Community Questionnaire

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Cholera Response Community Questionnaire

Knowledge, Attitudes and Practices

Date of Interview_________________ Interviewer______________________

Identification and Demographic Information

County __________

Village/Town_______________

Hello, my name is _______________. I am working with the Kenyan Ministry of Public Health to investigate illnesses in the community. We have a few questions about illness in the community and water issues. This may take about 20 minutes. May I please speak to the person in the home who usually takes care of the ill family members and brings the water for the family?

If YES, begin the interview. If NO, thank you.

What is your age in years?		Gender	1 0	Male Female
What is your year of birth?

Background Socioeconomic & Education

1. How many people live in your household?
2. How many children less than 5 years old live in your household?

Cholera General Knowledge Information

3. Have you ever heard of an illness called cholera?	1 0 99	Yes No Don’t Know
4. Have you heard about the cholera outbreak in your area recently?	1 0 99	Yes No Don’t Know
5. Can you tell me what the main symptoms of cholera are? (Do not read. Check all that are mentioned.)	1 2 3 4 5 6 7 99	Watery diarrhea Bloody diarrhea Vomiting Fever Dehydration Decreased appetite Other(specify)____________________ Don’t Know
6. Do you know what causes cholera? (Do not read. Check all that are mentioned.)	1 2 3 4 5 6 7 8 99	Drinking bad water Eating bad food Unwashed fruit/vegetables Flies/Insects Poor hygiene Spirits/Curse/Bad Omen People from other tribes Other (specify) ____________________ Don’t Know
7. Can cholera spread from one person to another?	1 0 99	Yes No Don’t know
8. How severe is cholera compared to other types of diarrhea? (Read all choices. Choose only 1.)	1 2 3 99	Less severe Equal severity More severe Don’t know
9. How can you prevent you or your family members from getting cholera? (Do not read. Check all that are mentioned. Prompt after each response.)	0 1 2 3 4 5 6 7 8 9 99	Cannot prevent Herbs Wash hands Cook food thoroughly Reheat stored food Cover food Boil or treat water Wash vegetables and fruit Clean cooking utensils/vessels Other (specify)____________________ Don’t Know
10. How can you treat cholera for yourself or your family members when you are at home and cannot get to a health facility? (Do not read. Check all that are mentioned. Prompt after each response)	1 2 3 4 5 6 7 8 9 10 11 12 13 14 0 99	Increase liquid intake Decrease liquid intake Increase food intake Decrease food intake Use oral rehydration solution (ORS) packets Use sugar-salt solution Pill or syrup medicine Injection Go to doctor Go to hospital Go to church/ mosque/other religious place Go to traditional healer Home remedy (specify)________________ Other (specify)_____________________ Do not treat Don’t Know

Cholera in Village

11. Have you heard that people in your village had cholera in the past 6 months?	1 0 99	Yes  Go to 12 No  Go to 17 Don’t Know  Go to 17
12. When was the most recent time you heard of cholera in your village?	0 1 2 3 4 99	Never heard Past 7 days In the past month Between 2-6 months Over 6 months ago Don’t know
13. Have you heard that people in your village died from cholera in the past 6 months?	1 0 99	Yes No Don’t know
14. Please tell me all the ways you heard about the cholera outbreak. (Do not read. Check all that are mentioned. Prompt after each response.)	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 99	Family member Neighbor Friend Chief (Baraza) Community Meeting Community health worker Health Worker Women’s group Church, Mosque or religious group School NGO or Volunteer Organization (ex.Red Cross, MSF, UNICEF) Radio Electronic media (TV, internet) Newspaper Poster or Wall Hanging Other (specify)__________ Don’t know
15. Did you hear messages about how to prevent cholera from these sources of information? (Please refer to sources identified in question 4.)	1 0 99	Yes  Go to 16 No  Go to 17 Don’t know  Go to 17
16. What did you hear? (Do not read. Check all that are mentioned. Prompt after response.)	1 2 3 4 5 6 7 8 9	Boil or treat water Build/Use latrines Wash hands Cover food Cook food thoroughly Wash vegetables and fruit Clean cooking utensils/vessels Seek treatment if you have severe, watery bloody diarrhea Other________________________

Cholera in Family Member

17. Did you or any of your family members become ill with cholera in the past 6 months?	1 0 99	Yes  Go to 18 No  Go to 35 Don’t know  Go to 35
18. How many family members became ill with cholera?
19. How many children under 5 years age became ill with cholera?
20. Have there been any deaths in your family due to cholera in the past 6 months?	1 0	Yes  Go to 21 No  Go to 23
21. How many family members passed away due to cholera?
22. How many children under 5 passed away with cholera?

23. Did you use any of the following to treat yourself or your family member in the home when having diarrhea? (Ask each item. Choose Yes, No or Don’t know for each item)
Herbal Treatment		Yes	No	Don’t Know
Fluid prepared from ORS packet		Yes	No	Don’t Know
Other solution prepared at home		Yes	No	Don’t Know
Ingredients of other solution	Salt	Sugar	Herbs	Other_________
Prayer therapy		Yes	No	Don’t Know
Oral medicine/Antibiotics		Yes	No	Don’t Know
Other (specify)______________________		Yes	No	Don’t Know

24. Did you or your family member seek care for cholera?	1 0 9	Yes  Go to 25 No  Go to 35 Don’t know  Go to 35
25. When was the last time you sought care for cholera for you or your family member?	1 2 3 4 99	In past 7 days Between 1 week - 1 month ago Between 1 month - 6 months ago Over 6 months ago Don’t know
26. Who was the person you last sought care for cholera?	1 2 3	Respondent Respondent’s family member  Age of family member_______years Other (specify)_______________  Age of other person _________years

(The following questions 27 - 34 are about the person identified in question 26)

27. Did you/your family member seek care at:
Hospital/Government Facility	Yes	No	Don’t Know
Cholera Treatment Center	Yes	No	Don’t Know
Private Clinic	Yes	No	Don’t Know
Dispensary/Health Center	Yes	No	Don’t Know
Chemist	Yes	No	Don’t Know
Kiosk/Shop	Yes	No	Don’t Know
Community Health Worker	Yes	No	Don’t Know
Traditional Healer	Yes	No	Don’t Know
Spiritual Leader	Yes	No	Don’t Know
Other (specify)___________________________	Yes	No	Don’t Know

Health Facility=Government Hospital, Cholera Treatment Center Private Clinic, Dispensary

If YES to Health Facility,  Go to 28

If NO or Don’t know to Health Facility  Go to 35

28. What did they give you at the health facility to treat your cholera illness? (Read all choices and check all that apply.)	1 2 3 4 5 6 7 8 9 99	ORS Fluid through a needle / IV Fluids Syrup or pill medicine by mouth Injection Antibiotics Anti-motility medicine Zinc sulfate Special air through a tube or mask / Oxygen Other (specify)_________________ Don’t Know
29. Were you/your family member hospitalized overnight?	1 0 99	Yes No Don’t know
30. Did the hospital take a blood test?	1 0 99	Yes No Don’t know
31. Did the hospital take a stool test?	1 0 99	Yes No Don’t know
32. What did the doctor/hospital give you/your family member to take home to treat cholera?	0 1 2 3 4	Nothing ORS Packet(s) Syrup or Pill Antibiotic Medicine Anti-motility Medicine
33. Did anyone at the health facility talk to you about preventing cholera?	1 0 99	Yes  Go to 34 No  Go to 35 Don’t know  Go to 35
34. What did they talk about? (Do not read. Check all mentioned. Prompt after response).	1 2 3 4 5 6 7 8 9 10 11 99	Treat water Build and use latrines Wash hands Cover food Cook food thoroughly Reheat stored food Wash vegetables and fruit Clean cooking utensils/ vessels Seek treatment if severe, watery, bloody diarrhea Diarrhea and children Other (specify) _______________ Don’t know
35. How many hours does it take to get to the health facility from your home?	0 # 99	Less than one hour _______ hours ______days Don’t know
36. How difficult is it to get to the health facility? (Read responses and check all that apply.)	1 2 3 99	No difficulty Some difficulty Very difficult Don’t Know

Oral Rehydration Solution (ORS)

37. Has anyone taught you how to prepare a home-made rehydration solution at home to treat diarrhea?	1 0 99	Yes  Go to 38 No  Go to 40 Don’t know  Go to 40
38. Who taught you to prepare the solution?	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 99	Spouse Mother Mother-in-law Father Father-in-law Co-wife Government Hospital/Clinic Private clinic Community health worker Traditional healer Spiritual healer Village chief Older woman in community Older man in community Other (specify)________________ Don’t know
39. What does this solution contain? (Do not read. Check all mentioned.)	1 2 3 4 5 6 7 8 99	Sugar Salt Herbs Water Tea Other fluid (specify)_______________ Contents of ORS Packet Other (specify)_________________ Don’t know
40. Have you heard of Oral Rehydration Solution or ORS?	1 0 99	Yes  Go to 41 No Go to 51 Don’t know  Go to 51
41. From who or where have heard of ORS? (Do not read. Check all that are mentioned.)	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 99	Family member Neighbor Friend Chief (Baraza) Community Meeting Community health worker Health worker Women’s group NGO or Volunteer Organization (ex. Red Cross, MSF, UNICEF) Radio Electronic media such as TV, internet Newspaper Poster or wall hanging School Health Facility Other, Specify _______________ Don’t know
42. What is ORS used as a treatment for?	1 2 3 4 99	Dehydration Diarrhea Children Other (specify)___________________ Don’t Know
43. Do you know how to prepare ORS?	1 0 99	Yes No Don’t know
44. Is ORS available in your village?	1 0 99	Yes No Don’t know
45. Where is it available? (Do not read. Check all that are mentioned.)	1 2 3 4 5 6 99	Health care facility Chemist/Pharmacy Kiosk/Shop in Village Supermarket NGO Other (specify)__________________ Don’t know
46. How much does one ORS packet cost?	1 2 99	____________Ksh  Go to 47 Can get it free at health facility  Go to 49 Don’t know  Go to 49
47. How do you find the price of ORS? (Read all choices. Mark only 1)	1 2 3	Cheap Fair Expensive
48. Have you purchased ORS in the past 6 months?	1 0 99	Yes No Don’t know
49. Do you have one or more packets of ORS in the home?	1 0 99	Yes  Go to 50 No  Go to 51 Don’t know  Go to 51
50. May I see the ORS packet(s)?	1 0 99	Present Absent Refused

Feeding Practices

51. When you or your family member has diarrhea, how much do you give to drink? (Read all choices. Choose only 1).	1 2 3 4 5 99	More than usual Usual Somewhat less than usual Much less than usual Nothing to drink Don’t know
52. When you or your family member has diarrhea, how much do you give them to eat? (Read all choices. Choose only 1.)	1 2 3 4 5 99	More than usual Usual Somewhat less than usual Much less than usual Nothing to eat Don’t know
53. Do you think giving more food than usual is good for a child with diarrhea?	1 0 99	Yes  Go to 54 No  Go to 55 Don’t know  Go to 56
54. Why is giving more food than usual for a child with diarrhea good? (Do not read. Mark all that are mentioned.)  Go to 56	1 2 3 4 99	Gives energy Prevents weight loss Helps fight infection Other (specify)__________________ Don’t know
55. Why is giving more food than usual for a child with diarrhea not good? (Do not read. Mark all that are mentioned.)	1 2 3 4 5 99	Child’s gut needs rest Child may throw up Foods may make diarrhea worse Child does not want more food/will waste it Other (specify)__________________ Don’t know

Water and Water Treatment Information

56. What is the main source of your household’s drinking water during the DRY season? (Do not read; Choose 1)	1 2 3 4 5 6 7 8 9 10 11 12 13 14	Open deep well Protected deep well Shallow well/hand-dug well Spring Lake Pond/Seasonal lake River Borehole Rain water catchment from roof Piped water to house Community tap Water vendor Dam Other (specify)______________________
57. What is your main source of drinking water during the RAINY season? (Do not read; Choose 1)	1 2 3 4 5 6 7 8 9 10 11 12 13 14	Open deep well Protected deep well Shallow well/hand-dug well Spring Lake Pond/Seasonal lake River Borehole Rain water catchment from roof Piped water to house Community tap Water vendor Dam Other (specify)_______________________
58. Where are you presently getting your water? (Do not read; Choose 1)	1 2 3 4 5 6 7 8 9 10 11 12 13 14	Open deep well Protected deep well Shallow well/hand-dug well Spring Lake Pond/Seasonal lake River Borehole Rain water catchment from roof Piped water to house Community tap Water vendor Dam Other (specify)_______________________
59. Are there any times during the year, when water is not readily available?	1 0	Yes  Go to 60 No  Go to 61
60. During the past year, how often was water not readily available? (Read choices. Choose only 1.)	1 2 3 4 5 6 99	One week during year One month during year Between 1- 3 months during year Between 3- 6 months during year Over 6 months during year Other (specify)_______________ Don’t know
61. Do you do something to your drinking water to make it safe to drink?	1 0 99	Yes  Go to 62 No  Go to 63 Don’t know  Go to 63
62. What do you do to treat the water? (Do not read. Check all that are mentioned. Prompt after each response.)	1 2 3 4 5 6 7 8 9 10 11 12 13 99	Boil Decanting Keep water in hot sun Filter Cloth filter Sand (shallow dug well) Alum WaterGuard PuR AquaGuard Aquatabs Use a ceramic/biosand filter Other (Specify) ____________________ Don’t know
63. Do you do something to your drinking water when you or your family member is ill and has diarrhea to make the water safe to drink?	1 0 99	Yes  Go to 64 No  Go to 65 Don’t know  Go to 65
64. What do you do to treat the water? (Do not read. Check all that are mentioned. Prompt after each response.)	1 2 3 4 5 6 7 8 9 10 11 12 99	Boil Decanting Keep water in hot sun Filter Cloth filter Sand (shallow dug well) Alum WaterGuard PuR AquaGuard Aquatabs Use a ceramic/biosand filter Other (Specify) ____________________ Don’t know
65. Have you ever heard about water treatment products?	1 0 99	Yes  Go to 66 No  Go to 68 Don’t know Go to 68
66. Which water treatment product have you heard of?	1 2 3 4 5	WaterGuard PuR AquaGuard Aquatabs Other (specify)______________
67. How did you hear about (Name of water treatment product)? (Do not read. Check all mentioned.)	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 99	Family member Neighbor Friend Chief (Baraza) Community Meeting Community health worker Women’s group NGO or Volunteer Organization (ex. Red Cross, MSF, UNICEF) Radio Electronic media such as TV, internet Newspaper Poster or wall hanging School Church, Mosque or religious group Health Facility Other (Specify) _______________ Don’t know
68. In the last 6 months, have you ever received any water treatment products or hygiene products for free from the government, NGO, or another organization to prevent or treat cholera?	1 0 99	Yes  Go to 69 No  Go to 74 Don’t know Go to 74
69. What were you given? (Do not read. Check all that are mentioned.)	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16	WaterGuard  Go to 70 PuR  Go to 70 AquaGuard  Go to 70 Aquatabs/chlorine tabs  Go to 70 Bottles of chlorine  Go to 70 Drums of chlorine  Go to 70 Soap Jerrycan Bucket Ceramic water filter Go to 74 Medicine/Antibiotics ORS Print material Incentives Advice Other____________________
70. Were you given any counseling or education on how to use these water treatment products?	1 0 99	Yes No Don’t know
71. Did you use any of these products?	1 0 99	Yes  Go to 72 No  Go to 73 Don’t know  Go to 74
72. What did you use?  Go to 74	1 2 3 4 5 6 99	WaterGuard PuR AquaGuard Aquatabs/chlorine tabs Bottles of chlorine Drums of chlorine Don’t know
73. Why did you not use these products?	1 2 3 4 5 6 7 99	Bad Taste Dangerous to use these products No container to treat water No need to treat water Did not know how to use the product Did not get education on how to use the product Other (specify)_____________________ Don’t know

Handwashing Information

74. When do you wash your hands? (Do not read. Check all that are mentioned.)	1 2 3 4 5 6 7 8 99	After using the toilet Before eating After eating When serving meals Before cooking After cleaning babies when they defecate Other (Specify) ______________________ Never wash hands Don’t Know
75. Do you have soap in the house?	1 0 99	Yes No Don’t know
76. For which purposes, do you use the soap? (Do not read. Check all that are mentioned).	1 2 3 4 5 99	Washing hands Laundry Cleaning utensils/ vessels Bathing Other (Specify)______________________ Don’t know

Education/Socioeconomic/Personal Information

77. Can you read and write?	1 0 99	Yes No Don’t know
78. What is the highest level of education you have attended? (Choose only 1)	0 1 2 3 4 99	None Lower Primary Upper Primary Secondary or Higher Other (specify)______ Don’t know
79. Does your household have the following? (Read all choices. Mark all that apply.)	1 2 3 4 5 6 7 8 9 10 0	Electricity Television Radio Animal-drawn cart Motorcycle/Scooter Bicycle Car/truck Refrigerator Telephone (mobile or non-mobile) Agricultural land None of the above
80. What type of cooking fuel does your household use? (Read all choices. Mark all that apply.)	1 2 3 4 5 6 7 8 9 10 0	Charcoal Wood Straw/shrubs/grass Animal dung Agricultural crop residue Electricity Liquid Propane Gas Natural Gas Kerosene Other (specify)____________________ None
81. Do you/your family own any of the following animals? (Read all choices. Mark all that apply.)	1 2 3 4 5 6 7 0	Goat Sheep Dog Cat Cow/Cattle Chicken, Ducks, other poultry Other (specify)__________________ No animals
82. What is the main source of family income? (Do not read. Choose only 1.)	1 2 3 4 5 6 7 99	Herding of Domestic Animals Fishing Small Business Farmer Employed/Salaried Unskilled labor Unemployed Don’t Know
83. What is your religious denomination? (Do not read. Check all that are mentioned.)	1 2 3 4 5 6	Christian Muslim Hindu None Other (specify)_________________ Refused

Home Information/Observations

84. Where do you defecate? (Do not read. Circle the one that applies.)	1 2 3 4 5 6 7	Flush Latrine Covered pit latrine Uncovered dry pit latrine Flying toilet Bush Lake or River Other, (Specify) _____________________
85. What is the main roofing material for the household’s dwelling? (Choose 1.)	1 2 3 4 5 6 7	Thatch Metal/Iron Sheets Tile/Asbestos sheets Wood Cement None; no household dwelling/structure Others (Specify)______________________
86. What is the main flooring material? (Choose 1)	1 2 3 4 5 6 7 8 9	Dung Earth/ sand/ mud Metal Wood Broken bricks Cement Tile None; no household dwelling/structure Other (Specify) ______________________
87. What is the material used for the walls? (Choose 1)	1 2 3 4 5 6 7 8	Dung/Mud Metal sheets Twigs Wood Cement/Plaster Bricks/blocks/stones None; no household dwelling/structure Other(Specify) _______________________
88. May I see where you store your water? (Mark all that are seen.)	1 2 3 4 5 6	Jerrycan Bucket Pot Cooking pot (Sufuria) Refused None
89. May I see the products you have purchased or have received from the government or NGOs? (Mark all that are seen.)	1 2 3 4 5 6 7 8 9 10 11 12 13	Soap WaterGuard PuR Aquatabs/chlorine tabs Bottles of chlorine Drums of chlorine Ceramic water filter Medicine/Antibiotics ORS Food Print material Other (specify)_______________________ None in the home
90. May I test a sample of drinking water to see if there is chlorine in it? Result of chlorine test:	1 2 3 4 5 6	Positive Negative No water stored Refused Test not done Other (specify)______________________

“The interview is now finished. Thank you.”

Public reporting burden of this collection of information is estimated to average 20 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)