MALARIA INDICATORS SURVEY
"EIPMD" 2013
HOUSEHOLD QUESTIONNAIRE
REPUBLIC OF MADAGASCAR
NATIONAL INSTITUTE OF STATISTICS
OFFICE OF DEMOGRAPHICS AND SOCIAL STATISTICS
IDENTIFICATION
NAME OF LOCALITY ______
NAME OF HEAD OF HOUSEHOLD ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER ______
REGION ______
COMMUNE ______
CITY/RURAL (CITY = 1, RURAL = 2) RESIDENCE ______
INTERVIEWER VISITS
(Repeat for up to 3 visits)
DATE _____
NAME OF INTERVIEWER ______
RESULT ______
TIME ______
MONTH ______
YEAR 2013
NAME ______
RESULT ______
2 NO FAMILY MEMBER AT HOME OR NO COMPETENT RESPONDENT AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR LONG PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR NO DWELLING AT ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ______
TOTAL PEOPLE IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN ______
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE ______
LONGITUDE ______
ALTITUDE ______
DATE ______
INTRODUCTION AND INFORMED CONSENT
Hello. My name is ______. I work for the National Institute of Statistics. We are conducting a national survey of malaria all over Madagascar. The information we collect will help the country plan health services. Your household was selected for the survey. I would like to ask you a few questions about your household. The survey usually takes between 10 and 20 minutes.
All the information you give us is strictly confidential and will not be shared with anyone other than members of the survey team. You are not obligated to take part in this survey, but we hope that you will accept to answer the questions because your opinion is very important. If you decide not to participate, there will be no change in the services you can receive from health programs. If I happen to ask a question that you do not wish to answer, tell me and I will go on to the next question; you can also stop the interview at any time. If you would like more information on any aspect of the survey, you can contact the people listed on this card.
GIVE RESPONDENT THE CARD WITH CONTACT INFORMATION FOR THESE PEOPLE.
Mr. Victor Rabeza, National Institute of Statistics ("INSTAT"). Tel: 0340755950
Dr. Louise Ranaivo, National Program in the Fight Against Malaria ("PNLP"). Tel: 0330280739
Dr. Arsène Ratsimbasoa, National Program in the Fight Against Malaria ("PNLP"). Tel: 0340541965
Interviewer's signature: ______
Date: ______
2 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED (Skip to END)
HOUSEHOLD SCHEDULE
Now we would like some information about people who usually live in your household or who are living with you now.
(Repeat Q.1 - 9 for up to 31 household members)
1. LINE NUMBER
2. HABITUAL RESIDENTS AND VISITORS
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.
3. RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
(Relationship code) ______
CODES FOR Q. 3: 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 OR MOTHER-IN-LAW
08 BROTHER OR SISTER
09 NIECE/NEPHEW
10 NIECE/NEPHEW BY MARRIAGE
11 OTHER RELATIVE
12 ADOPTED/FOSTER/STEPCHILD
13 NO RELATION
98 DK
4. GENDER
Is (NAME) male or female?
2 FEMALE
5. RESIDENCE
Does (NAME) usually live here?
2 NO
6. RESIDENCE
Did (NAME) stay here last night?
2 NO
IF 95 OR OLDER, RECORD '95'
8. ELIGIBLE WOMEN
CIRCLE THE LINE NUMBERS OF ALL WOMEN AGE 15 - 49
8A. PREGNANT NOW?
FOR ALL ELIGIBLE WOMEN, ASK:
2 NO/DK
9. ELIGIBLE CHILDREN
CIRCLE LINE NUMBERS OF ALL CHILDREN AGE 0 - 5.
CHECK THIS BOX IF YOU USE AN ADDITIONAL SHEET ______
NO ______
NO ______
NO ______
HOUSEHOLD CHARACTERISTICS
10. Where does the drinking water used by members of your household mainly come from?
12 IN YARD
13 PUBLIC FOUNTAIN
32 UNPROTECTED WELL
42 UNPROTECTED SPRING
61 TANKER TRUCK WATER
81 SURFACE WATER (RIVER/DAM/LAKE/POND/IRRIGATION CANAL)
91 BOTTLED WATER
96 OTHER (SPECIFY) ______
11. What kind of toilets do members of your household usually use?
12 FLUSH CONNECTED TO SEPTIC TANK
13 FLUSH CONECTED TO LATRINES
14 FLUSH CONNECTED TO SOMETHING ELSE
15 FLUSH CONNECTED TO UNKNOWN PLACE
22 PIT LATRINE WITH WASHABLE SLAB
23 PIT LATRINE WITH NON-WASHABLE SLAB
24 PIT LATRINE WITHOUT SLAB, OPEN PIT
41 BUCKETS/PAILS
51 SUSPENDED TOILETS/LATRINES
61 NO TOILET/NATURE (Skip to 13)
96 OTHER (SPECIFY) ______
12. Do you share these toilets with other households?
2 NO
13. In this household, do you have:
electricity?
a radio set?
a television set?
a cell phone?
a landline phone?
a 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 LIQUID PROPANE GAS ("GPL")
03 NATURAL GAS
04 BIOGAS
05 KEROSENE
06 LIGNITE COAL
07 CHARCOAL
08 WOOD
09 STRAW/BRANCHES/GRASSES
10 AGRICULTURAL PRODUCTS
11 DUNG
95 NO MEALS PREPARED IN HOUSEHOLD
96 OTHER (SPECIFY) ______
15. MAIN MATERIAL OF FLOOR
RECORD OBSERVATION.
12 DUNG
22 PALMS/BAMBOU
23 MATS
32 VINYL OR ASPHALT STRIPS
33 TILES
34 CEMENT
35 CARPET
16. MAIN MATERIAL OF ROOF
RECORD OBSERVATION.
12 THATCH/PALM LEAVES/LEAVES
13 CLUMPS OF EARTH
22 PALMS/BAMBOU
23 WOOD PLANKS
24 CARDBOARD
32 WOOD
33 ZINC/CEMENT FIBER
34 TILES
35 CEMENT
36 SHINGLES
17. MAIN MATERIAL OF EXTERIOR WALLS.
RECORD OBSERVATION.
12 BAMBOU/CANE/PALMS/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 WOODEN PLANKS/SHINGLES
18. How many rooms are used for sleeping in this household?
19. Does any member of your household own:
A watch?
A bicycle?
A motorcycle or scooter?
An animal-drawn cart?
A car or van?
A 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 has anyone come to your home to spray the interior walls for mosquitos to control malaria?
2 NO (Skip to 27)
8 DK (Skip to 27)
22. How many months has it been since this spraying of your dwelling's interior walls?
IF LESS THAN ONE MONTH, RECORD '00' MONTHS.
98 DK
23. Who sprayed the walls of the dwelling?
2 PRIVATE COMPANY
6 OTHER (SPECIFY) ______
8 DK
24. Did you pay anything for the spraying?
2 NO
8 DK
25. How long did you stay outside your home after the spraying?
IF LESS THAN ONE HOUR, RECORD IN MINUTES.
IF ONE OR MORE HOURS, RECORD IN HOURS.
2 HOURS OUTSIDE ______
998 DK/DON'T REMEMBER
26. Since the walls of your dwelling were sprayed, have you touched them up, for example by applying lime, paint, a coating or by 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 41A)
28. How many mosquito nets does your household own?
29. ASK RESPONDENT TO SHOW YOU THE HOUSEHOLD'S MOSQUITO NET(S).
IF MORE THAN 3 MOSQUITO NETS, USE ADDITIONAL QUESTIONNAIRE(S).
(Repeat for up to 3 mosquito nets)
2 NOT OBSERVED
30. How many months has the household had this mosquito net?
IF LESS THAN 3 YEARS, RECORD THE NUMBER OF MONTHS.
IF 36 OR MORE MONTHS, RECORD '95'.
95 36 OR MORE MONTHS
31. Where did you get the mosquito net?
11 DISTRIBUTION CAMPAIGN
12 HEALTH CENTER
13 COMMUNITY AGENT
14 MARKET
15 SHOP
96 OTHER
98 DK
32. Did you get the mosquito net during the last distribution campaign from November 2012 to January 2013?
2 NO
8 DK
33. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET. IF BRAND IS NOT KNOWN AND YOU CANNOT SEE THE MOSQUITO NET, SHOW RESPONDENT PHOTOS OF COMMON BRANDS AND TYPES OF MOSQUITO NETS.
11 OLYSET-NET
12 PERMANET
13 SUPER MOSQUITO NET
14 MILAY
15 TSARALAY
16 INTERCEPTOR
17 OTHER/DON'T KNOW BRAND
31 OTHER
98 DK BRAND
34. When you got this mosquito net, had it already been treated by the manufacturer with an insecticide that kills or repels mosquitos?
2 NO
8 UNSURE
35. Since you have had the mosquito net, has it been soaked or dipped in a liquid to kill or repel mosquitos?
2 NO (Skip to 37)
8 UNSURE (Skip to 37)
36. How many months ago was the mosquito net soaked or dipped 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 24 MONTHS OR MORE
98 UNSURE
37. Did anyone sleep under this mosquito net last night?
2 NO (Skip to 39)
8 UNSURE (Skip to 39)
38. Who slept under this mosquito net last night?
NAME ______
LINE NUMBER ______
39. RETURN TO Q. 29 FOR NEXT MOSQUITO NET; OR, IF NO MORE MOSQUITO NETS, CONTINUE TO Q. 40.
40. CHECK ALL COLUMNS OF Q. 38 AND HOUSEHOLD SCHEDULE. LIST BELOW THE LINE NUMBER AND NAME OF EACH HOUSEHOLD MEMBER WHO DID NOT SLEEP UNDER A MOSQUITO NET LAST NIGHT AND ASK THE CORRESPONDING QUESTION FOR EACH PERSON.
IF ALL HOUSEHOLD MEMBERS SLEPT UNDER A MOSQUITO NET, SKIP TO 41A.
IF MORE THAN 6 PEOPLE DID NOT SLEEP UNDER A MOSQUITO NET, USE AN ADDITIONAL QUESTIONNAIRE.
41. (Repeat for up to 6 people)
NAME ______
What is the main reason that (NAME) did not sleep under a mosquito net last night?
12 NOT ENOUGH MOSQUITO NETS
13 MOSQUITO NET IN BAD CONDITION/RUINED
14 NO ONE SICK
15 UNNECESSARY
16 DON'T LIKE TO SLEEP UNDER MOSQUITO NETS
17 NOT AFRAID OF MOSQUITOS
18 IT'S TOO HOT
19 SAVING MOSQUITO NET FOR FUTURE USE
96 OTHER
98 DK
IF NO OTHER PEOPLE, CONTINUE TO Q. 41A.
41A. CHECK COVER PAGE: CLUSTER NUMBER
CLUSTERS [117-126][237-243][275-284] ______ (Continue to 41B)
OTHER CLUSTERS ______ (Skip to 42)
41B. (Ask this question for clusters [80-91] [94-116][244-255]):
In the months of November and December 2012, did you hear or receive any messages about the distribution campaign of long-lasting insecticidal nets (LLIN)?
(Ask this question for clusters [117-126][237-243][275-284]):
In the months of December 2012 and February 2013, did you hear or receive any messages about the distribution campaign of long-lasting insecticidal nets (LLIN)?
2 NO (Skip to 42)
41C. Did you hear or receive any messages BEFORE the distribution?
2 NO (Skip to 41E)
41D. How did you hear or receive these messages?
Any other way?
RECORD ALL MENTIONED.
B COMMUNITY MEETINGS
C RADIO/TV ANNOUNCEMENTS
X OTHER (SPECIFY) ______
41E. Did you hear or receive any messages DURING the distribution?
2 NO (Skip to 41G)
41F. How did you hear or receive these messages?
No other way?
RECORD ALL MENTIONED.
B COMMUNITY MEETINGS
C RADIO/TV ANNOUNCEMENTS
X OTHER (SPECIFY) ______
41G. Did you hear or receive any messages AFTER the distribution?
2 NO (Skip to 42)
41H. How did you hear or receive these messages?
No other way?
RECORD ALL MENTIONED.
B COMMUNITY MEETINGS
C RADIO/TV ANNOUNCEMENTS
X OTHER (SPECIFY) ______
41I. What messages did you hear or receive?
No other types of messages?
RECORD ALL MENTIONED.
B WHEN TO GET A LLIN
C THE LLIN IS FREE
D HOW TO HANG UP A LLIN
E HOW TO CARE FOR A LLIN
F WHEN TO USE A LLIN
G REASONS TO GET A LLIN
W OTHER (SPECIFY) ______
X OTHER (SPECIFY) ______
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 own right now that you no longer use for sleeping?
IF 5 OR MORE MOSQUITO NETS, RECORD '5'.
2 USE AS CURTAIN
3 USE TO PROTECT CROPS
4 USE FOR FISHING
5 KEPT FOR FUTURE USE
6 OTHER USE
8 DK
2 GIVE IT TO BE RID OF IT
8 DK
46. Have you ever owned a mosquito net that you no longer have?
2 NO (Skip to 47A)
47. The last time that you got rid of your last mosquito net, what did you do with it?
12 BURIED
13 THROWN AWAY
14 COMPOST
15 GAVE IT TO SOMEONE
16 EXCHANGED FOR A NEW ONE
96 OTHER (SPECIFY)______
98 DK
47A. Some people prefer certain types of mosquito nets for sleeping, that is, certain shapes, colors, or textures. Do you have a preference?
2 NO (Skip to 47F)
3 NO PREFERENCE (Skip to 47F)
47B. What shape of mosquito net do you prefer for sleeping?
2 CONE-SHAPED
6 OTHER (SPECIFY) ______
7 NO PREFERENCE/DOESN'T MATTER
47C. What type of texture of mosquito net do you prefer for sleeping?
SHOW PHOTOS OF 2 TYPES OF MOSQUITO NETS: POLYESTER AND POLYETHYLENE
2 HARD TEXTURE/POLYETHYLENE
6 OTHER (SPECIFY) ______
7 NO PREFERENCE/DOESN'T MATTER
47D. What color mosquito net do you prefer for sleeping?
2 BLUE
3 GREEN
4 PINK
6 OTHER (SPECIFY) ______
7 NO PREFERENCE/DOESN'T MATTER
47E. What size mosquito net do you prefer for sleeping?
2 SHORT MOSQUITO NET (150cm)
6 OTHER (SPECIFY) ______
7 NO PREFERENCE/DOESN'T MATTER
47F. In many villages, some people use mosquito nets for other things besides sleeping, for example as a curtain or fishing net. Is that the case for new mosquito nets, old mosquito nets, or both?
2 OLD MOSQUITO NETS
3 BOTH (OLD AND NEW)
4 DOESN'T HAPPEN HERE
8 DK
ANEMIA AND MALARIA TESTS FOR CHILDREN AGE 0 - 5
48. CHECK COLUMN 9 OF HOUSEHOLD SCHEDULE. RECORD THE NAME AND LINE NUMBER 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 ANSWER QUESTIONS 56 AND 57.
LINE NUMBER ______
NAME ______
49A. Did (NAME) take any medicine for malaria in the last 30 days?
2 NO (Skip to 50)
3 DK (Skip to 50)
49B. What medications did (NAME) take for malaria?
No other medications?
RECORD ALL MENTIONED.
ASK TO SEE THE MEDICINE(S) IF TYPE OF MEDICINE IS NOT KNOWN.
IF TYPE OF MEDICINE CANNOT BE IDENTIFIED, SHOW RESPONDENT SOME COMMON ANTIMALARIALS.
B CHLOROQUINE (PALUSTOP)
C AMODIAQUINE (LARIMAL)
D QUININE
E NIVAQUINE
F ACTIPAL (ACT)
G LARIMAL (ACT)
H ARTEMODI (ACT)
I ARSUMOON (ACT)
J FALCIMON (ACT)
K COARSUCAM
L ASAQ
M ARTESUNATE
N OTHER ACT/UNDETERMINED ACT
O OTHER ANTIMALARIAL
Q PARACETAMOL, ACETAMINOPHEN
R IBUPROFEN
V OTHER (SPECIFY) ______
W OTHER (SPECIFY) ______
X OTHER (SPECIFY) ______
Z DK
49C. When was the last time (NAME) took medicine for malaria?
PROBE TO GET THE MONTH (EVEN APPROXIMATE) AND YEAR
98 DK DAY
MONTH ______
YEAR ______
50. What is (NAME)'s birthdate?
FOR CHILDREN WHO AREN'T INCLUDED IN ANY HISTORY, ASK THE DAY, MONTH AND YEAR.
MONTH ______
YEAR ______
2 NO (GO TO 49 FOR NEXT CHILD, OR IF NO MORE CHILDREN, END THE INTERVIEW)
2 OLDER
53. LINE NUNBER OF CHILD'S PARENT OR RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED.
54. READ THE INFORMED CONSENT FOR THE ANEMIA TEST TO CHILD'S PARENT OR OTHER RESPONSIBLE ADULT.
CIRCLE THE CODE AND SIGN.
2 REFUSED (Go to signature)
(SIGNATURE) ______
55. READ THE INFORMED CONSENT FOR THE MALARIA TEST TO THE CHILD'S PARENT OR OTHER RESPONSIBLE ADULT.
CIRCLE THE CODE AND SIGN.
1 GRANTED RAPID TESTS AND FUTURE
2 GRANTED ONLY RAPID TEST
3 GRANTED ONLY FUTURE TEST
4 REFUSED RAPID AND FUTURE TESTS
(SIGNATURE) ______
CARRY OUT TESTS ON CHILDREN FOR WHICH CONSENT WAS GRANTED AND CONTINUE WITH 58
56. RECORD THE HEMOGLOBIN LEVEL HERE.
994 ABSENT
995 REFUSED
996 OTHER
57. RECORD RESULT CODE FOR 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 THE 2ND STICKER TO THE CORRESPONDING SLIDE.
3) ATTACH THE 3RD STICKER TO THE CORRESPONDING FILTER PAPER.
4) ATTACH THE 4TH STICKER TO THE TRANSMISSION SHEET.
995 REFUSED
996 OTHER
OTHER ______ (Continue to 60)
2 OTHER POSITIVE
3 NEGATIVE (Skip to 69)
6 OTHER (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 present any of the following symptoms:
Prostration, that is, a state of extreme weakness?
Loss of consciousness?
Severe respiratory failure?
Convulsions?
Abnormal bleeding?
Jaundice (with coloring in eyes)?
Black or brown urine?
Uncontrollable vomiting?
RECORD ALL MENTIONED.
2 NO
8 DK
2 NO
8 DK
2 NO
8 DK
2 NO
8 DK
2 NO
8 DK
2 NO
8 DK
2 NO
8 DK
2 NO
8 DK
SYMPTOMS (Q. 62)
2 NO SEVERE ANEMIA (Q. 61 = 2) AND NO CODE 1 CIRCLED IN Q. 62
64. In the last two weeks has (NAME) followed a medical treatment for malaria prescribed by a doctor, health agent, or community agent?
2 NO
65. READ THE INFORMATION ON MALARIA TREATMENT AND INFORMED CONSENT TO CHILD'S PARENT OR OTHER RESPONSIBLE ADULT.
(SIGNATURE) ______
2. REFUSED
THEN SKIP TO 68
66. STATEMENT FOR SEVERE SYMPTOMS
THEN SKIP TO 68.
67. STATEMENT FOR CHILDREN ALREADY UNDERGOING TREATMENT
68. RECORD THE 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 1ST COLUMN IN ADDITIONAL QUESTIONNAIRE; IF NO MORE CHILDREN, END INTERVIEW.
STATEMENT OF INFORMED CONSENT FOR ANEMIA TEST
As part of this survey, we are asking children all over the country to take part in anemia testing. Anemia is a serious health problem which generally is a 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 2008 or later to participate in the anemia 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 it will be thrown away 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 (CHILD'S NAME) has severe anemia, we will refer him/her to the nearest health center for follow-up.
We would like to have your consent to test (CHILD'S NAME) for anemia.
Do you have any questions about the anemia test?
You can say 'yes' to the test or you can say 'no'.
It is your decision.
Will you allow (NAME OF CHILD/CHILDREN) to take part in the anemia test?
STATEMENT OF INFORMED CONSENT FOR MALARIA TEST
As part of this survey, we are asking children all over the country to take part in a test to see if they have malaria or not. Malaria is a serious health problem caused by a parasite transmitted by a mosquito bite. This survey will help the government develop programs to prevent malaria.
We are asking all children born in 2008 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 immediately for malaria and the results will be given to you right away. The other drops of blood will be tested later in the laboratory for more in-depth analysis of the malaria. The results of these additional tests will not be returned to you. The results are strictly confidential.
We would like to have your consent to test (CHILD'S NAME) immediately for malaria and to use a few drops of blood for additional malaria tests at the central laboratory.
Do you have any questions about the malaria test?
You can say 'yes' to the test or you can say 'no'.
It is your decision.
Will you allow (NAME OF CHILD/CHILDREN) to take part in the malaria test?
TREATMENT FOR CHILDREN WITH A POSITIVE MALARIA TEST
IF THE MALARIA TEST IS POSITIVE: The test to diagnose malaria shows that (CHILD'S NAME) has malaria. We can offer you some free medicine. These medicines are called ACT. ACT is very effective and should get rid of (NAME OF CHILD)'s fever and other symptoms within a few days. However, with all medicines there are side effects, and this medication can have some. The most common side effects are dizziness, fatigue, lack of appetite, and palpitations.
It is your decision.
Please tell me: will you accept the medication to treat (CHILD'S NAME) or not? If you don't accept, I will refer (CHILD'S NAME) to the nearest health center for treatment.
TREATMENT WITH ACT (Artesunate Amodiaquine Winthrop)
(Table)
Children under age of 1 year or weighing less than 8 kgs
Tablet of 25 mg Artesunate and 67.5 mg Amodiaquine (Packet with Pink Strip)
Day 2 (1 tablet)
Day 3 (1 tablet)
Children age 1 - 5 or weighing 8 - 17 kgs
Tablet of 50 mg Artesunate and 135 mg Amodiaquine (Packet with Purple Strip)
Day 2 (1 tablet)
Day 3 (1 tablet)
ALSO SAY THIS TO CHILD'S PARENT/RESPONSIBLE ADULT:
If (CHILD'S NAME) has any of the following symptoms, you must take him/her immediately to a doctor or health agent to receive care:
Convulsions, coma
Rapid breathing or difficulty breathing
Unable to drink or nurse
Gets sicker or doesn't improve in 2 days
STATEMENT FOR CHILDREN WITH A POSITIVE MALARIA TEST AND SEVERE ANEMIA AND/OR ANY SYMPTOM FROM Q. 62
The test to diagnose malaria shows that (CHILD'S NAME) has malaria. But he/she also has (SEVERE ANEMIA Q. 61 AND/OR ANY SYMPTOM IN Q.62) which means that he/she is seriously ill. I cannot treat him/her, but you should take him/her immediately to a doctor or health agent for treatment.
STATEMENT FOR CHILDREN WITH A POSITIVE MALARIA TEST AND ALREADY BEING TREATED
You told me that (CHILD'S NAME) is following/just followed a treatment for malaria, however, the test to diagnose malaria shows that he/she still has malaria. I cannot give him/her any treatment, but you should take him/her to a doctor or health agent for additional testing.