RETENTION Behavioral Assessment
Questions
SURVEY INFORMATION
SECTION I
Response
Code
1-1.
AMRS ID
Enter ID
1-2
Encounter Date
Date of Encounter
1-3
Name of the CHV
___________
__/__/____
Day/Month/Year
Name of CHV
_________________
RETENTION BEHAVIORAL ASSESSMENT
SECTION II
Part A: General
Question
Responses
Where do you usually go for health care?
Code
Dispensary 1
Health Center 2
District 3
Private Clinic 4
IIA-1.
Herbal Clinic 5
Never been to a 6
health facility
Other(Specify) 99
___________________
Foot 1
Bicycle 2
Motorcycle (boda boda) 3
IIA-1a.
When you go to the health facility, how do you get there?
Small bus (Matatu) 4
Private car 5
Never been to a health 6
facility
Refused/No answer 99
IIA-2.
On average, how long does it take you to get to the facility
Minutes
___
Hours
___
Refused/No answer
IIA-3a.
How would you rate the personal manner (courtesy, respect,
sensitivity, friendliness, and attitude) of the health care provider you
see?
99
Good 1
Fair 2
Poor 3
Refused/No answer 99
IIA-3b.
How would you rate the health care provider’s explanation of your
high blood pressure and the treatment you need?
Good 1
Fair 2
Poor 3
Refused/No answer 99
Good 1
IIA-3c
How would you rate the follow-up by your health care provider?
Fair 2
Poor 3
Refused/No answer 99
RETENTION Behavioral Assessment
Part B: Perceived Risks/Severity
Yes[read IIB-1a] 1
IIB-1.
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?
IIB1a.
No [go to IIB-2?] 2
Refused/No Answer 99
Yes
1
No
2
Refused/No Answer
99
Very serious 1
What is your perception of high blood pressure?
IIB-2.
Serious 2
Not that serious 3
Refused/No Answer 99
IIB-3.
Have you ever been told that you need to do any of the following:
IIB-3a
Come to the clinic regularly to monitor your blood pressure?
Yes
1
No
2
Refused/No Answer
IIB-3b
Take medication to manage your high blood pressure?
Yes
1
No
2
Refused/No Answer
IIB-3c
Control your weight
Reduce your salt intake
1
No
2
Exercise more
1
No
2
Reduce your alcohol use
1
No
2
Stop smoking or use of tobacco
1
No
2
99
Yes
1
No
2
Refused/No Answer
IIB-4
99
Yes
Refused/No Answer
IIB-3g
99
Yes
Refused/No Answer
IIB-3f
99
Yes
Refused/No Answer
IIB-3e
99
Yes
Refused/No Answer
IIB-3d
99
99
Are you currently…
IIB-4a
Taking medication to manage your high blood pressure?
Yes [read IIB-4b]
1
No [skip to IIB-4c]
2
Refused/No Answer
IIB-4b
Where did you get your medication
Chemist
Shop
From a peer
friend
Health center
Dispensary
Traditional herbalists
Other (Please specify)
Refused/No Answer
99
1
2
3
4
5
____________________
99
RETENTION Behavioral Assessment
IIB-4c
Controlling your weight?
Yes
1
No
2
Refused/No Answer
IIB-4d
Reducing your salt intake?
Yes
1
No
2
Refused/No Answer
IIB-4e
Exercising more? (E.g. Digging, running etc.)
Reducing your alcohol use?
1
No
2
Reducing or stopping your tobacco use?
1
No
2
Is your blood pressure controlled at the level your health care provider
wants it to be?
1
No
2
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? [If yes, read 8a. If no, read 9]
IIB-6a
How can you tell if your blood pressure is going up or down?
Because you feel….
1
No
2
1
No [skip to IIB-7]
2
Refused/No Answer
Angry/irritable
1
2
Fast
/palpitations/heart
pounding
3
Headache/head throbbing
Fatigue/weakness
Dizziness
Other (Please specify)
Refused/No Answer
4
5
6
7
8
9__________________
99
Sometimes we have trouble doing what the health care provider says. Have you ever…
IIB-7a
Missed your blood pressure appointment because you felt well?
Yes
1
No
2
Refused/No Answer
IIB-7b
Missed taking your blood pressure drugs when you were feeling better
99
Yes
1
No
2
Refused/No Answer
99
If you have high blood pressure and you don’t seek care, do you think you are at risk of…
IIB-8a
Having a stroke
Yes
1
No
2
Refused/No Answer
IIB-8b
99
Tense/nervous
Chest pain
IIB-8
99
Yes [read IIB-6a]
Shortness of breath
IIB-7
99
Yes
Refused/No Answer
IIB-6
99
Yes
Refused/No Answer
IIB-5
99
Yes
Refused/No Answer
IIB-4g
99
Yes
Refused/No Answer
IIB-4f
99
Developing kidney failure
Yes
99
1
RETENTION Behavioral Assessment
No
Refused/No Answer
IIB-8c
Developing heart disease
2
99
Yes
1
No
2
Refused/No Answer
99
Part C: Perceived Barriers
IIC-1
Have you delayed or not sought care for your high blood pressure for any of the following reasons:
IIC-1a
You lacked fare for transport
Yes
1
No
2
Refused/No Answer
IIC-1b
You lacked the mode of transportation?
Yes
1
No
2
Refused/No Answer
IIC-1c
You lacked money to pay for the medical procedure fee and blood
pressure drugs
IIC-1d
You thought it was more important to spend your money on school
fees, food, or farm inputs
Limited services at the health facility
1
No
2
Refused/No Answer
Long queues at the health facility
1
No
2
Corruption (taking bribes, Favoritism in queues, denial of service) at the
health facility
1
No
2
IIC-1h
1
No
2
IIC-1i
1
No
2
IIC-1j
1
No
2
IIC-1k
1
No
2
IIC-1l
1
No
2
You believe your faith will heal you
99
Yes
1
No
2
99
Yes
1
No
2
Refused/No Answer
IIC1m
99
Yes
Refused/No Answer
You bought your own medication from the chemist/shop
99
Yes
Refused/No Answer
You received medication from your friend or family member
99
Yes
Refused/No Answer
You preferred traditional herbal medicine
99
Yes
Refused/No Answer
You didn’t have time/You could not take time off from the
responsibilities you have
99
Yes
Refused/No Answer
You don’t think continuing care makes a difference
99
Yes
Refused/No Answer
IIC-1g
99
Yes
Refused/No Answer
IIC-1f
99
Yes
Refused/No Answer
IIC-1e
99
99
Yes
1
No
2
RETENTION Behavioral Assessment
Refused/No Answer
It is burdensome to take blood pressure drugs every day
IIC-1n
99
Yes
1
No
2
Refused/No Answer
99
Part D: Emotional Factors
IID-1
IID-1a
Have you delayed or discontinued care for your blood pressure in the last three months because you are…
Yes 1
Afraid of the stigma associated with high blood pressure
No 2
Refused/No Answer
IID-1b
Afraid of being seen at the AMPATH facility because of possible HIV
stigma
Afraid of the chronic nature of high blood pressure
IID-1c
Yes
1
No
2
Refused/No Answer
IID-1d
1
No
2
IID-2a
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)
99
Yes
1
No
2
Refused/No Answer
IID-2
99
Yes
Refused/No Answer
Afraid of taking high blood pressure drugs
99
99
Yes [read IID2a]
1
No [go to IIE1]
2
Refused/No
Answer
99
Being late
1
Not showing up for
appointment
2
Not taking medications
3
Other (Please specify)
4
Refused/No Answer
99
Part E: Motivation
IIE-1
What factors encourage you to seek health care? (Please do not read
the options aloud to the patient; select only those that the patient
mentions on her own accord)
Improved health
Response to medications
High blood pressure
being a manageable
disease
Follow-up by CHWs
Friendliness of the health
facility staff
Family and/or peer
support/encouragement
None
Others(specify)
Refused/No Answer
1
2
3
4
5
6
7
8__________________
99
Part F: Confidence
IIF-1
How confident are you that you will go back into care and seek blood
pressure care consistently?
Very confident [read IIF1a]
1
RETENTION Behavioral Assessment
Somewhat confident
[read IIF-1a]
2
Not very confident[go to
IIF-2]
3
Refused/No Answer
IIF-1a
Do you have a specific plan for how to do so?
Yes
1
No
2
Refused/No Answer
IIF-2
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?
1
Somewhat sure [read IIF2a]
2
Not very sure[go to IIF-3]
3
How confident are you that you will be able to modify your lifestyle,
such as exercising more, eating healthy, and controlling your weight?
IIF-3a
Have you thought of a specific way to do that?
99
Yes
1
No
2
Refused/No Answer
IIF-3
99
Very sure [read IIF-2a]
Refused/No Answer
IIF-2a
99
99
Very confident [read IIF3a]
1
Somewhat confident
[read IIF-3a]
2
Not very confident[End
survey]
3
Refused/No Answer [If
no, end survey]
99
Yes
1
No
2
Refused/No Answer
99
Based on the combination of participant responses, the following video clips are recommended to be shown. You can choose which
ones to show:
1. Video 1
2. Video 2
3. Etc…..