QUESTIONNAIRES FOR HOUSEHOLDS
This is an academic survey on Demand for Alcoholic Beverages and the Related Problems. A Case
Study in some selected Communities in Ghana. Please be assured that your responses will be treated
with utmost confidentiality. Your answers will only be used for academic exercise.
A
A SOCIO -DEMOGRAPHIC DATA OF RESPONDENTS
A1. Name of District
…………………………………………….
A2. Name of Community ………………………………………….
Q3. Community Type
1.
2.
Rural
Urban
Q4 Age …………….years
1. Sex
1.
2.
Male
Female
2. Marital Status
1.
2.
3.
4.
Single
Married
Widowed
Divorced
3. Number of own Children dependent on you
1.
2.
3.
4.
5.
6.
none
1
2
3
4
5 and more
4. Number of Other dependents
1.
2.
3.
4.
5.
6.
none
1
2
3
4
5 and more
1
5. Highest Educational level
1.
Basic
2.
Secondary
3.
Post Secondary but not Tertiary
4.
Tertiary
5.
Illiterate
6. Main Occupation
1.
2.
3.
4.
5.
6.
7.
8.
Student
Farmer / Fisherman
Teacher/Lecturer
Public Servant
Trader/Artisan/Driver
Unemployed
Retired
Other (Please Specify) ……………………..……..
7. Average Income of Respondents
………………………………….
8. Religion:
1.
2.
3.
4.
Christianity
Islam
African Traditional Religion
Any other (Please specify)……………………………….
2
Alcohol Use Disorders Inventory Test (AUDIT)
B: EVALUATION OF RISK LEVEL INTERVENTION
(Read the questions as written. Record responses carefully, scoring each answer according to number
in parentheses. Begin the AUDIT by saying “Now I am going to ask you some questions about your
use of alcoholic beverages during this past year.”
Explain what is meant by “alcoholic beverages” using examples of beer, wine, spirit, etc.)
B1. How often do you have a drink containing alcohol?
Never (skip to Questions 9 & 10) (0)
Monthly or less (1)
Two to four times a month (2)
Two to three times per week (3)
Four or more times a week. (4) Score: _____
B2. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2 (0)
3 or 4 (1)
5 or 6 (2)
7 to 9 (3)
10 or more. (4)
Score: _____
B3. How often do you have six or more drinks on one occasion?
Never (0)
Monthly or less (1)
Two to four times a month (2)
Two to three times per week (3)
Four or more times a week. (4)
Score: _____
(If total score is 0 at this point, skip to Questions B9 & B10)
3
B4. How often during the last year have you found that you were not able to stop drinking once you
had started?
Never (0)
Monthly or less (1)
Two to four times a month (2)
Two to three times per week (3)
Four or more times a week. (4)
Score: _____
B5. How often during the last year have you failed to do what was normally expected from you
because of drinking?
Never (0)
Monthly or less (1)
Two to four times a month (2)
Two to three times per week (3)
Four or more times a week. (4)
Score: _____
B6. How often during the last year have you needed a first drink in the morning to get yourself
going after a heavy drinking session?
Never (0)
Monthly or less (1)
Two to four times a month (2)
Two to three times per week (3)
Four or more times a week. (4) Score: _____
B7. How often during the last year have you had a feeling of guilt or remorse after drinking?
Never (skip to Questions 9 & 10) (0)
Monthly or less (1)
Two to four times a month (2)
Two to three times per week (3)
Four or more times a week. (4) Score: _____
4
B8. How often during the last year have you been unable to remember what happened the night
before because you had been drinking?
Never (0)
Monthly or less (1)
Two to four times a month (2)
Two to three times per week (3)
Four or more times a week. (4) Score: _____
B9. Have you or someone else been injured as a result of your drinking?
No (0)
Yes, but not in the last year (2)
Yes, during the last year. (4)
Score: _____
B10. Has a relative or friend, or a doctor or other health worker been concerned about volume of
your alcohol consumption and suggested you cut down?
No (0)
Yes, but not in the last year (2)
Yes, during the last year. (4)
Score: _____
Total Score: _____
INTERPRETATION
A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption.
Please consult a health care professional for advice. (See www.ensuringsolutions.org)
RISK LEVEL INTERVENTION SCORE AND HEALTH CARE
PROFESSIONAL ADVICE ON ALCOHOL CONSUMPTION
(a) Any Score that fall between 0 and 7 suggests Alcohol education
5
(b) Any Score that fall between 8 and 15 suggests Simple advice
(c) Any Score that fall between 16 and 19 suggests Simple advice plus brief counseling and
continued monitoring
(d) Any Score that fall between 20 and 40 suggest Referral to specialist for diagnostic
evaluation and treatment
C: GENERAL DRINKING PATTERNS OF RESPONDENTS WITH REGARD TO
CATEGORY OF ALCOHOLIC BEVERAGES
C1. Do you drink beer, Guinness, etc?
1. yes
2 no
(If no, go to question 14)
C2. If yes, how often, on the average, do you usually drink beer?
1.
2.
3.
4.
5.
every day
at least once a week but not every day
at least once a month but less than once a week
more than once a year but less than once a month
once a year or less
C3. When you drink beer, how much, on the average, do you usually drink at any one time?
1.
2.
3.
4.
5.
more than one six pack (6 or more cans or tavern glasses)
5 or 6 cans of beer or tavern glasses
3 or 4 cans of beer or tavern glasses
1 or 2 cans of beer or tavern glasses
less than 1 can of beer or tavern glass
C4. Do you drink wine?
1 yes
2 no
If no, skip to question C7
6
C5. If yes, how often do you usually drink wine?
1.
2.
3.
4.
5.
every day
at least once a week but not every day
at least once a month but less than once a week
more than once a year but less than once a month
once a year or less
C6. When you drink wine, how much, on the average, do you usually drink at any one time?
1.
2.
3.
4.
5.
over 6 wine glasses
5 or 6 wine glasses
3 or 4 wine glasses
1 or 2 wine glasses
less than 1 glass of wine
C7. Do you drink liquor?
1 yes
2 no
C8. If yes, how often do you usually have a drink of liquor?
1.
2.
3.
4.
5.
every day
at least once a week but not every day
at least once a month but less than once a week
more than once a year but less than once a month
once a year or less
C9. How many drinks, on the average, do you usually drink at any one time?
1.
2.
3.
4.
5.
over 6 drinks
5 or 6 drinks
3 or 4 drinks
1 or 2 drinks
less than 1 drink
7
If you currently drink or have ever drunk in the past, put the number corresponding to the
frequency of the occurrences in the box beside it.
1. At least once in the past two months and at least one additional time during the past year.
2. At least once within the past two months but not during the rest of this past year.
3. Not during the past two months but at least once during the past year.
4. Has happened at least once in my life but not during the past year.
5. Has not happened to me.
1. had a hangover
2. gotten nauseated and vomited from drinking
3. driven a car after having several drinks
4. driven a car when you knew you had too much to drink
5. driven a car while drinking
6. arrested for DWI (Driving While Intoxicated)
7. been criticized by someone you were dating drinking because of your drinking
8. had trouble with the law because of drinking
9. gotten into a fight after drinking
12. destroyed property, pulled a false fire alarm or other such behavior after drinking.
8
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