ACCESS-FP Postpartum IUCD Follow-Up Questionnaire, ID:______
ACCESS-FP PPIUCD Client Follow-up Questionnaire
Facility Name:Embu PGH / Woman’s Assigned ID:
Location (District/Province):
Embu / Interviewer’s Name:
1st attempt: ___:___ AM/PM (time)
…….(date)/ ……(month)/ …….(year) / Method
Call
Visit / Result / 01. Completed interview => data entry, file
02. Refused => data entry, file
03. Postponed => schedule call back or revisit time: ______
04. Did not reach woman => call back or revisit
2nd attempt: ___:___ AM/PM (time)
…….(date)/ ……(month)/ …….(year) / Call
Visit
3rd attempt: ___:___ AM/PM (time)
…….(date)/ ……(month)/ …….(year) / Call
Visit
4th attempt: ___:___ AM/PM (time)
…….(date)/ ……(month)/ …….(year) / Call
Visit
INTERVIEWER:
1) Introduce yourself: My name is xxxx and I represent the ACCESS-FP Program. We are speaking with women about the experience of postpartum IUCD. A few months ago, we spoke to you at Embu PGH and you kindly provided your phone number and your home address. Now we would like to see how you are doing and ask you some follow-up questions.
2) Ask if she is willing to answer a couple of questions anonymously.
3) Explain that you are interested in improving health programs for women and that her comments will be used only for that purpose.
4) Assure the woman that her answers will be CONFIDENTIAL and will in no way reflect the outcome of services she receives at the health facility.
Does the woman agree to participate in the interview?
[ ] Agree
[ ] Does not agree, record reason(s):______(End of interview now)
Signature of Interviewer:
______
SECTION FOR REVIEW AND DATA ENTRY
Data reviewed by: / Data entry:
[STAMP WHEN COMPLETED]
Date of Review:
…….(date)/ ……(month)/ …….(year)
No. / Question / Response / Skip pattern /
1. / Have you experienced any problems or complications since the postpartum IUCD (PPIUCD) insertion? / Yes…1
No…2 / à go to question 3 /
2. / If yes, please tell me all the problems or complications you have had. /
/ 2a. When did it happen? / Two weeks ago…1
Last month…2
Two months ago…3
Other specify ….4 /
/ 2b. How did you find out? /
3. / Are you still using the same IUCD inserted when you delivered the baby? / Yes…1
No…2 / à go to question 6
à go to question 4 /
4. / If no, when was it removed? / ______/______/20___ (Day/Month/Year) /
/ 4a. Why was it removed? / Reason(s): /
5. / Did you have another IUCD inserted after the removal of PPIUCD? / Yes…1
No…2 / à go to question 7 /
6. / (If yes) when was it inserted / _____/______/20___ (Day/Month/Year) /
7. / Are you currently using any family planning method? / Yes…1
No…2 / àgo to question 9 /
8. / If yes, which one(s)?
MULTIPLE RESPONSES ALLOWED / Female sterilization…1
Male sterilization…2
Pill…3
Regular IUCD…4
Injectables…5
Implants…6
Male condom…7
Female condom...8
Diaphragm…9
Foam/jelly…10
Withdrawal…11
Other, specify:______95 /
9. / Have you ever used any other family planning method other than PPIUCD since the birth of your last baby? / Yes…1
No…2 / à go to question 11 /
/ 9a. If yes, which one(s)?
MULTIPLE RESPONSES ALLOWED / Female sterilization…1
Male sterilization…2
Pill…3
Regular IUCD…4
Injectables…5
Implants…6
Male Condom…7
Female condom...8
Diaphragm…9
Foam/jelly…10
Withdrawal...11
Other, specify:______..95 /
10. / Have you had any follow-up visits since the IUCD was inserted? / Yes…1
No…2 / à go to question 14 /
/ 10a. If yes, how many times did you go for follow-up visits? / [___] /
11. / Please tell us more information about your follow-up visits:
RECORD INFORMATION ON UP TO 3 VISITS
Interviewer probe if woman consultated with the service provider about the IUCD during the MCH visits.
Ask for the MCH card if available. / Visit #1 ___/___/2009 (Day/Month/Year)
Location:______
Reason for visit:
______/ à record up to three visits then go to question 15 /
Visit #2 ___/___/2009 (Day/Month/Year)
Location:______
Reason for visit:
______
Visit #3 ___/___/2009 (Day/Month/Year)
Location:______
Reason for visit: /
Visit #4 ___/___/2009 (Day/Month/Year)
Location:______
Reason for visit: /
12. / If not, can you tell us why you have not had any follow-up visits? /
13. / How does PPIUCD compare to other family planning method(s) you had used?
Interviewer probe in areas of comfort, side effect, ease to use….etc /
14. / Based on your experience, would you recommend PPIUCD to a female relative or friend who is pregnant or has recently given birth? / Yes…1
No…2 /
/ 14a. Why? / Reason(s): /
/ 14b. Why not? / Reason(s): /
15. / Would you choose to use PPIUCD again if given the choice? / Yes…1
No…2 /
/ 15a. Why? / Reason(s): /
/ 15b. Why not? / Reason(s): /
16. / Do you want to have any more children? / Yes…1
No…2 / à go to question
à go to question /
17. / How long from now do you want to wait before getting pregnant again? / [ ] [ ] in years
Don’t know…99
Other, specify:______..95 /
18. / How long do you plan to continue using this PPIUCD? / [ ] [ ] in months
[ ] [ ] in years
Don’t know…99 /
19. / Thinking back to when the IUCD was inserted, did you have any pain or discomfort during insertion? / Yes…1
No…2 / à go to question 21 /
20. / On a scale of 1-5, 1 as “the least” and 5 “the most painful”, how would you rate the pain you experienced during and immediately after the PPIUCD insertion? / No pain at all…1
A little bit…2
In between..3
Somewhat painful..4
Very painful..5 /
21. / Do you have any concerns or questions regarding using the IUCD at this time? / Yes…1
No…2 / à end interview /
22. / If yes, what are your concerns or questions?
Interviewer can encourage woman to seek assistance at health facility as needed. /
INTERVIEWER: Thank the respondent for her time and responses! Invite her to contact us at XXX-XXXX if she has further questions regarding this interview.
Interviewer comments: /
Kenya 2009 Page 5 of 5