Questionnaire on examination of the

factors that influencing for tuberculosis

among patients at Tubeculosis clinics in
Eastern Province.
Minisry of The Open
Health Sri University of
Lanka Sri Lanka

Investigators:
Mr B.S. S De Silva. B Sc, M Sc
Mrs N.K.R.D. Wickramasinghe. B Sc, M Sc
Mr. V.V.Sanchayan, R.N. Under graduate
Mr.R.Yuharaj, R.N. Under graduate
Mr.S.Jeyanantha, R.N.Under graduate

Date

Serial no

A) Demographic data

Please answer the question by marking () most apprpriate answer in the sheet.
You can mark more than one reponse.

01) Age (in years) 04) Civil statu

a) Less than 20 a) Married
b) 21-34 b) Unmarried
c) 35-50 c) Widow
d) 51-65 d) Separated
e) More than 65 e) Others

02) Sex 05) Ethnicity

a) Male a) Tamil
b) Female b) Sinhala
c) Muslim
d) Others

03) Weight in Kg 06) Religion

a) Less than 20 a) Hindu
b) 21-40 b) Buddhist
c) 41-60 c) Muslim
d) 61-80 d) Christian
e) More than 60 e) Others
07) Educational level 09) Are you living with?
a) Below grade 3 a) Alone
b) Up to grade 8 b) Wife
c) Up to O/L c) Husband
d) Up to A/L d) Mother
e) Up to degree e) Father
f) Children
g) Relatives

08) Employment status 10) Status of BCG vaccination and scar formation
a) Unemployment Yes No
b) Government sector a) Vaccination
c) Private sector b) Scar formation
d) Self employment
e) Others 11) Is this first time do you have TB?
f) If others, occup a) Yes
b) No
If no, occurrence:

B. knowledge and attitude

12) General knowledge of tuberculosis(TB)

a) Infectious disease

Caused by bacteria
b)
c) Mainly afected Lungs
d) Other Body systems will
e) Complications will occur
f) Can be trasmited person

13) If (d) is Yes,What is/are the affected organ(s) or system(s) by

Yes No
a) Heart/ Cardio vascular system
b) Respiratory system
c) Bone/Skeletal system
d) Liver/ Gastro Intestinal system
e) Genito Urinary system
f) Nervous system

14) If (f) is yes; This disease can be Transmited person t

 Yes No
a) Food
b) Sharing common house hold items
c) Using common sanitori facilities
d) Air
e) Feeding mother to children
f) Pregnant mother to baby
g) Droplets
h) Transmitted by sputum
i) Person who is getting treatment for TB infection
j) Skin contact
k) Other Methods
If others, specify..

15) What are the symptoms of TB as you k

Yes No
a) Coughing
b) Night sweats
c) Loss of weight
d) Chest pain
e) Fever

If others, specify..

16) Do you like others know that you have

a) Yes
b) No
c) No idea

17) Do your occupation is related to the TB patien

Yes No No idea

18) If yes, frequency of working days per w

1 2 3 4 5 6 7

19) Is your occupation cause for the

Yes No
a) Strongly agree
b) Partialy agree
c) Agree
d) Partialy disagree
e) Strongly disagree
20) What you think regarding treatment of
Disagr
ee Agree No idea
a) There is no treatment at all
b) treatment can cure the TB
c) treatment
There are can only control the TB
alternative
d) 6medicine/
month anti TB drug
native theraphy is the best
tatments
e) can cure the TB

21) Knowledge and attitude about prevention of d

Not go Goo No idea
a) Avoiding infected person
b) Chewing beetle
c) Using common house ho
d) Need barrier for droplet
e) Spitting public places
f) Good hygienic food preparation
g) Isolation of the patient
h) Vaccination
I) Using barier mechanisms
j) Using uncleaned public t
k) Open air excreations
l) Tobaco smoking in public places
m) Alchohol consum

22) what are the activities, avoid transmission from one t

Not go Good No idea
a) Wearing mask
b) Using separate house hold items
c) Using separate sanitary facility
d) Sputum was not spit in public place
e) Sharing dresses
f) keep hand on the mouth before coughing
g) Using of hangercheif when on coughing

23) Do you follow the following practices when you are g

a) Take treatment according to the physi Yes No

b) Attending to clinic regularly
c) Follow the instruction to avoid the
transmission of the disease during the
treatment period
d) Giving the proper sputum sample for screening
e) In addition to the western treatment are you
following any other treatment for TB
 C) Nutritional factors

24) Food consumption

a) Vegetarian
b) Non Vegetarian

25) Poor nutrition causes TB

a) Yes
b) No
c) No idea

26) Time of having meals (breakfast, lunch and di

a) Breakfast Lunch Dinnner
Before 6 am Before 12 n Before 7 pm
b) 6 -8 am 12- 2 pm 7-9pm
c) 8-10 am 2 -4 pm 9-10 pm
e) After 10 am Afetr 4 pm After 10 pm

27) Type of main food

Yes No
a) Starchy food
b) Vegetables
c) Fish, Egg, meat
d) Full of cereals
e) Fruits
f) Dairy products
e) Others

28) Frequency of having foods in a d

Main Snacks
a) Less than 2 times
b) 2 Times
c) 3Times
e) More than 4 Times
If others, please specify .

29) If snacks yes, what are the snacks type take between main meals ?

a) Fruits and Vegita

b) Backed/fried shor
c) Bakery foods
d) Fried / Baked Cer
c) Fried yams
d Instead foods
30)Type of Drinks and frequencies

2 or More
more than
than One one
2 day in day in
times Once a a Once a
a day a day week week month
a) Plain tea
b) Tea
c) PlainCoffee
d) Milk coffee
e) Fresh milk
f) Milk powder
g) Fruit juice
h) presavative bevarages
i) Natural drinks

31) water consumption

Type Resources
PMC Own wpublic Tube wLagoons
well
a) Boiled cool water
b) without boiling
c) Filter using

32) Do you wash your hands?

Yes No No idea
a) before preparing the foods
b) before feeding
c) before serving

D) Socio Economic Factors

33) What is your income (LKR per month)?

a) Below 10000
b) 10000- 20000
c) 21000- 30000
d) More than 30000

34) Is this Treatment cost effective for you?

 Yes
No
No idea

35) How much money spends for your TB treatment per

TranspMedeciFoods
a) Below than 1000
b) Rs 1001- 2000
c) Rs 2001- 3000
d) Rs 3001- 4000
e) More than 4000

36) How many family members with

Alone 1 2 3 4 5 more than 5

37) Had family members have this disease?

a) Yes
b) No

38) If yes, do you belive that this disease caused by fam

a) Yes
b) No
c) No idea

39) Do you smoke? Yes

No

40) If yes; How many per day?

a) Less than 3
b) Three- five
c) Five- ten
d) More than Ten

41) Have you drink Alchohol? Yes

No

42) If yes; number of frequencies?

more than
1/4 bo1/2 bo3/4bott 1 bottl 1bottle
Daily
weekly
Monthly
Occationally
 Seldomly

43) surronding Environment of Your home

Yes No
a) Village
b) Town
c) Dairy farms
d) Near High ways
e) Near the Hospital
f) Near the chest cli
g) MC/UC Carbage dispose area
h) Have industrial fa

44) If (c) is yes, that dairy farm managed by and disternce fr

Man Less 101M

aged than 51M - - More than
by 50 M 100 M 250M 250 M
a) Own
b) Neighbours
c) Government
d) Private companies

45) Your home build by

Coco
Clay nut
Wall Tin Asbestbricks leaves Floor
a) Brics and cement
b) Tin *******
c) Coconut leaves *******
d) Clay and Sand

46) Availability of TB control programme in your area

a) Yes
b) No
c) No idea

47) Are TB awareness progrmmes conducted your

a) Yes
b) No
c) No idea

48) If yes; by whome

Yes No No idea
a) Government
 b) Non government Organizations
c) Social service clubs
d) Others
If others; please specify.

49) Garbage Disposal by;

a) Through Munucipalirity
b) Dip and close
c) Burning
d) Others
If others; please specify..

50) Distance between drinking water source and to

a) less than 10 feet
b) 10 feet
c) more than 10 feet

51) Are you user of the public transport ser Yes

No

52) If yes;
a) Type of vechicle Bus
Train

Two Three
Once times times
a a a Four or
Daily week week week more times
b) Frequency

Less
than 11- 61-
10 30 31-60 120 More than
Km Km Km Km 120 Km
c) Travelling disternce

53) Are you displaced from your own place Yes

No

54) If Yes;
How
long
Reason before
a) Business 1 month
b) Education 2 months
c) Environment 3 months
d) Fascilities 6 months
e) Powerty 9 months
f) War More than 1


Before
the
disease After the disease
Yes No Yes No
 Questionnaire on examination of the factors that influencing for
tuberculosis among patients at Tubeculosis clinics in Eastern
Province

A) Demographic data

Please answer the question by marking () most apprpriate answer in the sheet. You can mark
more than one reponse.

01) Age (in years) 05) Ethnicity

a) Less than 20 a) Tamil
b) 21-34 b) Sinhala
c) 35-50 c) Muslim
d) 51-65 d) Others
e) More than 65

Gender 06) Religion

a) Male a) Hindu
b) Female b) Buddhist
c) Muslim
d) Christian
e) Others

03) Weight in Kg 07) Educational level

a) Less than 20 a) Below grade 3
b) 21-40 b) Up to grade 8
c) 41-60 c) Up to O/L
d) 61-80 d) Up to A/L
e) More than 60 e) Degree or above

04) Civil status 08) Employment status

a) Married a) Unemployment
b) Unmarried b) Government sector
c) Widow c) Private sector
d) Separated d) Self employment
e) Others e) Others
If others, occupation: ..
09) Are you living with? 10) Status of BCG vaccination and scar formation
a) Alone Yes No
b) Wife a) Vaccination
c) Husband b) Scar formation
d) Mother
 e) Father 11) Is this first time do you have TB?
f) Children a) Yes
g) Relatives b) No
If no, occurrence:

12) What is your income (LKR per month)?

a) Below 10000
b) 10000- 20000
c) 21000- 30000
d) More than 30000

B. knowledge on TB
1) General knowledge of tuberculosis(TB)
Before the After the
disease disease
Yes No Yes No
a) Infectious disease
b) Caused by bacteria
c) Mainly afected Lungs
d) Other Body systems will affected
e) Complications will occur
f) Can be trasmited person to person

2) If (d) is Yes,What is/are the affected organ(s) or system(s) by this disease?

Yes No
a) Heart/ Cardio vascular system
b) Respiratory system
c) Bone/Skeletal system
d) Liver/ Gastro Intestinal system
e) Genito Urinary system
f) Nervous system

15) If (f) is yes; This disease can be Transmited person to person by;
Yes No
a) Food
b) Sharing common house hold items
c) Using common sanitori facilities
d) Air
e) Feeding mother to children
f) Pregnant mother to baby
g) Droplets
h) Transmitted by sputum
 i) Person who is getting treatment for TB infection
j) Skin contact
k) Other Methods
If others, specify..

16) What are the symptoms of TB as you know?

Yes No
a) Coughing
b) Night sweats
c) Loss of weight
d) Chest pain
e) Fever

If others, specify..

17) Do you like others know that you are suffering from TB ?
a) Yes b) No c) No idea

18) Do your occupation is related to the TB patient?

a) Yes b) No c) No idea

19) If yes, frequency of working days per week 1 2 3 4 5 6 7

20) What you think regarding treatment of TB?

Totally patially totally

agree Agree agrre disagree disagree
a) There is no treatment at all
b) treatment can cure the TB
c) treatment can only control the TB
d) 6medicine/
month anti TB drug
native theraphy is the best
tatments
e) can cure the TB

21) Knowledge and attitude about prevention of disease

Totally Patially Disagre Totally

agree Agree agrre e disagree
a) Avoiding infected person
b) Chewing beetle
c) Using common house hold items
d) Need barrier for droplet
e) Spitting public places
f) Good hygienic food preparation
 g) Isolation of the patient
h) Vaccination
I) Using barier mechanisms
j) Using uncleaned public toilets
k) Open air excreations
l) Tobaco smoking in public places
m) Alchohol consumption

22) what are the activities, avoid transmission from one to others?
Yes No No idea
a) Wearing mask
b) Using separate house hold items
c) Using separate sanitary facility
d) Sputum was not spit in public place
e) Sharing dresses
f) keep hand on the mouth before coughing
g) Using of hangercheif when on coughing

23) Do you follow the following practices when you are getting treatment
Yes No No idea
a) Take treatment according to the physician
b) Attending to clinic regularly
c) Follow the instruction to avoid the
transmission of the disease during the
treatment period
d) Giving the proper sputum sample for screening
e) In addition to the western treatment are you
following any other treatment for TB

C) Nutritional factors

24) Food consumption

a) Vegetarian b) Non Vegetarian

25) Time of having meals (breakfast, lunch and dinner) in a day?

a) Breakfast Lunch Dinner
Before 6 am Before 12 noon Before 7 pm
b) 6 -8 am 12- 2 pm 7-9pm
c) 8-10 am 2 -4 pm 9-10 pm
e) After 10 am Afetr 4 pm After 10 pm

26) Type of main food

a) Starchy food b) Vegetables c) Fish, Egg, meat

d) Full of cereals e) Fruits f) Dairy products
e) Others

27) Frequency of having foods in a day?

Main
meal Snacks
a) Less than 2 times
b) 2 Times
c) 3Times
e) More than 4 Times
If others, please specify .

28) If snacks yes, what are the snacks type take between main meals ?

a) Fruits and Vegitables b) Backed/fried short eats

c) Bakery foods d) Fried / Baked Cereals
e) Fried yams f) Instead foods

29)Type of Drinks and frequencies

2 or
more
times a Once a Twice Once a Once a
day day a week week month
a) Plain tea
b) Tea
c) PlainCoffee
d) Milk coffee
e) Fresh milk
f) Milk powder
g) Fruit juice
h) presavative bevarages
i) Natural drinks

30) water consumption

publi
Own c Tube Lago
PMC well well well ons
a) Raw water
b) Boiled water
c) Filtered water

D) Socio Economic Factors

31) How much money spends for your TB treatment per month?
Trans Mede Food
port cine s
a) Below than 1000
b) Rs 1001- 2000
c) Rs 2001- 3000
d) Rs 3001- 4000
e) More than 4000

32) Had family members have this disease?

Yes No

33) If yes, do you belive that this disease caused by family member?
a) Yes No No idea
b)
c)

34) Do you smoke?

Yes No

35) If yes; How many per day?

a) Less than 3
b) Three- five
c) Five- ten
d) More than Ten

36) Have you drink Alchohol?

Yes No

37) If yes; number of frequencies?

1/4 1/2 3/4bo 1
bottle bottle ttle bottle
a) Daily
c) weekly
e) Monthly
g) Occationally
i) Seldomly

38) Surronding Environment of Your home is

a) Village b) Near the Hospital

 c) Town d) Near the chest clinic
e) Naer dairy farms f) MC/UC Carbage dispose area
g) Near High ways h) Have industrial factories
i) Near to shanties j) highly croweded area

39) If (e) is yes, that dairy farm managed by and disternce from your home;
More
Less 101M than
than 51M- -
Managed by 50 M 100M 250M 250M
a) Own
b) Neighbours
c) Government
d) Private companies

40) Your home build by

Shelter
Wall Tin AsbestRoof tiCoconuFloor
a) Brics and cement
b) Tin *******
c) Coconut leaves *******
d) Clay and Sand

41) Availability of TB control programme in your area by MOH

a) Yes b) No c) No idea

42) Are there TB awareness progrmmes in your area?

a) Yes b) No c) No idea

43) If yes; by whom

a) Government b) Social service clubs

c) NGO d) Others
If others; please specify

44) Garbage Disposal by;

a) Through Munucipalirity b) Burning
c) Dip and close d) Others
If others; please specify..
45) Distance between drinking water source and toilet pit;
a) less than 10 feet b) more than 10 feet

46) Are you user of the public transport services?

a) Yes b) No

47) If yes;
a) Type of vechicle
Bus Train Others

b) Frequency c) Travelling disternce

Two Three Four Less More

Once times times or than 11- 61- than
a a a more 10 30 31-60 120 120
Daily week week week times Km Km Km Km Km

48) Are you displaced from your own place?

a) Yes b) No

49) If Yes;

1 2 3 6 9 More than 1
Reason month months months months months year

a) Business

b) Education

Environmen
c) t

d) Fascilities

e) Powerty
f) War
g) Job

If you are a health worker please don't answer following questions number 51 and 52

50) Under any conditions have you provide care to any person who are already have TB?
Yes
 No

51) If yes; to who

a) Parents
b) Blood relations
c) Children
d) Living with you
e) Neighbours
f) Friends

52)Have you ever been refugee camp with in five years?

Yes No

53) Have you visit refugee or displaced peoples camps with in last 4 years?
Regularly
Frequently
Occacianally
Never

E) Existing Medical Condition

54) Before suffered TB, are you Hospitalized for any other health care needs?
Yes
No

55) If yes; reason and how long before?

Reason 1 month 2 months 3 months 4 months More than 4months
a) Measels
b) Chicken pox
c) Dengue fever
d) Dengue
haemorragic fever
e) Malaria
f) Chikungunya
g) Hepatic diseases
h) For any surgery
i) Renal diseases
j) Others
If others; please specify.

56) Are you fallen sick consequently?

Yes
No

57)Which type of medicine you follow mostly?

a) Western medicine only b) Traditional medicine only
 c) Western and Traditional

58) Do you have One or more of following Conditions ?

a) Diabetic Mellaitus b) Wheezing/ Asthma

c) Sexual Transmitted d) HIV infections