You are on page 1of 2

Adapted questionnaire to Assess Barriers to inadequate Nutrition in

HIV infected and exposed children (Under 5 years).


Child's IP Age Weight Height

Parent Interviewed Last Viral Load

Name of Interviewer Title

1. Is your child breast fed? ☐ Yes ☐No or formula fed? ☐ Yes ☐No or both? ☐ Yes ☐No

If formula, what kind?


Is the formula iron-fortified? ☐ Yes ☐No

How much formula in 24 hours?

2. Does your child drink milk? ☐ Yes ☐No


3. Does your child drink from a bottle? ☐ Yes ☐No

What?

When ?

How much?

4. Does your child usually take a bottle to bed? ☐ Yes ☐No

If yes, what is usually in the bottle?

5. At what time does your child eat food during the day? (Other than formula or milk)

6. Please indicate which, if any, of these foods your child eats and how often

Never or Sometimes Every Day Or


Hardly Ever (Not Daily But at Nearly Every At Least 2 To
Answers (Less than Once Least Once a Day 3 Times a Day
a Week) Week)
RUTF Yes/ No
RUSF Yes/ No
*Traditional Yes/ No
fermented food
Other porridges Yes/ No
Familial food Yes/ No
*Specify
7. Is current HIV test done to your child? ☐ Yes ☐No

8. Child on post exposure prophylaxis ART? ☐ Yes ☐No

If yes, what regimen:

9. If yes, why ☐ Yes ☐No

10. Does your child take vitamins or iron drops? ☐ Yes ☐No

If yes, what kind?

How often

11. Is your child on a special diet? ☐ Yes ☐No

If yes, why?

12. Is there delay in physicians ordering the initiation of nutriment supplements? ☐ Yes ☐No
13. How long are you waiting for physician to assess the child? ☐ Yes ☐ No
14. Is nutrition therapy routinely discussed on child follows up? ☐ Yes ☐ No
15. How long are waiting for the dietitian to assess the child? ☐ Yes ☐ No
16. Is Dietitian routinely present on weekday during child follows up? ☐ Yes ☐ No
17. Is there enough time dedicated to education and training on how to optimally feed your child? ☐
Yes ☐No
18. Is Nutritional supplement always available in the hospital? ☐ Yes ☐ No
19. Does your child already suffered or is suffering from:
Tuberculosis ☐ gastro-enteritis ☐ pneumonia ☐ Anemia ☐ Oral thrust ☐ Others☐
Specify:
20. Is blood collected every six months to monitor HIV disease? ☐ Yes ☐ No
21. Estimated distance from home to the Health Centre?
< 10 Km ☐ 10 à 25 Km ☐ 25 à 50 Km ☐ > 50 Km☐
22. How often do you forget to give your child the medications (per week?)
1 Time ☐ 2 Times ☐ ≥ 3 Times ☐
23. How often did you miss your child’s appointments this year? 1 Time ☐ 2 Times ☐ ≥ 3 Times ☐
24. Is there any traditional medications administered to your child? ☐ Yes ☐ No

You might also like