Suppl. 1

Factors influencing intention of HPV vaccination

Questionnaire for commitment to and knowledge about HPV vaccination

I. Basic Information 1. What is your current age? ___________ 2. What is your major?________________ 3. Which college year are you in? □ 1. Freshman □ 2. Sophomore □ 5. The fifth year □ 6. The sixth year

□3. Junior □7. The seventh year

□4. Senior

4. What is your religion? □ 1. I don’t have one □ 2. Ordinary folk beliefs □ 3. Buddhist □ 4. Taoist □ 5. Catholic □ 6. Christian

□ 7. Other: _______

5. What is your current primary residential status? □ 1. With family □ 2. College dormitory

□ 4. Other：___________

□3. Off-campus rental

6. Did any family member (first, second and third-degree relatives such as grandmother, mother, aunt, or sister) ever suffer from gynecological cancer (cervical cancer, ovarian cancer, endometrial cancer, vaginal cancer, vulvar cancer) ? □ 1. Yes □ 2. No □ 3. Uncertain 7. What is the financial situation of your household? □ 1. Could cope with daily living expenses □ 2 . Barely cope □ 3. Unable to cope □ 4 . It depends, sometimes good and sometimes bad. 8. Please estimate your monthly living expenses? □ 1. Below 4,999 NTD □ 2. 5,000-9,999 NTD □ 4. 15,000-19,999 NTD □ 5. 20,000 NTD or above

□ 3. 10,000-14,999 NTD

9. What is your primary source of income? □ 1. Family support □ 2. Part-time job(s) □ 3. Mostly family support with some part-time job(s) □ 4. Mostly part-time job(s) with some family support 10. What is the highest level of education your father has completed (paternal education level)? □ 1. Illiterate □ 2. Elementary school □ 3. Junior high school □ 4. Senior high school/vocational school /college □ 5. Univeristy or above 11. What is the highest level of education your mother has completed (maternal education level)? □ 1. Illiterate □ 2. Elementary school □ 3. Junior high school □ 4. Senior high school/vocational school /college □ 5. Univeristy or above 12. Have you ever been diagnosed with any gynecologic disorder(s)?（for example：pelvic inflammatory disease, endometriosis, chocolate cyst of ovary, gynecologic cancer） □ 1. Yes □ 2. No

J Gynecol Oncol Vol. 25, No. 3:188-197

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Ping-Fen Kuo, et al.

cont.

II. Personal History and Experience 1. What is your current relationship status? □ 1. Single □ 2. Have a boy friend

2. Have you had sex? □ 1. Yes

□ 3. Have a girl friend

□4 . Married

□ 2. No (If the answer is “No”, please skip to Question 5)

3. How old were you when you first have sex?______________

4. How many people have you had sex with? □ One □ Two □ Three

□ Four

□ Five or above

5. Have you had a Pap smear test? □ 1. Yes □ 2. No

6. Have you heard about human papillomavirus (HPV)? □ 1. Yes □ 2. No

7. Have you heard about the HPV vaccine (i.e., cervical cancer vaccine)? □ 1. Yes □ 2. No

8. Has anyone recommended that you receive the HPV vaccine? □ 1. No □ 2. Yes (Please choose all that apply) □ 1. Medical staff □ 2. Teachers □ 3. Family □ 4. Boy/girlfriend □ 5. Peers □ 6. Other：___________________

S2 www.ejgo.org

http://dx.doi.org/10.3802/jgo.2014.25.3.188


cont.

III. Cervical Cancer/Cervical Cancer Vaccine Related Knowledge (Cervical cancer vaccine is the same as HPV vaccine) 1. Yes

2. No

3. Unknown

1.

Human papilloma virus, which can cause cervical cancer, is transmitted primarily through sexual contact.

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One can reduce the probability of getting cervical cancer by using condoms during sex.

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The number of sexual partners has no association with the probability of the occurrence of cervical cancer.

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As long as I am monogamous lifelong, I will not have cervical cancer.

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Once I have sex, I am at risk of getting cervical cancer.

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If one of my family members has cervical cancer, then I am also in the high risk group.

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Cervical cancer occurs most frequently in women after menopause.

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Once infected with human papilloma virus, one will certainly have cervical cancer.

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Cervical cancer vaccine is injected into the cervix.

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The preventive effect of cervical cancer vaccine is the same, regardless of age, as long as it is given before having sex for the first time.

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11.

One has to receive pap smear tests routinely, even though she has received cervical cancer vaccine.

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One should get cervical cancer vaccine if she has an abnormal pap smear result.

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Most of the cervical cancer vaccine in this country needs to be paid for out-of-pocket.

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The currently available cervical cancer vaccine in this country is recommended for women between 9 and 26 years of age.

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Only those who are infected with human papilloma virus need to receive cervical cancer vaccine.

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cont.

IV. Cervical Cancer Vaccine Effectiveness and Awareness Strongly agree

Agree

Disagree

Strongly disagree

1. I feel that getting the cervical cancer vaccine can help me avoid the occurrence of cervical cancer.

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2. If I have sex too soon, I would think that getting vaccinated against HPV would be important to me.

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3. I think that I might have been infected with human papilloma virus, and, as a result, it is very important for me to get the HPV vaccine.

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4. If I get the cervical cancer vaccine, I can reduce the probability of death from cervical cancer.

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5. If I have multiple sex partners, I would think that cervical cancer vaccine is important to me.

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6. If I have frequent sex, I would think that cervical cancer vaccine is important to me.

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7. I think it is very troublesome that the schedule for cervical cancer vaccine is to receive three doses within six months

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8. I am worried that the cervical cancer vaccine is not safe.

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9. I will not get the cervical cancer vaccine because it is too expensive (three doses for about NTD 12,000)

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10. I am very busy and have no time to get the cervical cancer vaccine.

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11. I feel that I really need to receive the cervical cancer vaccine; even though it is very expensive I will find a way to overcome the financial barrier.

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12. I feel that I really need to receive the cervical cancer vaccine; even though I am very busy, I will find time to get it.

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13. I feel that I really need to receive the cervical cancer vaccine; even though my family disagrees, I will still get it.

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cont.

Strongly agree

Agree

Disagree

Strongly disagree

14. I am afraid that the injections will hurt when I think about getting the cervical cancer vaccine.

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15. I am worried about the side effects (for example: pain and/or swelling at the injection site, fatigue, headaches) caused by the cervical cancer vaccine.

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16. I would be embarrassed to go to the outpatient gynecology clinic to get the cervical cancer vaccine.

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17. If medical staff advised me to receive cervical cancer vaccine, I would be willing to accept their advice.

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18. If family/friends advised me to receive cervical cancer vaccine, I would be willing to accept their advice.

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19. If my boyfriend/girlfriend (someone I am dating) suggested that I receive cervical cancer vaccine, I would be willing to accept their advice.

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20. If peers suggested that I receive cervical cancer vaccine, I would be willing to accept their advice.

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21. I would be willing to get vaccinated if peers wanted me to get the cervical cancer vaccine and we went together.

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22. If peers shared their experiences of getting the cervical cancer vaccine, it would affect my willingness to be vaccinated.

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23. I would be willing to accept the message if an advertisement suggested that I get the cervical cancer vaccine.

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24. The gynecological clinic is too far away from home; it is not convenient for me to go even if I am willing to get the vaccination.

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25. Media methods from which I have received cervical cancer vaccine related information

□ 1. Never seen any □ 2. On campus □ 3. Internet □ 4. TV □ 5. Newspapers □ 6. Flyer □ 7. Other: _________________


□ 5. I am not dating anyone currently

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cont.

V. Commitment and Behavior to Receive Cervical Cancer Vaccine and Vaccine History 1. Have you received the cervical cancer vaccine?

□ 1. Yes

□ 2. No

2. When did you receive the first dose?(choose one) □ 1. Elementary school □ 2. The summer between elementary and junior high school □ 3. Junior high school □ 4. The summer between junior and senior high school □ 5. Senior high school □ 6. The summer between senior high school and college □ 7. College

□ 8. Other: ________________________

Strongly agree

Agree

Disagree

Strongly disagree

3.

If I am infected with human papillomavirus (which may cause cervical cancer), I will get the cervical cancer vaccine immediately.

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I know the cervical cancer vaccine is good for me, and I don’t have any actual difficulties which prevent me from getting the vaccination

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I may receive the cervical cancer vaccine in the next six months.

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I will definitely receive the cervical cancer vaccine in the future.

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Taiwan's cervical cancer vaccine is now mostly self-financed (three injections for about NTD 12,000). Would you be willing to pay for it? □ 1. Willing □ 2. Reluctant. The price that I can afford is: _______________ NTD.

S6 www.ejgo.org
