2. SOCIAL NETWORKS
There are now questions about the people you may have interacted with over the last 12 months i.e. your current social network. If the person in the list is not in your social network, mark the “not applicable” column.
2. 1 Volume of contact
How often do you contact each of the persons below? Mark your choice with an X Not
applicable
Never Less than once a year
Once a year
Once a quarter
Once a month
Every 2 weeks
Once a week
2 – 6 times a week
Every day 1.Spouse or Partner
2.Child/children 3.Grandchild/ren
4.Other relative/s (specify) 5.Friend
6. Nurse 7. Doctor
8. Community group 9. Religious leader 10.Other (specify) 2.2 Closeness
How close do you feel is your relationship with each of the persons below? Mark your choice with an X.
Not applicable Not very close Somewhat close Very Close Extremely close 1.Spouse or Partner
2.Child/children 3.Grandchild/ren
4.Other relative /s (specify) 5.Friend
6. Nurse 7. Doctor
8. Community group 9. Religious leader
2.3 Trust
How likely are you to confide in or make important decisions with each of the persons below? Mark your choice with an X
Not applicable Not likely Somewhat likely Very likely 1.Spouse or Partner
2.Child/children 3.Grandchild/ren
4.Other relative /s (specify) 5.Friend
6. Nurse 7. Doctor
8. Community group 9. Religious leader 10.Other (specify) 2.4 Contact type
What is the most common form of contact you have with each of the persons below? Choose ONE option by marking the column with an X.
Not applicable
Face to face
Telephone (landline)
Cellphone (calls)
Cellphone (sms or instant messaging)
Email Letters by post
Social media (e.g. Facebook
®)
Video chat (Skype TM) 1.Spouse or Partner
2.Child/children 3.Grandchild/ren 4.Other relative/s (specify)
5.Friend 6. Nurse 7. Doctor
8. Community group 9. Religious leader 10.Other (specify)
3. SOCIAL CONNECTEDNESS
This set of questions relates to social connectedness. Please choose the options in the box next to the question and mark the box with an X.
3.1. Social participation within and outside the residence
a. Have you been involved in social activities that the residence has organized in the last 3 months? ……… Yes No b. Have you been involved in cultural, social of community groups outside the residence in the last 3 months? .………... Yes No c. How often have you had face to face contact with family /friend………….. Every day Few times
a week
Few times a month
Once a month
Not in the last month d. Apart from face to face contact, how often have you had other contact with
family /friends ………..
Every day Few times a week
Few times a month
Once a month
Not in the last month 3.2. Access to Social support (Oslo-3 social support)
a. How many people are so close to you that you can count on them if you have serious problems? ……….
none 1 or 2 3-5 6 or more
b. How much concern do people show in what you are doing? ………...
A lot of concern and interest
Some concern and interest
Uncertain Little concern and interest
No concern and interest c. How easily can you get practical help from others? …. Very easy Easy Possible Difficult Very difficult 3.3. Self-efficacy (Rate your level of agreement with these statements)
a. I am able to have a say with family / friends on important issues ………..
Strongly agree Agree Neither agree nor disagree
Disagree Strongly disagree b. I am able to have a say in the residence on important
issues………...
Strongly agree Agree Neither agree nor disagree
Disagree Strongly disagree 3.4. Trust (Choose the most appropriate response for you in relation to each of the phrases)
a. Generally people………… Can be trusted a lot
Can mostly be trusted
Can be trusted sometimes
Mostly cannot be trusted
Cannot be trusted at all
b. Towards my doctor I feel.…………...
A great deal of confidence
Quite a lot of confidence
A moderate amount of confidence
Not very much confidence
No confidence at all
c. Towards nurses I feel……. A great deal of confidence
Quite a lot of confidence
A moderate amount of confidence
Not very much confidence
No confidence at all
d. Towards hospitals I
feel.……….
A great deal of confidence
Quite a lot of confidence
A moderate amount of confidence
Not very much confidence
No confidence at all
e. Towards security in my surrounds I feel…………...
A great deal of confidence
Quite a lot of confidence
A moderate amount of confidence
Not very much confidence
No confidence at all
4. LONELINESS There follows 6 statements that you need to read and for each choose a “yes” or “no” response
5.
KESSL ER 6 Please mark with an X in the relevant box for each of the 6 following items.
During the past 4 weeks (28 days) how much of the time did you feel All of the time
Most of the time
Some of the time
A little of the time
None of the time a. So sad nothing could cheer you up ……….
b. Nervous ………...
c. Restless or fidgety ………..
d. Hopeless ……….
e. That everything was an effort ……….
f. Worthless ………
6. WHO (FIVE) WELL- BEING INDEX
There are five (5) statements. Please indicate for each of the five statements which is the closest to how you have been feeling over the last two weeks.
Notice that higher numbers mean better wellbeing. Please place an X in the relevant box.
All of the time
Most of the time
More than half of the time
Less than half of the time
Some of the time
At no time
a. I have felt cheerful and in good spirits ……….. 5 4 3 2 1 0
b. I have felt calm and relaxed ………... 5 4 3 2 1 0
c. I have felt active and vigorous ………... 5 4 3 2 1 0
a. I experience a general sense of emptiness ……… Yes No b. There are plenty of people I can rely on when I have problems ……….. Yes No c. There are many people I can trust completely ……….. Yes No d. There are enough people I feel close to ……… Yes No
e. I miss having people around me ………... Yes No
f. I often feel rejected ………... Yes No
7. TECHNOLOGICAL READINESS
We are now finished with the questions on your feelings and physical health. The next set of questions is about the communication devices (technologies) that you might or might not use.
7.1 Access to communication devices
The first questions are in relation to your access to these communication devices.
a. Do you have a landline in your room? ………. Yes No b. If yes to (a), is it prepaid or contract? ………... Prepaid Contract c. If no to (a), do you have access to a landline in the residence? ………... Yes No d. Do you own a cellphone? ………... Yes No e. If yes to (d), does your cellphone allow internet access? ... Yes No f. If yes to (d) is it prepaid or contract? ... Prepaid Contract g. If no to (d) to you have access to a cellphone? ……… Yes No h. Do you own a computer? ……... Yes No i. If yes to (h) is it a desktop, a lap top or a tablet? ……… Desktop Laptop Tablet j. If yes to (h) do you have internet access? ... Yes No k. If yes to (j) is it prepaid or contract? ……… Prepaid Contract l. If yes to (j), is the connectivity through 3G or ADSL? ……… 3G ADSL
7.2 Use of communication devices
In the above section you mentioned the availability of communication devices. This section deals with your ease of use, competency, duration of use, usefulness of use and frequency of use. Please refer to the choices in the top bar in relation to the statement in the left bar.
7.2.1 How easy (confident) is it for you to use each of the items listed below?
Please mark your choice with an X.
Don’t use Very Difficult Easy Very Easy 7.2.2 For how long have you been using each of the items listed below i.e. duration of use? Please mark your
choice with an X. Don’t use Less than 6 months 6 months – 1 year 1 – 2 years More than 2 years
a. Cellphone to make calls a. Cellphone to make calls
b. Cellphone to receive calls b. Cellphone to receive calls
c. Cellphone to send sms c. Cellphone to send sms
d. Cellphone to receive sms d. Cellphone to receive sms
e. Cellphone for instant messaging (e.g.
BBM® or WhatsApp)
e. Cellphone for instant messaging (e.g. BBM® or WhatsApp)
f. Cellphone to video chat (Skype TM) f. Cellphone to video chat (Skype TM) g. Cellphone to receive or send an e-
g. Cellphone to receive or send an e- mail
h. Cellphone for social media e.g.
facebook®
h. Cellphone for social media e.g.
facebook®
i. Cellphone for internet i. Cellphone for internet
j. Cellphone for playing games j. Cellphone for playing games k. Computer to receive e-mails k. Computer to receive e-mails
l. Computer to send e-mails l. Computer to send e-mails
m. Computer to video chat (Skype TM) m. Computer to video chat (Skype TM)
n. Computer for internet n. Computer for internet
o. Computer to play games o. Computer to play games
p. Computer for social media e.g.
facebook®
p. Computer for social media e.g.
facebook®
7.2.3 How useful to you are each of the devices listed below for e.g.
maintain contact or accessing information?
Don’t use Not useful at all Somewhat useful Useful Very useful 7.2.4 How frequently do you use the items listed below? Please mark your choice with an X.
Don’t use Less than Once a year Once a Once a month Once every 2 Once a week 2 – 6 times a Every day
a. Cellphone to make calls a. Cellphone to make calls
b. Cellphone to receive calls b. Cellphone to receive calls
c. Cellphone to send sms c. Cellphone to send sms
d. Cellphone to receive sms d. Cellphone to receive sms
e. Cellphone for instant messaging (e.g. BBM® or WhatsApp)
e. Cellphone for instant messaging (e.g. BBM® or WhatsApp)
f. Cellphone to video chat (Skype
TM)
f. Cellphone to video chat (Skype
TM) g. Cellphone to receive or send an
g. Cellphone to receive or send an e-mail
h. Cellphone for social media e.g.
facebook®
h. Cellphone for social media e.g.
facebook®
i. Cellphone for internet i. Cellphone for internet
j. Cellphone for playing games j. Cellphone for playing games k. Computer to receive e-mails k. Computer to receive e-mails
l. Computer to send e-mails l. Computer to send e-mails
m. Computer to video chat (Skype
TM)
m. Computer to video chat (Skype
TM)
n. Computer for internet n. Computer for internet
o. Computer to play games o. Computer to play games
p. Computer for social media e.g.
facebook®
p. Computer for social media e.g.
facebook®
This next set of questions has statements about technologically assisted communication (TAC) to which you need to choose “yes” or” no.” Mark the relevant box with an X. Examples of technologically assisted communication are SMS, instant messaging (e.g. BBM®, WhatsApp), email, video chat (SkypeTM) or social media (e.g. facebook®)
7.3 Perceived usefulness of technologically assisted communication (TAC)
a. Apart from phone calls, I would be able to contact my family /friends using other TAC ………. Yes No b. I could improve my contact with my family/friend/s by me using TAC ………..………. Yes No c. I could have greater control over my contact with my family / friend/s by me using TAC... Yes No 7.4 Behavioral intention towards technologically assisted communication (TAC)
a. I am already using technologically assisted communication ………. Yes No IF YES to (a), please move to 7.5. If no, please answer b, c and d.
b. I intend to use TAC ………...………..…... Yes No c. I have confidence that I will be able to use TAC ………... Yes No d. People who are important to me think I should use TAC ……….. Yes No 7.5 Attitude towards technologically assisted communication (TAC)
a. It is easy for me to learn something new such as using a new cellphone ……….. Yes No b. I have a positive attitude towards using TAC ……… Yes No c. I like the idea of being able to contact my family / friend/s using TAC………... Yes No d. I am happy to use TAC………... Yes No
7.6 Rating of technologically assisted communication.
a. Which technologically assisted communication generally has the greatest appeal to you (Please mark with a 5 in the box next to your choice)?
b. Which technologically assisted communication generally has the least appeal to you (Please mark with a 1 in the box next to your choice)?
Technologically assisted communication Rating a. E-mail
b. Instant Messaging ( BBM®/ WhatsApp) c. SMS
d. Social media (e.g. facebook®) e. Video chat (SkypeTM)
8. Other comments
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That brings the survey to a close. Thank you very much for both your time and your participation. In three months from now you be invite to an informal feedback session to provide you with the results of the study.