PROSPECTIVE URBAN AND RURAL EPIDEMIOLOGY (PURE) STUDY
Use of Traditional Herbal Medicine Questionnaire
PURE Participant ID:
________________________________ ________________________
Date of Interview:
________________________________________________________
Name of Interviewer:
________________________________________________________
_______________________________________________________________________
Part A: Participant demographic profile
1. Sex:
Male [
]
Female [
]
2. Age (completed years only): ………………….
3. Marital Status:
[
] Never Married
[
] Separated
[
] Other (Specify) …………………….
[
[
] Married
] Widow/Widower
[
[
] Divorced
] Cohabiting
4. Highest formal education level completed:
[
] No education
[
] Primary school
[ ] Secondary School
[
] Vocational
[
] Tertiary
[ ] Other (Specify) …………...
5. Employment status:
[
] Working full-time
[
] Working part-time [
] Unemployed
[
] Looking for a job
[
] Retired
] Self-employed
[
] Other (specify)……………….
[
6. How much is your monthly income (in Rands): ………………..
7. Religion:
[
] Christian [
] Muslim [
] Traditional [
[
] Other (specify)……………………….
] No religion
8. How many people are currently living in your household, including yourself?
---------Number of people
---------Of these people, how many are children (under 18 years)
---------Of these people, how many are adults (over 18 years)
---------Of the adults, how many bring income into the household?
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Part B: Traditional Herbal Medicine use for self and family members
1. Are you currently using any Traditional Herbal Medicine? [ ] Yes [ ] No
If “No” why?
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
2. Have you ever used any of these traditional medicines? (Tick all that apply)
a. African potato
[ ]
b. Honeybush tea
[ ]
c. Imphepo
[ ]
d. Senna
[ ]
e. Sutherlandia frutescens [ ]
f. Tulbaghia spp
[ ]
g. Warbugiasalutaris
[ ]
h. Other (Specify) ………………………………………….
3. How old were you when you first used traditional herbal medicine? ……………..
4. In what form are you taking the traditional herbal medicine? (Tick all that apply)
a. Tea infusion
[ ]
1
b. Tincture
[ ]
c. Dried decoction
[ ]
d. Powder
[ ]
e. Extract
[ ]
f. Capsule/Tablet
[ ]
g. Topical2
[ ]
h. Other (Specify) ………………………………………….
5. What is/are your reason(s) for using traditional herbal medicine? (Tick all that apply)
Treatment of a condition
[ ] General well-being [ ] Preventive measure [ ]
Other (Specify)…………………………………………..
6. In what quantity or dose is the medicine administered?
a. Cups
[ ]
b. Packets
[ ]
c. Brown paper bags
[ ]
d. Newspaper
[ ]
e. Bunches
[ ]
f. Other (Specify) ……………………………………….……
7. How often is the traditional herbal medicine taken?
Daily
[ ]
Weekly [ ]
Monthly
[ ] Occasionally [ ]
As needed [ ]
Other (Specify) ……………………………………………………………….
8. Who administered the traditional herbal medicine to you? (Tick all that apply)
Traditional Healer [ ]
Diviner [ ] Spiritualist [ ]
Pharmacists/Chemist [ ]
1
2
Plant extract made by soaking herbs in a liquid for a specific length of time, strained and the liquid used
Topical i.e. ointment/cream
Page 2 of 4
Doctor/GP
[ ] Friend
[ ] Specialist GP [ ]
[ ] Self-Administered
Nurse [ ] Family member
[ ] Other (Specify)…………………….
9. In addition to traditional herbal medicines, are you taking any other medication(s)?
Yes [ ]
No [ ]
If “YES”, what are they?
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………..
10. What condition are you treating with the traditional herbal medicine? (Tick all that apply)
HIV/AIDS
[ ]
Tuberculosis
[ ]
Diarrhea
[ ]
Kidney infection
[ ]
Colds and flu
[ ]
Throat infection
[ ]
Asthma
[ ]
Epilepsy
[ ]
Peptic ulcers
[ ]
Hypertension
[ ]
Heart disease
[ ]
Stroke
[ ]
Diabetes
[ ]
Bites or stings
[ ]
Swelling of body parts
[ ]
Other (specify)………………………………………………………………………
11. For how long have you been using the traditional herbal medicine?
Less than 3 months
[ ]
3 to 6 months
6 months to 1 year
[ ]
More than 1 year
Several years ago
[ ]
Unsure
[ ]
[ ]
[ ]
12. Do you find that traditional herbal medicine is helping you at all? (Please indicate the
percentage on the scale provided below)
Sometimes
[ ] Always
[ ]
Rarely [ ]
13. Would you recommend the use of traditional herbal medicine to others?
Yes
[ ]
No [ ]
If “YES”, indicate why?
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………………......... …………………………………..
…………………………………………………………………………………………………………
14. Do you take your traditional herbal medicines together with your other medications?
Yes
[ ]
No [ ]
15. How is it helping your condition(s)?
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
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16. Do you know people in your community or family members using traditional herbal medicine?
Yes
[ ]
No [ ]
If you answered “YES” to the above question, do you know what type of traditional herbal medicine
they use?
Yes
[ ]
No [ ]
Please specify below
………………………………………………………………………………………………………
17. Which of the following statements best describe the regularity of traditional medicine in your
family:
Daily
[ ] Weekly
[ ]
Monthly [ ]
Sometimes
[ ] Regular use [ ]
Never
[ ]
18. When you visit your clinic/hospital, do doctors, pharmacists or nurses ask you about your use
of traditional herbal medicines?
Yes [ ]
No [ ]
19. Have you mentioned your use of traditional herbal medicine with your health care professional
(doctor, nurse, and pharmacist)?
Yes [ ]
No [ ]
20. Would you prefer to purchase your traditional herbal medicine at the clinic/hospital?
Yes [ ]
No [ ]
Maybe [ ]
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