MINISTRY OF PUBLIC HEALTH AND THE FIGHT AGAINST AIDS (MSPLS)
MINISTRY OF FINANCE AND ECONOMIC DEVELOPMENT PLANNING (MFPDE)
SURVEY OF MALARIA INDICATORS IN BURUNDI (2012 EDITION)
EIPBU 2012
HOUSEHOLD QUESTIONNAIRE
Implementing agency:
INSTITUTE OF STATISTICS AND ECONOMIC STUDIES OF BURUNDI (ISTEEBU)
Technical assistance:
ICF International
SURVEY OF MALARIA INDICATORS IN BURUNDI
EIPBU 2012
HOUSEHOLD QUESTIONAIRE
REPUBLIC OF BURUNDI
INSTITUTE OF STATISTICS AND ECONOMIC STUDIES OF BURUNDI (ISTEEBU)
NAME OF LOCALITY/SUB-HILL (COLLINE) ______
NAME OF HEAD OF HOUSEHOLD ______
PROVINCE ______
COMMUNE ______
NAME OF HILL (COLLINE) ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER ______
URBAN-RURAL AREA (1 = URBAN, 2 = RURAL) ______
(Repeat up to 3 visits)
DATE ______
NAME OF INTERVIEWER ______
RESULT ______
NEXT VISIT:
DATE ______
TIME ______
FINAL VISIT
DAY ______
MONTH ______
YEAR 20______
INTERVIEWER NUMBER ______
RESULT ______
TOTAL NUMBER OF VISITS ______
RESULT CODES:
1 COMPLETED
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 PEOPLE IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN ______
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE ______
TEAM LEADER
NAME ______
FIELD EDITOR
(Number) ______
DATA ENTRY AGENT
(Number) ______
[###translator's note: Throughout this survey, all questions or statements that are directly addressed to the respondent are given in Kirundi as well as French]
INTRODUCTION AND INFORMED CONSENT
Hello. My name is ______ and I work for the Institute of Statistics and Economic Studies of Burundi (ISTEEBU). We are conducting a national survey on malaria throughout the country in collaboration with the Ministry of Health and the Fight Against AIDS. 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 10 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 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 ISTEEBU general management at 22 22 26 35.
Do you have any questions?
May I begin the interview now?
SIGNATURE OF INTERVIEWER: ______
DATE: ______
1 RESPONDENT AGREES TO BE INTERVIEWED (Continue to Household Schedule)
2 RESPONDENT DECLINES TO BE INTERVIEWED (Skip to END)
Now we would like some information on the people who usually live in your household or who are currently living in your household.
(Repeat Q. 1 - 16 for up to 20 people)
2. HABITUAL RESIDENTS AND VISITORS
Please give me the names of people who usually live in your household and of any visitors who spent the night here last night, beginning with the head of household.
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 - 16 FOR EACH PERSON.
______
3. FAMILY RELATIONSHIP TO HEAD OF HOUSEHOLD.
What is (NAME)'s relationship to head of household?
SEE CODES BELOW.
______
CODES FOR Q. 3: FAMILY RELATIONSHIP TO HEAD OF HOUSEHOLD
01 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 FATHER-IN-LAW/MOTHER-IN-LAW
08 BROTHER OR SISTER
09 NIECE/NEPHEW
10 NIECE/NEPHEW BY MARRIAGE
11 OTHER RELATIVE
12 ADOPTED/FOSTER/STEPCHILD
13 NO FAMILY RELATION
98 DK
4. GENDER
Is (NAME) male or female?
1 MALE
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?
YES ______ (ADD TO SCHEDULE)
NO ______
2B. Are there other people who are perhaps not family members, such as servants, renters, or friends who usually live here?
YES ______ (ADD TO SCHEDULE)
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?
YES ______ (ADD TO SCHEDULE)
NO ______
5. RESIDENCE
Does (NAME) usually live here?
1 YES
2 NO
6. RESIDENCE
Did (NAME) spend the night here last night?
1 YES
2 NO
IF 95 OR OLDER, RECORD '95'.
IN YEARS ______
8. ELIGIBLE WOMEN
CIRCLE THE LINE NUMBER OF ALL ELIGIBLE WOMEN AGE 15 - 49
8A. ELIGIBLE WOMEN
FOR ALL ELIGIBLE WOMEN, ASK:
Is (NAME) pregnant?
1 YES
2 NO/DK
9. ELIGIBLE CHILDREN
CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0 - 5.
12. IF AGE 5 OR OLDER
Has (NAME) ever attended school?
1 YES
2 NO/DK (Skip to 14)
13. IF AGE 5 OR OLDER
ATTENDED SCHOOL
What is the highest level of education that (NAME) reached?
SEE CODES BELOW
What is the last class/year that (NAME) successfully completed at that level?
IF NO YEAR WAS COMPLETED FOR A LEVEL, RECORD 0 FOR YEAR.
LEVEL ______
YEAR ______
CODES FOR COL. 13
LEVEL OF EDUCATION
1 PRIMARY
2 SECONDARY 1ST CYCLE
3 SECONDARY 2ND CYCLE
4 HIGHER
8 DK
PRIMARY
1 1st year
2 2nd year
3 3rd year
4 4th year
5 5th year
6 6th year
8 DK
SECONDARY 1ST CYCLE
1 7th year
2 8th year
3 9th year
4 10 year
8 DK
SECONDARY 2ND CYCLE
1 11th year
2 12th year
3 13th year
4 14th year
8 DK
HIGHER
1 1st year
2 2nd year
3 3rd year
4 4th year or higher
14. FOR EVERYONE (FEVER AND TREATMENT)
In the last two weeks, has (NAME) had any illness with a fever?
1 YES
2 NO (Go to next line)
8 DK (Go to next line)
15. FOR EVERYONE (FEVER AND TREATMENT)
Has (NAME) received any treatment to treat the fever in the last two weeks?
1 YES
2 NO (Go to next line)
8 DK (Go to next line)
16. FOR EVERYONE (FEVER AND TREATMENT)
Where was treatment for (NAME) sought out the first time?
SEE CODES BELOW
______
CODES FOR COL. 16
PUBLIC SECTOR
11 GOVERNMENT HOSPITAL
12 GOVERNMENT HEALTH CENTRE
13 HEALTH POST
14 MOBILE CLINIC
15 HEALTH AGENT
16 OTHER PUBLIC
PRIVATE SECTOR
21 HOSPITAL/CLINIC
22 PHARMACY
23 PRIVATE DOCTOR
24 PRIVATE HEALTH CENTRE
25 HEALTH AGENT
26 OTHER PRIVATE
OTHER SECTOR
31 SHOP
32 TRADITIONAL HEALER
33 MARKET
34 COMMUNITY HEALTH AGENT
36 OTHER
CHECK HERE IF USING ANOTHER SHEET ______
101. Where does the drinking water used by members of your household mainly come from?
11 FAUCET IN DWELLING (Skip to 104)
12 FAUCET IN YARD (Skip to 104)
13 PUBLIC TAP/STANDPIPE
14 PRIVATE FAUCET/FAUCET AT NEIGHBOR'S
21 BOREHOLE/PUMP WELL
DUG WELL
31 PROTECTED WELL
32 UNPROTECTED WELL
SPRING WATER
41 PROTECTED SPRING
42 UNPROTECTED SPRING
51 RAINWATER (Skip to 104)
61 TANKER WATER
81 SURFACE WATER (RIVERS/DAMS/LAKES/PONDS/IRRIGATION CANALS)
91 BOTTLED WATER
96 OTHER (SPECIFY) ______
102. Where is this water source located?
2 IN YOUR YARD/PLOT (Skip to 104)
3 ELSEWHERE
103. How long does it take to go there, get the water and come back?
998 DK
104. What kind of toilets do members of your household usually use?
11 CONNECTED TO SEWER SYSTEM
12 CONNECTED TO SEPTIC SYSTEM
13 CONNECTED TO TOILET PIT
14 CONNECTED TO SOMETHING ELSE
15 CONNECTED TO UNKNOWN PLACE
PIT LATRINE
21 IMPROVED SELF-AERATED PIT LATRINE
22 PIT LATRINE WITH WASHABLE SLAB
23 PIT LATRINE WITH NON-WASHABLE SLAB
24 PIT LATRINE WITHOUT SLAB/OPEN PIT
31 COMPOSTING TOILET
41 BUCKET/TIN PAIL
51 SUSPENDED TOILET/LATRINE
61 NO TOILET/IN NATURE (Skip to 107)
96 OTHER (SPECIFY) ______
105. Do you share this toilet with other households?
2 NO (Skip to 107)
106. How many households use this toilet?
95 10 OR MORE HOUSEHOLDS
98 DK
107. In this household, do you have (a):
Electricity?
Radio set?
Television set?
Mobile phone?
Landline phone?
Refrigerator?
1 YES
2 NO
RADIO
1 YES
2 NO
TELEVISION
1 YES
2 NO
MOBILE PHONE
1 YES
2 NO
LANDLINE PHONE
1 YES
2 NO
REFRIGERATOR
1 YES
2 NO
108. What type of fuel does your household mainly use for cooking?
02 LIQUIFIED PROPANE GAS (LPG)
03 NATURAL GAS
04 BIOGAS
05 KEROSENE
06 COAL, LIGNITE, PEAT
07 CHARCOAL
08 WOOD
09 STRAW/BRANCHES/GRASS
10 AGRICULTURAL WASTE
11 DUNG
95 NO MEALS PREPARED IN HOUSEHOLD
96 OTHER (SPECIFY) ______
109. MAIN MATERIAL OF FLOOR
RECORD OBSERVATION.
11 EARTH/SAND
12 DUNG
RUDIMENTARY MATERIAL
21 WOOD PLANKS
22 PALMS/BAMBOO
MANUFACTURED MATERIAL
31 PARQUET OR WAXED WOOD
32 VINYL/ASPHALT STRIPS
33 TILE
34 CEMENT
35 CARPET
96 OTHER (SPECIFY) ______
110. MAIN MATERIAL OF ROOF
RECORD OBSERVATION.
11 NO ROOF
12 THATCH/PALM LEAVES/LEAVES
13 CLUMPS OF EARTH
RUDIMENTARY MATERIAL
21 MATS
22 PALMS/BAMBOO
23 WOOD PLANKS
24 CARDBOARD
MANUFACTURED MATERIAL
31 SHEET METAL/METAL/"INTERNIT"
32 WOOD
33 CONCRETE
34 CERAMIC TILES
35 CEMENT
36 CLAY TILES
96 OTHER (SPECIFY) ______
[###translator's note: unable to translate Code 31, "INTERNIT"]
111. MAIN MATERIAL OF EXTERIOR WALLS
RECORD OBSERVATION.
11 NO WALLS
12 BAMBOO/TREE TRUNKS/PALM
13 EARTH
RUDIMENTARY MATERIAL
21 BAMBOO WITH MUD
22 STONES WITH MUD
23 UNFINISHED ADOBE
24 PLYWOOD
25 CARDBOARD
26 SALVAGED WOOD
DEVELOPED MATERIAL
31 CEMENT
32 STONES WITH LIME/CEMENT
33 FIRED BRICKS
34 CEMENT BLOCKS
35 FINISHED BRICKS (NOT FIRED)
36 WOOD PLANKS/SHINGLES
96 OTHER (SPECIFY) ______
112. In this household, how many rooms are used for sleeping?
113. Does any member of your household own a/an:
Watch?
Bicycle?
Motorcycle or a scooter?
Animal-drawn cart?
Car or van?
Motorboat?
1 YES
2 NO
BICYCLE
1 YES
2 NO
MOTORCYCLE/SCOOTER
1 YES
2 NO
ANIMAL-DRAWN CART
1 YES
2 NO
CAR/VAN
1 YES
2 NO
MOTORBOAT
1 YES
2 NO
114. Does any member of your household own any agricultural land?
2 NO (Skip to 116)
115. How many hectares of agricultural land do members of your household own?
IF 95 OR MORE, CIRCLE '9500'.
9500 95 HECTARES OR MORE
9998 DK
116. Does your household own any livestock, herds of other farm animals or poultry?
2 NO (Skip to 118)
117. How many of the following animals does your household own?
IF 95 OR MORE, RECORD '95'.
IF DK, RECORD '98'.
Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Pigs?
Poultry (Chickens, duck, pigeon, turkey, guinea fowl)?
Guinea pigs?
Rabbits?
HORSES, DONKEYS, OR MULES ______
GOATS ______
SHEEP ______
PIGS ______
POULTRY ______
GUINEA PIGS ______
RABBITS ______
118. Does any member of your household have an account in a bank or other financial institution?
2 NO
119. At any time in the last 12 months did someone come to your dwelling to spray the interior walls for mosquitos to fight malaria?
2 NO (Skip to 121)
8 DK (Skip to 121)
120. Who sprayed the walls of the dwelling?
B PRIVATE COMPANY
C NON-GOVERNMENTAL ORGANIZATION (NGO)
X OTHER (SPECIFY) ______
Z DK
121. Does your household have any mosquito nets that can be used for sleeping?
2 NO (Skip to 201)
122. How many mosquito nets does your household have?
IF 7 OR MORE MOSQUITO NETS, RECORD '7'.
123. ASK RESPONDENT TO SHOW YOU THE HOUSEHOLD'S MOSQUITO NETS.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
(Repeat Q. 123 - 130 for up to 3 mosquito nets)
1 OBSERVED
2 NOT OBSERVED
123A. Did you receive this mosquito net:
a) during the 2009 campaign
b) during the 2010 campaign
c) during the 2011 campaign
d) at an antenatal check-up
e) at a child's vaccination appointment
f) on another occasion
2 2010 CAMPAIGN
3 2011 CAMPAIGN
4 ANTENATAL CONSULTATION/DELIVERY
5 VACCINATION
6 OTHER
124. How many months has your household had the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'.
95 36 MONTHS OR MORE
98 NOT SURE
125. OBSERVE OR ASK THE BRAND OF MOSQUITO NET
IF BRAND IS NOT KNOWN AND YOU CANNOT OBSERVE THE MOSQUITO NET, SHOW PHOTOS OF COMMON MOSQUITO NETS TO THE RESPONDENT.
(Codes 11 - 16 all skip to 127A)
11 OLYSET
12 INTERCEPTOR
13 PERMANET
16 OTHER/DK BRAND
PRE-TREATED MOSQUITO NET
21 INSECTICIDE-TREATED NET
26 OTHER/DK BRAND
96 OTHER BRAND
98 DK BRAND
126. Since you have had this mosquito net, has it been soaked or dipped in an insecticide to kill or repel mosquitos?
2 NO (Skip to 127A)
8 NOT SURE (Skip to 127A)
127. How many months ago was the mosquito net dipped or soaked for the last time?
IF LESS THAN ONE MONTH, RECORD '00'. IF LESS THAN TWO YEARS, RECORD THE NUMBER OF MONTHS. IF '12 MONTHS' OR '1 YEAR', PROBE TO GET THE EXACT NUMBER OF MONTHS.
95 24 MONTHS OR MORE
98 NOT SURE
127A. OBSERVE THE MOSQUITO NET AND EVALUATE ITS CONDITION OR ASK
Would you say this mosquito net is in good condition, average condition or bad condition?
2 AVERAGE CONDITION
3 BAD CONDITION
128. Did anyone sleep under the mosquito net last night?
2 NO (Skip to 130)
8 NOT SURE (Skip to 130)
129. Who slept under the mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
NAME ______
LINE NUMBER ______
130. RETURN TO 123 FOR NEXT MOSQUITO NET OR, IF THERE ARE NO MORE NETS, CONTINUE TO 130A.
130A. Do you currently own a mosquito net that you are not using/no longer using for sleeping?
2 NO (Skip to 201)
130B. How many mosquito nets do you currently own that you are not using/no longer using for sleeping?
IF 5 OR MORE MOSQUITO NETS, RECORD '5'
130C. What are the mosquito nets being used for if they are not being used for sleeping?
B CURTAIN
C CROP PROTECTION
D FISHING
E FUTURE USE
X OTHER USE (SPECIFY) ______
Z DK
ANEMIA AND MALARIA TESTING FOR CHILDREN AGE 0 - 5
201. CHECK COLUMN 9 OF HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL CHILDREN AGE 0 - 5 IN Q. 202. IF THERE ARE MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
202. LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2
(Repeat Q. 202 - 228 for up to 6 children)
LINE NUMBER ______
NAME ______
203. IF MOTHER IS RESPONDENT, COPY THE MONTH AND YEAR OF BIRTH FOR THE CHILD FROM THE BIRTH HISTORY (Q. 215) 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 2007 OR LATER?
2 NO (GO TO 203 FOR NEXT CHILD, OR IF NO MORE CHILDREN, END INTERVIEW)
205. CHECK 203:
IS THE CHILD AGE 0 - 5 MONTHS, THAT IS, WAS HE/SHE BORN DURING THE MONTH OF SURVEY OR IN THE 5 PRECEDING MONTHS?
2 OLDER
206. LINE NUMBER OF CHILD'S PARENT/OTHER RESPONSIBLE ADULT (COLUMN 1, 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.
[###translator's note: text given only in Kirundi language. Standard consent declaration for anemia testing from MIS survey used]
We are asking all children born in 2007 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.
[###translator's note: text given only in Kirundi language. Standard consent declaration for malaria testing from MIS survey used]
We are asking all children born in 2007 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?
NAME FROM COLUMN 2
NAME ______
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.
ATTACH THE 1ST BAR CODE STICKER HERE
99995 REFUSED
99996 OTHER
ATTACH THE 2ND AND 3RD BAR CODES ON THE SLIDES AND THE 4TH ON THE TRANSMISSION SHEET.
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 OTHER POSITIVE (Skip to 218)
3 MIXED POSITIVE (Skip to 218)
4 NEGATIVE
6 OTHER
HEMOGLOBIN LEVEL
2 8.0 G/DL OR HIGHER (Skip to 229)
4 ABSENT (Skip to 229)
5 REFUSED (Skip to 229)
6 OTHER (Skip to 229)
217. STATEMENT FOR REFERRAL FOR SEVERE ANEMIA.
[###translator's note: text given only in Kirundi language. Standard Statement for Referral for Severe Anemia from MIS survey used]
NAME FROM COLUMN 2
NAME ______
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?
1 YES
2 NO
HEART PROBLEMS
1 YES
2 NO
LOSS OF CONSCIOUSNESS
1 YES
2 NO
FAST BREATHING
1 YES
2 NO
CONVULSIONS
1 YES
2 NO
ABNORMAL BLEEDING
1 YES
2 NO
JAUNDICE/YELLOW SKIN
1 YES
2 NO
DARK URINE
1 YES
2 NO
IS THERE AT LEAST ONE YES =1 CIRCLED?
2 AT LEAST ONE 'YES' (1) CIRCLED (Skip to 222)
HEMOGLOBIN LEVEL
2 8.0 G/DL OR HIGHER
4 ABSENT
5 REFUSED
6 OTHER
221. In the last two weeks, did (NAME) take or is (NAME) taking (FIRST LINE MEDICATION) given by a doctor or health centre to treat the malaria?
CHECK BY ASKING TO SEE THE TREATMENT.
2 NO (Skip to 224)
222. STATEMENT FOR REFERRAL FOR SEVERE MALARIA.
[###translator's note: text given only in Kirundi language. Standard Statement for Referral for Severe Malaria from MIS survey used]
223. STATEMENT FOR REFERRAL FOR CHILDREN ALREADY TAKING FIRST LINE 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 (Go to signature)
6 OTHER
MEDICATION ACCEPTED
2 REFUSED (Skip to 228)
6 OTHER (Skip to 228)
227. TREATMENT FOR CHILDREN WHO TEST POSITIVE FOR MALARIA.
FOR CHILDREN AGE 1 TO 5, USE THE BROWN PACK.
INSTRUCTIONS FOR DOSAGE
ACT TREATMENT (Artesunate + Amodiaquine)
Weight (in Kg) - Approximate age
4.5 Kg to 8 Kg (6 to 11 months old)
Day 1 1 Tablet (25mg Artesunate + 67.5mg Amodiaquine)
Day 2 1 Tablet (25mg Artesunate + 67.5mg Amodiaquine)
Day 3 1 Tablet (25mg Artesunate + 67.5mg Amodiaquine)
9 Kg to less than 18 Kg (1 to 5 years old)
Day 1 1 Tablet (50mg Artesunate + 135mg Amodiaquine)
Day 2 1 Tablet (50mg Artesunate + 135mg Amodiaquine)
Day 3 1 Tablet (50mg Artesunate + 135mg Amodiaquine)
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.
228. RECORD THE RESULT CODE FOR TREATMENT OF MALARIA OR REFERRAL.
2 MEDICINE REFUSED
3 REFERRAL FOR SEVERE MALARIA
4 REFERRAL FOR CHILD ALREADY TAKING ACT
6 OTHER
229. RETURN TO 203 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE EXTRA QUESTIONNAIRE(S); IF NO MORE CHILDREN, END HERE.