TRIAL ID
Assessor Code
Date of Interview
Union Council
Village Cluster
Arm
ITT
PP
Name of lady health
Woman Name
Age
Husband Name
1. Have you read the information sheet or has it been read to you andyou have understood it?
2. I agree to take part in the study.
Section c: Checking for eligibility criteria
Inclusion Criteria of study
LMP
Duration of pregnancy in days
Duration of pregnancy in weeks
Duration of pregnancy in months
1. Being in the 2nd Trimester of pregnancy and early 3rd Trimester
2. Being 18 and above years of age
3. Intending to reside within the study area for the entire duration of the study.
1. Women requiring inpatient care for any reason (medical or psychiatric) determined by their primary health care personnel
2. Those who do not speak and comprehend Urdu language
CURRENT MAJOR DEPRESSIVE EPISODE: Now I would like to ask some questions about your mood
Depressed mood
Loss of interest
Weight/ Appetite loss or gain
Sleep disturbance
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or inappropriate guilt
Diminished ability to concentrate or indecisiveness
Recurrent thoughts of death or suicidal ideation
Symptoms cause significant distress or impairment
Not due to direct effects of a substance or medical condition
Not better accounted for by bereavement
CURRENT MAJOR DEPRESSIVE EPISODE
CURRENT MDE Date of onset:
Is she eligible for baseline?
1. I confirm that I have understood the information in the attached document. I have had the chance to carefully consider it and ask questions. I was provided with satisfactory replies for my questions.
2. I understand that my participation is entirely voluntary. I am free to withdraw at any time without giving any reason, prior to having my information/data anonymized
3. I understand that my responses will be kept strictly confidential. I give permission for members of the research team to have access to my fully anonymized responses.
4. I understand that the information I provide will be held securely and in line with data protection requirements at the research office. Only anonymized data will be used for reporting in journals and conferences to help support future research.
5. I agree to voluntarily take part in the study
Eligibility
Status
Participant Education:
Husband Education:
structure of family
How many people live in your home?
Participant Employment Status:
Participant Occupation:
Husband Employment Status:
Estimated Monthly income:
No of dependents:
Is it your 1st Pregnancy:
How many children do you have?
a. Sons:
b. Daughters
Do you live with your husband?
Age difference of husband: (in years)
Duration of marriage: (in years)
Any family history of psychiatric illness:
Living Status:
Contact # 1
Contact # 2
Contact # 3
Parity
1. Duration of pregnancy
2. Total numbers of pregnancies: including current pregnancy
3. Any miscarriage?
3a. If yes, how many?
4. Any still birth?
4a. If yes, how many?
5. How many children were less than 2 kg at the time of birth?
6. Any preterm birth?
6a. If yes, how many?
1. Feeling tired or having little energy.
2. Poor appetite or overeating.
3. Trouble falling or staying asleep or sleeping too much.
4. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual.
5. Trouble concentrating on things, such as reading the newspaper or watching television.
6. Little interest or pleasure in doing things.
7. Feeling down, depressed, or hopeless.
8. Feeling bad about yourself or that you are a failure or have let yourself or your family down.
9. Thoughts that you would be better off dead, or of hurting yourself.
10. If you had any of above problems, how difficult these problems made it for you to do your work, take care of things at home, or get along with other people?
PHQ Total T0
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
1. Do you have any long standing illness (one year or more), disability or infirmity? By long standing, I mean anything that has troubled you over a period of time or that is likely to affect you over a period of time.
1a.If yes, what illness? (Record verbatim)
In the last 30 days, how much difficulty did you have in:
2. Standing for long periods such as 30 minutes?
3. Taking care of your household responsibilities?
4. Learning a new task, for example, learning how to get to a new place?
5. Joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
6. Concentrating on doing something for at least ten minutes?
7. Walking a long distance such as a kilometer [or equivalent]?
8. Washing your whole body?
9. Getting dressed?
10. Dealing with people you do not know?
11. Maintaining a friendship?
12. Your day to day work?
13.. How much have you been emotionally affected by your health problems?
14. Overall, how much did these difficulties interfere with your life?
15. Overall, in the past 30 days, how many days were these difficulties present?
16. In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
17. In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?
We are interested in how you feel about the following statements. Listen each statement carefully. Answer/tell how you feel about each statement.
There is a special person who is around when you are in need.
There is a special person with whom you can share your joys and sorrows.
You have a special person who is a real source of comfort to you.
There is a special person in your life that cares about your feelings.
Your family really tries to help you.
You get the emotional help and support you need from your family.
You can talk about your problems with your family.
Your family is willing to help you make decisions.
Your friends really try to help you.
You can count on your friends when things go wrong.
You have friends with whom you can share your joys and sorrows
You can talk about your problems with your friends.
Under each heading, please tick the ONE box that best describes your health TODAY.
1. MOBILITY
2. SELF-CARE
3. USUAL ACTIVITIES
4. PAIN / DISCOMFORT
5. ANXIETY / DEPRESSION
6. We would like to know how good or bad your health is TODAY.
1. YOUR USE OF SERVICES
Please indicate any contacts you yourself have had with the following health and social care professionals over the last 6 months?
SERVICES
1. Obstetrician
1a. Usual location
1b. Total number of contacts in last 6 months
1c. Average duration of each contact (in minutes)
2. Midwife/LHV
2a. Usual location
2b. Total number of contacts in last 6 months
2c. Average duration of each contact (in minutes)
3. Primary care / family doctor(GP doctor, private doc)
3a. Usual location
3b. Total number of contacts in last 6 months
3c. Average duration of each contact (in minutes)
4. Other primary care worker (e.g. nurse, health visitor, LHW, LHS, LHV)
4a. Usual location
4b. Total number of contacts in last 6 months
4c. Average duration of each contact (in minutes)
5. Home help (above normal)
5a. Usual location
5b. Total number of contacts in last 6 months
5c. Average duration of each contact (in minutes)
6. Psychiatrist
6a. Usual location
6b. Total number of contacts in last 6 months
6c. Average duration of each contact (in minutes)
7. Psychologist
7a. Usual location
7b. Total number of contacts in last 6 months
7c. Average duration of each contact (in minutes)
8. Others
8a. Traditional healer
8a(i). Usual Location
8a(ii).. Total number of contacts in last 6 months
8a(iii). Average duration of each contact (in minutes)
8b. Faith healer
8b(i).. Usual location
8b(ii). Total number of contacts in last 6 months
8b(iii).. Average duration of each contact (in minutes)
8c. Traditional birth attendant
8c(i). Usual location
8c(ii). Total number of contacts in last 6 months
8cii(i). Average duration of each contact (in minutes)
Have you yourself used any of these hospital inpatient services over the last 6 months?
1. Maternity ward (includes childbirth)
1a. Provider
1b. Total number of separate admissions
1c. Total number of days (all admissions)
2. Medical/surgical ward
2a. Provider
2b. Total number of separate admissions
2c. Total number of days (all admissions)
3. General psychiatric ward
3a. Provider
3b. Total number of separate admissions
3c. Total number of days (all admissions)
4. Mother and Baby Unit (psychiatric)
4a. Provider
4b. Total number of separate admissions
4c. Total number of days (all admissions)
5. Others
5a. Specify
5b. Provider
5c. Total number of separate admissions
5d. Total number of days (all admissions)
Thank You
1. Was this women referred?
1a. Reason for referral:
2. Did the woman accept the referral?
2a. Reason for not accepting the referral:
Observation
UNION COUNCIL
VILLAGE CLUSTER
Maternal Death
Date of Maternal Death
Child Status
date of Death
Child Name
Gender
Date of birth of child
Temporary Absent
Permanentaly Moved
Development of a serious medical condition requiring in-patient care
Feelings of worthlessness or inappro priate guilt
PHQ Total t1
5.Being so restless that its hard to sit still
13. How much have you been emotionally affected by your health problems?
The PREMIUM Abbreviated Activation Scale (PAAS)
1. Are you content with the amount and types of things you did?
2. Did you engage in many different activities?
3. Were you an active person and accomplished the goals you set out to do?
4. Did you spend long periods thinking over and over about your problems?
5. Did you do things that were enjoyable?
Problem Solving Confidence Subscale of the Problem Solving Inventory
1. I am usually able to think up creative and effective alternatives to solve a problem
2. I feel satisfied after making a decision that outcome will be according to my expectations.
3. When faced with a difficult problem, I am not sure if I will be able to deal with it.
4. When I make plans to solve a problem, I am almost certain that I can make them work.
5. I am confident that I will be able to deal with innovative and complex situations faced by me.
6. When I become aware of a problem, one of the first things I do is to try to find out exactly what the problem is.
7. With appropriate time and effort, I am able to solve those problems where there are no apparent solutions.
Cognitive Restructuring Subscale of the Frequency of Actions and Thoughts Scale
1. Stop yourself from thinking unhelpful or unrealistic thoughts
2. Change your thinking to be more realistic and helpful
3. Reframe a negative situation into a more positive one
1. Did the health worker or peer convey information to you in an understandable manner?
2. Did the health worker or peer show respect for you and your family?
3. Did the health worker or peer able to establish a good and trustworthy relationship with you?
4. Did the health worker or peer able to establish a warmth, friendliness and an empathetic relationship with you?
5. Did the health worker or peer tried to understand (or explore) the impact of your health (physical and emotional state (on you and significant members of your family?
6. Did the health worker or peer listened to you with care and attention?
7. Did the health worker or peer make appropriate eye contact throughout the session, and showed interest to you??
8. Did the health worker or peer use open ended questions, and summarize and clarify statements?
9. Did the health worker or peer make you feel understood your needs, feelings and, your experiences?
10. Did the health worker or peer acknowledged your feelings to you and made you realize these are normal feelings in your situation
11. Did the health worker or peer elicit your feedback on her performance?
12. Did the health worker or peer explored your expectations and build hope toward improving your overall health?
CSRI
Other
Specify
Provider
Total number of separate admissions
Total number of days (all admissions)
Have any of the following pediatric services been used for the care of your new baby over the last 3 months?
Pediatric ward
Total number of separate admissions in last 3 months
total days of admission
Pediatrician
Total number of contacts in last 3 months
Average duration of each contact
Hospital emergency department
Child-Related Outcome Measures
1-IMMUNIZATION STATUS:
Has your baby received the following immunization?
1. In the last two weeks, were there any days that your child passed liquid or semi-liquid stools?
2. How many passed liquid or semi-liquid stools did your child have in 24 hours?
3. Was there any visible blood in the stool?
4. Were his/her stool forceful or of bursting nature?
5. Was there more than one episode (i.e., started again after a diarrhea-free period of three days)?
5a. No of diarrheal episodes
3- 24 hour recall: Breast Feeding Question
Now I am going to ask you a question about what food your child has been having recently.
1. What has the child had in the last 24 hours?
Other- Specify
4- QUESTIONS ON CAREGIVER PRACTICES TO STIMULATE CHILD DEVELOPMENT.
1. Within the past month, how often would you say you played with your child to help him/her learn new things?
2. Within the past month, how often would you say child’s father played with your child to help him/her learn new things?
3. How often have you talked to your family, friends and relatives about your child’s learning, emotional and cognitive development within the last month?
5- ACUTE RESPIRATORY INFECTION (ARI)
1. In the last two weeks, were child had any of the symptoms like cough and cold, running or blocked nose, sore throat, rapid breathing, noisy breathing, stops feeding and or drinking, chest in drawing etc.?
1a. Number of ARI episodes:
6-FERTILITY SECTION
1. Are you pregnant?
2. Are you practicing any contraceptive methods to ensure intervals between the births of children?
2a. If Yes What type of contraceptive method you are using?
3. Who played the main role in helping you make this decision?
3a. Specify
4. Do you plan to use contraception or any other sort of family planning method to delay or avoid pregnancy at any time in the future?
Was this women referred?
Reason for referral:
Did the woman accept the referral?
Reason for not accepting the referral:
Development of a psychotic or manic episode
3. Have any of the following pediatric services been used for the care of your new baby over the last 3 months?
1. Pediatric ward
1a. Total number of separate admissions in last 3 months
1b.Total days of admission
2. Pediatrician
2a. Total number of contacts in last 3 months
2b. Average duration of each contact
3. Hospital emergency department
3a. Total number of contacts in last 3 months
3b. Average duration of each contact
4. Other
4a. Specify
4b. Total number of contacts in last 3 months
4c. Average duration of each contact
GAD Total T0
GAD Total T1
GAD Total T2
MSPSS SPECIAL T0
MSPSS FAMILY T0
MSPSS FRIEND T
MSPSS SPECIAL T1
MSPSS FAMILY T1
MSPSS FRIEND T1
MSPSS SPECIAL T2
MSPSS FAMILY T2
MSPSS FRIEND T2
PAAS Total T1
Problem Solving Inventory Total T1
Cognitive Restructuring Subscale of the Frequency of Actions and Thoughts Scale TOTAL T1
Empathy Scale for Lay-Therapists (ESLT) TOTAL T1
CAREGIVER PRACTICES TO STIMULATE CHILD DEVELOPMENT TOTAL T1
CAREGIVER PRACTICES TO STIMULATE CHILD DEVELOPMENT TOTAL T2
WHO-DAS TOTAL T0
WHO-DAS TOTAL T1