ENQUÊTE SUR LES INDICATEURS DU PALUDISME
EIPM 2016
QUESTIONNAIRE MENAGE

RÉPUBLIQUE DE MADAGASCAR
INSTITUT NATIONAL DE LA STATISTIQUE
DIRECTION DE LA DÉMOGRAPHIE ET DES STATISTIQUES SOCIALES

IDENTIFICATION
PLACE NAME ___________________

NAME OF THE LOCALITY _______________________

NAME OF HOUSEHOLD HEAD __________________________

CLUSTER NUMBER ________________________

HOUSEHOLD NUMBER ______________________________

REGION ____

DISTRICT ____

COMMUNE ____

MILIEU

CITY 1
RURAL 2

INTERVIEWER VISITS:

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

DATE _______
INTERVIEWER'S NAME _________
RESULT* ____

NEXT VISIT

DATE ____
TIME ____

FINAL VISIT

DAY ____
MONTH ____
YEAR _____

TOTAL NUMBER OF VISITS ______

*RESULT CODES:

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT 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

QUESTIONNAIRE LANGUAGE** ____

LANGUAGE OF INTERVIEW** ____

NATIVE LANGUAGE OF RESPONDENT** ___

TRANSLATOR USED

YES 1
NO 2

**LANGUAGE CODES

FRENCH 01
MALGACHE 02
OTHER (SPECIFY) ____ 03

SUPERVISOR

NAME ____
NUMBER ___

INTRODUCTION AND CONSENT

Hello. My name is _______________________________________. I am working with National Institute of Statistics. We are conducting a survey about malaria all over Madagascar. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take between 10 and 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 you decide not to be in the survey, there will be no changes in the services you can access through health programs. 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 this card.

GIVE CARD WITH INFORMATION TO CONTACT THESE PERSONS:
Mr. RABEZA Victor, Institut National des Statistiques (INSTAT). Tel: 0340755850
Pr. RATSIMBASOA Arsène, Programme National de Lutte contre le Paludisme (PNLP). Tel: 0340541965

Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER ____
DATE ____

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

100) RECORD THE TIME.

HOURS ____
MINUTES __

HOUSEHOLD TABLE

01) LINE NUMBER.

02) USUAL 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.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-9 FOR EACH PERSON.

02A) Just to make sure that I have a complete listing: are there any other people such as small children or infants that we have not listed?

YES (ADD TO TABLE)
NO

02B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?

YES (ADD TO TABLE)
NO

02C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

YES (ADD TO TABLE)
NO

03) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

SEE CODES BELOW:

CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER/STEPCHILD 10
NO PARENT 11
DON'T KNOW 98

(RESULT CODE) ____

04) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

05) RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

06) RESIDENCE: Did (NAME) stay here last night?

YES 1
NO 2

07) AGE: How old is (NAME)?

IF 95 OR OLDER, RECORD '95'.

IN YEARS ____

08) ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL WOMEN 15-49

09) ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL CHILDREN 0-5

____ CHECK HERE IF AN ADDITIONAL QUESTIONNAIRE IS USED

HOUSEHOLD CHARACTERISTICS

101) What is the main source of drinking water for members of your household?

PIPED WATER

PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14 (GO TO 103)

TUBE WELL OR BOREHOLE 21 (GO TO 103)

DUG WELL

PROTECTED WELL 31 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)

WATER FROM SPRING

PROTECTED SPRING 41 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)

RAINWATER 51 (GO TO 103)
TANKER TRUCK 61 (GO TO 103)
CART WITH SMALL TANK 71 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 103)
BOTTLED WATER 91

OTHER (SPECIFY) ____ 96 (GO TO 103)

102) What is the main source of water used by your household for other purposes such as cooking and handwashing?

PIPED WATER

PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14

TUBE WELL OR BOREHOLE 21

DUG WELL

PROTECTED WELL 31
UNPROTECTED WELL 32

WATER FROM SPRING

PROTECTED SPRING 41
UNPROTECTED SPRING 42

RAINWATER 51
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81

OTHER (SPECIFY)____ 96

103) Where is the water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

104) How long does it take to go there, get water, and come back?

MINUTES _____
DON'T KNOW 998

105) CHECK 101 AND 102: CODE '14' OR '21' CIRCLED

YES (GO TO 106)
NO (GO TO 107)

106) In the past two weeks, was the water from this source not available for at least one full day?

YES 1
NO 2
DON'T KNOW 8

107) Do you do anything to the water to make it safer to drink?

YES 1
NO 2 (GO TO 109)
DON'T KNOW 8 (GO TO 109)

108) What do you usually do to the water to make it safer to drink?

Anything else?

RECORD ALL MENTIONED

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F

OTHER (SPECIFY) ____ X
DON'T KNOW Z

109) What kind of toilet facility do members of your household usually use?

IF IT IS NOT POSSIBLE TO DETERMINE THE TYPE OF TOILET, ASK FOR PERMISSION TO SEE THE FACILITY.

FLUSH OR POUR FLUSH TOILET

FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15

PIT LATRINE

VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23

COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 113)

OTHER (SPECIFY) ____ 96

110) Do you share this toilet facility with any other households?

YES 1
NO 2 (GO TO 112)

111) Including your own household, how many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10 ____

10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

112) Where is that toilet facility located?

IN OWN DWELLING 1
IN OWN YARD/PLOT 2
ELSEWHERE 3

113) What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
LIQUID PROPANE GAS (LPG) 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL 06
CHARCOAL 07
WOOD 08
SAWDUST/WOOD CHIPS 09
STRAW/SHRUBS/GRASS 10
ANIMAL DUNG 11

NO FOOD COOKED IN HOUSEHOLD 95

OTHER (SPECIFY) ____ 96

114) How many rooms in this household are used for sleeping?

ROOMS ____

115) Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
NO 2 (GO TO 117)

116) How many of the following animals does this household own?

IF NONE, RECORD '00'
IF 95 OR MORE, RECORD '95'
IF UNKNOWN, RECORD '99'

a) Milk cows or bulls?

MILK COWS OR BULLS ____

b) Other cattle?

OTHER CATTLE ____

c) Horses, donkeys, or mules?

HORSES, DONKEYS, OR MULES ____

d) Goats?

GOATS ____

e) Sheep?

SHEEP ____

f) Chickens or other poultry?

CHICKENS OR OTHER POULTRY _____

g) Pigs?

PIGS ____

117) Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 119)

118) How many hectares of agricultural land do members of this household own?

IF 95 OR MORE, CIRCLE '950'.

HECTARES ____

95 HECTARES OR MORE 950
UNKNOWN 998

119) Does your household have:

a) Electricity?

YES 1
NO 2

b) A radio?

YES 1
NO 2

c) A television?

YES 1
NO 2

d) A non-mobile telephone?

YES 1
NO 2

e) A computer?

YES 1
NO 2

f) A refrigerator?

YES 1
NO 2

120) Does any member of this household own:

a) A watch?

YES 1
NO 2

b) A mobile phone?

YES 1
NO 2

c) A bicycle?

YES 1
NO 2

d) A motorcycle or motor scooter?

YES 1
NO 2

e) Animal-drawn cart?

YES 1
NO 2

f) A car/truck?

YES 1
NO 2

g) A motorboat?

YES 1
NO 2

121) Does any member of this household have a bank account?

YES 1
NO 2

122A) At any time in the last 12 months did organizers stop by your home to raise awareness about the Indoor Residual Spraying (IRS) campaign?

YES 1
NO 2
DON'T KNOW 8

122AA) At any time in the past 12 months, has anyone come to your house to spray your interior walls to control malaria?

YES 1
NO 2 (GO TO 128)
DON'T KNOW (GO TO 128)

122B) Did you agree to have the walls of your home sprayed?

YES 1 (GO TO 123)
NO 2 (GO TO 122C)
DON'T KNOW 8 (GO TO 128)

122C) Why did you not agree to have the walls of your home sprayed?

RECORD ALL MENTIONED.

SMELL A
MESSY B
MOVING OF FURNITURE C
MAKES YOU ILL D
CONTAMINATION OF PLANTS AND AGRICULTURAL PRODUCTS E
OTHER (SPECIFY) X

GO TO 128

123) How many months ago was the house sprayed?

IF LESS THAN ONE MONTH, RECORD '00' MONTHS AGO

MONTHS SINCE SPRAYING ____
DON'T KNOW 98

124) Who sprayed the house?

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C

OTHER (SPECIFY) ____ X
DON'T KNOW Z

125) Did you pay for your dwelling to be sprayed?

YES 1
NO 2
DON'T KNOW 8

126) How long did you stay out of your home after it was sprayed?

IF LESS THAN ONE HOUR, RECORD IN MINUTES
IF ONE HOUR OR MORE, RECORD IN HOURS

MINUTES OUTSIDE ____ 1
HOURS OUTSIDE ____ 2
DON'T KNOW/DON'T REMEMBER 998

127) Since the walls of your home where sprayed, have you treated them, for example by putting lime, paint, or plaster on them or washing them?

YES 1
NO 2 (GO TO 128)
DON'T KNOW/DON'T REMEMBER 8 (GO TO 128)

127A) How many months ago did you treat the walls of your home?

MONTHS SINCE TREATING ____
DON'T KNOW 8

128) Does your household have mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 141A)

128A) How many mosquito nets does your household have?

IF 7 MOSQUITO NETS OR MORE, RECORD '7'.

NUMBER OF MOSQUITO NETS __

MOSQUITO NETS

129) ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2

130) How many months ago did your household obtain the mosquito net?

IF LESS THAN ONE MONTH, RECORD '00'.

MONTHS AGO ____
MORE THAN 36 MONTHS 95
NOT SURE 98

131) CHECK OR ASK THE BRAND OF MOSQUITO NET. IF BRAND UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

LONG-LASTING INSECTICIDAL MOSQUITO NET (LLIN)

OLYSET 11 (GO TO 133A)
PERMANET 12 (GO TO 133A)
SUPER MOUSTIQUAIRE 13 (GO TO 133A)
MILAY 14 (GO TO 133A)
TSARALAY 15 (GO TO 133A)
INTERCEPTOR 16 (GO TO 133A)
BESTNET/NETPROTECT 17 (GO TO 133A)
YORKOOL 18 (GO TO 133A)
ROYAL SENTRY 19 (GO TO 133A)
OTHER/DON'T KNOW BRAND 20 (GO TO 133A)

PRE-TREATED NET

ANY BRAND 21 (GO TO 133A)

OTHER TYPE 96
DON'T KNOW TYPE 98

131A) When you got the net, did it come with a bag or without a bag?

YES 1
NO 2
NOT SURE 8

132) When you got the net, was it already factory-treated with an insecticide to kill or repel mosquitos?

YES 1
NO 2
NOT SURE 8

133A) In the past 12 months, have you washed the net?

YES 1
NO 2 (GO TO 133D)

133B) How many times?

NUMBER OF TIMES ____
NOT SURE 98

133C) How do you dry the net?

IN THE SHADE 1
IN THE SUN 2
DRY ANY WAY 3
NOT SURE 8

133D) When the net is torn, do you mend it?

YES 1
NO 2
NOT SURE 8

134) Did you get the net through the 2015 mass distribution campaign, during
an antenatal care visit, or during an immunization visit?

YES, MASS DISTRIBUTION 1 (GO TO 136)
YES, ANC 2 (GO TO 136)
YES, IMMUNIZATION VISIT 3 (GO TO 136)
NO 4

135) Where did you get the net?

GOVERNMENT HEALTH FACILITY 01
PRIVATE HEALTH FACILITY 02
DISTRIBUTION SITE 03
PHARMACY 04
SHOP/MARKET 05
COMMUNITY HEALTH WORKER 06
RELIGIOUS INSTITUTION 07
PRIVATE ORGANIZATION 08
NGO 09
OTHER 96
DON'T KNOW 98

136) Did anyone sleep under the mosquito net last night?

YES 1
NO 2 (GO TO 139)
NOT SURE 8

137) Who slept under the mosquito net last night?

ENTER THE NAME OF THE PERSON AND RESPECTIVE LINE NUMBER FROM HOUSEHOLD TABLE.

NAME ____
LINE NUMBER ____

NAME ____
LINE NUMBER ____

NAME ____
LINE NUMBER ____

NAME ____
LINE NUMBER ____

138) GO BACK TO 139 FOR THE NEXT MOSQUITO NET; IF THERE ARE NO MORE NETS, GO TO 139.

MESSAGES AND KNOWLEDGE

139) CHECK 137: ALL COLUMNS AND HOUSEHOLD TABLE. BELOW LIST THE LINE NUMBER AND NAME OF EACH HOUSEHOLD MEMBER THAT 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, GO TO 141A.

IF MORE THAN 6 PEOPLE DID NOT SLEEP UNDER A MOSQUITO NET, USE ADDITIONAL QUESTIONNAIRE(S).

140A)

LINE NUMBER ____
NAME ____