information level Question 3, which inquired about the desire for information before the visit, also had ten response options. For the analysis, responses from 1 to 5 were considered "no further information desired," and responses from 6 to 10 were considered "desire for more information. 53.7% of the patients wished for more information before their visit. Further analysis indicated that the desire for more information correlates with the form of information acquisition (p-value < 0,001). While 63,6% of the women who had obtained information from the internet wished for more information, only 47,0% of those informed by their gynecologist reported the same (Table 4 ). This is underscored by the fact that only 35,3% of the patients informed by their gynecologist felt poorly informed while 45,8% of those obtaining information by the internet reported the same (Table 5 ). Table 4 Cross table concerning information acquisition and wish for more information. With for more information measured from 1 to 10. No further information desired = 1–5. Desire for more information = 6–10. Wish for information 1 2 3 4 5 6 7 8 9 10 No information acquisition Observed count 7 1 4 2 3 0 3 4 2 4 Percentage 23,3 3,3 13,3 6,7 10 0 10 13,3 6,7 13,3 Information through gynecologist Observed count 45 21 21 7 34 18 25 30 8 33 Percentage 18,6 8,7 8,7 2,9 14 7,4 10,3 12,4 3,3 13,6 Information through internet (solely) Observed count 12 6 8 5 25 10 17 26 13 32 Percentage 7,8 3,9 5,2 3,2 16,2 6,5 11 16,9 8,4 20,8 Information through family/friends Observed count 2 0 0 0 6 3 4 2 3 5 Percentage 8 0 0 0 24 12 16 8 12 20 Sum 57 23 28 12 45 24 35 48 18 65 Table 5 Cross table concerning information acquisition and information level. Information level measured from 1 to 10. Poorly informed = 1–5, Well informed = 6–10. Information Level 1 2 3 4 5 6 7 8 9 10 No information acquisition Observed count 4 1 4 2 5 2 4 4 2 2 Percentage 13,3 3,3 13,3 6,7 16,7 6,7 13,3 13,3 6,7 6,7 Information through gynecologist Observed count 7 10 9 12 48 15 31 47 25 40 Percentage 2,9 4,1 3,7 4,9 19,7 6,1 12,7 19,3 10,2 16,4 Information through internet (solely) Observed count 4 11 14 12 29 15 19 24 14 11 Percentage 2,6 7,2 9,2 7,8 19 9,8 12,4 15,7 9,2 7,2 Information through family/friends Observed count 0 1 1 3 4 3 3 5 2 3 Percentage 0 4 4 12 16 12 2 20 8 12 Sum 15 21 25 21 63 27 40 61 36 48 Psychological burden based on patients' education level Question 4 of the questionnaire aimed to assess the education level of the patients. The response options were "no school degree," „vocational training“ or "general matriculation standard“. The analysis of question 4 showed that 5.1% of the patients had no school degree, 61.1% had vocational training, and 33.5% possessed a general matriculation standard. To investigate whether the type of information acquisition depended on the education level, the distribution of information acquisition was calculated separately for different education categories. Overall, patients with vocational training and a general matriculation standard tended to obtain information from more than one source. There was a negative significant correlation between patients' overall insecurity and their education level (p-value = 0.038), indicating that patients with lower education levels were more insecure compared to well-educated patients. Possible reasons for increased psychological distress and the effects of increased psychological distress Younger women have a greater concern compared to older women about not being able to have children anymore (p-value < 0.001). Regardless of age, women who wished for more information beforehand are significantly more concerned about developing cancer (p-value < 0.001). Women exhibiting increased psychological distress experienced the examination as significantly more unpleasant than patients who were well-informed (p-value < 0.001). Discussion This study aimed to investigate the extent of psychological distress in patients with abnormal Pap smears and the factors that influence this distress. We were able to demonstrate that nearly 60,0% of the patients already experience psychological distress during their initial visit to our special dysplasia consultation hour at the Department of Obstetrics and Gynecology (University of Wuerzburg). In 2020, Jentschke et al. conducted a survey concerning the mental state of over 2000 women, who had to attend follow-up appointments over an extended period due to abnormal Pap smears. For many women, the uncertain situation with prolonged waiting times between appointments caused significant distress. The proportion of psychologically distressed individuals was 70,0%, which aligns with the findings of our study [ 10 ]. This is a considerable percentage, taking into consideration that an abnormal Pap smear affects several million women annually in Germany. It underscores the importance of comprehensive education and providing informational materials. When considering the age of the affected women it is noteworthy that many women experience abnormal findings at a young age. In 2020, one-third of new cases of cervical carcinoma occurred in women under 44 years of age [ 11 ]. In the analysis of the collected questionnaire data, half of the patients with abnormal Pap smears were younger than 44 years old. As expected, the younger group of patients, especially those with concerns about fertility and sexuality, experiences greater distress. These results are consistent with the findings of Jentschke et al. in 2020, which indicated that abnormal Pap smears particularly lead to high distress and affect family planning for women with existing fertility desires. Regarding information acquisition according to age, both groups primarily obtained information from their gynecologist. However, the internet played a more important role as an information source for the younger group, which may lead to a higher risk of misinformation [ 12 ]. Based on the education distribution, it can be observed that patients with lower education levels generally experience higher distress. However, as seen above, the younger, better-educated group of women exhibited higher average psychological distress than the older patients. Overall, over 40% of patients reported feeling poorly informed. This is a substantial portion, considering that patients had already been informed about the abnormal findings by their gynecologist. Patients are further referred to the clinic and have the opportunity to gather additional information before their visit to our consultation hour. This raises two questions: Can a more comprehensive education potentially improve patients' knowledge and thereby reduce psychological distress? And is there a lack of necessary informational materials that patients can review by themselves at home? As mentioned in the introduction, despite the national HPV vaccination campaign and increased availability of information and education, many patients still find the provided information inadequate [ 12 ]. It should be acknowledged that variations in patient education by their respective physician can affect patient knowledge. When examining the information available on the internet, it becomes clear that most health insurance companies highlight key points about screening on their websites and brochures from the Joint Federal Committee (Gemeinsamer Bundesausschuss) are also available. The brochure from the Joint Federal Committee contains all the necessary information regarding early detection, basic information on cervical carcinoma, the procedure of examinations, and the significance of examination results. Additionally, it explains the pros and cons of early detection. These brochures are available for free download. A study conducted in the USA in 1993 demonstrated the effect of targeted information and education regarding abnormal Pap smears before a clinic visit. Patients in this study were given the choice of receiving informational materials before their appointment. Those who received the materials reported significantly less concern about the abnormal Pap smear and the risk of cancer in subsequent questionnaires compared to the cohort which did not receive the materials [ 13 ]. Another study conducted in 1994 provided evidence that patients who received informational brochures were significantly more likely to attend follow-up appointments after abnormal Pap smears compared to those who did not receive informational materials [ 14 ]. The desire for more information is evident, with over 50% of patients wishing for more information before their visit. Furthermore, since over 68% of patients primarily obtain information from their gynecologist, with the internet being the second most common source, it underscores the importance of the doctor-patient relationship. Taken together, we can summarize that patients who obtained information from the internet reported feeling less informed, had a greater desire for information before their visit, and experienced greater distress. These results, coupled with the fact that the gynecologist remains the primary source of information for patients, emphasizes how crucial adequate education and the provision of informational materials from treating doctors are. Conclusion This study shows the significant psychological distress faced by patients with abnormal Pap smears or cervical dysplasia. Factors which influence psychological stress include age, education and information acquisition. Age and education level emerged as defining factors in distress levels. Younger patients, especially those under 44 years, experience heightened distress due to concerns about fertility and future health. Patients with lower education levels tend to experience higher distress. The age and education related variations in information sources and preferences underline the importance of tailoring educational resources to different age groups. Furthermore, it is important to ensure the accuracy of online health information as it seems that numerous patients are not fully utilizing reliable informational resources. Thus, this study underlines the need for improved patient education and the dissemination of accurate information by health care providers to alleviate the psychological distress experienced by patients with abnormal Pap smears. Abbreviations AC Scherer-Quenzer: protocol development, manuscript writing/editing SL Herbert and J Findeis and JP Grunz: data analysis T Schlaiss: manuscript proofreading A Woeckel: supervision J Diessner: manuscript proofreading M Kiesel: protocol development, manuscript writing/editing Declarations Acknowledgments None Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Data availability: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors have no relevant financial or non-financial interests to disclose. Author contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Lina Gruber, Saskia-Laureen Herbert, Jelena Findeis and Jan-Peter Grunz. The first draft of the manuscript was written by Anne Cathrine Scherer-Quenzer and Matthias Kiesel. The manuscript proofreading was done by Tanja Schlaiss, Achim Woeckel and Joachim Diessner. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Certificate of non-objection number: 20210628 01 Consent to participate: Informed consent was obtained from all individual participants included in the study. 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Stewart DE, Buchegger PM, Lickrish GM, Sierra S (1994) The effect of educational brochures on follow-up compliance in women with abnormal Papanicolaou smears. Obstet Gynecol. doi: 10.1097/00006250-199404000-00016. Supplementary Files Appendix.docx Cite Share Download PDF Status: Published Journal Publication published 01 Aug, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted Reviewers agreed at journal 15 Apr, 2024 Reviewers invited by journal 09 Apr, 2024 Editor assigned by journal 29 Mar, 2024 First submitted to journal 28 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4185892","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":289379656,"identity":"c5429fd1-fe9f-4f91-b63a-f7fa12db6842","order_by":0,"name":"Anne Cathrine Scherer-Quenzer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvUlEQVRIiWNgGAWjYFAD9gZmIMlMihaeAyRrkUggUgvfjeRjD39U3GPgn/nG2JiHwVqOoBbJG2npBhJnihkkbucYJ/MwpBsT1GJwI8dMwrAtgYEBqOVwDsPhxAbCWvK/SST+S2CQv3kGrKWeCC05bBIHGxKADB7jZKCWBMJ+OfPMTLLhWAKD4Zm0YuM/BumGBG3hO578TPJHTQKD3PHDmyVnVFjLE7SF4QCEgnrBgLAGuJZRMApGwSgYBbgBAPHvOL6CX/crAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0001-9271-0311","institution":"Universitätsklinikum Würzburg Frauenklinik und Poliklinik: Universitatsklinikum Wurzburg Frauenklinik und Poliklinik","correspondingAuthor":true,"prefix":"","firstName":"Anne","middleName":"Cathrine","lastName":"Scherer-Quenzer","suffix":""},{"id":289379657,"identity":"b6ad35d8-1e0c-402d-9522-1ab0a18ba10c","order_by":1,"name":"Saskia Laureen Herbert","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Saskia","middleName":"Laureen","lastName":"Herbert","suffix":""},{"id":289379658,"identity":"5a3e7a28-0a98-45ec-935b-a48c234ac22d","order_by":2,"name":"Tanja Schlaiss","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Tanja","middleName":"","lastName":"Schlaiss","suffix":""},{"id":289379659,"identity":"43f36491-b6d0-4ec6-bfda-549059f849dd","order_by":3,"name":"Achim Wöckel","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Achim","middleName":"","lastName":"Wöckel","suffix":""},{"id":289379660,"identity":"a87152c3-1c1e-42e1-944c-4be0b69506bf","order_by":4,"name":"Joachim Diessner","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Joachim","middleName":"","lastName":"Diessner","suffix":""},{"id":289379661,"identity":"e9a4aa78-3d34-41ad-86dd-0111ca12a3b9","order_by":5,"name":"Jan-Peter Grunz","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Jan-Peter","middleName":"","lastName":"Grunz","suffix":""},{"id":289379662,"identity":"4d84cc2e-8b9e-4e01-b12e-8303f5b73eeb","order_by":6,"name":"Jelena Findeis","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Jelena","middleName":"","lastName":"Findeis","suffix":""},{"id":289379663,"identity":"ea460ae8-dc6b-4d66-bdd4-64cda447e8c4","order_by":7,"name":"Matthias Kiesel","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Matthias","middleName":"","lastName":"Kiesel","suffix":""}],"badges":[],"createdAt":"2024-03-29 05:55:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4185892/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4185892/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00404-024-07660-6","type":"published","date":"2024-08-01T15:56:58+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61793306,"identity":"c57ae781-7a40-4781-b2e4-e96b8f25cc1b","added_by":"auto","created_at":"2024-08-05 16:10:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":859946,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4185892/v1/fc5b3cb7-94b1-4dd2-955c-8ac3c42aab35.pdf"},{"id":54559161,"identity":"fc9e7fe5-a2cb-4668-9bb8-fe2f328bcea4","added_by":"auto","created_at":"2024-04-12 09:23:12","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17073,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-4185892/v1/bb2bd1f009d52db9dd3bd05c.docx"}],"financialInterests":"","formattedTitle":"Assessment of psychological distress in patients with cervical dysplasia according to age, education, information acquisition and information level","fulltext":[{"header":"What does this study adds to the clinical work","content":"\u003cp\u003eThis study highlights the prevalence of psychological distress among patients with cervical dysplasia and investigates the extent to which factors such as age, information acquisition, level of information, desire for more information and educational level have an influence on patients\u0026apos; psychological distress. These findings can help tailor patient education strategies and improve doctor-patient communication and overall quality of care for patients undergoing cervical screening and diagnosis.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eIn 2022 cancer was diagnosed in 19.98 million people worldwide [1]. It is well known that cancer diagnosis is associated with psychological distress [2]. The extent of psychological comorbidity in cancer patients was first scientifically investigated in the 1970s and 1980s. Since then, the scientific focus on this topic has increased [3]. A comparative study of oncology patients, chronically ill patients and healthy people showed that 20% of oncology patients described themselves as psychologically distressed, compared with 10.6% of healthy people and 14.8% of chronically ill people. The risk of subsequent mental disorders is particularly high in young long-term survivors [4].\u003c/p\u003e\n\u003cp\u003eOne type of cancer that particularly affects young women is cervical cancer. According to recent data, it is the 14th most common cancer and the 4th most common cancer in women worldwide [5]. In a study conducted in the USA in 2005, patients with an average age of 45 years who were being followed for 5-10 years after treatment for cervical cancer were asked about their diagnosis. The patients were healthy at the time of the survey and reported a good quality of life. However, 69% said they would have attended a support group if it had been offered at the time of diagnosis [6]. A study conducted in Germany in 2015 with 595 patients found that after being informed of an abnormal Pap smear, 68.8% of women reacted with anxiety and 26.3% reacted with panic. For 63.9% of patients, talking to their doctor was the most important source of information. But even after the discussion, 51.4% were still worried and only 24.4% were reassured [7]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe aim and interest of this study is, firstly, to investigate the psychological distress experienced by patients with abnormal Pap smears or dysplastic changes of the cervix. The second aim is to determine whether age, education and the way in which information is obtained have an influence on the psychological distress of patients, in order to optimise and support patient care, patient education and patient information in the future.\u003c/p\u003e\n\u003cp\u003eThe main questions, which are to be answered in this work, are the following:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDoes the age of patients with abnormal Pap smears have an effect on the psychological burden?\u003c/li\u003e\n \u003cli\u003eDoes information level and information acquisition have an effect on the psychological burden?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIs there a correlation between the psychological burden of patients with dysplasia or precancerous lesions of the cervix and their level of education?\u003c/li\u003e\n\u003c/ol\u003e\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"},{"header":"Methods","content":"\u003cp\u003eHuman Patient Data\u003c/p\u003e\u003cp\u003eThis retrospective study was registered with the Institutional Review Board (Ref. No. 20210628 01)\u003c/p\u003e\u003cp\u003eThe female patients were referred to the special dysplasia consultation hour at the Department of Obstetrics and Gynecology (University of Wuerzburg) by their respective gynecologists in case of abnormal Pap smears or HPV positivity for further diagnostics and treatment. During their initial visit, the patients were given the questionnaire found in the appendix. In addition, information was extracted from each patient’s medical report.\u0026nbsp;\u003c/p\u003e\u003cp\u003eThe questions are based on a validated questionnaire for assessing psychological distress in patients with cervical dysplasia (Cervical Dysplasia Distress Questionnaire = CDDQ), which was validated by Shinn et al. in a study involving 661 participants [8]. The CDDQ was supplemented with four questions addressing background information of the affected individual and the Distress Thermometer. The Distress Thermometer is a developed screening instrument from the National Comprehensive Cancer Network to measure psychosocial distress in oncologically ill patients. The thermometer allows patients to indicate their psychological burden on a numerical scale from 0 to 10. „0“ represents \"no burden\" and „10“ represents \"very burdened.\" Over the years, the thermometer has been validated through numerous studies [9].\u0026nbsp;\u003c/p\u003e\u003cp\u003eThe four additional questions related to the level of education, the subjective level of information, the desire for further information, the method of obtaining information about dysplasia, and the adequacy of prior information provided by the personal gynecologist. These four questions were chosen to specifically assess the patients' level of knowledge and then to discuss possible ways of optimising education and information in the future. Each patient could choose up to five answers.\u0026nbsp;\u003c/p\u003e\u003cp\u003ePap smears were interpreted by two experienced gynecological cytologists with more than 20 years of experience at the Department of Obstetrics and Gynecology (University of Wuerzburg). HPV testing was evaluated by polymerase chain reaction (PCR) amplification followed by genotyping at the Institute of Virology and Immunology (University of Wuerzburg). The genotypes were categorised as 'high risk' and 'low risk'.\u003c/p\u003e\u003cp\u003eStatistical analysis\u003c/p\u003e\u003cp\u003eAll variables were documented in an Excel file (Microsoft Office Excel 2013, Washington, USA). The data was analyzed using the statistical software SPSS (Version 24) from IBM (SPSS Inc., Chicago, IL. USA) and the following statistical test procedures:\u003c/p\u003e\u003cp\u003e- Descriptive Data Analysis\u003c/p\u003e\u003cp\u003e- Correlation analysis using Spearman's rank correlation coefficient (rho)\u003c/p\u003e\u003cp\u003e- Mann-Whitney U test\u003c/p\u003e\u003cp\u003e- Chi squared test\u003c/p\u003e\u003cp\u003e- Kruskal-Walis test\u003c/p\u003e\u003cp\u003ep-values of \u0026lt;0.05 were considered statistically significant.\u003c/p\u003e\u003cp\u003eUse of Large Language Models\u003c/p\u003e\u003cp\u003eChatGPT Version 4.0 (OpenAI Inc., San Francisco) was used for language quality check.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePatient cohort\u003c/h2\u003e \u003cp\u003eThe patient cohort consisted of a total of 364 female patients aged between 20 and 80 years, with a mean age of 43.3 years (SD\u0026thinsp;=\u0026thinsp;11.3). Of the Pap tests performed, Pap IVa-p was the most common (25.5%), followed by Pap IIID2 (21.4%) and IIp (21.2%). In addition, 70.3% of patients had a high-risk HPV subtype. Patients' overall psychological distress was assessed using the Distress Thermometer [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. For analysis, responses from 1 to 5 were grouped as \"not distressed\" and responses from 6 to 10 were grouped as \"distressed\". 56.9% of patients reported psychological distress. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003ePatient characteristics.\u003c/em\u003e SD\u0026thinsp;=\u0026thinsp;standard deviation. HPV high risk\u0026thinsp;=\u0026thinsp;16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, HPV low risk\u0026thinsp;=\u0026thinsp;40, 42, 43, 44, 54, 61, 72, 81, low distress level measured from 1 to 5 (according to Distress Thermometer), high distress level measured from 6 to 10 (according to Distress Thermometer)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD) or number (percentage)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge in years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43,3 (11,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePap IVa-p\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (25,5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePap IIID2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (21,4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePap IIp\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (21,2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOthers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116 (31,9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV high risk\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e256 (70,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV low risk\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (3,6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV negativ\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (8,8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo Data\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (17,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLow Distress Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157 (43,1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHigh Distress Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e207 (56,9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePsychological burden and information acquisition based on patients' age\u003c/h2\u003e \u003cp\u003eThe following results aim to illustrate how the patients' age influences their psychological burden and concerns. The cohort was divided into a group of younger and older women according to the mean age of the group of 43.3 years, which was used as a threshold between \"young\" and \"old\". While 57.3% of the younger women reported psychological distress, only 42.8% of the older patients reported the same (p-value\u0026thinsp;=\u0026thinsp;0.018). There was also a statistically significant difference in information seeking between younger and older patients (p-value\u0026thinsp;=\u0026thinsp;0.028). Among younger patients, 62.1% sought information from their gynecologist, compared to 74.8% of older patients. 27.2% of younger patients obtained information only from the internet, compared to 14.8% of older patients. Although most patients in both groups were generally informed by the attending gynecologist (67.6%), statistical analysis shows that younger women were significantly more likely than older women to obtain their information only from the internet, and older women were significantly more likely than younger women to obtain their information only from their gynecologist (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eInformation acquisition based on patients' age.\u003c/em\u003e Cross tabulation and Chi-square test. R\u0026thinsp;=\u0026thinsp;Standardized residual.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYoung (\u0026lt;\u0026thinsp;43.3\u0026nbsp;year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOld (\u0026ge;\u0026thinsp;43.3\u0026nbsp;year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo information acquisition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpected count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProportion within the group (in%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through gynecologist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e244\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpected count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e104,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e244,0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProportion within the group (in%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62,1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74,8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67,6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through internet (solely)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpected count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79,0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProportion within the group (in%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27,2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14,8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21,9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through family/friends\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpected count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7,0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProportion within the group (in%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePsychological burden based on information level\u003c/h2\u003e \u003cp\u003eQuestion 1 assessed the patients' level of information during their initial visit. Patients could select their answers on a numerical scale from 1 to 10. For the analysis of Question 1 responses from 1 to 5 were grouped as \"poorly informed\u0026ldquo;, and responses from 6 to 10 were grouped as \"well informed.\" The distribution of Question 1 revealed that 40.9% of the patients felt poorly informed. These patients also reported a higher psychological burden (based on the Distress Thermometer) compared to others (p-value\u0026thinsp;=\u0026thinsp;0.048).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePsychological burden based on information acquisition\u003c/h2\u003e \u003cp\u003eQuestion 2 examined where patients had obtained information prior to their first visit. The response options for question 2 were 'not at all', 'from the gynecologist', 'from the internet' or 'from friends/acquaintances'. Multiple answers were possible for this question. Overall, 67.6% of patients obtained information from their gynecologist. The second most common source was the internet with 21.9%. Only 8.6% of patients had received no information before their first visit (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). While 62.3% of the women who had obtained information from the internet were psychologically distressed, 57.8% of those who had been informed by their gynecologist reported the same (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Correlation analysis shows that the level of psychological distress does not depend on the way in which the information was obtained (p-value\u0026thinsp;=\u0026thinsp;0.971).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eCross table concerning information acquisition and measured distress level.\u003c/em\u003e Distress level measured from 1 to 10. Low distress level\u0026thinsp;=\u0026thinsp;1\u0026ndash;5. High distress level\u0026thinsp;=\u0026thinsp;6\u0026ndash;10.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDistress-Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo information acquisition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through gynecologist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e15,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e13,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e10,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through internet (solely)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e9,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e7,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e11,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e14,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e16,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e12,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through family/friends\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e16,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e11,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e11,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e27,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e16,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e5,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSum\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCorrelation between information acquisition, wish for information and information level\u003c/p\u003e \u003cp\u003eQuestion 3, which inquired about the desire for information before the visit, also had ten response options. For the analysis, responses from 1 to 5 were considered \"no further information desired,\" and responses from 6 to 10 were considered \"desire for more information. 53.7% of the patients wished for more information before their visit. Further analysis indicated that the desire for more information correlates with the form of information acquisition (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0,001). While 63,6% of the women who had obtained information from the internet wished for more information, only 47,0% of those informed by their gynecologist reported the same (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This is underscored by the fact that only 35,3% of the patients informed by their gynecologist felt poorly informed while 45,8% of those obtaining information by the internet reported the same (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCross table concerning information acquisition and wish for more information. With for more information measured from 1 to 10. No further information desired\u0026thinsp;=\u0026thinsp;1\u0026ndash;5. Desire for more information\u0026thinsp;=\u0026thinsp;6\u0026ndash;10.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWish for information\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo information acquisition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e13,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e6,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e13,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through gynecologist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e7,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e10,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e12,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e13,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through internet (solely)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e16,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e16,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e8,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e20,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through family/friends\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSum\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCross table concerning information acquisition and information level. Information level measured from 1 to 10. Poorly informed\u0026thinsp;=\u0026thinsp;1\u0026ndash;5, Well informed\u0026thinsp;=\u0026thinsp;6\u0026ndash;10.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInformation Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo information acquisition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e16,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e13,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e13,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e6,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e6,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through gynecologist\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e6,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e12,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e19,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e10,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e16,4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through internet (solely)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e9,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e12,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e15,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e9,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e7,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInformation through family/friends\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserved count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSum\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePsychological burden based on patients' education level\u003c/h2\u003e \u003cp\u003eQuestion 4 of the questionnaire aimed to assess the education level of the patients. The response options were \"no school degree,\" \u0026bdquo;vocational training\u0026ldquo; or \"general matriculation standard\u0026ldquo;. The analysis of question 4 showed that 5.1% of the patients had no school degree, 61.1% had vocational training, and 33.5% possessed a general matriculation standard. To investigate whether the type of information acquisition depended on the education level, the distribution of information acquisition was calculated separately for different education categories. Overall, patients with vocational training and a general matriculation standard tended to obtain information from more than one source. There was a negative significant correlation between patients' overall insecurity and their education level (p-value\u0026thinsp;=\u0026thinsp;0.038), indicating that patients with lower education levels were more insecure compared to well-educated patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePossible reasons for increased psychological distress and the effects of increased psychological distress\u003c/h2\u003e \u003cp\u003eYounger women have a greater concern compared to older women about not being able to have children anymore (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Regardless of age, women who wished for more information beforehand are significantly more concerned about developing cancer (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Women exhibiting increased psychological distress experienced the examination as significantly more unpleasant than patients who were well-informed (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to investigate the extent of psychological distress in patients with abnormal Pap smears and the factors that influence this distress.\u003c/p\u003e \u003cp\u003eWe were able to demonstrate that nearly 60,0% of the patients already experience psychological distress during their initial visit to our special dysplasia consultation hour at the Department of Obstetrics and Gynecology (University of Wuerzburg). In 2020, Jentschke et al. conducted a survey concerning the mental state of over 2000 women, who had to attend follow-up appointments over an extended period due to abnormal Pap smears. For many women, the uncertain situation with prolonged waiting times between appointments caused significant distress. The proportion of psychologically distressed individuals was 70,0%, which aligns with the findings of our study [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This is a considerable percentage, taking into consideration that an abnormal Pap smear affects several million women annually in Germany. It underscores the importance of comprehensive education and providing informational materials.\u003c/p\u003e \u003cp\u003eWhen considering the age of the affected women it is noteworthy that many women experience abnormal findings at a young age. In 2020, one-third of new cases of cervical carcinoma occurred in women under 44 years of age [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In the analysis of the collected questionnaire data, half of the patients with abnormal Pap smears were younger than 44 years old. As expected, the younger group of patients, especially those with concerns about fertility and sexuality, experiences greater distress. These results are consistent with the findings of Jentschke et al. in 2020, which indicated that abnormal Pap smears particularly lead to high distress and affect family planning for women with existing fertility desires.\u003c/p\u003e \u003cp\u003eRegarding information acquisition according to age, both groups primarily obtained information from their gynecologist. However, the internet played a more important role as an information source for the younger group, which may lead to a higher risk of misinformation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on the education distribution, it can be observed that patients with lower education levels generally experience higher distress. However, as seen above, the younger, better-educated group of women exhibited higher average psychological distress than the older patients.\u003c/p\u003e \u003cp\u003eOverall, over 40% of patients reported feeling poorly informed. This is a substantial portion, considering that patients had already been informed about the abnormal findings by their gynecologist. Patients are further referred to the clinic and have the opportunity to gather additional information before their visit to our consultation hour. This raises two questions: Can a more comprehensive education potentially improve patients' knowledge and thereby reduce psychological distress? And is there a lack of necessary informational materials that patients can review by themselves at home? As mentioned in the introduction, despite the national HPV vaccination campaign and increased availability of information and education, many patients still find the provided information inadequate [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt should be acknowledged that variations in patient education by their respective physician can affect patient knowledge. When examining the information available on the internet, it becomes clear that most health insurance companies highlight key points about screening on their websites and brochures from the Joint Federal Committee (Gemeinsamer Bundesausschuss) are also available. The brochure from the Joint Federal Committee contains all the necessary information regarding early detection, basic information on cervical carcinoma, the procedure of examinations, and the significance of examination results. Additionally, it explains the pros and cons of early detection. These brochures are available for free download. A study conducted in the USA in 1993 demonstrated the effect of targeted information and education regarding abnormal Pap smears before a clinic visit. Patients in this study were given the choice of receiving informational materials before their appointment. Those who received the materials reported significantly less concern about the abnormal Pap smear and the risk of cancer in subsequent questionnaires compared to the cohort which did not receive the materials [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Another study conducted in 1994 provided evidence that patients who received informational brochures were significantly more likely to attend follow-up appointments after abnormal Pap smears compared to those who did not receive informational materials [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The desire for more information is evident, with over 50% of patients wishing for more information before their visit. Furthermore, since over 68% of patients primarily obtain information from their gynecologist, with the internet being the second most common source, it underscores the importance of the doctor-patient relationship.\u003c/p\u003e \u003cp\u003eTaken together, we can summarize that patients who obtained information from the internet reported feeling less informed, had a greater desire for information before their visit, and experienced greater distress. These results, coupled with the fact that the gynecologist remains the primary source of information for patients, emphasizes how crucial adequate education and the provision of informational materials from treating doctors are.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study shows the significant psychological distress faced by patients with abnormal Pap smears or cervical dysplasia. Factors which influence psychological stress include age, education and information acquisition. Age and education level emerged as defining factors in distress levels. Younger patients, especially those under 44 years, experience heightened distress due to concerns about fertility and future health. Patients with lower education levels tend to experience higher distress. The age and education related variations in information sources and preferences underline the importance of tailoring educational resources to different age groups. Furthermore, it is important to ensure the accuracy of online health information as it seems that numerous patients are not fully utilizing reliable informational resources. Thus, this study underlines the need for improved patient education and the dissemination of accurate information by health care providers to alleviate the psychological distress experienced by patients with abnormal Pap smears.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAC Scherer-Quenzer: protocol development, manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eSL Herbert and J Findeis and JP Grunz: data analysis\u003c/p\u003e\n\u003cp\u003eT Schlaiss: manuscript proofreading\u003c/p\u003e\n\u003cp\u003eA Woeckel: supervision\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJ Diessner: manuscript proofreading\u003c/p\u003e\n\u003cp\u003eM Kiesel: protocol development, manuscript writing/editing\u003c/p\u003e"},{"header":"Declarations","content":"\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003eFunding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eData availability: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eAuthor contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Lina Gruber, Saskia-Laureen Herbert, Jelena Findeis and Jan-Peter Grunz. The first draft of the manuscript was written by Anne Cathrine Scherer-Quenzer and Matthias Kiesel. The manuscript proofreading was done by Tanja Schlaiss, Achim Woeckel and Joachim Diessner. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eCertificate of non-objection number: 20210628 01\u003c/p\u003e\n\u003cp\u003eConsent to participate: Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal Cancer Observatory: Cancer Today. https://gco.iarc.who.int/media/globocan/factsheets/cancers/39-all-cancers-fact-sheet.pdf. Accessed 21 March 2024\u003c/li\u003e\n\u003cli\u003eShankar A, Dracham C, Ghoshal S, Grover S (2016) Prevalence of depression and anxiety disorder in cancer patients: An institutional experience. Indian J Cancer. doi: 10.4103/0019-509X.200651.\u003c/li\u003e\n\u003cli\u003eMoorey S (2013) \u0026lsquo;I know they are distressed. What do I do now?\u0026apos;. Psychooncology. doi: 10.1002/pon.3297.\u003c/li\u003e\n\u003cli\u003eDewar EO, Ahn C, Eraj S, Mahal BA, Sanford NN (2021) Psychological distress and cognition among long-term survivors of adolescent and young adult cancer in the USA. J Cancer Surviv. doi: 10.1007/s11764-020-00969-6.\u003c/li\u003e\n\u003cli\u003eFowler JR, Maani EV, Dunton CJ, Gasalberti DP, Jack BW (2023) Cervical Cancer. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan\u0026ndash;. PMID: 28613745.\u003c/li\u003e\n\u003cli\u003eWenzel L, DeAlba I, Habbal R, Kluhsman BC, Fairclough D, Krebs LU, Anton-Culver H, Berkowitz R, Aziz N (2005) Quality of life in long-term cervical cancer survivors. Gynecol Oncol. doi: 10.1016/j.ygyno.2005.01.010.\u003c/li\u003e\n\u003cli\u003eThangarajah F, Einzmann T, Bergauer F, Patzke J, Schmidt-Petruschkat S, Theune M, Engel K, Puppe J, Richters L, Mallmann P, Kirn V (2016) Cervical screening program and the psychological impact of an abnormal Pap smear: a self-assessment questionnaire study of 590 patients. Arch Gynecol Obstet. doi: 10.1007/s00404-015-3821-z.\u003c/li\u003e\n\u003cli\u003eShinn E, Basen-Engquist K, Le T, Hansis-Diarte A, Bostic D, Martinez-Cross J, Santos A, Follen M (2004) Distress after an abnormal Pap smear result: scale development and psychometric validation. Prev Med. doi: 10.1016/j.ypmed.2004.02.004.\u003c/li\u003e\n\u003cli\u003eSnowden A, White CA, Christie Z, Murray E, McGowan C, Scott R (2011) The clinical utility of the distress thermometer: a review. Br J Nurs. doi: 10.12968/bjon.2011.20.4.220.\u003c/li\u003e\n\u003cli\u003eJentschke M, Lehmann R, Drews N, Hansel A, Schmitz M, Hillemanns P (2020) Psychological distress in cervical cancer screening: results from a German online survey. Arch Gynecol Obstet. doi: 10.1007/s00404-020-05661-9.\u003c/li\u003e\n\u003cli\u003eFerlay J, Colombet M, Soerjomataram I, Parkin DM, Pi\u0026ntilde;eros M, Znaor A, Bray F (2021) Cancer statistics for the year 2020: An overview. Int J Cancer. doi: 10.1002/ijc.33588.\u003c/li\u003e\n\u003cli\u003eMonsonego J, Cortes J, da Silva DP, Jorge AF, Klein P (2011) Psychological impact, support and information needs for women with an abnormal Pap smear: comparative results of a questionnaire in three European countries. BMC Womens Health. doi: 10.1186/1472-6874-11-18.\u003c/li\u003e\n\u003cli\u003eStewart DE, Lickrish GM, Sierra S, Parkin H (1993) The effect of educational brochures on knowledge and emotional distress in women with abnormal Papanicolaou smears. Obstet Gynecol. 81(2):280-2.\u003c/li\u003e\n\u003cli\u003eStewart DE, Buchegger PM, Lickrish GM, Sierra S (1994) The effect of educational brochures on follow-up compliance in women with abnormal Papanicolaou smears. Obstet Gynecol. doi: 10.1097/00006250-199404000-00016.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"psychological burden, abnormal Pap smear, risk factors","lastPublishedDoi":"10.21203/rs.3.rs-4185892/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4185892/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003e\u003c/em\u003eThis study aims to investigate the psychological distress experienced by patients with initial diagnosis of abnormal Pap smears or dysplastic changes of the cervix uteri. It is investigated whether patients' age, education, information level and approach to information acquisition have an impact on their psychological distress.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods: \u003c/strong\u003e\u003c/em\u003eA total of 364 female patients, aged 20-80 years, referred to the special dysplasia consultation hour at the Department of Obstetrics and Gynecology, Wuerzburg, completed a questionnaire containing validated items to assess information level, information acquisition, information needs and psychological distress, including a distress thermometer. Data from questionnaires and medical reports were used for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u003c/em\u003eThe study found that 56.9% of patients experienced psychological distress before their first visit. Patients under 44 years of age, especially those with concerns about fertility and sexuality, and those with lower levels of education showed higher levels of distress (p-value=0.018 and p-value=0.037). 40.9% of patients felt poorly informed and 53.7% of patients wanted more information before their visit. Correlational analysis showed that the method of obtaining information correlated with the desire for more information (p-value \u0026lt;0.001). Those who received information via the Internet felt less informed, wanted more information and experienced more anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003eThese findings highlight the need for improved patient education strategies and effective doctor-patient communication to address the knowledge gap and reduce patient distress. In addition, healthcare providers should ensure that patients have access to reliable online resources for accurate information.\u003c/p\u003e","manuscriptTitle":"Assessment of psychological distress in patients with cervical dysplasia according to age, education, information acquisition and information level","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-12 09:23:06","doi":"10.21203/rs.3.rs-4185892/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2024-04-15T09:48:51+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-09T16:57:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-29T06:59:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2024-03-29T01:55:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f58da807-0339-494c-88fb-e43a163c2279","owner":[],"postedDate":"April 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-05T15:59:32+00:00","versionOfRecord":{"articleIdentity":"rs-4185892","link":"https://doi.org/10.1007/s00404-024-07660-6","journal":{"identity":"archives-of-gynecology-and-obstetrics","isVorOnly":false,"title":"Archives of Gynecology and Obstetrics"},"publishedOn":"2024-08-01 15:56:58","publishedOnDateReadable":"August 1st, 2024"},"versionCreatedAt":"2024-04-12 09:23:06","video":"","vorDoi":"10.1007/s00404-024-07660-6","vorDoiUrl":"https://doi.org/10.1007/s00404-024-07660-6","workflowStages":[]},"version":"v1","identity":"rs-4185892","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4185892","identity":"rs-4185892","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}