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FORM 4

URBAN = 1 RURAL = 2
PROVINCE/CITY.........................................

DISTRICT.....................................................
COMMUNE/WARD.......................................
TYPE OF FACILITY
COMMUNE/WARD HEALTH CENTER............ 1
REGIONAL POLYCLINIC............................2
NAME OF RESPONDENT:.............................................................
(DIRECTOR OF REGIONAL POLYCLINIC OR HEALTH CENTER)
YEAR
DATE INTERVIEW ENDED
ANTHROPOMETRIST..............................................................
TEAM LEADER........................................................................
HEALTH FACILITY QUESTIONNAIRE
MONTH
CODE
CODE
MINISTRY OF HEALTH - GENERAL STATISTICAL OFFICE
DAY
2001 - 2002
INTRODUCTION WHEN INTERVIEWING THE DIRECTOR OF THE
CHC OR THE REGIONAL POLYCLINIC
Let me introduce myself:
I am: ..............................................., the doctor from the National Health Survey team.
The National Health Survey is being implemented in all 61 provinces/cities
throughout the country with 1200 communes/wards selected randomly at the central
level. In each of the communes/wards selected, the CHC or regional polyclinic is
one of the subjects of the survey. The contents of the survey focus on areas such as
physical facility, personnel, technical qualifications of commune health workers.
Therefore today I would like to ask you some information about the above subjects.
The information you provide will not be used for purposes of inspecting or
evaluating, but only to assess the overall current situation throughout the country in
order to propose appropriate policies and solutions for improving quality and
efficiency at the grassroots level. All information will be kept confidential.
We hope that you will cooperate with us to collect the necessary information, contributing
together with the government to more appropriate policies for our health sector.
Thank you.
HEALTH FACILITY QUESTIONNAIRE
A. RESPONDENT'S BACKGROUND A
1 2 3 4 5
Age Sex Medical qualification Year of Years of medical
Doctor................................... 1 graduation experience
General P A............................. 2
Pediatrics/Obstetrics PA.......... 3
Other Physician's assistant....... 4 RECORD LAST
Nurse........................................ 5 TWO DIGITS
Mid-level midwife....................... 6
Basic level midwife..................... 7
Traditional practitioner.............. 8
Male..........1 Other........................................ 9
Female......... 2
YEAR YEAR YEARS
B. BASIC CHARACTERISTICS OF THE FACILITY B
1 2 3 4
When How is this Does the facility What needs to be repaired ?
was this CHC - facility built ? currently need Walls.................................... 1
regional repairs ? Roof.......................................2
polyclinic OBSERVE Floor................................ 3
established ? Solid................ 1 Sanitary facilities.......................... 4
RECORD LAST Semi-solid.......... 2 Yes......... 1 Water, electricity............................... 5
TWO DIGITS Temporary..............3 No.............2 5 Others....................................... 6
YEAR SECOND THIRD
5 6 7
Does this facility How often is electricity service What is the main source of water
have electricity ? interrupted ? used at this facility ?
DON'T INCLUDE Almost every day........................... 1 Piped city water.................................................................... 1
BATTERY OR One or two times per week..............2 Drilled well.......................................................... 2
SOLAR One or two times per month............... 3 Dug well................................................... 3
Once ever 2-3 months.....................4 Rain water........................................................................... 4
Yes................... 1 Never.................................... 5 River/spring/pond water............... 5
No............ 2 7 Piped mountain spring water............ 6
Other (specify)................................................... 7
FIRST
3
HEALTH FACILITY QUESTIONNAIRE
B
8 9 10 11 12
Is this source of How far is this How many days On average in a day, how Does this
water available source of water per week is this much time does this facility commune/ward have
at this health facility from this health facility open for devote to diagnosis and village health
building ? facility? diagnosis and treatment? workers?
Yes................ 1 10 treatment? Yes.......... 1
No................. 2 No..............2 17
METERS
13 14 15 16 17
How many villages How many km away How many village How many village How far is it
in the commune/ from this facility is health workers are able health workers from this facility
ward have a village the furthest village to do prenatal know how to give to the assigned
health worker? health worker in checkups and assist in injections ? referral hospital?
your commune/ normal deliveries?
ward?
,
IF INTERVIEWING REGIONAL POLYCLINIC, RECORD 0 IN QUESTION 18, 19, 20 FOR THE ROW
FOR REGIONAL POLYCLINIC. IF NOT AVAILABLE OR DON'T KNOW RECORD KB IN ALL SQUARES
OF THE RELEVANT ROW FOR Q. 18, 19 AND 20.
18 19 20
Mode of transport codes: Distance in km from What are the most How much time does
On foot...............................1 this facility to the common modes of it take to get to [...]
Horse, animal cart.................. 2 nearesr [......] transport to go to using those modes of
Other non-motorized (LESS THAN 1 KM, [...]? transport ?
transport..................... 3 RECORD TENTHS
Motorized transport............ 4 OF KM) SEC-
Other....................................... 5 KM HOURS
A. Regional Polyclinic ,
B. District or Sectoral/ ,
Ministerial hospital
C. Provincial/city hospital ,
D. Central or military hospital ,
E. Private facility ,
F. Traditional practitioner ,
MINUTES
NUMBER OF
KM PERSONS PERSONS VILLAGES KM
HOURS DAYS MINUTES
FIRST OND THIRD
Can you tell me, for each day of the week, whether the clinic is
4
HEALTH FACILITY QUESTIONNAIRE
C. EQUIPMENT C
1 2
Does this facility have the following functioning Does this facility use
equipment and conditions? this [...]?
Have, functioning............. 1
Don't have/broken......... 2 NEXT EQ. Yes.............1
TYPE OF EQUIPMENT No................ 2 NEXT EQ
A Phone
B Refrigerator/cold chain
C Sterilization equipment
D Eye chart
E Blood pressure cuff
F Thermometer
G Stethoscope (binaural 2 ears)
H Child growth chart
I Infant scale
J Malnutrition program scale
K Adult scale
L Microscope
M Delivery/Family Planning bed/table
N Gynecological/FP instruments
O Fetal monaural stethoscope
P Instrument to measure pelvis
Q Ear, nose, throat instruments
R Electric acupuncture
S Pressure point chart (acupressure)
5
HEALTH FACILITY QUESTIONNAIRE
3 C
Currently in this facility, do you have the Yes............... 1
following chemicals and materials? No................. 2
A Disinfectant alcohol
B Iodine antiseptic
C Disinfecting chemicals
D Bandages/gauze
E Gloves
F Quickstick pregnancy test
G Albumin urine test strip
H Sterilized injection devices and needles
(including also plastic disposable syringes and needles)
I Acupuncture needles
6
HEALTH FACILITY QUESTIONNAIRE
D. DIAGNOSIS, TREATMENT AND PREVENTION OF DISEASES D
1 2 3 4 5
Are there any cases Does the facility Does the facility How many private In the past 12 months,
coming for record fully all cases provide practitioner report have there been any
diagnosis and who just come to consultation/ to the facility or meetings between the
treatment that are buy/receive treatment at polyclinic about facility/polyclinic and
not recorded in the medicine without a patient's home? social disease or private providers?
recordbooks? consultation epidemics?
Yes............... 1 Yes.......... 1 Yes............... 1 Yes............1
No..............2 No.................... 2 No.............. 2 No............ 2
ASK TO SEE CONSULTATION AND IMMUNIZATION RECORDS OF THIS FACILITY
6 7 8 9 10
In the past 4 weeks, In the past 4 weeks, how In the past 4 weeks Does the facility Does this facility
how many patient many patients have how many patients assign night assign staff to work
visits did you have been referred to a higher did the clinic shift duty? off the premises of
at this facility ? level facility immunize to prevent the facility?
disease? Yes................ 1 Yes................ 1
No................ 2 No................ 2
11 12
Does this facility What is the fee charged for one
provide the following time of [....]? (including
services? medicine and materials)
Yes.............. 1
No................... 2 NEXT IF NOT CHARGED RECORD 000
SERVICE SERVICE THOUSAND DONG
A. Normal delivery THOUSAND DONG
B. Prenatal checkup THOUSAND DONG
C. Muscle injection(including materials, but
not medicine fees) THOUSAND DONG
D. Consultation for common illness THOUSAND DONG
E. Simple operation THOUSAND DONG
F. Menstrual regulation/suction abortion THOUSAND DONG
G. Acupuncture/ massage/ acupressure THOUSAND DONG
H. Take pulse and prescribe herbal medicine THOUSAND DONG
PERSONS
VISITS PEOPLE PEOPLE
7
HEALTH FACILITY QUESTIONNAIRE
13 D
In the past 12 months, how
often has [PROGRAM/
PROJECT] been implemented?
Regularly.......................... 1
Monthly......................... 2
Once every two months............... 3
Quarterly............................... 4
Two times per year............... 5
Yearly.......................... 6
Less than once a year............. 7
PROGRAM/PROJECT Don't implement program........... 8
A Expanded Program for Immunization (EPI)
B Control of Diarrheal Disease (CDD)
C Acute Respiratory Infection (ARI)
D Malnutrition control
E Population/FP, reproductive health
F TB control
G Goiter control
H Malaria control
I Xeropthalmia (Vitamin A)
J Anemia in pregnancy
K Obstetrics/Gynecology
L Pediatrics
M Rehabilitation
N HIV/AIDS/STD control
O Clean water/sanitation
P Food safety
Q Rural health development
R Health care for the poor
S Other (specify)...................................
14 On average in a week, how much time does this facility devote to implementing national
health programs such as those just mentioned? HOURS
8
HEALTH FACILITY QUESTIONNAIRE
E. STAFF E
1
Please let me know about each person who works in this facility?
A B C
Please give me What is [NAME]'s highest Does [NAME]
the name of training level? have a private
O everyone who Doctor................................... 01 practice?
R works at this General P A............................. 02 (provide
D facility? Pediatrics/Obstetrics PA.......... 03 consultations and
E Other Physician's assistant....... 04 treatment for a
R Nurse........................................ 05 private fee)
Mid-level midwife....................... 06
Basic level midwife..................... 07
Univ/High school Pharm......... 08
Basic pharmacist.................s................. 09
Traditional practitioner.............. 10 Yes.............. 1
Other........................................ 11 No............... 2
1
DIRECTOR
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
ONLY NEED
FIRST NAME
9
HEALTH FACILITY QUESTIONNAIRE
F. TRAINING F
1 2
In the 3 years (1998, 1999, 2000) have staff of With regard to the
[FACILITY] had any training in any of the following facility's need for this
programs or areas? training, how do you
(EXCLUDE TRAINING TO BECOME evaluate the need for
NURSE, PHYSICIAN'S ASSISTANT ... training in [...]?
AND TRAINING TO BE PROMOTED Very necessary...................... 1
FROM NURSE TO PHYSICIAN'S Necessary......................... 2 NEXT
ASSISTANT OR FROM PHYSICIAN'S Yes.......... 1 Fair..................... 3 TRAIN-
ASSISTANT TO DOCTOR.) No............... 2 Not necessary................ 4 ING
A Expanded Program for Immun. (EPI)
B Control of Diarrheal Disease (CDD)
C Acute Respiratory Infection (ARI)
D Malnutrition control
E Population/FP, reproductive health
F TB control
G Goiter control
H Malaria control
I Xeropthalmia (Vitamin A)
J Anemia in pregnancy
K Obstetrics/Gynecology
L Pediatrics
M Rehabilitation
N HIV/AIDS/STDs control
O Clean water/sanitation
P Diagnosis and treatment
Q Management and Planning
R Traditional medicine
S Pharmacy
T Other (specify)............................
10
HEALTH FACILITY QUESTIONNAIRE
G. MEDICINE G
1 2 3 4 5
Does this facility How much is the current How many types of Does the facility In the past 4 weeks
sell medicine? medicine capital of this drugs does the clinic have the 4th how many patient
facility? (including currently have? version of the visits did you have
value of medicines and (SEE MEDICINE essential who bought
cash) BOOK OR CHEST) medicine list medicine without a
issued in 1999? consultation?
Yes.............. 1 Yes.......... 1 (SEE RECORDS)
No................ 2 THOUSAND DONG No................ 2
6 7 8
Does this facility plant herbal How many types of plants are Does this facility use/produce
medicines? there in the garden? herbal medicine ?
Yes....................1 Yes..................... 1
No....................... 2 8 No....................... 2
TYPES OF
MEDICINES PATIENT VISITS
TYPES OF PLANTS
11
HEALTH FACILITY QUESTIONNAIRE
9 G
Currently does the facility have each of the following Yes............1
medicines ? (SEE RECORDS OR MEDICINE CHEST) No............ 2
A. Artemisinin
B. Mebendazol /Albendazol
C. Iron pills
D. Oxytocin
E. ORESOL
F. Amoxicillin
G. Paracetamol
H. Diclofenac
I. Clorpheniramin
J. Adrenaline
K. Diazepam
L. Dexamethason
M. Metronidazol
N. Nystatin
O. Co-trimoxazol/biseptol
P. Atropine sulfat
Q. Cefalexin
R. Dextromethorphan 15 mg
S. ASA alcohol (fungus)
T. Theophylin
10
Normally at this facility how much do you charge for the following drugs ?
IF THE FACILITY DOESN'T SELL THE TYPE OF MEDICINE ASKED, RECORD 00,0 IN BOXES
NAME OF DRUG UNIT SALE PRICE
A Amoxicillin capsule 500 mg VN Card 10 tablets , THOUSAND DONG
B Paracetamol tablet 500 mg VN Card 10 tablets , THOUSAND DONG
C Diclofenac tablet 50 mg VN Card 10 tablets , THOUSAND DONG
D Mebendazol 500 mg VN 1 tablet , THOUSAND DONG
E ORESOL VN Package , THOUSAND DONG
CHECK QUESTION 1 ON
PAGE 9:
IF THE ANSWER IS 2,
DON'T ASK QUESTION 10,
SECTION H
12
HEALTH FACILITY QUESTIONNAIRE
H. FINANCE H
Now I would like to ask a few questions about revenues and expenditures of this facility
Let me see the helath statistics report for the commune/ward for the 12 months of the year 2000
INTERVIEWER COPY THIS INFORMATION
SOURCES OF REVENUE FOR THE FACILITY
A From higher level (Central, City/Prov., District) . THOUSAND DONG
B Commune/ward People's Committee . THOUSAND DONG
C Income from health insurance . THOUSAND DONG
D Fees from consultations . THOUSAND DONG
E Outside assistance . THOUSAND DONG
F Medicine sales (CHECK SECT. G, Q. 1) . THOUSAND DONG
G People's contributions . THOUSAND DONG
H Others (cash and in-kind) . THOUSAND DONG
I Total income . THOUSAND DONG
EXPENDITURES OF THIS FACILITY
J Staff salaries . THOUSAND DONG
K Purchases . THOUSAND DONG
L Expenditures for the poor (exemptions/reductions) . THOUSAND DONG
M Basic construction . THOUSAND DONG
N Others (cash and in-kind) . THOUSAND DONG
O Total expenditures . THOUSAND DONG
13
HEALTH FACILITY QUESTIONNAIRE
I. SUPERVISION AND INSPECTION I
1
In the past 12 months has anyone come to inspect or Yes.............1
supervise the activities of this facility? No................ 2 4
2
What did they inspect or supervise? Yes.......... 1
No..............2
A Technical skills or equipment?
B Management
C Sanitation/environment
D Medicine?
E Finances ?
3
How many times did they supervise or inspect?
TIMES
4
In your opinion, in order to improve the quality of services of
this facility, what methods are needed?
Invest in equipment, infrastructure funds............................. 01
Train to improve technical skills............................................... 02
Put doctor in commune/ward............................................... 03 FIRST
Guarantee living standard of health staff.................................. 04
Increase village health worker net work.................................. 05 SECOND
Increase staff numbers............................................................ 06
Greater co-operation with authorities and mass organizations.............. 07 THIRD
Strengthen inspections of higher levels................................. 08
Tighter management of private medical/drug providers................... 09
Other solutions (specify).................................................... 10
LIST IN ORDER OF
IMPORTANCE
14
HEALTH FACILITY QUESTIONNAIRE
J. DIRECT OBSERVATION OF THE CONDITIONS OF THE FACILITY J
1. AFTER LOOKING THROUGH EACH ROOM, YARD, GARDEN,... INTEVIEWER GIVE
GENERAL COMMENT ON HYGIENE OF THIS FACILITY.
CLEAN................................ 1
DIRTY................................. 2
2. IS THERE WATER AND FACILITIES FOR WASHING Yes................... 1
HANDS IN EACH OF THE FOLLOWING ROOMS: No.................... 2
No room with that function........................... 3
A
ROOM USED FOR CONSULTATIONS A
B
ROOM USED FOR IMMUNIZATIONS B
C
ROOM USED FOR BIRTHING (DELIVERY) C
D
ROOM USED FOR FAMILY PLANNING PROVISION D
3. How is medical waste of this facility disposed of? Yes................ 1
No............. 2
A Disinfected prior to disposal A
B Buried B
C Burned C
D Collected and taken away D
E Thrown anywhere E
4. WHAT KIND OF TOILET DOES THIS FACILITY HAVE?
FLUSH TOILET WITH SEWAGE PIPES/SEPTIC TANK........ 1
DOUBLE VAULT COMPOST LATRINE............................. 2
SIMPLE TOILET/BUCKET...................................................... 3 6
OTHER............................................................................................ 4 6
NO TOILET................................................................................. 5 6
5. IS THE TOILET SANITARY? Yes............... 1
(NO SMELL, NO FLIES, CLEAN, DRY AND ENCLOSED) No............... 2
6.
Does this facility face any difficulties in sterilization? Yes.............1
No................ 2 SECT K
7. What difficulties? RECORD 1 IF RESPONDENT Yes............. 1
A Autoclave broken down MENTIONS PROBLEM. No................ 2 A
B Drying cabinet broken down AFTER THAT RECORD 2 IN ALL B
C No electricity, materials REMAINING BOXES C
D Lack of chemical substances D
E Lack of devices,equipments E
F Lack of knowledge F
G Other, specify G
15
HEALTH FACILITY QUESTIONNAIRE
K. KNOWLEDGE K
FACILITY DIRECTOR INTRODUCE STAFF MEMBERS IN CHARGE OF
THE FOLLOWING PROGRAMS:
NAME OF STAFF MEMBER
ARRANGE A TIME SCHEDULE OF SHORT INTERVIEWS FOR EACH OF THESE STAFF
MEMBERS WITH THE RELEVANT QUESTIONS. IF NOBODY DOES OBSTETRICS, DROP
QUESTIONS 6, 7, 8.
INTERVIEW THE STAFF MEMBER IN CHARGE OF THE ARI PROGRAM
1
According to you, to identify a case of a child
under age 1 year with acute respiratory infection, Fast breathing >=50 /min................1
what symptoms would she/he have? Contraction of thorax..................................... 2
NO PROMPTING Fever > 37.5 degrees .............................. 3
CIRCLE THE RESPONSE CODES Cough......................................................... 4
2
For the case of a 2 year old child with a cough and fever Could use............... 1
(over 37.5 degrees), breathing >50 times/minute, based on the Should not use...............2
list of medicine below, categorize them by type that DK........................ 9
could be used or should not be used? A Amoxicillin tablet
B Penicillin tablet
READ NAME OF EACH MEDICINE C Ampicillin tablet
ASK RESPONDENT TO CLASSIFY D Tetracycline tablet
E Peflacin tablet
F Penicillin injection
G Prednisolon
H Erythromycin tablet
I Dexamethazon tablet
J Paracetamol tablet
K Biseptol/Bactrime
L Cough syrup
M Cough suppressant
CDD PROGRAM
MALNUTRITION PROGRAM
PRENATAL CHECKUP/DELIVERY
ADULT HEALTH CONSULTATIONS
ARI PROGRAM
16
HEALTH FACILITY QUESTIONNAIRE
INTERVIEW THE STAFF MEMBER IN CHARGE OF THE CDD PROGRAM K
3
According to you, which symptoms should a Number of BMs............................................. 1
mother pay attention to in case her child has Nature of feces (runny, hard, bloody) 2
diarrhea? Vomiting............................................ 3
NO PROMPTING Thirst...................................................... 4
CIRCLE THE RESPONSE CODES Fever....................................................... 5
4
According to you what should a mother be
told to do when her child has a simple Use antibiotics......................................... 1
diarrhea without a fever? Eat or nurse as usual................................. 2
NO PROMPTING Drink ORESOL or alternative solution....................................... 3
CIRCLE THE RESPONSE CODES Bring child to health facility....................... 4
INTERVIEW THE STAFF MEMBER IN CHARGE OF THE MALNUTRITION PROGRAM
5
According to you which of the following could lead to child malnutrition?
READ OUT LOUD FOR RESPONDENT TO Yes............................... 1
HEAR EACH CAUSE No............................. 2
CAUSE No response/DK.............9
A Child weaned at age 2
B Child often contracts acute respiratory infection
C Child infected with worms/parasites
D Apart from breastfmilk, fed with baby cereal starting at age 5 months
E Child breastfed until the 10 month, no other food
F Child weaned at 4 months of age
G Child with harelip and cleft palate
H Child breastfed according to a schedule
I No breastfeeding when child has diarrhea
J Child fed diluted powdered milk
K Child born premature
L Mother breastfed whenever child is hungry
17
HEALTH FACILITY QUESTIONNAIRE
INTERVIEW THE STAFF MEMBER IN CHARGE OF OBSTETRICS K
INSTRUCTIONS TO INTERVIEWER ON RECORDING SCORES FOR VIGNETTES
INTERVIEWER READ VIGNETTE AND QUESTIONS TWO TIMES
RECORD CODE 1 FOR EACH QUESTION THE RESPONDENT STATES ON HIS/HER OWN
I) IF THE RESPONDENT GIVES ALL LISTED QUESTIONS, THEN RECORD 1 TO ALL
BOXES AND GO ON TO THE NEXT QUESTION
II) IF THE RESPONDENT FAILS TO ANSWER ALL THE QUESTIONS, INTERVIEWER
SHOULD ASK ANOTHER QUESTION "According to you is that all?"
IF THE RESPONDENT SAYS HE/SHE IS FINISHED, THE INTERVIEWER SHOULD
RECORD 0 IN THE BOXES FOR THE REMAINING QUESTIONS.
VIGNETTE 1
OBSTETRICS CASE
(READ TWO TIMES)
A 24-year old woman had previously been pregnant. Currently she is 8
months pregnant and has come in for her first prenatal checkup.
SCORES
- RESPONDS WITHOUT PROMPTING..............................................
1
- DOES NOT PROVIDE THIS RESPONSE................................
0
6
What 10 questions related to pregnancy would you ask this woman?
A First day of last period?
B Number of previous pregnancies?
C Number of children born alive and dead?
D Number of miscarriages/abortions?
E Complications of previous delivery?
F Intervention during previous delivery?
G Birthweight of baby from previous delivery?
H Health status of child from previous birth?
I Current health/symptoms of woman?
J Symptoms of pregnancy such as nausea, vomiting, gain or loss in weight
AFTER RECORDING SCORE IN ALL BOXES, GO ON TO CONTINUATION OF VIGNETTE 1
SCORE
DIRECTOR............................1
FIRST LISTEN TO THE RESPONDENT. ANY QUESTION THAT HE OR SHE MENTIONS
RESPONSE CODES:
READ OUT QUESTIONS a-f ONLY IF THE RESPONDENT DID NOT MENTION THEM. AGAIN, FIRST LET THE RESPONDENT ANSWER. AFTER HE OR SHE IS
RESPONSE CODES:
READ OUT QUESTIONS a-c ONLY IF THE RESPONDENT DID NOT
RESPONSE CODES:
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HEALTH FACILITY QUESTIONNAIRE
CONTINUATION OF VIGNETTE 1 K
(READ TWO TIMES)
The woman had one earlier pregnancy with a normal delivery, never miscarried or
had an abortion. Currently this woman feels she has gained weight faster than in
the previous pregnancy but is healthy. The woman does not smoke, drink alcohol,
come in contact with toxins and in this pregnancy has not used any type of
medicine.
SCORES
- RESPONDS WITHOUT PROMPTING..............................................
1
- DOES NOT PROVIDE THIS RESPONSE................................
0
7.
What eight things would you examine in this case?
A Check pulse or measure blood pressure
B Measure height
C Measure weight
D Manual checking of fetus, measure height of fundus
E Listen to fetal heartbeat
F Measure the pelvis
G Check genital organs
H Check for edema in legs
AFTER COMPLETING ALL BOXES, CONTINUE ON WITH QUESTION 8
SCORE
19
HEALTH FACILITY QUESTIONNAIRE
K
8
According to you, should a pregnant woman with one or several of the
following conditions deliver the baby at the CHC or be transfered?
INTERVIEWER READ EACH OF THE
CONDITIONS AND RECORD CODE At CHC........................... 1
AS APPROPRIATE Transfer up...................... 2
CONDITIONS No response/DK...................... 9
A Mother healthy, 150 cm tall
B Premature birth
C First baby
D Mother's age at time of delivery is 30 years old
E Mother healthy, 140 cm tall
F Disproportion between mother's pelvis and baby's head
G Baby full-term (38 to 42 weeks)
H Mother gained weight regularly on average 1.5 kg/month
I Mother's age at time of delivery is 38 years old
J Single birth (not twin or triplets..)
K Not breech birth
L Eighth delivery for this woman
M Too much amniotic fluid
N No sign of fetal distress
20
HEALTH FACILITY QUESTIONNAIRE
VIGNETTE 2 CASE OF HIGH BLOOD PRESSURE
K
INTERVIEW HEALTH WORKER IN CHARGE OF DIAGNOSIS AND TREATMENT
INSTRUCTIONS TO INTERVIEWER ON VIGNETTES
INTERVIEWER READ VIGNETTE AND QUESTIONS TWO TIMES
RECORD CODE 1 FOR EACH QUESTION THE RESPONDENT STATES ON HIS/HER OWN
I) IF THE RESPONDENT GIVES ALL LISTED QUESTIONS, THEN RECORD 1 TO ALL
BOXES AND GO ON TO THE NEXT QUESTION
II) IF THE RESPONDENT FAILS TO ANSWER ALL THE QUESTIONS, INTERVIEWER
SHOULD ASK ANOTHER QUESTION "According to you is that all?"
IF THE RESPONDENT SAYS HE/SHE IS FINISHED, THE INTERVIEWER SHOULD
RECORD 0 IN THE BOXES FOR THE REMAINING QUESTIONS.
(READ TWO TIMES)
SCORES
- RESPONDS WITHOUT PROMPTING..............................................
1
- DOES NOT PROVIDE THIS RESPONSE...............................
3
9.
Which 11 questions related to high blood pressure would you ask this man?
QUESTIONS RELATED TO ILLNESS
A
Ask about signs of illness? (headache, dizziness, fuzzy vision, pain in chest)?
B
For how long has he had these symptoms ?
C History of high blood pressure?
D Any other illnesses?
E Has or is currently treating any illness?
F Anyone else in the family with high blood pressure?
QUESTIONS RELATED TO LIFESTYLE
G Occupation or Age?
H Diet?
I Whether smokes or drinks alcohol?
J Ask about exercise regime?
K Whether the person suffers from stress?
AFTER COMPLETING ALL BOXES, CONTINUE ON TO CONTINUATION OF VIGNETTE 2
Score
A 58 year old man with high blood pressure comes in for a check up
DIRECTOR............................1 DIRECTOR............................1
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HEALTH FACILITY QUESTIONNAIRE
CONTINUATION OF VIGNETTE 2 K
(READ TWO TIMES)
The man mentioned above has never been treated for high blood pressure
He smokes 1 to 2 packages of cigarettes per day and drinks two cups of
beer in the evenings on weekends. He eats "anything the wife cooks"
and gets practically no exercise.
SCORES
- RESPONDS WITHOUT PROMPTING..............................................
1
- DOES NOT PROVIDE THIS RESPONSE................................
3
10
What 9 factors would you examine at any medical facility, in order to determine the disease,
cause of disease and any complications of the disease? (Do not include lab tests.)
A Measure blood pressure
B Measure blood pressure in both arms/legs
C Listen to heart and lungs
D Examine eyes
E Examine pulse
F Examine liver, spleen
G Examine kidneys
I Examine nerves
J Take weight
AFTER COMPLETING ALL THE BOXES, FINISH THE INTERVIEW
Thank you very much for the co-operation in the interview.
Score
22
HEALTH FACILITY QUESTIONNAIRE
Anthropometrist
Signature........................................................
Remarks
Team leader
Signature ....................................
Remarks
23

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