annex i questionnaire english and amharic versions section
TRANSCRIPT
1
Annex I Questionnaire English and Amharic versions
Section 1: Socio-demographic characteristics S.No Question Response Skip
101 What is your sex? 1. Male
2. Female
102 How old are you? ---------years
103 What is your religion? 1. Orthodox
2. Muslim
3. Protestant
4. Jewish
5. Other specify
104 Ethnicity 1. Amhara
2. Tigre
3. Oromo
4. Other specify-------------
105 Marital status 1. Single
2. Married
3. Separated
4. Divorced
5. Widow/erd
6. Other
specifyâŚâŚâŚâŚâŚ.
106 Educational status 1. Illiterate
2. Read and write
3. Primary
4. Secondary
5. Higher
107 Occupation 1. Jobless
2. Daily Labourer
3. Government employee
4. Merchant
5. Farmer
6. Driver
7. House wife
8. Student
9. Others SpecifyâŚâŚâŚâŚ
108 Average monthly income 1. < 500 Birr
2. 500-999 Birr
3. >1499 Birr
4. I donât know
109 Whom do you live with? 1. Live alone
2. With my spouse
3. With parents
4. Unstable
5. Donât need to specify
110 Is there any other disease in addition to diabetic 1. Yes
2. No
2
111 If yes to Q No 110, What is the diagnosis 1. Hypertension
2. Heart problem
3. Other, Specify--------
112 Time since diagnosis for your disease 1. 0 to 6 months
2. 7 to 12 months
3. > 12 months
113 Time since started diabetic follow up 1. 0 to 6 months
2. 7 to 12 months
3. > 12 months
Section 2: Environmental factors
201 Is there Television in your house? 1. Yes
2. No
202 Is there radio in your house? 1. Yes
2. No
203 How do you travel to come here for the diabetic
care service?
1. On foot
2. By car
3. By animal
4. Other specifyâŚâŚâŚâŚ..
204 How much time does it take you to come here in
your routine way of transportation?
1. Less than 1 hour
2. More than 1 Hour
205 Is there electricity in your house? 1. Yes
2. No
206 Is there network in your house 1. Yes
2. No
Section 3: Health Carefactors
301 Are you satisfied with the health care service
provided to you
1. Yes
2. No
302 Do you have open communication with
clinicianfollowing you?
1. Yes
2. No
303 How often do you visit your Facility 1. every month
2. every 2 month
3. every 3 month
4. Variable
304 Do you obtain the education or
Assistant you need during your visits?
1. Yes
2. No
3. Not sure
305 Do you obtained the medication regularly 1. Yes
2. No
3. Not sure
306 Are you satisfied by the changes/ improvements
you obtain for your treatment?
1. Yes
2. No
3
3. Not sure
307 Are you satisfied in the scheduling appointments
and confidentiality of the treatment unit?
1. Yes
2. No
3. Not sure
308 Have you ever missed your health care
appointments?
1. Yes
2. No
309 If your answer for the above question is yes, What
was the reason to miss your appointment?
1. I forgot it
2. I was sick and unable to
come myself
3. I didnât get permission from
my employers
4. Other specifyâŚâŚâŚ
Section 4: Psychological factors
401 4.1. Do you bother about the long term treatment provided to you
1. Yes
2. No
402 Do you have a sense of care, safety, security of
support from your family, co-workers, fewer do
or other people in your community?
1. Yes 2. No 3. Not sure
403 What kind of support or care you obtain from the
above people?
1. Material / practical
2. Information / advice
3. Other specifyâŚâŚâŚâŚâŚ
404 Are you satisfied with their help? 1. Yes
2. No
405 Are you esteemed or valued for you skills or
abilities by other?
1. Yes
2. No
406 Are you satisfied with the way people hold you in
esteem or value for your skills or abilities?
1. Yes
2. No
407 Do you think this treatment benefits you? 1. Yes
2. No
Section 5: Behavioral factors
501 Do you feel comfortable when you take your
medication in front of others?
1. Yes
2. No
502 Do you use any reminder mechanisms? 3. Yes
4. No
If No>>>go
to Q 504
4
503 If your answer for the above question is yes, What
type of reminding mechanism do you use?
1. Pillbox
2. Written
schedule
3. Watch bell
4. Mobile phone
5. Other specify
506 Do you take any addicting substances? 1. Yes
2. No
If
No>>>>go
to Q 601
507 If your answer for Q506 is yes, what kind of
substances do you take?
1. Alcohol
2. Kchat
3. Cigarette
4. Other specify
508 Have you habit of taking excessive sugar 1. Yes
2. No
509 What is your habit on exercise 1. Two times
daily
2. One times
daily
3. Weekly
4. Monthly
5. Not at all
Section 6: Pattern of cell phone use
601 Do you have mobile phone? 1. Yes
2. No
If your answer is
yes >>>>go to
602, If no stop
602 Do you use this cell phone as your appointment
reminder
1. Yes
2. No
602 Do you use this cell phone as your medication
reminder
1. Yes
2. No
603 What is your preferred way of communication in
your cell phone?
1. Verbal
2. Text
3. Email
604 How often do you have your cell phone with
you?
1. Always
2. Sometimes
3. Seldom
4. Never
605 Have you had your cell phone lost, damaged or
theft in the past?
1. Yes
2. No
5
606 Do you have any other phone number? 1. Yes
2. No
607 Switch off cell phone during day 1. Yes
2. No
608 There is sometimes a time or place where no
calls are taken
1. Yes
2. No
609 Are there times that you donât answer unknown
calls?
1. Yes
2. No
610 Do you use phone pass words? 1. Yes
2. No
611 Do you put your cell phone in a place where
others could use and access?
1. Yes
2. No
612 Do you share your cell phone with other person? 1. Yes
2. No
613 Can you read/send text message using your
mobile?
1. Yes
2. No
If No>>>>go to
Q618
614 If your answer for the above question is yes, do
you delete text message without reading it?
1. Yes
2. No
615 How likely is that a text message received on
your phone to be seen by others?
1. Very likely
2. Somewhat likely
3. Somewhat unlikely
4. Very unlikely
616 Do you use internet on your phone? 1. Yes
2. No
If âYesâ >>>>go
to Q617
617 If your answer for Q616 is yes, what is the
website page that you most frequently visit?
1. Social network pages
like Face book
2. Email
3. Google
4. Others specify
619 Are you willing to be contacted by your mobile
phone from your health service provider to
remind your follow up?
1. Yes I am willing
2. No I donât like to be
contacted
620 How do you want to be reminded? 1. Mobile phone calls
2. Text messages
3. Mobile phone pager
4. Both are helpful for me
621 Do you think mobile based support could be
helpful in your adherence to follow up?
1. Yes
2. No
If ânoâ >>>>go
to Q622
622 If your answer for the above question is no, what
do you think is bad to receive mobile based
reminder?
1. It ruins my privacy
2. Text message from
oneâs healthcare
6
provider would be
annoying
3. Other specify
623 Will you pay for mobile based service you send
to your clinic to remind your medication and
appointments according to the current
telecommunication tariffs?
1. Yes
2. No
624 If we were going to develop an application for
people living with diabetic in our hospital using
cell phones â what sort of things would you like
to see? More than one answer is possible
1. Automatic medication
reminders
2. Automatic appointment
reminders
3. Health advices/tips
4. Other specify
Thank you for your cooperation.
7
á ááá áá áá
1. Socio-demographic characteristics
á°.á áĽáŤá ááá˝ ááá
101 ááł 1. áááľ
2. á´áľ
102 áĽáľá ---------á ááľ
103 áááááľ 1. áŚááśáśááľ
2. áá°áá
3. ááŽá´á°áłááľ
4. á¤á° áĽáľáŤá¤á
5. áá áŤá ááĽááąâŚâŚâŚâŚâŚâŚâŚâŚ
104 áĽáá 1. á ááŤ
2. áľááŹ
3. áŚáŽá
4. áá áŤá ááĽááą-------------
105 á¨ááĽáť áááł 1. áŤáááŁ/á˝
2. áŤááŁ/á˝
3. á¨á°ááŤáŹ/á˝
4. á¨á°ááł/á˝
5. á¨áá°á áľ/áŁáľ
6. áá áŤá ááĽááąâŚâŚâŚâŚâŚ.
106 á¨áľáá ááľ á°á¨á 1. ááá áĽá ááťá á¨ááá˝á/
2. ááá áĽá ááťá á¨áá˝á/
3. á áá°á á°á¨á
4. ááá°á á°á¨á
5. áŽáá á á¨á፠á áá
107 áĽáŤ 1. áĽáŤ ááá
2. á¨áá á°áŤá°á
3. á¨ááááľáľ á°áŤá°á
4. ááá´
5. áá áŹ
6. ášáá
7. á¨á¤áľ áĽáá¤áľ
8. á°ááŞ
9. áá /ááĽááąâŚâŚâŚâŚ.
108 á ááŤá áááá áᢠ1. á¨500 áĽá á áłá˝
2. 500-999 áŁá
3. >1499 áĽá
4. á ááááá
8
109 á¨áá áá áá áááŠáľ; 1. áĽáťá¨á
2. á¨áŁáá¤á´ áá
3. á¨á¤á°á°áŚá¸ áá
4. á ááľ áŚáł á°á¨ááḠá áááá
5. áááá˝ á ááááá
110 ᨠáľáłá á áá á°á¨á᪠áá á áá
á áááľ
1. á á
2. á¨áá
111 ááĽáŤá ááĽá 110 áááľá á á á¨
áááŁáá á áá áá á
1. á¨á°á áááľ
2. á¨áἠá áá
3. áá áŁááááš----------------
112 áľáłá á áá á á°áá ááአáŤáá áľááľ
áá ááááľ
1. ᨠ6 áá á áłá˝
2. ᨠ7 áĽáľá¨ 12 ááŤáľ
3. á¨12 ááŤáľ á áá
113 ᨠáľáłá á áá ááľáľá á¨ááአáá áŤá á
áᤠááááłá
1. ᨠ6 áá á áłá˝
2. ᨠ7 áĽáľá¨ 12 ááŤáľ
3. á¨12 ááŤáľ á áá
Section 2: Environmental factors
20
1
á¨áááŠá áľá¤áľááľáĽá´ááŞáĽáá á? 3. á á
4. á¨áá
20
2
á¨áááŠá áľá¤áľááľáĽáŹá˛áŽá á? 1. á á
2. á¨áá
20
3
áá á ᨠáľáłá ááľáľá á áááááľáááááľ á¨ááĄáľ á áááľááá? 5. á áĽááŹ
6. á ááŞá
7. á á á á/á áá¨
áľ
8. áááŤáááĽá
áąâŚ
20
4 á ááá°á¨áá áá ááá áľá¨áľáŤááľáá¨áľá ááŤáá°á á áááĽááá
áľá¨áľáá áŤáá á°á áľ ááá áĽááłá?
3. ᨠ1
á á áľá áłá˝
4. ᨠ1 á°á áľá áá
20
5 á áááŠá áľ á¤áľ ááľáĽ á¤áááľáŞá á á? 1. á á
2. á¨áá
20
6 á áááŠá áľ á¤áľ ááľáĽ ááľááá á á? 1. á á
2. á¨áá
Section 3: Health Care Factors
9
30
1
á¨á ááá á áááááľ á áá°áĽááľ ááľááłá á°á°á°á áááľ? 3. á á
4. á áá°áá
á
30
2
áá á á¨á ááá ááľáľá á áááááľ á¨áá°áĽááľ áŁáá፠áá ááá˝
á¨áá ááááľ áŤá°ááá?
3. á á
4. á¨áá
30
3 ááľááłáá á á¨áľááľ áá ááá ááłá ? 5. á á¨ááŠ
6. á á¨áááľ
áá
7. á ᨠ3 áá
8. á°ááá
á
30
4 áá° áá á°á áá áááľáľá á ááááá° á˛áᥠá¨áááááľá á¨á¤á
áľáá á¨áľá áľáá áŤááá?
4. á á
5. á¨áá
6. áĽááá á
á áá°áá
á
30
5
á áááááááá¨ááľáááááľáááľáááľáłáááŤá¨áĽá¨ááŤáááĽá
ááľááľááá°á¤áľá á?
1. á á
2. á¨áá
3. áĽááá á
á áá°áá
á
30
6
ááľáááľá¨áááŠá áááá á°áá ááááľá¨á¤áááťáťáá°áľá°ááááľ? 1. á á
2. á¨áá
3. áĽááá á
á áá°áá
á
30
7
á áá áŽááá á°áŁáĽáá ááľáááľá á°áŁáĽáá°áĽáŤáááľááá°áľá°ááá
áľ?
1. á á
2. á¨áá
3. áĽááá á
á áá°áá
á
30
8
áĽáľáŤááá á áááá áááááľáá áľáá áŽááááá áłááááŤááá? 1. á á
2. á¨áá
30
9
ááĽáŤáááĽá 308
áááľáá áá¨ááá¨áá áŽáááááŤáłááá áľááááŤáľáááá á?
5. á¨áľá¸áá
á á
6. á ááá°áá
á ááá
áŁáľá ááť
ááŠá
10
7. á¨ááľá¨áŤ
á¤á°áááľ
áľááááá
8. áááŤáá¨
áĽááąâŚ
Section 4: Psychological factors
40
1
áľá á áááá áááá á áľá á áŤááá ?
1. á á
2. á¨áá
3. áĽááá áá áá°áá
á
40
2
á¨á¤á°á°áĽááŁá¨áľáŤáŁáá°á¨áŁááááá¨ááá˝á°áá˝áĽáááĽáŤá¤ááá
áľáááĽáá°ááŤáááá°áááłá?
4. á á
5. á¨áá
6. áĽááá áá áá°áá
á
40
3
á¨ááá¨á°á ááąáľá°áá˝ááá áááľáľáááŤááá ? 1. á¨ááľ/á¨á°ááŁá
2. á¨áá¨á/ááá
3.
áááŤáááĽááąâŚâŚâŚâŚ
âŚ
40
4
á¨ááá á°á ááąáľá°áá˝á áá°áĽááá¨áłáłáá¨áŤá? 1. á á
2. á¨áá
40
5
áĽááľááŁáááľá˝ááłááááá ááľááááŤáľá¨áá°áĽááľááĽááá
áááá á?
3. á á
4. á¨áá
40
6
áĽááľááŤáááľáá˝ááłááááá ááľá°áá˝á áá°áĄááľááĽáááá
áááá¨áŤá?
3. á á
4. á¨áá
40
7
áá ááľáááľ áĽáá°áá á áááľáŤáľáŁá? 3. á á
4. á ááľáĽá
Section 5: Behavioral factors
501 ᨠáľáłá á áá ááľáááľáá á á°áá˝ ááľ á˛ááľáą áĽáŠ á°ááľ
áá°áááłá?
1. á á
2. á¨áá
502 ᨠáľáłá á áá ááľáááľáá ááá°áľáá áĽááłáá¨áą
á¨ááŤáľáłááľ ááááľ áá ááá?
1. á á
2. á¨áá
áááľáá¨ááá¨áá
>>>áá°áĽáŤá504
11
503 á¨áááá°á áá°ááĽáŤááááľáá áá¨áá,
ááľáááľááááá°áľááááá°áłááľááá áááľááááľáá ááá
?
6. á¨ááľáááľá
áá°áá°áá á¨áĽ
7. á¨á°áťááá áŽá
áŤáŁ
8. á¨á°á á°á°áá
9. á¨ááŁáááľáá
10. áááŤáááĽááą
504 áąáľá¨ááŤá˛ááááŽá˝ááá ááá? 3. á á
4. á¨áá
áááľáá¨ááá¨áá
>>>>áá°áĽáŤá601
áááą
505 á¨áááá°á áá°ááĽáŤááááľáá áá¨ááá¨áá áááľáąáľá¨ááŤáľá
áááááááľááá?
5. á ááá
6. áŤáľ
7. á˛ááŤ
8. áááŤáááĽááą
506 á¨áá á áŤáá áľáłá á¨áá áá áááľ á áááľ áá ? 1. á á
2. á áá áá
á
507 á¨á áŤá áĽáá áľáá´ á á¨áľááľ ááá áŤá°ááá? 1. á áá 2 áá
2. á áá 1 áá
3. á áłáááľ
1 áá
4. á áá 1
áá
5. ááá
áĽáá áľáá´
á áá°ááá
Section 6:Pattern of cell phone use
601 á¨ááŁáááľááá áááľ? 3. á á
4. á¨ááá
áááľáá áá¨áá If >>>>áá°áĽáŤá
602, áááą
602 á¨ááŁáááľááááá¨áá ᎠáááááĽáá˛áŤá°áłááľááľáá ááá áłá? 3. á á
4. á áá ááá
603 á¨ááŁáááľáááá á¨ááľáááľ ááá°á áááááĽáá˛áŤá°áłááľááľáá ááá áłá? 5. á á
6. á áá ááá
604 á ááŁáááľáá¨ááľá ááŤá°áááľá¨áĽááľá°ááľáááááľá¨ááá¨áĄáľá¨áááááá´áááľááá? 4. á¨áááááááľ
12
5. á¨á˝áááááááľ
6. á˘áá
605 á¨ááŁáááľááááááŤá ááááĽá¨áľááááááłá? 5. áááá
6. á ááłááľáá
7. á áŁáá ááá áá
8. áááá áááá
606 á¨ááŁáááľáá¨ááľá ááśáŁá°á áá˝áśáĽááľáááá á°á¨áááŤááá? 3. á á
4. á¨áá
607 á ááá¨áá ááá áľáááááľááááĽááá ááá? 3. á á
4. á¨áá
608 á¨ááŁáááľááááľááááááĽáŞáĽááłááá ááŤá°ááá? 3. á á
4. á¨áá
609 á áŁááłááľáááááá á ááłááľáŚáłáľááá¨ááááłá áľáááłá á 3. á á
4. á¨áá
610 á ááŤáááľáľááááĽááá°áľááááľá˛á°ááá¨ááŤááąá áľáááłá á? 1. á á
2. á¨áá
611 áĽááááľáá áá°áááľ (á¨ááááá) ááááá? 3. á á
4. á¨áá
612 á¨ááŁáááľááááľáááá˝ááŤáááľááá ááá áľá¨áá˝áá áľáŚáłáŤá°áááŁá? 3. á á
4. á¨áá
613 á¨ááŁáááľááááľááááá°ááŤááŤá? 5. á á
3. á¨áá
614 á¨ááŁáááľááááá áá ááá¨á˝áááááááľáááŤá/áŤááŁá? 3. á á
4. á¨áá
áááľáá¨ááá¨áá>>>>áá°áĽáŤá
618 áááą
615 ááĽáŤáááĽá 613 áááľáá áá¨ááá¨á°áá¨áááľáá¨á˝áááááááľáłáŤááĄáŤá áá? 3. á á
4. á¨áá
616 á¨á°áá ááľá¨á˝áááááááľá ááá˝á°áá˝á¨ááá áĽááľááááŤá áááááá? 5. á áŁáá¨áá°á
6. á¨áá°á
7. áá á°á
8. á áŁááá á°á
617 á¨ááŁáááľááááá¨á˘áá°áááľá áááááľáá ááá áłá? 3. á á
4. á¨áá
618 ááĽáŤáááĽá 617áááľáá áá¨ááá ááá°á¨áá¨ááá ááľáľá¨áá ááá°ááá? 5. áĽáá° Face book áŤááá á áŤááľá¨áážá˝á
6. á˘áááážá˝á
7. áááá
13
8. áááŤáááľááą
619 á¨á¤áá áááááľá¨ááŤááá áľá°áááá ááŁáááľááááŁááŤáááľá°á°áááááľáááá¨á˝ááááááľá°ááŽáááľá¨áá Ꭰáááá áĽááłáá¨áąá˘á°á¨áááá°ááááľ? 3. á áááá°ááá
4. á ááááá
áááľáá áá¨ááâşâşâşâşâşâşâşâşáá°áĽáŤáááĽ
á 620 áááą
620 á¨á¤áá ááááá°á°áŞá áááá¨áá Ꭰáááá áĽááłáá¨áąá ááá áááľááááľá˘áŤá°áłááľáááá¨áŁá? 5. á ááŁááá°á°áááá
6. á á˝áááááááľ
7. á áááąáááááľ
621 áĽáá°ááá°á¤ááľáá áąááá¤ááľáá áąáá°áĽá¨áľáá¨ááŁáááľáá ááá á áááááááľááááĽá˘á°á¨áá¨á°áŠá ááľáľáááá á ááŁáĄááłáá¨áąáĽáá˛ááľáąáá á ááá ááá¨áľáŁá? 3. á á
4. á¨áá
áááľáá¨ááá¨ááâşâşâşâşâşâşáá°áĽá¨á
ááĽá 622 áááą
622 á¨áááá°á áá°ááĽáŤááááľáá¨ááá¨ááá¨ááá¨á ááá¨ááŁáááľáá ááá áááááľááŁááááááłáľááá¨áááĽáááŤáľáŁá? 4. áá°áĽáŹááŤááŁáĽáá
5. á¨á¤áá áááááľá°áŞáľáááľá¨áááá¨ááŁáááááááľáááááľáá¨áĽ
áťá
6. áááŤáááĽááą
623 á¨áá áŽááááľááááľáááľááá°áľáŤááĽááľáááá˘á¨áąááááľáłááľá˘áááá¨á áááá áááááľáá°ááŤááá áľá°áááá¨ááŁáááááĽá¨áľáá¨áááá°áłááľá¨ááŤáľá˝áá áááááľá˘áŤááá¨áá áąáá¨á´ááłáŞááá°á¨áľáŤá°á¨ááááŤ
áá¨ááá?
3. á á
4. á¨áá
624 áĽá á áá ááľááłá á ááŁáá á ááŤáááľ á¨áá°áŤ ááľáŠá á ááá°áá˝ á¨ááá á áááŹá˝á áĽáá°áŤáŁáá á áááľ áááŽá˝ á˘áá áááááá¤á¨ á ááľ á áá áááľ á¨áťáááĄáĄ 1. á ááśáá˛á á¨ááľáááľ ááľáłááť
2. á ááśáá˛á á¨áá Ꭰááľáłááť
3. á¨á¤á áááŽá˝
4. áá áŤá ááĽááą-----
áľááľáĽáĽáááľá áá°áááá!!