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. 2022 Jun 14;137(4):373–389. doi: 10.1017/S0022215122001396

Table 1.

Patient perspective questionnaire: carer

Part 1: demographics
24. What is the child's gender?

  1. Female

  2. Male

  3. Other

b) Prefer not to answer
25. What is the child's age?
Answer:
26. Where is the child's current place of residence? (district, village or town)
Answer:
27. How many hours did you travel to reach CSC?
Answer:
28. What is the highest education level that you, as carer of the child, have completed at school?

  1. Did not attend school

  2. Pre-primary school

  3. Primary school

  4. Secondary school

  5. University

  6. Prefer not to answer

29. Your employment

  1. Never worked

  2. Currently working

  3. Not currently working

  4. Prefer not to answer

30. What is your occupation?

  1. Not currently working

  2. Seller

  3. Driver

  4. Factory or construction worker

  5. Teacher

  6. Farmer

  7. Retired

  8. Trader

  9. Student

  10. Work for the government

  11. Other:

  12. Prefer not to answer

Part 2: reason for attendance
31. What is the reason for the child's visit today?

  1. First visit

  2. Follow-up consultation

  3. Ear surgery in-patient

  4. Post-operative follow-up consultation

  5. Rehabilitation (e.g. hearing aids)

  6. Other:

32. How did you hear about CSC?

  1. Health professional referred (e.g. doctor, All Ears Cambodia, other hospital)

  2. Family member

  3. Friend

  4. Social media (e.g. Facebook or Instagram)

  5. Radio

  6. Other:

33. Before attending CSC, what had been the child's main ear/hearing symptoms? (circle all that apply)

  1. Hearing loss

  2. Ear pain

  3. Discharging ear

  4. Tinnitus (ringing sound or noise in ears)

  5. Blocked ear or ear fullness

  6. Dizziness or balance problem

  7. Headache

  8. Cannot speak

  9. Other:

34. How long did the child have these symptoms from when the problem first began? (circle closest answer)

  1. Less than a week

  2. Less than a month

  3. Up to 6 months

  4. Up to 1 year

  5. 1–3 years

  6. 4–6 years

  7. 7–10 years

  8. 11–15 years

  9. More than 15 years

35. Why did you decide to bring the child to CSC now? (choose all that apply)

  1. Worsening symptoms

  2. Could not go to school due to ear problem

  3. Recently heard about the services at CSC

  4. Other treatments did not work

  5. Other hospital does not treat ear problems

  6. Wait too long to have operation at other hospital

  7. Change in circumstances (e.g. now living closer to hospital)

  8. Referred by health professional

  9. Other reason:

Part 3: wellbeing
36. In the last six months, what effect have the child's ear problems had on their life?
a) Difficulties hearing school teacher
 Yes No Does not apply
b) Does not attend school because of ear problem
 Yes No Does not apply
c) Difficulties talking in family conversations
 Yes No Does not apply
d) Difficulties talking with friends
 Yes No Does not apply
37. What do you think caused the child's ear problem?
Please explain:
Part 4: access to services
38. What services for ear or hearing care are available in your district? (circle all that apply)

  1. Government, district or referral hospital or health centre

  2. Private hospital or health centre

  3. Qualified doctor or nurse

  4. Pharmacy

  5. Kru Khmer (traditional healer/herbalist)

  6. No services available

  7. Other:

39. Do other people in your district use these services

  1. Yes

  2. No. If not, why?

40. Why did you decide to bring the child to CSC now?
Accessibility
a) Hospital or service was too far away YES / NO
b) Roads are in poor condition to reach hospital or service YES / NO
c) No one could take care of other children YES / NO
d) On waiting list for too long YES / NO
Knowledge
e) Did not know any ear care services were available YES / NO
f) Did not think the ear problem was serious enough to need help YES / NO
Financial
g) You could not miss work YES / NO
h) Treatment was too expensive YES / NO
i) Transport very expensive YES / NO
j) Food needed very expensive YES / NO
k) Childcare expensive for other children YES / NO
Acceptability
l) Thinks that the ear problem cannot be treated YES / NO
m) Felt scared about going to the hospital or service YES / NO
If yes, why?
n) Any other reason:
41. Among all the reasons you selected, which one do you believe is the main reason?
(Choose one option)
Answer:
42. What other ear care services did you seek for the child before coming to CSC? (circle all that apply)

  1. None

  2. Government, district or referral hospital or health centre

  3. Private hospital or health centre

  4. Qualified doctor

  5. Specialist ear doctor

  6. Pharmacy

  7. Drug shop

  8. Kru Khmer (traditional doctor/healer)

  9. Other:

43. What previous treatment for the child's ear problem were sought before coming to CSC?
(circle all that apply)

  1. None

  2. Ear drops or topical medicine

  3. Oral medication

  4. Ear surgery

  5. Traditional medicine (eg. herbal remedy)

  6. Dietary recommendation

  7. Other (please list):

44. Do you have any other comments or questions?