A Survey for Women Living with Hepatitis C

Women living with hepatitis C are invited to participate in the following survey. The 45 questions below will take around 15 - 20 minutes to complete.

The survey contains seven sections, covering

1. Housing and Finance
2. Work
3. Lifestyle and Support
4. Health Management
5. Treatment
6. Carer Responsibilities
7. Getting Older

The information gathered by this survey will help to raise the consciousness of policy makers and the community to the social, economic and health impacts of Hepatitis C.

THE SURVEY IS COMPLETELY ANONYMOUS – no names are used. All questions are OPTIONAL. Some questions are tick box and some provide space for comments.

Paper copies of the survey are available from the Hepatitis Resource Centre. If you would like more information about the survey; or to make a confidential appointment contact: ACT Hepatitis Resource Centre 1300 301 383.

Thank you for considering this survey,
ACT Hepatitis Resource Centre.

 

Australian Women, Ageing and HCV Survey

Please tick appropriate answer and make additional comments in space provided

1. What is your Age?
Under 25 years 25 – 34 years 35 – 44 years 45 – 55 years 56 – 65 years 65+
2. Postcode:
3. Marital Status
Married Single Divorced Separated Widowed De-facto Other

Housing and Finance

4. Is your current accommodation:
Private Rental Own Home Owner Public Housing Tenant Homeless Other please specify

5. If you own your home will the mortgage be paid off by your retirement age?

Yes No Not Applicable


Please comment:

6. Do you have a financial safety net? e.g. ‘rainy day’ savings or investments

Yes No


Please describe:

7. Do you have superannuation?

Yes No


Please comment:

8. Will you have enough superannuation for retirement?

Yes No


Please comment:

9. Upon retirement, will you be reliant on a Government Aged pension?

Yes No


Please comment:

Work

10. What is your source of income? Please select those applicable
Full Time Employment
Part Time Employment
Casual Employment
Age/service/war/war widow pension
Income from savings and investments
Lump sum superannuation
Pension or annuity		 Income/pension from spouse/partner
Disability support pension
Other government pension or allowance
Income from a business
Don't know
Other sources
Financial support from family

11. What is your estimated annual income?

   

12. What is your occupation?

 

13. At what age do you plan to stop working/retire?

years

14. What will make it possible for you to stop working/retire?

Please comment

15. What impact does your Hepatitis C have on your ability to work?

None   Moderate   Unable to Work
1 2 3 4 5 6 7 8 9 10

Please comment:

16. Does having Hepatitis C affect your employment choices i.e. type of work, hours of employment etc?

Yes No Unable to Work


Please comment:

17. Have you disclosed your Hepatitis C status to anyone in your workplace?

Yes No Not Applicable


Please comment:

Lifestyle and Support

18. How would you rate the overall quality of your life now in the following areas?

  Excellent Good Fair Poor
Daily Routine
Work
Major physical activities
Health
Leisure and social life
Sex Life
Family life and friendships
Overall quality of life

Please comment:

19. How much, if at all does you health limit you physically in each of the following activities?

  A Lot A Little Not at All
Vigorous activities, eg lifting heavy objects, strenuous sports, etc?
Moderate activities eg moving a table, carrying groceries?
Housework
Shopping
Walking uphill or climbing stairs?
Walking one block?
Bending, lifting or stooping?
Eating, dressing, bathing or using the toilet?

Please comment:

20. Please choose the answer that best describes how you have been feeling during the last month? How much of the time, during the past month…

  All the Time Most of the Time Some of the Time Not at All
Have your physical or emotional problems limited your social activities (eg visiting friends or relatives)?
Have you been anxious?
Have you felt calm and peaceful?
Have you felt down and blue?
Have you been a happy person?
Have you felt very depressed?

Please comment:

21. What impact, if any, has Hepatitis C had on your relationship with others?

A) With your partner?

B) With your family?

C) With your friends?

22. During the past month has having Hepatitis C kept you from attending social or family functions?

Yes No


Please comment:

Health Management

23. In general would you say your health is:

Poor   Good   Excellent
1 2 3 4 5 6 7 8 9 10

24. In general would you say your health is:

Arthritis Foot Pain Pain behind or around the eyes
Cold Chills/Hot Flushes Gastro-intestinal Disturbances (tummy and Bowels) Pain in the region of the liver
Concentration Difficulties (brain fog) Headaches Rash on the legs
Depression Irregular Periods Sore Muscles
Dizziness Itchy Skin Swollen joints
Dry Eyes Memory Loss Watery Eyes
Dry Mouth Mood Swings No Symptoms
Dry or Flaky Skin Muscle Cramps Other
Fatigue Nose Bleeding  

Please comment:

25. Are any of these long term symptoms?

Yes No


Please comment:

26. How do you manage these symptoms?

Yes No


Please comment:

27. If you need help because of your Hepatitis C related symptoms, are you able to access assistance from?

friends family health workers community agencies other

Please comment:

28. Are there services that you would like to access but are unable to access/or source?

Please describe:

29. Do you know where to get information to assist in the management of your Hepatitis C?

Yes No


Please comment:

Treatment

30. Do you have regular monitoring checkups regarding your Hepatitis C?

Yes No


Please comment:

31. When was your last liver function blood test?
32. Do you currently have private health insurance?

Yes No

33. Do you feel your health care provider listens carefully to your health concerns?

Please comment:

34. Have you been informed of available treatments?

Yes No


Please comment:

35. Have you ever had conventional medical treatment for Hep C?

Yes No


Please comment:

36. If no, was this a health or lifestyle choice?

Yes No


Please comment:

37. If yes, and treatment was not successful would you undergo further treatment in the future?

Yes No Unsure


Please comment:

38. Have you ever used complementary medicine eg herbal supplements, massage, and/or acupuncture?

Yes No


Please comment:

39. Have you ever felt discriminated by members of the health profession because of your Hepatitis C status?

Yes No

If Yes by whom?
Doctor Dentist Pharmacist Nurse Other


Please comment:

Carer Responsibilities

40. Are you a carer?

Yes No

If Yes to who?
Parent Partner Child Other


Please comment:

41. If you are currently a carer, during the past month has care that you provided for someone else caused you to…

miss work feel more stressed than usual None of the above
cut down on social activities affected your finances Not applicable

 

42. Do you see yourself taking on a carer role in the future?

Yes No Unsure


Please comment if you have any concerns about taking on this role in the future:

Getting Older

43. When you think about getting older, what do you look forward to most?

Please comment:

44. What about getting older do you think of most often?

Please comment:

45. In thinking about growing old, what money factors concern you?

Please comment:

Is there anything more you would like to add to this survey?

I have read and understood the information provided and I agree to participate in this research.