Behavioral Assessment

Demographics

AMRS ID Number:

Family Name:

Given Name:

Middle Name:

Gender:

Date Of Birth:

Encounter Details

Name of Dispensary:*

CHV Name:

Enter CHV's system-id:*

Encounter Date:*

SECTION II
Part A: General

Where do you usually go for health care?*

Specify*

When you go to your usual health facility, how do you generally get there? *

On average, how long does it take you to get to the facility? *

How would you rate the personal manner(courtesy, respect,sensitivity, friendliness, and attitude) of the health care provider you see *

How would you rate the health care provider's explanation of your high blood pressure and the treatment you need*

How would you rate the follow-up by your health care provider*

Part B: Perceived Risks/Severity

Have you ever been told by a health care provider that you might have high blood pressure or hypertension *

Do you believe that you have high blood pressure *

What is your perception of high blood pressure *

Have you ever been told that you need to do any of the following

Come to the clinic regularly to monitor your blood pressure*

Yes

No

Refused/No Answer

Take medication to manage your high blood pressure*

Yes

No

Refused/No Answer

Control your weight*

Yes

No

Refused/No Answer

Reduce your salt intake*

Yes

No

Refused/No Answer

Exercise more(E.g. Digging,running etc.)*

Yes

No

Refused/No Answer

Reducing your alcohol use*

Yes

No

Refused/No Answer

Reducing or stopping tobaco use *

Yes

No

Refused/No Answer

Are you currently taking medication to manage your high blood pressure *

Where did you get your medication?*

Specify*

Are you currently.....

Controlling your weight*

Yes

No

Refused/No Answer

Reducing your salt intake*

Yes

No

Refused/No Answer

Exercising more*

Yes

No

Refused/No Answer

Reducing your alcohol use*

Yes

No

Refused/No Answer

Reducing or stopping your tobacco use*

Yes

No

Refused/No Answer

Is your blood pressure controlled at the level your health care provider wants it to be *

Do you think you can tell when your blood pressure is going up or down without a blood pressure measurement by noticing how you feel? *

How can you tell if your blood pressure is going up or down?
Because you feel *

Specify*

Sometimes we have trouble doing what the health care provider says. Have you ever...

Missed your blood pressure appointment because you felt well? *

Missed taking your blood pressure drugs when you were feeling better *

If you have high blood pressure and you don't seek care, do you think you are at risk of...

Having a stroke*

Yes

No

Refused/No Answer

Develop kidney failure*

Yes

No

Refused/No Answer

Develop heart disease*

Yes

No

Refused/No Answer

Part C: Perceived Barriers
Have you delayed or not sought care for your high blood pressure for any of the following reasons:

You lacked fare*

Yes

No

Refused/No Answer

You lacked the mode of transportation*

Yes

No

Refused/No Answer

You lacked money to pay for the medical procedure fee and blood pressure drugs*

Yes

No

Refused/No Answer

You thought it was more important to spend your money on school fees, food, or farm inputs*

Yes

No

Refused/No Answer

Limited services at the health facility*

Yes

No

Refused/No Answer

Long queues at the health facility*

Yes

No

Refused/No Answer

Corruption (taking bribes, Favoritism in queues, denial of service)at the health facility*

Yes

No

Refused/No Answer

You don't think continuing care makes a difference *

Yes

No

Refused/No Answer

You didn't have time/You could not take time off from the responsibilities you have*

Yes

No

Refused/No Answer

You preferred traditional herbal medicine*

Yes

No

Refused/No Answer

You received medication from your friend or family member*

Yes

No

Refused/No Answer

You bought your own medication from the chemist/shop*

Yes

No

Refused/No Answer

You believe your faith will heal you*

Yes

No

Refused/No Answer

It is burdensome to take blood pressure drugs every day*

Yes

No

Refused/No Answer

Part D: Emotional Factors

Have you delayed or discontinued care for your blood pressure in the last three months because you are…

Afraid of the stigma associated with high blood pressure*

Yes

No

Refused/No Answer

Afraid of being seen at the AMPATH facility because of possible HIV stigma*

Yes

No

Refused/No Answer

Afraid of the chronic nature of high blood pressure*

Yes

No

Refused/No Answer

Afraid of taking high blood pressure drugs*

Yes

No

Refused/No Answer

Have you ever been treated rudely/shouted by your health care provider?*

For which of the following reasons were you harassed by your health care provider (Select all that apply):*

Being late

Not showing up for appointment

Not taking medications

Other

Specify*

Refused/No Answer

Part E: Motivation

What factors encourage you to seek hypertension care (Please do not read the options aloud to the patient; select only those that the patient mentions on her own accord)*

Improved health

High blood pressure being a manageable disease

Follow-up by CHWs

Friendliness of the health facility staff

Family and/or peer support/encouragement

Response to medication

None

Others

Specify*

Refused/No Answer

Part F: Confidence

How confident are you that you will go back into care and seek blood pressure care consistently?*

Do you have a specific plan for how to do so?*

How sure are you that you will be able to follow instructions provided by your health care provider, such as taking your medications?*

Have you thought of a specific way to do that?*

How confident are you that you will be able to modify your lifestyle, such as exercising more, eating healthy, and controlling your weight?*

Have you thought of a specific way to do that?*

RETENTION Behavioral Assessment

Demographics

Encounter Details

SECTION IIPart A: General

Part B: Perceived Risks/Severity

Have you ever been told that you need to do any of the following

Are you currently.....

Sometimes we have trouble doing what the health care provider says. Have you ever...

If you have high blood pressure and you don't seek care, do you think you are at risk of...

Part C: Perceived BarriersHave you delayed or not sought care for your high blood pressure for any of the following reasons:

Part D: Emotional Factors Have you delayed or discontinued care for your blood pressure in the last three months because you are…

Part E: Motivation

Part F: Confidence

SECTION II
Part A: General

Part C: Perceived Barriers
Have you delayed or not sought care for your high blood pressure for any of the following reasons:

Part D: Emotional Factors

Have you delayed or discontinued care for your blood pressure in the last three months because you are…