New Polish Questionnaire Measures the Hidden Anxiety of an Abnormal Smear Result

For most women, a letter or phone call reporting an abnormal cervical screening result is one of the most stressful pieces of medical news they will ever receive. The screening itself is routine, quick, and largely painless, but the words “abnormal cells detected” can trigger a cascade of fear, self-blame, and dread of cancer that persists for weeks or months. Now, a team of Polish researchers has validated the first Polish-language instrument designed specifically to measure that distress, opening the door to a more psychologically informed approach to cervical cancer prevention in the country. The study, published in PLOS ONE, offers both clinical reassurance and a sobering reminder of the emotional weight carried by routine diagnostics.

The instrument in question is the Cervical Dysplasia Distress Questionnaire, or CDDQ, a 23-item scale originally developed from the Psychosocial Effects of Abnormal Pap Smears Questionnaire, which was created in 1995 to capture the psychosocial toll of an abnormal smear. The CDDQ asks women to rate their distress across four subscales: tension and discomfort, embarrassment, sexual and reproductive consequences, and health consequences. Each item is scored on a four-point Likert scale from “not at all” to “very much so,” with higher average scores indicating greater distress. The questionnaire has already been validated in German, Serbian, and Turkish populations, but until now no culturally adapted Polish version existed, and no other valid instrument adequately captured the stress experienced by women attending colposcopy units in Poland.

To fill that gap, researchers led by Agata Szmigiel-Soja and Dominika Trojnarska at the University Hospital in Kraków and the Jagiellonian University Medical College conducted a rigorous five-stage adaptation following the Brislin model. The process involved independent forward translation by a linguist and a professional translator, reconciliation of the two versions, back-translation into English by an independent bilingual translator, comparison with the original items, and final evaluation by a panel of five experts, including two psychologists, one gynecologist, and two gynecologic oncologists. A cognitive debriefing with ten patients from the target population confirmed that the items were clear, culturally appropriate, and clinically relevant. Only after this meticulous linguistic and conceptual calibration did the team move to large-scale psychometric testing.

Between September 2024 and September 2025, the team recruited women referred to the colposcopy unit at the University Hospital in Kraków after receiving an abnormal screening result. Of 300 questionnaires distributed, 285 were included in the final analysis. The participants had a mean age of 38.69 years, and the sample skewed urban and highly educated: nearly 58 percent lived in cities with more than half a million inhabitants, and over 60 percent held higher education degrees. Participants completed the CDDQ along with a self-designed anxiety questionnaire administered before and after their colposcopy visit, and a subgroup of 95 women also completed the Short Form Health Survey, the SF-36, to enable assessment of how distress relates to broader quality of life.

The results revealed a distinctive psychological profile. The mean total CDDQ-PL score was 2.21 on the one-to-four scale, but the subscale averages told a more nuanced story. Fear of health consequences dominated, scoring 3.02, followed by sexual and reproductive concerns at 2.00. Tension and discomfort averaged 1.96, while embarrassment was lowest at 1.47. The researchers suggest that the pronounced floor effects on several embarrassment-related items may indicate that Polish women are relatively accustomed to gynecological examinations and experience less stigma in this context than populations studied previously, a pattern that echoes findings from the Turkish validation of the scale.

Anxiety measurements before and after the colposcopy visit added a striking dynamic dimension. Mean anxiety dropped significantly from 6.51 out of 10 before the appointment to 4.87 afterwards, suggesting that the consultation itself, with its explanations and reassurance from clinicians, acts as a powerful anxiolytic even when the underlying diagnostic uncertainty has not yet been fully resolved. This observation carries practical weight: the anticipatory dread that brings women to the clinic can be substantially alleviated by a single, well-structured visit, which strengthens the case for clear communication and psychological support as standard components of colposcopy care.

On the technical side, the psychometric results were strong. Cronbach’s alpha coefficients, the standard measure of internal consistency, ranged from 0.830 for the tension and discomfort subscale to 0.919 for health consequences, all comfortably above the accepted threshold of 0.70. Because the CDDQ has a predefined four-factor structure, the team used confirmatory factor analysis with a weighted least squares estimator suited to ordinal data rather than exploratory methods. The model fit met accepted criteria under the two-index strategy of Hu and Bentler, and all factor loadings were statistically significant, supporting the theoretical architecture of the scale in its new linguistic context. Item-total correlations were positive throughout, indicating that every item contributes meaningfully to its domain.

Convergent and construct validity also held up under scrutiny. Total CDDQ-PL scores showed moderate positive correlations with anxiety both before the visit, at r = 0.378, and after it, at r = 0.381, both highly statistically significant, with the health consequences subscale showing the strongest association. Higher distress scores correlated with poorer quality of life on the SF-36, particularly in the domains of emotional well-being, role limitations due to emotional problems, pain, and energy or fatigue, with the pain domain showing the strongest negative correlation at r = −0.379. Importantly, these correlations were moderate rather than excessive, suggesting the questionnaire captures disease-specific distress beyond what generic anxiety or quality-of-life measures can detect.

The clinical stakes of this work extend well beyond psychometrics. Previous research cited by the authors estimates that up to 60 percent of women who receive abnormal cervical cytology results do not proceed with the recommended follow-up examinations, with emotional distress identified as a key contributing factor. Anxiety at this stage can undermine adherence to the very diagnostic pathway designed to catch precancerous changes before they become life-threatening. A validated distress measure therefore gives clinicians a practical tool to identify women at heightened risk of disengagement, tailor counselling to their specific concerns, whether fear of cancer, worry about fertility, or unease about the procedure itself, and refer those who need it for psychological support. The CDDQ-PL could be administered after an abnormal result is communicated or before colposcopy, giving healthcare providers a structured window into each patient’s emotional state.

The authors are careful to spell out the limits of what the new tool can and cannot do. Test–retest reliability was not assessed, so the temporal stability of scores remains unconfirmed and must be established in future repeated-administration studies. The questionnaire has no established clinical cutoff scores and should not yet be used on its own to predict non-attendance or to determine referral decisions. The sample was recruited at a single tertiary center through convenience sampling and was predominantly urban, educated, and composed of women who actually attended their appointments, meaning those deterred by anxiety or access barriers may be underrepresented. The SF-36 analyses relied on only about a third of the sample and should be treated as preliminary. Larger, multicenter validations across diverse socioeconomic and geographic settings will be needed before the instrument can be fully embedded in screening pathways. Still, the study marks a significant step forward for cervical cancer prevention in Poland, where the national program is transitioning to primary HPV testing every five years and where screening participation remains uneven. By giving Polish clinicians a scientifically validated way to see, and measure, the fear behind an abnormal result, the CDDQ-PL may help ensure that fewer women fall through the cracks of one of medicine’s most successful preventive enterprises.

Subject of Research: Validation of the Polish version of the Cervical Dysplasia Distress Questionnaire to measure psychological distress in women with abnormal cervical cancer screening results

Article Title: Psychological distress among women with abnormal cervical cancer screening results in Poland: Validation of the Polish version of the Cervical Dysplasia Distress Questionnaire (CDDQ-PL)

Article References: Szmigiel-Soja, A., Kot, J., Sieńko-Hans, K., Gawron, I., Jach, R., Malinowska-Lipień, I., & Trojnarska, D. (2026). Psychological distress among women with abnormal cervical cancer screening results in Poland: Validation of the Polish version of the Cervical Dysplasia Distress Questionnaire (CDDQ-PL). PLOS One, 21(10), e0360240. https://doi.org/10.1371/journal.pone.0360240

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0360240

Keywords: cervical cancer screening, psychological distress, CDDQ-PL, questionnaire validation, colposcopy, anxiety, quality of life, PLOS ONE, Poland, HPV testing, psychometrics, women's health