MALARIA INDICATOR SURVEY IN ANGOLA HOUSEHOLD QUESTIONNAIRE
NAME OF LOCALITY
REGION
PROVINCE
MUNICIPALITY
CLUSTERED NUMBER IN AMIS
URBAN / RURAL
RURAL 2
HOUSEHOLD NUMBER
NAME OF HOUSEHOLD HEAD
MARK "X" IN CIRCLE IF HOUSEHOLD WAS SELECTED FOR MALARIA TESTING
DATE
INTERVIEWER'S NAME
RESULT
NO HOUSEHOLD MEMBER HOME/NO COMPETENT RESPONDENT 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
LAST VISIT
DAY
MONTH
YEAR: 2011
CODE
RESULT
NO HOUSEHOLD MEMBER HOME/NO COMPETENT RESPONDENT 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
NUMBER OF VISITS
TOTAL PERSONS IN HOUSEHOLD
TOTAL WOMEN 15-49
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
NAME
DATE
FIELD EDITOR
KEYED BY
Hello, my name is __ and I'm from the Ministry of Health. We are doing a survey all over the country about malaria. I would like to ask you some questions. I hope you will agree. The information you give will help the government to plan health services. The survey usually takes about 15 to 20 minutes to complete.
The information you give will be kept confidential and will not be shared with anyone other than members of the survey team. You do not have to participate in the survey. If I ask any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope you will participate in the survey since your views are important.
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)
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 household. AFTER LISTING THE NAMES, RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-14 FOR EACH PERSON.
3. What is the relationship of (NAME) to the head of the household? SEE CODES BELOW.
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
ADOPTED CHILD 04
SON-IN-LAW OR DAUGHTER-IN-LAW 05
GRANDCHILD 06
PARENT 07
PARENT-IN-LAW 08
BROTHER OR SISTER 09
NIECE/NEPHEW BY BLOOD 10
NIECE/NEPHEW BY MARRIAGE 11
OTHER RELATIVE 12
STEPCHILD 13
NOT RELATED 14
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. Is (NAME) currently pregnant?
NO/DON'T KNOW 2
10. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
TICK HERE IF CONTINUATION SHEET USED
2A) Just to make sure that I have a complete listing, are there any other persons such as small children or infants that we have not listed?
NO
2B) Are there any other people who may not be members of your family, like domestic servants, lodgers, or friends who usually live here?
NO
2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
101. What is the main source of drinking water for members of your household?
PIPED TO 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/LAKE/STREAM/PIPE) 81
BOTTLED WATER 91
OTHER (SPECIFY) 96
102. What kind of toilet facility do members of your household usually use?
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
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61
OTHER (SPECIFY) 96
103. Does your household have:
Electricity from public network?
NO 2
A generator?
NO 2
A radio?
NO 2
A refrigerator?
NO 2
A sewing machine?
NO 2
A television?
NO 2
104. Does any member of this household own:
A watch?
NO 2
A mobile telephone?
NO 2
A bicycle?
NO 2
A motorcycle?
NO 2
A car or truck?
NO 2
A boat or canoe?
NO 2
105. What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02
OIL 03
COAL 04
WOOD 05
STRAW 06
DUNG/MANURE 07
NO FOOD COOKED IN HOUSEHOLD 95
OTHER (SPECIFY) 96
106. MAIN MATERIAL FO THE FLOOR. RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL/ASPHALT STRIPS 32
CERAMIC TILES/MOSAIC/BRICK 33
CEMENT 34
CARPET 35
107. MAIN MATERIAL FO THE ROOF OF THE HOUSEHOLD. RECORD OBSERVATION.
WOOD PLANKS 22
TARPAULIN/PLASTIC 23
ASBESTOS SHEETS SHINGLES 32
CERAMIC TILES 33
CONCRETE/CEMENT 34
OTHER 96
108. MAIN MATERIAL OF THE OUTSIDE WALLS OF THE HOUSEHOLD. RECORD OBSERVATION.
CARDBOARD/PLASTIC 14
MUD AND STICKS 15
MUD BLOCKS 16
CANE/PALM/TRUNKS 17
REUSED WOOD 18
BRICKS 32
WOOD PLANKS/SHINGLES 33
109. How many rooms in this household are used for sleeping?
109A. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?
NO 2 (GO TO 110)
DON'T KNOW 8 (GO TO 110)
109B. How many months ago was the dwelling sprayed? IF LESS THAN ONE MONTH, RECORD '0'
109C. Who sprayed the dwelling?
NON-GOVERNMENTAL ORGANIZATION B
PRIVATE COMPANY C
OTHER (SPECIFY) X
DON'T KNOW Y
110. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 112)
111. How many mosquito nets does your household have? IF 7 OR MORE NETS, RECORD '7'.
112. Why doesn't your household have any mosquito nets? CIRCLE ALL MENTIONED.
NETS NOT AVAILABLE B
DON'T LIKE TO USE NETS C
TOO EXPENSIVE D
OTHER (SPECIFY) X
GO TO 200.
113. ASK RESPONDENT TO SHOW YOU THE NETS. IF MORE THAN 3, USE ADDITIONAL QUESTIONNAIRE(S).
OBSERVED, DOES NOT HAVE HOLES 2
NOT OBSERVED 3
114. How many months ago did your household obtain the mosquito net? IF LESS THAN ONE MONTH, WRITE '00' IF YEARS, CONVERT TO MONTHS
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
115. Did you buy the net or was it given to you free?
FREE 2 (SKIP TO 117)
DON'T KNOW 8 (SKIP TO 117)
116. How much did you pay for the net? IF DON'T KNOW, WRITE '9998'
117. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.
OLYSET 12 (SKIP TO 121)
PERMANET 13 (SKIP TO 121)
SEGURO E SALVO 14 (SKIP TO 121)
OTHER BRAND 15 (SKIP TO 121)
PERMANENT 16 (SKIP TO 121)
OTHER BRAND TREATED 46
OTHER BRAND, DON'T KNOW IF TREATED 96
DON'T KNOW BRAND 98
118. When you got the net, was it already treated with an insecticide to kill or repel mosquitos?
NO 2
NOT SURE 8
119. Since you got the mosquito net, was it ever soaked or dipped in a liquid to kill or repel mosquitos?
NO 2 (SKIP TO 121)
NOT SURE 8 (SKIP TO 121)
120. How many months ago was the net last soaked or dipped? IF LESS THAN ONE MONTH, WRITE '00'
MORE THAN 24 MONTHS AGO 95
NOT SURE 98
121. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 123)
NOT SURE 8 (SKIP TO 123)
122. Who slept under this mosquito net last night? RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NO. ___
123. GO BACK TO 113 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 201.
ANEMIA AND MALARIA TESTING FOR CHILDREN AGE 0-5
201. CHECK COLUMN 10. WRITE THE LINE NUMBER AND NAME FOR ALL CHILDREN 0-5 YEARS IN Q. 202 IN ORDER BY LINE NUMBER. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRES. BE SURE TO FILL Qs. 209 AND
202. LINE NUMBER FROM COLUMN 10 AND NAME FROM COLUMN 2
NAME ___
203. IF MOTHER INTERVIEWED, COPY CHILD'S MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?
MONTH ___
YEAR ___
204. CHECK 203: CHILD BORN IN JANUARY 2006 OR LATER?
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE, GO TO 215)
205. CHECK 203: IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?
6 MONTHS OR OLDER 2
206. LINE NUMBER OF PARENT OR ADULT RESPONSIBLE FOR CHILD (COL. 1 IN HOUSEHOLD QUESTIONNAIRE). RECORD '00' IF NOT LISTED.
207. READ ANEMIA CONSENT STATEMENT TO PARENT OR OTHER ADULT IDENTIFIED IN 206 AS RESPONSIBLE FOR CHILD.
REFUSED (SIGN) 2
208. READ MALARIA CONSENT STATEMENT TO PARENT OR OTHER ADULT IDENTIFIED IN 206 AS RESPONSIBLE FOR CHILD.
CONDUCT TESTS FOR WHICH CONSENT IS GRANTED AND CONTINUE TO 209
209. RECORD RESULT CODE OF ANEMIA TEST.
NOT PRESENT 2 (SKIP TO 211)
REFUSED 3 (SKIP TO 211)
OTHER 6 (SKIP TO 211)
210. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET
211. RECORD RESULT CODE OF MALARIA TEST
NOT PRESENT 2 (SKIP TO 215)
REFUSED 3 (SKIP TO 215)
OTHER 6 (SKIP TO 215)
212. BAR CODE LABEL. PASTE BAR CODE HERE AND ON SLIDE AND ON TRANSMITTAL FORM.
NEGATIVE 2 (SKIP TO 215)
OTHER 6 (SKIP TO 215)
214. READ INFORMATION FOR MALARIA TREATMENT FOR CHILDREN WHO TESTED POSITIVE FOR MALARIA
REFUSED 2
ALREADY HAS ACT 3
NOT ELIGIBLE 4
OTHER 6
215. GO BACK TO 203 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, END INTERVIEW.
CONSENT STATEMENT FOR ANEMIA TEST
As part of this survey, we are asking that children all over the country take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or disease. This survey will help the government to develop programs to prevent and treat anemia.
We request that all children born in 2006 or later participate in the anemia testing part of this survey and give a few drops of blood from a finger. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately and the result will be told to you right away. The result will be kept confidential and won't be shared with anyone other than members of our survey team.
Do you have any questions about the anemia test?
You can say yes to the test or you can say no. It is up to you to decide.
Will you allow (NAME(S) OF CHILD(REN) to participate in the anemia test?
CONSENT STATEMENT FOR MALARIA TEST
As part of this survey, we are asking that children all over the country take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by a mosquito bite. This survey will help the government to develop programs to prevent malaria.
We request that all children born in 2006 or later participate in the malaria testing part of this survey and give a few drops of blood from a finger. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test. (We will use blood from the same finger prick made for the anemia test).
The blood will be tested for malaria immediately and the result will be told to you right away. The result will be kept confidential and won't be shared with anyone other than members of our survey team.
Do you have any questions about the malaria test?
You can say yes to the test or you can say no. It is up to you to decide.
Will you allow (NAME(S) OF CHILD(REN) to participate in the malaria test?
TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TESTS
IF MALARIA TEST IS POSITIVE: The malaria test shows that your child has malaria. We can give you free medicine. The medicine is called artemisin-based combination therapy or ACT. This drug is very effective and in a few days it should get rid of the fever and other symptoms.
BEFORE PROVIDING ACT, FIRST ASK IF THE CHILD IS ALREADY TAKING OTHER DRUGS AND IF SO, ASK TO SEE THEM. IF CHILD IS ALREADY TAKING ACT, CHECK ON THE DOSE ALREADY AVAILABLE. BE CAREFUL NOT TO OVERTREAT.
You do not have to give the child the medicine. This is up to you. Please tell me whether you accept the medicine or not.