FREE STATE POVERTY AND HEALTH SURVEY CONSENT FORM: HOUSEHOLD INTERVIEW

Appendix C: Information document and consent form

FREE STATE POVERTY AND HEALTH SURVEY CONSENT FORM: HOUSEHOLD INTERVIEW

RESPONDENT:

Ek,

_______________________________________________________________________ [VOLLE NAME VAN RESPONDENT IN HOOF LETTERS]

 het al die bogaande inligting gelees en verstaan; Ja Nee

 het die geleentheid gehad om die inligting te bespreek en om vrae te vra; Ja Nee

 neem vrywillig deel aan hierdie studie; Ja Nee

 bevestig dat ek ‘n kopie van hierdie vorm ontvang het Ja Nee

Handtekening van respondent: Datum:

__________________________ ______________

ONDERHOUDVOERDER:

Ek,

_______________________________________________________________________ [VOLLE NAME VAN ONDERHOUDVOERDER IN HOOF LETTERS]

 het die volle aard en doel van die studie aan die respondent verduidelik; Ja Nee  bevestig dat ek ‘n kopie van hierdie vorm aan die respondent gegee het Ja Nee

Handtekening van onderhoudvoerder: Datum:

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FREE STATE POVERTY AND HEALTH SURVEY HOUSEHOLD INTERVIEW

 The University of the Free State – in collaboration with the Free State Department of Health – is doing research to investigate poverty and health in our communities. Your community is one of twelve communities selected to participate in this study and your family has been chosen randomly to partake in this research.

 There are no known benefits associated with your participation in this research. The data that we obtain from the study will enable us to provide the Departments of Health and Social Development and other policy makers with information, which will be used to inform decision making processes regarding policy.

 You and the members of your household will be asked various questions by a team of trained interviewers. We will be collecting the following information from you and your family members:

Respondent: Type of information: Duration:

1. Household head and/or other key decision makers; all household members (for anthropometric measures)

Anthropometric measures (e.g. height/weight); socio-demographics; education; disability; morbidity, mortality

60-90 minutes 2. Person in charge of

household finances Housing; basic services; household assets; food security; expenditure; income; savings; debt 60-90 minutes 3. Household members ≥ 10

years

24-hour activity schedule 10-15

min/person 4. Household members ≥ 15

years Work and labour force participation 15-20 min/person

5. Household members ≥ 16

years Health, health seeking behaviour and knowledge on health-related issues 30-45 min/person These interviews will take approximately 3-4 hours to complete in total. Children younger than 16 years must be assisted by a parent/guardian/caregiver during the taking of the anthropometric measures and when completing the 24-hour activity schedule. We will also ask the parent/guardian/caregiver of school-going children for Centre for Health Systems Research & Development

Sentrum vir Gesondheidsisteemnavorsing en Ontwikkeling FACULTY OF THE HUMANITIES/FAKULTEIT GEESTESWETENSKAPPE BLOEMFONTEIN 9300 REPUBLIC OF SOUTH AFRICA REPUBLIEK VAN SUID‐AFRIKA REPHABLIKE YA AFRIKA BORWA SA (051) 401‐2623 Fax/Faks: SA (051) 444‐6758 E‐: BooysenF.EKW@ufs.ac.za

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consent to access these children’s school records, which will assist us to make a detailed study of how poverty impacts on children’s education. It is important to note that the answers to all these questions will remain confidential and will not be viewed by other household members (with the exception of children < 16 years, we will interview each respondent individually and in a quiet place away from other household members) or by any person/party not directly involved in the study. The forms with your answers and the accompanying signed consent forms will be kept safe in a locked building.

 Although this is only a survey, some of the questions relate to personal and sensitive issues. Some people may find it upsetting to recall and discuss their experiences. You and any person in your household are however free to decline to answer any specific question if you feel the information is too sensitive or personal. Members of your household, including yourself, are also free to stop the interview at any time and to withdraw from the study, with no consequences.

 As the research team is particularly interested in changes over time in household welfare and in health, your household will not only be interviewed only this once. We will also be visiting you twice more over the next twelve months, this to collect information on similar issues in order to determine how the households’ and household members’ circumstances have changed during the intervening months.

 Your participation in this study is voluntary. Should you agree to participate, each of the persons in your household that we will interview, including yourself, is required to sign this informed consent form, the contents of which we will explain again to each person prior to asking them the relevant questions. Individual household members are free to refuse to participate in the survey if they so wish.

Should you require any additional information concerning this study, you are welcome to contact any of the following persons:

Name: Phone number:

Prof Frikkie Booysen 051 401 2623 / 083 381 5874 The Director: CHSR&D 051 401 2181

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FREE STATE POVERTY AND HEALTH SURVEY CONSENT FORM: HOUSEHOLD INTERVIEW RESPONDENT:

_______________________________________________________________________ _

[FULL NAME OF RESPONDENT IN BLOCK LETTERS]

 have read and understood all the above information; Yes No

 was given the opportunity to discuss this information and to ask questions; Yes No

 volunteer to take part in this study; Yes No

 confirm that I have received a copy of this consent form Yes No

Signature of respondent: Date:

__________________________ ______________

INTERVIEWER:

_______________________________________________________________________ _

[FULL NAME OF INTERVIEWER IN BLOCK LETTERS]

 have explained the nature and purpose of the study to the respondent in full; Yes No  confirm that I have given the respondent a copy of this consent form Yes No

Signature of interviewer: Date:

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FREE STATE POVERTY AND HEALTH SURVEY HOUSEHOLD INTERVIEW

 University ya Free State ka kopanelo le lefapha la bophelo la Free State di tshwere diphuputso mabapi le bofuma le bophelo bo botle ka hare ho metse ya bo lona. Motse wa lona ke o mong o kgethilweng ka hare ho metse e 12, e tlong ho nka karolo, mme lelapa la lona ke Ie leng la malapa a hlwailweng ho nka karolo.

 Ha ho merokotso e tla lebellwa ho nkeng karolo diphuputsong. Dipalopalo tse tlang ho bokelletswa ke tsona tse tlang ho thusa lefapha la bophelo bo botle le la thekolohelo ho nka diqeto ho seo se lokelwang ho etswa.

 Wena le ba lelapa la hao le tla botswa dipotso tse mmalwa ke sehlopha sa batho ba rupeletsweng. Re tlo bokella lesedi le latelang ho wena le ba lelapa:

Moikarabeli: Mofuta wa lesedi: Nako:

1. Hloho ya lelapa kapa emong wa banking qeto lapeng; maloko a lelapa kaofela (for anthropometric measures)

Anthropometric measures (e.g. height/weight); socio-demographics; education; disability; morbidity, mortality

60-90 metsotso 2. Motho ya ikarabellang

ditshenyehelong tsa lelapa Housing; basic services; household assets; food security; expenditure; income; savings; debt 60-90 metsotso 3. Maloko a lelapa ≥ 10

dilemo

24-hour activity schedule 10-15

metsotso /motho 4. Maloko a lelapa ≥ 15

dilemo Work and labour force participation 15-20 metsotso

/motho 5. Maloko a lelapa ≥ 16

dilemo Health, health seeking behaviour and knowledge on health-related issues 30-45 metsotso /motho Dipuisano di tla nka dihora tse 3-4 ho phethelwa. Bana ba ka tlase ho dilemo tse 16 ba lokelwa ho thuswa ke batswadi/bahlokomedi ba bona ha re tla be renka dianthropometric measures le kapuisano ya 24-hour activity schedule.Re tla kopa hape le ho batshehetsi ba bana hore re ka hlwela Ie ditokomane tsa bona tsa sekolo,ho re thusa ho etsa dipatlisiso tse kenelletseng mabapi Ie kamoo bofuma bo nkang karolo ka Centre for Health Systems Research & Development

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teng maphelong a bana.Ho molemo ho dula o ntse o hopola hore tsena tsohle di tla dula e Ie lekunutu ka nako tsohle, Ie kekeng la tsejwa ke malapa a mang. (bana ba ka tlasa 16 ya dilemo batla botswa dipotso ka thoko moo ho senang setho sa lelapa se tlang ho tseba letho, kapa ke motho ho hang ya sa ameheng diphuputsong.Ditokomane mmoho le dikarabo tsa hao di tla bolokwa sebakeng se bolokehileng.

 Le hoja hona e le dipatlisiso feela,tse ding tsa dipotso di ka amana le maikutlo a batho. Ha batho ba ang batla utlwa bohloko ke tse ding tsa diketsahalo tseo ba tlang ho di hopola. Wena le ba lelapa la hao le ka nna la tlohela ho araba tse ding tsa dipotso tse jwalo. Le na le bolokolohi ba ho ka emisa dipuhisano ka nako efe kapa efe, kapa ho ikgula diphuputsong ka ntle le ho lahlehelwa ke menyetla efe kapa efe.

 Jwalokaha diphuputso di na le thahasello diphetohong ka nako e telele ho tsa lelapa, thekolohelo le bophelong bo botle, dipuisano di keke tsa fella mona. Re tla boela re tlo le bona hape habedi ka nako ya dikgwedi tse 12. Ho tla lekola hore na ho bile le diphetoho malapeng ka morao ho dipuisano.

 Karolo ya hao diphuputsong ke bo-ithaopi, ha o dumela ho nka karolo, emong le emong wa lelapa ho kenyelletswa le wena o lokela ho saena tokomane e itseng.Dikahare tsa ditokomane di tla hlaloswa ka botlalo ho e mong le e mong wa lelapa. Le na le tokelo ya ho hana ho tswela pele ka diphuputso.

Ha o hloka lesedi bakeng sa diphuputso, o ka letsetsa batho ba latelang:

Mabitso: Nomoro ya ho

letsa:

Prof Frikkie Booysen 051 401 2623 / 083 381 5874 The Director: CHSR&D 051 401 2181

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FREE STATE POVERTY AND HEALTH SURVEY CONSENT FORM: HOUSEHOLD INTERVIEW MOARABEDI:

Nna,

_______________________________________________________________________ _

[LEBITSO LEFELETSI]

 kebadile ka utlwisisa lesedi le kahodimo kaofela; Ee Tjhe

 ka fumantshwa monyetla waho buisana ka lesedi ke botsa le dipotso; Ee Tjhe

 ke ithaopile honka karolo diphuphutsong tsena; Ee Tjhe

 ke a dumela hore kefumane kopi (copy) ya tokomane ena Ee Tjhe

Tekena: Letsatsi __________________________ ______________ MOPHUPHUTSI: Nna, ______________________________________________________________________ [LEBITSO LEFELETSI]

 ke hlaisitse maemo le molemo wa diphuphutso ho moikarabeli ka botlalo; Ee Tjhe

 ka mofa le lengolo la tumellano Ee Tjhe

Tekena: Letsatsi:

161

EFFEKTIEWE VIGS BEHANDELING EN ONDERSTEUNING (FEATS)

In document The impact of a high protein food supplement on the nutritional status of HIV infected patients on ARV treatment and their families (pagina 178-185)