Form Approved
OMB No. 0920-1011
Exp. Date 3/31/2017
Appendix 2: KAP Survey
Crimean-Congo Hemorrhagic Fever
Knowledge, Attitudes, and Practice Survey
October 2014
Tbilisi, Georgia
Interviewer Name:
Interview Date:
Location (Village/Region/District):
GPS Coordinates:
Note: When administering the following survey, do not prompt any of the multiple choice answers; please have the participant state their own answers and circle all that apply.
To the interviewee: “Thank you for being willing to participate in this survey. I am going to start by asking you basic questions about yourself to get to know you better. Please note that your name and any other identifying information will not be collected during this survey. If you want to have the survey stopped at any time or for any reason, please tell us immediately.”
Date of birth (DD/MM/YYYY):
Sex:
Male
Female
Nationality:
Georgian
Azery
Armenian
Other:
Residence:
Rural
Urban
Household Size (including the participant): ____________
Highest education level:
Elementary
Secondary
Vocational
Higher
None
Other: ______________
Occupation:
Farmer
Herder
Field worker
Slaughterhouse worker
Healthcare worker
Veterinarian
Other
Do you own or take care of animals? Yes/No
If yes, what type?
Sheep
Goats
Cattle
Buffalo
Other ________________
In the last four months, have you performed the following activities:
Herding
No
Sheep
Goats
Cattle
Buffalo
Other
Animal birthing assistance
Have assisted in animal birthing but have used PPE (gloves, gowns, boots)
Have assisted in animal birthing but have not used PPE
Have not assisted in animal birthing
Slaughtering
No
Sheep
Slaughter sheep using PPE (gloves, gowns, boots)
Slaughter sheep without PPE (gloves, gowns, boots)
Goats
Slaughter goats using PPE (gloves, gowns, boots)
Slaughter goats without PPE (gloves, gowns, boots)
Cattle
Slaughter cattle using PPE (gloves, gowns, boots)
Slaughter cattle without PPE (gloves, gowns, boots)
Buffalo
Slaughter buffalo using PPE (gloves, gowns, boots)
Slaughter buffalo without PPE (gloves, gowns, boots)
Other
Slaughter animals using PPE (gloves, gowns, boots)
Slaughter animals without PPE (gloves, gowns, boots)
Butchering/handling raw meat
No
Sheep
Goats
Cattle
Buffalo
Other
Handled ticks with bare hands
No
Removed ticks from animal and threw is out
Removed ticks from animals and killed with bare hands
Removed ticks from yourself and threw it out
Removed ticks from yourself and killed with bare hands
Other ________________
Worked in a health care setting
No
Primary healthcare
Outpatient clinic
Hospital
Other
Drank unpasteurized milk
Yes
No
Gardening
Yes
No
Any other outdoor activity not previously asked:
None
Hiking
Camping
Hunting
Fishing
Picnicking outside
In the last four months, have you had a tick bite?
No
If yes, describe each situation:
Date of Tick Bite (MM/YYYY) |
Where? (village/region/district) |
Where? (body location) |
How much time did it take to get it removed after it was found? |
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Any travel or migration in the last four months?
No
If yes, describe:
Location (village/region/district) |
Reason |
Dates |
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Were you visited by the household educational campaign last month?
Yes
No
I don’t remember
Reminder: When administering the survey, do not prompt any of the multiple choice answers; please have the participant state their own answers and circle all that apply.
To the interviewee: “Now I am going to ask you questions regarding what you know about Crimean-Congo Hemorrhagic Fever and what you do to protect yourself.”
Have you ever heard about Crimean-Congo Hemorrhagic Fever, also known as CCHF?
Yes (proceed to question 2)
No (proceed to Attitudes section)
I don’t know
Other_________________
Where have you learned/heard about CCHF? (circle all that apply)
School
Media
TV
Radio
Newspaper/Magazines
Pamphlets
Where did you receive it? _________________
Posters
Where did you see it? _________________
Educational campaign last few months (July-October)
Training courses
Health care worker
Know someone who had CCHF
No
Yes, who?
Other____________________
What are ways in which a human can become infected? (circle all that apply)
Bite from a tick
Crushing a tick with bare hands
Contact with blood from infected animals
Contact with birthing tissues/fluids from infected animals
Eating infected meat
Contact with people sick from CCHF
Drinking unpasteurized milk
Other _____________________
What activities can put you at risk? (circle all that apply)
Working with livestock
Working in produce/vegetable/grain fields
Working in a rural, woody area
Slaughtering animals
Butchering meat
Working in a hospital
Being a abattoir/slaughterhouse worker
Working as a veterinarian
Other______________________
What are the signs and symptoms of CCHF? (circle all that apply)
Fever
Headache
Nausea/Vomiting
Diarrhea
Muscle pain
Weakness
Cough
Hematuria
Hematochezia/Melena
Hemoptysis
Other_________________
Do people frequently get bitten by ticks in your community?
Yes
No
I don’t know
Other_________________
Do you think ticks are a problem in your community?
Yes
No
I don’t know
Other_________________
Do you think there are more ticks this year than previously?
Yes
No
I don’t know
Other__________________
Do you think CCHF is a problem in your community?
Yes
No
I don’t know
Other_________________
Do you think CCHF is something you should be worried about?
Yes
No
I don’t know
Do you think you can protect yourself from CCHF?
Yes
If yes, how? _________________
No
I don’t know
Other_________________
Do you have any interaction with ticks during your job?
Yes
Please describe_________________
No
Other_________________
What method do you use to remove ticks off yourself?
Remove by hand
Remove with tweezers
Go to a hospital/health care center
Other_________________
What do you do to protect yourself from ticks/CCHF? (circle all that apply)
Protective clothing (i.e. long pants, socks, etc.)
How often? Always Sometimes Never
Treat your clothing with repellent
How often? Always Sometimes Never
Insect repellent
How often? Always Sometimes Never
Use pesticides in the environment
How often? Always Sometimes Never
Avoid woody/rural areas
How often? Always Sometimes Never
Other_________________
How often? Always Sometimes Never
What care would you seek, if any, if you experienced symptoms of CCHF (fever, muscle aches, nausea/vomiting, bloody stools or urine)? (circle all that apply)
Go to a hospital/healthcare facility
Primary healthcare
District
Regional
Tbilisi ID hospital
Any other clinic in Tbilisi:
Other:_________________
Stay at home
Try local pharmacy
Go to a local healer
Other_________________
The following questions refer to livestock; if the participant said NO to Question 8, skip to the question below and proceed to the Educational Campaign section.
How do you prevent ticks for your animals? (circle all that apply)
Use insecticides/acaricide
Spray
Pour on
Dipping the animals
Other_______________
Other________________
What method do you use to remove ticks off your livestock? (circle all that apply)
Remove by hand
Remove with tweezers
Go to a veterinarian
Other________________
Note: If the participant answered no to Question 12 and/or is not from the following regions, skip this section and proceed to the Recent Illness section.
Please check which one applies:
Samtskhe-Javakheti Region
Borjomi PHC (Chobiskhev, Dxirl)
Shida Kartli Region
Khashrui PHC (Ali, Brili, Vaka, Natsargora)
Shida Kartli Region
Kreli PHC, Gori PHC, Kaspi PHC
To the interviewee: “Now I am going to ask you questions about the educational campaign that was performed recently regarding Crimean-Congo Hemorrhagic Fever.”
Has your understanding of CCHF changed since the educational campaign?
Yes
How? _________________
No
Why not? _________________
I don’t know
Other_________________
Has your perception of CCHF changed since the educational campaign?
Yes
How? _________________
No
Why not?_________________
I don’t know
Other_________________
Has the way you protect yourself changed since the educational campaign?
Yes
How? _________________
No
Why not?_____________
I don’t know
Other_________________
Has the way you interact with ticks changed since the educational campaign?
Yes
How? _________________
No
Why not?
I don’t know
Other_________________
To the interviewee: “Now I am going to ask about any illnesses you might have had during in the past four months”
Have you ever been diagnosed with CCHF?
No
If yes, describe:
Date:
Where were you diagnosed:
What symptoms did you have?
Fever
Headache
Nausea/Vomiting
Diarrhea
Muscle pain
Weakness
Cough
Hematuria
Hematochezia/Melena
Hemoptysis
Other_________________
Have you had any illness in the last four months?
Yes
No (Finish questionnaire)
How many times have you been ill in the last four months? And what are those dates?
Date Started (DD/MM/YYYY) |
Date Ended (DD/MM/YYYY) |
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What signs or symptoms did you have during this illness?
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1st Illness |
2nd Illness |
3rd Illness |
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Signs/Symptoms |
Yes |
No |
Yes |
No |
Yes |
No |
Fever |
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Weakness/Lethargy |
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Headache |
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Body / muscle pain |
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Joint pain |
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Cough |
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Abdominal Pain |
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Vomiting |
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Diarrhea |
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Jaundice (yellowing of the skin) |
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Bruising |
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Petechiae (small dark purple or dark red dots that don’t go away when you push down on them) |
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Nose Bleeding |
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Bleeding from gums |
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Blood in vomitus |
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Blood in stool |
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Blood in urine |
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Coughing blood |
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Other, please list: |
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Did you seek any care for your symptoms?
If yes, where? _____________ And when?________________
If no, why not? ______________________
If you were hospitalized, how long were you in the hospital for? ___________
Did you receive any medications or treatments?
If yes, what? ________________
Received medication or treatment from:
Primary healthcare
District
Regional
Tbilisi ID hospital
Any other clinic in Tbilisi:
Local pharmacy
Local healer
Other
Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
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File Created | 2021-01-25 |