| General information | ||
| 1 | Age at last birthday: | o ………… Years |
| 2 | Education level: | o No formal education o Primary school o Preparatory school o Secondary school o University or equivalent |
| 3 | Husband’s education: | o No formal education o Primary school o Preparatory school o Secondary school o University or equivalent |
| 4 | Marital status: | o Never married o Married o Divorced o Widowed |
| Duration of marriage (years): …………………………………… | ||
| 5 | Employment status: | o Employed o Unemployed |
| 6 | Parity “Number of children that you have given birth to”: | o No children o 1 o 2 o 3 o ≥4 |
| 7 | Number of miscarriages or voluntary terminations of pregnancy: | o 0 o 1 o 2 o ≥3 |
| 8 | Did you have any gynecological problems in the past? | o Yes o No |
| If yes, please specify …………………………………………….. | ||
| 9 | Have you or any other female family member ever diagnosed with cervical cancer? | o Yes o No |
| 10 | Have you ever heard about the Pap smear test? | o Yes o No |
| 11 | Where did you hear about the Pap smear test for the first time? | o Relatives, friends o Gynaecologist o Mass media (newspaper, internet, television) o Family physician o Nurse o Other, Please specify: ______ |
| 12 | Do you know about the cervical cancer? | o Yes o No |
| 13 | What do you think are the risk factors that can lead to cervical cancer? | o Sexually transmitted disease o Smoking o Early age of marriage, o <18 years o Marriage to man with other women o Diet |
| 14 | Is it possible to detect cervical cancer with the Pap smear test before symptoms appear? | o Yes o No |
| 15 | Is early detection of cervical cancer good for treatment outcome? | o Yes o No |
| 16 | Is it to possible to cure cervical cancer? | o Yes o No |
| 17 | Is there a vaccine to protect you from cervical cancer? | o Yes o No |
| If yes, name the vaccine ……………………………………………….. | ||
| 18 | Have you ever had a Pap smear test done? | o Yes o No |
| 19 | If you were told that a Pap smear test is simple, painless and good for early detection of cervical cancer, would you like to have one? | o Yes o No |
| 20 | If No, explain why you do not want to get a Pap Smear test done. ……………………………………………………………………………………… | |
| 21 | If yes, Where would you prefer to have this test done? | o Well women clinic in the primary health care center o Gynecology clinic in general hospital o Private clinic o No preference |