Community Leader Interview - English

Form Approved

OMB No. 0920-XXXX

Expiration Date xx/xx/xxxx

Attachment 4

Information Collection Instrument- Community Leader Interview

Assessment on Public Knowledge, Attitudes, and Practices Relating to Ebola Virus Disease (EVD) Prevention and Medical Care in Guinea

Team Identification

Coordinator Name and ID:

Enumerator Name and ID:

Supervisor Name and ID:

Village/Neighbourhood & Identification

Prefecture/Conakry commune name: __________________________ Sub-prefecture name: __________________________ (Fill in with one of randomly sampled 24 prefectures or Conakry communes) Administrative Region of Prefecture/Commune: Conakry ___ Boké ___ Kindia ___ Mamou ___ Labe ___ Faranah ___ Kankan ___ Nzérékoré ___

Cluster #:____ ____ Village / Community __________________________

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-XXXX.

A- General Information

1. Enumerator Name :

2. Supervisor Name :

3. Coordinator Name :

4. What administrative region do you live in?

1. Conakry 2. Boké 3. Kindia 4. Mamou 5. Labe 6. Faranah 7. Kankan 8. N’Zérékoré

Check selected administrative region

5. What is your place of residence?

1. Kaloum

2. Dixinn

3. Matam

4. Matoto

5. Coyah

6. Ratoma

7. Boffa

8. Boke

9. Fria

10. Dinguiraye

11. Dubreka

12. Forecariah

13. Gaoual

14. Koubia

15. Koundara

16. Lélouma

17. Labé

18. Lola

19. Mali

20. Télimélé

21. Tougué

22. Macenta

23. Beyla

24. Dabola

25. Dalaba

26. Farana

27. Guékédou

28. Kankan

29. Kérouané

30. Kindia

31. Kissidou

32. Kouroussa

33. Mandiana

34. Mamou

35. Pita

36. Siguiri

37. Yomou

Check selected prefecture or commune of resident of the respondent

6. What is name of your sub-prefecture? _______________________________ (Write the name of the sub-prefecture)

7. What is name of your village or neighborhood? _______________________ (Write the name of the village or neighborhood)

8. What is your age? ____________ (years)

9. Gender:

   1. Male

   2. Female

10. Title in community: __________________________________________

11. How many people in this community believe that Ebola exists in Guinea (read responses)?

    1. Most believe

    2. Some believe

    3. Few believe

    4. None believe

    5. No response

For the next three questions, please say whether you strongly agree, disagree, agree, or strongly agree:

12. Ebola is no longer a threat in Guinea

    1. Strongly disagree

    2. Disagree

    3. Agree

    4. Strongly agree

13. Ebola is no longer a threat in my prefecture

    1. Strongly disagree

    2. Disagree

    3. Agree

    4. Strongly agree

14. Ebola is no longer a threat in my community/village/town

    1. Strongly disagree

    2. Disagree

    3. Agree

    4. Strongly agree

15. What are the preferred sources of information about Ebola in your community? (select all applicable; do not read)

    1. Radio

    2. Television

    3. Health worker

    4. Religious leader

    5. Village midwife

    6. Traditional healer

    7. Community educators

    8. Others

    9. Friends or family members

    10. Newspapers

    11. Internet

    12. Other: ________________________

16. Has anyone in your village received training on Ebola prevention or control?
    a. Yes
    b. No
    c. Not sure

17. Guinea continues to have a few cases of Ebola. What behaviors do you think are most important to target to help get to zero? (select all applicable; do not read)

1. People avoid touching/washing corpses

2. All burials are being handled by the Burial Teams

3. People seek prompt medical care when they are sick

4. Survivors’ use of condom when having sex

e. Involving community leaders to the BCC campaign

6. Strong control of the population movement from one place to another

7. Other ______________________________________________

8. I don’t know / not sure

9. No response

18. What can the Government of Guinea do as a final push to get to zero?

    1. Improvement in response time by Ambulance Teams

    2. Improvement in the safety of Ebola Treatment Facilities

    3. Restriction on public gatherings

    4. Closing of businesses/markets/restaurants by 6pm

_______________________________________________

5. I don’t know / not sure

6. No response

19. How many, if any, community meetings have been held about Ebola during which people have received education? __________________________

20. When people start feeling sick in this community, who do they usually first seek from?

1. Medical/health facility

2. Healthcare worker outside of facility

3. Traditional healers (including sowies and secret societies)

4. Spiritual healer

5. God/prayer

6. Pharmacy

7. Family/Parents Members

8. Drug Peddler

9. Dot not initially seek care

10. Other:___________________________

11. No response

21. Since the Ebola outbreak in Guinea, how would you describe the level of community-level engagement in this village/town to help contain the spread of the disease?

    1. Very high

    2. High

    3. Medium

    4. Low

    5. Very Low

22. Over the last 6 months, how many events have occurred in your village/town for Ebola education for the community? Events include town meetings, health screenings, and visits by community outreach workers door-to-door.

    1. 0

    2. 1-2

    3. 3-5

    4. 5 or more

    5. I don’t know / not sure

    6. No Response

23. Have you encountered health workers, interviewers, or other persons who are attempting to prevent or control Ebola?

1. Yes

2. No

3. I don’t know / not sure

4. No Response

24. If yes, what type of Ebola control workers have you encountered?

1. Health educators

2. Health workers trying to find cases or contacts of cases

3. Workers trying to help with safe burial

4. Others

25. Have you listened to their ideas or advice?

    1. Yes

    2. No

    3. I don’t know / not sure

    4. No Response

26. If no, why not?

    1. It is not necessary/not at risk

    2. It is not needed – I can handle family health problems without their help

    3. Other people told me they will take me or my family members away without my permission

    4. These teams/investigators could carry Ebola or other diseases

    5. I don’t trust government health workers

    6. Other

CHALLENGES AND RECOMMENDATIONS ABOUT ERADICATING EBOLA

27. What are the key challenges preventing the eradication of Ebola in your community?

________________________________________________________________________________________________________________________________________________________________________

28. What key recommendations would you make about eradicating Ebola in your community?

________________________________________________________________________________________________________________________________________________________________________

29. What questions do you have for us? (write in)

________________________________________________________________________________________________________________________________________________________________________

CLOSING SCRIPT

• Thank you for taking the time to discuss these important issues with me.

• Again, please be rest assured that your responses will be kept private.

• Your name or any other identifiers of your family or household will not be included in the report.

• The responses you have provided would help in improving social mobilization efforts aiming to help contain the Ebola epidemic in Guinea

• Once again, thank you very much.

If you have additional questions, please contact my team supervisor

Name:__________________________________________ Phone number: ______________________

You may also contact the Guinea Ethic and Scientific Review Committee regarding any concerns, injury, or risks posed to you as a result of your participation in the assessment.

Contact Person:____________________________ ____ __ Tel:____________________________

(Note: Contact persons will be the lead supervisor for each respective cluster to ensure that respondent is able to speak to person who knows their local language.)

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