[afro-nets] Data collection instrument in behavioural studies

[Dr. Shamim ul Moula <shamimul.moula@gmail.com>]

Data collection instrument in behavioural studies
-------------------------------------------------

Dear Sir,

I received requests from some of my overseas colleagues who are
in need of the data collection instruments for in-depth inter-
viewing in a behavioural study like that of mine. I hereby send
one of my main questionnaire used for my Ph.D. study, so if they
feel, they can adopt some idea from it. No doubt, it is a long
instrument, but it served the purpose well. I shall suggest
writing a computer program in SPSS/PC edition 11+ to analyze the
responses in a database to pick up the multiple responses wher-
ever applicable. Once, I also sought help, but could get little
as it is not always present in the hands who want to help. This
is why I am sending it to AFRO-NETS, so if required, somebody
can pick up the respective ones. Country, population and situa-
tion may defer from place to place, but the quest for life re-
mains same in everywhere, in every population groups and those
are determined by the tradition, need and the socio-economic
situation.

This questionnaire was used in the rural setting of Bangladesh,
in the most populated but the poorest region of the world. De-
spite its size, I shall be happy if the AFRO-NETS authority pub-
lishes it.

Sincerely

Dr. Shamim ul Moula
Bangladesh
mailto:shamimul.moula@gmail.com

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Psychosocial factors related to the Health Care Behavior of the
rural Bangladeshi people under Rajshahi Division

Data Collection Instrument for Ph.D. Research Study
In-depth Questionnaire No. 1
(For Primary Respondent)

A. Primary Information:
1.1. Questionnaire No.----
1.2. Location of the House:
1.2.1. Name of the Village:
1.2.2.Name of the Mahalla/Para:
1.2.3.Holding/Name of the House:
1.2.4. Holding No.:
1.2.5. Identification:
1.3. Name of the Respondent:
1.4. Sex: 1) Male 2) Female
1.5. Age:
1.6. Religion: 1) Muslim 2) Hindu 3) Others
1.7. Personality (as anticipated by the interviewer): 1) Strong
2) Average 3) Weak
1.8. Educational Qualification: 1) Illiterate 2) Primary Level
3) High School Level 4)>S.S.C. 5)>Degree
1.9. Health (as seen by the interviewer physically): 1) Good 2)
Average 3) Bad
1.10. Diseased conditions: 1) Present 2) Not present
1.11. Physical Disability: 1) Present 2) Not present
1.12. Mental Disability: 1) Present 2) Not present
1.13. Look: 1) Sharp and Intelligent 2) Average 3) Blank
1.14. Smartness: 1) Very Smart 2) Average 3) Not Smart
1.15. Speech and Thought Process: 1) Very coordinated 2) Average
3) Less/not coordinated
1.16. Confidence level: 1) Overconfident 2) Average 3) Less/not
confident
1.17. Shyness/introverts: 1) Extrovert 2) Average 3) Introvert
1.18. Appearance: 1) Handsome/Beautiful 2) Average 3) Not hand-
some/beautiful
1.19. Proactive: 1) Proactive 2) Average 3) Not proactive

B. Socio-economic Information:
2.1. Type of the Area: 1) typically rural 2) some amenities of
the town are present
2.2. Total number of family member:
2.3. a) Occupation: b) Economic status: 1) Good 2) Average 3)
Not Good
2.4. Source of income earnings:) Agriculture 2) Business 3) Ser-
vice 4) Professional 5) Others
2.5. Total monthly income of the family:
2.6. Is the respondent is income earning: 1) yes 2) no
(If 2.2. is 1, then)
2.7. Respondent's income earning per month:
2.8. Ownership of the residence (House): 1) Self 2) Sheltered
2.9. Built of the residence: 1) Kachha,\ 2) Semi-Pucca 3) Pucca
2.10. Communication of the residence: 1) Good 2) Average 3) Not
well
2.11. Amenities: 1) Tube-well 2) Electricity 3) No tube-well or
electricity
2.12. Do they have the followings in their family?
1) Radio 2) Television 3) Wristwatch 4) Bicycle 5) Rick-
shaw/Van/Bullock-curt 6) Boat
7) Motor Cycle 8) Motor Vehicle
2.13. (If the respondent is a female): Education of the husband:
Illiterate 2) Primary Level 3)
High School Level 4)>S.S.C. 5)>Degree
2.14. (If the respondent is a male): Education of the wife: Il-
literate 2) Primary Level 3) High
School Level 4)>S.S.C. 5)>Degree
2.15. Do they have any one within the family related to health
service delivery in the area?
1) No 2) yes
2.16. Do they have any NGO in their village: 1) Yes 2) No
2.17. (If yes in 2.1.6.) Do they have any health program? 1) Yes
2) No
2.18. (If yes in 2.1.6.) is the respondent/family member associ-
ated with that NGO?
1) Yes 2) No

C. Health Service Facilities in the area, knowledge, Attitudes,
Practice and psychology of the people regarding care seeking in
disease:

3.1. Is there any Union Sub-center/MCWC in the village or
nearby?
1) Yes 2) No
3.2. Do you go there for treatment in any diseased condition of
you or your family members?
1) Yes 2) No 3) occasionally
3.3. (If the answer is 1 or 3 in Q, 3.2.) Do you satisfied in
the treatment there?
1) Yes 2) No 3) Other answers
3.4. ((If the answer is 2 in Q, 3.2.) Why do not you go there
for treatment?
3.5. Where do you go generally in your or your family member's
disease?
1) Government facilities 2) Private doctors 3) Quacks/Health
professionals in private practice other than doctors 4) Homeo-
paths/Traditional healers 5) Religious and Spiritual healers 6)
NGO service facilities

3.6. (As the answer to Q. 3.5.) Why do you prefer to go there
for treatment?
3.7. a) Are you satisfied with the treatment there?
1) Satisfied 2) Not satisfied
b) Cause of that
3.8. What do you think about the cause of a disease?
1) Originated from germs 2) Punishment from the God 3) Others
3.9. Do you or your family members are occasionally treated as
immediate measures in home,
when diseased?
3.10. According to you, what are the diseases that can be
treated in home?
3.11. Have you got any convenience to treat the disease in home
up to the capacity?
a) 1) Yes 2) No
b) Why
3.12. Who usually take care of those home treatments in your
family?
1) Female leader of the house 2) Male leader of the house 3)
Others
3.13. How she/he learnt those?
3.14. Why she/he learnt those?
3.15. According to you, how effective is your home treatment?
3.16. Do you believe in folk/traditional medicine/treatment?
c) 1) Yes 2) No
d) What are those medicines and for what diseases
Disease Folk medicines used 1 Diarrhea 2 ARI (Pneumonia) 3
RTI/STD 4 Abortion (pregnant): 5 Jaundice 6 Pre-Eclapmtic Toxe-
mia (of pregnant) 7 Hysteria 8 Mental retardation 9 10 11 12 13
e) Why (1or 2
3.17. Do you or your any of family members feels
shy/submissiveness/inertness to be treated for disease?
a) 1) Yes 2) No
b) Cause (If yes)
3.16. Do you or any of your family members feels that if dis-
eased, you create problem for your
family or having feelings of guilty? 1) Yes 2) No
3.17. Do you or your family members think that the disease is
the desire of almighty
Allah/Bhagaban?
a) 1) Yes 2) No
b) Why?
3.18. Do you know any habit, customs or beliefs that can con-
tribute in disease of a human being?
a) 1) Yes 2) No
b) (If yes) 1) What are those?
2) How they contribute?
c) Can you tell me the etiologies of the following diseases?
Disease Perceived etiology by the respondent 1 Diarrhea 2 ARI
(Pneumonia) 3 RTI/STD 4 Abortion (pregnant): 5 Jaundice 6 Pre-
Eclapmtic Toxemia (of pregnant) 7 Hysteria 8 Mental retardation
9 Madness 10 "Ban" 11 "Jadu" 12 "Batas" 13 "Bhoi"
3.19. Do you think that it is better to be treated as soon as
possible you feel the anomalies?
associated with the disease?
a) 1) Yes 2) No
b) (If No) Why
3.20. If you or any of your family member is diseased and if you
have enough money, where you will go first for the treatment?
a) 1) Government facilities 2) Private doctors 3) Quacks 4) Ho-
meopaths/Traditional healers 5) Religious/Spiritual healers 6)
NGO facilities
b) Why?
3.21. Can you please tell me the symptoms/adverse effects
a) Diarrhea?: 1) Frequent loose motion 2) Vomiting 3) Dehydra-
tion 4) Fever 5) Weakness 6) Others
b) ARI (Pneumonia)?: 1) Fever 2) Cough 3) Increased respiratory
rate 4) Depression of the chest cage during respiration 5) Cya-
nosis 6) Others
c) RTI/STD?: 1) Increased frequency of (micturation) urination
2) Burning urination 3) Genital ulcers 4) Lower abdominal pain
5) Discharge through genital organs 6) Others
d) Abortion (pregnant): 1) Blood/discharge per vagina 2) Lower
abdominal pain 3) Pallor or pale face 4) Fever 5) Toxic 6) Oth-
ers
e) Jaundice: 1) Yellowish tints of the eyes and skin (mucus mem-
brane) 2) Vertigo 3) Fever 4) Nausea and vomiting 5) Anorexia 6)
Others
f) Pre-Eclapmtic Toxemia (of pregnant): 1) Edema foot and body
2) High blood pressure
3) Convulsion 4) Others
g) Hysteria: 1) Fit 2) Convulsion 3) Tongue bites 4) Others
h) Madness:
i) Mental disability:
3.22. Do you think that the above-described diseases are healed:
1) Spontaneously? 2) With proper treatment? 3) By Both? 4) By
mercy of Allah 5) Others
3.2.3. a) Do you learn anything new about the diseases and
health care information? Name of the Disease/Topics of health
care Present Knowledge Previous knowledge Diarrhea ARI (Pneumo-
nia) RTI/STD Abortion ( of pregnant) Jaundice Pre-Eclapmtic
Toxemia (of pregnant) Hysteria Madness "Ban" "Jadu" "Batas"
"Bhoi" Mental disability Primary health Care Knowledge about the
health service facilities b) Source of the knowledge: 1) Govern-
ment health workers 2) NGO health workers 3) Radio/TV/Newspapers
4) Primary teachers 5) Imams and religious personalities 6) Com-
munity leaders 7) Others
3.24. What do you do immediately in the following disease condi-
tion (your or your family member's)
Headache:
Abdominal Pain:
Jaundice:
Fever with cold:
STD/RTI:
Mental depression:
Incoherent speech and work:
Hysteria :
"Madness":
1.0. According to you, who are the best health service provid-
ers?
a) 1) Government facilities 2) Private doctors 3) Quacks/Health
professionals in private practice other than doctors 4) Homeo-
paths/Traditional healers 5) Religious and Spiritual healers 6)
NGO service facilities
b) Why?
2.0. Are you satisfied with your area's Government health fa-
cilities?
a) 1) Yes 2) No
b) Why?
3.0. Can you please tell me the "good (convenience)" and "bad
(problems)" of the following health service providers regarding
receiving treatment?

Sl Health service Providers Good Bad 1 Government facilities 2
Private doctors 3 Quacks/Health professionals in private prac-
tice other than doctors 4 Homeopaths/Traditional healers 5 Reli-
gious and Spiritual healers 6 NGO service facilities

3.28. Do you think that talisman, holly water, spiritual media-
tions etc. or prayers alone can cure a patient?
1) Yes 2) No
3.29. Do you think that you (if female) or female members of
your family needs essential consents of the male members for
their treatment when diseased?
a) 1) Yes 2) No
b) Why?
3.30. Suppose two people in a house are diseased in same ex-
tents, within them one is male and another one is female. Ac-
cording to you, who will be treated first?
a) 1) Male patient first 2) Female patient first 3) Both at a
time and according to necessity
b) Why?
3.31. Will you treat them with equal importance committing same
amount of money if required?
a) 1) Yes 2) No
b) Why?
3.32. Do you consult with any one outside the family in any dis-
ease condition within your family to decide where and how that
diseased family member to be treated or taken for treatment?
a) 1) Yes 2) No
b) Why?
3.33. a) Do you know how many Government, NGO and other health
service facilities (service outlets) are present in this area?
(Compare with the correct answer)
b) What are their names/What is their locations? (Compare with
the correct answer)
c) What are the health services available there?
1) All types of treatment for all 2) Treatment for children 3)
ANC, Delivery, PNC
4) Others (Compare with the correct answer).
3.34. a) Can you please inform me about the following informa-
tion for treatment of the described diseases:
Sl no. Name of the Disease How frequent seeking modern treatment
(1= occasionally 2= frequently 3 = not at all) Place/places of
treatment Average cost informed by the respondent 1 Diarrhea 2
ARI (Pneumonia) 3 RTI/STD 4 Abortion ( of pregnant) 5 Jaundice 6
PreEclapmtic Toxemia (of pregnant) 7 Hysteria 8 Madness 9 Mental
disability 10 "Ban" 11 "Jadu" 12 "Batas" 13 "Bhoi"
b) Are you satisfied in these costs?
1) Yes 2) No
c) (If no) Why?
3.35. a) Please tell me about the expense of conveyance to go
the health service facilities (nearest clinic/hospital) for
treatment: Tk.
b) Do you think that this conveyance cost is reasonable?
1) No 2) Yes
3.36. a) Is there sufficient transport available to go to the
nearest clinic/doctor/hospital for treatment in emergency?
3) Yes 2) No
b) Are you satisfied in the present situation regarding communi-
cation to the clinic/doctor/hospital?
1) Satisfied 2) Not satisfied
3.37. a) How much time you require in minimum to visit your
nearest clinic/doctor/hospital to treat a patient due to the
communication? 1) Less than a hour 2) less than 3 hours 3) More
than 3 hours
b) Are you satisfied in this time requirement to treat a pa-
tient?
1) No 2) Yes
3.38. a) Do you think every adult in your family understand
their disease conditions immediately he/she got those?
1) No 2) Yes
b) (If no) Why they can not understand that?
c) Do you think every adult in your family inform their disease
conditions to some one responsible in the family immediately af-
ter he/she got those?
1) Yes 2) No
d) Who informs it frequently than other?
1) Male 2) Female 3) Both the male and female expresses their
sickness in same frequency
3.39. a) Do you think that "problems" and disease are the same?
1) Yes 2) No
b) (If no) please tell me some names of "problems" and "dis-
eases"
Sl No. "Problems" described by the respondent Anticipated dis-
eases 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

3.40. a) Do you think that the adolescents of your family are
occasionally reluctant to inform their disease conditions?
1) Yes 2) No
b) (If yes) Why?
1) Not caring 2) Afraid to tell 3) Do not want to burden the
guardians more
c) (If yes) Is it more with whom?
1) Male adolescent 2) Female adolescent 3) Both
3.41. a) Sometimes, some persons in the family relatively less
spoken and prefer to stay isolated in compare to others or stay
isolated due to some other reasons, do you think that if they
are diseased, their treatment is delayed?
1) Yes 2) No
b) Cause:
3.42. What is your opinion about the followings regarding the
health service providers and the health service facilities in
your area where you go to seek the treatment for your diseased
family members?
Health service facility Professional expertise of the service
providers perceived by the respondent
(Good=1, Not good=2, Average=3) Behave of the service providers
to the patients perceived by the respondent
(Good=1, Not good=2, Average=3)

Sufficient medicines
/facilities for treatment (present=1, not present=2) perceived
by the respondent If any body of respondent's family is sick,
where he/she prefers to treat the diseased
(Describe the most preferred one from 1) Which health service
facility is most convenient as perceived by the respondent
(Describe the most preferred one from 1) For all For adolescents
and married women For all For adolescents and married women 1
Government facilities/Government doctors and health providers 2
Private doctors 3 Quacks/Health professionals in private prac-
tice other than doctors 4 Homeopaths/Traditional healers 5 Reli-
gious and Spiritual
healers 6 NGO service facilities 7 Others

3.43. a) Do you think that the doctors in the Government hospi-
tals are kind and dutiful enough to the patients seeking treat-
ment there?
1) Yes 2) No
b) (If no) Why you think so?

3.44. a) What is your comment about the environment or climate
of the Government health facilities (hospital) in your area?
1) Good 2) Not good
c) (If not) Why?
1.0. Do you think that the Government doctors/health workers
listen your problems carefully
and counsel you enough while treating you for the disease?
1) Yes 2) No
2.0. Who listens your problems most carefully and counsels you
while treating you?
(Please note the best from 1)
Health service deliverers Best to worst listening the problems
and counsels 1 Government facilities/Government doctors and
health providers 2 Private doctors 3 Quacks/Health professionals
in private practice other than doctors 4 Homeopaths/Traditional
healers 5 Religious and Spiritual
healers 6 NGO service facilities 7 Others
3.0. a) Do you think that occasionally a family member is criti-
cized by abusive remarks within
the family if diseased?
1) Yes 2) No
b) (If yes) Why?
4.0. a) Do you think, is it possible that the family sometimes
denies bearing medical expenditure of any of its member, if dis-
eased?
1) Yes 2) No
b) (If yes) Why?
5.0. a) Do you think that some of the patients can not go for
treatment to service providers
because of not having any one with her/him to accompany ?
1) Yes 2) No
3.50. a) Have you got any mental patient in your family?
1) Yes 2) No
b) (If yes) What his/her illness? (Note respondent's descrip-
tion)
1) Madness 2) Hysteric 3) Less responsive 4) Others
c) (If yes) Was he/she treated for the problem?
1) Yes 2) No
d) (If yes) Where he/she was taken for treatment?
1) Government facilities 2) Private doctors 3) Quacks/Health
professionals in private
practice other than doctors 4) Homeopaths/Traditional healers 5)
Religious and Spiritual
healers 6) NGO service facilities
e) Why he/she was taken there for treatment and not other fa-
cilities according to you?

f) (If yes) Do you think this is a disease?
1) Yes 2) No
g) Can you tell how some one is caught by this problem/disease?

Name of the mental problem/disease Etiology perceived by the re-
spondent 1 Madness 2 Hysteric 3 Less responsive 4 Depressive 5
Agitated 6 7 8
h) Do you think this problem is curable?
1) Yes 2) No 3) Curable, but will take much effort

3.51. a) Do you/any one of your family go for consulta-
tion/treatment if diseased
1) Mostly alone 2) Mostly accompanied with some one
b) Who in your family accompanies a second person more while go-
ing for treatment?
1) Male patient 2) Female patient
3.52. a) Do you or any body in your family got STD/RTI problems
any time previously?
1) Yes 2) No
b) (If Yes) Are they male or female?
1) Male 2) Female 3) Mostly male 4) Mostly female
c) Did he/she/they go for treatment to anywhere?
1) Yes 2) No
d) (If no) Why?
1) Not required, cured spontaneously 2) Some body else go to the
doctor and took medicines for him/her
e) (If c is yes) Did he/she accompany any second person while
went for treatment?
1) Yes 2) No
f) Why?

g) Can you please tell me what about the STD/RTI:
(Respondent can add in the disease list)
Disease Symptoms as per the respondent Etiology respondent 1
Syphilis 2 Gonorrhea 3 AIDS 4 5 6 7 8 9

3.53. a) Do you or any body of your family member now sick?
1) Yes 2) No
b) (If Yes), What is the disease or diseases he/she/they are
suffering for?

c) How many days she/he/you are suffering?
1) Less than 3 days 2) Less than a week 3) More than a week 4)
More than fortnights
d) Were she/he/ you treated for the disease?
1) Yes 2) No
e) (If yes) Where?
f) (Please note the treatment, latter a MBBS doctor will deter-
mine the treatment was standard or not) 1) Standard 2) Not stan-
dard