Questionnaire

Please fill out the questionnaire below and tick it as appropriate. The information that is

presented in this survey will be treated with high confidentiality and will be used only for the

purposes of research.

 Choose the appropriate age bracket that you belong to (Tick as appropriate)

10 – 20 years [ ], 20 – 30 years [ ], 30 – 40 years [ ], 40 – 50 years [ ] and above 50

years of age [ ]

 What is your marital status?

Single [ ], Separated [ ], Married [ ], Divorced [ ], Widowed [ ]

 Levels of education

High school [ ], Diploma [ ], College [ ], University [ ], Masters [ ], PhD [ ],

others (specify)……………………..

 What is your religion?

Hindu [ ], Christian [ ], Muslim [ ], Others (specify) ……………………….

 The number of children you have given birth to………………………………………

 How far is your home from the nearest healthcare facility or hospital? (Tick as

appropriate)

1 kilometre [ ], 1-5 kilometres [ ], 5-10 kilometres [ ], more than 10 kilometres [ ]

 Does the healthcare facility near you have screening services for cervical cancer

…………………………………………………………………………………………?

 Does it have cancer screening equipment and is it

functional?..............................................................................................................................

................................................................................................................................................
 How much money do you pay in order to reach the nearest healthcare

facility?.........................................................................................................................

 Does the healthcare facility in question organise outreach cervical cancer screening

programs ………………………………………………………………………………...?

 If yes, how frequently do they organise for the outreach cervical cancer screening

programs………………………………………………………………………………….

 Do the healthcare professional answer all of your questions concerning cervical cancer

screening at any time – as per when you require clarification

Yes [ ] No [ ]

 Why do you think cancer screening is conducted? (Tick as appropriate)

a. To establish for cancer or early changes in cervix cancer [ ]

b. Check for infections that are transmitted via sex [ ]

c. I don’t know [ ]

 How would you judge your risk when it comes to developing cervical cancer?

a. Low risk of developing cancer [ ]

b. High risk of developing cancer [ ]

c. I don’t know [ ]

 How serious is cervical cancer as compared to other forms of cancer?

Less severe [ ] Similar to others [ ] More severe [ ] Don‘t know [ ]

 How frequently does a nurse or doctor commend for a woman to come for a cervical

cancer screening

test.............................................................................................................................?
 Do believe that healthcare professionals in the United Kingdom are skilled to conduct

screening for cervical cancer?

Yes [ ] No [ ] Don‘t know [ ]