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Health Provider Template -Form Fill
Identification
Q01
Serial number
Q02
District name
Q03
District code
Q04
Block name
Q05
Block code
Q06
Health Facility name
Q07
Health Facility code
Q08
Type of Health Facility
DISTRICT HOSPITAL (DH)
SUB-DISTRICT HOSPITAL (SDH/CH)
FIRST REFERRAL UNIT COMMUNITY HEALTH CENTRE (FRU CHC)
NON FRU COMMUNITY HEALTH CENTRE (NON-FRU CHC)
PRIMARY HEALTH CENTRE (PHC)
Q09
Date of interview (DD/MM/YYYY)
Q10
Start time of interview
Q11
End time of interview
Q12
Name of the interviewer
Q13
Name of the supervisor
Q14
Interview Result
Completed
Partly Completed
Refused by respondent
Respondent not available
Other (specify)
Background Information
A01
Age of the respondent
A02
Gender of the Respondent
Male
Female
Third Gender
A03
Please indicate your highest qualification
POST GRADUATION
GRADUATION
COMPLETED CLASS 12TH SCHOOL
OTHERS, SPECIFY
A04
How long have you been working as Adolescent counsellor?
A05
How long have you been working as Adolescent counsellor in this facility?
A06
On an average, how many counselling sessions do you handle in a week?
A07
On what areas do you provide counselling to adolescent?
A07_1
Family planning methods and services
Yes, spontaneous
Yes, aided
No
A07_2
Abortion services
Yes, spontaneous
Yes, aided
No
A07_3
Post abortion care
Yes, spontaneous
Yes, aided
No
A08
If ‘no’in A07_1, can you tell us the reason for not providing contraception counselling services to adolescents?
Don’t get adolescents wanting contraception
Do not have contraception service available at the facility
Adolescents shouldn’t be given information about couselling
Others, specify
A09
If ‘no’ in A07_2, can you tell us the reason for not providing counselling for safe abortion services?
Don’t get adolescents wanting contraception
Do not have contraception service available at the facility
Adolescents shouldn’t be given information about couselling
Others, specify
A10
If ‘no’ in A07_3, can you tell us the reason for not providing counselling for safe post abortion- services?
Don’t get adolescents wanting contraception
Do not have contraception service available at the facility
Adolescents shouldn’t be given information about couselling
Others, specify
A11
Client/ patients of what age group comes to you?
10-17 years
18-19 years
Above 19 years
All age groups
Other specify
A12
Do boys come to you?
Yes
No
A13
What percent of clients that come to you are boys?
0-10%
10-20%
20-30%
30-40%
40-50%
50-60%
60-70%
70-80%
80-90%
90-100%
A14
If yes, what % of boys that come to you are married?
0-10%
10-20%
20-30%
30-40%
40-50%
50-60%
60-70%
70-80%
80-90%
90-100%
A15
If no, where do adolescent boys go for counselling?
Women health counsellor
Private clinics/ hospitals
NGO clinic/ hospital
Quacks
Don’t know
Other (specify)
A16
Do girls come to you?
Yes
No
A17
What percentage of clients that come to you are girls?
0-10%
10-20%
20-30%
30-40%
40-50%
50-60%
60-70%
70-80%
80-90%
90-100%
A18
If yes, what % of girls that come to you are married?
0-10%
10-20%
20-30%
30-40%
40-50%
50-60%
60-70%
70-80%
80-90%
90-100%
A19
If no, where do married adolescent girls go for counselling?
Women health counsellor
Private clinics/ hospitals
NGO clinic/ hospital
Quacks
Don’t know
Other (specify)
Knowledge assessment
B01
Family Planning methods
B02
What is the schedule followed for using the new oral contraceptive called Chhaya?
Twice a week for the first 3 months followed by once a week thereafter
Don’t know
Others, specify
B03
If a woman misses a Chhaya/weekly pill, should she take the missed pill as soon as possible?
Yes
No
B04
Emergency contraceptive pills can be used as regular contraception method – true or false
1
Don’t know
B05
Within how many hours of intercourse can the EC pill be taken?
72 hours/3 days
Don’t know
Others, specify
B06
If a client forgets to take 1 pill of Combined Oral Contraceptives (COC), when should she take the next dose?
Take the pill as soon as possible
Take 2 pills on the next day
Don’t know
Others, specify
B07
If a person misses Combined OCP for 2 days, what should be the course of action of taking doses on the next consecutive 3 days?
Take 2 tablets each on 3rd and 4th day and on 5th day take one tablet
Don’t know
Others, specify
B08
What to recommend if a person misses Combined Oral Contraceptives (COC), for 3 days?
Inform your doctor
Don’t know
Others, specify
B09
Male sterilization is a reversible contraceptive method – true or false
1
Don’t know
B10
What would you recommend to adolescent if she has missed her periods for 6-8 weeks?
Refer to doctor after counselling
Don’t know
Other specify
B11
What is the legal age to have consensual sex?
18 years
Don’t know
other specify
B12
Abortion and post abortion care
B13
Are abortion legal in India
Yes
No
B14
An abortion can be done legally up to 24 weeks of pregnancy with the opinion of two doctors - True or False
1
Don’t know
B15
Medical abortion can be done by up to 8 weeks of pregnancy - True or False
1
Don’t know
B16
Do you communicate to the patient that a form C consent form has to be filled by patient in case of abortion?
Yes
No
B17
Adolescent health services
B18
Providing information on reproductive health and life skill education/ sexuality and safe sex to adolescents will do more harm than good -True or False
1
Don’t know
B19
Some people say that if safe abortion services are made available and accessible to adolescents, it will encourage promiscuity.
No, absolutely not
Not sure
Yes, absolutely
B20
Unmarried adolescents do not need counselling on contraceptive methods -True or False
1
Don’t know
B21
What are sexual and reproductive health related concerns of adolescent boys?
Nutrition
Puberty related concerns
Premarital Counselling
Sexual Problems,
FP/ Contraception
Substance abuse
Learning problems
Stress
Depression
Suicidal Tendency
Violence
Sexual Abuse
Other Mental Health Issues
Health lifestyle
Risky behaviour
Night fall in boys
RTIs/STIs – Hygiene
Non-communicable disease
Don’t know
Others, specify
B22
What are sexual and reproductive health related concerns of adolescent girls?
Nutrition
Puberty related concerns
Premarital Counselling
Sexual Problems,
FP/ Contraception
Substance abuse
Learning problems
Stress
Depression
Suicidal Tendency
Violence
Sexual Abuse
Other Mental Health Issues
Health lifestyle
Risky behaviour
Night fall in boys
RTIs/STIs – Hygiene
Non-communicable disease
Don’t know
Others, specify
B23
What is the ideal message related to Family Planning, abortions, post abortion care that should be given to the age group of 10-14 years?
FP commodities are freely available at health care facility
Safe sex practices
Contraception are important to prevent unwanted pregnancy
Contraception are important to prevent sexually transmitted disease/ reproductive tract infection
Do not go to quacks for any services
Abortions are legal in India
Sign and symptoms of pregnancy
Don’t know
Other specify
B24
What is the ideal message related to Family Planning, abortions, post abortion care that should be given to the age group of 15-17 years?
FP commodities are freely available at health care facility
Safe sex practices
Contraception are important to prevent unwanted pregnancy
Contraception are important to prevent sexually transmitted disease/ reproductive tract infection
Do not go to quacks for any services
Abortions are legal in India
Sign and symptoms of pregnancy
Don’t know
Other specify
B25
Which contraceptive method do you recommend to clients/ patients of age group 10-14 years?
Condoms
IUCD
Injectable/ Antara/ DMPA
Oral contraceptive pills (daily pills)
Chhaya (Weekly pills)
Emergency contraceptive pills
Male sterilization
Female sterilization
Don’t know
B26
Which contraceptive method do you recommend to clients/ patients of age group 15-17 years?
Condoms
IUCD
Injectable/ Antara/ DMPA
Oral contraceptive pills (daily pills)
Chhaya (Weekly pills)
Emergency contraceptive pills
Male sterilization
Female sterilization
Don’t know
B27
Which contraceptive method do you recommend to clients/ patients of age group 18-19 years?
Condoms
IUCD
Injectable/ Antara/ DMPA
Oral contraceptive pills (daily pills)
Chhaya (Weekly pills)
Emergency contraceptive pills
Male sterilization
Female sterilization
Don’t know
B28
Which contraceptive method do you recommend to clients/ patients of age group 20-24 years?
Condoms
IUCD
Injectable/ Antara/ DMPA
Oral contraceptive pills (daily pills)
Chhaya (Weekly pills)
Emergency contraceptive pills
Male sterilization
Female sterilization
Don’t know
B29
What % of adolescent male clients/ patients are aware about condom?
0-20 % are aware
20-40% are aware
40-60% are aware
60-80% are aware
80-100% are aware
B30
What % of adolescent male clients/ patients are aware about Chhaya/ weekly pill?
0-20 % are aware
20-40% are aware
40-60% are aware
60-80% are aware
80-100% are aware
B31
What % of adolescent male clients/ patients are aware about Oral contraceptive / daily pills?
0-20 % are aware
20-40% are aware
40-60% are aware
60-80% are aware
80-100% are aware
B32
What % of adolescent male clients/ patients are aware about Emergency contraceptive pill?
0-20 % are aware
20-40% are aware
40-60% are aware
60-80% are aware
80-100% are aware
B33
What % of adolescent female clients/ patients are aware about condom?
0-20 % are aware
20-40% are aware
40-60% are aware
60-80% are aware
80-100% are aware
B34
What % of adolescent female clients/ patients are aware about Chhaya/ weekly pill?
0-20 % are aware
20-40% are aware
40-60% are aware
60-80% are aware
80-100% are aware
B35
What % of adolescent female clients/ patients are aware about Oral contraceptive / daily pills?
0-20 % are aware
20-40% are aware
40-60% are aware
60-80% are aware
80-100% are aware
B36
What % of adolescent female clients/ patients are aware about Emergency contraceptive pill?
0-20 % are aware
20-40% are aware
40-60% are aware
60-80% are aware
80-100% are aware
B37
What challenges do you face in counselling adolescents?
Lack of interest,
Lack of demand,
Insufficient IEC
Not updated information
Not enough training
Not enough time
Adolescent feel awkward talking about their problems
Difficult to counsel adolescents who are accompanied by a guardian
Other specify
Counselling skills assessment
C01
Ruksana, 18 years old and Salim, 21 years old are a just married couple with no children. They do not want children for another 2 years as Salim has just started working and cannot support a child. They visit the nearby health facility for consultation on family planning. The busy nurse asks them to enter consultation room and quickly take their seat. She notes down their names in the register and asks them the purpose of their visit. Ruksana and Salim share their concern about not wanting a child so soon. But as their family was against contraception, they were not sure what to do. Interrupting Ruksana at this point, the nurse tells them she has seen many such cases from their community. Thinking that the couple would not adhere to any method regularly, the nurse told them they should use IUCD method for contraception. She told them that Ruksana should come on Tuesday to get the IUCD inserted at the family planning OPD. The nurse handed them a pamphlet on IUCD and told them to read it before coming on Tuesday. The nurse called out for the next client.
C01_1
The nurse was respectful in her behaviour towards Ruksana and Salim
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
C01_2
The nurse was non-judgemental towards Ruksana and Salim and their situation.
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
C01_3
The nurse suggested the right method for the couple as per their needs.
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
C01_4
The nurse provided appropriate information to Ruksana and Salim.
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
C01_5
The nurse provided appropriate referral for contraception to the young couple.
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
C02
During an OPD session, Kavita, a 16-year-old unmarried girl comes with her mother for a checkup at the hospital. She has been keeping unwell for a few weeks with occasional bouts of vomiting, especially in the morning. She seems to be the youngest among all the patients waiting there. The lady doctor calls Kavita and her mother into consultation room and greets them. After taking history form the Kavita, the doctor does an abdominal check-up in a private area while her mother waits outside. While doing the examination, Kavita tells her that she also has missed her periods. The doctor becomes suspicious that Kavita may be pregnant. The angry doctor asks Kavita to tell the truth as she thinks that she is 12 weeks pregnant. Scared Kavita reveals that she has a boyfriend and he had forced her to have sex a few times. The doctor scolds her that she should have concentrated on studying instead of having a relationship.
C02_1
The doctor reacted appropriately to Kavita’s situation.
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
C02_2
The doctor was non-judgemental towards Kavita and her situation.
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
C02_3
The doctor gave Kavita the right legal information regarding abortion.
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
C02_4
The doctor gave all the relevant information to Kavita regarding abortion.
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
C02_5
The doctor provided appropriate referral advice to Kavita.
Strongly agree
Agree
Not sure
Disagree
Strongly disagree
Service provision and referral mechanism
D01
How comfortable do you feel when discussing about family planning methods with adolescent?
Very uncomfortable
Uncomfortable
Comfortable
Very comfortable
D02
Based on what criteria, do you suggest a particular method of family planning to an adolescent girl who maybe married or unmarried?
Age of the client
Marital status
Number of children
Preference of the client
Others, Specify
D03
Do you recommend Chaya to your clients?
Yes
No
D04
If no, then why you they not recommend Chhaya to your clients?
Patients do not ask for it
Supply not available
Others, Specify
D05
From where are the adolescents requiring counselling for sexual and reproductive health issues referred to you?
Referred by OPD Registration counter
Referred by doctor
Referred by NGOs
Referred from wards
Walk-in
Others, specify
D06
Do you provide referral services to adolescents who come for family planning counselling services?
Yes
No
D07
Who do you refer the adolescents for IUD / PPIUD services?
ANM at Sub-centre
PHC
CHC
SDH/CH
DH
Private clinic
NGO/Trust run clinic
Others, specify
D08
Who do you refer the adolescents for Injectable services?
ANM at Sub-centre
PHC
CHC
SDH/CH
DH
Private clinic
NGO/Trust run clinic
Others, specify
D09
Do you provide referral services to adolescents who come for abortion?
Yes
No
D10
Where do you refer the adolescents for abortion related services?
PHC where abortion services available
CHC where abortion services available
SDH where abortion services available
DH where abortion services available
Any other government health facility where abortion services are available
Private clinic where abortion service is available
NGO/ Trust run clinic where abortion service is available
Others, specify
D11
In case of abortion related complications, where do you refer the patients for care?
PHC
CHC
FRU CHC
SDH
DH
Any private hospital
Trust Hospital
Others, Specify
D12
For what sexual and reproductive health issues, do you provide referral to adolescents?
For uptake of contraception
For abortion
For post abortion care
Other specify
Information Provision and information delivery mechanisms
E01
Where do you provide information related to contraception to adolescents?
At OPD
At AFHS counselling room
At patient bedside
At home of the client
Others, specify
E02
What are the methods/job-aids you use for providing information related to contraception to your adolescents?
Flipcharts
Pamphlets
Posters
Audio-visual films
One-to-one verbal communication
Group counselling
Role play
Street play
Others, specify
E03
Where do you provide information related to abortion to adolescents?
At OPD
At AFHS counselling room
At home of the client
Others, specify
E04
What are the methods/job-aids you use for providing information related to abortion to adolescents?
Flipcharts
Pamphlets
Posters
Audio-visual films
One-to-one verbal communication
Group counselling
Role play
Street play
Others, specify
E05
When do you provide information related to other sexual and reproductive health related (SRH) issues to adolescents?
When adolescents approach for other SRH issues
During IEC sessions
Others, specify
E06
Where do you provide information related to other sexual and reproductive health related issues to adolescents?
At OPD
At AFHS counselling room
At home of the client
At Anganwadi
At school
Others, specify
E07
What are the methods/job-aid you use for providing information related to other sexual and reproductive health related issues to adolescents?
Flipcharts
Pamphlets
Posters
Audio-visual films
One-to-one verbal communication
Group counselling
Role play
Street play
Others, specify
Training in family planning, abortion and adolescent health counselling services
F01
Did you ever receive this training?
F01_1
Oral Contraceptive Pills
Yes
No
F01_2
Emergency Contraceptive Pills
Yes
No
F01_3
Family planning counselling
Yes
No
F01_4
Pre-abortion care
Yes
No
F01_5
Post-abortion care
Yes
No
F01_6
Rashtriya Kishore Swasthya Karyakram (RKSK/ Adolescent Friendly Health Clinic) counselling
Yes
No
F01_7
Swasthya Samwaad Kendra (SSK) sounselling
Yes
No
F02
Did you receive this training in last 12 months?
F02_1
Oral Contraceptive Pills
Yes
No
F02_2
Emergency Contraceptive Pills
Yes
No
F02_3
Family planning counselling
Yes
No
F02_4
Pre-abortion care
Yes
No
F02_5
Post-abortion care
Yes
No
F02_6
Rashtriya Kishore Swasthya Karyakram (RKSK/ Adolescent Friendly Health Clinic) counselling
Yes
No
F02_7
Swasthya Samwaad Kendra (SSK) sounselling
Yes
No
F03
Which topic were covered in it?
F03_1
Family planning counselling
Procedure
Advantages
Disadvantages
Side effects
Danger signs
counselling technique
F03_2
Pre-abortion care
Procedure
Advantages
Disadvantages
Side effects
Danger signs
counselling technique
F03_3
Post-abortion care
Procedure
Advantages
Disadvantages
Side effects
Danger signs
counselling technique
F03_4
Rashtriya Kishore Swasthya Karyakram (RKSK/ Adolescent Friendly Health Clinic) counselling
Procedure
Advantages
Disadvantages
Side effects
Danger signs
counselling technique
F03_5
Swasthya Samwaad Kendra (SSK) sounselling
Procedure
Advantages
Disadvantages
Side effects
Danger signs
counselling technique
F04
Are you satisfied with the training?
F04_1
Family planning counselling
Yes
No
F04_2
Pre-abortion care
Yes
No
F04_3
Post-abortion care
Yes
No
F04_4
Rashtriya Kishore Swasthya Karyakram (RKSK/ Adolescent Friendly Health Clinic) counselling
Yes
No
F04_5
Swasthya Samwaad Kendra (SSK) sounselling
Yes
No
F05
Do you want this training to be conducted?
F05_1
Family planning counselling
Yes
No
F05_2
Pre-abortion care
Yes
No
F05_3
Post-abortion care
Yes
No
F05_4
Rashtriya Kishore Swasthya Karyakram (RKSK/ Adolescent Friendly Health Clinic) counselling
Yes
No
F05_5
Swasthya Samwaad Kendra (SSK) sounselling
Yes
No
Workflow in abortion cases
G01
Have you ever seen a case of under 18 married teen pregnancy that may be unwanted?
Yes
No
G02
If yes, what do you do in such cases?
Refer for abortion
Seek opinion of a doctor
Turn away the case/refuse to manage the case
Inform the police before providing any service
Inform the police after providing services
Talk to patient’s guardian
Refer to counsellor
Others, specify
G03
Have you ever seen a case of under 18 unmarried teen pregnancy that may be unwanted?
Yes
No
G04
If yes, what do you do in such cases?
Inform the police before providing any service
Inform the police after providing services
Talk to patient’s guardian
Refer for abortion
Seek opinion of a doctor
Turn away the case/refuse the case
Refer to counsellor
Others, specify
G05
Have you ever seen a case of unmarried pregnant woman above 18 years of age seeking abortion?
Yes
No
G06
If yes, what do you do in such cases?
Talk to patient’s guardian
Refer for abortion to a doctor
Seek opinion of a doctor
Turn away the case/refuse the case
Refer to counsellor
Others, specify
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