Head and Neck Cancer Awareness Survey for Non Doctors (A public health initiative by ICON Trust)

Demographics

Age (as on 31st July, 2009): * Respondents should be between the ages 15-65 both inclusive

Gender: *

Location of Residence: *

Educational Qualification: *

Gross Personal Income (monthly): *

Questionnaire

Do you know someone who is a heavy smoker (smokes more than twenty cigarettes a day) or chews tobacco (more than 5 packets per day) ? *

Do you know someone who consumes more than 3 alcoholic drinks per day? *

Are you familiar with the term head and neck cancer? *

Do you know anyone who has been diagnosed with head and neck cancer? *

Please estimate the number of people in India who develop head and neck cancer every year? * For reference: current Indian population is more than 1.2 billion (1.200,000,000)

Please indicate all statements that you think are TRUE about head and neck cancer: *

Head and neck cancer can be hereditary
Certain lifestyle factors may increase the likelihood of developing head and neck cancer (eg smoking, chewing tobacco and/or drinking alcohol)
Head and neck cancer can just happen without any risk factors
Promiscuous sexual habits can raise the probability of getting head and neck cancer (e.g. multiple sexual partners, oral sex).

What percent of patients with head and neck cancer do you think will live for 5 years or more after their first diagnosis? *

From the following potential symptoms / consequences of head and neck cancer, you are required to pick which of them you feel would cause the most distress to someone diagnosed with the condition.

PLEASE NOTE: For the following 6 questions please ensure that you assign a unique value on the scale of 1 to 6 to each different question (i.e. the same rating on the scale should not be given to more than one potential symptom / consequence)

Difficulty eating and swallowing * Please remember to rank a UNIQUE value from 1 to 6 in order of how distressing you feel the following would be for the person diagnosed with head and neck cancer

	1	2	3	4	5	6
Most Distressing							Least Distressing

Difficulty speaking or loss of speech * Please remember to rank a UNIQUE value from 1 to 6 in order of how distressing you feel the following would be for the person diagnosed with head and neck cancer

	1	2	3	4	5	6
Most Distressing							Least Distressing

Formation of visible ulcers and swelling * Please remember to rank a UNIQUE value from 1 to 6 in order of how distressing you feel the following would be for the person diagnosed with head and neck cancer

	1	2	3	4	5	6
Most Distressing							Least Distressing

Bleeding in the mouth * Please remember to rank a UNIQUE value from 1 to 6 in order of how distressing you feel the following would be for the person diagnosed with head and neck cancer

	1	2	3	4	5	6
Most Distressing							Least Distressing

Consequences of surgery (e.g. speech problems, visible scarring, loss of pharynx, larynx, tracheotomy, disfigurement, need for feeding tube) * Please remember to rank a UNIQUE value from 1 to 6 in order of how distressing you feel the following would be for the person diagnosed with head and neck cancer

	1	2	3	4	5	6
Most Distressing							Least Distressing

Consequences of chemotherapy or radiotherapy (e.g. inflammation and ulceration of mucous membranes (mucositis), loss of saliva, feeding tube) * Please remember to rank a UNIQUE value from 1 to 6 in order of how distressing you feel the following would be for the person diagnosed with head and neck cancer

	1	2	3	4	5	6
Most Distressing							Least Distressing

If you or your relative is suspected to have cancer, what will you do? *

Why do you think people ignore or hide the problem, if they suspect/ have cancer? * Please choose all that you think apply.

Fear of society
Since cancer is always fatal
Since its treatment is painful/ has too many side effects
Fear of losing job

Do you think tobacco is harmful to human health? *

Would you support a total ban on tobacco products? *