2009 LIBERIA MALARIA INDICATOR SURVEY
WOMAN'S QUESTIONNAIRE

NATIONAL MALARIA CONTROL PROGRAM - MINISTRY OF HEALTH AND SOCIAL WELFARE
LIBERIA INSTITUTE OF STATISTICS AND GOE-INFORMATION SERVICES

IDENTIFICATION

NAME OF COUNTY
DISTRICT
CLAN/TOWNSHIP
LMIS CLUSTER NUMBER
HOUSEHOLD NUMBER
URBAN

MONROVIA 1
OTHER URBAN 2
VILLAGE 3

NAME OF HOUSEHOLD HEAD
NAME AND LINE NUMBER OF WOMAN

INTERVIEWER VISITS

DATE
INTERVIEWERS NAME
RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7

NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7

SUPERVISOR
NAME
DATE
OFFICE EDITOR
KEYED BY

INTRODUCTION AND CONSENT

Hello. My name is ____ and I'm from the Ministry of Health. We are talking to people 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 10 to 20 minutes to complete. The information you give will be kept confidential and will not be shared with anyone other than members of our 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 the interviewer ___
Date___

RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE TIME.

HOUR
MINUTES

102. How long have you been continuously living in (NAME OF CURRENT PLACE OR RESIDENCE)? IF LESS THAN ONE YEAR, RECORD '00' YEARS.

YEARS__
ALWAYS 95 (GO TO 104)
VISITOR 96 (GO TO 104)

103. Just before you moved here, did you live in a city, in a town, or in a village?

CITY 1
TOWN 2
VILLAGE 3

104. In what month and year were you born?

MONTH__
DON?T KNOW MONTH 98
YEAR ____
DON?T KNOW YEAR 9998

105. How old are you? COMPARE AND CORRECT 104 AND/OR 105 IF INCONSISTENT.

AGE IN COMPLETED YEARS__

106. Have you ever attended school?

YES 1
NO 2 (GO TO 110)

107. What is the highest level of education you attended: primary, secondary, or higher?

PRIMARY 1
SECONDARY 2
HIGHER 3

108. What is the highest grade you completed?

GRADE__

109. CHECK 108

PRIMARY (CONTINUE)
SECONDARY OR HIGHER (GO TO 111)

110. Now I would like you to read this sentence to me. SHOW SENTENCE TO RESPONDENT. IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?
1. The child is reading a book
2. Farming is hard work
3. Parents should care for their children
4. The rains were heavy this year

CANNOT READ AT ALL 1
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) 4
BLIND/VISUALLY IMPAIRED 5

111. What is your religion?

CHRISTIAN 1
MUSLIM 2
TRADITIONAL RELIGION 3
NO RELIGION 4
OTHER (SPECIFY) 6

112. What dialect do you speak very well (besides English)?

BASSA 01
GBANDI 02
BELLE 03
DEY 04
GIO 05
GOLA 06
GREBO 07
KISSI 08
KPELLE 09
KRAHN 10
KRU 11
LORMA 12
MANDIGO 13
MANO 14
MENDE 15
VAI 16
NONE/ONLY ENGLISH 17
OTHER 96

SECTION 2. REPRODUCTION

201. Now I would like to ask you about all the births you?ve had during your life. Have you ever born a child?

YES 1
NO 2 (GO TO 206)

202. Do you have any children you born who are living with you? I mean belly born.

YES 1
NO 2 (GO TO 204)

203. How many sons live with you? And how many daughters live with you? IF NONE, RECORD '00'.

SONS AT HOME___
DAUGHTERS AT HOME___

204. Do you have any children you born who are alive but do not live with you?

YES 1
NO 2 (GO TO 206)

205. How many sons are alive but do not live with you? And how many daughters are alive but do not live with you? IF NONE, RECORD '00'

SONS ELSEWHERE___
DAUGHTERS ELSEWHERE___

206. Have you ever born a child who was born alive and later died? IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

YES 1
NO 2 (GO TO 208)

207. How many boys have died? And how many girls have died? IF NONE, RECORD '00'

BOYS DEAD__
GIRLS DEAD__

208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'

TOTAL__

209. CHECK 208: So in all you have belly born __ (TOTAL) children in your life. Is that correct?

YES (CONTINUE)
NO (PROBE AND CORRECT 201-208 AS NECESSARY)

210. CHECK 208

ONE OR MORE BIRTHS (CONTINUE)
NO BIRTHS, Q.208 IS '00' (GO TO 224)

211. Now I want the names of all the children you born, whether still alive or not, starting with the first one. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (IF THERE ARE MORE THAN 12 BIRTHS, USE ADDITIONAL QUEATIONNAIRE STARTING WITH THE SECOND ROW)

212. What is/was the name of your (first/next) child?

NAME__

213. Were any of these births twins?

SINGLE 1
MULTIPLE 2

214. Is (NAME) a boy or a girl?

BOY 1
GIRL 2

215. In what month and year was (NAME) born? (PROBE) What is his/her birthday?

MONTH__
YEAR____

216. Is (NAME) still living?

YES 1
NO 2 (GO TO 220)

217. IF LIVING: How old is (NAME)? RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS__

218. IF LIVING: Is (NAME) still living with you?

YES 1
NO 2

219. IF LIVING: RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD)

LINE NUMBER__ (GO TO 221)

220. IF DEAD: How old was (NAME) when he/she died? IF '1YR', PROBE: How many months old was (NAME)? RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN 2 YEARS; OR YEARS.

DAYS 1__
MONTHS 2__
YEARS 3__

221. Did you born any other child between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth?

YES 1 (ADD BIRTH)
NO 2 (NEXT BIRTH)

222. Did you born any child since the birth of (NAME OF LAST BIRTH)? IF YES, RECORD BIRTH(S) IN TABLE.

YES 1
NO 2

223. COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

NUMBERS ARE SAME (CHECK: FOR EACH BIRTH: MONTH AND YEAR OF BIRTH IS RECORDED. FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

224. CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2003 OR LATER. IF NONE, RECORD '0' AND CONTINUE TO Q. 225

225. Are you pregnant now?

YES 1
NO 2 (GO TO 227)
UNSURE 8 (GO TO 227)

226. How many months pregnant are you? RECORD NUMBER OF COMPLETED MONTHS.

MONTHS__

227. CHECK 224:

ONE OR MORE BIRTHS IN 2003 OR LATER (CONTINUE)
NO BIRTHS IN 2003 OR LATER (GO TO 501)

SECTION 3. PREGNANCY AND INTERMITTENT PREVENTATIVE TREATMENT

301. CHECK 212 AND 215: ENTER IN 302 THE NAME AND LINE NUMBER OF THE MOST RECCENT BITH SINCE 2003 EVEN IF THE CHILD IS NO LONGER ALIVE. Now I would like to ask you some questions about your last pregnancy that ended in live birth.

302. NAME AND LINE NUMBER FROM 212

NAME OF LAST BIRTH____
LINE NUMBER__

303. When you were pregnant with (NAME) did you see anyone for a check up (prenatal care) for this pregnancy? IF YES: whom did you see? Anyone else? PROBE TO INDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

DOCTOR A
NURSE/MIDWIFE B
PHYSICIAN ASSISTANT C
TRADITIONAL MIDWIFE D
OTHER (SPECIFY) X
NO ONE Y

303A. During this pregnancy, did anyone tell you that pregnant women need to take some kind of medicine to keep them from getting malaria? EMPHASIZE THE WORD 'KEEP'.

YES 1
NO 2
DON?T KNOW 8

304. During this pregnancy did you take any drugs to keep you from getting malaria? EMPHASIZE 'KEEP'. DO NOT CIRCLE '1' IF SHE WAS ONLY GIVEN DRUGS BECAUSE SHE HAD MALARIA.

YES 1
NO 2 (GO TO 401)
DON?T KNOW 8 (GO TO 401)

305. What drugs did you take to keep from getting malaria? RECORD ALL MENTIONED. IF SHE DOES NOT KNOW THE TYPE OF DRUG, SHOW HER THE TYPICAL ANTIMALARIAL DRUGS. TREATMENT WITH SP/FANSIDAR USUALLY CONSISTS OF TAKING 3 BIG WHITE TABLETS AT THE HEALTH FACILITY.

SP/FANSIDAR A
CHLOROQUINE B
OTHER (SPECIFY) X
DON?T KNOW Z

306. CHECK 305: DRUGS TAKEN FOR MALARIA PREVENTION

CODE 'A' CIRCLED (CONTINUE)
CODE 'A' NOT CIRCLED (GO TO 401)

307. How many times did you take (SP/Fansidar) during this pregnancy?

TIMES__

308. CHECK 303: PRENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

CODE 'A', 'B', OR 'C' CIRCLED (CONTINUE)
OTHER (GO TO 401)

309. Did you get the (SP/Fansidar) during any prenatal care visit, during another visit to a health facility or from another source?

PRENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE (SPECIFY) 6

SECTION 4: FEVER IN CHILDREN

401. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2003 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE FIRST COLUMN). Now I would like to ask you some questions about the health of your children. (We will talk about each one separately.

402. LINE NUMBER FROM 212

LINE NUMBER__

403. FROM 212 AND 216

NAME__
LIVING (CONTINUE)
DEAD (GO TO 403 IN NEXT COLUMN OR, IF NO MORE BIRTHS GO TO 501)

404. Has (NAME) been ill with a fever at any time in the last 2 weeks?

YES 1
NO 2 (GO TO 403 IN NEXT COLUMN OR, IF NO MORE BIRTHS GO TO 501)
DON?T KNOW 8 (GO TO 403 IN NEXT COLUMN OR, IF NO MORE BIRTHS GO TO 501)

405. How many days ago did the fever start? IF LESS THAN ONE DAY, WRITE '00'.

DAYS AGO__
DON?T KNOW 98

406. Did you seek advice or treatment for the fever from any source?

YES 1
NO 2 (SKIP TO 411)

407. Where did you get treatment from? Anywhere else? PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

PUBLIC SECTOR

GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH CLINIC C
OTHER PUBLIC (SPECIFY) D

PRIVATE MEDICAL SECTOR

PRIVATE HOSPITAL/CLINIC E
PHARMACY F
PRIVATE DOCTOR G
MOBILE CLINIC H
OTHER PRIVATE MEDICAL (SPECIFY) I

OTHER SOURCE

SHOP J
TRADITIONAL PRACTITIONER K
OTHER (SPECIFY) X

408. CHECK 407:

TWO OR MORE CODES CIRCLED (CONTINUE)
ONLY ONE CODE CIRCLED (SKIP TO 410)

409. Where did you first go for advice or treatment? USE LETTER CODE FROM 407

FIRST PLACE__

410. When the fever started, how long it took for you to carry the child for advice or treatment? IF THE SAME DAY, RECORD '00'

DAYS__

411. Is (NAME) still sick with fever?

YES 1
NO 2
DON?T KNOW 8

411A. At any time during the illness did (NAME) have a drop of blood taken from his/her finger or heel?

YES 1
NO 2
DON?T KNOW 8

412. At any time during illness, did (NAME) take any drugs for the illness?

YES 1
NO 2 (GO BACK TO 403 IN THE NEXT COLUMN; OR, IF NO MORE BIRTHS, GOT TO 501)
DON?T KNOW 8 (GO BACK TO 403 IN THE NEXT COLUMN; OR, IF NO MORE BIRTHS, GOT TO 501)

413. What drugs did (NAME) take? Any other drugs? RECORD ALL MENTIONED. IF SHE DOES NOT KNOW THE TYPE OF DRUG, SHOW HER THE TYPICAL ANTIMALARIAL DRUGS. IF SHE STILL IS NOT SURE, ASK TO SEE THE DRUGS.

ANTIMALARIAL DRUGS

SP/FANSIDAR A
CHLOROQUINE B
QUININE C
NEW MALARIA MEDICINE (ACT) D
OTHER ANTIMALARIAL (SPECIFY) E

OTHER DRUGS

ASPIRIN F
ACETAMINOPHEN G
IBUPROFEN H
OTHER (SPECFIY) X
DON?T KNOW Z

414. CHECK 413: ANY CODE A-E CIRCLED?

YES (CONTINUE)
NO (GO BACK TO 403 IN THE NEXT COLUMN; OR, IF NO MORE BIRTHS, GOT TO 501)

415. Did you already have (NAME OF DRUG FROM 413) at home when the child became ill? ASK SEPERATELY FOR EACH OF THE DRUGS 'A' THROUGH 'E' THAT THE CHILD IS RECORDED AS HAVING TAKEN IN 413. IF YES FOR ANY DRUG, CIRCLE CODE FOR THAT DRUG. IF NO FOR ALL DRUGS, CIRCLE 'Y'

ANTIMALARIAL DRUGS

SP/FANSIDAR A
CHLOROQUINE B
QUININE C
NEW MALARIA MEDICINE-ACT D
OTHER ANTIMALARIAL (SPECIFY) E

NO DRUG AT HOME Y

416. CHECK 413: SP/FANSIDAR ('A') GIVEN

CODE 'A' CIRCLED (CONTINUE)
CODE 'A' NOT CIRCLED (SKIP TO 419)

417. How long after the fever started did (NAME) first take SP/Fansidar?