social-development

	QUESTIONS -English	QUESTIONS -Bahasa Indonesia	PROMPT / OPTIONS -Englsih	PROMPT / OPTIONS -Bahasa Indonesia	NOTES

HOUSEHOLD HEALTH & TREATMENT BEHAVIOR

302 What is your perception of the health of your household?

good -very healthy
moderate -mostly healthy
poor -severe illness within household / frequently unhealthy

303 Has any member of your household been sick in the last 30 days?

yes (specify illness)
no

304 Which of the following sickness / illness / condition have members of the households suffered in the last year? Selama 12 bulan, apakah ada anggota keluarga bapak/ibu yang mengalami penyakit di bawah ini?

accident/injury kecelakaan / cedera
allergy alergi
arthritis arthritis
rheumatism rematik
acute respiratory infections (bacterial and viral) infeksi saluran pernapasan akut (bakteri dan virus)
anemia anemia
asthma asma
bronchitis bronchitis
cancer kanker
chlamydia klamidia
cholera kolera
cold
dengue demam berdarah
diabetes
diarrhea diare
dysentery disentri
ear disease penyakit telinga
ectoparasites (fleas, ticks, lice)
eye disease penyakit mata
fever demam
gastroenteritis (bacterial and viral) gastritis / gastroenteritis (bakteri dan virus)
giardia giardia
gonorrhea kencing nanah
headache/migraine sakit kepala / migren
hepatitis b hepatitis b
hiv/aids hiv / aids
hook and pin worms hook dan pin cacing
hypertension (high blood pressure) hipertensi (tekanan darah tinggi)
infectious skin diseases penyakit kulit infeksi
influenza influensa
ispa ispa
leprosy/hansen
llng disease / bronchitis penyakit paru-paru/bronkitis
lymphatic filariasis
malaria malaria
micro-nutrient deficiencies (including folate, vitamin a, iron, iodine) kekurangan zat gizi mikro (termasuk folat, vitamin, zat besi, yodium)
onchocerciasis onchocerciasis
penile abscess/gonorhea/syphillis penis abses / gonorhea / syphillis
pneumonia, and tuberculosis pneumonia, dan tuberkulosis
power high blood tenaga darah tinggi
rabies
respiratory illness / infections Infeksi Saluran Pernapasan Atas
skin disease penyakit kulit
stunting
syphilis
teeth and mouth gigi dan mulut
toothache sakit gigi
trypanosomiasis trypanosomiasis
tuberculosis (TB / TBC) tuberkulosis (tb)
typhoid penyakit tipus
typhus tipus
wasting
other (specify) lainnya (sebutkan)
disease epidemics

305 Did sick member seek treatment?

306 If yes, from whom was treatment sought?

health worker (general)
doctor dokter
nurse perawat
midwife bidan
traditional healer tabib
faith healer ahli pengobatan dgn menggunakan kebatinan
herbalist penjual jamu
nutritionist gizi / ahli gisi
pharmacist farmasi
district health center puskesmas/pustu/pusling/posyandu
hospital rumah sakit
maternity hospital rumah bersalin
integrated health center puskesmas
community health center posyandu
clinic / health center klinik/ balai kesehatan
clinic polindes
provincial hospital
private hospital
other (specify) lainnya (sebutkan)
health worker (general)
unknown

307 How much did you / your family pay to get the health services?

treatment was free / no cost
self-paid (note cost in rupiah) paid by health insurance (note whether ASKES/BPJS, etc)
paid by company

308 How far was it to the treatment/health facility? Berapa jauh jarak dari rumah bapak/ibu ke tempat pengobatan?

(meters/kilometers)
(minutes / hours)

309 How did you / your family member get there?

transportation mode on foot berjalan kaki
on foot, with hand trolley berjalan kaki, dengan tangan troli
bicycle, self-owned sepeda, self-milik
bicycle, borrowed sepeda, dipinjam
bicycle, hired sepeda, disewa
motorbike, self-owned sepeda motor, self-milik
motorbike, borrowed sepeda motor, dipinjam
motorbike taxi ojek
public transportation transportasi umum
others (specify) lainnya (sebutkan)
passenger cars mobil penumpang umum
mobil bus mobil bus
mobil barang mobil barang
motorcycle taxi ojek
kapal pelni kapal pelni
kapal perintis kapal perintis
kapal ferry kapal ferry
kapal motor kapal motor
ketinting ketinting

310 How much does it cost to get there, if any?

(cost in rupiah)
no cost

311 If you did not seek treatment, what was your reason?

no financial resources tidak ada sumber daya keuangan
high cost of consultation tingginya biaya konsultasi
health center far from residence puskesmas jauh dari tempat tinggal
transportation costs were would be too high biaya transportasi yang mahal
other (specify) lainnya (sebutkan)

312 If did not seek treatment, what did you do in order to recover?

self medication
consume traditional medicine
did not do anything

313 If a member of your household were to become ill in the future, where would you most likely take them for diagnosis and treatment? Jika bapak/ibu dan atau anggota keluarganya sakit, dimana biasanya mereka dibawa berobat?

hospital rumah sakit
doctor on call dokter jaga
polyclinic poliklinik
municipal health center puskesmas/pustu/puskesdes
clinic / health center klinik/ balai kesehatan
clinics polindes
integrated health center posyandu
community health center puskesmas
provincial hospital
private hospital
alternative treatment pengobatan alternative
traditional healer dukun pengobatan tradisional
faith healer
herbalist
healed own disembuhkan sendiri
other (specify) lainnya (sebutkan)

314 If a member of your household were to become ill in the future, how would you pay for it? Bagaimana bapak/ibu membayar pengobatan penyakit?

ASKES ASKES
paid by the company dibayarkan oleh perusahaan
health card (from the government) kartu sehat (dari pemerintah)
health funds (from the government or from other parties) dana kesehatan (dari pemerintah atau dari pihak lainnya)
free gratis
pay for itself membayar sendiri

315 What health facilities exist in the area?

316 How far away is the nearest treatment/health facility? Berapa jauh jarak dari rumah bapak/ibu ke tempat pengobatan? kilometers:

317 How would you get to a treatment facility?

(transportation mode) on foot, hours:
motorcycle, hours:
vehicle, hours:

318 How much do you estimate transportation would cost to each facility? Berapa biaya yang dikeluarkan untuk menuju ke tempat pengobatan? rupiah:

319 How many qualified health professionals are there for each facility?

320 How many traditional healers are there in the area?

321 What pharmacies exist in the area?

322 What personal, social, economic, institutional and environmental factors do you feel affect public health in this area?

323 What traditional knowledge, attitudes and beliefs exist in the area?

324 What are the prevalence rates for non-communicable diseases (hypertension, diabetes cardiovascular disorders, cancer) in the area?

USE OF TRADITIONAL MEDICINE

325 How important is the use of traditional medicine to your or members of your household?

very important
somewhat important
not important

326 Is there a traditional / natural healer in this village?

327 Have you ever used traditional medicine?

yes (go to qX) ya
no (go to qY) tidak

328 Do you know many natural / traditional remedies?

329 Where did you get traditional medicines? Dimana bapak/ibu mendapatkan tanaman obat tradisional tersebut?

330 What kind of plants / animals / ingredients are commonly used to make medicine?

331 Is there a particular person in the community who collects ingredients for traditional medicine?

332 Do you, or members of your household, collect any ingredients for traditional medicine locally (herbs, etc)?

name of ingredient
location collected

333 What natural resources / species are targeted?

334 What are they used for?

335 Are pythons or bats or any other species caught for medicinal purposes?

336 Did you find it difficult to find / gather / obtain the ingredients for traditional medicines? If so, why? Apakah bapak/ibu memiliki kesulitan mendapatkan tanaman obat tradisional tersebut? Jika ya, kenapa?

337 Have you noticed any trends in the availability of natural medicines?

338 Are there alternative locations where medicinal herbs could be collected and, if so, where are these located?

339 Are there any restrictions on the collection of plants for medicinal purposes (e.g. permits / licenses required)?

340 Is there any collection of natural medicines (herbs, etc) in the project area?

341 What are they used for?

342 Are there alternative locations where medicinal herbs could be collected and, if so, where are these located?

343 Are there any restrictions on the collection of plants for medicinal purposes (e.g. permits / licenses required)?

343 Are pythons or bats or any other species caught for medicinal purposes?

TARGETED QUESTIONS FOR MEDICAL PRACITIONERS / HEALTH AGENCIES

344 What are the most common diseases amongst local communities living within or immediately around the project area?

345 Are any of these waterborne or could they be attributed to environmental factors (e.g. transmission by birds/mammals, standing water, vegetation clearance)?

346 What vector related diseases (malaria, schistosomiasis, dengue, onchocerciasis etc) are present in the area?

347 What is the prevalence of soil and water borne disease (giardiasis, worms, water access & quality, sanitation) in the area?

348 What is the prevalence and incidence of respiratory issues (acute respiratory infections [bacterial & viral], pneumonia, tuberculosis) from housing conditions, overcrowding and house inflation?

349 What is the prevalence of zootonic issues (Brucellosis, rabies, bovine TB, bird flu etc.) in the area?

350 What is the prevalence of sexually transmitted disease in the area?

351 Are there any food and nutrition issues [stunting, wasting, micronutrient diseases, gastroenteritis (bacterial and viral)] that are especially prevalent in the area?

352 What personal, social, economic, institutional and environmental factors determine the status of population health in the area?

MORTALITY AND MORBIDITY

353 Was any member of the family born in the past 12 months? yes (go to qX)

name of person born no (go to qY)
sex
delivery attendant doctor banyaknya penolong kelahiran -dokter
nurse
midwife banyaknya penolong kelahiran -bidan
traditional birth attendant (tba) banyaknya penolong kelahiran -dukun
other (specify) lainnya (sebutkan)
place of delivery
hospital clinic
home/residence
village health station/birthing room
other (specify) lainnya (sebutkan)

354 How is the baby’s’ health assessed at birth (according to which diagnostic criteria)?

355 Did any member of the household die in the past 12 months? Apakah bapak/ibu memiliki anggota keluarga yang meninggal selama 12 bulan terakhir? yes

name of deceased yes -multiple
sex no
age

356 Please indicate the cause of death.

accident/injury kecelakaan / cedera
cancer, kanker,
complication during pregnancy or childbirth komplikasi selama kehamilan atau persalinan
complications during pregnancy or childbirth, komplikasi selama kehamilan atau persalinan,
diarrhea diare
disease of the heart (cardiovascular disease) penyakit jantung (penyakit jantung)
disease of the vascular system, penyakit sistem vaskular,
low birth weight (<2500 grams) berat badan lahir rendah (<2500 gram)
malaria/dengue/rabies (endemic) malaria / demam berdarah / rabies (endemik)
measles campak
pneumonia pneumonia
sexually transmittable disease (hiv/aids) penyakit menular seksual (hiv / aids)
tuberculosis (tb / tbc) tuberkulosis (tb / tbc)
typhoid penyakit tipus
other causes, specify penyebab lain, tentukan
disease epidemics epidemi penyakit

DISABILITY

357 Does any member of the household have any disabilities?

name of deceased yes
sex yes -multiple
age no

358 Please indicate the type of disability

blind tuna netra
partial blindness
low vision
deaf tuna rungu
partially deaf
hard of hearing
mute tuna wicara
speech impediment
physically handicapped
one hand
no hands
one leg
no legs
mentally handicapped
mild cerebral palsy
severe cerebral palsy
intellectually impaired
severely intellectually impaired
mental illness
severely impaired by mental illness
physically and mentally handicapped cacat fisik dan mental
multiple impaired
severely multiple impaired
blind and mute (speech impairment) tuna rungu dan wicara
blind, deaf and mute (speech impairment) tuna netra rungu dan wicara
deaf and mute (speech impairment) tuna rungu wicara dan cacat tubuh
deaf, blind and mute (speech impairment) tuna rungu wicara netra dan cacat tubah

359 Does the disabled person receive any forms of support/ or assistance?

living in an orphanage
study in special class/school
looked after by community
other (specify) lainnya (sebutkan)

HEALTH BEHAVIOUR

360 Do you smoke?

yes (go to qX)
no (go to qY)

361 If yes, do you smoke inside the house and near children?

362 Do you consume alcohol?

yes (go to qX)
no (go to qY)

363 How often do you drink alcohol?

every day
occasionally during party or adat event
other (specify) lainnya (sebutkan)

364 Are you influenced after drinking alcohol?

yes (explain)
no

NUTRITION NUTRISI

365 Do you eat regular meals? Berapa kali bapak/ibu dan anggota keluarga makan setiap hari?

yes (record how many times/day)
no, why

366 Are there any types of food that you prefer over others?

yes (specify)
no

367 Are there any types of food that are difficult to maintain?

368 Are there any types of food that are considered “prestigious”?

yes (specify)
no

369 Are there any types of food that you eat mostly / only for ceremonial occasions?

yes (specify)
no

370 Have you experienced any food shortages during the past 12 months? Apakah bapak/ibu pernah mengalami kekurangan makanan selama 12 bulan terakhir?

yes ya
no tidak

371 If so, in what month? Jika pernah, di bulan apa?

january januari
february februari
march maret
april april
may mei
june juni
july juli
august agustus
september september
october oktober
november november
december desember

372 Do you find alternates for the food?

yes (specify)
no

SANITATION AND PERSONAL HYGENE

373 Do you have access to hygienic facilities for bathing, washing and waste water? Apakah bapak/ibu memiliki fasilitas higienis untuk mandi, cuci dan buang air?

yes ya
no tidak

374 If you do not have access to hygienic facilities, where to you go to attend to personal hygiene? Jika tidak punya, dimana bapak/ibu biasanya melakukan kegiatan higienis?

season: bucket, in own home
dry bucket, in neighbour’s home
rainy personal bath, indoors
personal bath, outdoors
neighbours’ bath, indoors
neighbours’ bath, outdoors
public MCK (bathing, washing & latrine)
in the home yard di halaman rumah
in a field di ladang
river
mangrove
ocean
other (specify)

375 Do you wash hands before eating or after defecating?

376 Do you take regular bath?