ANGOLA MALARIA INDICATOR SURVEY HOUSEHOLD QUESTIONNAIRE
COSEP - CONSULTORIA, LDA / CONSAUDE
PLACE NAME
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER
REGION
URBAN/RURAL
RURAL 2
MALARIA ENDEMIC REGION
Mesoendemic Stable (Zaire, Luanda, Bengo, Benguela, K. Sul, Huambo, Bié) 2
Mesoendemic Unstable (Moxico, K. Kubango, Kunene, Huila, Namibe) 3
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT
HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT
HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
TOTAL NO. OF VISITS
TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
NAME
DATE
OFFICE EDITOR
KEYED BY
Hello. My name is and I am working with (NAME OF ORGANIZATION). We are conducting a national survey about malaria. We would very much appreciate your participation in this survey. The information you provide will help the government to plan health services. The survey usually takes about 20 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.
Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey?
May I begin the interview now?
Signature of interviewer: ____
Date: ___
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
Now we would like some information about the people who usually live in your household or who are staying with you now
1. LINE NO.
2. Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.
RELATIONSHIP TO HEAD OF HOUSEHOLD
3. What is the relationship of (NAME) to the head of the household?
WIFE/HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER/ STEPCHILD 10
NOT RELATED 11
DON'T KNOW 98
4. Is (NAME) male or female?
FEMALE 2
5. Does (NAME) usually live here?
NO 2
6. Did (NAME) stay here last night?
NO 2
7. How old is (NAME)?
8. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
9. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5 YEARS
TICK HERE IF CONTINUATION SHEET USED
Just to make sure that I have a complete listing:
1.) Are there any other persons such as small children or infants that we have not listed?
NO
2.) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?
NO
3.) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
10. What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL 81
BOTTLED WATER 91
OTHER (SPECIFY) 96
11. What kind of toilet facilities does your household use? "Permanent" is a factory treated net that does not require any further treatment.
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61
OTHER 96
Public electricity?
NO 2
Alternative source of electricity (generator; solar panel)?
NO 2
A radio?
NO 2
A television?
NO 2
A telephone (fixed or mobile)?
NO 2
A refrigerator?
NO 2
13. What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02
OIL 03
FIREWOOD 04
COAL 05
STRAW 06
DUNG 07
OTHER (SPECIFY) 96
14. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) 96
15. Does any member of your household own:
A bicycle?
NO 2
A motorcycle or motor scooter?
NO 2
A car or truck?
NO 2
A wagon?
NO 2
A horse/donkey?
NO 2
15A. At any time in the past 12 months, has anyone sprayed the interior walls of your dwelling against mosquitoes?
NO 2 (GO TO 16)
DON'T KNOW 8 (GO TO 16)
15B. How many months ago was the house sprayed? IF LESS THAN ONE MONTH, RECORD '00' MONTHS AGO
15C. Who sprayed the house? "Pretreated" is a net that has been pretreated, but requires further treatment after 6-12 months.
PRIVATE COMPANY (NAME OF COMPANY, IF KNOWN) 2
HOUSEHOLD MEMBER 3
OTHER (SPECIFY) 6
DON'T KNOW 8
16. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 27)
17. How many mosquito nets does your household have? IF 7 OR MORE NETS, RECORD '7'.
18. ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. IF MORE THAN THREE NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
19. How long ago did your household obtain the mosquito net?
MORE THAN 3 YEARS AGO 95
19a. (IF BETWEEN 0 AND 6 MONTHS) Did you obtain this mosquito net during the "Viva a vida com saúde" campaign?
NO 2
DON'T KNOW 8
20. OBSERVE OR ASK THE BRAND OF MOSQUITO NET. IF BRAND IS UNKNOWN, AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.
PERMANET 12 (SKIP TO 24)
JOIA 16 (SKIP TO 24)
OTHER/DON'T KNOW BRAND 17 (SKIP TO 24)
BRAND D 22 (SKIP TO 22)
OTHER (SPECIFY) 26 (SKIP TO 22)
DON'T KNOW BRAND 98
21. When you got the net, was it already factory-treated with an insecticide to kill or repel mosquitos?
NO 2
NOT SURE 8
22. Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitoes or bugs?
NO 2 (SKIP TO 24)
NOT SURE 8 (SKIP TO 24)
23. How long ago was the net last soaked or dipped? IF LESS THAN 1 MONTH AGO, RECORD '00' MONTHS. IF LESS THAN 2 YEARS AGO, RECORD MONTHS AGO. IF '12 MONTHS AGO' OR '1 YEAR AGO,' PROBE FOR EXACT NUMBER OF MONTHS.
MORE THAN 2 YEARS AGO 95
NOT SURE 98
24. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 26)
NOT SURE 8 (SKIP TO 26)
25. Who slept under this mosquito net last night? RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NO. ___
26. GO BACK TO 18 FOR NEXT NET; OR, IF NO MORE NETS, VERIFY IN HOUSEHOLD LISTING THE ELIGIBLE WOMEN, AND START A NEW INDIVIDUAL WOMAN'S QUESTIONNAIRE WITH EACH ELIGIBLE WOMAN.
HEMOGLOBIN MEASUREMENT FOR CHILDREN UNDER 5 YEARS
CHECK COLUMN (7) OF HOUSEHOLD LISTING: RECORD THE LINE NUMBER, NAME AND AGE OF ALL CHILDREN UNDER 5 YEARS. THEN ASK THE DATE OF BIRTH
27. LINE NUMBER FROM COL. 1
30. What is (NAME's) date of birth? FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR
31. CHECK HERE IF CHILD IS ELIGBLE FOR MEASUREMENT (AGE 6-59 MONTHS)
HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN 2001 OR LATER
32. LINE NUMBER OF PARENT/ADULT RESPONSIBLE FOR THE CHILD. RECORD '00' IF NOT LISTED IN HOUHSEHOLD SCHEDULE
33. READ CONSENT STATEMENT TO PARENT/ADULT RESPONSIBLE FOR THE CHILD. CIRCLE CODE AND SIGN
REFUSED (SIGN) 2
NOT PRESENT 2
REFUSED 3
OTHER (SPECIFY) 4
IF 2-4, GO TO NEXT.
35. HEMOGLOBIN LEVEL (G/DL) ___
36. CHECK 34: NUMBER OF CHILDREN WITH HEMOGLOBIN LEVEL BELOW 7 G/DL
NONE (GIVE EACH PARENT/ADULT RESPONSIBLE FOR THE CHILD THE RESULT OF THE HEMOGLOBIN MEASUREMENT AND END THE HOUSEHOLD INTERVIEW.)
37. We detected a low level of hemoglobin in the blood of [NAME OF CHILD(REN)]. This indicates that (NAME OF CHILD(REN) has/have developed severe anemia, which is a serious health problem. We suggest you go to ______________ [THE NEAREST HEALTH FACILITY] to receive appropriate treatment for [NAME OF CHILD(REN)] condition. Do you agree to go to that facility to have [NAME OF CHILD(REN)'S] anemia treated?
NAME OF CHILD WITH HEMOGLOBIN BELOW 7 G/DL
NAME OF PARENT/RESPONSIBLE ADULT
AGREES TO REFERRAL?
NO 2
HEMOGLOBIN MEASUREMENT FOR WOMEN 15-49 YEARS
CHECK COLUMN (7) OF HOUSEHOLD LISTING: RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN 15-49 YEARS OLD. THEN ASK THE DATE OF BIRTH
38. LINE NUMBER FROM COL. 1
NO 2
42. LINE NUMBER OF PARENT/ADULT RESPONSIBLE FOR THE WOMAN (FOR UNDER 18) RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE
43. READ CONSENT STATEMENT TO WOMAN OR PARENT/ADULT RESPONSIBLE FOR THE WOMAN UNDER 18 CIRCLE CODE AND SIGN
REFUSED (SIGN) 2
NOT PRESENT 2
REFUSED 3
OTHER (SPECIFY) 4
IF 2-4, GO TO NEXT.
45. HEMOGLOBIN LEVEL (G/DL) ___
TICK HERE IF CONTINUATION SHEET USED
CONSENT STATEMENT: As part of this survey, we are studying anemia among women between 15-49 years old. Anemia is a serious health problem that results from poor nutrition or diseases such as malaria. This survey will assist the government to develop programs to prevent and treat these important health problems. We request that all women aged 15-49 years participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential. May I now ask that (NAME OF WOMEN) participate in the anemia test. However, if you decide not to get tested [or have her/them tested], it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
NUMBER OF WOMEN 15-49 YEARS WITH HEMOGLOBIN LEVEL BELOW 7 G/DL
NONE (GIVE EACH WOMAN [PARENT/ADULT RESPONSIBLE FOR THE WOMAN] THE RESULT OF THE HB MEASUREMENT AND END THE HOUSEHOLD INTERVIEW.)
47. We detected a low level of hemoglobin in the blood of [NAME OF WOMAN]. This indicates that (NAME OF WOMAN) has/have developed severe anemia, which is a serious health problem. We suggest you go to ______________ [THE NEAREST HEALTH FACILITY] to receive appropriate treatment for the condition. Do you agree to go to that facility to have [NAME OF WOMAN] anemia treated?
NAME OF WOMAN 15-49 YEARS WITH HEMOGLOBIN BELOW 7 G/DL
NAME OF WOMAN OR PARENT/RESPONSIBLE ADULT
AGREES TO REFERRAL?
NO 2
MALARIA TESTING - CHILDREN 6-59 MONTHS
CHECK COLUMN (7) OF HOUSEHOLD LISTING: RECORD THE LINE NUMBER, NAME AND AGE OF ALL CHILDREN 6-59 MONTHS THEN ASK THE DATE OF BIRTH.
48. LINE NUMBER FROM COL. 9
50. LINE NUMBER OF PARENT/ ADULT RESPONSIBLE FOR THE CHILD RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE
51. READ CONSENT STATEMENT TO PARENT/ADULT RESPONSIBLE FOR THE CHILD CIRCLE CODE AND SIGN
REFUSED (SIGN) 2
NOT PRESENT 2
REFUSED 3
OTHER (SPECIFY) 4
NEGATIVE 2
OTHER 3
54. BAR CODE LEVEL PUT 1ST BAR CODE LABEL IN BOX BELOW. PUT THE 2ND LABEL ON THE SLIDE AND 3RD ON THE TRANSMITTAL FORM
DECLINED 2
CONTRAINDICATED 3
TICK HERE IF CONTINUATION SHEET USED
CONSENT STATEMENT: As part of this survey, we are studying malaria among children and pregnant women. Malaria is a serious health problem caused by a parasite that is transmitted by a mosquito bite. This survey will assist the government to develop programs to prevent and treat malaria. We request that all children born in 20011 or later participate in the malaria testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential. May I now ask that (NAME OF CHILD[REN]) participate in the malaria test However, if you decide not to have him/her/them tested, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
MALARIA TESTING--PREGNANT WOMEN
CHECK COLUMN (9) OF HOUSEHOLD LISTING: RECORD THE LINE NUMBER, NAME AND AGE OF ALL PREGNANT WOMEN
56. LINE NUMBER FROM COL 8 AND PAGE 38. FOR ELIGIBLE PREGNANT WOMEN.
59. How many months pregnant are you? [INDICATE GESTATIONAL AGE IN COMPLETE MONTHS AND WEEKS] RECORD GESTATIONAL AGE IN MONTHS AND WEEKS
WEEKS ___
MALARIA TESTING FOR PREGNANT WOMEN
60. LINE NUMBER OF WOMAN OR PARENT/ADULT RESPONSIBLE FOR THE PREGNANT WOMAN (IF UNDER 18) RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE
61. READ CONSENT STATEMENT TO PREGNANT WOMAN OR PARENT/ADULT RESPONSIBLE FOR THE PREGNANT WOMAN CIRCLE CODE AND SIGN
REFUSED (SIGN) 2
NOT PRESENT 2
REFUSED 3
OTHER (SPECIFY) 4
NEGATIVE 2
OTHER 3
64. IF POSITIVE AND PREGNANT LESS THEN OR EQUAL TO 3 MONTHS, CHECK BOX, AND DO NOT OFFER TREATMENT. (MARK 3 IN Q. 65)
DECLINED 2
CONTRAINDICATED 3
MALARIA TESTING AND PRESCRIPTION
PRESCRIPTION WARNINGS FOR MALARIA POSITIVE CASES AMONG PREGNANT WOMEN: READ THE STATEMENT FOR PREGNANT WOMEN WHO RESULT POSITIVE WITH THE RAPID DIAGNOSTIC TEST
The test has given back a positive result. This means you seem to have active malaria. We can provide you with a full treatment free of charge with a medicine called quinine®. Quinine is an effective medication and should help you to feel better in a few days. As with every medicine, this medicine may have undesired effects on you. The most common are headache, flushing and sweating, nausea, ringing in the ears, dizziness, blurred vision, and changes in seeing colors. There can be more severe symptoms, including disturbances in the heart rhythm, swelling and lack of blood coagulation. If any of these or other severe symptoms develop, they usually go if you stop taking the medication. If you are breastfeeding a baby, there should not be any problems with taking the medication.
Although you should feel better after the treatment, you have the right to decline receiving the treatment, with no repercussions to you. Please tell us whether you accept treatment or not.
MARK IN THE MALARIA TESTING SHEET WHETHER THE RESPONDENT AGREES TREATMENT FOR HER.
Give 650 mg of Quinine Sulfate (2 capsules of 324 mg each) every 8 hours (three times daily), preferably with food, for a total of 3 days (7 days?).
PRESCRIPTION WARNINGS FOR MALARIA POSITIVE CASES IN CHILDREN UNDER 5 YEARS
READ THE STATEMENT FOR CHILDREN UNDER 5 WHO RESULT POSITIVE WITH THE RAPID DIAGNOSTIC TEST
The test has given back a positive result. This means your child[ren] seem[s] to have active malaria. We can provide him/her/them with a full treatment free of charge with a medicine called Coartem®. Coartem is very effective, and should in a few days rid him/her/them from fever and other symptoms. Coartem® is also very safe. However, as with every medicine, this medicine may have undesired effects. The most common are dizziness, fatigue, lack of appetite, palpitations. Coartem should not be taken by persons with severe heart problems or severe malaria (e.g. cerebral), or problems regulating their body salts [ASK IF THE CHILD[REN] HAS/HAVE ANY OF THESE PROBLEMS, THAT THEY ARE AWARE OF; IF SO, DO NOT OFFER COARTEM, EXPLAIN THE RISKS OF MALARIA, AND REFER HIM/HER/THEM TO NEAREST HEALTH FACILITY].
Although [NAME OF CHILD/REN] should feel better after the treatment, you have the right to decline GIVING THE CHILD/REN the treatment, with no repercussions to you [OR TO THE CHILD/REN]. Please tell us whether you accept treatment or not.
MARK IN THE MALARIA TESTING SHEET WHETHER THE RESPONDENT AGREES OR DECLINES TREATMENT FOR [EACH OF] HER CHILD[REN]
Weight (in Kg) -- Approximate Age
Dosage (First day starts by taking first dose followed by the second one 8 hours later; on subsequent days the recommendation is simply "morning" and "evening" (usually around 12 hours apart))
5 to less than 15 -- under 3 years of age: 1 tablet twice daily for 3 days
15 to less than 25 -- 3 to 8 years of age: 2 tablets twice daily for 3 days
25 to less than 35 -- 9 to 14 years of age: 3 tablets twice daily for 3 days
35 or more (adults) -- 15 + years of age: 4 tables twice daily for 3 days