PLANNING AND STATISTICAL UNIT/M-HEALTH
NATIONAL DEPARTMENT OF STATISTICS AND INFORMATION
REPUBLIC OF MALI

IDENTIFICATION:

PLACE NAME__
CLUSTER NUMBER___
COMPOUND NUMBER__
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD__

URBAN/RURAL ____

ARRONDISSEMENT__

HOUSEHOLD SELECTED FOR:

INTERVIEWER VISITS:

INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
INTERVIEWER NAME____

RESULTS___

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

FINAL VISIT
DAY__
MONTH__
YEAR 2006
INTERVIEWER__
RESULT__

TOTAL NUMBER OF VISITS____

TOTAL IN THE HOUSEHOLD__
TOTAL ELIGIBLE WOMEN__
TOTAL ELIGIBLE MEN__
RESPONDENT'S LINE NUMBER__

SUPERVISOR
NAME___
DATE___

FIELD EDITOR
NAME__
DATE__

OFFICE EDITOR__
KEYED BY___

HOUSEHOLD SCHEDULE

We would now like information on the persons who usually live in your household and who are currently living with you.

1. LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

2. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who slept 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?

4. SEX: Is (NAME) male or female?

5. RESIDENCE: Does (NAME) usually live here?

6. RESIDENCE: Did (NAME) stay here last night?

7. AGE: How old is (NAME) in completed years?
IF LESS THAN ONE YEAR RECORD '00'.
FOR 95 OR MORE RECORD '95'.

CHRONIC ILLNESS - IF AGE IS 15-59 YEARS:

7A. Has (NAME) been very sick during the past 12 months?
By "very sick" I mean too sick to work or to do his or her normal household activities.

ELIGIBILITY:
8. CIRCLE THE LINE NUMBER OF ALL WOMEN BETWEEN 15-49 YEARS.

ELIGIBILITY:
9. CIRCLE THE LINE NUMBER OF ALL THE CHILDREN LESS THAN 6 YEARS.

ELIGIBILITY:
9A. CHECK TO SEE IF THE HOUSEHOLD WAS CHOSEN FOR A MEN'S SURVEY. CIRCLE THE LINE NUMBER OF ALL THE MEN.

SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS:

10. Is (NAME'S) biological mother still alive?

11. IF ALIVE: Does the (NAME'S) biological mother live in the household?
IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER. RECORD 00 IF THE BIOLOGICAL PARENTS ARE NOT LISTED IN THE HOUSEHOLD TABLE.

12. Is (NAME'S) biological father still alive?

13. IF ALIVE: Does the (NAME'S) biological father live in the household?
IF YES: What is his name?

RECORD FATHER'S LINE NUMBER. RECORD 00 IF THE BIOLOGICAL PARENTS ARE NOT LISTED IN THE HOUSEHOLD TABLE.

BIRTH CERTIFICATE. IF 0-4 YEARS:

13A. Does (NAME) have a birth certificate?
IF NO INSIST: Was (NAME)'s birth recorded by the state?

EDUCATION. IF 5 YEARS OR MORE:

14. Has (NAME) attended school?

15. What is the highest level of education attained by (NAME)? What is the last class completed by (NAME) at this level?

EDUCATION. IF 5-24 YEARS OLD:

16. Does (NAME) currently attend school?

17. Has (NAME) attended school during the current school year at any time?

18. During the current school year, which level did (NAME) achieve and in which grade?

19. Did (NAME) attend school at any time during the previous school year?

20. During the current school year which level did (NAME) achieve and in which class?

MARK HERE IF ANOTHER SHEET WAS USED___

Just to be sure that I have a complete list:

1) Are there other persons such as small children or infants that we have not recorded on the list?

2) Are there other persons who maybe are not members of your family such as domestic workers, renters or friends who usually live here?

3) Are there guests or temporary visitors who are at your household, or other persons who spent the last night here who were not listed?

CARE OF CHILDREN 3-5 YEARS AND WORK OF CHILDREN 5-14 YEARS

20A. LIST OF CHILDREN FROM 3-14 YEARS.

CHECK COLUMN 7 OF THE HOUSEHOLD TABLE AND RECORD THE NAMES OF ALL OF THE CHILDREN AGED 3 TO 14 YEARS IN THE ORDER OF THE HOUSEHOLD TABLE. IF THERE ARE NO CHILDREN, (GO TO 21)

20B. CARE OF CHILDREN 3-5 YEARS: Has (NAME) attended a place of education outside of the home such as a preschool, daycare, kindergarten, community center, or other?

20C. IF YES. Which one?

20D. For how many years?

Now I would like to ask you about all the types of work done by the children living in your household last week.

IF 5-14 YEARS OLD:

20E. Did (NAME) do any kind of work for someone who is not a member of this household last week?
IF YES: Was (NAME) paid?

20F. IF YES: Since last (DAY OF THE WEEK) about how many hours did he/she work for someone who is not a member of the household?
IF MORE THAN ONE JOB, TAKE THE SUM OF ALL THE HOURS.

20G. Did (NAME) help with household work last week? For example: get groceries, cook, clean, get water, watch children, wash clothes??

20H. Since last (DAY OF THE WEEK) about how many hours did he/she spend doing this household work?
IF MORE THAN ONE JOB, TAKE THE SUM OF ALL THE HOURS.

20I. Did (NAME) do other work for the family last week (such as farm work, commerce, business,?) ?

21. What is the main source of drinking water for members of your household?

21A. Who usually goes to this source to fetch water?

22. How long does it take to go there, get water, and come back?

22A. Do you do anything to make the water safer to drink? For example, do you boil it or filter it or even add some product before using it as drinking water?

22B. You said that the water that members of your household primarily drink comes mainly from (SOURCE INDICATED IN 21). Were there interruptions in availability of water at this source during the past two weeks?

22C. Did these interruptions in water availability happen every day, many days a week, some days a week or rarely?

22D. How long did these interruptions in water availability during the past two weeks last: hours, more than a day, more than a week or the whole time?

23. What kind of toilet facility does the majority of the members of your household use?

23A. Is the toilet facility inside or outside of the yard/plot or dwelling?

24. Do you share this toilet facility with other households?

24A. How many other households use this toilet facility?
IF THERE ARE 5 HOUSEHOLDS OR MORE, RECORD '5'.

24B. What is the main method of disposing of household garbage for your household?

24C. What is the main method of disposing of dirty water of your household?

25. Does your household have:

Electricity?
Radio?
Television?
TV5 antenna?
Subscription to CANAL?
Telephone (land line)?
Cellular telephone?
Washing machine?
Refrigerator?
Gas or electric stove/cooking range?
Improved stove?
Video dvd/cd player ?
Air conditioner?
Computer?
Internet in the house?

26. What type of fuel does your household mainly use for cooking?

27. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION

27A. How many rooms in this household are used for sleeping?

28. Is there anyone in your household who owns:

28A. What types of health facilities are available in your village/neighborhood?

28B. How long does it take you to get to the nearest health facility?
LESS THAN AN HOUR, RECORD '00' FOR HOURS AND EVALUATE IN MINUTES.

28C. How long does it take to get to the nearest school?
LESS THAN AN HOUR, RECORD '00' FOR HOURS AND EVALUATE IN MINUTES.

28D. How long does it take to get to the nearest market?
LESS THAN AN HOUR, RECORD '00' FOR HOURS AND EVALUATE IN MINUTES.

28E. What other types of social/community infrastructures are there in your village/neighborhood?

28F. How far away is the nearest market?

28G. How far away is the nearest healthcare center?

28H. How far away is the nearest school?

29. Does your household have any mosquito nets that can be used while sleeping?

29A. How many mosquito nets does your household have?
IF 7 OF MORE NETS, RECORD '7'.

30. Ask the respondent to show you all of the nets in the household.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRES.

31. How long ago did your household get the mosquito net?
IF LESS THAN A MONTH AGO, RECORD '00'

32. Observe or ask the brand/type of mosquito net.

32A. When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

32B. Since you got the net was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

32C. How many months ago was the net last soaked or dipped?
IF LESS THAN A MONTH AGO, RECORD '00'

32D. Did someone sleep under this net last night?

32E. Who slept under this net last night?
RECORD THE LINE NUMBER FROM THE HOUSEHOLD TABLE.

32F. RETURN TO THE FIRST COLUMN OF LINE NO. 30 OF A NEW QUESTIONNAIRE; OR IF THERE ARE NO MORE NETS IN THE HOUSEHOLD, GO TO 33.

33. Where do members of your household most often wash their hands?

33A. Do most of the members of your household wash their hands with soap when leaving the toilet facility?

34. Ask to see the place used most often for hand washing and check to see is the following objects are there.

35. Ask the respondent for a teaspoon of cooking salt, then test for iodide.
Record the PPM (Proportion per million)

[Note: Begin by using the container with the violet cover to see if the salt is iodized with iodide. If the result of the iodide test is 0 PPM (no iodide), use the container with the black cover for iodate.]

35A. WOMAN'S SELECTION TABLE FOR "RELATIONSHIPS IN THE HOUSEHOLD"
THIS SECTION APPLIES TO ALL OF THE HOUSEHOLDS IN THE SAMPLE, HOWEVER ONLY ONE WOMAN PER HOUSEHOLD WILL BE SURVEYED IN THIS SECTION.
THE TABLE BELOW ALLOWS YOU TO RANDOMLY CHOOSE THIS WOMAN IN THE HOUSEHOLD:

1- THERE IS ONLY ONE WOMAN IN THE HOUSEHOLD
Write the woman's name, age and line number of the woman (see Column (8) of the Household Table) on the first line of the following table: this woman will be surveyed in "Relationships in the Household."

2- THERE ARE MULTIPLE ELIGIBLE WOMAN IN THE HOUSEHOLD
(1) Write in the table the name, age and line number of all of the eligible women (see Column (8) of the Household Table), beginning with the oldest and ending with the youngest.

(2)Take the last digit of the compound number written on the cover page of the questionnaire and circle the corresponding number on the heading line on the following table. Go down the column identified by this number until you reach the line corresponding to the last woman recorded on the table. Circle the corresponding number at the intersection of this column and of this line.

(3) This number gives you the number of order of the selected woman for section 10 of the woman's questionnaire (the first, second, third, etc,. . . listed woman). Then circle on the table the LINE NUMBER of the selected woman.

REMINDER: THE WEIGHT AND HEIGHT OF CHILDREN UNDER 6 AND WOMEN BETWEEN 15-49 ARE MEASURED IN ALL OF THE HOUSEHOLDS IN THE SURVEY.
WEIGHT AND HEIGHT MEASUREMENTS

CHECK COLUMNS (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL OF THE WOMEN 15-49 AND OF ALL OF THE CHILDREN LESS THAN 6.
WOMEN 15-49

WOMEN BETWEEN 15-49 YEARS:

36. LINE NO. FROM COLUMN (8) or (6)

37. FIRST AND LAST NAME FROM COL. (2)

38. AGE FROM COL. (7)

39. What is the birthdate for (FIRST AND LAST NAME)?

FOR CHILDREN NOT INCLUDED IN ANY SECTION 2 ON THE REPRODUCTION OF A WOMAN'S QUESTIONNAIRE (ORPHANS, ADOPTED CHILDREN, ETC.), REQUEST THE DAY, MONTH AND YEAR OF BIRTH. FOR ALL THE OTHER CHILDREN, COPY THE MONTH AND THE YEAR FROM Q.215 IN SECTION 2 OF THEIR MOTHER AND ASK THE DAY OF BIRTH.

40. WEIGHT (KILOGRAMS)

41. HEIGHT (METERS)

42. MEASURED LYING DOWN OR STANDING

43. RESULT:

CHECK HERE IF ANOTHER SHEET WAS USED __

CHECK THE COVER PAGE:

MEASUREMENT OF HEMOGLOBIN LEVEL (ANEMIA TEST)

As part of this survey, we would like to know the level of anemia in women and children. Anemia, which is due to poor nutrition, is a serious health problem. The results of this survey will assist the government to develop programs to prevent and treat anemia.

We request that you (you and all of your children born in 2001 or later) take an anemia test. For this test we use sterile, non-reusable instruments that are clean and risk-free. Blood will be analyzed with new equipment and the results will be given to you immediately. The results are confidential.

May I request now that you take, and (and FIRST AND LAST NAME OF CHILDREN), this anemia test? However, if you decide to refuse, know that you have this right and that we respect your decision. Now, can you tell me if you accept to take this test?

MEASUREMENT OF HEMOGLOBIN LEVEL OF WOMEN 15-49 YEARS:

44. CHECK COLUMN (38):

45. LINE NO. OF PARENT/RESPONSIBLE ADULT.
RECORD "00" IF IT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

46. READ THE CONSENT STATEMENT TO THE WOMAN/PARENT/RESPONSIBLE ADULT. CIRCLE THE CODE (AND SIGN)

47. HEMOGLOBIN LEVEL (G/DL)

48. CURRENTLY PREGNANT?

49. RESULT:

MEASUREMENT OF HEMOGLOBIN LEVEL OF CHILDREN BORN IN 2001 (9) OR LATER:

45. LINE NO. OF THE PARENT/RESPONSIBLE ADULT.
RECORD "00" IF IT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

46. READ THE CONSENT STATEMENT TO THE PARENT/RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN).

47. HEMOGLOBIN LEVEL (G/DL)

49. RESULT:

Note: In the countries or certain survey zones at an altitude of more than 1,000 meters, information on the altitude must be collected for each zone with an altitude of more than 1,000 meters so that estimates of anemia levels can be adjusted appropriately.

50. CHECK 47 AND 48:

NUMBER OF USUAL RESIDENTS WHOSE HEMOGLOBIN IS BELOW THE CRITICAL THRESHOLD.
The critical threshold is 9g/dl for pregnant women and 1 g/dl for children, men, and woman who are not pregnant (or who don't know if they are pregnant)

51. We have detected a low level of hemoglobin in (your blood/ the blood of NAME OF CHILD/CHILDREN). The means that (you/ NAME OF CHILD/CHILDREN) are severely anemic, this is a serious health problem. We wish to inform the doctor of __ about (your condition /the condition of NAME OF CHILD/CHILDREN). This will help you to get the appropriate treatment for your condition. Do you accept to have this information concerning the hemoglobin level of (your blood/ the blood of NAME OF CHILD/CHILDREN) given to the doctor?

WOMEN 18-49
[repeat for each woman in this age group below the critical threshold]

WOMEN 15-17 AND CHILDREN
[repeat for each woman in this age group or child below the critical threshold]

HIV TEST

INFORMED CONSENT STATEMENT (HIV Test):

INFORMED CONSENT FOR ADULT 18 YEARS OR MORE
As part of this survey, we are doing a study of HIV/AIDS among women aged 15-49 years and men aged 15-59 years. You may know that HIV is the virus that causes AIDS. AIDS is a serious illness, usually mortal. We are currently giving HIV tests to see how serious a problem AIDS is in Mali.

For the HIV test, we ask all the eligible women and men to give a couple drops of blood from a finger. To take this blood we use sterile instruments, new material which is not reusable. It has never been used before and will be thrown away after the test.

The blood will then be sent to a lab to be analyzed. No name will be linked to the result. Thus, we will not be able to tell you your test results. No one else will know that result of the blood test either. However, I will give a reference paper to go to a Centre de Dépistage Volontaire (voluntary testing center) to have a free test if you wish.

Do you have any questions? Now, do you agree to take this HIV test?

PROCEED TO COLUMN (67) AND CIRCLE THE APPROPRIATE CODE.

INFORMED CONSENT FOR YOUTH 15-17 YEARS:

(1) ASK THE INFORMED CONSENT OF THE PARENT/RESPONSIBLE ADULT

The study of HIV/AIDS included young women and men 15years or older. For the HIV test of these young persons from 15-17 years, we ask that their parent or responsible adult give their consent, as well as the youth.

We ask that the youth, [NAME], take an HIV test by giving us a few drops of blood from a finger. To take this blood we use sterile instruments, new material which is not reusable. It has never been used before and will be thrown away after the test.

The blood will then be sent to a lab to be analyzed. No name will be linked to the result. Thus, we will not be able to tell you your test results. No else will know that result of the blood test either. However, if [NAME OF YOUTH] wishes, I will give a reference paper to go to a Centre de Dépistage Volontaire (voluntary testing center) to have a free test.

Now, do you accept that [NAME] take this HIV test?
PROCEED TO COLUMN (66) AND CIRCLE THE APPROPRIATE CODE.

(2) INFORMED CONSENT OF THE YOUTH

IF THE PARENT/RESPONSIBLE ADULT ACCEPTED THAT HE/SHE TAKE THE TEST, READ THE CONSENT STATEMENT TO THE YOUTH.

As part of this survey, we are doing a study of HIV/AIDS among women aged 15-49 years and men aged 15-59 years. You may know that HIV is the virus that causes AIDS. AIDS is a serious illness, usually mortal. We are currently giving HIV tests to see how serious a problem AIDS is in Mali.

For the HIV test we ask all the eligible women and men to give a couple drops of blood from a finger. To take this blood we use sterile instruments, new material which is no reusable. It has never been used before and will be thrown away after the test.

The blood will then be sent to a lab to be analyzed. No name will be linked to the result. Thus, we will not be able to tell you your test results. No else will know that result of the blood test either. However, I will give a reference paper to go to a Centre de Dépistage Volontaire (voluntary testing center) to have a free test if you wish.

Do you have any questions? Now, do you agree to take this HIV test?

HOUSEHOLD HEALTH EXPENSES

70. CHECK THE COVER PAGE:

70A. Please, tell me if a member of your household is currently sick, or suffers from a chronic illness or from an injury, or has been sick in the past 30 days.

70B. How many members of your household are currently sick, or suffering from a chronic illness or from an injury, or have been sick in the past 30 days.

Now I would like to ask you some questions about each person who has been sick or injured at some time during the past 30 days.

70C. Could you tell me the name of each one? Then we will discuss in detail each one.

71. NAME AND LINE NUMBER COL (2) AND COL (1) FROM THE HOUSEHOLD TABLE.

72. In your opinion, is (NAME)'s illness serious, moderate or slight?

73. Have you or (NAME) self-medicated?

73A. Where did you go to get the medicine for (NAME)'s self-medication?

73B. How much did the medications for (NAME)'s self-medication cost?

PRICE IN FCFA:

73C. After self-medicating, did (NAME) go for a consultation or for care elsewhere to heal his/her illness (injury)?

74. Did someone try to get a consultation or a prescription to treat (NAME)'s illness?

75. From whom did you/someone try to get a consultation or a prescription to treat (NAME)'s illness?

IF THE RESPONDENT SAYS "HOSPITAL" CHECK THE NAME AND TYPE OF HOSPITAL OR HEALTH CENTER AND CIRCLE THE CORRESPONDING CODE.
IF THE RESPONDENT SAYS "DOCTOR" CHECK IF THE SICK PERSON WENT TO THE DOCTOR OF IF THE DOCTOR MADE A HOUSE CALL TO THE SICK PERSON'S HOME AND CIRCLE THE CORRESPONDING CODE .

75A. What was the total expense to go to and return from (PLACE OF CARE Q.75)?

TOTAL IN FCFA:

75B. What was the total expense for the consultation and care (PLACE OF CARE Q.75)?

TOTAL IN FCFA:

75C. What was the total expense for the medicines, tests and other products prescribed at (PLACE OF CARE Q.75)?

TOTAL IN FCFA:

75D. Was (NAME) admitted to the hospital for at least one night to treat his/her illness (injury)?

75E. What was the total expense of the hospitalization at (PLACE OF CARE Q.75)?

TOTAL IN FCFA:

75F. What was the total expense for transportation for this hospitalization?

TOTAL IN FCFA:

76. After the first trip to (PLACE OF CARE Q.75), was there a second consultation at the same place or to get care elsewhere to heal the illness (injury) of (NAME)?

77. For this second recourse where did you/someone try to get a consultation or a prescription for (NAME)'s illness (injury)?

IF THE RESPONDENT SAYS "HOSPITAL" CHECK THE NAME AND TYPE OF HOSPITAL OR HEALTH CENTER AND CIRCLE THE CORRESPONDING CODE.
IF THE RESPONDENT SAYS "DOCTOR" CHECK IF THE SICK PERSON WENT TO THE DOCTOR OF IF THE DOCTOR MADE A HOUSE CALL TO THE SICK PERSON'S HOME AND CIRCLE THE CORRESPONDING CODE .

77A. What was the total expense to go to and return from (PLACE OF CARE Q.77)?

TOTAL IN FCFA:

77B. What was the total expense for the consultation and care (PLACE OF CARE Q.77)?

TOTAL IN FCFA:

77C. What was the total expense for the medicines, tests and other products prescribed at (PLACE OF CARE Q.77)?

TOTAL IN FCFA:

77D. Was (NAME) admitted to the hospital for at least one night to treat his/her illness (injury)?

77E. What was the total expense of the hospitalization at (PLACE OF CARE Q.77)?

TOTAL IN FCFA:

77F. What was the total expense for transportation for this hospitalization?

TOTAL IN FCFA:

82. CHECK 73B, 75A, 75B, 75C, 77E, 77A, 77B, 77C, 77E AND 77F:

82A. Who paid for the expenses generated from (NAME)'s illness?
RECORD UP TO 3 PEOPLE AND RECORD THE LINE NUMBER OF THE PERSONS.

82B. Where did (NAME 82A) find the money to pay the transport, care and medicine expenses for (NAME 71)?
RECORD UP TO 3 PEOPLE

83. RETURN TO Q.70 IN THE PREVIOUS COLUMN FOR EACH SICK PERSON.
IF NO OTHER SICK PEOPLE (GO TO 84)

84. END OF HOUSEHOLD QUESTIONNAIRE.
RETURN TO THE COVER PAGE TO COMPLETE.