QUESTIONNAIRE
1. QUESTIONAIRE (FOR SURVEY TOOL) QUESTIONAIRE (FOR SURVEY TOOL)
A) DEMOGRAPHIC DATA
County population male………………. Female …………….
Name of sub-counties
Number of community units in S/C
Number of health facilities providing maternal health care Total
number of CEHW in the sub-county ----------------
Number of community health units present -----------------
SECTION A: PERSONAL INFORMATION.
1. What is your average age?
< 18 years []
18 to 24years []
25 to 34 years []
35 to 44years []
>44 years [ ]
What is your sex?
Male []
Female [ ]
2. Level of education (highest affordable)
Primary education []
Secondary education []
Tertiary (specific) []
None []
3. Have you ever been trained on community Maternal Health Care?
Yes []
No []
4. If yes how long was it?
One day []
Three days []
5. If yes in (5) did it add value to you in maternal health management?
Yes []
No [ ]
6. Who supports your community unit?
GOK []
Partners []
None [ ]
SECTION B
QUESTIONAIRE ON AWARENESS CREATION
1. Do you ever talk about mothers ‘health during pregnancy while visiting homestead on your
routine work?
Sometimes []
Always []
Never [ ]
2. If positive response in above, what do you talk about? (Tick the correct appropriate)
Antenatal care
Family planning
Mortality
[]
[ ]
[]
HIV/AIDs
None of the above
[]
[ ]
3. Do you hold action days in your CU.?
Yes
No
[]
[ ]
4. If yes how frequent?
Monthly []
Quarterly []
Biannually []
Annually [ ]
5. Have you ever talked about maternal health care in action day or Barazas
Yes []
No [ ]
If No (explain why)
If yes (explain how)
6. In your opinion, are pregnant women with birth complications face stigma in your
community?
Yes []
No [ ]
If yes above, which type of stigma? (Tick where applicable)
a). Isolation []
b). Use of separate plates []
c). Not visited by friends []
d) Sent back to the village to avoid shame in town []
e) Women with TB divorced/chased by husbands []
Gossip/teasing []
f) Mocking []
g)finger-pointing
h)Church leaders condemn mothers for promiscuity, adultery, breaking moral laws []
i) Children separated/isolated from others []
j) Children teased i.e. “your parents died because of their bad behaviour” []
m) In market, people stop buying from a market seller who is suspected to have HIV [ ]
7. What re some of the effects of stigma on birth complications patients?
i. Personal shame [ ]
ii. Self-blame [ ]
iii. Isolation [ ]
iv. Loneliness [ ]
v. Loss of status [ ]
vi. Loss of self-esteem [ ]
vii. Depression [ ]
viii. Denial and anger [ ]
ix. Violence and alcoholism [ ]
x. Suicide and death [ ]
xi. Family quarrels, mutual blame and conflict [ ]
xii. Separation and divorce [ ]
xiii. Property grabbing [ ]
xiv. Defaulting treatment or getting tested []
8. What can you do to reduce stigma?
a) Involvement of patients, providers and commitment []
b) Use of “home care volunteers” to disseminate information. [ ]
C). QUESTIONAIRE ON CULTURAL ACTORS AFFECTING MATERNAL
HEALTH CARE
1. Do you think your culture plays a role in the maternal health care?
Yes [ ]
No [ ]
If No (explain why)
If yes (explain how)
2. What is the role of Religion in the maternal health care in your region?( Islamic,
Christianity and others )
3. Do you believe that the cultural background of gender roles blinded women from
accessing maternal health care?
Yes [ ]
No [ ]
4. What is the role of the medicine men in your community?
(i) They are a source of Healing and treatment [ ]
(ii) They are more educated in our issues [ ]
(iii) They don’t matter in women issues [ ]
(iv) They get money for nothing [ ]
D.QUESTIONAIRE ON REFERRAL MECHANISM
1. Who are some of the supporting agents in
your area? NGO [ ]
Government only [ ]
Religion bodies [ ]
Privet individuals [ ] NGOs and Government
[ ]
2. In your area are there any referral places
Yes [ ]
No [ ]
If No (explain why)
If yes (explain how)
3. What are some of referral mechanism used in your area?
(i) Mobile Clinic
(ii) Peripheral facilities
(iii) District Hospitals
Any other explain
E.QUESTIONAIRE ON COST OF HEALTH CARE
1. Do you pay any money health care services?
Yes [ ]
No [ ]
If No (explain why)
If yes (explain how)
3. What is the role of the following institution in relation to cost of health care?
(a) Central Government
(c) County Government
(d) Private businesses
APPENDIX III: QUESTIONNAIRE TO HEALTH CARE PROVIDERS (CHEW).
1. How many community units do you manage?
One [ ]
Two [ ]
> Three [ ]
2. How is the community units in your area funded?
GOK [ ]
Partner [ ]
Community itself [ ]
None [ ]
3. Please list down your roles as a CHEW in maternal health care control in the community.
4. How many public Barasa did you hold in the last 3
months? None [ ]
<2 [ ]
> 3 [ ]
5. Do you hold school Health program in your area of
jurisdiction? Yes [ ]
No [ ]
If yes, in above question; how many schools did you visit in the last 3 months?
.1 – 5 [ ]
.6 - 9 [ ]
.None [ ]
Do you have records as regards community maternal health care? Yes [ ]
No. [ ]
If yes in above question; please list down the records / reports you submit
. If yes above, list down the successes
6. In your opinion, do you think community strategy is succeeding?
Yes [ ]
No [ ]
7. Please list down; what you think can be done to improve community strategy on
maternal health care?
