Data Collection Questionnaire
Section A: The SERVQUAL Questionnaire
Introduction Measuring the quality of a service can be a very difficult exercise. Unlike product where there are specific specifications such as length, depth, width, weight, colour, etc. a service can have numerous intangible or qualitative specifications. In
addition there is the expectation of the customer with regards the service, which vary considerably based on a range of factors such as prior experience, personal needs and what other people may have told them.
SERVQUAL – a methodology for measuring service quality
As a way of trying to measure service quality, we have developed and appropriately modified service quality questionnaire survey tool, also known as SERVQUAL. It examines five dimensions of CCC service quality:
Reliability Responsiveness Assurance; Empathy, and
Tangible (e.g. appearance of physical facilities, equipment, etc.)
For each dimension of service quality above, the tool measures both the expectation and perception of the service on a scale of 1 to 7, 22 questions in total. Then, each of the five dimensions are weighted according to customer importance, and the score for each dimension multiplied by the weighting. Following this, the Gap Score for each dimension is calculated by subtracting the Expectation score from the Perception score. A negative Gap score indicates that the actual service (the Perceived score) was less than what was expected (the Expectation score).
The Gap score is a reliable indication of each of the five dimensions of service quality. Using SERVQUAL, service providers can obtain an indication of the level of quality of their service provision, and highlight areas requiring improvement.
Dimension Statemen t Expectatio n Score Perceptio n Score
Gap Score Average for Dimension Tangibles Reliability Responsivenes s Assurance Empathy
Table 1 - Calculation of SERVQUAL Scores
SERVQUAL
Importance Weights
Listed below are the five sets of features pertaining to
Comprehensive Care Centres (CCC) and the services they offer. We would like to know how much each of these sets of features is important to the patient. Please allocate 100 points among the five sets of features according to how important it is to you. Make sure the points add up to 100.
Features Points
1. The appearance of the CCC physical facilities, equipment, personnel and communication materials.
2. The staff‟s ability to perform the promised service dependably and accurately
3. The doctors and nurses‟ willingness to help clients and provide prompt service.
4. The knowledge and courtesy of the CCC's employees and their ability to convey trust and confidence.
5. The caring individual attention the doctors and nurses provides its customers.
Total: 100
Table 2 - SERVQUAL Importance Weights
SERVQUAL Dimension
Score from Table 1 Weighting from Table 2
Weighted Score Weighted deception Expectatio n Perceptio n Tangibility Reliability Responsiven ess Assurance Empathy
Table 3 - Calculation of Weighted SERVQUAL Scores
The Survey The questionnaire below is in two sections. The first section asks you to rank all CCC staff according to your expectations i.e. what you expect all CCC staff to provide. The second section asks you to rank the CCC staff you chose for the survey according to your experiences and perceptions.
Expectations This section of the survey deals with your opinions of the CCC. Please show the extent to which you think CCC should posses the following features. What we are interested in here is a number that best shows your expectations about CCC staff offering services.
You should rank each statement as follows:
Strongly fairly Disagree Don‟t Agree Fairly Strongly
Disagree disagree know Agree Agree
1 2 3 4 5 6 7
Statement Score
1. Excellent CCC will have modern looking equipment. 2. The physical facilities at CCC will be visually appealing. 3. Staff i.e. doctors and nurses will be neat in their appearance.
4. Materials associated with the service, i.e. IEC (pamphlets or statements) will be visually appealing
5. When CCC promises to do something by a certain time, they do, i.e. the Citizen Service Charter timelines are respected and adhered to.
6. When a patient has a problem, staff will show a sincere interest in solving it. 7. Doctors and nurses at the CCC will perform the service right the first time. 8. Doctors and nurses at the CCC will provide the service at the time they
promise to do so.
Statement Score
10. Employees of the CCC facility will tell patients exactly when services will be performed.
11. Members of the CCC facility will give prompt service to patients. 12. All staff will always be willing to help patients.
13. Staff at the CCC will never be too busy to respond to patients‟ requests. 14. The behaviour of doctors and nurses will instill confidence in patients. 15. Patients of excellent CCC will feel safe in transactions.
16. CCC staff will be consistently courteous with patients.
17. Staff at the CCC will have the knowledge to answer patients' questions. 18. Staff will give patients individual attention.
19. Staff at the CCC will have operating hours convenient to all their patients. 20. CCC will have staffs who gives patients personal service.
21. CCC will have their patients' best interest at heart.
22. Staff at the CCC will understand the specific needs of their patients.
Perceptions The following statements relate to your feelings about the particular doctor or nurse you have chosen. Please show the extent to which you believe this doctor or nurse has the features described in the statement. Here, we are interested in a number from 1 to 7 that shows your perceptions about the doctor or nurse.
You should rank each statement as follows:
Strongly fairly Disagree Don‟t Agree Fairly Strongly
Disagree disagree know Agree Agree
Statement Score
1. The CCC/Clinic has modern looking equipment.
2. The CCC/Clinic's physical features are visually appealing. 3. The CCC/Clinic's reception desk employees are neat appearing. 4. Materials associated with the service i.e. IEC (such as pamphlets or
statements) are visually appealing
5. When the CCC staff promises to do something by a certain time, it does so, i.e. the citizen service charter timelines are met and adhered to.
6. When you have a problem, the doctor or nurse shows a sincere interest in solving it.
7. The staffs at the CCC perform the service right the first time.
8. The staffs at the CCC provide its service at the time it promises to do so. 9. The staffs at the CCC insist on error free records.
10. The staffs at the CCC tell you exactly when the services will be performed. 11. Staff at the CCC gives you prompt service.
12. Staffs at the CCC are always willing to help you.
13. Employees in the CCC are never too busy to respond to your request. 14. The behaviour of staff in the CCC instills confidence in you.
15. You feel safe in your transactions with the staff at the CCC. 16. The staffs at the CCC are consistently courteous with you.
17. Employees in the CCC have the knowledge to answer your questions. 18. The staffs at the CCC give you individual attention.
19. The CCC has operating hours convenient to all its patients. 20. The CCC has staffs who give you personal attention. 21. The CCC has your best interests at heart.
22. The employees of the CCC understand your specific needs.
INSTRUCTIONS TO THE INTERVIEWER:
The “Toolkit” should be given to the participant prior to any clinical exam and preferably in a quiet, secluded area (e.g., exam room or other office). After obtaining signed consent from the participant at the beginning of the visit, please tell the participant:
“Hello, my name is_____________. I am an interviewer working on the quality of life project leading to a Master degree in Public Health of Kenyatta University. We would like you to answer some questions about your quality of life, physical activities, about the treatment you have been receiving, and the symptoms you may be experiencing. Each question has a series of responses. Please pick the response that is closest to the way you feel now. It is important that you answer every question as completely as possible. The questionnaire will take approximately one half hours to complete. The answers you provide will remain confidential and will not be able to be traced back to you. Your answers will help us to understand how HIV affects peoples‟ quality of life. Thank you.”
Please read each question exactly as written. If the participant does not understand the question, repeat the question. Do not attempt to explain the questions, as this may introduce bias.
Please attempt to maintain a neutral and conversational tone during the interview. Please mark an “X” to indicate the participant‟s response choice in the space provided.
Interviewer name __________________________________________________
SECTION B: PATIENT REPORTED OUTCOME (PRO) FOR PERSONS LIVING WITH HIV/AIDS
Patient number__ __ __ __ Date of interview __ __/__ __/__ __ __ __ (DD/MM/YYYY) Patient‟s sex: ____ (male [1]) ____ (female[2])
Age:______ Years of school completed:__________ Occupation:______________
Patient on ART? ___Y ___N How long on ART? ____ Patient last CD4++ count: ________ CD 8++ count ________ Patient last HB level: ________
Date of last CD4++ count __ __/__ __/__ __ __ __ (DD/MM/YYYY) Date of patient‟s last hospitalization: ________
Reason for hospitalization:___________
Start time: __ __:__ __ End time: __ __:__ __
Patient number__ __ __ __ Date of interview __ __/__ __/__ __ __ __ (DD/MM/YYYY) Start time: __ __:__ __
I.1 HIV HEALTH SURVEY
1. In general, would you say your health is: (Tick One)
___ Excellent (1) ___ Very Good (2) ___ Good (3) ___ Fair (4) ___ Poor (5)
2. How much bodily pain have you generally had during the past 4 weeks? (Tick One) ___ None (1) ___ Very Mild (2) ___ Mild (3) ___ Moderate (4) ___ Severe (5) ___ Very Severe (6)
3. During the past 4 weeks, how much did pain interfere with your normal work (or your normal activities, including work outside the home and housework)? (Tick One)
___ A little bit (2) ___ Moderately (3) ___ Quite a bit (4) ___ Extremely (5)
4. The following questions are about activities you might do during a typical day.
4.1 Does your health now limit you in these
activities? If so, how much? Yes, limited a lot (1) Yes, limited a little (2) No, not limited (3)
4.2 activities you can do, like lifting heavy objects, running or participating in strenuous sports
4.3 The kinds or amounts of moderate
activities you can do, like moving a table, carrying groceries or bowling 4.4 Walking uphill or climbing (a few flights of stairs) 4 .5 Bending, lifting or stooping
4.5 Walking one block 4.6 Eating, dressing, bathing or using the toilet
5. Have you been unable to do certain kinds or amounts of work, housework, or School work because of your health? (Tick One)
___ No (2)
For each of the following questions, please check the box for the one answer that comes closest to the way you have been feeling during the past 4 weeks.
How much of the time, during the past 4weeks… All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6)
7. Has your health limited your social activities (like visiting with friends or close relatives)? 8.1 Have you been a very nervous person? 8.2 Have you felt calm and peaceful? 8.3 Have you felt downhearted and blue?
8.4 Have you been a happy person? 8.5 Have you felt so down in the dumps that nothing could cheer you up? 9.1 Did you feel full of pep?
mos9x2] 9.2 Did you feel worn out? 9.3 Did you feel tired?
9.4 energy to do the things you wanted to do?
weighed down by your health problems? 9.6 Were you discouraged by your health problems? 9.7 Did you feel despair over your health problems? 9.8 Were you afraid because of your health?
How much of the time, during the past 4 weeks… All of the time (1) Most of the time (2) A good bit of the time (3) Some of the time (4) A little of the time (5) None of the time (6)
10.1 Did you have difficulty
reasoning and solving problems, for
example, making plans, making decisions, learning new things? 10.2 Did you forget things
that happened recently, for example,
where you put things and when you had Appointments?
10.3 Did you have trouble
keeping your attention on any activity
For long?
10.4 Did you have difficulty doing activities involving concentration and thinking?
11. Please check the box that best describes whether each of the following statements is true or false for you. (Tick one box on each line.)
11.1 I am somewhat ill Definitely true (1) Mostly true (2) Not sure (3) Mostly false (4) Definitely false (5) 11.2 I am as healthy as anybody I know 11.3 My health is excellent
11.4 I have been feeling bad lately
12. How has the quality of your life been during the past 4 weeks? That is, how have things been going for you? (Tick One)
___ Very well; could hardly be better (1)
___ Pretty good (2)
___ Good and bad parts about equal (3)
___ Very bad; could hardly be worse (5)
13. How would you rate your physical health and emotional condition now compared to 4 weeks ago? (Tick One)
___ Much better (1)
___ A little better (2)
___ About the same (3)
___ A little worse (4)
___ Much worse (5)
14. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
15. Accomplished less than you would like
___ No (2)
___ Yes (1)
16. Were limited in the kind of work or other activities
___ No (2)
___ Yes (1)
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
___ No (2)
___ Yes (1)
18. Didn't do work or other activities as carefully as usual
___ No (2)
___ Yes (1)
19. During the past 4 weeks, how much did pain interfere with your normal work
(including both work outside the home and housework)?
___ Not at all (1) ___ A little bit (2) ___ Moderately (3) ___ Quite a bit (4) ___ Extremely (5) Disability
During the past 3 months as well as you can remember...
20. How many days did you stay in bed because you were not feeling well?
___ None (0) ___ 1 – 2 (1) ___ 3 – 5 (2) ___ 6 – 10 (3) ___ 11 – 16 (4) ___ >16 (5)
21. HOW MANY DAYS did you cut down on your usual daily activities, such as you job, housework, school because of your health?
___ None (0) ___ 1 – 2 (1) ___ 3 – 5 (2) ___ 6 – 10 (3) ___ 11 – 16 (4) ___ >16 (5)