KAP QUESTIONNAIRE – DIABETES MELLITUS

Personal Identification
Sex 1 = male
2 = female
Education 1 = not schooled
2 = primary school
3 = junior high school
4 = high school
5 = bachelor/diploma
Marital status 1 = married
2 = not yet married
3 = other
Current Illness
Diagnosed with Diabetes Mellitus (DM) 1 = yes
2 = no
Currently treated for DM 1 = yes
2 = no
Medicine 1 = metformin
2 = glibenclamid
3 = insulin
4 = other
Complication 1 = heart disease
2 = renal disease
3 = stroke
4 = gangrene foot
5 = other
Family history of DM 1 = yes
2 = no
If yes, who?
1 = father
2 = mother
3 = sibling
4 = other
Health Application
Do you regularly use the application? 1 = yes
2 = no
How often do you use it? 1 = everyday
2 = every month
3 = every 3 months
4 = every 6 months
5 = other
What actions do you take after knowing 1 = do nothing
the results? 2 = change to a healthier lifestyle
3 = do regular visits to the doctor
 4 = do regular blood test
5 = other
Knowledge
a1 Definition of diabetes mellitus (DM) Ya
a2 DM is a hereditary disease Ya
a3 People of all ages and genders can get DM Ya
a4a Risk factor for DM: family history Ya
a4 Risk factor for DM: obesity Ya
b
a4c Risk factor for DM: diet Ya
a4 Risk factor for DM: smoking Ya
d
a4e Risk factor for DM: lack of physical exercise Ya
a5a Main symptom of DM: get hungry easily Ya
a5 Main symptom of DM: get thirsty easily Ya
b
a5c Main symptom of DM: urinate frequently Ya
a6a DM complication: heart disease Ya
a6 DM complication: stroke Ya
b
a6c DM complication: renal disease Ya
a6 DM complication: gangrene Ya
d
a7 Routine examination for DM are random blood glucose and fasting Ya
blood glucose
a8 DM can be cured Tidak
a9 DM treatment is a lifetime treatment Ya
Attitude
b1 I do routine exams and measure vitals regularly if I get DM Tidak
b2 If I have DM symptoms, I will go to the nearest health facility Ya
b3 I will cut down sweet foods to prevent DM Ya
b4 I will gradually lose weight to prevent DM Ya
b5 If I take medicine regularly, I don’t need to implement healthy lifestyle Tidak
b6 I will make lifestyle changes because it is the key element to prevent Ya
worsening of DM
Practice
c1a Healthy diet: right amount Ya
c1b Healthy diet: right variety (T plate model) Ya
c1c Healthy diet: right time (3 main meals, 2-3 light snacks) Ya
c2 I have implemented this diet to reduce DM risk Ya
c3 I will implement this diet if I’m diagnosed with DM Tidak
c4 I don’t need regular exercise because I’m not diagnosed with DM Tidak
c5 I exercise regularly, 3 times a week for 30 minutes Ya
c6 I prefer irregular strenuous exercise rather than regular light exercise Tidak
c7 I don’t need to exercise because I have lots of house chores Tidak
 c8 I prefer herbal medicine rather that chemical medicine Tidak
c9 I smoke Tidak
c10 If yes, I intend to quit in one year Ya
c11 I will quit smoking if I’m diagnosed with DM Tidak
c12 I will go to the doctor regularly if I’m diagnosed with DM Ya
c13 I will help give motivation and education to other DM patients Ya

KAP QUESTIONNAIRE – HYPERTENSION

Personal Identification
Sex 1 = male
2 = female
Education 1 = not schooled
2 = primary school
3 = junior high school
4 = high school
5 = bachelor/diploma
Marital status 1 = married
2 = not yet married
3 = other
Current Illness
Diagnosed with hypertension 1 = yes
2 = no
Currently treated for hypertension 1 = yes
2 = no
Medicine 1 = amlodipine
2 = captopril
3 = candesartan
4 = bisoprolol
5 = other
Complication 1 = heart disease
2 = renal disease
3 = other
Family history of DM 1 = yes
2 = no
If yes, who?
1 = father
2 = mother
3 = sibling
4 = other
Health Application
Do you regularly use the application? 1 = yes
2 = no
How often do you use it? 1 = everyday
 2 = every month
3 = every 3 months
4 = every 6 months
5 = other
What actions do you take after knowing 1 = do nothing
the results? 2 = change to a healthier lifestyle
3 = do regular visits to the doctor
4 = do regular blood pressure measurement
5 = other
Knowledge
a1 Definition of hypertension Ya
a2 Hypertension is a hereditary disease Ya
a3 People of all ages and genders can get hypertension Ya
a4a Risk factor for hypertension: family history Ya
a4b Risk factor for hypertension: obesity Ya
a4c Risk factor for hypertension: diet Ya
a4d Risk factor for hypertension: smoking Ya
a4e Risk factor for hypertension: lack of physical exercise Ya
a5a Main symptom of hypertension: headache Ya
a5b Main symptom of hypertension: pain on the back of the neck Ya
a6a Hypertension complication: blurry vision Ya
a6b Hypertension complication: heart failure Ya
a6c Hypertension complication: renal disease Ya
a7 Routine examination for hypertension is blood pressure measurement Ya
a8 Hypertension can be cured Tidak
a9 Hypertension treatment is a lifetime treatment Ya
Attitude
b1 I do routine exams and measure vitals regularly if I get hypertension Tidak
b2 If I have hypertension symptoms, I will go to the nearest health facility Ya
b3 I will cut down salty and fatty foods to prevent hypertension Ya
b4 I will gradually lose weight to prevent hypertension Ya
b5 If I take medicine regularly, I don’t need to implement healthy lifestyle Tidak
b6 I will make lifestyle changes because it is the key element to prevent Ya
worsening of hypertension
Practice
c1a Healthy diet: right amount Ya
c1b Healthy diet: right variety (T plate model) Ya
c1c Healthy diet: right time (3 main meals, 2-3 light snacks) Ya
c2 I have implemented this diet to reduce hypertension risk Ya
c3 I will implement this diet if I’m diagnosed with hypertension Tidak
c4 I don’t need regular exercise because I’m not diagnosed with hypertension Tidak
c5 I exercise regularly, 3 times a week for 30 minutes Ya
c6 I prefer irregular strenuous exercise rather than regular light exercise Tidak
c7 I don’t need to exercise because I have lots of house chores Tidak
c8 I prefer herbal medicine rather that chemical medicine Tidak
 c9 I smoke Tidak
c10 If yes, I intend to quit in one year Ya
c11 I will quit smoking if I’m diagnosed with hypertension Tidak
c12 I will go to the doctor regularly if I’m diagnosed with hypertension Ya
c13 I will help give motivation and education to other hypertension patients Ya

Area Code

0 = Jember

1 = Deli Serdang

2 = Kediri

3 = Medan