2012 MALAWI MALARIA INDICATOR SURVEY
HOUSEHOLD QUESTIONNAIRE
PLACE NAME ____________________
DISTRICT _______________________
CLUSTER NUMBER _______________
HOUSEHOLD NUMBER ____________
NAME OF HOUSEHOLD HEAD ________________________
VISITS 1, 2, 3
DATE __________
INTERVIEWER'S NAME ___________
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER _______________(SPECIFY) 9
NEXT VISIT:
TIME ___________
FINAL VISIT
MONTH __________
YEAR __________
INTERVIEWER NUMBER _______________
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER _______________(SPECIFY) 9
TOTAL NUMBER OF VISITS _____________
TOTAL PERSONS IN HOUSEHOLD ______________
TOTAL ELIGIBLE WOMEN _____________
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _______________
LANGUAGE OF QUESTIONNAIRE: ENGLISH 04
LANGUAGE OF INTERVIEW:
TUMBUKA 2
YAO 3
ENGLISH 4
OTHER __________(SPECIFY) 6
NATIVE LANGUAGE OF RESPONDENT:
TUMBUKA 2
YAO 3
ENGLISH 4
OTHER __________(SPECIFY) 6
TRANSLATOR USED
SOMETIME 2
ALL THE TIME 3
Hello. My name is _______________________________________. I am working with the Ministry of Health. We are conducting a survey about health all over Malawi. 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 about 15 to 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 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 CONTACT INFORMATION.
Do you have any questions?
May I begin the interview now?
SIGNATURE OF INTERVIEWER ___________________
DATE _______
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
01. LINE NO.
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 5-10 FOR EACH PERSON.
02A. Just to make sure that I have a complete listing: Are there any other persons 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?
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
NOT RELATED 11
DON'T KNOW 98
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
07. AGE: How old is (NAME)?
IF 95 OR MORE, RECORD '95'.
08. WOMEN AGE 15-49: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.
09. CHILDREN AGE 0-5: CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (SKIP TO 104)
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER ___________________(SPECIFY) 96
102. Where is that water source located?
IN OWN YARD/PLOT 2 (SKIP TO 104)
ELSEWHERE 3
103. How long does it take to go there, get water, and come back?
DON'T KNOW 998
104. What kind of toilet facility do members of your household usually use?
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET HAT 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (SKIP TO 107)
OTHER __________________(SPECIFY) 96
105. Do you share this toilet facility with other households?
NO 2 (SKIP TO 107)
106. How many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
107. Does your household have:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
108. What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02
BIOGAS 03
KEROSENE 04
COAL, LIGNITE 05
CHARCOAL 06
WOOD 07
STRAW/SHRUBS/GRASS 08
ANIMAL DUNG 09
NO FOOD COOKED IN HOUSEHOLD 95
OTHER ______________(SPECIFY) 96
109. MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION
DUNG 12
PALM/BAMBOO 22
BROKEN BRICKS 23
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
110. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.
THATCH/PALM LEAF 12
PALM/BAMBOO/GRASS 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
111. MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.
CANE/PALM/TRUNKS 12
DIRT 13
STONE WITH MUD 22
PLYWOOD 23
CARDBOARD 24
REUSED WOOD 25
STONE WITH LIME/CEMENT 32
BURNT BRICKS 33
UNBURNT BRICKS 34
CEMENT BLOCKS 35
WOOD PLANKS 36
112. How many rooms in this household are used for sleeping?
112A. How many separate rooms are in this household?
112B. How many separate sleeping spaces are there in your household?
113. Does any member of this household own:
NO 2
NO 2
NO 2
114. Does any member of this household own any agriculture land?
NO 2 (SKIP TO 116)
115. How many hectares of agriculture land do members of this household own?
1 HECTARE = 2.47 ACRES
1 ACRE = 0.4 HECTARE
IF 95 OR MORE, CIRCLE '950'
RECORD IN UNITS RESPONDENT USES.
HECTARES ____.__ 2
FOOTBALL PITCHES ____.__ 3
95 OR MORE HECTARES 9995
DON'T KNOW 9998
116. Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (SKIP TO 118)
117. How many of the following animals does this household own?
IF NONE, ENTER '00'.
IF 95 OR MORE, ENTER '95'.
IF UNKNOWN, ENTER '98'.
___________________
PIGS
____________________
CATTLE
____________________
SHEEP
____________________
POULTRY
____________________
OTHER
(SPECIFY)____________________
118. Does any member of this household have a bank account?
NO 2
119. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?
NO 2 (SKIP TO 121)
DON'T KNOW 8 (SKIP TO 121)
119A. How many months ago was the house sprayed?
IF LESS THAN 1 MONTH AGE, RECORD '00'.
PRIVATE COMPANY 2
NONGOVERNMENTAL ORGANIZATION (NGO) 3
OTHER ______________(SPECIFY) 6
DON'T KNOW 8
120A. At any time in the past 12 months, have the walls in your dwelling been plastered or painted?
NO 2 (SKIP TO 121)
DON'T KNOW 8 (SKIP TO 121)
120B. How many months ago were the walls plastered or painted?
IF LESS THAN 1 MONTH AGO, RECORD '00'.
121. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (SKIP TO 122A)
122. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.
122A. Has anyone in your household ever sold or given away a mosquito net?
NO 2
DON'T KNOW 8
123. ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
123A. OBSERVE (OR ASK ABOUT) THE CONDITION OF THE MOSQUITO NET: DOES THE NET HAVE HOLES IN IT (HOLES THE SIZE OF THE TIP OF YOUR THUMB OR LARGER)?
NO 2
123B. OBSERVE (OR ASK) THE COLOR OF THE MOSQUITO NET.
DARK BLUE 02
LIGHT BLUE 03
RED 04
BLACK 05
WHITE 06
OTHER 96
123C. OBSERVE (OR ASK) THE SHAPE OF THE MOSQUITO NET.
RECTANGLE 2
OTHER 6
123D. Is the net hanging for sleeping?
NO 2
124. How many months age did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
125. Is this net a long-lasting net, retreatable, or an untreated net?
OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.
OLYSNET (LIGHT BLUE, SQUARE)
LIFENET (WHITE, SQUARE)
PERMANET (GREEN, SQUARE)
THERE ARE OTHER BRANDS
BE AWARE THAT MANY BRANDS MAY EXIST AND BE DISTRIBUTED BY DIFFERENT ORGANIZATIONS.
OLYSET 12 (SKIP TO 128)
LIFENET 13 (SKIP TO 128)
PERMANET 14 (SKIP TO 128)
OTHER/DK BRAND 16 (SKIP TO 128)
OTHER/DK BRAND 26 (SKIP TO 126)
OTHER/DK BRAND 36
125A. When you received this net, did it come with a treatment kit?
NO 2
NOT SURE 8
126. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?
NO 2 (SKIP TO 128)
NOT SURE 8 (SKIP TO 128)
127. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 24 MONTHS AGO 95
NOT SURE 98
127A. Did you pay to have the net soaked or dipped?
NO 2 (SKIP TO 128)
NOT SURE 8 (SKIP TO 128)
127B. How much did you pay to soak or dip the net?
DON'T KNOW 9998
128. Where did you obtain the net?
NEIGHBORHOOD HEALTH COMMITTEE (NHC) 02
COMMUNITY HEALTH WORKER (CHW) 03
SHOP 04
PHARMACY 05
WORKPLACE 06
OTHER ___________________(SPECIFY) 96
DON'T KNOW 98
128A. Did you purchase the net?
NO 2 (SKIP TO 129)
NOT SURE 8 (SKIP TO 129)
128B. How much did you pay for the net when you purchased it?
DON'T KNOW 9998
129. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 130C)
NOT SURE 8 (SKIP TO 130C)
129A. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NUMBER __________________
130. ANY CHILDREN UNDER AGE 5 WHO DID NOT SLEEP UNDER A MOSQUITO NET
130A. Why did (NAME OF CHILD) (and (NAME OF CHILD)) not sleep under a mosquito net last night?
Any other reason?
RECORD ALL MENTIONED.
TOO COLD B
CHILD CRIES C
CHILD AFRAID D
NOT ENOUGH NET E
NET NOT HUNG UP F
USED BY ADULTS G
NET NOT USED WHEN TRAVELING H
NET NOT IN GOOD CONDITION I
NET BAD FOR CHILDREN'S HEALTH J
OTHER _________________(SPECIFY) X
YES (SKIP TO 131)
130D. You do not have a mosquito net in your house. If you have a choice, what color of mosquito net do you prefer?
GREEN 2
RED 3
WHITE 4
BLACK 5
OTHER _____________(SPECIFY) 6
DON'T KNOW/NO PREFERENCE 8
130E. What shape of mosquito net do you prefer?
RECTANGULAR 2
DON'T KNOW/NO PREFERENCE 8