SURVEY OF MALARIA INDICATORS IN BURKINA FASO
(EIPBF - 2017)
HOUSEHOLD QUESTIONNAIRE
BURKINA FASO
NATIONAL INSTITUTE OF STATISTICS AND DEMOGRAPHY (INSD)
PROGRAM TO SUPPORT HEALTH DEVELOPMENT (PADS)
NATIONAL PROGRAM IN FIGHT AGAINST MALARIA (PNLP)
NAME OF LOCALITY ______
NAME OF HEAD OF HOUSEHOLD ______
CLUSTER NUMBER ______
CONCESSION NUMBER ______
HOUSEHOLD NUMBER ______
ADMINISTRATIVE REGION ______
PROVINCE ______
HEALTH DISTRICT ______
AREA (URBAN = 1, RURAL = 2) ______
SPECIFIC AREA (OUAGADOUGOU = 1, OTHER CITY = 2, RURAL = 3) ______
(Repeat up to 3 visits)
NAME OF INTERVIEWER ______
RESULT ______
TIME ______
MONTH ______
YEAR 2017
INTERVIEWER CODE ______
RESULT ______
TOTAL NUMBER OF VISITS ______
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 NUMBER OF PEOPLE IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN ______
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE ______
LANGUAGE OF QUESTIONNAIRE 01
LANGUAGE OF INTERVIEW ______
NATIVE LANGUAGE OF RESPONDENT ______
TRANSLATOR (YES = 1, NO = 2) ______
LANGUAGE OF QUESTIONNAIRE FRENCH
02 MOORE
03 PEUHL/FULFULDE
04 DIOULA
05 GULMANTCHEMA
06 BISSA
07 DAGARA
08 OTHER (SPECIFY) ______
INTRODUCTION AND CONSENT REQUEST
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. I would like to ask you some questions about your household. The questions usually take between 15 and 20 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 you decide not to participate, there will be no change in the services that you might receive from health programs. 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.
Do you have any questions for me?
May I begin the interview now?
DATE ______
2 RESPONDENT REFUSES TO BE INTERVIEWED (Skip to END)
MINUTES ______
HOUSEHOLD SCHEDULE
(Repeat Q.1 - 9 for up to 20 people)
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 - 9 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/STEPCHILD
11 NO FAMILY RELATION
98 DK
2 FEMALE
2A. Just to be sure I have a complete list: are there any other people such as small children or infants that we have not listed?
NO ______
2B. Are there other people who are perhaps not family members, such as servants, renters, or friends who usually live here?
NO ______
2C. Do you have any guests or temporary visitors who are in your home, or other people who slept here last night and were not listed?
NO ______
2 NO
2 NO
IN YEARS ______
7B. IF AGE 15 OR OLDER
MARITAL STATUS
2 DIVORCED/SEPARATED
3 WIDOWED
4 NEVER MARRIED AND NEVER LIVED WITH ANYONE
______
TICK HERE IF ANOTHER QUESTIONNAIRE IS USED ______
HOUSEHOLD CHARACTERISTICS
101 (2). Where does the drinking water used by members of your household mainly come from?
12 FAUCET IN YARD/PLOT (Skip to 105)
13 FAUCET AT NEIGHBOR'S (Skip to 105)
14 PUBLIC TAP/STANDPIPE (Skip to 103)
32 UNPROTECTED WELL (Skip to 103)
42 UNPROTECTED SPRING (Skip to 103)
61 TANKER WATER (Skip to 103)
71 CART WITH SMALL CISTERN/BARREL (Skip to 103)
81 SURFACE WATER (RIVERS/DAMS/LAKES/PONDS/IRRIGATION CANALS) (Skip to 103)
91 BOTTLED WATER
96 OTHER (SPECIFY) ______ (Skip to 103)
102. Where does the water mainly come from that your household uses for other needs, such as cooking and handwashing?
12 FAUCET IN YARD/PLOT (Skip to 105)
13 FAUCET AT NEIGHBOR'S (Skip to 105)
14 PUBLIC TAP/STANDPIPE
32 UNPROTECTED WELL
42 UNPROTECTED SPRING
61 TANKER WATER
71 CART WITH SMALL CISTERN/BARREL
81 SURFACE WATER (RIVERS/DAMS/LAKES/PONDS/IRRIGATION CANALS)
96 OTHER (SPECIFY) ______
103. Where is this water source located?
2 IN YOUR YARD/PLOT (Skip to 105)
3 ELSEWHERE
104. How long does it take to go there, get the water and come back?
998 DK
105 (3). What kind of toilets do members of your household usually use?
IF UNABLE TO DETERMINE TYPE OF TOILETS, ASK PERMISSION TO SEE THE FACILITY.
12 CONNECTED TO SEPTIC SYSTEM
13 CONNECTED TO TOILET PIT
14 CONNECTED TO SOMETHING ELSE
15 CONNECTED TO UNKNOWN PLACE
22 PIT LATRINE WITH WASHABLE 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 108)
106. Do you share this toilet with other households?
2 NO (Skip to 108)
107. Including your own household, how many households use this toilet?
95 10 OR MORE HOUSEHOLDS
98 DK
108. What type of fuel does your household mainly use for cooking?
02 LIQUIFIED PROPANE GAS
03 NATURAL GAS
04 BIOGAS
05 KEROSENE
06 COAL, LIGNITE
07 CHARCOAL
08 WOOD
09 STRAW/BRANCHES/GRASS
10 AGRICULTURAL WASTE
11 DUNG
96 OTHER (SPECIFY) ______
109. In this household, how many rooms do you use for sleeping?
110. Does your household own any livestock, herds, other farm animals or poultry?
2 NO (Skip to 112)
111 (4). How many of the following animals does your household own?
IF NONE, RECORD '00'.
IF 95 OR MORE, RECORD '95'.
IF DK, RECORD '98'.
b) Other livestock?
c) Horses, donkeys or mules?
d) Goats?
e) Sheep?
f) Chickens or other poultry?
g) Pigs?
b) OTHER LIVESTOCK ______
c) HORSES, DONKEYS OR MULES ______
d) GOATS ______
e) SHEEP ______
f) CHICKENS OR OTHER POULTRY ______
g) PIGS ______
112. Does any member of your household own any agricultural land?
2 NO (Skip to 114)
113. 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
114. In this household, do you have (a):
a) Electricity?
b) Radio set?
c) Television?
d) Landline telephone?
e) Computer?
f) Refrigerator/freezer?
g) Table/chair?
h) Wardrobe/bookcase?
i) Stove/hot plate?
j) Hunting rifle?
k) Plow?
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
115. Does any member of your household own (a/an):
a) Watch?
b) Mobile phone?
c) Bicycle?
d) Motorcycle or scooter?
e) Animal-drawn cart?
f) Car or van?
g) Motorboat?
h) Dugout canoe?
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
116. Does any member of your household have a bank account?
2 NO
119. Does your household have any mosquito nets that can be used for sleeping?
2 NO (Skip to 131)
120. How many mosquito nets does your household have?
IF 7 OR MORE MOSQUITO NETS, RECORD '7'.
121. ASK RESPONDENT TO SHOW YOU ALL OF THE HOUSEHOLD'S MOSQUITO NETS.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
(Repeat Q. 121 - 130 for up to 3 mosquito nets)
MOSQUITO NET #1
2 NOT OBSERVED
122. How many months has your household had the mosquito net?
95 MORE THAN 36 MONTHS
98 NOT SURE
123. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS NOT KNOWN AND YOU CANNOT OBSERVE THE MOSQUITO NET, SHOW THE RESPONDENT PHOTOS OF COMMON MOSQUITO NET BRANDS AND TYPES.
12 PERMANET
13 INTERCEPTOR
14 SERENA
15 DURANET
20 OTHER/DK BRAND
98 DK TYPE
126 (6). Did you get the mosquito net during the 2010 campaign (or 7 years ago), the 2013 campaign (or 4 years ago) or the 2016 campaign (or 1 year ago), or during an antenatal visit or at a vaccination appointment?
(Codes 1 - 6 all skip to 128)
2 YES, 2013 CAMPAIGN
3 YES, 2016 CAMPAIGN
4 YES, A CAMPAIGN, BUT DON'T KNOW WHICH
5 YES, ANTENATAL VISIT
6 YES, VACCINATION VISIT
7 NO
127. Where did you get the mosquito net?
02 PRIVATE HEALTH FACILITY
03 PHARMACY
04 SHOP/MARKET
05 COMMUNITY HEALTH AGENT
06 RELIGIOUS INSTITUTION
07 SCHOOL
96 OTHER
98 DK
128. Did anyone sleep under this mosquito net last night?
2 NO (Skip to 130)
8 NOT SURE (Skip to 130)
129. Who slept under this mosquito net last night?
NAME ______
LINE NUMBER ______
130. RETURN TO 121 FOR NEXT MOSQUITO NET OR, IF THERE ARE NO MORE NETS, CONTINUE TO 131.
OTHER CHARACTERISTICS OF DWELLING
131 (3). OBSERVE THE MAIN MATERIAL OF DWELLING'S FLOOR.
RECORD OBSERVATION.
12 DUNG
22 PALMS/BAMBOO
32 VINYL OR ASPHALT STRIPS
33 TILE
34 CEMENT
35 CARPET
132 (3). OBSERVE THE MAIN MATERIAL OF DWELLING'S ROOF.
RECORD OBSERVATION.
12 THATCH/PALMS/LEAVES
13 CLUMPS OF EARTH
22 PALMS/BAMBOO
23 WOOD PLANKS
24 CARDBOARD
32 WOOD
33 ZINC/CEMENT FIBER
34 TILES
35 CEMENT
36 SHINGLES
96 OTHER (SPECIFY) ______
133 (3). OBSERVE THE MAIN MATERIAL OF EXTERIOR WALLS OF DWELLING.
RECORD OBSERVATION.
12 BAMBOO/CANE/PALM/TRUNKS
13 EARTH
22 STONES WITH MUD
23 UNFINISHED ADOBE
24 PLYWOOD
25 CARDBOARD
26 RECYCLED WOOD
32 STONES WITH LIME/CEMENT
33 BRICKS
34 CEMENT BLOCKS
35 FINISHED ADOBE
36 WOOD PLANKS/SHINGLES
ANEMIA AND MALARIA TESTING FOR CHILDREN AGE 0 - 5
201. CHECK COLUMN 9 OF HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL ELIGIBLE CHILDREN AGE 0 - 5 IN Q. 202; IF THERE ARE MORE THAN 3 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
NO CHILD AGE 0 - 5 ______ (Skip to 231)
202. CHECK HOUSEHOLD SCHEDULE:
LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2
NAME ______
203. IF MOTHER IS RESPONDENT, COPY THE CHILD'S BIRTHDATE (DAY, MONTH AND YEAR) FROM BIRTH HISTORY. IF MOTHER IS NOT RESPONDENT, ASK:
MONTH ______
YEAR ______
204 (2). CHECK 203:
CHILD BORN IN JANUARY 2012 OR LATER?
2 NO (Skip to 230)
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 (2). ASK CHILD'S PARENT/OTHER RESPONSIBLE ADULT FOR CONSENT FOR ANEMIA TEST.
In this survey, we are asking people all over 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 2012 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)
3 ABSENT/OTHER
CHECK HOUSEHOLD SCHEDULE: LINE NUMBER FROM COLUMN 9
NAME ______
209 (2). ASK PARENT'S/OTHER RESPONSIBLE ADULT'S 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 2012 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.
210. CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND RECORD YOUR FIELD AGENT NUMBER.
2 REFUSED (Go to signature)
________
3 ABSENT/OTHER
211. PREPARE THE EQUIPMENT AND SUPPLIES ONLY FOR THE TESTS FOR WHICH CONSENT HAS BEEN GIVEN AND CONTINUE WITH THE TEST(S).
CHECK HOUSEHOLD SCHEDULE: LINE NUMBER FROM COLUMN 9
NAME ______
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 ("OM") (Skip to 218)
3 FP POSITIVE/("OMV/PAN" (Skip to 218)
4 NEGATIVE
6 OTHER
[###translator's note: unsure of "OMV" translation. Possibly "ovale, malariae, vivax"; incomplete words in Codes 2 and 3]
SEVERE ANEMIA VERIFICATION IN CHILDREN WITHOUT MALARIA (216 - 217)
216. CHECK 213:
HEMOGLOBIN LEVEL
2 8.0 G/DL OR HIGHER (Skip to 230)
3 ABSENT (Skip to 230)
4 REFUSED (Skip to 230)
6 OTHER (Skip to 230)
217. STATEMENT FOR REFERRAL FOR SEVERE ANEMIA.
RECORD THE HEMOGLOBIN TEST RESULT IN ANEMIA AND MALARIA BOOKLET.
The anemia test shows that (CHILD'S NAME) has severe anemia. Your child is seriously ill and should be taken to a health facility immediately.
(Skip to 230)
CHECK HOUSEHOLD SCHEDULE: LINE NUMBER FROM COLUMN 9
CHILD 1
NAME ______
SEVERE MALARIA VERIFICATION (218 - 219)
218 (4). Does (NAME) suffer from any of the following illnesses or show any of the following symptoms:
a) Extreme weakness?
b) Heart problems?
c) Loss of consciousness?
d) Respiratory failure?
e) Convulsions?
f) Abnormal bleeding?
g) Jaundice/yellow skin?
h) Black or brown urine?
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
219. CHECK 218:
ANY "YES" CIRCLED?
YES ______ (Skip to 222)
VERIFICATION OF SEVERE ANEMIA IN CHILDREN WITH SIMPLE MALARIA (220 - 221)
2 8.0 G/DL OR HIGHER
3 ABSENT
4 REFUSED
6 OTHER
221 (5). 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)
CHILDREN WITH SEVERE MALARIA (222 - 223)
222. STATEMENT FOR REFERRAL FOR SEVERE MALARIA.
RECORD THE RESULT IN THE ANEMIA AND MALARIA BOOKLET.
The diagnostic test for malaria shows that (CHILD'S NAME) has malaria. Your child is showing symptoms of severe malaria. The medicine that I have for malaria will not help your child, and I cannot give him/her any treatment. Your child is seriously ill and must be taken to a health facility right away. (Skip to 228)
223 (5). STATEMENT FOR REFERRAL FOR CHILDREN ALREADY TAKING ACT MEDICATION.
You have told me that (CHILD'S NAME) has already received ACT for malaria. I cannot give you additional ACT. However, the test shows that he/she has malaria. If your child has a fever for 2 days after the last dose of ACT, you should take your child to the nearest health centre for further testing. (Skip to 230)
CHECK HOUSEHOLD SCHEDULE: LINE NUMBER FROM COLUMN 9
NAME ______
224 (2). READ THE INFORMATION FOR MALARIA TREATMENT AND STATEMENT OF CONSENT TO THE PARENT/OTHER RESPONSIBLE ADULT FOR CHILD.
The malaria test shows that your child has malaria. We can give you free medicine. The medicine is called ACT. ACT is very effective and in a few days, he/she will no longer have a fever or any other symptoms. You do not have to give the medicine to your child. It is your decision. Please tell me whether you accept the medication or not.
225. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
2 REFUSED (sign name)
6 OTHER
226. CHECK 225:
MEDICINE ACCEPTED
2 REFUSED (Skip to 230)
6 OTHER (Skip to 230)
227. TREATMENT FOR CHILDREN WHO TEST POSITIVE FOR MALARIA.
Children under age 1
Day 2 (1/2 pill two times per day)
Day 3 (1/2 pill two times per day)
Children age 1 - 5
Day 2 (1 pill two times per day)
Day 3 (1 pill two times per day)
ALSO TELL THE CHILD'S PARENT/RESPONSIBLE ADULT: If (NAME) has a high fever, difficulty breathing or fast breathing, if he/she cannot drink or nurse, if his/her condition gets worse or does not improve in two days, you must take him/her immediately to see a health professional for treatment.
(Skip to 230)
2 8.0 G/DL OR HIGHER (Skip to 230)
3 ABSENT (Skip to 230)
4 REFUSED (Skip to 230)
6 OTHER (Skip to 230)
229. STATEMENT OF REFERRAL FOR SEVERE ANEMIA
The diagnostic test for anemia shows that (NAME OF CHILD) has severe anemia. Your child is seriously ill and must be taken to a health facility immediately.
230. RETURN TO 203 IN THE NEXT OF COLUMN OF THIS QUESTIONNAIRE OR THE FIRST COLUMN OF THE FOLLOWING PAGE; IF NO MORE CHILDREN, GO TO 231.
MINUTES ______
INTERVIEWER'S OBSERVATIONS
TO BE FILLED OUT ONCE THE INTERVIEW IS COMPLETED
______
COMMENTS ABOUT PARTICULAR QUESTIONS
______
OTHER COMMENTS
______
TEAM LEADER'S OBSERVATIONS
______
NAME OF TEAM LEADER ______
DATE ______
SUPERVISOR'S OBSERVATIONS
______