2009 LIBERIA MALARIA INDICATOR SURVEY
HOUSEHOLD QUESTIONNAIRE
NATIONAL MALARIA CONTROL PROGRAM - MINISTRY OF HEALTH AND SOCIAL WELFARE
LIBERIA INSTITUTE OF STATISTICS AND GEO-INFORMATION SERVICES
NAME OF COUNTY
NAME OF DISTRICT
NAME OF CLAN/TOWNSHIP
NAME OF CITY/TOWN/VILLAGE
LMIS CLUSTER NUMBER
HOUSEHOLD NUMBER
URBAN:
OTHER URBAN 2
VILLAGE 3
NAME OF HOUSEHOLD HEAD
DATE
INTERVIEWERS NAME
RESULT
NO HOUSEHOLD MEMBBER/NO COMPETENT RESPONDENT 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
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NO HOUSEHOLD MEMBBER/NO COMPETENT RESPONDENT 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 THE HOUSEHOLD
TOTAL WOMEN 15-49
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
SUPERVISOR
NAME
DATE
OFFICE EDITOR
KEYED BY
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 15 to 20 minutes to complete.
The information you give will be kept confidential and will not be shared with anyone other than members of the 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 interviewer___
Date__
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
1. LINE NO.
2. 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, RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-14 FOR EACH PERSON.
3. What is the relationship of (NAME) to the head of the household? SEE CODES BELOW
WIFE OR HUSBAND 2
SON OR DAUGHTER 3
SON-IN-LAW OR DAUGHTER-IN-LAW 4
GRANDCHILD 5
PARENT 6
PARENT-IN-LAW 7
BROTHER OR SISTER 8
NIECE/NEPHEW BY BLOOD 9
NIECE/NEPHEW BY MARRIGE 10
OTHER RELATIVE 11
ADOPTED/FOSTER/STEPCHILD 12
NOT RELATED 13
DON'T KNOW 98
4. Is (NAME) male or female?
FEMALE 2
5. Does (NAME) usually live here?
NO 2
6. Did (NAME) stay here last night?
NO 2
7. How old is (NAME)?
8. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
9. Is (NAME) currently pregnant?
NO/DON'T KNOW 2
10. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
FOR EVERYONE FEVER AND TREATMENT
11. In the last 4 weeks, has (NAME) been sick with a fever at any time?
NO 2 (GO TO NEXT LINE)
DON'T KNOW 8 (GO TO NEXT LINE)
12. Did (NAME) get any treatment for the fever in the last four weeks?
NO 2 (GO TO NEXT LINE)
DON'T KNOW 8 (GO TO NEXT LINE)
13. Where did (NAME) go for treatment? USE CODES BELOW.
GOVERNMENT HEALTH CENTER 02
GOVERNMENT HEALTH CLINIC 03
PRIVATE HOSPITAL/CLINIC 04
PHARMACY 05
PRIVATE DOCTOR 06
MOBILE CLINIC 07
SHOP 08
TRADITIONAL PRACTITIONER 09
BLACK BAGGER, DRUG PEDDLAR 10
OTHER 96
DOES NOT KNOW 98
14. How much did the treatment cost? INCLUDE COST OF DOCTOR, NURSE, DRUGS, TESTS IF > 9990, WRITE '9990'.
TICK HERE IF CONTINUATION SHEET USED
2A) Just to make sure that I have a complete listing, are there any other persons 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, like 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
101. Where do you people get your drinking water from?
PIPED INTO YARD/PLOT 12
PUBLIC TAP/STANDPIPE 13
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER/RIVER/LAKE/STREAM 81
BOTTLED WATER 91
OTHER (SPECIFY) 96
102. What type of toilet do you use here?
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61
OTHER (SPECIFY) 96
103. Does your household have:
Electricity?
NO 2
A generator?
NO 2
A radio?
NO 2
A mobile telephone?
NO 2
An ice box?
NO 2
A table?
NO 2
Chairs?
NO 2
A cupboard?
NO 2
A mattress (not made of straw of grass)?
NO 2
A sewing machine?
NO 2
A television?
NO 2
A computer?
NO 2
104. What do you use for cooking--coal, gas, wood?
GAS CYLINDER 02
KEROSENE STOVE 03
FIRE COAL / COAL / CHARCOAL 04
WOOD 05
NO FOOD COOKED IN HOUSEHOLD 95
OTHER (SPECIFY) 96
105. MAIN MATERIAL FOR THE FLOOR OF THE HOUSEHOLD. RECORD OBSERVATION. IF DIFFERENT ROOMS HAVE DIFFERENT FLOOR MATERIAL, CIRCLE THE CODE FOR THE MOST COMMON, i.e., WHAT COVERS THE LARGEST AREA.
FLOOR MAT, LINOLEUM, VINYL 32
CERAMIC TILES 33
CONCRETE, CEMENT 34
CARPET 35
106. MAIN MATERIAL OF THE ROOF OF THE HOUSEHOLD. RECORD OBSERVATION.
WOOD PLANKS 22
TARPAULIN, PLASTIC 23
WOOD 32
CERAMIC TILES 34
CONCRETE, CEMENT 35
ASBESTOS SHEETS, SHINGLES 36
OTHER (SPECIFY) 96
107. MAIN MATERIALS OF THE OUTSIDE WALLS OF THE HOUSEHOLD. RECORD OBSERVATION.
CANE/PALM/TRUNKS 12
STRAW, THATCH MATS 13
PLYWOOD, REUSED WOOD 22
CARDBOARD, PLASTIC 23
BRICKS 32
WOOD PLANKS/SHINGLES 33
108. How many rooms in this household are used for sleeping?
109. Does any member of this household own:
A watch?
NO 2
A bicycle?
NO 2
A motorcycle or motor scooter?
NO 2
A car or truck?
NO 2
A boat or a canoe?
NO 2
110. Does your household have any mosquito nets that can be used while sleeping?
NO 2
111. Why doesn't your household have any mosquito nets? CIRCLE ALL METIONED.
NOT AVAILABLE B (GO TO 201)
DON'T LIKE TO USE NETS C (GO TO 201)
TOO EXPENSIVE D (GO TO 201)
OTHER (SPECIFY) X (GO TO 201)
112. How many mosquito nets does your household have? IF 7 OR MORE NETS, RECORD '7'.
113. ASK RESPONDENT TO SHOW YOU THE NETS. IF MORE THAN 3, USE ADDITIONAL QUESTIONNAIRE(S).
OBSERVED, DOES NOT HAVE HOLES 2
NOT OBSERVED 3
114. How many months ago did your household obtain the mosquito net? IF LESS THAN ONE MONTH, WRITE '00'.
37 OR MORE MONTHS AGO 95
NOT SURE 98
115. Did you buy the net or was it given to you for free?
FREE 2 (SKIP TO 117)
DON'T KNOW 8 (SKIP TO 117)
116. How much did you pay for the net? IF DON'T KNOW, WRITE '998'.
117. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.
PERMANET 12 (SKIP TO 121)
OTHER/DON'T KNOW BRAND BUT ITN 16 (SKIP TO 121)
DON'T KNOW BRAND 98
118. When you got the net, was it already treated with an insecticide to kill or repel mosquitos?
NO 2
NOT SURE 8
119. Since you got the mosquito net, was it ever soaked or dipped in a liquid to kill or repel mosquitos?
NO 2 (SKIP TO 121)
NOT SURE 8 (SKIP TO 121)
120. How many months ago was the net last soaked or dipped? IF LESS THAN ONE MONTH, WRITE '00'.
25 OR MORE MONTHS AGO 95
NOT SURE 98
121. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 123)
NOT SURE 8 (SKIP TO 123)
122. Who slept under this mosquito net last night? RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NUMBER__
123. GO BACK TO 113 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 201.
ANEMIA AND MALARIA TESTING FOR CHILDREN AGE 0-5
201. CHECK COLUMN 10. WRITE THE LINE NUMBER AND NAME FOR ALL CHILDREN 0-5 YEARS IN QUESTION 202 IN ORDER BY LINE NUMBER. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRES. BE SURE TO FILL QUESTIONS 209 AND 211
202. LINE NUMBER FROM COLUMN 10. NAME FROM COLUMN 2
NAME__
203. IF MOTHER INTERVIEWED, COPY CHILD'S MANTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?
MONTH__
YEAR__
204. CHECK 203: CHILD BORN IN JANUARY 2003 OR LATER?
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE, GO TO 215)
205. CHECK 203; IS CHILD 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?
OLDER 2
206. LINE NUMBER OF PARENT OR ADULT RESPONSIBLE FOR CHILD. RECORD '00' IF NOT LISTED.
207. READ ANEMIA CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.
REFUSED (SIGN) 2
208. READ MALARIA CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.
REFUSED (SIGN) 2
CONDUCT TESTS FOR WHICH CONSENT IS GRANTED AND CONTINUE TO 209
209. RECORD RESULT CODE OF ANEMIA TEST
NOT PRESENT 2 (SKIP TO 211)
REFUSED 3 (SKIP TO 211)
OTHER 6 (SKIP TO 211)
210. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.
211. RECORD RESULT CODE OF MALARIA TEST
NOT PRESENT 2 (SKIP TO 215)
REFUSED 3 (SKIP TO 215)
OTHER 6 (SKIP TO 215)
212. BAR CODE LABEL. PASTE BAR CODE HERE AND ON SLIDE AND ON TRANSMITTAL FORM.
NEGATIVE 2 (SKIP TO 215)
OTHER 6 (SKIP TO 215)
214. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD. ASK ABOUT ANY TREATMENT THE CHILD HAS ALREADY RECEIVED.
REFUSED 2
ALREADY HAS ACT 3
NOT ELLIGIBLE 4
OTHER 6
215. GO BACK TO 203 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, END THE INTERVIEW.
CONSENT STATEMENT FOR ANEMIA TEST
As part of this survey, we are asking that children all over the country take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or disease. This survey will help the government to develop programs to prevent and treat Anemia.
We request that all children born in 2003 or later participate in the anemia testing part of this survey and give a few drops of blood from a finger. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately and the result will be told to you right away. The result will be kept confidential.
Do you have any questions about the anemia test?
You can say yes to the test or you can say no. it is up to you to decide.
Will you allow (NAME(S) OF CHILD(REN) to participate in the anemia test?
CONSENT STATEMENT FOR MALARIA TEST
As part of this survey, we are asking that children all over the country take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by mosquito bite. This survey will help the government to develop programs to prevent malaria.
We request that all children born in 2003 or later participate in the malaria testing part of this survey and give a few drops of blood from a finger. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test. (we will use blood from the same finger prick made for the anemia test)
The blood will be tested for malaria immediately and the result will be told to you right away. The result will be kept confidential.
Do you have any questions about the malaria test?
You can say yes to the test or you can say no. it is up to you to decide.
Will you allow (NAME(S) OF CHILD(REN) to participate in the malaria test?
TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TESTS
IF MALARIA TEST IS POSITIVE: 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 it should get rid of the fever and other symptoms.
BEFORE PROVIDING ACT, FIRST ASK IF THE CHILD IS ALREADY TAKING OTHER DRUGS AND IF SO, ASK TO SEE THEM. IF THE CHILD IS ALREADY TAKING ACT, CHECK ON THE DOSE ALREADY AVAILABLE. BE CAREFUL NOT TO OVERTREAT.
You do not have to give the child the medicine. This is up to you. Please tell me whether you accept the medicine or not.