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
RURAL 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
INTERVIEWER'S NAME _________
RESULT* ____
NEXT VISIT
TIME ____
FINAL VISIT
MONTH ____
YEAR _____
TOTAL NUMBER OF VISITS ______
*RESULT CODES:
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** ____
QUESTIONNAIRE LANGUAGE** ____
LANGUAGE OF INTERVIEW** ____
NATIVE LANGUAGE OF RESPONDENT** ___
TRANSLATOR USED
NO 2
**LANGUAGE CODES
MALGACHE 02
OTHER (SPECIFY) ____ 03
SUPERVISOR
NAME ____
NUMBER ___
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 DOES NOT AGREE TO BE INTERVIEWED 2 (END)
100) RECORD THE TIME.
MINUTES __
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?
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?
NO
02C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
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
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?
FEMALE 2
05) RESIDENCE: Does (NAME) usually live here?
NO 2
06) RESIDENCE: Did (NAME) stay here last night?
NO 2
IF 95 OR OLDER, RECORD '95'.
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
101) What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)
UNPROTECTED SPRING 42 (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
102) What is the main source of water used by your household for other purposes such as cooking and handwashing?
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
PROTECTED WELL 31
UNPROTECTED WELL 32
PROTECTED SPRING 41
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
103) Where is the water source located?
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3
104) How long does it take to go there, get water, and come back?
DON'T KNOW 998
105) CHECK 101 AND 102: CODE '14' OR '21' CIRCLED
NO (GO TO 107)
106) In the past two weeks, was the water from this source not available for at least one full day?
NO 2
DON'T KNOW 8
107) Do you do anything to the water to make it safer to drink?
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
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
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 TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 113)
110) Do you share this toilet facility with any other households?
NO 2 (GO TO 112)
111) Including your own household, how many households use this toilet facility?
NO. OF HOUSEHOLDS IF LESS THAN 10 ____
DON'T KNOW 98
112) Where is that toilet facility located?
IN OWN YARD/PLOT 2
ELSEWHERE 3
113) What type of fuel does your household mainly use for cooking?
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
114) How many rooms in this household are used for sleeping?
115) Does this household own any livestock, herds, other farm animals, or poultry?
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'
117) Does any member of this household own any agricultural land?
NO 2 (GO TO 119)
118) How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '950'.
95 HECTARES OR MORE 950
UNKNOWN 998
119) Does your household have:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
120) Does any member of this household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
121) Does any member of this household have a bank account?
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?
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?
NO 2 (GO TO 128)
DON'T KNOW (GO TO 128)
122B) Did you agree to have the walls of your home sprayed?
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.
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
DON'T KNOW 98
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
DON'T KNOW Z
125) Did you pay for your dwelling to be sprayed?
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
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?
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?
DON'T KNOW 8
128) Does your household have mosquito nets that can be used while sleeping?
NO 2 (GO TO 141A)
128A) How many mosquito nets does your household have?
IF 7 MOSQUITO NETS OR MORE, RECORD '7'.
129) ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
130) How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'.
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.
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)
DON'T KNOW TYPE 98
131A) When you got the net, did it come with a bag or without a bag?
NO 2
NOT SURE 8
132) When you got the net, was it already factory-treated with an insecticide to kill or repel mosquitos?
NO 2
NOT SURE 8
133A) In the past 12 months, have you washed the net?
NO 2 (GO TO 133D)
NOT SURE 98
IN THE SUN 2
DRY ANY WAY 3
NOT SURE 8
133D) When the net is torn, do you mend it?
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, ANC 2 (GO TO 136)
YES, IMMUNIZATION VISIT 3 (GO TO 136)
NO 4
135) Where did you get the net?
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?
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.
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).
NAME ____
What is the main reason (NAME) did not use the mosquito net last night?
NOT ENOUGH NETS 12
NET IN POOR CONDITION/DESTROYED 13
PERSON SICK 14
WASN'T NECESSARY 15
DON'T LIKE SLEEPING UNDER NET 16
NOT AFRAID OF MOSQUITOS 17
TOO HOT 18
SAVING NET FOR FUTURE USE 19
OTHER (SPECIFY) ____ 96
DON'T KNOW 98
IF NO OTHER PERSON, GO TO 141A.
NAME ____
What is the main reason (NAME) did not use the mosquito net last night?
NOT ENOUGH NETS 12
NET IN POOR CONDITION/DESTROYED 13
PERSON SICK 14
WASN'T NECESSARY 15
DON'T LIKE SLEEPING UNDER NET 16
NOT AFRAID OF MOSQUITOS 17
TOO HOT 18
SAVING NET FOR FUTURE USE 19
OTHER (SPECIFY) ____ 96
DON'T KNOW 98
IF NO OTHER PERSON, GO TO 141A.
NAME ____
What is the main reason (NAME) did not use the mosquito net last night?
NOT ENOUGH NETS 12
NET IN POOR CONDITION/DESTROYED 13
PERSON SICK 14
WASN'T NECESSARY 15
DON'T LIKE SLEEPING UNDER NET 16
NOT AFRAID OF MOSQUITOS 17
TOO HOT 18
SAVING NET FOR FUTURE USE 19
OTHER (SPECIFY) ____ 96
DON'T KNOW 98
IF NO OTHER PERSON, GO TO 141A.
NAME ____
What is the main reason (NAME) did not use the mosquito net last night?
NOT ENOUGH NETS 12
NET IN POOR CONDITION/DESTROYED 13
PERSON SICK 14
WASN'T NECESSARY 15
DON'T LIKE SLEEPING UNDER NET 16
NOT AFRAID OF MOSQUITOS 17
TOO HOT 18
SAVING NET FOR FUTURE USE 19
OTHER (SPECIFY) ____ 96
DON'T KNOW 98
IF NO OTHER PERSON, GO TO 141A.
NAME ____
What is the main reason (NAME) did not use the mosquito net last night?
NOT ENOUGH NETS 12
NET IN POOR CONDITION/DESTROYED 13
PERSON SICK 14
WASN'T NECESSARY 15
DON'T LIKE SLEEPING UNDER NET 16
NOT AFRAID OF MOSQUITOS 17
TOO HOT 18
SAVING NET FOR FUTURE USE 19
OTHER (SPECIFY) ____ 96
DON'T KNOW 98
IF NO OTHER PERSON, GO TO 141A.
NAME ____
What is the main reason (NAME) did not use the mosquito net last night?
NOT ENOUGH NETS 12
NET IN POOR CONDITION/DESTROYED 13
PERSON SICK 14
WASN'T NECESSARY 15
DON'T LIKE SLEEPING UNDER NET 16
NOT AFRAID OF MOSQUITOS 17
TOO HOT 18
SAVING NET FOR FUTURE USE 19
OTHER (SPECIFY) ____ 96
DON'T KNOW 98
IF NO OTHER PERSON, GO TO 141A.
141A) During the months of September, October, and November of 2015, did you hear or receive messages about the long-lasting insecticidal mosquito net (LLIN) distribution campaign?
NO 2 (GO TO 142)
141B) Did you hear or receive these messages BEFORE the distribution campaign?
NO 2 (141D)
141C) How did you hear or receive these messages?
Any other ways?
RECORD ALL MENTIONED.
GROUP FACILITATION B
RADIO/TELEVISION SPOTS C
HEALTH CENTER D
ANTENATAL CARE VISIT E
VACCINATION F
OTHER (SPECIFY) ____ X
141D) Did you hear or receive messages DURING the distribution campaign?
NO 2 (GO TO 141F)
141E) How did you hear or receive these messages?
Any other ways?
RECORD ALL MENTIONED.
GROUP FACILITATION B
RADIO/TELEVISION SPOTS C
HEALTH CENTER D
ANTENATAL CARE VISIT E
VACCINATION F
OTHER (SPECIFY) ____ X
141F) Did you hear or receive messages AFTER the distribution campaign?
NO 2 (GO TO 141H)
141G) How did you hear or receive these messages?
Any other ways?
RECORD ALL MENTIONED.
GROUP FACILITATION B
RADIO/TELEVISION SPOTS C
HEALTH CENTER D
ANTENATAL CARE VISIT E
VACCINATION F
OTHER (SPECIFY) ____ X
141H) What messages did you hear or receive (before, during, or after the distribution campaign)?
Any other messages?
RECORD ALL MENTIONED.
WHEN TO GET A LLIN B
LLIN IS FREE C
HOW TO HANG A LLIN D
HOW TO CARE FOR A LLIN E
WHEN TO USE A LLIN F
INTEREST IN GETTING A LLIN G
OTHER (SPECIFY) ____ X
141I) In the last 12 months, how many times did you hear messages about malaria awareness?
IF 6 OR MORE TIMES, RECORD '6'.
DON'T KNOW 98
142) Do you currently have a mosquito net that you no longer use for sleeping?
NO 2 (GO TO 146)
143) How many mosquito nets do you currently have that you don't use for sleeping?
IF MORE THAN 5 MOSQUITO NETS, RECORD '5'.
a) ONLY ONE NET: How do you use the mosquito net you no longer use for sleeping?
USED AS CURTAIN 2
USED TO PROTECT CROPS 3
USED FOR FISHING 4
SAVED FOR FUTURE USE 5
OTHER USE (SPECIFY) ____ 6
b) MORE THAN ONE NET: How do you use the last mosquito net you no longer use for sleeping?
USED AS CURTAIN 2
USED TO PROTECT CROPS 3
USED FOR FISHING 4
SAVED FOR FUTURE USE 5
OTHER USE (SPECIFY) ____ 6
a) ONLY ONE NET: Would you rather keep the mosquito net for other uses than sleeping or give it to local officials for disposal?
GIVE FOR DISPOSAL 2
DON'T KNOW 8
b) MORE THAN ONE NET: Would you rather keep the last mosquito not used for sleeping or give it to local officials for disposal?
GIVE FOR DISPOSAL 2
DON'T KNOW 8
146) Did you ever have a mosquito net that you no longer have?
NO 2 (GO TO 147A)
147) How did you dispose of your last mosquito net?
BURIED 12
THREW OUT 13
COMPOSTED 14
GAVE TO SOMEONE 15
TRADED IN FOR A NEW ONE 16
OTHER (SPECIFY) ____ 96
DON'T KNOW 98
147A) Some people prefer certain types of mosquito nets for sleeping, that is certain shapes, colors, or textures. Do you have a preference?
NO 2 (GO TO 148)
NO PREFERENCE 3 (GO TO 148)
147B) What texture of mosquito net do you prefer for sleeping?
SHOW PHOTOS OF 2 TYPES OF MOSQUITO NETS: POLYESTER AND POLYETHYLENE
RIGID TEXTURE/POLYETHYLENE 2
NO PREFERENCE/NOT IMPORTANT 7
147C) What color of mosquito net do you prefer for sleeping?
BLUE 2
GREEN 3
PINK 4
NO PREFERENCE/NOT IMPORTANT 7
148) OBSERVE THE MAIN MATERIAL OF THE FLOOR OF THE DWELLING.
RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
RUSTIC MAT 23
VINYL/ASPHALT STRIPS 32
CERAMIC TILES 33
CONCRETE 34
CARPET 35
149) OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.
THATCH/PALM LEAF 12
SOD 13
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBER 33
TILES 34
CONCRETE 35
ROOFING SHINGLES 36
144) OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.
BARK/STRAW/PALM/BAMBOO 12
EARTH 13
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/ROOFING SHINGLES 36
MINUTES __
TO BE COMPLETED AFTER INTERVIEW
COMMENTS ON THE INTERVIEW:
____
COMMENTS ON SPECIFIC QUESTIONS:
____
OTHER COMMENTS:
____
____
____