APPENDICES

APPENDIX 1: INFORMED CONSENT ENGLISH VERSION

Introduction:

Dear,

My name is Lutfi Abdallah, a resident doctor at the Catholic University of Health and Allied Science
(CUHAS).

Purpose of the Study: As part of the requirements for the master’s degree in Internal Medicine, I am
conducting a study on “Knowledge and acceptance on use of PrEP among adolescents at Njombe”
You are requested to participate in this research because the information obtained from your
participation may help to improve care for you and other individuals with the same condition.

Willingness, rights, and privacy; your participation in this study should be completely voluntary, and
your decision not to participate in this study will not violate your rights to be treated and have all the
patients' care when needed. If you agree to take part in this study all your information will be kept
confidential, the findings of this study will be presented in my final thesis report and may be
published in scientific journals; the names of participants will not be mentioned.

Benefits: The results of these tests will be given to you or kept in your files for use by your attending
doctor. There will not be any financial benefits in participating in this study.

Communication: In case of any questions or concerns regarding this study please contact Lutfi
Abdallah (principal Investigator) through this address: P. O. Box 992, Mwanza, Tel: +255-716649229
Or in any case of any question about your rights as a study participant, please contact; Chairman of
CUHAS/BMC research ethics and review committee (CREC) P. O. Box 1464, Mwanza.

If you agree to take part in this study, please sign the consent form hereafter:

CONSENT FORM:

I……………………………………………… agree to participate in Lutfi Abdallah’s study I have

read the information on this form, and I have understood the purpose and nature of the study, I have
voluntarily agreed to participate.
I understand that I can withdraw from the study at any time and that will not affect my management. I
understand that confidentiality will be observed and my identity will not be disclosed. I also
understand that the data collected can be used for scientific publication.

Signature………………………………………. Date………………………………….
Witness………………………………………. Signature………………………............. Researcher’s
statement

I have accurately given the information from this consent form to the potential participant, and to the
best of my ability I made sure that the participant has understood what will be done in my study.

I confirm that the participant was allowed to ask questions about the study, and all the questions were
answered correctly to the best of my knowledge. I confirm that the participant was not forced to give
consent; it was given freely and voluntarily. Name of the

Research……………………………………………
Signature: …………….
Date……………

APPENDIX 2: DATA COLLECTION FORM IN ENGLISH

Read questions as written. Record answers carefully. Circle the correct answer number at the right.
The interviewer should fill in this section before beginning the questionnaire.
1. What is your Age___________
2. Participants Sex
a) Male
b) Female

3. Marital status
a) Single
b) Married
c) Divorced
d) Widowed

4. Education Level
a) No formal education
b) Primary school education
c) Secondary school education
d) College/University
5. Have you ever heard of PrEP (Pre-Exposure Prophylaxis)?
a) Yes
b) No
c) No sure

6. What does PrEP stand for?

a) Post-Exposure Prophylaxis
b) Pre-Exposure Prophylaxis
c) Preventive Emergency PillPost-exposure prophylaxis
d) I don't know

7. What is the primary purpose of PrEP?

a) To cure HIV/AIDS
b) To prevent HIV infection
c) To treat other sexually transmitted infections
d) I don't know

8. Who can use PrEP?

a) Only HIV-positive individuals
b) Only HIV-negative individuals
c) Both HIV-positive and HIV-negative individuals
d) I don't know

9. Are there any potential side effects of using PrEP?

a) Yes
b) No
c) I don't know

11. Would you consider using PrEP if it were available to you?

a) Definitely yes
b) Not sure

c) Definitely no
12. How comfortable would you feel discussing PrEP with your healthcare provider?
a) Comfortable
b) Neutral
c) Uncomfortable
13. How concerned are you about the potential side effects of PrEP?
a) Very concerned
b) Somewhat concerned
c) Neutral
d) Slightly concerned
e) Not concerned at all

14. Would you be comfortable telling your sexual partner that you are using PrEP?
a) Definitely yes
b) Not sure
c) Definitely no
15. Do you think using PrEP would make you feel more in control of your sexual health?
a) Strongly agree
b) Agree
c) Neutral
d) Disagree
e) Strongly disagree
16. Would the cost of PrEP influence your decision to use it?
a) Definitely yes
b) Not sure
c) Definitely no
17. How likely are you to recommend PrEP to your friends or peers?
a) Very likely
b) Somewhat likely

c) Neutral
d) Somewhat unlikely

e) Very unlikely
18. Do you think there is a stigma associated with using PrEP in your community?
a) Definitely yes
b) Not sure
c) Definitely no
APPENDIX 3: INFORMED CONSENT SWAHILI VERSION

Ndugu,

Utambulisho: Jina langu ni Lutfi Abdallah, ni Mwanafunzi wa udaktari bingwa katika Chuo kikuu cha
Afya cha kikatoliki (CUHAS). Dhumuni la utafiti: Kama sehemu ya mafunzo ninafanya utafiti
unaohusu “Kiwango cha atria fibrillia na mambo yanayohusiana Kwa watu wenye tatizo la figo
endelevu wanaotegemea kusafishwa damu kliniki Bugando hospitali”.

Unaombwa kushiriki katika utafiti huu na taarifa zitakazopatikana kutokana na ushiriki wako
zitatumika katika utafiti huu. Tutafanya vipimo baada ya kujibu maswali katika dodoso la utafiti na
kufanyiwa uchunguzi wa mwili. Utayari, haki na usiri;

Ushiriki wako katika utafiti huu unapaswa kuwa kwa hiyari yako, na uamuzi wa kutoshiriki
hautakuzuia kupata haki ya kutibiwa maradhi uliyonayo, na ukikubali, taarifa zote zinazokuhusu
zitakuwa siri, majibu ya utafiti yataripotiwa katika taarifa za utafiti na yanaweza kutumika katika
majarida ya kisayansi bila kutaja majina ya washiriki.

Maumivu na madhara; Hatutarajii madhara yoyote kutokea na ukipatwa na madhara utatibiwa

kulingana na taratibu zilizopo

Faida ya kushiriki; Majibu ya vipimo yatahifadhiwa katika jarada lako kwa matumizi ya daktari wako
anaekutibu. Hakutakuwa na mapato yoyote kwa kushiriki kwako.

Mawasiliano; Kama una swali lolote kuhusiana na utafiti huu tafadhali wasiliana na Lutfi Abdallah
(mtafiti mkuu) kupitia anuani na simu ifuatayo: S.L.P 1464, Mwanza. Simu: +255-716382800

Au ukiwa na swali kuhusu haki zako kama mshiriki wa utafiti huu, Tafadhali wasiliana na;

Mwenyekiti wa kamati ya maadili kuhusu utafiti wa tiba Bugando., S.L.P 1464, Mwanza. Kama
unakubali kushiriki katika utafiti huu tafadhali jaza fomu hii ya kuridhia kushiriki:

Fomu ya kuridhia kushiriki Mimi……………………………………………naridhia kushiriki katika

utafiti unaofanywa na Lutfi Abdallah.

Nimesoma na kuelewa taarifa zote katika fomu hii na kuelewa madhumuni ya utafiti huu na
ninakubali kushiriki bila kushurutishwa. Nimeelewa kuwa ninaweza kujitoa katika ushiriki na
haitaathiri matibabu yangu. Nimeelewa kutakua na usiri kuhusu taarifa zangu na hazitawekwa wazi.
Pia nimeelewa kuwa taarifa za utafiti huu zitatumika katika majarida ya kisayansi.

Saini………………………………………. Tarehe……………………….
Shahidi…………………………………… Sahihi…………………………

Kauli ya mtafiti.
Nimemtaarifu mshiriki taarifa zilizomo katika fomu hii ya kuridhia ushiriki kwa usahihi na kwa
uwezo wangu nimehakikisha ameelewa nini kitafanyika katika utafiti huu. Ninathibitisha kuwa
mshiriki aliruhusiwa kuuliza maswali na maswali yote yalijibiwa kwa usahihi kwa kiwango cha
uelewa wangu Ninathibitisha kuwa mshiriki hakulazimishwa kukubali ushiriki wake katika utafiti na
amekubali kwa hiari yake.

Jina la Mtafiti……………………………………….……………………….
Saini: ………………………. ….
Tarehe: ………………………………
1. Una Umri gani?___________
2. Jinsia ya mshiriki
a) Mwanaume
b) Mwanamke

3. Hali yako ya ndoa ikoje?

a) Sijaoa/sijaolewa
b) Nipo kwenye ndoa
c) Tumeachana
d) Tunaishi pamoja

4. Je una kiwango gani cha elimu?

a) Sijasoma
b) Elimu ya shule ya msingi
c) Elimu ya shule ya sekondari
d) Elimu ya Chuo

5. Ulishawahi kusikia kuhusu dawa kinga za virusi vya Ukimwi (VVU) kitaalamu PrEP (Pre-
Exposure Prophylaxis)?
a) Ndio
b) Hapana
c) Sina uhakika

6. Dawa kinga za VVU zinamaanisha nni?

a) Dawa za kuzuia maambukizi baada ya kufanya ngono hatarishi
b) Dawa za kuzuia maambukizi kabla ya kufanya ngono hatarishi
c) Dawa za kuzuia maambukizi za dharula baada ya kufanya ngono hatarishi
d) Sifahamu
7. Nini Malengo hasa ya dawa kinga za kuzuia virusi vya ukimwi (PrEP)?
a) Kutibu virusi vya ukimwi
b) Kuzuia maambukizi ya virusi vya ukimwi
c) Kutibu magonjwa ya zinaa
d) Sifahamu

8. Nani anaweza kutumia dawa kinga za kuzuia virusi vya ukimwi (PrEP)?
a) Wale wenye maambukizi ya virusi vya ukimwi
b) Wale wasio na maambukizi ya virusi vya ukimwi
c) Wote wenye maambukizi na wasio na maambukizi
d) Sifahamu

9. Je kuna madhara ya kutumia dawa kinga za kuzuia virusi vya ukimwi (PrEP)?
a) Ndio
b) Hapana
c) Sijui

10. Je ungependa kutumia dawa kinga za kuzuia virusi vya ukimwi (PrEP) kama zingepatikana?
a) Ndio hakika
b) Sina uhakika

c) Hapana kabisa
11. Ni kwa kiasi gani ungekuwa huru kujadili kuhusu dawa kinga za kuzuia virusi vya ukimwi
(PrEP) na mtoa huduma wa Afya?
a) Ningekuwa huru
b) Sina uhakika

c) Nisingekuwa huru
12. Ni kwa kiasi gani una wasiwasi juu ya madhara ya dawa kinga za kuzuia virusi vya ukimwi
(PrEP)?
a) Nina wasiwasi sana
b) Nina wasiwasi kiasi
c) Kawaida tu
d) Nina wasiwasi wa kawaida
e) Sina wasiwasi hata kidogo
13. Ungekuwa huru kumwambia mpenzi wako kuwa unatumia dawa kinga za kuzuia virusi vya
ukimwi (PrEP)?
a) Ndio
b) Sina uhakika
c) Hapana
14. Unadhani matumizi ya dawa kinga za kuzuia virusi vya ukimwi (PrEP) zinakupa kumudu
afya yako ya uzazi?
a) Nakubali kabisa
b) Nakubali
c) Sina uhakika
d) Sikubali
e) Sikubali kabisa
15. Je Gharama za dawa kinga za kuzuia virusi vya ukimwi (PrEP) zingeweza kuathiri maamuz
yako ya kuzitumia?
a) Ndio
b) Sina uhakika
c) Hapana
16. Ni kwa kiasi gani ungeweza kushauri matumizi ya dawa dawa kinga za kuzuia virusi vya
ukimwi (PrEP) kwa marafiki zako au wenzako?
a) Ningeshauri kabisa
b) Nadhani ningeshauri

c) Sina uhakika
d) Nadhani nisingeshauri

e) Nisingeshauri kabisa
17. Je unadhani kuna unyanyapaa kutokana na matumizi ya dawa kinga za kuzuia virusi vya
ukimwi (PrEP)?
a) Ndio
b) Sina uhakika

c) Hapana