KENYATTA UNIVERSITY.

SCHOOL OF PUBLIC HEALTH AND APPLIED HUMAN SCIENCES.

DEPARTMENT OF POPULATION, REPRODUCTIVE HEALTH AND

COMMUNITY RESOURCE MANAGEMENT
BSC. POPULATION HEALTH

PPH 423: COMMUNITY DIAGNOSIS

DR. ROSEBELLA KIPKALOM

NESTORY WASHE Q126/4877/2017

PURITY MUTISYA Q126/1048/2018
ISA CHEDA Q126/0673/2017
PASCAL BUNGUKE Q126F/27063/2017
KIPKIRUI GODWIN Q126/1069/2017
COMMUNITY DIAGNOSIS

CONSENT FORM
INFORMED CONSENT
Date ….……………
I am a student at Kenyatta University, inviting you to participate in a study to explore factors that
are associated with unhealthy relationships amongst college students. Data gathered in this study
will be documented in the final report. The survey time should not exceed 15-20 minutes.
The benefits of participating in this study include helping me to formulate a better understanding
and diagnosing of the health problems that affect your community. This will aid us in coming
up with strategies and remedies to solve the problems through a multisectoral approach with the
different stakeholders including the government.
The data collected will be kept confidential. Providing your name and signing shows you are
willing and ready to give genuine information. Thank you for working with the researcher

Name……………………………………………………
Phone number……………………….
Signature………………

INSTRUCTIONS:

1. Greet the house hold introduce yourself and explain the Ministry or organisation or
institution that you represent.
2. Explain the purpose of your visit. Establish the rapport and obtain permission to start the
interview by signing the consent form.
INTERVIEW SCHEDULE

A) DEMOGRAPHIC PROFILE
1. Name of the community………………………………………………………...
2. Area……………………………………………………………………………..
3. House number…………………………………………………………………..
4. Name of the family member ……………………………….……………..........
5. Position in the family (e.g., father, mother etc) ……………………………………
6. Gender……………………………………………………………………..........
7. Age……………………………………………………………………………...
8. Highest education attained………………………………………………………
9. Occupation……………………………………………………………………...
10. How many people live in this house?...................................................................
11. Are there people who sometimes move away?....................................................
12. Where do they go and why?................................................................................
13. Who heads this household?..................................................................................

B) FAMILY MEDICAL HISTORY

1. In the past 6 months, has anyone in the family had:
● Diarrhoea
● Cough and colds
● Abdominal pain
● Dizziness
● Difficulty of breathing
● Fever
● Vomiting
● Headache
● Loss of consciousness
● Other
Specify………………………………………………………………………………
2. Was consult sought for these conditions?
● Yes
● No
● For some, but not all (please explain why) ………………………………………….
3. If yes, where was consultation done?
● Health centre or government clinic
● Private clinic
● Traditional healer
● Hospital
4. If ‘No’ please cite reasons…………………………………………….......
…………………………………………………………………………………..
…………………………………………………………………………………..
…………………………………………………………………………………
 5. If someone in the family is sick, who do you approach for initial consultation
● Nurse
● Doctor
● Clinical Officer
● Community health worker
● Other………………………
● No one, patient is treated at home
● Explain why?.......................................................................................................
6. Who accompanies the patient for consultation?
● Mother
● Sibling
● Father
● Grandparent
● Others………………………………………………..
7. Do you have easy access to drug store?
● Yes, can walk
● No, have to use cycle to the nearest drug store
8. In the past one year have had any death in the family?
● No
● Yes (Explain reasons for death) …….…………………………………………

C. MATERNAL HEALTH

1. Is there a pregnant female in the family?

● Yes
● No
2. If yes, what is the age range of the pregnant female?
● 13-17
● 18-22
● 23-27
● 28 and above
3. What is the number of the pregnancy?..................................
4. Does she have Antenatal check ups
● Yes
● No, If No Please Indicate reasons for this……………………………………
……………………………………………………………………………..........
…………………………………………………………………………………..
5. Where is Antenatal check up done?.....................................................................
6. If any female member already delivered, where was the delivery done?
● Home
● Government Clinic
● Hospital
● Private Clinic
 7. How old was the youngest child at the time of delivery?....................................
8. Is family planning being practiced?
● Yes
● No, if No give reasons…………………………………………………………
…………………………………………………………………………………..
…………………………………………………………………………………..
…………………………………………………………………………………..
9. What kind of family planning method is practiced?
● Natural Method
● Pill
● Abstinence
● condoms
● Injection
● IUD
● Other, specify…………………….
10. Do children in the family have regular immunisation follow up?
● Yes
● No
14.Have they received (please Tick)
● BCG
● DPT
● Polio
● Measles
● Other ………………….

D. NUTRITION PROFILE

1. How many times a day does the family eat when they are at home?..................
2. What meals are usually skipped?
● Breakfast
● Lunch
● Dinner.
3. Are there foods preferred in the family?
● Yes
● No
4. What are these food preferences?........................................................
……………………………………………………………………………….
……………………………………………………………………………….
……………………………………………………………………………….
5. Where do you get your food?.........................................................................
…………………………………………………………………………..
…………………………………………………………………………..
6. How is the food availability for each season?................................................
 …………………………………………………………………………..
………………………………………………………………………......
7. Does the child breast feed?
● Yes
● No
8. If No, explain………………………………………………………………..
……………………………………………………………………………….
……………………………………………………………………………….
9. What do children like eating?........................................................................
………………………………………………………………………………
………………………………………………………………………………
10. Are children given vitamin supplements?
● Yes
● No

E) COMMUNITY HEALTH

1. What are the main diseases in this area as indicated by local

people?..........................................................................................
…………………………………………………………………………..
…………………………………………………………………………..
…………………………………………………………………………..
2. As stated by the clinic……………………………………………………….
…………………………………………………………………………..
…………………………………………………………………………..
…………………………………………………………………………..
3. Seasonal Diseases…………………………………………………………...
…………………………………………………………………………..
…………………………………………………………………………..
4. Why do you have these problems?.................................................................
…………………………………………………………………………..
…………………………………………………………………………..
…………………………………………………………………………..
5. How far is the nearest health care facility
● Walking distance
● Have to take a cycle
● Have to take a bus
6. What attitudes do people have towards health services?
…………………………………………………………………………..
…………………………………………………………………………..
…………………………………………………………………………..
…………………………………………………………………………..
 7. Have you experienced a member of the community dying in last six months?
● Yes
● No
8. What was the cause of death?
…………………………………………………………………………..
9. Who died?......................................................................................................
● Child
● Female adult
● Male Adult
● A youth
10. How old was the person who died?................................................................
11. Where did the person die?..............................................................................
12. What do you think was the major problem that to that death and how could it have been
prevented?
…………………………………………………………………………..
…………………………………………………………………………..
…………………………………………………………………………..

F) WATER SUPPLY AND SANITATION

1. What is your water source for drinking?

● Tap water
● well
● Communal Kiosk
● Bore hole
● River/stream
2. What do use to treat your water?
● Chlorine
● Boiling
● Other (indicate)…………………………
3. How far is your water source?
● Walking distance
● One need to ride a bicycle
4. What do you use to store your water?
● Bucket
● Container
● Tanks
● Jerricans
● Others (Indicate)........................................................
5. Is your water source protected?
● Yes
● No
6. If No, why not?.................................................................................................
 …………………………………………………………………………..
………………… …………………………………………………………………………..
7. Do you have a latrine?
● Yes
● No
8. If No, where do people go to answer the call of nature…………………………
9. Does your toilet have a lid?
● Yes
● No

G) ECONOMIC ACTIVITIES

1. What do you do for living?..............................................................................

…………………………………………………………………………..
………………………………………………………………………......
2. Probe for other sources of income……………………………………………
………………………………………………………………………......
…………………………………………………………………………..
3. Average income per month………………………………………………….
………………………………………………………………………….
4. What activities do you engage in?
● Farming
● Fishing
● Handcraft
● Trading
● Others ……………………………………………………………..

H) HOUSING AND POPULATION

1. Type of the house they are living in ……………………………………………

2. What material was used to for the house?...................................................
…………………………………………………………………………………..
…………………………………………………………………………………..
3. How many rooms does the house have?.......................................................
4. How many people sleep in one room?.................................................................
5. Do some members of the house move away at certain times?
● Yes
● No
6. If yes explain…………………………………………………………………..
…………………………………………………………………………………..
…………………………………………………………………………………..
…………………………………………………………………………………..
I) POLITICAL ORGANISATION

1. Who are the political leaders here (MP, Councillor)?

………………………………………………………………………………….
…………………………………………………………………………………………………
2. Who are the traditional leaders?
…………………………………………………………………………………
…………………………………………………………………………………..
…………………………………………………………………………………..
3. Which people have a lot of influence?
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………………………….
4. Do you have committees in this area?
● Yes
● No
5. If yes mention these committees
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………………………….
6. Do you think these committees are helpful?
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
7. What developmental activities have taken place in the past six month?
…………………………………………………………………………………..
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………...………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………………………….
8. Did the community participate?
● Yes
 ● No
J) COMMUNICATION SYSTEM

1. Do you have access to any of these?

● Radio
● TV
● News paper
● Telephone
2. Which one is the commonest communication system?
● Telephone
● Radio
● TV
● News paper
3. Which communication system you prefer most among these ?
● Radio
● TV
● News paper
● Telephone

Ask the household if they have any question to ask you

● ............................................................................................................................
● .. ............................................................................................................................
● .. ............................................................................................................................
● .. ............................................................................................................................
● .. ..........................................................................................................................

Please do not promise them anything.

Thank the household for taking time to take part in your interview.
Indicate number of minutes taken..............................................................................