Supplementary Materials: Study Tools

INSPIRE STUDY TOOLS

Cohort profile: Indian Network of Population-Based Surveillance Platforms for Influenza

and Other Respiratory Viruses among the Elderly (INSPIRE)

Anand Krishnan 1 , Lalit Dar 1 , Ritvik Amarchand 1 , Aslesh O Prabhakaran 2 , Rakesh Kumar 1 , Prabu

Rajkumar 3 , Suman Kanungo 4 , Sumit Dutt Bhardwaj 5 , Avinash Choudekar 1 , Varsha Potdar 5 , Alok

Kumar Chakrabarty 4 , Girish Kumar CP 3 , Giridara Gopal P 1 , Shivram Dhakad 1 , Byomkesh

Manna 4 , Ashish Choudhary 1 , Kathryn E Lafond 6 , Eduardo Azziz-Baumgartner 6 , Siddhartha Saha 2

1. All India Institute of Medical Sciences, New Delhi

2. Influenza Division, Centers for Disease Control and Prevention-India Office, New Delhi

3. National Institute of Epidemiology, Chennai

4. National Institute of Cholera and Enteric Diseases, Kolkata

5. National Institute of Virology, Pune

6. Centers for Disease Control and Prevention, Atlanta

Supplementary Materials: Study Tools

For more information contact: [email protected]

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any relianceSupplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Open

doi: 10.1136/bmjopen-2021-052473:e052473. 11 2021;BMJ Open, et al. Krishnan A

INSPIRE STUDY TOOLS

1. Enrolment form

2. Date form filled

3. Form filled by *(Drop down or login id)

4. Name of the village/ ward (drop down list)

5. Allocated household number

6. Address – house number or, landmark

7. Capture the GIS Location Latitude:_________________

Longitude:__________________

8. How many adults aged 60 or more residing for

more than 6 months

(Adminster PIS to each and seek written informed

consent)

9. Total number of elderly individuals consented

10. Phone Numbers of person (non participant)

Landline:

Mobile__Number_

______

(name of the

person)

11. Total number of persons living in the household:

(include everyone from a one day old child onwards)

12. List of individuals in the household ( Age in completed years as on Date of Interview)

Sn

o

Name Age Gende

r

(M/F)

Sn

o

Name Age Gender

(M/F)

1 8

2 9

3 10

4 11

5 12

6 13

7 14



INSPIRE STUDY TOOLS

2. Community Surveillance questionnaire

This is weekly surveillance form to be filled by nurses

Q1 Please select the day

Monday-M

Tuesday-T

Wednesday-W

Thursday-H

Friday-F

Q2 Please select nurse code 1, 2, 3, 4, 5

Q2.1 Please select serial no. as per the day’s route 1 2 3….so on (as per nurses route map)

Does the system date dd/mm/yyyy and csv date dd/mm/yyyy match? If yes tick the check box. If not please check

whether you have selected the correct day and inform programmer- data cannot be collected if the dates do not match.

Q3 Please check name, age and gender displayed

below with that of the participant in this house. If

correct, go to next screen else go to the previous

screen and select the correct house serial no.

Name (DISPLAY FROM csv file )

H.No. (DISPLAY FROM csv file)

Age (DISPLAY FROM csv file)

Gender (DISPLAY FROM csv file)

Q4 Is the Participant available? If not is he/she likely

to return in next 2-3 hours or is the house locked?

Yes at home =1

Not at home but likely to return by 1 pm=2

Participant not available and unlikely to return

today=3

House locked at first visit=4

House locked on second visit=5

Yes at home but refused to provide information=6

If 1 go to Q11

If 2 or 4 return

after 3 hours or

time suggested

by informer

and go for at

least 2 visit

AND FILL

FROM THIS

POINT ON

, if unavailable

go to Q5 and



INSPIRE STUDY TOOLS

after second visit

fill 3 and proceed

If 3 go to Q6

If 5 go to Q86

If 6 note in

logbook and

inform

supervisor and

go to Q86

Q5 Select no: of visit Visit 1

Visit 2

If still

unavailable after

visit 1 and visit 2

,go to Q86

Q6 Ask the participants whereabouts

Participant has died=1

Participant has migrated out/ shifted won’t return =3

Participant is away for last 3 or more days =4

Participant is away for last 1 or 2 days =5

If 1 go to 7

If 3 go to Q8

If 4 and 5 go to

Q9

Q7 Details related

to death

Date of death(Select date from

calendar)

d d m m y y y y

Note this your

logbook and

inform

supervisor and

go to Q86 Place of death In Hospital

Outside Hospital

Do not know

Q8 Details related

to Migration

Date migrated (select date from

calendar)

d d m m y y y y

Note this in your

logbook and

inform

Supervisor and

go to go to Q86 Place migrated to



INSPIRE STUDY TOOLS

Q9 Can the participant be reached on phone? if yes call

and inform purpose of calling

No=1; Yes =2

If 2 go to Q11

Q10 The participant could not be contacted, can you or

someone else present in the house answer questions

about his health in last seven days.

Yes someone who can tell is available=1

No, none of the persons present can provide any

info=2

If 1 go to Q11

and if 2 mark

visit 1 or 2 and

go to Q86

Q11 Informant

Self in person=1

Self (on phone)=2

Another adult=3

If self (1 or 2)

go to Q14

Q12 Name of the adult informant ___________________

Q13 Relationship with participant

Spouse=1; Son=2 ; Daughter=3

Daughter in law=4 ; Adult grandchild =5

Others=6

Go to Q14

Q14 Were you (the participant) hospitalized in last

seven days? Yes=1, No=2

If 2 go to 18

Q15 HOSPITALIZATION

DETAILS

Name of hospital (Note

this in your logbook)

Inform

Supervisor

Address of hospital(Note


Date of admission Note


d d m m y y y y

Reason for admission

(Note in your logbook)



INSPIRE STUDY TOOLS

Q16 Status of Hospitalized Patient(Note this in your

logbook)

Still in Hospital=1,Discharged=2 If 1 inform

supervisor and

go to Q86

Q17 Date of discharge (Select date from calendar)(note


d d m m y y y y

Now I am going to ask you about respiratory systems in last seven days

Q18 Last week when I visited you had informed that

cough was “Present /Absent” (will be automatically displayed )

(this will be prefilled and

“PRESENT ” will display When participant was visited last week and

he/ she had cough)

if displays

Absent, go to Q

21

Q19 Has that cough ended?

Yes=1, No=2

If 2 go to Q25

Q20 Date of end of cough (Select date from calendar) d d m m y y y y

Write date and

Go to Q55

Q21 Did you (the participant) have cough in last seven

days? Yes=1, No=2

If 2 Go to Q55

Q22 Date of start of cough d d m m y y y y

Q23 Has cough ended?

Yes=1, No=2

If 2 go to Q28

Q24 Date of end of cough d d m m y y y y

Go to Q55

Q 25 Last week when I visited you had informed that

sputum was “Present /Absent” (will be automatically displayed )


“PRESENT ” will display When participant was visited last week he/

she had sputum associated with

cough)

If Absent go to Q

30

Q26 Has that sputum ended? Yes=1 No=2

If 2 go to Q32

Q27 Date of end of sputum (select date from calendar) d d m m y y y y

Write the date

and Go to Q55

Q28

Did you (the participant) have sputum in last seven

days?

Yes=1; No=2

If 2 go to Q55



INSPIRE STUDY TOOLS

Q29 Date of start of sputum (select date from calendar) d d m m y y y y

Q30 Has the sputum ended? Yes=1 No=2

If 2 go to Q37

Q31 Date of end of sputum (select date from calendar) d d m m y y y y

Write the date

and Go to Q55

Q32 Last week when I visited you had informed that an

increased volume of sputum was “Present /Absent” (will be automatically displayed )



she had an increased volume of

sputum was)

If Absent go to

Q35

Q33 Has that increased volume of sputum come back to

usual level? Yes=1 No=2

If 2 go to Q39

Q34 Date the volume of sputum associated with cough

came back to usual level (select date from

calendar)

d d m m y y y y

go to Q39

Q35 Has the volume of sputum increased in last seven

days level? Yes=1 No=2

If 2 go to Q39 or

Q42

Q36 Date on which the volume of sputum increased

over its usual level (select date from calendar)

d d m m y y y y

Q37 Has the volume of sputum come back to usual

level? Yes=1 No=2

If 2 go to Q39 or

Q42

Q38 Date the increased volume of sputum associated

with cough came back to usual level (select date

from calendar)

d d m m y y y y

Go to Q42

Q39

Last week when I visited you had informed that an

change in color of sputum was “Present /Absent” (will be automatically displayed )



she had an change in color of

sputum)

If Absent go to

Q42

Q40

Has the sputum color returned to its usual color?

Yes=1 , No=2

If 2 go to Q46

Q41

DATE on which the sputum returned to its usual

color? (select date from calendar)

d d m m y y y y

Go to Q46



INSPIRE STUDY TOOLS

Q42 Did you (the participant) notice a change from

usual in color of sputum in last seven days?

Yes=1 No=2

If 2 go to Q46 or

Q49

Q43 Date the change in sputum color was noticed? d d m m y y y y

Q44 Has the sputum returned to its usual color?

Yes=1; No=2

If 2 go to Q45 or

Q49

Q45 Date the sputum color came back to its usual color d d m m y y y y

Go to Q49

Q46

Last week when I visited you had informed that

blood was “Present /Absent” (will be automatically displayed )


“PRESENT” will display When participant was visited last week he/

she had blood in sputum)

If Absent go to

Q49

Q47

Has the blood cleared from sputum? Yes=1 No=2

If 2 go to Q 53

Q48 Date blood cleared from sputum (select date from

calendar)

d d m m y y y y

Go to Q 53

Q49 Did you (the participant) notice blood in sputum in

last seven days? Yes=1, No=2

If 2 go to Q53

Q50 Date from which blood was noticed in sputum d d m m y y y y

Q51 Has the blood cleared from sputum?

Yes=1, No=2

If 2 go to Q53

Q52 Date blood cleared from sputum d d m m y y y y

Q53 Last week when I visited you had informed that

difficulty in Breathing was “Present /Absent” (will be automatically displayed )

(this will be prefilled and PRESENT

will display when participant was

visited last week he/ she had

difficulty in breathing

If Absent skip to

Q 56

Q54 Has that difficulty in breathing ended?

Yes=1, No=2

If 2 go to Q60



INSPIRE STUDY TOOLS

Q55 Date of end of difficulty in breathing d d m m y y y y

Write date and

Go to Q 62

Q56 Did you have difficulty in breathing in the last

seven days? Yes =1; No= 2

If 2 Go to Q 62

Q57 Date of start of difficulty in breathing select date

from calendar)

d d m m y y y y

Q58 Has difficulty in breathing ended?

Yes=1, No=2

If 2 go to Q60

Q59 Date of end of difficulty in breathing d d m m y y y y

Q60 Is there chest pain associated with difficulty in

breathing?

Yes=1, No=2

If 2 Go to Q62

Q61 Does the chest pain increase with respiration?

Yes=1, No=2

If 2 Go to Q62

Q62

Last week when I visited you had informed that

fever was “Present /Absent” (will be automatically

displayed )

(this will be prefilled and PRESENT

will display when participant was

visited last week he/ she had fever

If Absent go to

Q65

Q63 Has that fever ended? Yes=1, No=2

If 2 got to Q70

Q64 Date of end of fever (select date from calendar) d d m m y y y y

Write date and

go to Q70

Q65 Did you have fever in last seven days?

Yes =1; No= 2

If 2go to Q70

Q66 Date of start of fever d d m m y y y y

Q67 Has that fever ended? Yes=1, No=2

If 2go to Q70

Q68 Date of end of fever (select date from calendar) d d m m y y y y

Q69 Did you have chill and Rigor in last seven days ?

Yes = 1 ; No = 2

Q71 Did you have malaise in last seven days?

Yes =1; No= 2



INSPIRE STUDY TOOLS

Q72 Did you have headache in last seven days?

Yes =1; No= 2

Q73 Did you have muscle pain in last seven days?

Yes =1; No= 2

If participant reports respiratory symptoms in last seven days proceed for clinical assessment

IF any of these are reported afresh in last seven days ( cough/ difficulty in breathing / sore throat or, nasal

discharge ) or persistent cough ( continued from last week) with ( sputum with cough/ increase in volume of

sputum/ change in color of sputum/ blood in sputum) or persistent cough ( continued from last week) with

fever in last seven days or, persistent difficulty in breathing ( continued from last seven days) with (fever in

last seven days or, chest pain associated with difficulty in breathing )

Clinical Assessment

Q 74 Temperature (Axillary) (In Fahrenheit) .

Q75

Pulse rate (per minute – count for one minute)

Q76 Respiratory Rate (count for a minute)

Q77 Oxygen Saturation

(Read after 1 minute )

Q 78 Auscultation Findings

a) Crepitation

Yes =1; No= 2

b) Rhonchi

Yes =1; No= 2

c) Reduced air entry

Yes =1; No= 2

Others ______(specify)_________



INSPIRE STUDY TOOLS

Q79 If patient is classified as ALRI(will be automatically displayed )

(Presence of symptoms of an acute lower respiratory tract illness i.e. cough and at least one other lower

respiratory tract symptom (dyspnea, chest pain) AND at least one systemic feature (sweating, fevers, shivers,

aches and pains and/or temperature of 38° C or more) AND tachypnea (respiratory rate> 20).

Proceed and collect a nasal and a throat swab. Go to Q.95 and Q 96

Q80 If patient is classified as AURI (for those not classified as ALRI, will be automatically displayed )

and today is your designated day to collect samples take a nasal and a throat swab

Q 81 Was Nasal swab collected?

This was not the designated day =1

Yes =2; No= 3 Refused to provide swab=8

If 1 go to go to

Q85

If 2 , 3 or 8 go to

Q85

Q82 Was throat swab collected?

This was not the designated day =1

Yes =2; No= 3 Refused to provide swab =8

If either nasal or

throat swab is

taken go to 83

Else go to 85

Q83 Scan the barcode used for the samples

Get Barcode

Q84 SAMPLE ID ALLOCATED

(Bar Code Number)

Q85 For the ongoing /previous ARI episode did you

(the participant) visit any : 1 PUBLIC HEALTH SECTOR

(modern system)

2) PRIVATE HEALTH SECTOR

(modern system)

3 OTHER (specify)

Q86

Outcome

Select either a or b and save the

form

a)Form completed

b)Need to return to fill the form

If algorithm suggests use of antibiotics/ PCM/ Referral please follow the directions

Handheld screen will display the directions as per the algorithm



INSPIRE STUDY TOOLS

3. Baseline Household form

1 Date form filled (automatically generated by system)

2 ID of the person filling the form (interviewer code) -2 digits

3 Please select city code (select one –radio button)

4 Please select area code (Two digit)

(Ward/ village code)

5

Please enter the allocated structure number (4 Digits followed by 1 alphabet) in three centers the

alphabet is fixed as A as the mapping has happened for the first time

6 Please enter the allocated household number (as per list of households in each structure) (Two

digit)

If for any question respondent refuses to answer / let the worker observe write 8/88

7 What is the MAIN source of drinking water for

your household most of the time of the year?

Piped water in own house =01 ,

Piped water from community pipe =02

Hand pump=03, Tube well= 04,

Dug well =05,Bottled water=06 ,

Tanker truck=07Surface Water=11,

Others=12Specify_________

8 Do you treat water before drinking in all seasons? Yes= 1, No=2

9 If Yes, mention how does your household mostly

treat your drinking water?

Boiling =01, Filtering by cloth =02, Using

candle filter =03, Adding Chlorine

Solution/tablet =04, Aquaguard=05,

Reverse Osmosis =06, Others =07Specify

10 What is the MAIN source of water used by your

household for purposes other than drinking such

as cooking most of the time of the year?

Piped water in own house =01,

Piped water from community pipe =02

Hand pump=03, Tube well= 04,

Dug well =05, Bottled water = 06,

Tanker truck =07, Surface Water=11,

Others=12Specify ___________

11 What kind of toilet facility do members of your

family usually use

Water Seal latrine =01; Pit Latrine =02, Dry

Latrine =03,

No facility/uses open space or field =4

If choice =4 go to Q7

12 Do you share this toilet facility with other

households

Open Fire =01, Chullah=2 , Improved

Stove=3,=4 ,Induction plate/ Electric Heater

=5,

Gas Stove =6 ; Kerosene stove=7, OthersSpecify=11_________

13 What type of stove is usually used for cooking? Open Fire=01, Chullah=2 , Improved

Stove=4 ,Induction plate/ Electric Heater

=5,

Gas Stove=6 ; Kerosene stove=7, OthersSpecify=11_________

14 Does your household have a hand washing

facility?

Yes= 1, No=2

15 If yes then is water available there? Yes= 1, No=2

16 If yes then is soap available there? Yes= 1, No=2



INSPIRE STUDY TOOLS

Record your observation regarding the built of the floor, roof and walls of the household.

17 MAIN material of the floor Mud/clay/earth/cow dung=1, Unburnt

brick/stone=2

Bricks/Concrete/tiles/marble=3,

Others = 04(specify) _________________

18 MAIN material of the roof Thatched/Leaves/Mud/polythene sheet =1,

Unburnt brick/stone slab/ wooden planks/

Bamboo =2, Cement/Concrete/Asbestos

sheet/ tiles/Burnt brick, Others =

04(specify)_________________

19 MAIN material of exterior walls Thatched/Leaves/Mud/polythene sheet=1,

Stone with mud/mud brick/ wooden

planks=2, Concrete/Burnt brick/Asbestos

sheets =3 Others =

04(specify)_________________

Ask and note the detail about rooms and their ventilation

20 What is the total number of rooms in the house

used by your household?

Room

21 Do you use a separate kitchen for cooking, or do

you use part of another room for cooking food or

do you cook in open space outside the house?

Cook in a separate kitchen =1

Use part of another room for cooking =2

Cook in open space outside the house=3

22 Is there proper ventilation most of the time in

rooms used for sleeping and living room (observe

possibility of cross ventilation/ ask if need be)

Yes= 1, No=2

23 How is the ventilation at the place used for

cooking ?

Room/ Kitchen with eave spaces affording

some ventilation=2

Room/ Kitchen with open Windows/door

affording good ventilation=3

Veranda/ Partially open space=4

Outdoors=5If choice is 4 or 5 go to Q20

Ask for the ownership of immovable and movable assets of the family

24 Does this household own this or any other house? Yes= 1, No=2

25 Does this household own any land? Yes= 1, No=2

26 If yes, how much? Specify (Acres or another size/unit) ________

27 What is the type of your electricity connection? Metered=01, Unmetered=02, No

connection=03

28 Ownership of animals or Birds? Yes= 1, No=2

29 If yes, which of these animals or birds Yes= 1, No=2

Cows/ Buffalo

Horse/donkey/mule/ Bull

Goats/Sheep

Pig

Poultry(Hen/Fowl/Duck/Pigeon/Parrot)

Others (specify) अन्य(बताय)े_________________

30 Do you have the following items in your household? Yes owns = 1, No does not own =2

Desert cooler Pressure cooker

Air conditioner Mattress

Computer Chair

Refrigerator Cot/bed

Radio/transistor Table



INSPIRE STUDY TOOLS

B & W television Mobile telephone

Colour television Any other telephone

Watch/clock Animal-drawn cart

Sewing machine Car

Bicycle Water pump

Motorcycle/scooter Thresher

Electric fan Tractor

31 Does any member has a bank account/post office

account?

Yes= 1, No=2, Don’t know=3

32 What is the type of ration card that this household

has?

APL=1 , BPL=2, Antodaya =3, None

=4 DNK=7

No response/ do not want to tell =8

33 What all type of fuel does your household use for cooking tell all the fuels that are used? (multiple

option)( fill Yes= 1, No=2 for each option)

Charcoal Electricity

Straw/ Shrubs/ Grass/Crop waste LPG Gas

Coal Biogas

Dung Cakes Kerosene

Wood Othersअन्यspecify___________

35 Which is the main fuel used for cooking? 1. Charcoal

2. Straw/ Shrubs/ Grass/Crop waste

3. Coal

4. Dung Cakes

5. Wood

6. Electricity

7. LPG Gas

8. Biogas

9. Kerosene

36 What all type of fuels does your family use for heating water or heating room in winters?

(multiple option)( fill Yes= 1, No=2 for each option)

Charcoal Electricity

Straw/ Shrubs/ Grass/Crop waste LPG Gas

Coal Biogas

Dung Cakes Kerosene

Wood Othersअन्यspecify___________

37 Does anyone living in this household regularly

smoke cigarette, bidis, hukkahs or other tobacco

products inside the home?

Yes =1 , No =2 , Do Not Know=7

No response/ do not want to tell =8

38 Number of children aged less than 5 years living

in the house?

39 Number children aged less than 18 years living in

the house who go to school?



INSPIRE STUDY TOOLS

4. Baseline Individual form

Individual ID

Data Collected By: (drop down)

Date Form Filled: (dd/mm/yyyy) ___ ___ / ___ ___ / ___ ___ ___ ___

1. Name of the participant gender and age

would be displayed

2. Please tell me your current marital

Status

Never married=1Married =2Widow/widower= 3 Divorced or separated =4 Do not want to tell = 8

3. Please tell the number of years you

spent attaining education

Years

4. Currently employed in any income

generating activities Yes=1 No=2

5. If yes, what is your current occupation

6. If No, what was your last occupation

7. Are you receiving any pension? None=1 Old age=2 Post retirement =3

8. Do you currently have any have health

insurance?

Yes=1 No=2

8.1 If yes for 8, specify

1. ESI

2. CGHS

3. Community Health insurance

4. Reimbursement from employer

5. Private Purchased

6. Insurance through employer

7. RSBY

8. Others (Specify)----------

9. Aadhar No (Write 7777-7777-7777 if

do not have Aadhar card, Write 8888-

8888-8888 if do not want to share

Aadhar details

10. Contact Number

(Note the number of the elderly individual)

Pre-existing Health Conditions and treatment

Now I will ask you about some chronic health conditions please let me know if you suffer from them.

( For each health problem that the participant responds as yes ask whether he/ she is on treatment for the same )

11.Have you ever been told by a healthcare

provider that they you suffer from :

Options

Yes=1 No=2

Do not Know=7

For each of the condition

for which participant says

yes he/ she is suffering

from this askes, are you

currently receiving

Options

Yes=1 No=2

Do not Know=7

11.1 Diabetes



INSPIRE STUDY TOOLS

11.2 High Blood Pressure treatment or taking

medication for this

condition?

11.3 Heart Condition

11.4 Chronic Liver disease

11.5 Stroke/CVA

11.6 HIV/AIDS

11.7 Chronic Kidney disease

11.8 Tuberculosis

11.9 Chronic respiratory disease

11.10 Malignancy

11.11 Arthritis

11.12 Anemia

11.13 Depression

11.14 Other conditions lasting for more than

6 months (specify below):

________________

11.15 Do you have any problems related to

vision ?( distant/ near )Yes=1 No =2

11.16 Do you find any difficulty in hearing?

Yes=1 No=2

11.17 Is your physical movement restricted ?

Yes=1 No=2

12 Are you currently under treatment for chronic treatment?

Yes=1 No=2

12.1 If yes to 12, are you taking oral or systemic steroids for

treatment?

Yes=1 No=2

13 Have you received any vaccine in last one year? Yes=1 No=2 If yes go to 13.1

If no goto 14

13.1 If yes to 13, list the vaccines 1.__________

2.__________

14 Lifestyle factors



INSPIRE STUDY TOOLS

14.1 Do you currently smoke tobacco on daily basis? Yes=1 No=2

14.2Have you smoked tobacco daily in past? Yes=1 No=2

14.3 Do you currently use smokeless tobacco on a daily

basis?

Yes=1 No=2

14.4Have you used smokeless tobacco daily in past? Yes=1 No=2

14.5 Do you usually drink alcohol more than once a week? Yes=1 No=2

14.5 Have you worked in place where you were exposed to

dust, smoke or fumes for prolonged period of time in last 10

years

Yes=1 No=2

14.7 Have you been exposed to household smoke in last 10

years

Yes=1 No=2

14.8 How often do you wash your hand with soap in a day

1. 2-3 times

2. At least once in a dayl

3. Never

Social Capital

Q How frequently do you socialize with family or friends

who are not living with you in this house? 1-once in a week or more

0-otherwise

Q How frequently do you socialize with neighbours? 1-once in a week or more

0-otherwise

Q How frequently do you attend religious or social events? 1-once in a week or more

0-otherwise

Q In past 3 months, did you lose any close family member or

friends?

या हैं ?

1 - Yes

2 – No

Q When you need help can you count on someone from the

following who is willing and able to help you :

1 Spouse

0-Never

1-sometimes

2-yes always

3-Not Applicable

2 Family member

2-yes always

1-sometimes

0-Never

3 Friends/Neighbours

2-yes always

1-sometimes

0-Never

Q How often do you open up to the following about your

personal problems:



INSPIRE STUDY TOOLS

1 Spouse

0-hardly ever

1-Sometimes

2-Often

3-Not Applicable

2 Family member

0-hardly ever

1-Sometimes

2-Often

3 Friends/Neighbours

0-hardly ever

1-Sometimes

2-Often

Social Capital

Q How frequently do you socialize with family or friends

who are not living with you in this house? 1-once in a week or more

0-otherwise

Q How frequently do you socialize with neighbours? 1-once in a week or more

0-otherwise

Q How frequently do you attend religious or social events? 1-once in a week or more

0-otherwise

Q In past 3 months, did you lose any close family member or

friends?

या हैं ?

1 - Yes

2 – No

Q When you need help can you count on someone from the

following who is willing and able to help you :

1 Spouse

0-Never

1-sometimes

2-yes always

3-Not Applicable

2 Family member

2-yes always

1-sometimes

0-Never

Physical measurements

16.Anthropometry

Now we want to measure your weight - could you please keep your shoes off and step on this scale.

15.1Weight (in kilograms)

I would now like to measure how tall you are. To measure your height I need you to please take off your shoes. Put your

feet and heels close together, stand straight and look forward standing with your back, head and heels touching the wall.

Look straight ahead.

15.2 Height (in centimetres)

15.3 Arm span (in centimetres)



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16. Grip strength

16.1 Have you had any surgery on your left arm, hand or

wrist in the last 3 months OR arthritis or pain in your left

hand or wrist?

1 YES -> DO NOT TEST LEFT HAND

2 NO

16.2 Have you had any surgery on your right arm, hand or

wrist in the last 3 months OR arthritis or pain in your right

hand or wrist?

1 YES -> DO NOT TEST RIGHT HAND

2 NO

16.3 Which hand do you consider your dominant hand?

Dominant Hand - Check one answer. If a respondent is

ambidextrous, the hand that is used for signing/writing is

considered the dominant hand.

1 LEFT

2 RIGHT

3 USE BOTH THE SAME

Remain sitting and let your hand drop to your side. Keep your upper arm against your body and bend your elbow to 90

degrees with palm facing in (like shaking hands). Keep your elbow pressed against your side.( DEMONSTRATE.)

Then grab the two pieces of metal together like this. (DEMONSTRATE).

I will ask you to do this two times in each hand. Let’s start with your left hand, please take this in your left hand. If you

feel any pain or discomfort, tell me and we will stop. When I say "squeeze", squeeze as hard as you can.

(INTERVIEWER: Check positioning and grip to make sure it is correct. WHEN HE OR SHE BEGINS, SAY: SQUEEZE,

SQUEEZE,)

Ready? Squeeze, squeeze, squeeze!

16.4 Grip strength-First test left hand (in Kg)

16.5 Grip strength-Second test left hand (in Kg)

16.6 Grip strength-First test right hand (in Kg)

16.7 Grip strength-Second test right hand(in Kg)

17 Frailty assessment

17.1 Please imagine that this pre-drawn circle is a clock.

I would like you to place the numbers in the correct positions

then place the hands to indicate a time of ‘ten after eleven’

0-No error

1-Minor spacing error

2. Other error

17.2 In the past year, how many times have you been

admitted to a hospital? 0-Zero

1-one to two

2. More than two

17.3 In general, how would you describe your health? 0-Excellent, very good, good

1-fair

2. Poor

17.4 How many of the following activity do you need help? 0-No, 1-Yes

17.4.1 Meal preparation

0-No, 1-Yes



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17.4.2 Shopping,

0-No, 1-Yes

17.4.3 Transportation

0-No, 1-Yes

17.4.4 Telephone

0-No, 1-Yes

17.4.5 Housekeeping

0-No, 1-Yes

17.4.6 Laundry

0-No, 1-Yes

17.4.7 Managing money 0-No, 1-Yes

17.4.8 Taking medications 0-No, 1-Yes

17.5 When you need help, can you count on someone

who is willing and able to meet your needs? 0-Always

1-Sometimes

2. Never

17.6 Do you use five or more different prescription

medications on a regular basis?

0-No, 1-Yes

17.7 At times, do you forget to take your prescription

medications?

0-No, 1-Yes

17.8 Have you recently lost weight such that your clothing

has become looser? 0-No, 1-Yes

17.9 Do you often feel sad or depressed? 0-No, 1-Yes

17.10 Do you have a problem with losing control of urine

when you don’t want to? 0-No, 1-Yes

17.11 I would like you to sit in this chair with your back and

arms resting. Then, when I say ‘GO’, please stand up and walk at a safe and comfortable pace

to the mark on the floor (approximately 3 m away), return to

the chair and sit down’

0- Zero to 10 sec

1- 11 to 20 sec

2- >20 sec or unwilling or require assistance



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5. Frailty follow-up assessment questionnaire

Individual ID

Data Collected By: (drop down)

Date Form Filled: (dd/mm/yyyy) ___ ___ / ___ ___ / ___ ___ ___ ___

11. Name of the participant gender and age

would be displayed

2.1 In past 3 months did you suffer from or had been diagnosed with any acute

illness (1- Yes, 2-No)

2.2 If yes,

duration of

illness

(in days)

2.3 Were you

hospitalized

(1- Yes, 2-No)

2.1.1 Acute respiratory illness (upper or lower respiratory infections,

exacerbation of asthma or COPD, pneumothorax etc)

2.1.2 Acute gastro intestinal illness (diarrheal disease, typhoid,

gastritis, hepatitis, pancreatitis, appendicitis

2.1.3 Acute Uro-genital illness (urinary tract infections)

2.1.4 Acute musculo-skeletal illness (

2.1.5 Acute cardiac vascular diseases (Myocardial infarction, stroke

etc)

2.1.6 Others (specify)

2.1.7 In past 3 months did you suffer from any injury, accidents or fall

3 In past 3 months did you undergo any elective or emergency

surgical procedure 1- Yes, 2-No

4 In past 3 months, did you lose any close family member or friends? 1- Yes, 2-No

5. In past 3 months had been diagnosed with any Chronic conditions

(1- Yes, 2-No)

5.1 Diabetes 5.7 Chronic Kidney disease

5.2 High Blood Pressure 5.8 Tuberculosis

5.3 Heart Condition 5.9 Chronic respiratory disease

5.4 Chronic Liver disease 5.10 Malignancy

5.5 HIV/AIDS 11.11 Arthritis

5.6 Depression



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6. Frailty assessment

6.1 Please imagine that this pre-drawn circle is a clock.

I would like you to place the numbers in the correct positions then place the hands

to indicate a time of ‘ten after eleven’

0-No error

1-Minor spacing error

2. Other error

6.2 In the past year, how many times have you been admitted to a hospital? 0-Zero

1-one to two

2. More than two

6.3 In general, how would you describe your health? 0-Excellent, very good, good

1-fair

2. Poor

6.4 How many of the following activity do you need help? 0-No, 1-Yes

6.4.1 Meal preparation

0-No, 1-Yes

6.4.2 Shopping,

0-No, 1-Yes

6.4.3 Transportation

0-No, 1-Yes

6.4.4 Telephone

0-No, 1-Yes

6.4.5 Housekeeping

0-No, 1-Yes

6.4.6 Laundry

0-No, 1-Yes

6.4.7 Managing money 0-No, 1-Yes

6.4.8 Taking medications 0-No, 1-Yes

6.5 When you need help, can you count on someone who is willing and able to

meet your needs?

0-Always

1-Sometimes

2. Never

6.6 Do you use five or more different prescription medications on a regular basis? 0-No, 1-Yes

6.7 At times, do you forget to take your prescription medications? 0-No, 1-Yes

6.8 Have you recently lost weight such that your clothing has become looser? 0-No, 1-Yes



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6.9 Do you often feel sad or depressed? 0-No, 1-Yes

6.10 Do you have a problem with losing control of urine

when you don’t want to? 0-No, 1-Yes

6.11 I would like you to sit in this chair with your back and arms resting. Then,

when I say ‘GO’, please stand up and walk at a safe and comfortable pace

to the mark on the floor (approximately 3 m away), return to the chair and sit

down’

3- Zero to 10 secons

4- 5 to 20 sec

5- >20 sec or unwilling or

require assistance

7. Grip strength

7.1 Have you had any surgery on your left arm, hand or wrist in the last 3 months

OR arthritis or pain in your left hand or wrist?

1 Yes -> do not test left hand

2 No

7.2 Have you had any surgery on your right arm, hand or wrist in the last 3 months

OR arthritis or pain in your right hand or wrist?

1 Yes -> do not test right hand

2 No

7.3 Which hand do you consider your dominant hand? Dominant Hand - Check one

answer. If a respondent is ambidextrous, the hand that is used for signing/writing is

considered the dominant hand.

1 Left

2 Right

3 Use both the same

Remain sitting and let your hand drop to your side. Keep your upper arm against your body and bend your elbow to 90

degrees with palm facing in (like shaking hands). Keep your elbow pressed against your side. ( DEMONSTRATE.)

Then grab the two pieces of metal together like this. (DEMONSTRATE).

I will ask you to do this two times in each hand. Let’s start with your left hand, please take this in your left hand. If you

feel any pain or discomfort, tell me and we will stop. When I say "squeeze", squeeze as hard as you can.

(INTERVIEWER: Check positioning and grip to make sure it is correct. WHEN HE OR SHE BEGINS, SAY: SQUEEZE,

SQUEEZE,)

Ready? Squeeze, squeeze, squeeze!

7.4 Grip strength-First test left hand (in Kg)

7.5 Grip strength-Second test left hand (in Kg)

7.6 Grip strength-First test right hand (in Kg)

7.7 Grip strength-Second test right hand(in Kg)



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6. Cost Data Collection

A

B

C

D

E

F

Onset date of the episode (X)

Type of Care -

Non medically

attended/

Emergency/OPD/

IPD/ICU

Place of

treatment

(Private/Public/

Secondary/

Tertiary)

Direct medical cost Direct non-medical cost Indirect cost

End date of the episode (Y) Medication Consultation Investigation Transport Lodging Food

Care

giver Self

X

-

-

-

-

-

-

-

-

-

-

Y



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Documents

Supplementary Materials: Study Tools