APPENDIX A
Thai Women’s Cervical Cancer Study
First, we’d like to know some information about yourself.
- In whatcountry were you born? (Check one)
United States
Thailand
Laos
Other – Please specify: ______
- How well would you saythat you speak Thai? (Check one)
Fluently
Well
Fair
Poor
Not at all
- What languageare you most comfortable speaking? (Check one)
Only English
Mostly English
Both English and Thai
Mostly Thai
Only Thai
- How many years of education have you completed…
a. …in Thailand? ______years
b. …in the U.S.? ______years
- …in another country?______years
- What is your marital status? Are you… (Check one)
Legally married
Divorced/Separated
in a long term relationship (Never married)
Single (Never married)
Widowed
- How old are you? We know this can be a sensitive question, but it is very important to understanding your risk for cervical cancer. (Check one)
18-25
26-35
36-45
46-55
56-65
66-75
76 or older
Now we would like to ask some questions about Pap smears. A Pap smear is a routine test in which the doctor examines a woman’s womb and gently wipes the opening of the womb with a flat wooden stick and/or clean cotton Q-tip to check the health of the surface skin of the opening of the womb.
- Have you ever had a Pap smear examination? (Check one)
No Yes
a) When was your most recent Pap smear exam? ______/______
month year
b) Where did you go to get this Pap smear exam?
______
c) What was the main reason you had this Pap smear exam? (Check one)
Part of a pregnancy exam
Because of a specific gynecological problem
Follow-up to a past gynecological problem
Part of a routine physical (or pregnancy) exam
d) About how many times have you had a Pap smear exam as part of a routine exam in your lifetime?
______times
e) Did you find out the results of your Pap smear exam?
No
Yes
f) Have you ever had a Pap smear exam where the results were not normal?
No
Yes
- At what age do you think a woman should start having a Pap smear exam?
At about ______years old
- How often do you think a woman your age should get a Pap smear exam? (Check one)
Once every two years
Once a year
Twice a year
Only if she feels she has a problem
Only during the years she is having babies
- How comfortable would you feel talking about Pap smears with a family member or friend?
Very comfortable
Somewhat comfortable
Somewhat uncomfortable
Very uncomfortable
- Do you plan to get a Pap smear exam within the next year? (Check one)
No
Yes
I’m not sure
The next questions ask about your knowledge of cervical health and Pap smears.
- Which of these things do you think increases a woman’s chance of getting cancer of the cervix?
(Check all that apply)
Getting older in age
High fat diet
Low fiber diet
Obesity
Smoking
Using birth control pills
Beginning to have sex at an early age
Having many sexual partners
If husband has had many sexual partners
If exposed to cigarette smoke
Poor personal hygiene
Using an intrauterine device (IUD)
Other ______
- Please tell us if you agree or disagree with each statement about Pap smears.
a) I am embarrassed to get a Pap smear. Agree Disagree
b) I have family or friends who encourage me to get Pap smears. Agree Disagree
c) I am afraid to get a Pap smear. Agree Disagree
d) A woman does not need to get Pap smears after she reaches menopause. Agree Disagree
e) A woman does not need to get Pap smears after she stops having children. Agree Disagree
f) I am too old to need a Pap smear. Agree Disagree
g) I don’t believe results from Pap smears are always accurate. Agree Disagree
h) Only women who are sexually active should get Pap smears. Agree Disagree
i) I don’t think getting a Pap smear is important. Agree Disagree
j) I’m too busy to get a Pap smear. Agree Disagree
k) It is more important to take care of my family than myself. Agree Disagree
l) I don’t have time to get a Pap smear. Agree Disagree
m) I don’t know where to go to get a Pap smear. Agree Disagree
- Now, please tell us if you agree or disagree with each statement about cervical cancer.
a) If I have cervical cancer, I’d rather not know about it. Agree Disagree
b) Cancer of the cervix is so rare I don’t have to worry about it. Agree Disagree
c) Getting regular Pap smears can help prevent cervical cancer. Agree Disagree
d) If I get cervical cancer, it is because I am being punished by the spirits. Agree Disagree
e) If cancer of the cervix is found early, it can be cured. Agree Disagree
f) There is nothing I can do to prevent cervical cancer. Agree Disagree
g) If I get cervical cancer, it is because it is my fate. Agree Disagree
15. Which of these things describe how you feel about a pap smear? (Check all that apply)
I don’t like to think about pap smears
I don’t like to talk about pap smears
I don’t like to learn about pap smears
I would never talk to a doctor about a pap smear
I would never talk to a friend about a pap smear
I would never talk to a family member about a pap smear
Other ______
Now, we would like to know just a few more things about yourself.
16. Do you have health insurance? (Check one)
No Yes
a)What kind?(Check all that apply)
Private- Please specify: ______
Medi-Cal
Medicare
Other – Please specify: ______
17. Is there one particular clinic, health center, doctor’s office, or other medical place that you usually go to if you are sick or need advice about your health? (Check one)
No Yes
a) What type of place is it?
a doctor’s office
a hospital emergency room
a hospital outpatient clinic
a public health clinic
some other type of clinic
- What is your family’s total gross income for one month? We know this can also be a sensitive question, but we will keep this information completely confidential.(Check one)
less than $500 per month
$500 - $999 per month
$1,000 - $1,499 per month
$1,500 - $1,999 per month
$2,000 - $2,499 per month
$2,500 – 2,999 per month
$3,000 or more per month
- How many people live off of this income? ______people
Finally, we would like to talk to you again in three months, in order to see whether your knowledge has changed over time.
What is your telephone number to call you in 3 months? ( )______
In case your telephone number changes or we have difficulty reaching you, can you please give us the name and telephone number of a close relative who will know how to reach you?
Name Telephone number ( )