| 11 | Relationship status | Single……………………………………………………… Married……………………………………………………… In a relationship but not married……………………… Divorce/Separated………………………………………… Widowed/widower………………………………………… | 1 2 3 4 5 |
| 12 | The first treatment resort when not well | Self-medication ……………………………………………. Traditional healer/Spiritualist …………………………….. Health facility …………………….……………………….. Church……………………………………………………… Other………………………………………………………… | 1 2 3 4 96 |
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| Basic Information |
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| 13 | What are the commonest diseases in your community? | Malaria……………………………………………………… Buruli ulcer ……………………………………………….. Typhoid Fever …………………………………………….. TB…………………………………………………………… Cholera……………………………………………………… Other………………………………………………………… | 1 2 3 4 5 96 |
| 14 | How many health facilities do you have in your community? | 1……………………………………………………………… 2……………………………………………………………… 3……………………………………………………………… Other………………………………………………………… | 1 2 3 96 |
| 15 | What types of health facilities are available to you | Clinic/hospital……………………………………………… Drug shop …………………………………………………… Traditional healer ….……………………….......................... Prayer camp …….…………………………………………. Other………………………………………………………… | 1 2 3 4 96 |
| 16 | Which of these facilities do you prefer to visit when you are not well | Clinic/hospital……………………………………………… Drug shop …………………………………………………. Traditional healer …………….…………………………… Prayer camp ……………..………………………………. Other………………………….………….......................... | 1 2 3 4 96 |
| 17 | How far is the nearest health facility from your home? | Very Far……………………............................................................ Far……………………………………………………............ Near………………………………………………………… Very near……………………………………………………. | 1 2 3 4 |
| 18 | How do you get to the nearest health facility when you are not well? | Walk………………………………………………………… Bicycle……………………………………………………… Motorbike…………………………………………………… Car (private/taxi/trotro) …………………….……………… | 1 2 3 4 |
| 19 | How do you get to the nearest herbalist/traditional healer when you get sick? | Walk………………………………………………………… Bicycle……………………………………………………… Motorbike…………………………………………………… Car (private/taxi/trotro) ….……………………………….... | 1 2 3 4 |
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| Knowledge of BU signs and symptoms |
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| 20 | Have you heard of the disease that causes wounds, nodule, plaque etc (Buruli ulcer) | Yes……………………………………………………... No……………………………………………………… | 1 2 |
| 21 | What is its local name? | …………………………………………………………….. |
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