KAP Survey

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:

Introduction

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.”

Demographics

1. Date of birth (DD/MM/YYYY):

2. Sex:

   1. Male

   2. Female

3. Nationality:

   1. Georgian

   2. Azery

   3. Armenian

   4. Other:

4. Residence:

   1. Rural

   2. Urban

5. Household Size (including the participant): ____________

6. Highest education level:

   1. Elementary

   2. Secondary

   3. Vocational

   4. Higher

   5. None

   6. Other: ______________

7. Occupation:

   1. Farmer

   2. Herder

   3. Field worker

   4. Slaughterhouse worker

   5. Healthcare worker

   6. Veterinarian

   7. Other

Risk Factors

8. Do you own or take care of animals? Yes/No

1. If yes, what type?

1. Sheep

2. Goats

3. Cattle

4. Buffalo

5. Other ________________

9. In the last four months, have you performed the following activities:

1. Herding

1. No

2. Sheep

3. Goats

4. Cattle

5. Buffalo

6. Other

2. Animal birthing assistance

1. Have assisted in animal birthing but have used PPE (gloves, gowns, boots)

2. Have assisted in animal birthing but have not used PPE

3. Have not assisted in animal birthing

3. Slaughtering

1. No

2. Sheep

1. Slaughter sheep using PPE (gloves, gowns, boots)

2. Slaughter sheep without PPE (gloves, gowns, boots)

3. Goats

1. Slaughter goats using PPE (gloves, gowns, boots)

2. Slaughter goats without PPE (gloves, gowns, boots)

4. Cattle

1. Slaughter cattle using PPE (gloves, gowns, boots)

2. Slaughter cattle without PPE (gloves, gowns, boots)

5. Buffalo

1. Slaughter buffalo using PPE (gloves, gowns, boots)

2. Slaughter buffalo without PPE (gloves, gowns, boots)

6. Other

1. Slaughter animals using PPE (gloves, gowns, boots)

2. Slaughter animals without PPE (gloves, gowns, boots)

4. Butchering/handling raw meat

1. No

2. Sheep

3. Goats

4. Cattle

5. Buffalo

6. Other

5. Handled ticks with bare hands

1. No

2. Removed ticks from animal and threw is out

3. Removed ticks from animals and killed with bare hands

4. Removed ticks from yourself and threw it out

5. Removed ticks from yourself and killed with bare hands

6. Other ________________

6. Worked in a health care setting

1. No

2. Primary healthcare

3. Outpatient clinic

4. Hospital

5. Other

7. Drank unpasteurized milk

1. Yes

2. No

8. Gardening

1. Yes

2. No

9. Any other outdoor activity not previously asked:

1. None

2. Hiking

3. Camping

4. Hunting

5. Fishing

6. Picnicking outside

10. In the last four months, have you had a tick bite?

    1. No

    2. 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?

11. Any travel or migration in the last four months?

1. No

2. If yes, describe:

Location (village/region/district)	Reason	Dates

12. Were you visited by the household educational campaign last month?

1. Yes

2. No

3. I don’t remember

KAP Information

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.”

Knowledge

13. Have you ever heard about Crimean-Congo Hemorrhagic Fever, also known as CCHF?

1. Yes (proceed to question 2)

2. No (proceed to Attitudes section)

3. I don’t know

4. Other_________________

14. Where have you learned/heard about CCHF? (circle all that apply)

1. School

2. Media

1. TV

2. Radio

3. Newspaper/Magazines

4. Pamphlets

   1. Where did you receive it? _________________

5. Posters

   1. Where did you see it? _________________

3. Educational campaign last few months (July-October)

4. Training courses

5. Health care worker

6. Know someone who had CCHF

1. No

   1. Yes, who?

7. Other____________________

15. What are ways in which a human can become infected? (circle all that apply)

1. Bite from a tick

2. Crushing a tick with bare hands

3. Contact with blood from infected animals

4. Contact with birthing tissues/fluids from infected animals

5. Eating infected meat

6. Contact with people sick from CCHF

7. Drinking unpasteurized milk

8. Other _____________________

16. What activities can put you at risk? (circle all that apply)

1. Working with livestock

2. Working in produce/vegetable/grain fields

3. Working in a rural, woody area

4. Slaughtering animals

5. Butchering meat

6. Working in a hospital

7. Being a abattoir/slaughterhouse worker

8. Working as a veterinarian

9. Other______________________

17. What are the signs and symptoms of CCHF? (circle all that apply)

1. Fever

2. Headache

3. Nausea/Vomiting

4. Diarrhea

5. Muscle pain

6. Weakness

7. Cough

8. Hematuria

9. Hematochezia/Melena

10. Hemoptysis

11. Other_________________

Attitudes

18. Do people frequently get bitten by ticks in your community?

1. Yes

2. No

3. I don’t know

4. Other_________________

19. Do you think ticks are a problem in your community?

1. Yes

2. No

3. I don’t know

4. Other_________________

20. Do you think there are more ticks this year than previously?

1. Yes

2. No

3. I don’t know

4. Other__________________

21. Do you think CCHF is a problem in your community?

1. Yes

2. No

3. I don’t know

4. Other_________________

22. Do you think CCHF is something you should be worried about?

1. Yes

2. No

3. I don’t know

23. Do you think you can protect yourself from CCHF?

1. Yes

1. If yes, how? _________________

2. No

3. I don’t know

4. Other_________________

Practices

24. Do you have any interaction with ticks during your job?

1. Yes

   1. Please describe_________________

2. No

3. Other_________________

25. What method do you use to remove ticks off yourself?

1. Remove by hand

2. Remove with tweezers

3. Go to a hospital/health care center

4. Other_________________

26. What do you do to protect yourself from ticks/CCHF? (circle all that apply)

1. Protective clothing (i.e. long pants, socks, etc.)

1. How often? Always Sometimes Never

2. Treat your clothing with repellent

1. How often? Always Sometimes Never

3. Insect repellent

1. How often? Always Sometimes Never

4. Use pesticides in the environment

1. How often? Always Sometimes Never

5. Avoid woody/rural areas

1. How often? Always Sometimes Never

6. Other_________________

1. How often? Always Sometimes Never

27. 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)

1. Go to a hospital/healthcare facility

1. Primary healthcare

2. District

3. Regional

4. Tbilisi ID hospital

5. Any other clinic in Tbilisi:

6. Other:_________________

2. Stay at home

3. Try local pharmacy

4. Go to a local healer

5. 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.

28. How do you prevent ticks for your animals? (circle all that apply)

1. Use insecticides/acaricide

1. Spray

2. Pour on

3. Dipping the animals

4. Other_______________

2. Other________________

29. What method do you use to remove ticks off your livestock? (circle all that apply)

1. Remove by hand

2. Remove with tweezers

3. Go to a veterinarian

4. Other________________

Educational Campaign

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.”

30. Has your understanding of CCHF changed since the educational campaign?

1. Yes

   1. How? _________________

2. No

   1. Why not? _________________

3. I don’t know

4. Other_________________

31. Has your perception of CCHF changed since the educational campaign?

1. Yes

   1. How? _________________

2. No

   1. Why not?_________________

3. I don’t know

4. Other_________________

32. Has the way you protect yourself changed since the educational campaign?

1. Yes

1. How? _________________

2. No

1. Why not?_____________

3. I don’t know

4. Other_________________

33. Has the way you interact with ticks changed since the educational campaign?

1. Yes

1. How? _________________

2. No

1. Why not?

3. I don’t know

4. Other_________________

Recent Illness

To the interviewee: “Now I am going to ask about any illnesses you might have had during in the past four months”

34. Have you ever been diagnosed with CCHF?

2. No

3. If yes, describe:

   1. Date:

   2. Where were you diagnosed:

   3. What symptoms did you have?

      1. Fever

      2. Headache

      3. Nausea/Vomiting

      4. Diarrhea

      5. Muscle pain

      6. Weakness

      7. Cough

      8. Hematuria

      9. Hematochezia/Melena

      10. Hemoptysis

      11. Other_________________

35. Have you had any illness in the last four months?

1. Yes

2. No (Finish questionnaire)

36. 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)

37. What signs or symptoms did you have during this illness?

	1st Illness		2nd Illness		3rd Illness
Signs/Symptoms	Yes	No	Yes	No	Yes	No
Fever
Weakness/Lethargy
Headache
Body / muscle pain
Joint pain
Cough
Abdominal Pain
Vomiting
Diarrhea
Jaundice (yellowing of the skin)
Bruising
Petechiae (small dark purple or dark red dots that don’t go away when you push down on them)
Nose Bleeding
Bleeding from gums
Blood in vomitus
Blood in stool
Blood in urine
Coughing blood
Other, please list:

38. Did you seek any care for your symptoms?

1. If yes, where? _____________ And when?________________

2. If no, why not? ______________________

39. If you were hospitalized, how long were you in the hospital for? ___________

40. Did you receive any medications or treatments?

5. If yes, what? ________________

6. Received medication or treatment from:

   1. Primary healthcare

   2. District

   3. Regional

   4. Tbilisi ID hospital

   5. Any other clinic in Tbilisi:

   6. Local pharmacy

   7. Local healer

   8. 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)