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
NAME OF COUNTY
NAME OF DISTRICT
NAM OF CLAN/TOWNSHIP
NAME OF CITY/TOWN/VILLAGE
LMIS CLUSTER NUMBER
HOUSEHOLD NUMBER
URBAN
OTHER URBAN 2
VILLAGE 3
NAME OF HOUSEHOLD HEAD
NAME AND LINE NUMBER OF WOMAN
DATE
INTERVIEWER'S NAME
RESULT
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
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
SUPERVISOR
NAME
DATE
OFFICE EDITOR
KEYED BY
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 DOES NOT AGREE TO BE INTERVIEWED 2 (END)
SECTION 1. RESPONDENT'S BACKGROUND
101. RECORD THE TIME
MINUTES
102. In what month and year were you born?
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.
104. Have you ever attended school?
NO 2 (GO TO 107)
105. What is the highest level of school you attended: primary, secondary, or higher?
SECONDARY 2
HIGHER 3
106. What is the highest grade you completed?
MUSLIM 2
TRADITIONAL RELIGION 3
NO RELIGION 4
OTHER (SPECIFY)6
108. What dialect do you speak very well (besides English)?
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
201. Now I would like to ask about all the births you have had during your life. Have you ever born a child?
NO 2 (GO TO 206)
202. Do you have any children you born who are living with you? I mean belly born.
NO 2 (GO TO 204)
203. How many sons live with you? And how many daughters live with you? IF NONE, RECORD '00'.
DAUGHTERS AT HOME__
204. Do you have any children you born who are alive but do not live with you?
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'.
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?
NO 2 (GO TO 208)
207. How many boys have died? And how many girls have died? IF NONE, RECORD '00'.
GIRLS DEAD__
208. SUM ANSWERS TO 203, 205, AND 207 AND ENTER TOTAL. IF NONE, CIRCLE '00'.
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?
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'.
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?
GIRL 2
214. Were any of these births twins?
MULTIPLE 2
215. In what month and year was (NAME) born? PROBE: What is his/her birthday?
YEAR__
NO 2 (NEXT BIRTH)
217. IF LIVING: How old is (NAME)? RECORD AGE IN COMPLETED YEARS.
218. IF LIVING: Is (NAME) living with you?
NO 2
219. IF LIVING: RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD).
220. Did you born any other child between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after 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.
NO 2
222. COMPARE 210 WITH NUMBER OF BIRTHS IN HISTORY AND MARK:
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)
223. CHECK 215: ENTER THE NUMBER OF BIRTHS IN 2006 OR LATER. IF NONE, CIRCLE '0'.
NONE 0
NO 2 (GO TO 226)
UNSURE 3 (GO TO 226)
225. How many months pregnant are you? RECORD NUMBER OF COMPLETED MONTHS.
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
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.
NURSE/MIDWIFE B
PHYSICIAN ASSISTANT C
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'.
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.
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.
CHLOROQUINE B
OTHER (SPECIFY) X
DON'T KNOW Y
306. CHECK 305: DRUGS TAKEN FOR MALARIA PREVENTION.
CODE 'A' NOT CIRCLED (GO TO 401)
307. How many times did you take (SP/Fansidar) during this pregnancy?
308. CHECK 303: PRENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNENCY.
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?
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6
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
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?
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?
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)
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
MOBILE CLINIC D
FIELDWORKER E
OTHER PUBLIC SECTOR (SPECIFY) F
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
FIELDWORKER K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) L
TRADITIONAL PRACTITIONER N
MARKET O
BLACK BAGGER/DRUG PEDDLER P
OTHER (SPECIFY) X
ONLY ONE CODE CIRCLED (SKIP TO 411A)
409. Where did you first go for advice or treatment? USE LETTER CODE FROM 407
411A. At any time during the sickness did (NAME) have a drop of blood taken from his/her finger or heel?
NO 2
DON'T KNOW 8
412. At any time during the sickness did (NAME) take any medicine for the sickness?
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.
CHLOROQUINE B
QUININE C
NEW MALARIA MEDICINE (ACT) D
OTHER ANTIMALARIAL (SPECIFY) E
INJECTION G
PARACETOMOL I
IBUPROFEN J
OTHER (SPECIFY) X
DON'T KNOW Z
414. CHECK 413: ANY CODE A-E CIRCLED?
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' NOT CIRCLED (SKIP TO 419)
417. How long after the fever started did (NAME) first take SP/Fansidar?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
419. CHECK 413: CHLOROQUINE ('B') GIVEN
CODE 'B' NOT CIRCLED (SKIP TO 422)
420. How long after the fever started did (NAME) first take chloroquine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
422. CHECK 413: QUININE ('C') GIVEN
CODE 'C' NOT CIRCLED (SKIP TO 425)
423. How long after the fever started did (NAME) first take quinine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
425. CHECK 413: NEW MALARIA MEDICINE (ACT) ('D') GIVEN
CODE 'D' NOT CIRCLED (SKIP TO 428)
426. How long after the fever started did (NAME) first take the new malaria medicine (ACT)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
428. CHECK 413: OTHER ANTIMALARIAL ('E') GIVEN
CODE 'E' NOT CIRCLED (SKIP TO 431)
429. How long after the fever started did (NAME) first take the (OTHER ANTIMALARIAL)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
431. GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501.
SECTION 5. KNOWLEDGE OF MALARIA
501. Have you ever heard of a sickness called malaria?
NO 2 (SKIP TO 512)
502. What are some things that can happen to you when you have malaria? CIRCLE ALL MENTIONED,
CHILLS B
HEADACHE C
JOINT PAIN D
POOR APETITE E
BODY PAIN F
OTHER (SPECIFY) X
DOES NOT KNOW ANY Z
503. Which group of people are most likely to get malaria? CIRCLE ALL MENTIONED
PREGNANT WOMEN B
ADULTS C
ELDERLY D
EVERYONE E
DOES NOT KNOW Z
504. What causes malaria? CIRLCE ALL MENTIONED.
DIRTY WATER B
DIRTY SURROUNDINGS C
BEER D
CERTAIN FOODS E
OTHER (SPECIFY) X
DOES NOT KNOW ANY Z
505. Are there things people can do to stop them from getting malaria?
NO 2 (SKIP TO 507)
506. What are some things that people can do to stop them from getting malaria? CIRCLE ALL MENTIONED
USE MOSQUITO COILS B
USE INSECTICIDE SPRAY C
KEEP DOORS AND WINDOWS CLOSED D
USE INSECT REPELLANT E
KEEP SURROUNDINGS CLEAN F
CUT THE GRASS G
OTHER (SPECIFY) X
DOES NOT KNOW ANY Z
507. Can malaria be treated? CIRCLE ALL MENTIONED
CHLOROQUINE B
QUININE C
NEW MALARIA DRUG (ACT) D
ASPIRIN, PANADOL, PARACETEMOL E
OTHER (SPECIFY) X
DOES NOT KNOW ANY Z
509. In the past few months, have you seen or heard any messages about malaria?
NO 2 (SKIP TO 512)
510. What messages about malaria have you seen or heard? CIRCLE ALL MENTIONED.
SLEEP UNDER MOSQUITO BED NETS B
PREGNANT WOMEN SHOULD TAKE DRUGS TO PREVENT MALARIA C
MALARIA KILLS D
OTHER (SPECIFY) X
DOES NOT KNOW ANY Z
511. Where did you hear or see these messages? CIRCLE ALL MENTIONED.
BILLBOARD B
POSTER C
T-SHIRT D
LEAFLET/FACT SHEET/BROCHURE E
TELEVISION F
VIDEO CLUB G
SCHOOL H
COMMUNITY HEALTH WORKERS, TTM, TBA, HEALTH PROMOTERS I
PEER EDUCATORS J
OTHER (SPECIFY) X
MINUTES
INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT RESPONDENT
COMMENTS ON SPECIFIC QUESTIONS
ANY OTHER COMMENTS
SUPERVISOR'S OBSERVATIONS
NAME OF SUPERVISOR
DATE