FORMATTING DATE: 16 SEP. 2019
ENGLISH LANGUAGE: 29 SEP. 2016
2019 GHANA MALARIA INDICATOR SURVEY HOUSEHOLD QUESTIONNAIRE
MINISTRY OF HEALTH
GHANA STATISTICAL SERVICE
IDENTIFICATION
LOCALITY NAME _____________________________
NAME OF HOUSEHOLD HEAD ___________________________
REGION _________________________
DISTRICT _________________________
CLUSTER NUMBER ________________
HOUSEHOLD NUMBER _______________________
VISITS 1, 2, AND 3
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:
TIME _____________________
FINAL VISIT
MONTH ____________
YEAR 2019
INTERVIEWER NUMBER ________________
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 NUMBER OF VISITS _________________
TOTAL PERSONS IN HOUSEHOLD ______________
TOTAL ELIGIBLE WOMEN _______________
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONAIRE _____________
LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
AKAN 02
GA 03
EWE 04
DAGBANI 05
OTHER ____________(SPECIFY) 06
AKAN 02
GA 03
EWE 04
DAGBANI 05
OTHER ____________(SPECIFY) 06
NO 2
NUMBER ___________________
Hello. My name is __________________________. I am working with Ghana Statistical Service and the Ministry of Health. We are conducting a survey about malaria all over Ghana. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you 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. In case you need more information about the survey, you may contact the person listed on this card.
GIVE CARD WITH CONTACT INFORMATION
Do you have any questions? May I begin the interview now?
DATE ___________
RESPONDENT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES __________________
01. LINE NUMBER ___________________
02. USUAL RESIDENTS AND VISITORS
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.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-9 FOR EACH PERSON.
2A. Just to make sure that I have a complete listing: are there any other people 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, such as 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
03. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
WIFE OR 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
04. SEX: Is (NAME) male or female?
FEMALE 2
05. Does (NAME) usually live here?
NO 2
06. Did (NAME) stay here last night?
NO 2
07. AGE: How old is (NAME)?
IF 95 OR MORE, RECORD '95'.
7A. DATE OF BIRTH: What is (NAME)'s date of birth? On what day, month, and year was (NAME) born?
IF DON'T KNOW DAY, RECORD '98'
IF DON'T KNOW MONTH, RECORD '98'
IF DON'T KNOW YEAR, RECORD '9998'
MONTH__________
YEAR _________
8. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
9. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (SKIP TO 105)
PIPED TO NEIGHBOR 13 (SKIP TO 105)
PUBLIC TAP/STANDPIPE 14 (SKIP TO 103)
TUBE WELL OR BOREHOLE 21 (SKIP TO 103)
DUG WELL
UNPROTECTED WELL 32 (SKIP TO 103)
WATER FROM SPRING
UNPROTECTED SPRING 42 (SKIP TO 103)
RAINWATER 51 (SKIP TO 103)
TANKER TRUCK 61 (SKIP TO 103)
CART WITH SMALL TANK 71 (SKIP T0 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRICATION CHANNEL) 81 (SKIP TO 103)
BOTTLED WATER 91
SACHET WATER 92
OTHER ___________________(SPECIFY) 96 (SKIP TO 103)
102. What is the main source of water used by your household for other purposes such as cooking and handwashing?
PIPED TO YARD/PLOT 12 (SKIP TO 105)
PIPED TO NEIGHBOR 13 (SKIP TO 105)
PUBLIC TAP/STANDPIPE 14
TUBE WELL OR BOREHOLE 21
DUG WELL
UNPROTECTED WELL 32
WATER FROM SPRING
UNPROTECTED SPRING 42
RAINWATER 51
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRICATION CHANNEL) 81
BOTTLED WATER 91
SACHET WATER 92
OTHER ___________________(SPECIFY) 96
103. Where is that water source located?
IN OWN YARD/PLOT 2 (SKIP TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
105. What kind of toilet facility do members of your household usually use?
IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
FLUSH, BIO-DIGESTER (BIOFIL) 16
PIT LATRINE
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUBCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (SKIP TO 108)
OTHER ________________(SPECIFY) 96
106. Do you share this toilet facility with other households?
NO 2 (SKIP TO 108)
107. Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
108. What type of fuel does your household mainly use for cooking?
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COOKING GEL 06
CHARCOL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP RESIDUE 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95
OTHER ________________(SPECIFY) 96
109. How many rooms in this household are used for sleeping?
110. Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (SKIP TO 112)
111. How many of the following animals does this household own?
IF NONE, RECORD '00'.
IF 95 OR MORE, RECORD '95'.
IF UNKNOWN, RECORD '98'.
b. Other cattle?
c. Horses, donkeys, or mules?
d. Goats?
e. Sheep?
f. Chickens or other poultry?
g. Pigs?
h. Rabbits?
i. Grasscutter?
112. Does any member of your household own any agricultural land?
NO 2 (SKIP TO 114)
113. How many hectares or acres or plots of agricultural land do members of this household own?
IF 95 OR MORE HECTARES, RECORD '950'
IF 95 OR MORE ACRES, RECORD IN HECTARES
IF 95 OR MORE PLOTS, RECORD IN ACRES
ACRES 2 ___________._____
PLOTS 3 ___________.____
95 OR MORE HECTARES 950
DON'T KNOW 998
114. Does your household have:
NO 2
b. A radio?
NO 2
c. A television?
NO 2
d. A non-mobile telephone?
NO 2
e. A computer/Tablet computer?
NO 2
f. A refrigerator?
NO 2
g. A freezer?
NO 2
h. An electric generator/Invertor?
NO 2
i. A washing machine?
NO 2
j. A photo camera? (NOT ON PHONE)
NO 2
k. A video deck/DVD/VCD?
NO 2
l. A sewing machine?
NO 2
m. A bed?
NO 2
n. A table?
NO 2
o. A chair?
NO 2
p. A cabinet/cupboard?
NO 2
115. Does any member of this household own:
NO 2
b. A mobile phone?
NO 2
c. A bicycle?
NO 2
d. A motorcycle or motor scooter?
NO 2
e. An animal-drawn cart?
NO 2
f. A car or truck?
NO 2
g. A boat with a motor?
NO 2
h. A boat without a motor?
NO 2
116. Does any member of this household have a bank account?
NO 2
117. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?
NO 2 (SKIP TO 119)
DON'T KNOW 8 (SKIP TO 119)
118. Who sprayed the dwelling?
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER _________________(SPECIFY) X
DON'T KNOW Z
119. Does your household have any mosquito nets?
NO 2 (SKIP TO 131)
120. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.
NET #1, #2, AND #3
121. ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
OBSERVED NOT HANGING/PACKAGED 2
NOT OBSERVED 3
122. How many months age did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
123. OBSERVE OR ASK BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT
PERMANET 12
INTERCEPTOR 13
ROYAL SENTRY 14
DURANET 15
LIFE NET 16
DAWA PLUS 17
MAGNET 18
YORKOOL 19
OTHER/DON'T KNOW BRAND 20
OTHER TYPE 96
DON'T KNOW TYPE 98
126. Did you get the net through the 2018 mass distribution campaign, during an antenatal care visit, during an immunization visit, or during a school distribution?
YES, ANC 2 (SKIP TO 128)
YES, IMMUNIZATION VISIT 3 (SKIP TO 128)
YES, SCHOOL DISTRICT 4 (SKIP TO 128)
NO 5
127. Where did you get the net?
PHARMACY/CHEMIST/DRUG STORE 02
SHOP/MARKET 03
RELIGIOUS INSTITUTION 04
NGO 05
COMMUNITY BASED AGENTS (CBAs) 06
PETROL STATION/MOBILE MART 07
PRIOR MASS DISTRIBUTION CAMPAIGN 08
OTHER 96
DON'T KNOW 98
128. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 129A)
NOT SURE 8 (SKIP TO 129A)
129. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.
LINE NUMBER ____________ (SKIP TO 130)
129A. Why was this net not used last night?
RECORD ALL MENTIONED.
NO MOSQUITOES B
NO MALARIA C
PREFER OTHER METHOD (COILS, SPRAY, FANS) D
NET TOO OLD/TORN E
CHEMICALS IN NET ARE UNSAFE F
DON'T LIKE SMELL G
NET TOO SHORT/SMALL H
USUAL USER DID NOT SLEEP HERE I
EXTRA NET/SAVING FOR LATER J
NET WAS BEING WASHED/DRIED/AIRED K
SLEPT OUTSIDE L
NET BROUGHT BUGS M
DON'T LIKE SHAPE N
OTHER X
130. GO BACK TO 121 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 131.
ADDITIONAL HOUSEHOLD CHARACTERISTICS
131. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING.
RECORD OBSERVATION.
DUNG 12
RUDIMENTARY FLOOR
PALM/BAMBOO 22
FINISHED FLOOR
VINYL OR ASPHALT STRIPS 32
CERAMIC/MARBLE/PORCELAIN TILES/TERRAZO 33
CEMENT 34
WOOLEN CARPETS/SYNTHETIC CARPET 35
LINOLEUM/RUBBER CARPET 36
OTHER _______________(SPECIFY) 96
132. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.
THATCH/PALM LEAF 12
SOD 13
RUDIMENTARY ROOFING
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
WOOD 32
CERAMIC/BRICK TILES 33
CEMENT 34
ROOFING SHINGLES 35
ASBESTOS/SLATE ROOFING SHEETS 36
OTHER _________________(SPECIFY) 96
133. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.
CANE/PALM/TRUNKS 12
MUD/LANDCRETE 13
RUDIMENARY WALLS
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED WALLS
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER _____________________(SPECIFY) 96
MINUTES ______________
INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW:
_______________________________________
COMMENTS ON SPECIFIC QUESTIONS:
_______________________________________
ANY OTHER COMMENTS:
_______________________________________
SUPERVISOR'S OBSERVATIONS
_______________________________________