BIGPIC MEDICAL USE AND COST ASSESSMENT
Demographics
AMRS ID Number:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Encounter Details
Interview Location:
*
Name of Interviewer
*
Josephine Kisato
Catherine Chiliswa
Derek Levembe
Jackson Rotich
Penina Kiptoo
Kennedy Kirwa
Abraham Saat Kimaru
Keviner Chavera Asigi
Interviewer ID:
*
Interview Date:
*
SECTION A - DEMOGRAPHICS
Enter Participant ID:
*
Select County
*
...
Busia
Kisumu
Uasin Gishu
Trans Nzoia
AMPATH Facility/BIGPIC Community Unit [
]:
*
...
Aboloi
Akichelesit
Anguri
Bumala A
Bumala B
Changara
Kamolo
Khunyango
Malaba
Matayos
Moding
Sunga
Chulaimbo
Riat
Siriba
Chepngoror
Kipkabus
Moi's Bridge
Ziwa
Cherengani
Endebes
Kapsara
Matunda
Saboti
village:
*
What conditions have you ever been told that you have by a doctor or other health worker?
*
Diabetes
Heart disease
Hypertension (high pressure)
Lung disease
Hyperlipidemia
HIV
Cancer
Cancer Type
Breast
Cervical
Colon
Lung Disease
Prostate
Lymphoma
Leukemia
Other
Specify Other Cancer type
Other
Specify Other health condition
Don't Know
Refused/No Answer
During the past 12 months, have you seen a doctor or other health worker?
*
...
Yes
No
Don't Know
Refused
SECTION B - INPATIENT ADMISSIONS
Have you at any time during the
past 12 months
been admitted in a hospital for at least one night?
*
...
Yes
No
Don't Know
Refused
How many times were you admitted overnight to a hospital in the
past 12 months
?
*
For each of the admissions you listed, we are now going to ask you some additional questions
Inpatient Admission 1
Approximate admission date:
What is the reason not providing/reporting admission date?
*
...
Don't Know
Refused
What was the reason for admission?
*
Injury
Diabetes
Stroke
Heart Disease
Lung Disease
Others
Specify other reason/disease:
*
Don't Know
Refused/No Answer
Did you pay for this admission using any of the following sources: Please select all that apply
NHIF
Private Medical Insurance
Out of pocket
Loaning from Chama
Harambee
Waiver
Donations
Family/Friends
Don't Know
Refused
How much was the
total bill
for the admission?
*
Don't Know
Refused
How much did you have to pay using your own money (including money from loans)?
*
Don't Know
Refused
During your last hospital admission
What means of transport did you use to get to the hospital?
*
On foot
Boda Boda
Matatu
Private Vehicle
Other
Don't know
Refused
How much time did it take to reach the hospital?
Hours
...
0
1
2
3
4
5
6
7
8
9
10
11
12
Minutes
...
0
5
10
15
20
25
30
35
40
45
50
55
Time to Hospital in minutes:
*
Don't Know
Refused
How much was the transport cost?
Don't Know
Refused
SECTION C - OUTPATIENT SERVICES
Have you at any time during the
past 3 months
received medical care at a Health Centre or Dispensary or a hospital where you did not spend at least one night?
*
...
Yes
No
Don't Know
Refused
In the
last 3 months
, how many times did you visit each of the following places?
Health Center:
*
Dispensary:
*
Hospital Outpatient Clinic:
*
Private Clinic:
*
For each of the visits you listed, we are now going to ask you some additional questions
Outpatient center Visit 1
Approximate visit date:
What is the reason not providing/reporting visit date?
*
...
Don't Know
Refused
Type of facility:
*
...
Health Center
Dispensary
Hospital Outpatient Clinic
Private Clinic
Don't Know
Refused
What was the reason for the visit?
*
Injury
Diabetes
Hypertension
Heart Disease
Lung Disease
Typhoid
Malaria
Pneumonia
Pregnancy
HIV
Other
Specify other reason/disease:
*
Don't Know
Refused/No Answer
During the visit were you prescribed or given any drugs to use?
*
...
Yes
No
Don't Know
Refused
How much did you pay out of pocket for the visit including drug costs if applicable?
*
Don't Know
Refused
Now, thinking about your LAST visit
What means of transport did you use to get there?
*
On foot
Boda Boda
Matatu
Private Vehicle
Other
Don't know
Refused
How much time did it take to reach there?
Hours
...
0
1
2
3
4
5
6
7
8
9
10
11
12
Minutes
...
0
5
10
15
20
25
30
35
40
45
50
55
Time to LAST visit in minutes:
*
Don't Know
Refused
How much was the transport cost?
Don't Know
Refused
SECTION D - HERBAL MEDICINE/SPIRITUAL HEALER
Have you at any time during the past 3 months visited a herbalist or spiritual healer?
*
...
Yes
No
Don't Know
Refused
In the past three months how many times did you visit?
*
Herbalist:
*
Spiritual Healer:
*
For each of the visits you listed, we are now going to ask you some additional questions.
Herbalist visit 1
Approximate visit date:
What is the reason not providing/reporting visit date?
*
...
Don't Know
Refused
Was the visit to an herbalist or a healer?
*
...
Herbalist
Spiritual Healer
Don't Know
Refused
What was the reason for the visit?
*
Injury
Diabetes
Hypertension
Heart Disease
Lung Disease
Typhoid
Malaria
Pneumonia
Pregnancy
HIV
Other
Specify other reason/disease:
*
Don't Know
Refused/No Answer
Were you given any medications or interventions to use by your herbalist or spiritual healer?
*
...
Yes
No
Don't Know
Refused
What was the
total cost
for the visit, including the cost of any interventions?
*
Don't Know
Refused
Now, thinking about your LAST visit:
What means of transport did you use to get there?
*
On foot
Boda Boda
Matatu
Private Vehicle
Other
Don't know
Refused
How much time did it take to reach there?
Hours
...
0
1
2
3
4
5
6
7
8
9
10
11
12
Minutes
...
0
5
10
15
20
25
30
35
40
45
50
55
Time to Herbalist/Spiritual Leader LAST visit in minutes:
*
Don't Know
Refused
How much was the transport cost?
*
Don't Know
Refused
SECTION E - GROUP MEDICAL VISITS
Have you ever had care in a group medical visit before?
*
...
Yes
No
Don't Know
Refused
How often did you receive care in a group medical visit?
*
...
One time only
Once a month
Every few months
Once a year
Don't Know
Refused
Have you at any time during the
past 3 months
had a group medical visit?
*
...
Yes
No
Don't Know
Refused
In the
past three months
how many group medical visits have you had?
*
For each of the visits you listed, we are now going to ask you some additional questions.
Group Medical visit 1
Approximate visit date:
What is the reason not providing/reporting visit date?
*
...
Don't Know
Refused
What was the reason for the visit?
*
Injury
Diabetes
Hypertension
Heart Disease
Lung Disease
Typhoid
Malaria
Pneumonia
Pregnancy
HIV
Other
Specify other reason/disease:
*
Don't Know
Refused/No Answer
During the visit were you prescribed or given any drugs to use?
*
...
Yes
No
Don't Know
Refused
How much did you pay using your own money for the visit
NOT
including medication costs?
*
Don't Know
Refused
Now, thinking about your LAST visit:
What means of transport did you use to get there?
*
On foot
Boda Boda
Matatu
Private Vehicle
Other
Don't know
Refused
How much time did it take to reach there?
Hours
...
0
1
2
3
4
5
6
7
8
9
10
11
12
Minutes
...
0
5
10
15
20
25
30
35
40
45
50
55
Time to Herbalist/Spiritual Leader LAST visit in minutes:
*
Don't Know
Refused
How much was the transport cost?
*
Don't Know
Refused
SECTION F - PRESCRIBED MEDICINES
In the past 3 months
, have you
TAKEN
any medicines that were prescribed by your health care provider (excluding herbalists or spiritual healer)?
*
...
Yes
No
Don't Know
Refused
How many different prescriptions medicines have you taken in the past 3 months.
*
Don't Know
Refused
Have you ever not filled a prescription or skipped a medical visit because of cost?
*
...
Yes
No
Have you ever run out of medications waiting for your next clinic appointment?
*
...
Yes
No
Now we're going to ask you some questions about taking your medicines
Do you sometimes forget to take your medicine?
*
...
Yes
No
People sometimes miss taking their medicines for reasons other than forgetting. Thinking over the past 2 weeks, were there any days when you did not take your medicine?
*
...
Yes
No
Have you every cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it?
*
...
Yes
No
When you travel or leave home, do you sometimes forget to bring along your medicine?
*
...
Yes
No
Did you take all your medicines yesterday?
*
...
Yes
No
When you feel like your symptoms are under control, do you sometimes stop taking your medicine?
*
...
Yes
No
Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan?
*
...
Yes
No
How often do you have difficulty remembering to take all your medicine?
*
...
Never/rarely
Once in a while
Sometimes
Usually
All the time
We are now going to ask you some questions about each of the PRESCRIPTION medicines you have TAKEN over the past 3 months.
1st prescription
What is the name of the medicine?
*
...
Insulin(Lispro,NPH,70/30)
Glibenclamide(Glyburide)
Glimepiride
Metformin
Enalapril
Losartan
Atenolol (Tenormin)
Aspirin
HCTZ
Furosemide
Pioglitazone(Glustin/Actos/Zactos)
Nifedipine(Adalat/Procardia)
Amlodipine
Carvedilol
Amitriptyline(Elavil)
Carbamazepine(Equetro/Carbatrol/Tegretol)
Omeprazole(Prilosec)
Atorvastatin(Lipitor)
Paracetamol(Calpal,Panadol)
Ibuprofen
Diclofenac
Cetirizine
Other
Don't Know
Refused
Specify other medicine:
*
What medical condition or disease(s) was the medicine for?
*
Injury
Diabetes
Hypertension
Heart Disease
Lung Disease
Typhoid
Malaria
Pneumonia
Pregnancy
HIV
Others
Don't Know
Refused/No Answer
Specify other reason/disease:
*
Where did you get the prescription from?
*
...
Private pharmacy
Government chemist
Dispensary/Health Center
Revolving Fund Pharmacy
Don't Know
refused
How much did you pay for the medicine?
*
Don't Know
Refused
How long was the medicine supposed to last?
*
Don't Know
Refused
SECTION G - HEALTH INSURANCE
Do you have NHIF insurance?
*
...
Yes
No
Don't Know
Refused
Have you ever used your NHIF insurance to pay for health services?
*
...
Yes
No
Don't Know
Refused
Do you currently have Zuri insurance?
*
...
Yes
No
Don't Know
Refused
Have you ever used your Zuri insurance to pay for health services?
*
...
Yes
No
Don't Know
Refused
Are you currently covered by any other health insurance apart from NHIF or Zuri?
*
...
Yes
No
Don't Know
Refused
Note which other insurance.
*
SECTION H - MICROFINANCE
Have you ever been in a group-based savings program (e.g. chamas, AMPATH GISE group, SACCOs, formal microfinance groups, merry-go-round, table banking, etc.)?
*
...
Yes
No
Don't Know
Refused
Are you currently in any group-based savings program?
*
...
Yes
No
Don't Know
Refused
Currently
, how many groups are you involved with?
*
Chama/Merry-go-round:
*
SACCO:
*
Formal microfinance group:
*
Table banking:
*
AMPATH GISE group:
*
Other:
*
Name of Other micro-finance group:
*
For each of the visits you listed, we are now going to ask you some additional questions.
Microfinance Group 1
Approximate admission date:
What is the reason not providing/reporting visit date?
*
...
Don't Know
Refused
What kind of group is this?
*
...
Chama
SACCO
Formal microfinance group
Table-banking
AMPATH GISE
Other
What is the composition of this group members?
*
...
Gender Specific
Location Specific
Occupation Specific
Health Status
Community specific
How long have you been in this group?
Years:
*
Months:
*
On average, how much money have you put into this group in total?
*
How much money have you borrowed from this group in total?
*
Please rank from 1 to 6; what did you most often use the money that you borrowed for?
*
School Fees:
*
1
2
3
4
5
6
Medical expenses:
*
1
2
3
4
5
6
Insurance:
*
1
2
3
4
5
6
Food:
*
1
2
3
4
5
6
Business investments:
*
1
2
3
4
5
6
Pay off debts:
*
1
2
3
4
5
6
SECTION I - LIFESTYLE/HABITS
I am going to first ask you about vigorous activities then later ask about moderate activities that you did
in the last seven days
. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work and as part of your house, to get from place to place, and in your spare time for recreation, exercise or sport.
Vigorous
physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.
During the
last 7 days
, on how many days did you do
vigorous
physical activities like heavy lifting, digging, running, playing foot ball or fast bicycling?
*
...
None
1 day
2 days
3 days
4 days
5 days
6 days
7 days
How much time did you usually spend doing
vigorous
physical activities on days that you do them?
Hours
...
0
1
2
3
4
5
6
7
8
9
10
11
12
Minutes
...
0
5
10
15
20
25
30
35
40
45
50
55
Time spent doing vigorous physical activities, in minutes:
*
Don't Know
Refused
During the
last 7 days
, on how many days did you do
moderate
physical activities like carrying light loads, bicycling at a regular pace? Do not include walking unless you are purposely walking at a fast pace.
*
...
None
1 day
2 days
3 days
4 days
5 days
6 days
7 days
How much time do you usually spend doing moderate physical activities on days that you do them?
Hours
...
0
1
2
3
4
5
6
7
8
9
10
11
12
Minutes
...
0
5
10
15
20
25
30
35
40
45
50
55
Time spent doing vigorous physical activities, in minutes:
*
Don't Know
Refused
For the last one month, how many grams of salt did you purchase?
*
8ksh of salt = 250g, 15ksh of salt = 500g, 25ksh of salt = 1000g, 50ksh of salt = 2000g
Don't Know
Refused
In a typical week, on how many days do you eat fruit?
*
...
None
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Don't Know
refused
One serving of fruit is approximately the size of your fist; how many servings of fruit do you eat on one of those days?
*
...
None
1 serving
2 servings
3 servings
4 servings
5 servings
Don't Know
refused
In a typical week, on how many days do you eat vegetables?
*
...
None
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Don't Know
refused
One serving of cooked vegetables is about half the size of your fist; how many servings of vegetables do you eat on one of those days?
*
...
None
1 serving
2 servings
3 servings
4 servings
5 servings
Don't Know
refused
Tobacco Use
Are you currently using any form of tobacco?
*
...
Yes
No
What form of tobacco do you currently use (i.e. cigarettes, pipe, sniffed, chew)
*
...
Cigarretes
Pipe
Chew
Sniffed
How many cigarettes do you smoke each day?
*
...
None
Less or equal to 10
Between 11-20
Between 21-30
More than 30
How many years have you used tobacco regularly?
*
Alcohol Use
Are you currently drinking any form of alcohol?
*
...
Yes
No
what form of alcohol do you use? (choose all that apply)
*
Beer
Local Brew
Local Brew
Wine
Other hard liquor
In a typical week, how many servings of alcohol do you consume?
*
Typical alcohol servings:
Beer: 350 mL (12 oz can)
Wine: 150 mL (5 oz glass)
Hard liquor: 44 mL (1.5 oz shot)
...
Less than 5
Between 6-10
Between 11-15
More than 15
SECTION J - HEALTH STATUS
We are now going to ask you questions about your health-related quality of life.
How would you describe your mobility?
*
...
I have no problems in walking about
I have some problems in walking about
I am confined to bed
How would you describe your ability to take care of yourself (e.g. washing and dressing yourself)?
*
...
I have no problems with self-care
I have some problems washing or dressing myself
I am unable to wash or dress myself
How would you describe your usual Activities? (e.g. work, study, housework, family or leisure activities)?
*
...
I have no problems with performing my usual activities
I have some problems with performing my usual activities
I am unable to perform my usual activities
How would you describe your pain/discomfort ?
*
...
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort
How would you describe your mood?
*
...
I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed
In
GENERAL
, would you say your health is:
*
...
Very Poor
Poor
Fair
Good
Very Good
Excellent
In the past two weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things.
*
...
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things.
*
...
Not at all
Several days
More than half the days
Nearly every day
We would like to know how good your health is TODAY.
The scale is numbered from 0 to 100.
100 means the BEST health you can imagine.
0 means the WORST health you can imagine
Please select the number you based on the scale
*
SECTION K - WORK PRODUCTIVITY
What is your primary job
*
...
None
Farmer
Business person
Public sector employee
Casual Labor
Temporal work
Other
Other job Specify
*
How many hours do you work in a typical day?
*
How much do you earn per month before taxes and other deductions? include business income, wages and salary?
*
...
Less than kshs 4999
Kshs 5000-9,999
Kshs 10,000-19,999
Kshs 20,000-29,999
Kshs 30,000-39,999
Over Kshs 40,000
Don't Know
Refused
What is the primary reason you are not working right now?
*
...
Could not find work
Retired
Illness or disability
Temporary layoff
Maternity/paternity leave
Going to school
Taking care of home or family
Wanted some time off
Waiting to start new job
Other
Other reason Specify
*
During the
past 30 days
, how many days did you miss from work because of your
health problems
? Include days/half days you missed on sick days, times you went in late, left early, etc., because of your health problems.
*
...
None
1 day
2 days
3 days
4 days
5 days
6 days
7 days
8 days
9 days
10 days
11 days
12 days
13 days
14 days
15 days
16 days
17 days
18 days
19 days
20 days
21 days
22 days
23 days
24 days
25 days
26 days
28 days
29 days
30 days
What are the health problems that caused you to miss work?
*
Acute sickness
Injury
Chronic condition
Other
Specify other reason/disease:
*
SECTION L - HOUSEHOLD QUESTIONS
What is the size of your household?:
Does your household own or have the following items?:
TV
Yes
No
Don't Know
Refrigerator
Yes
No
Don't Know
Mobile phone
Yes
No
Don't Know
Bike
Yes
No
Don't Know
Car
Yes
No
Don't Know
Cheap utensils (< Ksh 5,000)
Yes
No
Don't Know
Expensive utensil (> Ksh 30,000)
Yes
No
Don't Know
What is the quality of the:
Main source drinking water?
*
...
Unprotected well, spring, or surface water
Water piped into dwelling/premises, public tap, or protected well
Bottled/boiled water
Don't Know
Toilet facility usually used?
*
...
Traditional pit latrine or no toilet facility
Public toilet or improved pit latrine
Flush toilet
Don't Know
Main floor material?
*
...
None, earth, or dung
Cement, concrete, or wood
Finished floor with carpet/tiles/linoleum, etc
Don't Know
Number of rooms used for sleeping:
*
What is the main material of the roof in your home?
*
...
Grass/thatch/makuti
Tin cans
Corrugated iron (mabati)
Asbestos sheets
Concrete
Tiles
Other
Don't Know
Refused
What is the highest year of school the head of your household completed?
*
Primary
Select Year
...
0
1
2
3
4
5
6
7
8
Secondary
Select Year
...
9
10
11
12
University
Select Year
...
13
14
15
16
Post-grad
Select Year
...
17
18
19
20
Don't know
Refused
SECTION M - PHYSICAL MEASUREMENTS
Height (CM):
Weight (KG):
Waist circumference (CM):
Hip circumference (CM):
Blood Pressure
Systolic:
*
Diastolic:
*
Random blood glucose: