Household Member Interview - English

Form Approved

OMB No. 0920-XXXX

Expiration Date xx/xx/xxxx

Attachment 6

Information Collection Instrument- Household Member Interview

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

A- General Information

1. Enumerator Name :

2. Supervisor Name :

3. Coordinator Name :

4. What is your 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. 

    Public reporting burden of this collection of information is estimated to average 1 hour 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.

    
    
    

    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 residence 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 range?

1. 14-19 years

2. 20-35 years

3. 35 or older

Check before the age range

9. What is your sex?

1. Male 2. Female

Response is mandatory

10. What is your marital status?

1. Single

2. Married

3. Divorced

4. Widowed

Response is mandatory

11. What is your occupation?

1. Homemaker 2. Merchant 3. Student 4. Farmer 5. Laborer

6. Official 7. Unemployed 8. Other

Check the occupation of the respondent

12. How many children are living in your household?

1. None 2. 1-2 children 3. 3-6 children 4. 6 or more children

Check the correct range of the number of children living in the respondent’s household

B- SOURCES OF HEALTH INFORMATION

Check before the selected responses

13. Have you heard of Ebola before (prior to this interview)?

1. Yes 2. No 3. I don’t know/not sure 4. No response

14. What are the best sources of information about Ebola?

1. Radio FM

2. Television

3. Health worker

4. Red Cross worker

5. Village midwife

6. Traditional healer

7. Community educators

8. Friends or family members

9. Newspapers

10. Internet

11. Other(s): _______________________ (please specify)

Check before any sources of information that the respondent refers to

C- RISK PERCEPTION

Check before the appropriate response(s)

15. What level of risk do you think you have in getting Ebola in the next 6 months?

1. No risk –-> GO TO Q 17

2. Low risk

3. High risk

4. I don’t know / not sure

5. No Response

Choose only one answer

16. Why do you believe that you are at risk? (select all applicable choices; DO NOT read)

1. I have been experiencing signs and symptoms of Ebola since ______ day(s) ago

(If respondent reports any signs and symptoms in last 6 months: stop the interview, recommend that the person goes to the nearest health facility, provide the Ebola hotline phone number, record the address)

2. Someone in my family/household/dwelling has/had Ebola in the past ______ days

(if respondent reports Ebola in family or household member in last 60 days: stop the interview, finding out if the person is still in the dwelling, recommend that the person goes to the nearest health facility, provide the Ebola hotline phone number, record the address)

3. I am a health care professional who provides healthcare

4. I live in the same household with a health care professional who provides healthcare

5. I eat or touch bushmeat

6. Ebola is everywhere

7. I washed/touched the dead body of someone suspected/confirmed to have had Ebola

8. I have attended a burial/funeral ceremony of someone suspected/confirmed to have had Ebola

9. I may get Ebola from mosquito bites

10. I may get Ebola through the air

11. I have unprotected sex with someone who has survived Ebola

12. I don’t know / not sure

13. Others_________________________________________________(please specify)

14. No Response 18

Select all that apply (maximum of 5 responses)

Answer is mandatory

17. Why do you believe that you are NOT at risk? (select all applicable choices; DO NOT read)

1. I do not hunt or touch bush meat or bats

2. I am not a health care or medical professional

3. I am a clean person / Ebola only affects unclean people

4. I don’t live in an area where there is high risk of Ebola

5. God is protecting me from Ebola

6. I have traditional powers that protect me from Ebola

7. I do not participate in burial ceremonies that involve the handling (touching/washing) of the dead body

8. I avoid all funerals and burials

9. I avoid unprotected contact with bodily fluids

10. I wash my hands regularly with soap or other disinfectants

11. I do not have unprotected sex with someone who has survived Ebola

12. Others__________________________________________________(Please specify)

13. I don’t know / not sure

14. No Response

Select all that apply

D- KNOWLEDGE / ATTITUDES

(Do not read. Check all answers that apply for the respondent)

18. What causes Ebola?

1. Ebola Virus

2. Wild Animals (Bats / Monkeys / Chimpanzees / Other wild animals)

3. Sent by politicians

4. Sent by the whites (foreigners) (researchers, laboratories)

5. God or higher power

6. Curse, Witchcraft, Evildoing / Sin

7. Others _________________________________________________(Please specify)

8. I don’t know/ not sure

9. Declines to respond

Select all that apply, do not read

19. How does a person get Ebola?

1. By air (Ebola can be transmitted by air)

2. Contact with (preparing, eating, touching) bush meat (bats, chimpanzees, monkeys, rodents)

3. Eating fruits that have been bitten by animals (bats, chimpanzees, monkeys, rodents)

4. Contact with biological fluids (blood, saliva, breast milk, sweat, sperm, urine, feces) of an infected person

5. Physical contact with sick patients

6. God’s will

7. Witchcraft

8. Participating in burial ceremonies that involve the handling (touching/washing) of the dead body

9. Going to the hospital / health facility

10. Others _____________________________________________(please specify)

11. I don’t know / not sure

12. Declines to respond

Select all that apply; do not read

20. Can I prevent myself from getting Ebola by avoiding contact with blood and body fluids (blood, saliva, breast milk, semen, sweat, stool, urine, vaginal fluids, and runny nose) from an infected person?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

21. Can I prevent myself from getting Ebola by bathing with salt and hot water?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

22. Can I prevent myself from getting Ebola by avoiding mosquito bites?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

23. Can I prevent myself from getting Ebola by not touching anyone else?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

24. Can I prevent myself from getting Ebola by avoiding funeral or burial rituals that require handling the body of someone who has died from Ebola?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

25. What are some of the signs and symptoms of someone infected with Ebola?

1. Any Fever (temperature above 38.5 °C)

2. Sudden onset of high fever

3. Severe headache

4. Weakness

5. Vomiting (sometimes with blood)

6. Diarrhea (sometimes with blood)

7. Bleeding (internal or external)

8. Others___________________________________________(please specify)

9. I don’t know / not sure

10. Declines to respond

Select all applicable choices; DO NOT read

26. Is it possible to survive and recover from Ebola?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

27. If a person has Ebola he/she has a higher chance of survival if he/she goes immediately to a Health Facility?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

28. If a person with Ebola goes immediately to a Health Facility he/she will reduce the chance of spreading it to family/people living with them?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

29. Have you heard of people that have survived Ebola?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

30. Once a person is certified as Ebola-free can they continue to spread Ebola to others through casual contact?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

31. Once a person is certified cured of Ebola, are they unlikely to get Ebola again?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

32. What are some safe ways to help care for a family member suspected of having Ebola while waiting for help to arrive?

1. Isolate the person from others

2. Use a single caregiver

3. Do not touch the person or their body fluids

4. Do not touch things the person has touched (e.g., soiled clothes or bed sheets)

5. Use protective barriers such as gloves

6. Frequently wash hands

7. Provide sick person with food, water, and other fluids

8. Other______________________________________(please specify)

9. I don’t know / not sure

10. Declines to respond

Select all applicable choices; DO NOT read

E- INFORMATION CHANNELS & SOURCES

33. Through what means/ways did you hear about Ebola?

1. Radio

2. Television

3. Community meeting

4. Internet

5. Ministry of Health

6. Newspaper

7. Church, Mosque, other religious venues

8. Others_____________________________________________(please specify)

9. I don’t know / not sure

10. Declines to respond

Select all applicable choices

34. Through what ways would you prefer to get information on Ebola?

1. Radio

2. Television

3. Community meeting

4. Internet

5. Ministry of Health

6. Newspaper

7. Church, Mosque, other religious venues

8. Others_____________________________________________(please specify)

9. I don’t know / not sure

10. Declines to respond

Select all applicable choices

35. Do you need more information on Ebola?

1. Yes 2. No  Q37 3. I don’t know / not sure 4. Declines to respond

36. What area(s) do you need additional information on?

1. Cause / origin of the disease

2. Signs and symptoms of the disease

3. Ways to prevent the disease

4. Survivors of Ebola

5. How to protect others in the house if a household member is suspected of Ebola

6. Others_____________________________________________(please specify)

7. I don’t know / not sure

8. Declines to respond

Select all applicable choices; DO NOT read

37. Do you know the number to call to report a suspected Ebola case or ask questions about Ebola?

1. Yes 2. No41 3. Not sure41 4. Declines to respond 41

38. Have you ever called the Call Center?

1. Yes 2. No41 3. I don’t know / not sure41 4. Declines to respond41

39. What was the reason for calling the Call Center?

1. Get health information on Ebola

2. Report a death

3. Report a suspected case

4. Want to know if the number is working

5. Other __________________________________________(please specify)

6. I don’t known/ not sure

7. Declines to respond

Select all applicable choices; DO NOT read

40. Did you get immediate response when you called the 115 Call Center?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

F- BEHAVIOUR

Choose the single best response

41. Since you heard of Ebola, have you taken any action to avoid being infected?

1. Yes 2. No 43 3. I don’t know / not sure 43 4. Declines to respond43

42. In what ways have you changed your behavior or taken actions to avoid being infected?

1. I wash my hands with soap and water often

2. I try to avoid crowded places

3. I drink a lot of water / juice

4. I wear gloves (if so ask, how many times you change the gloves daily:_________)

5. I drink traditional herbs (for example, gbangban)

6. I avoid physical contact with people I suspect may have Ebola

7. I use a condom when having sex with someone who has survived Ebola

8. Others_______________________________________________(please specify)

9. I don’t know / not sure

10. Declines to respond

Select all applicable choices; DO NOT read

43. If you had a high fever, would you go to a health facility?

1. Yes 45 2. No 44 3. I don’t know / not sure 45 4. Declines to respond45

44. If NO – Why Not?

1. I have no money / can’t afford to pay

2. I believe the hospital/health facility is contaminated with Ebola

3. People will think I have Ebola

4. I prefer to go to a nearby pharmacy instead

5. I prefer to go to a traditional/spiritual healer

6. Other__________________ (please specify)

7. I don’t know / not sure

8. No Response

Select all applicable choices; DO NOT read

45. Would you go to the hospital or health facility if you suspect you have Ebola?

1. Yes Q47 2. No  Q46 3. I don’t know / not sure Q47 4. Declines to respond Q47

46. If NO – Why not?

1. I have no money / can’t afford to pay

2. I believe the hospital is contaminated with Ebola

3. People will think I have Ebola

4. I prefer to go to a nearby pharmacy instead

5. I prefer to go to a traditional/spiritual healer

6. Other__________________ (please specify)

7. I don’t know / not sure

8. Declines to respond

Select all applicable choices; DO NOT read

47. What would you do if you suspect someone in your family has Ebola
    
    
    

1. Nothing Q49

2. Help care for the person at home  Q49

3. Check their temperature by touching their body Q49

4. Avoid all physical contact and bodily fluids of that person Q44

5. Call the hospital/ health facility / Ebola phone line Q49

6. Take the person to the hospital Q49

7. Hide them Q48

8. Others_____________________________________(please specify) Q49

9. I don’t know / not sure Q49

10. Declines to respond Q49

Select all applicable choices; DO NOT read

48. Why would you hide a family member suspected of Ebola?

1. I can provide better care for the family member at home

2. The hospital/health facility cannot help the family member

3. I prefer to take the family member to a traditional healer

4. I prefer to take the family member to a spiritual healer

5. I prefer to take the family member to a local pharmacy

6. They will quarantine our household for 21 days (not allowed to leave house)

7. Neighbors will no longer accept us in the community

8. Others____________________________________(please specify)

9. I don’t know / not sure

10. Declines to respond

Select all applicable choices; DO NOT read

49. While waiting for help, how would you care for a family member suspected of having Ebola?

1. Isolate the person from others

2. Use a single caregiver

3. Do not touch the person or their body fluids

4. Do not touch things the person has touched (e.g soiled clothes)

5. Use protective barriers such as gloves

6. Frequently wash hands

7. Provide sick person with food and water

8. Provide Oral Rehydration Salt (ORS) – “WataMerecin”

9. Other______________________________________(please specify)

10. I don’t know / not sure

11. Declines to respond

Select all applicable choices; DO NOT read choices

50. If a family member became sick and died tomorrow from Ebola in your home, what would you do?

1. Call 115

2. Avoid touching the body

3. Avoid touching anything that has come in contact with the person who died or their body fluids

4. Restrict access to the house (do not allow others to enter the house)

5. Allow burial teams to carry out safe medical burial for the family member

6. Touch or wash the body

7. Plan and conduct a traditional funeral/burial

8. Allow people to come to the house and pay their respect

9. Pray for the family member

10. Clean and sanitize the home myself

11. Allow health professionals to clean and sanitize the home

12. Cooperate with local health teams in their contact tracing efforts

13. Follow directions if they quarantine the house

Select all applicable choices; DO NOT read

51. If a family member became sick and died tomorrow, would you touch or wash the dead body?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

52. If a family member died of Ebola, would you touch or wash the dead body?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

53. If a family member became sick and died tomorrow, would you wait for the burial team to bury the body?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

54. If a family member suspected of having Ebola died, would you wait for the burial team to bury the body?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

55. Do you believe that traditional healers can treat Ebola successfully?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

56. Do you believe that spiritual healers can treat Ebola successfully?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

57. What happens if someone suspected of having Ebola goes to the hospital / health facility? (select all applicable choices; DO NOT read)

1. They won’t be able to do anything for him/her and may die there

2. They will take care of him/her (rehydrate, give medicines/food, monitor status)

3. They will definitely cure the person from Ebola

4. They will find a way to kill the patient so that he/she doesn’t spread Ebola to others

5. They will be turned away

6. Others ____________________________________________(please specify)

7. I don’t know / not sure

8. Declines to respond

Select all applicable choices; DO NOT read

58. In the past month, have you been around a dead body?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

59. Did YOU participate in a funeral/burial ceremony in the past month (30 days)?

1. Yes 60 2. No61 3. I don’t know / not sure 4. Declines to respond61

60. During the funeral / burial ceremony which of the following did you do?

1. Touched the dead body

2. Washed the dead body

3. Touched other people at the burial ceremony (hug, handshake, etc.)

4. Cried over the body but did not touch it

5. I did not do any of the above

6. Other____________________________________________(please specify)

7. I don’t know/ not sure

8. Declines to respond

Select all applicable choices – read ALL Choices

61. If a family member died, would you accept alternatives to traditional funeral/burial that would NOT involve the touching or washing of the dead body?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

62. What would you consider an acceptable alternative to traditional funeral/burial for a family member who died of Ebola?

1. Having religious leader give last prayer at home before the body is taken

2. Observing the funeral/burial from a safe distance

3. Knowing the location of the burial site

4. Having a name plate of the deceased family member on the burial site

5. Other_______________________________________(please specify)

6. I don’t know / not sure

7. Declines to respond

Select all applicable choices; DO NOT read

G- STIGMA AND DISCRIMINATION

63. Would you buy fresh vegetables from a shopkeeper who survived Ebola and has a certificate from a Government Health Facility stating he/she is now Ebola-free?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

64. If a member of your family became ill with Ebola, would you want it to remain secret?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

65. Do you think that a school pupil who has survived Ebola and has a certificate from a Government Health Facility stating he/she is Ebola-free puts other pupils in their class at risk of infection?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

66. Would you welcome someone back into your community/neighborhood after he/she has recovered from Ebola?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

67. Once a man has survived Ebola, should he use condom during sex for 3 months? (read all choices; select one)

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

68. Do you agree that a person diagnosed with Ebola must be admitted in an Ebola Treatment Centre?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

69. Do you agree that people who have been in direct contact with a person who has been diagnosed with Ebola must be quarantined (kept in house or confined place) for 3 weeks?

1. Yes 2. No 3. I don’t know / not sure 4. Declines to respond

Select a single response

70. Do you think survivors who have fully recovered from Ebola might be able to help stop the spread of Ebola in your community?

1. Yes 2. No 72 3. I don’t know / not sure72 4. Declines to respond72

Select a single response

71. In what ways do you think survivors who have fully recovered from Ebola might be able to help stop the spread of Ebola in your community?

1. Stay at home and not touch others

2. Encourage and motivate those who are ill with Ebola to have hope

3. Provide care and support for those now ill with Ebola

4. Educate the community on how to avoid Ebola

5. Others_____________________________________________(please specify)

6. I don’t know / not sure

7. No response

Select all applicable choices; DOT NOT read

H- SOCIO-DEMOGRAPHICS

72. What is your sex?

1. Male 2. Female

Select only one response

73. What is your age?

_____ (years)

Write the age of the respondent

74. What is you highest level of education?

1. No formal education

2. Some primary school

3. Completed primary school

4. Completed Junior Secondary School (JSS)

5. Completed Senior Secondary School (SSS)

6. Completed Diploma / Postsecondary Training

7. Completed Bachelors

8. Completed Masters / Doctorate

9. No Response

Select all that apply

75. What kind of work do you currently do?

1. Private business (excluding petty traders)

2. Plumber / Carpenter / Electrician

3. Petty Trader

4. Farmer

5. Teacher / lecturer / instructor

6. Public transportation driver (taxi, buses, podapoda)

7. Medical or health professional

8. Student

9. Unemployed

10. Retired

11. No Response

12. Other ____________________________________(please specify)

Select all that apply

76. Average monthly income: Le______________________________

Write the amount specified by the respondent

77. What is your religion?

1. Islam

2. Christianity

3. Other____________________________ (please specify)

4. I don’t hold any religious beliefs

5. No Response

Select a single response

I- RETICENCE CONCERNING EBOLA PREVENTION AND CONTROL

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

1. Yes 2. No82 3. I don’t know / not sure82 4. No Response82

Select a single response

79. 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

Select a single response

80. Have you listened to their ideas or advice?

1. Yes82 2. No81 3. I don’t know / not sure82 4. No Response82

81. 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

J- VACCINATION

82. If there were a vaccine that could prevent Ebola, would you accept it for yourself?

    1. Yes 2. No 3. I don’t know / not sure 4. No Response

Select a single response

83. If there were a vaccine that could prevent Ebola, would you accept it for your children?

1. Yes 2. No 3. I don’t know / not sure 4. No Response 5. Not applicable (I do not have any children)

Select a single response

84. If you please, tell me if you agree, disagree, or have no opinion about this statement. “ A vaccine to protect against Ebola is necessary to control the epidemic in Guinea.”

1. Agree strongly 2. Agree somewhat 3. Do not agree 4. I don’t know / not sure

Select a single response

85. If a vaccine that that was tested for safety in humans could protect against Ebola were available in Guinea, how would your family feel about taking this vaccine?”

1. Agree strongly 2. Agree somewhat 3. Do not agree 4. I don’t know / not sure

Select a single response

REOMMENDATIONS ABOUT ERADICATING EBOLA

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

(write the recommendations) _____________________________________________________________

87. What strategies would you recommend in order to succeed in the fight against Ebola in your community?

(write the strategies) _____________________________________________________________

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

    1. Yes: Which questions __________________________________________

____________________________________________________________

2. No

3. Thank you for your participation

Select a single response

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 Ethic and Scientific Review Committee regarding any concerns, injury, or risks posed to you as a result of your participation in the assessment:

Name:__________________________________________ Phone number: ______________________

NOTE: NAMES OF TEAM SUPERVISOR AND ETHICAL COMMITTEE MEMBER WILL DEPEND ON THE CLUSTER TO ENSURE THAT RESPONDENTS CAN SPEAK TO OFFICIAL WHO SPEAKS LOCAL LANGUAGE.