2011 LIBERIA MALARIA INDICATOR SURVEY
WOMAN'S QUESTIONNAIRE

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

IDENTIFICATION

NAME OF COUNTY
NAME OF DISTRICT
NAM OF CLAN/TOWNSHIP
NAME OF CITY/TOWN/VILLAGE
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
INTERVIEWER'S 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 __. I am working with the Ministry of Health. We are conducting a survey about health all over Liberia. The information we will collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 10 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 the card that has already been given to your household. Do you want to ask me anything about the survey? May I begin the interview now?

Signature of interviewer__
Date__

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

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE TIME

HOUR
MINUTES

102. In what month and year were you born?

MONTH__
DON'T KNOW MONTH 98
YEAR__
DON'T KNOW YEAR 9998

103. How old are you? COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

AGE COMPLETED IN YEARS__

104. Have you ever attended school?

YES 1
NO 2 (GO TO 107)

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

PRIMARY 1
SECONDARY 2
HIGHER 3

106. What is the highest grade you completed?

GRADE__

107. What is your religion?

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

108. 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 about all the births you have 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, CIRCLE '00'.

TOTAL BIRTHS__
NONE 00

209. CHECK 208: Just to make sure that I have this right; you have had in TOTAL __ births during your life. Is that correct?

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

210. Now I'd like to ask you about your more recent births. How many births have you had in the last 6 years? IF NONE, CIRCLE '00'.

TOTAL BIRTHS IN LAST 6 YEARS__
NONE 00 (GO TO 224)

211. Now I want the names of all the children you born in the last six years, whether still alive or not, starting with your last/most recent birth. RECORD NAMES OF ALL THE BIRTHS IN THE LAST 6 YEARS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS.

212. What is/was the name of your (most recent/next) child? RECORD NAME. BIRTH HSTORY NUMBER.

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

BOY 1
GIRL 2

214. Were any of these births twins?

SINGLE 1
MULTIPLE 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 (NEXT BIRTH)

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

AGE IN YEARS__

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

YES 1
NO 2

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

HOUSEHOLD LINE NUMBER__ (NEXT BIRTH)

220. 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)

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

YES 1
NO 2

222. COMPARE 210 WITH NUMBER OF BIRTHS IN HISTORY AND MARK:

NUMBERS ARE SAME (CONTINUE)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

223. CHECK 215: ENTER THE NUMBER OF BIRTHS IN 2006 OR LATER. IF NONE, CIRCLE '0'.

NUMBER OF BIRTHS__
NONE 0

224. Are you pregnant now?

YES 1
NO 2 (GO TO 226)
UNSURE 3 (GO TO 226)

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

MONTHS__

226. CHECK 223:

ONE OR MORE BIRTHS IN 2006 OR LATER (CONTINUE)
NO BIRTHS IN 2006 OR LATER OR IS BLANK (GO TO 501)

SECTION 3. PREGNANCY AND INTERMITTENT PREVENTATIVE TREATMENT

301. CHECK 212 AND 215: ENTER IN 302 THE NAME AND BIRTH HISTORY NUMBER OF THE MOST RECENT BIRTH SINCE 2006 EVEN IF THE CHILD IS NO LONGER ALIVE. Now I would like to ask you some questions about your last pregnancy that ended in a live birth.

302. NAME AND BIRTH HISTORY NUMBER FROM 212

NAME OF LAST BIRTH__
BIRTH HISTORY 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 IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PERSONNEL

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 3

304. During this pregnancy, did you take any medicine 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 3 (GO TO 401)

305. What medicine 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 Y

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 PREGNENCY.

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 6

SECTION 4. FEVER IN CHILDREN

401. CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2006 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES). Now I would like to ask some questions about the health of your children born since January 2006. (We will talk about each separately.)

402. BIRTH HISTORY NUMBER FROM 212

BIRTH HISTORY 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 BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)
DON'T KNOW 8 (GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

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

YES 1
NO 2 (SKIP TO 411A)

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 PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

NAME OF PLACE(S)

PUBLIC SECTOR

GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
MOBILE CLINIC D
FIELDWORKER E
OTHER PUBLIC SECTOR (SPECIFY) F

PRIVATE MEDICAL SECTOR

PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
FIELDWORKER K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) L

OTHER SOURCE

MEDICINE STORE M
TRADITIONAL PRACTITIONER N
MARKET O
BLACK BAGGER/DRUG PEDDLER P
OTHER (SPECIFY) X

408. CHECK 407:

TWO OR MORE CODES CIRCLED (CONTINUE)
ONLY ONE CODE CIRCLED (SKIP TO 411A)

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

FIRST PLACE__

411A. At any time during the sickness 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 the sickness did (NAME) take any medicine for the sickness?

YES 1
NO 2 (GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)
DON'T KNOW 8 (GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

413. What medicine did (NAME) take? Any other medicine? RECORD ALL MENTIONED.

ANTIMALARIAL DRUGS

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

ANTIBIOTIC DRUGS

PILL/SYRUP F
INJECTION G

OTHER DRUGS

ASPIRIN H
PARACETOMOL I
IBUPROFEN J
OTHER (SPECIFY) X
DON'T KNOW Z

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

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

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?