SURVEY OF MALARIA INDICATORS IN BURKINA FASO (EIPBF - 2014)
HOUSEHOLD QUESTIONNAIRE
BURKINA FASO
NATIONAL INSTITUTE OF STATISTICS AND DEMOGRAPHY (INSD)
PROGRAM TO SUPPORT HEALTH DEVELOPMENT (PADS)
NATIONAL PROGRAM IN FIGHT AGAINST MALARIA (PNLP)
IDENTIFICATION
NAME OF HEAD OF HOUSEHOLD ______
CLUSTER NUMBER ______
CONCESSION NUMBER ______
HOUSEHOLD NUMBER ______
ADMINISTRATIVE REGION ______
AREA (URBAN = 1, RURAL = 2) ______
SPECIFIC AREA (OUAGADOUGOU = 1, OTHER CITY = 2, RURAL = 3) ______
INTERVIEWER VISITS
NAME OF INTERVIEWER ______
RESULT ______
TIME ______
MONTH ______
YEAR 2014
INTERVIEWER NUMBER ______
RESULT ______
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR LONG PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR NO DWELLING AT ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ______
TOTAL IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN ______
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE ______
INTRODUCTION AND INFORMED CONSENT
Hello. My name is ______ and I work for the National Institute of Statistics and Demography (INSD). We are conducting a national survey on malaria throughout the country. The information that we collect will help your government to improve health services. Your household was selected for this survey. The questions usually take between 5 and 10 minutes. All the information you give us is strictly confidential and will not be shared with anyone other than members of the survey team. You do not have to participate in this survey but we hope you will agree to participate because your opinion is very important. If I happen to ask a question that you do not want to answer, tell me and I will move on to the next question; you can also stop the interview at any time.
If you would like more information about the survey, you can contact the people whose names are on this card.
GIVE THE CARD WITH CONTACT INFORMATION.
May I begin the interview now?
DATE: ______
2 RESPONDENT REFUSES TO ANSWER (Skip to END)
HOUSEHOLD SCHEDULE
(Repeat Q. 1 - 11 for up to 20 people)
1. LINE NUMBER 01
2. HABITUAL RESIDENTS AND VISITORS
AFTER LISTING NAMES AND RECORDING THE FAMILY RELATIONSHIP AND GENDER FOR EACH PERSON, ASK QUESTIONS 2A - 2C TO BE CERTAIN THAT THE LIST IS COMPLETE.
THEN ASK THE APPROPRIATE QUESTIONS IN COLUMNS 5 - 11 FOR EACH PERSON.
______
3. FAMILY RELATIONSHIP TO HEAD OF HOUSEHOLD.
SEE CODES BELOW.
______
CODES FOR Q. 3: FAMILY RELATIONSHIP TO HEAD OF HOUSEHOLD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW/DAUGHTER-IN-LAW
05 GRANDSON/GRANDDAUGHTER
06 FATHER/MOTHER
07 IN-LAWS
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED/FOSTER
11 STEPCHILD
12 COWIFE
13 NO FAMILY RELATION
98 DK
2 FEMALE
NO ______
2B. Are there other people who are perhaps not family members, such as servants, renters, or friends who usually live here?
NO ______
NO ______
2 NO
2 NO
IN YEARS ______
8. IF AGE 15 OR OLDER
MARITAL STATUS
2 DIVORCED/SEPARATED
3 WIDOWED
4 NEVER MARRIED AND NEVER LIVED WITH ANYONE
______
9. WOMAN AGE 15 - 49
ELIGIBILITY
11. CHILD AGE 0 - 5
ELIGIBILITY
TICK HERE IF ANOTHER QUESTIONNAIRE IS USED ______
HOUSEHOLD CHARACTERISTICS
102. Where does the drinking water used by members of your household mainly come from?
12 FAUCET IN YARD/PLOT (Skip to 107)
13 PUBLIC TAP/STANDPIPE
14 FAUCET AT NEIGHBOR'S
32 UNPROTECTED WELL
42 UNPROTECTED SPRING
61 TANKER WATER
71 CART WITH SMALL CISTERN/BARREL
81 SURFACE WATER (RIVERS/DAMS/LAKES/PONDS/IRRIGATION CANALS)
91 BOTTLED WATER
96 OTHER (SPECIFY) ______
103. Where is this water source located?
2 IN YOUR YARD/PLOT (Skip to 107)
3 ELSEWHERE
104. How long does it take to go there, get the water and come back?
998 DK
107. What kind of toilets do members of your household usually use?
12 CONNECTED TO SEPTIC SYSTEM
13 CONNECTED TO TOILET PIT
14 CONNECTED TO SOMETHING ELSE
15 CONNECTED TO UNKNOWN PLACE
22 PIT LATRINE WITH SLAB
23 PIT LATRINE WITHOUT SLAB/OPEN HOLE
31 COMPOSTING TOILET
41 BUCKET/TIN PAIL
51 SUSPENDED TOILET/LATRINE
61 NO TOILET/IN NATURE (Skip to 110)
108. Do you share this toilet with other households?
2 NO (Skip to 110)
109. How many households use this toilet?
95 10 OR MORE HOUSEHOLDS
98 DK
110. In this household, do you have: (4)
Electricity?
Radio set?
Television?
Mobile phone?
Landline phone?
Refrigerator?
Table?
Chair?
Wardrobe/bookcase?
Stove/hot plate?
Freezer?
Hunting rifle?
Plow?
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
111. What type of fuel does your household mainly use for cooking?
02 GAS/OIL
07 CHARCOAL
08 WOOD
95 NO MEALS PREPARED IN HOUSEHOLD
96 OTHER (SPECIFY) ______
114. MAIN MATERIAL OF FLOOR
RECORD OBSERVATION.
12 DUNG/GRAVEL
34 CEMENT
96 OTHER (SPECIFY) ______
115. MAIN MATERIAL OF ROOF
RECORD OBSERVATION.
116. MAIN MATERIAL OF EXTERIOR WALLS
RECORD OBSERVATION.
13 EARTH
22 STONES WITH MUD
23 UNFINISHED ADOBE
32 STONES WITH LIME/CEMENT
33 BRICKS
34 CEMENT BLOCKS
35 FINISHED ADOBE
36 WOOD PLANKS
117. In this household, how many rooms are used for sleeping?
95 UNDER A TREE/OUTDOORS
118. Does any member of your household own:
Dugout canoe?
Watch?
Bicycle?
Motorcycle or scooter?
Animal-drawn cart?
Car or van?
Motorboat?
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
119. Does any member of your household own any agricultural land?
2 NO (Skip to 121)
120. How many hectares of agricultural land do members of your household own?
IF 95 OR MORE, CIRCLE '950'.
950 95 HECTARES OR MORE
998 DK
121. Does your household own any livestock, herds of other farm animals or poultry?
2 NO (Skip to 123)
122. How many of the following animals does your household own?
IF NONE, RECORD '00'.
IF 95 OR MORE, RECORD '95'.
IF DK, RECORD '98'.
Horses, donkeys, or mules?
Goats?
Pigs?
Sheep?
Poultry (Chicken/Ducks, etc.)?
HORSES/DONKEYS/MULES ______
GOATS ______
PIGS ______
SHEEP ______
CHICKENS/DUCKS ______
123. Does any member of your household have a bank account?
2 NO
124. At any time in the last 12 months did someone come to your dwelling to spray the interior walls for mosquitos?
2 NO (Skip to 126)
8 DK (Skip to 126)
125. Who sprayed the walls of the dwelling?
PROBE: who else?
RECORD ALL MENTIONED
B PRIVATE COMPANY
C NON-GOVERNMENTAL ORGANIZATION (NGO)
X OTHER (SPECIFY) ______
Z DK
125A. Are there fewer mosquitos in your dwelling since it has been sprayed?
2 NO
126. Does your household have any mosquito nets that can be used for sleeping?
2 NO (Skip to 137)
127. How many mosquito nets does your household have?
NUMBER OF MOSQUITO NETS ______
128. ASK RESPONDENT TO SHOW YOU THE HOUSEHOLD'S MOSQUITO NETS.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
(Repeat Q. 128 - 136 for up to 3 mosquito nets)
MOSQUITO NET #1
2 NOT OBSERVED
129. How many months has your household had the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'.
95 MORE THAN 36 MONTHS
98 NOT SURE
130. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET
IF BRAND IS NOT KNOWN AND YOU CAN NOT OBSERVE THE MOSQUITO NET, SHOW A PHOTO OF A COMMON MOSQUITO NET TO THE RESPONDENT.
(Codes 11 - 26 all skip to 131A)
12 PERMANET
13 INTERCEPTOR
14 SERENA
16 OTHER/DK BRAND
26 DK BRAND
98 DK BRAND
131. When you got this mosquito net, had it already been treated with an insecticide to kill or repel mosquitos?
2 NO
8 NOT SURE
131A. What shape is this mosquito net?
2 RECTANGULAR
131B. Where did you get this mosquito net?
2 ANTENATAL CONSULTATION
3 CHILD VACCINATION
4 MARKET
5 PHARMACY
6 OTHER ______
131C. Is the mosquito net hanging up?
2 NO (Skip to 136)
2 INSTALLATION AGENT
3 NEIGHBOR
8 DK
134. Did anyone sleep under the mosquito net last night?
2 NO (Skip to 136)
8 NOT SURE (Skip to 136)
135. Who slept under the mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
(Record up to 4 people per mosquito net)
LINE NUMBER ______
136. RETURN TO 128 FOR NEXT MOSQUITO NET OR, IF THERE ARE NO MORE NETS, CONTINUE TO 137.
137. Did your household own mosquito nets before the last distribution campaign?
2 NO (Skip to 144)
138. How many mosquito nets did your household own before the campaign?
IF 7 OR MORE MOSQUITO NETS, RECORD '7'.
8 DK
SEVERAL MOSQUITO NETS ______ (Skip to 142)
140. Was the mosquito net used?
2 NO
141. Why didn't your household use the mosquito net?
PROBE: other reasons?
RECORD ALL MENTIONED.
B SOME HOUSEHOLD MEMBERS DO NOT LIKE MOSQUITO NETS
C WRONG SIZE
D WRONG SHAPE
E BAD SMELL
F CAUSES IRRATIONS/COUGH
G MAKES SICK
H MAKES NAUSEOUS
I PRODUCES DANGEROUS CHEMICALS
J CAN SUFFOCATE/BREATHING DIFFICULTIES
K HEAT
L MOSQUITO NET GETS DIRTY QUICKLY
M NO REASON
X OTHER (SPECIFY) ______
Z DK
142. Were all these mosquito nets used?
2 YES, SOME
3 NO, NONE
B SOME HOUSEHOLD MEMBERS DO NOT LIKE MOSQUITO NETS
C WRONG SIZE
D WRONG SHAPE
E BAD SMELL
F CAUSES IRRATIONS/COUGH
G MAKES SICK
H MAKES NAUSEOUS
I PRODUCES DANGEROUS CHEMICALS
J CAN SUFFOCATE/BREATHING DIFFICULTIES
K HEAT
L MOSQUITO NET GETS DIRTY QUICKLY
M NO REASON
X OTHER (SPECIFY) ______
Z DK
144. Did your household get any treated mosquito nets during the last mosquito net distribution campaign?
2 NO (Skip to 146)
145. How many mosquito nets did your household get?
98 DK
146. Did anyone visit your household after the campaign to talk to you about mosquito nets?
2 NO (Skip to 201)
2 Explain the importance of sleeping under an LLIN every night?
1 HOW TO HANG UP AN LLIN
2 NO
8 DK
2 IMPORTANCE OF SLEEPING UNDER AN LLIN
2 NO
8 DK
ANEMIA AND MALARIA TESTING FOR CHILDREN AGE 0 - 5
201. CHECK COLUMN 11 OF HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL CHILDREN AGE 0 - 5 IN Q. 202 IN ORDER, ACCORDING TO THE LINE NUMBER. IF THERE ARE MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
NO CHILD AGE 0 - 5 ______ (Skip to END)
202. LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2
(Repeat Q. 202 - 227 for up to 6 children)
NAME ______
203. IF MOTHER IS RESPONDENT, COPY THE MONTH AND YEAR OF BIRTH FOR THE CHILD FROM THE BIRTH HISTORY AND ASK THE DAY; IF MOTHER IS NOT RESPONDENT, ASK:
What is (NAME)'s birth date?
MONTH ______
YEAR ______
204. CHECK 203:
CHILD BORN IN JANUARY 2009 OR LATER?
2 NO (GO TO 203 FOR NEXT CHILD OR IF THERE ARE NO MORE CHILDREN, END INTERVIEW)
205. CHECK 203:
IS CHILD AGE 0 - 5 MONTHS, THAT IS, WAS HE/SHE BORN IN MONTH OF SURVEY OR IN 5 PRECEDING MONTHS?
2 OLDER
206. LINE NUMBER OF CHILD'S PARENT/OTHER RESPONSIBLE ADULT (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD '00' IF NOT LISTED.
207. ASK CONSENT FOR ANEMIA TEST FROM CHILD'S PARENT/OTHER ADULT IDENTIFIED IN 206 AS RESPONSIBLE ADULT.
In this survey, we are asking all the children in the country to participate in anemia testing. Anemia is a serious health problem generally resulting from poor nutrition, infections, or chronic illnesses. The results from this study will allow the government to develop programs to prevent and treat anemia.
We are asking all children born in 2009 or later to participate in the anemia test included in this survey by giving a few drops of blood from a finger or heel. For this test, we use clean and risk-free equipment. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately and you will know the results right away. The results are strictly confidential and will not be shared with anyone outside of the survey team.
Do you have any questions to ask me?
You can say 'yes' for the test or you can say 'no'. It's your decision.
Will you allow (NAME OF CHILD) to participate in the anemia test?
208. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGNATURE) ______
2 REFUSED (Go to signature)
5 ABSENT
6 OTHER
209. ASK PARENT'S/OTHER RESPONSIBLE ADULT'S (AS IDENTIFIED IN 206) CONSENT FOR MALARIA TESTING OF CHILD.
As part of this survey, we are asking children all over the country to participate in testing to see whether or not they have malaria. Malaria is a serious health problem caused by a parasite transmitted by a mosquito bite. This survey will help the government to develop programs to prevent malaria.
We are asking all children born in 2009 or later to participate in the malaria test included in this survey by giving a few drops of blood from a finger or heel. For this test, we use clean and risk-free equipment. It has never been used before and will be thrown away after each test. (We will use the blood from the same blood draw and same finger as for the anemia test).
A drop of blood will be tested for malaria immediately and you will know the results right away. A few other drops will be placed on one or more slides and sent to a laboratory to be tested. The laboratory test results will not be given to you. The results are strictly confidential and will not be shared with anyone outside of the survey team.
Do you have any questions to ask me?
You can say 'yes' to the test or you can say 'no'. It is your decision.
Do you give (CHILD'S NAME) permission to participate in the malaria test?
210. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGNATURE) ______
2 REFUSED (Go to signature)
5 ABSENT
6 OTHER
211. PREPARE THE EQUIPMENT AND SUPPLIES ONLY FOR THE TESTS FOR WHICH CONSENT HAS BEEN GIVEN AND CONTINUE WITH THE TEST(S).
212. BAR CODE STICKER FOR MALARIA TEST.
99995 REFUSED
99996 OTHER
213. RECORD THE HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA AND MALARIA BOOKLET.
994 ABSENT
995 REFUSED
996 OTHER
214. RECORD THE RESULT CODE OF MALARIA RAPID TEST.
2 ABSENT (Skip to 216)
3 REFUSED (Skip to 216)
6 OTHER (Skip to 216)
215. RECORD THE RESULT OF MALARIA RAPID TEST HERE AND IN THE ANEMIA AND MALARIA BOOKLET.
2 SPECIES POSITIVE ("OMV") (Skip to 218)
4 NEGATIVE
6 OTHER
[###translator's note: unsure of "OMV" translation. Possibly "ovale, malariae, vivax"]
2 8.0 G/DL OR HIGHER (Skip to 228)
4 ABSENT (Skip to 228)
5 REFUSED (Skip to 228)
6 OTHER (Skip to 228)
217. STATEMENT FOR REFERRAL FOR SEVERE ANEMIA.
218. Does (NAME) suffer from any of the following illnesses or show any of the following symptoms:
Extreme weakness?
Heart problems?
Loss of consciousness?
Fast breathing or difficulty breathing?
Convulsions?
Abnormal bleeding?
Jaundice/yellow skin?
Dark urine?
IF NONE OF THE SYMPTOMS ABOVE, CIRCLE CODE Y.
B HEART PROBLEMS
C LOSS OF CONSCIOUSNESS
D FAST BREATHING OR DIFFICULTIES BREATHING
E CONVULSIONS
F ABNORMAL BLEEDING
G JAUNDICE/YELLOW SKIN
H DARK URINE
Y NONE OF THE SYMPTOMS ABOVE
2 ONLY CODE Y CIRCLED
2 6.0 G/DL OR HIGHER (Skip to 222)
4 ABSENT (Skip to 222)
5 REFUSED (Skip to 222)
6 OTHER (Skip to 222
)
221. STATEMENT FOR REFERRAL FOR SEVERE MALARIA.
222. In the last two weeks, did (NAME) take or is (NAME) taking ACT given by a doctor or health centre to treat the malaria?
.
2 NO (Skip to 224)
223. STATEMENT FOR REFERRAL FOR CHILDREN ALREADY TAKING ACT MEDICATION.
224. READ THE INFORMATION FOR MALARIA TREATMENT AND STATEMENT FOR CONSENT OF PARENT/OTHER RESPONSIBLE ADULT FOR CHILD.
225. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGNATURE) ______
2 REFUSED (Skip to 227)
6 OTHER (Skip to 227)
226. TREATMENT FOR CHILDREN WHO TEST POSITIVE FOR MALARIA.
25 mg Artesunate and 67.5 mg Amodiaquine pill (Pink strip on blister pack)
DAY 2 (1 PILL)
DAY 3 (1 PILL)
50 mg Artesunate and 135 mg Amodiaquine pill (Purple strip on blister pack)
DAY 2 (1 PILL)
DAY 3 (1 PILL)
227. RECORD THE RESULT CODE OF TREATMENT OF MALARIA OR REFERRAL SHEET.
2 MEDICINE REFUSED
3 REFERRAL FOR SEVERE MALARIA
4 REFERRAL FOR CHILD ALREADY TAKING ACT
6 OTHER
228. RETURN TO 202 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE EXTRA QUESTIONNAIRE(S); IF NO MORE CHILDREN, END THE INTERVIEW.
INTERVIEWER'S OBSERVATIONS
TO BE FILLED OUT ONCE THE INTERVIEW IS COMPLETED
______
COMMENTS ABOUT PARTICULAR QUESTIONS
______
OTHER COMMENTS
______
TEAM LEADER'S OBSERVATIONS
______
DATE: ______
SUPERVISOR'S OBSERVATION
______
DATE: ______