Instrument Title: Social Capital Instrument for Adolescents and the

Elderly

Instrument Author: De Souza, E. M., & Grundy, E.

Cite instrument as: De Souza, E. M., & Grundy, E.. (2012) . Social

Capital Instrument for Adolescents and the Elderly .

Measurement Instrument Database for the Social

Science. Retrieved from www.midss.ie

 QUESTIONNAIRE FOR THE COLLECTION OF DATA FROM ELDERLY PEOPLE

(English)

INTERGENERATIONAL RELATIONSHIPS AS A MEANS OF PROMOTING HEALTH

AND CHANGING ATTITUDES: A MULTIMETHODOLOGY STUDY IN CEILANDIA,
DISTRITO FEDERAL , BRAZIL

NAME OF INTERVIEWER

INTERVIEWER CODE

DATE OF INTERVIEW

BEGINNING OF INTERVIEW END OF INTERVIEW

TIME SPENT ON INTERVIEW

NAME OF INTERVIEWEE

ADDRESS OF INTERVIEW EE

TELEPHONE NUMBER
OF INTERVIEWEE
(If appropriate)

261
 I – GENERAL INFORMATION

1) Name
1) Sex:
1 Male 2 Female

2) Age

3) Date of birth:

5) Place of birth
City: _______________________

Estate:

6) How long have you been living in the Distrito Federal?

7) How long have you been living in Ceilândia…………………..

8) How long have you been living at this address?……………….

9) What is (was) the highest level of education you got?

No education 1 2 Less than primary

Primary 3 4 Less than secondary

5 6
Secondary High School

College/ University 7 8 Don’t Know

10) What is your current marital status?

Single never Married Married 1st time

1 2
Married 2nd time Live together
3 4 But not married

Widow 5 6 Separated

Divorced 7

11) How many alive children do you have?

12) Are you currently taking part in any activity as sport activities, church association, or
any other association?

262
Yes 1 (specify )………………………………………..

No 2
II – ECONOMIC RESOURCES

NOW WE WOULD LIKE TO ASK YOU SOME QUESTION RELATED TO WORK AND
INCOME

13) What is (was) your main occupation?……………………………………….

14) How is your situation at the moment?

1 Employed 2 Unemployed

3 Retired 4 Out of work due to health problems

Never worked House wife

5 6

9 Domestic employment 10 Other (specify)

11 Don’t know 12 Didn’t answer

15) Currently which is your main source of income?

1 Wage 2 Retirement pension

State pension Widow pension
3 4
5 Children aid 6 Investments (rents, interests etc)
7 Relatives aid 8 Friends aid

10 Don’t know 9 Other (specify)

11 Didn’t answer

16) Do you think your income is enough to cover your daily needs?

1 Yes 2 No

3 Don’t know 4 Didn’t answer

17) Do you receive any extra resource to complement your monthly income?

Yes (specify) No
1 2

Don’t know 3 4 Didn’t answer

263
18) Currently do you support financially any of your children or grandchildren?

Yes (specify) No
1 2
……………………………

Don’t know 3 4 Didn’t answer

19) Currently do you receive any financial support from any of your children or
grandchildren?

Yes (specify) No
1 2
……………………………

Don’t know 3 4 Didn’t answer

III - SOCIAL RESOURCES AND SOCIAL CAPITAL

A - Now we would like to know about your relationship with your family.

20) With whom do you live at the moment?

Lives alone 1 2 Spouse

With daughter 3 4 With son

With relatives 5 6 With friends

Other (specify)…… 7 ………………..…

21) Generally speaking would you say you are satisfied with your family? (Family is
considered spouse, children and grandchildren even if not living together)

Very satisfied 1
Satisfied 2
Unsatisfied 3
Very Unsatisfied
4
Don’t now 5

Didn’t answer
6

Has no family 7 (Go to question 25 and tick Not

applicable to questions 22, to ,24)

264
22) How do you rate your relationship with your family?

Very good Good 2 3 Fair

1
Bad Very bad 5
4

Don’t know 6 Didn’t answer 7

Not applicable 8

23) During the last two months would you say that your relationship with your family had
improved or deteriorated?

Improved Improved Still the same

1 2 3
quite a lot

Deteriorated Deteriorated Don’t know

4 5 6
quite a lot

Not applicable 7

24) Generally speaking would you say your family can be trusted?
Yes No
1 2

Not sure 4 Don’t know Didn’t answer

3 5
Not applicable
6

25) With whom do you share your problems? (Interviewer tick only the most important
person)

Spouse Daughter 3 Son

1 2

Other relatives 4 5 Friends) 6 Others (specify)

Nobody 7 8 Don’t know Didn’t answer

9

26) With whom do you share your happiness? (Interviewer tick only the most important
person)

Spouse Daughter 3 Son

1 2

Other relatives 4 5 Friends) 6 Others (specify)

Nobody 7 8 Don’t know Didn’t answer

9
265
27) In a moment of need or crisis with whom could you really count?

Spouse Daughter 3 Son

1 2

Other relatives 4 5 Friends 6 Others (specify)

Nobody 7 8 Don’t know Didn’t answer

9

B-Now we would like to know about your relationship with your friends

28) How many close friends do you have? (Friends are those with whom you can go out
to talk and share any kind of subject).

One or two 1 2 Three or four

Five or more 3 4 None (Go to question

33 and tick “Not applicable” in
the questions 29; to 32)

29) Generally speaking are you satisfied with your friends?

Very satisfied 1

Satisfied 2
Unsatisfied 3
Very unsatisfied
4
Don’t know
5
Didn’t answer
6

Not applicable
7

30) Generally speaking would you say your friends can be trusted?

Yes No
1 2
Not sure Don’t know
4 5

Didn’t answer 6 7 Not applicable

266
31) How many favours have you done for your friends in the last two months?

Many Some 3 Few

1 2

None Don’t know

4 5

Didn’t answer 6 7 Not applicable

32) How many favours have any of your friends done for you during the last two months?

Many Some 3 Few

1 2

None Don’t know

4 5

Didn’t answer 6 7 Not applicable

C-Now we would like to know about your relationship with your neighbours.

33) Do you know most people in your street?

Most people 1

Know some people 2

Know few people
3

Know only next door neighbours

4

Know nobody (go to question 38and tick

5
“Not applicable” in the” questions 34 to 37

34) Generally speaking, would you say your neighbours can be trusted?

All of them, Most 3 Few

1 2
None Don’t know Didn’t answer
4 5 6

Not applicable 7

35) Would you say most your neighbours try to be helpful?

Most Some 3 Few

1 2

None Don’t know 6 Didn’t answer

4 5
Not applicable
7

267
36) How many favours have you received from your neighbours in the last two months?

Many Some 3 Few

1 2
None Don’t know 6 Didn’t answer
4 5
Not applicable
7

37) How many favour have you done to your neighbours in the last two months?

Many Some 3 Few

1 2
None Don’t know Didn’t answer
4 5 6

Not applicable 7

D - Now we would like to know about your impression of people in general (trust
and reciprocity

38) Generally speaking do you think most people try to be fair with each other?

Most people Some people 3 Few people

1 2
Nobody Don’t know Didn’t answer
4 5 6

39) Do you think most people try to take advantage of you if they get a chance?

Most people Some people 3 Few people

1 2
Nobody Don’t know 6 Didn’t answer
4 5

40) Generally speaking would you say most people can be trusted?

Most people Some people 3 Few people

1 2
Nobody Don’t know Didn’t answer
4 5

41) Generally speaking , would you say that most people try to be helpful?

Most people Some people 3 Few people

1 2

None Don’t know 6 Didn’t answer

4 5

268
42) What is your general impression about young people?

Very good Good Fair

1 2 3
Bad Very bad Don’t know
4 5 6
Didn’t answer
7

43) What is your general impression about younger adults?

Very good Good Fair

1 2 3
Bad Very bad Don’t know
4 5 6
Didn’t answer
7

44) What is general impression about elderly people?

Very goood Good Fair

1 2 3
Bad Very bad Don’t know
4 5 6
Didn’t answer
7

III - SELF-RATED HEALTH STATUS

A - NOW WE WOULD LIKE TO KNOW WHAT DO YOU THINK ABOUT YOUR HEALTH

45) How would you rate your health at the moment?

Very good Good Fair

1 2 3

Bad Very bad Don’t know

4 5 6
Didn’t answer
7

46) Comparing the last two months would you say that your health is better or worse?

Much better Better The same

1 2 3
Worse Much worse Don’t know
4 5 6

Didn’t answer 7

269
47) Do you suffer any of the health problems described below? ( Interviewer you can tick
more than one)

1 Rheumatism 2 High blood pressure

3 Asthma / Bronchitis 4 Diabetes

5 Heart disease 6 Insomnia

7 Depression 8 Other (specify) …………………………

9 No health problem

48) Have you had visited any doctor in the last two months?

1 Regularly 2 Sometimes
3 Rarely 4 Not at all

5 Don’t know Didn’t answer

6

49) Did you need to go to casualty for any health problem in the last two months?
1 Regularly 2 Sometimes
3 Rarely 4 Not at all

5 Don’t know Didn’t answer

6

50) Have you been admitted at hospital in the last two months)?
1 Regularly 2 Sometimes
3 Rarely 4 Not at all

5 Don’t know 6 Didn’t answer

270
IV - EVALUATION OF THE INTERVIEWER
This part of the questionnaire should be answered by the interviewer immediately after
leaving the interviewee’s place.

Number of the questionnaire

Name of interviewer Code of the interviewer

1 - Time spent for the interview……………………………………

Reliability of answers
2 - Do you think the answers were reliable?
Most were reliable,
Few were reliable
Most were not reliable

3 – Do you think the interviewee understood all the questions?

All of them
Most of them
Few of them

4 - How was the reaction of the interviewee?

Very positive
Positive
Negative
Very negative

5 – There was any other person in the room during the interview?
Yes
No (go to question 7 and tick “Not applicable” in question 6)

6 - Do you think the presence of other person influenced the quality of interview?
Influenced in a very positive way
Influenced in a positive way
Influenced in a negative way
Influenced in a very negative way
Not applicable
7 - Please make any additional comments related to the interview you think is relevant

271