10. Annexes

Annex-1: Consent form in English

Greeting to the patient

My name is______As you know I am working in the TB clinic of this health center. Now I am working as a data collector on the study of undernutrition among adult TB patients. The data will be collected through interviews and anthropometric measurement. I will be asking you for about thirty minutes.

Whose main aim is to Study nutritional status and associated factors among adult tuberculosis patients. There is no risk in participating in this research and you will not be provided any incentives to take part in this study. You have the full right to refuse from participating in this research if you do not wish to participate and to withdraw from this study at any time you wish to.

Are you willing to participate in this study?

Agree Disagree

The researcher explained me all the necessary information about the objective of the study. In addition, I have been informed as I have the right to not participate and withdraw from the study at any time.

Based on the information, I confirm my agreement to participate on the study and provide necessary information.

If the client agrees, thank and precede the interview.

If the client disagrees, thank and Proceed to the next client.

Signature of Patient…………….Interviewer name and Signature……………….

Date of Interview……………….Supervisor name and Signature…………….

Name of Health Center………………

Questionnaire in English

PART ONE=SOCIO-DEMOGRAPHIC INFORMATION

S.No / Question / Possible answers / Skip pattern
101 / Age / …………(completed year)
102 / sex / Male…………………….1
Female………………..…2
103 / Religion / Orthodox………………..1
Muslim…………………..2
Catholic………………….3
Protestant………………..4
Other (specify)………….99
104 / Ethnicity / Amhara………………..….1
Tigre……………………...2
Oromo……………………3
Gurage………………..….4
Other (specify)………….99
105 / Marital status / Single………………….….1
Married………….……..…2
Divorced………….………3
Separated…………..……..4
Widowed…………..……..5
Living together……..…..…6
Other (specify)……………99
106 / Educational status / Illiterate……………………1
Read and write………...…..2
Primary school ………..…..3
Secondary school………….4
Certificate………….….…..5
Diploma…………….……..6
Degree or higher…………..7
107 / Occupational status / House wife………………...1
Employed…………………2
Unemployed………………3
Student……………………4
Daily laborer………….…...5
Merchant…………………..6
House6 made…………..….7
Other (specify)………..…99
108 / Partners occupational status / House wife…………….…..1
Employed…………………2
Unemployed………………3
Student……………………4
Daily laborer……………....5
Merchant…………………..6
House made…………....….7
Other (specify)……………99
109 / Income per month / No income……………..…..1
Don’t know………….….....2
No answer……….……...…3
____(birr/month)…………..4

PART TWO=NUTRITIONAL HISTORY OF PATIENTS

201 / Family Size per household / 1………………………………………….1
2………………………………………….2
3………………………………………….3
4………………………………………….4
5………………………………………….5
6 or more than six…………….………….6
202 / How much money is spent monthly per house hold? / ………ET birr/month
203 / How many times per day you eat?( only one from the list that best describes your usual eating pattern) / One meal with no snake………………….1
One meal plus snake……………………..2
Two meal with no snake…………….…...3
Two meal plus snake………………...…..4
Three meal with no snake……………….5
Three meal plus snake…………………...6
More than three meals plus snake……….7
No specific meals………….………….…8
Other (specify)………………………….99
204 / In the past 4 weeks, was there ever no food to eat of any kind in your house because of lack of resources to get food? / Never…………………………………….1
Rarely (once or twice )…...... 2
Some times(3—10 times)………………..3
Often (more than 10 times )……………..4
205 / In the past 4 weeks, did you or any HH members go to sleep at night due to the shortage of food? / Never…………………………………….…1
Rarely (once or twice )…...... 2
Some times(3—10 times)…………………..3
Often (more than 10 times )………………..4
206 / In the past 4 weeks, did you or any household member go a whole day and night Without eating anything because there was not enough food? / Never…………………………………….…1
Rarely (once or twice )…...... 2
Some times(3—10 times)…………………..3
Often (more than 10 times )…………….….4
207 / How often do you take the following foods? / Once per two weeks or less………………..1
Once a week……………………………….2
Twice a week……………………………...3
Once a week……………………………....4
Twice a day……………………………….5
Three times a day or more………………...6
Staples(injera with wet)------
Whole milk ፣Cheese or egg ------
Meats(e.g.Fish,Beef,lamb or chicken)------
Grains(e.g.Peas &Beans)------
Rice,Pasta,Macaroni------
Fruits/Fruite juice------
Vegetables------
208 / Which of the following substances have you tried, if any? / Once or less per week ……………………1
Twice per week …………………………...2
Three times/week………………………….3
Four times per week………………………4
Above four times per week……………….5
Khat…………………..
Smoking……………...
Hashish……………….
Cocaine……………….
Other (Specify)………….

PART THREE=KNOWLEDGE ABOUT TB

301 / Have you ever heard of an illness called tuberculosis or TB? / Yes………….…………………………………1
No……….…………………………………….2
302 / How can a person get tuberculosis or TB ? / Through the air when coughing or sneezing……………………………………….1
Through sharing utensils……………..……….2
Through touching a person with TB……..…...3
Through food……………………………..…4
Through sexual contact……………………...5
Through mosquito bites……………………..6
Through drinking un boiled milk……………7
Exposure to cold………………………...…..8
Other (specify)………………………………99
303 / What symptoms will a person with tuberculosis? / Persistent cough(greater than two weeks)……………………………………...1
Weight loss………………………………....2
Poor appetite…………………………...…..3
Night sweating………………………….…..4
Chest pain…………………………..…..…..5
fever………………………………….……..6
Don’t know ………………………………...7
Other (specify)…………………..………....99
304 / Can tuberculosis or TB be cured? / Yes………………………………….…..….1
No……………………………………..…...2
Don’t know………………………………...3
305 / If a member of your family got tuberculosis or TB, would you want it to remain a secret or not? / Yes, remain a secret…………………………1
No ...... ………...... 2
Don’t know/not sure…………..……………3
Depends ...... ………...... 4

PART FOUR=PAST AND PRESENT STATUS OF THE PATIENT

401 / Measurements / Calculate BMI
Weight in Kilogram
------/ ------
Height in meter
------
402 / Reason for today’s visit? / For collecting medication……………………1
For anti TB initiation……………………..….2
403 / Duration since anti TB started in weeks / 1 week………………………………………1
2 week………………………………………2
3 week………………………………………3
4 week………………………………………4
5 week………………………………………5
6—8week…………………………..………6
404 / What is your type of TB( data collector look at registration Book) / 1pulmonary positive TB……………………1
2 pulmonary negative TB…………………..2
3 Extra pulmonary TB……………………...3
405 / Do you have any other chronic illness? / Yes………………………………………….1
No…..………………………………………2 / If 2 go to 407
406 / If yes to the above, which one do you have? / HIV/AIDS………………………………….1
Diabetes Mellitus……………………………2
Hypertension………………………………..3
Cancer…………………………………..…..4
Other (specify)……………………………..99
407 / Is there any witnessed food allergy or intolerance? / Yes…………………………………………..1
No……………………………………………2
408 / Do you have problems with eating? / Yes……………………………………………1
No……………………………………………2 / If 2 go to 410
409 / If yes for the above what kinds of problem do you have? / Mouth ulcer………………………………….1
Nausea and/or vomiting………………….….2
Poor appetite………………………………...3
Pain/difficulty of swallowing……………….4
Other (specify)……………………………..99
410 / Do you feel sad or depressed? Or have you lost interest/pleasure in things you usually enjoy? / Yes…………………………………………1
No………………………………………….2 / If 2 go to 412
411 / If yes for the above which of the following problems do you have?
(Encircle all that applies) / Disturbed sleep………………………………1
Appetite loss Or increased…………………...2
Poor concentration……………………..…….3
Moves slowly……………………………..…4
Decreased libido……………………………..5
Loss of self confidence or esteem………..….6
Thoughts of suicide or death………………..7
Guilty feelings………………………………8
412 / What is functional status of the patient? / Working…………………………………...…1
Ambulatory………………………..…………2
Bed ridden………………….………………..3

PART FIVE=NUTRITIONAL INTERVENTION HISTORY

501 / Do you get Nutritional care and Support from any Organization? / Yes…………………………….1
No………………………..……2 / If 2 go to 503
502 / If yes to the above, what type of support do you get? / Food products………………….1
Money…………………...……..2
Clothing………………………..3
Shelter and food………………..4
Others (specify)…………….…99
503 / For how long have you been supported by this organization? / Less than one month…………...1
1—3 month…………………....2
More than 3 month…………….3
504 / Are you still being supported? / Yes…………………………….1
No……………………………..2
505 / Have you been given any dietary counseling/advice? / Yes………………………….…1
No……………………………..2
506 / Do you practice recommended dietary responses to symptoms(e.g.Nausea,Diarrhoea) / Yes………………………….…1
No……………………………..2

Thank you for your participation.