STUDY OF MALARIA INDICATORS
EIPMD 2011
HOUSEHOLD QUESTIONNAIRE
REPUBLIC OF MADAGASCAR
NATIONAL INSTITUTE OF STATISTICS
OFFICE OF DEMOGRAPHY AND SOCIAL STATISTICS
NAME OF HEAD OF HOUSEHOLD ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER ______
REGION ______
COMMUNE ______
CITY/RURAL (CITY = 1, RURAL = 2) _______
INTERVIEWER VISITS
(Repeat up to 3 visits)
DATE ______
NAME OF INTERVIEWER ______
RESULT ______
TIME ______
MONTH ______
YEAR 2011
NAME ______
RESULT ______
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT TIME OF VISIT
3 HOUSEHOLD TOTALLY ABSENT FOR LONG PERIOD
4 POSTPONED
5 REFUSED
6 VACANT DWELLING OR NO DWELLING AT ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ______
TOTAL NUMBER OF PEOPLE IN HOUSEHOLD ______
TOTAL NUMBER OF ELIGIBLE WOMEN ______
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE ______
DATE ______
INTRODUCTION AND INFORMED CONSENT
Hello. My name is ______ and I work for the National Institute of Statistics. We are conducting a survey on malaria throughout Madagascar. The information that we collect will help the country plan health services. Your household has been selected for the survey. I would like to ask you some questions about your household. The survey usually takes between 10 and 20 minutes.
All the information that you give us is strictly confidential and will not be shared with anyone other than members of the survey team. You do not have to participate in this survey but we hope you will agree to answer questions because your opinion is very important. If you decide not to participate, there will be no changes in the services you can receive from health programs. If I happen to ask a question that you do not want to answer, tell me and I will move on to the next question; you can also stop the interview at any time. If you would like more information about any aspect of the survey, you can contact the people whose names are on this card.
GIVE RESPONDENT THE CARD WITH INFORMATION FOR CONTACTING THESE PEOPLE.
Dr. Hortense Rakotonirainy, National Program of the Fight Against Malaria (PNLP). Tel: 0331161498
Mr. Andry Rakotorahalay, National Program of the Fight Against Malaria (PNLP). Tel: 0331463102
Signature of interviewer: ______
Date ______
2 RESPONDENT DECLINES TO BE INTERVIEWED (Skip to END)
HOUSEHOLD SCHEDULE
Now we would like information on the people who usually live in your household or who are currently living in your household.
(Repeat Q. 1 - 9 for up to 31 people)
1. LINE NUMBER
2. HABITUAL RESIDENTS AND VISITORS
3. FAMILY RELATIONSHIP TO HEAD OF HOUSEHOLD.
______
CODES FOR Q. 3: FAMILY RELATIONSHIP TO HEAD OF HOUSEHOLD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW/DAUGHTER-IN-LAW
05 GRANDSON/GRANDDAUGHTER
06 FATHER/MOTHER
07 FATHER-IN-LAW/MOTHER-IN-LAW
08 BROTHER OR SISTER
09 NIECE/NEPHEW
10 NIECE/NEPHEW BY MARRIAGE
11 OTHER RELATIVE
12 ADOPTED/FOSTER/STEPCHILD
13 NO FAMILY RELATION
98 DK
2 FEMALE
2 NO
2 NO
IN YEARS ______
8A. CURRENTLY PREGNANT?
FOR ALL ELIGIBLE WOMEN, ASK:
2 NO/DK
9. ELIGIBLE CHILDREN
CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0 - 5.
Just to be sure that I have a complete list:
NO ______
NO ______
NO ______
HOUSEHOLD CHARACTERISTICS
10. Where does the drinking water used by members of your household mainly come from?
12 FAUCET IN YARD
13 PUBLIC FOUNTAIN
21 BOREHOLE/PUMP WELL
32 UNPROTECTED WELL
42 UNPROTECTED SPRING
61 TANKER WATER
81 SURFACE WATER (RIVERS/DAMS/LAKES/PONDS/IRRIGATION CANALS)
91 BOTTLED WATER
96 OTHER (SPECIFY) ______
11. What kind of toilet do members of your household usually use?
12 CONNECTED TO SEPTIC SYSTEM
13 CONNECTED TO TOILET PIT
14 CONNECTED TO SOMETHING ELSE
15 CONNECTED TO UNKNOWN PLACE
22 PIT LATRINE WITH WASHABLE SLAB
23 PIT LATRINE WITH NON-WASHABLE SLAB
24 PIT LATRINE WITHOUT SLAB/OPEN PIT
31 COMPOSTING TOILET
41 BUCKET/TIN PAIL
51 SUSPENDED TOILET/LATRINE
61 NO TOILET/IN NATURE (Skip to 13)
12. Do you share this toilet with other households?
2 NO
13. In this household, do you have (a):
Electricity?
Radio set?
Television set?
Mobile phone?
Landline phone?
Refrigerator?
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
14. What type of fuel does your household mainly use for cooking?
02 LIQUIFIED PROPANE GAS (LPG)
03 NATURAL GAS
04 BIOGAS
05 KEROSENE
06 COAL, LIGNITE
07 CHARCOAL
08 WOOD
09 STRAW/BRANCHES/GRASS
10 AGRICULTURAL WASTE
11 DUNG
95 NO MEALS PREPARED IN HOUSEHOLD
96 OTHER (SPECIFY) ______
15. MAIN MATERIAL OF FLOOR
RECORD OBSERVATION.
12 DUNG
22 PALMS/BAMBOO
23 MATS
32 VINYL/ASPHALT STRIPS
33 TILE
34 CEMENT
35 CARPET
96 OTHER (SPECIFY) ______
16. MAIN MATERIAL OF ROOF
RECORD OBSERVATION.
12 THATCH/PALM LEAVES/LEAVES
13 CLUMPS OF EARTH
22 PALMS/BAMBOO
23 WOOD PLANKS
24 CARDBOARD
32 WOOD
33 ZINC/CEMENT FIBER
34 TILES
35 CEMENT
36 SHINGLES
96 OTHER (SPECIFY) ______
17. MAIN MATERIAL OF EXTERIOR WALLS
RECORD OBSERVATION.
12 BAMBOO/CANE/ PALM /TREE TRUNKS
13 EARTH
22 STONES WITH MUD/ADOBE
23 PLYWOOD
24 CARDBOARD
25 SALVAGED WOOD
32 STONES WITH LIME/CEMENT
33 BRICKS
34 CEMENT BLOCKS
35 WOOD PLANKS/SHINGLES
18. In this household, how many rooms are used for sleeping?
19. Does any member of your household own a/an:
Watch?
Bicycle?
Motorcycle or a scooter?
Animal-drawn cart?
Car or van?
Motorboat?
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
20. Do any members of your household have a bank account?
2 NO
21. At any time in the last 12 months did someone come to your dwelling to spray the interior walls for mosquitos to fight malaria?
2 NO (Skip to 27)
8 DK (Skip to 27)
22. How long ago was this spraying of the interior walls of your dwelling?
98 DK
23. Who sprayed the walls of the dwelling?
2 PRIVATE COMPANY
6 OTHER (SPECIFY) ______
8 DK
24. Did you pay for the spraying?
2 NO
8 DK
25. How long did you stay outside your home after the spraying?
IF ONE HOUR OR MORE, RECORD IN HOURS
.
2 HOURS OUTSIDE ______
998 DK/DON'T REMEMBER
26. Since the walls of your home were sprayed, have you modified them, for example by applying lime, paint or a primer, or washing them?
2 NO
8 DK/DON'T REMEMBER
27. Does your household have any mosquito nets that can be used for sleeping?
2 NO (Skip to 42)
28. How many mosquito nets does your household own?
29. ASK RESPONDENT TO SHOW YOU THE HOUSEHOLD'S MOSQUITO NETS.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
(Repeat Q. 30 - 39 for up to 3 mosquito nets)
1 OBSERVED
2 NOT OBSERVED
30. How many months has your household owned this mosquito net?
95 37 OR MORE MONTHS
31. Where did you get this mosquito net?
(Codes 12 - 98 skip to 33)
12 HEALTH CENTRE
13 COMMUNITY AGENT
14 MARKET
15 SHOP
96 OTHER
98 DK
32. Did you get the mosquito net during the last distribution campaigns in November-December 2009 or November 2010?
2 NO
8 DK
32A. Did you get the mosquito net during the last distribution campaign in October 2007?
2 NO
8 DK
33. OBSERVE OR ASK FOR THE MOSQUITO NET'S BRAND.
IF BRAND IS NOT KNOWN AND YOU CANNOT OBSERVE THE MOSQUITO NET, SHOW PHOTOS OF COMMON BRANDS/TYPES OF NETS TO RESPONDENT.
(Codes 11 - 17 all skip to 38)
12 PERMANET
13 SUPER MOUSTIQUAIRE
14 MILAY
15 TSARALAY
16 INTERCEPTOR
17 OTHER/DK BRAND
31 OTHER
98 DK BRAND
34. When you got this mosquito net, had it already been treated by the manufacturer with an insecticide to kill or repel mosquitos?
2 NO
8 NOT SURE
35. Since you have had this mosquito net, has it been dipped or soaked in a liquid to kill or repel mosquitos?
2 NO (Skip to 37)
8 NOT SURE (Skip to 37)
36. How many months ago was the mosquito net dipped or soaked for the last time?
IF LESS THAN 2 YEARS, RECORD THE NUMBER OF MONTHS.
IF '12 MONTHS' OR '1 YEAR', PROBE TO GET THE EXACT NUMBER OF MONTHS
95 25 OR MORE MONTHS
98 NOT SURE
37. Did anyone sleep under this mosquito net last night?
2 NO (Skip to 39)
8 NOT SURE (Skip to 39)
38. Who slept under the mosquito net last night?
NAME ______
LINE NUMBER ______
39. RETURN TO Q. 29 FOR NEXT MOSQUITO NET OR, IF THERE ARE NO MORE NETS, CONTINUE TO Q. 40
.
40. CHECK Q. 38 ALL COLUMNS AND HOUSEHOLD SCHEDULE. LIST THE LINE NUMBER AND NAME OF EACH HOUSEHOLD MEMBER BELOW WHO DID NOT SLEEP UNDER A MOSQUITO NET LAST NIGHT AND ASK THE CORRESPONDING QUESTION FOR EACH PERSON.
IF MORE THAN 6 PEOPLE DID NOT SLEEP UNDER A MOSQUITO NET, USE AN ADDITIONAL QUESTIONNAIRE.
NAME ______
What is the main reason that (NAME) did not sleep under a mosquito net last night?
IF NO OTHER PERSON, CONTINUE TO Q. 42.
12 NOT ENOUGH MOSQUITO NETS
13 MOSQUITO NET IN POOR CONDITION/RUINED
14 NO ONE ILL
15 UNNECESSARY
16 DO NOT LIKE TO SLEEP UNDER MOSQUITO NET
17 NOT AFRAID OF MOSQUITOS
18 TOO HOT
19 KEEPING MOSQUITO NET FOR FUTURE USE
96 OTHER
98 DK
42. Do you currently own a mosquito net that you no longer use for sleeping?
2 NO (Skip to 46)
43. How many mosquito nets do you currently own that you no longer use for sleeping?
IF 5 OR MORE MOSQUITO NETS, RECORD '5'.
2 USING AS CURTAIN
3 USING TO PROTECT CROPS
4 USING FOR FISHING
5 KEEPING FOR FUTURE USE
6 OTHER USE
8 DK
2 GIVE IT TO GET RID OF IT
8 DK
46. Did you ever own a mosquito net that you no longer have?
2 NO (Skip to 48)
47. The last time that you got rid of your last mosquito net, what did you do with it?
12 BURIED IT
13 THREW IT OUT
14 COMPOSTED IT
15 GAVE IT TO SOMEONE
16 EXCHANGED FOR A NEW ONE
96 OTHER (SPECIFY) ______
98 DK
ANEMIA AND MALARIA TESTING FOR CHILDREN AGE 0 - 5
48. CHECK COLUMN 9 OF HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL CHILDREN AGE 0 - 5 IN Q. 49 IN ORDER ACCORDING TO THE LINE NUMBER. IF THERE ARE MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
BE SURE TO FILL OUT Q. 56 AND 57.
(Repeat Q. 40 - 68 for up to 3 children)
49. LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2
NAME ______
50. What is (NAME)'s birthdate?
RECOPY THE MONTH AND YEAR OF BIRTH FROM 215 IN MOTHER'S BIRTH HISTORY AND ASK THE DAY.
FOR CHILDREN WHO ARE NOT INCLUDED IN ANY HISTORY, ASK THE DAY, MONTH AND YEAR OF BIRTH.
MONTH ______
YEAR ______
2 NO (GO TO 49 FOR NEXT CHILD, OR IF NO MORE CHILDREN, END INTERVIEW)
2 OLDER
53. LINE NUMBER OF CHILD'S PARENT OR RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED.
54. READ THE INFORMED CONSENT FOR THE ANEMIA TEST TO THE PARENT OR OTHER ADULT RESPONSIBLE FOR CHILD.
2 CONSENT REFUSED (Go to signature)
(SIGNATURE) ______
55. READ THE INFORMED CONSENT FOR THE MALARIA TEST TO THE PARENT OR OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE THE CODE AND SIGN.
(All go to signature)
2 CONSENT GIVEN ONLY FOR RAPID TEST
3 CONSENT GIVEN ONLY FOR FUTURE TEST
4 RAPID AND FUTURE TESTS REFUSED
(SIGNATURE) ______
CARRY OUT TESTS ON CHILDREN FOR WHICH CONSENT HAS BEEN GIVEN AND CONTINUE WITH 58.
56. RECORD HEMOGLOBIN LEVEL HERE.
2 ABSENT
3 REFUSED
6 OTHER
57. RECORD THE RESULT CODE OF MALARIA TEST.
2 TEST REFUSED BUT BLOOD COLLECTED
3 TESTED BUT BLOOD REFUSED (Skip to 59)
4 TEST AND BLOOD REFUSED (Skip to 69)
5 ABSENT (Skip to 69)
6 OTHER (Skip to 69)
2) ATTACH 2ND STICKER ON CORRESPONDING SLIDE
3) ATTACH 3RD STICKER ON CORRESPONDING FILTER PAPER
4) ATTACH 4TH STICKER ON TRANSMISSION SHEET
ATTACH 1ST STICKER HERE ______
59. CHECK Q. 57
RESULT CODE OF MALARIA TEST
OTHER ______ (Continue to 60)
2 VIVAX POSITIVE
3 NEGATIVE (Skip to 69)
61. CHECK Q. 56
HEMOGLOBIN LEVEL
2 8.0 G/DL OR HIGHER
62. Does (NAME) suffer from any of the following illnesses or show any of the following symptoms:
Loss of consciousness?
Respiratory failure?
Convulsions?
Abnormal bleeding?
Jaundice/yellow skin (with yellowing of eyes)?
Black or brown urine?
Uncontrollable vomiting?
RECORD ALL MENTIONED
B LOSS OF CONSCIOUSNESS
C RESPIRATORY FAILURE
D CONVULSIONS
E BLEEDING
F JAUNDICE
G BLACK/BROWN URINE
H VOMITING
HEMOGLOBIN LEVEL (Q. 61)
SYMPTOMS (Q. 62)
2 NO SEVERE ANEMIA (Q. 61 = 2) AND NO CIRCLED CODE IN Q. 62
64. In the last two weeks, has (NAME) followed a medical treatment for malaria that was prescribed by a doctor, health agent, or community agent?
2 NO
65. READ INFORMATION ON TREATMENT FOR MALARIA AND INFORMED CONSENT TO CHILD'S PARENT OR OTHER RESPONSIBLE ADULT.
(SIGNATURE) ______
2 MEDICINE REFUSED
SKIP TO 68
66. STATEMENT FOR SEVERE SYMPTOMS
67. STATEMENT FOR CHILDREN ALREADY BEING TREATED
68. NOTE RESULT OF MALARIA TREATMENT
2 MEDICINE REFUSED BUT REFERRED
3 SERIOUSLY ILL, NOT TREATED BUT REFERRED
4 ALREADY TREATED AND REFERRED
69. RETURN TO NEXT COLUMN IN Q. 49 IN THIS QUESTIONNAIRE OR THE 1ST COLUMN IN ADDITIONAL QUESTIONNAIRE(S); IF THERE ARE NO MORE CHILDREN, END INTERVIEW.
STATEMENT OF INFORMED CONSENT FOR ANEMIA TEST
In this survey, we are asking children all over the country to participate in anemia testing. Anemia is a serious health problem which is generally the result of poor nutrition, infections or illnesses. This survey will help the government develop programs to prevent and treat anemia.
We are asking all children born in 2006 or later to participate in anemia testing included in this survey by giving a couple drops of blood from a finger. For this test we use clean and risk-free supplies. It has never been used before and will be thrown out after each test.
The blood will be tested for anemia immediately and will be destroyed. The results will be given to you right away. The results are strictly confidential. If the test indicates that (NAME OF CHILD) has severe anemia, we will refer him/her to the nearest health centre for care.
Do you have any questions about the anemia test?
You can say 'yes' to the test or you can say 'no'.
It's your decision.
Will you allow (NAME OF CHILD/CHILDREN) to participate in anemia testing?
STATEMENT OF INFORMED CONSENT FOR MALARIA TESTING
As part of this survey, we are asking children all over the country to participate in testing to see whether or not they have malaria. Malaria is a serious health problem caused by a parasite transmitted by a mosquito bite. This survey will help the government to develop programs to prevent malaria.
We are asking all children born in 2006 or later to participate in the malaria test included in this survey by giving a few drops of blood from a finger. For this test, we use clean and risk-free equipment. It has never been used before and will be thrown away after each test. (We will use the blood from the same blood draw and same finger as for the anemia test).
A drop of blood will be tested for malaria immediately and you will know the results right away. The other drops of blood will be tested later in a laboratory for more detailed malaria analysis. The laboratory test results will not be given to you. The results are strictly confidential.
We would like to have your consent to test (NAME OF CHILD) immediately for malaria and to use several drops of blood for additional malaria testing in the central laboratory.
Do you have any questions about the malaria testing?
You can say 'yes' to the test or you can say 'no'. It is your decision.
Do you give (NAME OF CHILD/CHILDREN) permission to participate in the malaria test?
TREATMENT FOR CHILDREN TESTING POSITIVE FOR MALARIA
IF MALARIA PARASITEMIA IS POSITIVE: The diagnostic test for malaria shows that (CHILD'S NAME) has malaria. We can give you free medicine. This medicine is called ACT. ACT is very effective and in a few days (CHILD'S NAME) fever will be gone as well as any other symptoms. ACT is also very safe. However, every medication has some side effects, and this medication may cause some. The most common side effects are dizziness, fatigue, loss of appetite, and palpitations.
It is your decision.
Please tell me if you accept this medication or not to treat (CHILD'S NAME). If you do not accept it, I will refer (CHILD'S NAME) to the nearest health centre for treatment.
ACT TREATMENT (Artesunate Amodiaquine Winthrop)
Day 1 1 tablet
Day 2 1 tablet
Day 3 1 tablet
Day 1 1 tablet
Day 2 1 tablet
Day 3 1 tablet
ALSO TELL THE CHILD'S PARENT/RESPONSIBLE ADULT:
If (NAME OF CHILD) has any of the following symptoms, you must take him/her immediately to a doctor or health professional to receive care:
Convulsions, coma
Fast breathing or difficulty breathing
Is not able to drink or nurse
Gets sicker or does not get better in 2 days
STATEMENT FOR CHILDREN TESTING POSITIVE FOR MALARIA AND SEVERE ANEMIA AND/OR ANY SYMPTOM FROM Q. 58B
The diagnostic test for malaria shows that (CHILD'S NAME) has malaria. But he/she also has (SEVERE ANEMIA Q. 58 AND/OR ONE OR MORE SYMPTOMS FROM Q. 59), that is to say that he/she is seriously ill. I cannot give him/her a treatment, but you should take him/her immediately to a doctor or health agent for care.
[###translator's note: question numbers "58B", "58", and "59" are incorrect)
STATEMENT FOR CHILDREN TESTING POSITIVE FOR MALARIA AND ALREADY UNDERGOING TREATMENT
You have told me that (CHILD'S NAME) is/was being treated for malaria, however the diagnostic test for malaria shows that he/she still has malaria. I cannot give him/her a treatment, but you should take him/her to a doctor or health agent for further tests.