Thursday, April 24, 2014

UCU-MICAH QUESTIONNAIRE

Our identity is UCU-MICAH a students’ led initiative at Uganda Christian University.
This questionnaire was drafted by the MICAH team in order to establish the health
facilities in place especially in our communities of operation that is Kyazanga TCLwengo

district and Nabukalu Sub-County- Bugiri District. Please answer all the
questions with honest. The information you will give is purely intended to help our
team and the local leaders in improving the health conditions in our communities
and it will be treated with a lot of confidentiality. We are requesting you to kindly
participate in this study by responding to the following questions.
Section A: Background Characteristics
Village …………………………………… Parish…………………………………
Sub-county……………………………….. District…………………………………
A
C
Bio-data:
1

2

Copyright@2012, MICAH N.S

3
4

5
Copyright@2012, MICAH N.S
Water used at household Categories
6
water for members of your household?
1. Piped water
2. Open well/spring
3. Protected well/spring
4. Borehole
5. River/stream/pond/lake/Dam
6. Rain water
7. Bottled water
7
8
9
10
11
12
Toilet/Latrine coverage
13. What type of toilet/latrine facility do
members of your household usually
use?
14. 9. Do you share this toilet/latrine
facility with other households?
1. Piped water
2. Open well/spring
3. Protected well/spring
4. Borehole
5. River/stream/pond/lake/Dam
6. Rain water
7. Bottled water
……………..Minutes
………………Minutes
1. Mother
2. Father
3. Daughter
4. Son
5. Others specify ………..
1. Yes
2. No
3. Don’t know
1. Boil
2. Add bleach/chlorine/Tablets
3. Water filter/ Strain with cloth
4. Sunlight bottle
5. Other specify………………..
1. Flush toilet
2. Vip latrine
3. Covered pit with no slab
4. Covered pit with slab
5. Uncovered pit no slab
6. Uncovered pit with slab
7. Compositing toilet
8. Bush
9. Other specify…………..
1. Yes
2. No
Copyright@2012, MICAH N.S
15. If yes, how many other households do
you share with?
16. Do you wash your hands after using
the toilet/latrine?
17. If yes, what do you use to wash your
hands?
18. Do you wash your hands before you
eat?
19. If yes, do you use soap and water when
you wash your hands?
20. Do you use purified/clean water to
wash your hands?
Fuel used at the household
21. What type of fuel does your household
mainly use for cooking?
22. Where is the cooking usually done
from?
23. Does your household possess a rubbish
pit or container?
……………… household(s
1. Yes
2. No
......................................................
1. Yes
2. No
1. Yes
2. No; just water only.
1. Yes
2. No
3. Don’t know
1. Electricity
2. Natural gas/ Biogas
3. Kerosene/paraffin
4. Charcoal
5. Firewood
6. Dry banana leaves.
7. Animal dung
8. Other specify…………………..
1. In the main house
2. Kitchen
3. Open space
4. Other specify…………………
1. Yes
2. No
24. If no, how do you dispose off wastes? ………………………………
25. Does your H/h have a all the sanitary
facilities like dish drying rake, soak pit,
a bathroom and a separate shelter for
animals or birds?
26. If no, what is the practice like drying
utensils, disposing off water from
bathroom among other liquid wastes.
1. Yes
2. No
……………………………………...
Copyright@2012, MICAH N.S
Disease And Illnesses Incidents
27. Do you have any children under age 5 in
your household?
28. Has any of your children had diarrhea in the
past 2 weeks?
1. Yes
2. No
1. Yes
2. No
29. If yes, what do you think was the cause? 1. Eating contaminated food
2. Drinking un boiled water
3. Others
specify………………….
30. How did you treat it? 1. Local herbs
31. Has anyone in your household suffered
from malaria?
32. If yes, what do you think is the cause of
malaria?
33. Are there pre-exposing factors for malaria
spread?
34. If yes, what are some of those pre-exposing
factors?
35. If you have a fever how do you know it is
Malaria?
2. Took the child to the health
facility
3. Healed naturally
4. Any other, specify………….
1. Yes
2. No
1. Mosquitoes
2. Witch Craft
3. Other specify……………
1. Yes
2. No
1. Bushes around homes
2. Open potholes
3. Presence of broken pots,
glasses, plastics that collect
water
4. Uncollected wastes
5. Others, specify………………
1. Pain in the joints
2. Headache
3. Loss of appetite
4. Any other specify
……………….
36. How do you treat Malaria? 1. Local herbs
37. Are there ways that can be employed to
prevent malaria?
2. I buy drugs from shops
3. Get treatment from a trained
personnel
4. Any other, specify……………
1. Yes
2. No
38. If yes, what are they? 1. Sleeping under mosquito treated
Nets
2. Spray house
3. Smoke the houses
4. Slashing the bushes around homes
5. Clearing all collected waters around
homes
Copyright@2012, MICAH N.S
6. Any other……………………
39. Does your household have any mosquito
net
40. If yes, how many mosquito nets does your
household have?
41. Ask if you may view the nets. In what
conditions are they?
……………. In number
1. Good
2. Fair
3. Poor
42. Who the net? 1. Self
2. Government
3. NGO
4. Relative
5. Any other, specify ….………
43. Have you ever heard of an illness called
Tuberculosis or TB?
YES
NO
44. How does TB spread from one person to another? a. air – sneezing/coughing
b. sharing utensils
c. touching people with TB
d. food
e. sexual contact
f. mosquito bites
g. other
h. don’t know
45. Can TB be cured? 1. Yes
2. No
3. Don’t know
46. If a member of your family got TB, would you want
it to remain a secret or not?
47. Have you heard of HIV/AIDS? 1. Yes
2. No
48. Can people reduce their chances of getting the
AIDS virus by having just one uninfected sexual
partner who has no other sex partners?
49. Can people get HIV/AIDS virus from mosquito
bites?
50. Can people reduce their chances of getting the
AIDS virus by using a condom every time they
have sex?
51. Can people get AIDS by sharing food with a person
who has AIDS?
52. Can people reduce their chance of getting AIDS by
not having sexual intercourse at all?
1. Yes
2. No
3. Not sure/depends
1. Yes
2. No
3. Don’t know
1. Yes
2. No
3. Don’t know
1. Yes
2. No
3. Don’t know
1. Yes
2. No
3. Don’t know
1. Yes
2. No
Copyright@2012, MICAH N.S
3. Don’t know
53. Can people get AIDS because of witchcraft or
other supernatural means?
Yes
No
Don’t know
54. Is it possible for a health-looking person
to have AIDS
55. Can the virus that causes AIDS be
transmitted from a mother to her baby?
56. Are there any drugs that a doctor or nurse
can give to a women infected with AIDS
to reduce the risk of transmission to the
baby?
57. Have you heard about any drugs that
people infected with HIV/AIDS can get
from a doctor or nurse to help them live
longer?
Yes
No
Don’t know
1. During pregnancy?
2. During delivery?
3. By breastfeeding?
58. Do these drugs cure HIV/AIDS or treat? 1. Cure
2. Treat
59. Have you ever been tested for AIDS? 1. Yes
2. NO
FAMILY PLANNING
60. From one menstrual period to the next, are there
certain days when a woman is more likely to
become pregnant if she has sexual relations?
61. Is this time just before, during, or right after her
period, or halfway between two periods?
62. Have you heard of any methods with which you
can use to avoid pregnancy?
1. Yes
2. No
3. Don’t know
1. Yes
2. No
3. Don’t know
1. Yes
2. No
3. Don’t know
Copyright@2012, MICAH N.S
Yes
Yes
Yes
1. Just before
2. During
3. Right after
4. Halfway between
1. YES
2. NO
63. If yes, which one? 1. Female sterilization
2. Male sterilization
3. Pill-birth control
4. IUD
5. Injection
6. Condom
7. Female condom
8. Withdrawal
9. Emergency contraception
10. Other…………………
64. Are these services provided with this area? 1. Yes
2. No
3. Don’t know
No
No
No
65. If yes, where? …………………………..
NUTRITION SEGMENT
63. Have you or your child had any of the following
types of foods either today, or last night
Yes = 1, No = 2 and Don’t Know
= 3

other roots and tubers
1 2 3


1 2 3
1 2 3

spinnach, amaranths, bugga, sunsa, jjobyo, and
marakwang

1 2 3
1 2 3

candies, pastries, cakes or biscuits
1 2 3

Thank you for your participation in this survey.
Copyright@2012, MICAH