Research Questionnaire

Factors Affecting The Compliance To Facility-Based Delivery in Selected

Barangays in
San Remigio, Antique
PART I: DEMOGRAPIC PROFILE
Name: (optional)
Civil status:
( ) Single

( ) Married

( ) Separated

( ) Widow

Age Bracket:
( ) 16-18
( ) 19-25

( ) 26-35
( ) 36-40

Educational Background:
( ) Elementary Level

( ) Elementary graduate

( ) High School Level

( ) High School Graduate

( ) Vocational course

( ) College Level

( ) College Graduate

( ) Post Graduate

Location :
( ) 5 15 minutes travel away to birthing clinic
( ) 15 30 minutes travel away to birthing clinic
( ) 30 minutes 1 hour travel away to birthing clinic
( ) 1 hour and above - travel away to birthing clinic
Preferred Birthing Facility:
( ) Home Delivery
delivery

( ) Government- owned facility-based

( ) Private-owned facility-based delivery

( ) Hospital

Part II- Factors Affecting the Compliance to Facility-Based Delivery in

Selected Barangays in San Remigio,Antique
Instruction: Please rate the following factors affecting your compliance to facility
based delivery. Check the corresponding number of choice.
4 Very much affecting
3- Much affecting
2- Least affecting
1- Not affecting
A. SOCIO- ECONOMIC FACTORS
a. Is distance of health facility from residence greatly
affects your compliance in accessing facility-based
delivery?
b. Is your level of education affects your compliance
to FBD?
c. Is family income greatly affects your compliance to
accessing FBD?
d. Do your employment status and occupation affect
your compliance to FBD?
B. CULTURAL FACTORS
1. Is your awareness and readiness in accessing SBS
affects your compliance?
2. Is Old habit, tradition, customs and beliefs towards
facility-based delivery affect your compliance?
3. Is your preference between home delivery and
FBD affects your compliance?
4. Are your previous experiences with facility-based
delivery (eg. Unpleasant procedure and delays in the
hospital) affects your compliance?
5. Is your perception about FBD services rendered
affects your compliance?
6. Is parental decision making power affects your
compliance?