REPUBLIC OF MOZAMBIQUE
MALARIA INDICATOR SURVEY
IIM 2018
HH QUESTIONNAIRE
PLACE NAME ____
NAME OF HOUSEHOLD HEAD ____
PROVINCE ______
DISTRICT _____
CLUSTER NUMBER (IIM I.D) __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
DATE ____
INTERVIEWER'S NAME ____
NEXT VISIT: DATE ___
TIME: ____
NOTES ____
FINAL VISIT
DAY __ __
MONTH __ __
YEAR 2018
RESULT CODES: TOTAL PERSONS IN HOUSEHOLD
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT
AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER
TOTAL NUMBER OF VISITS ___
TOTAL NUMBER IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN __ __
TOTAL ELIGIBLE MEN __ __
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __ __
LANGUAGE OF QUESTIONNAIRE 01
LANGUAGE OF INTERVIEW 01
NATIVE LANGUAGE OF RESPONDENT ___
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE: PORTUGUESE
LANGUAGE CODES:
02 ENGLISH
03 EMAKHUWA 08 CINYANJA 09 CINDAU
04 XICHANGANA 10 XITSWA
05 CISENA 11 CINYUNGWE
06 ELOMWE 12 CIYAO
07 ECHUWABO 96 SHONA
SUPERVISOR
NAME
NUMBER __ __ __ __
My name is (SAY THE NAME). I am a collaborator of the National Institute of Health (INS), which, in coordination with the National Malaria Control Program (PNCM) and the National Institute of Statistics (INE), is carrying out a study to find out how many children in Mozambique have malaria and anemia. The study also aims to find out what families do to protect children, pregnant women and other household members from malaria, and that
measures caregivers or guardians take when children show symptoms or signs of malaria. This is my identification (SHOW CARD). The information we are gathering will help the Mozambican government in planning health services. Thank you for your participation and that of your family in this survey. Your contributions will help the government of Mozambique to improve health services related to prevention and treatment of malaria. As part of the survey, we would like to ask you some questions about your household. The interview usually takes 20 minutes. In addition to the interview, all children residing here will be tested for malaria and anemia. The information you provide to us will be confidential and will not be shared with anyone other than work team members.
Participation in this survey is voluntary and you are under no obligation to answer all questions. If there is any question you don't want to answer, let us know and we'll move on to the next question. You are free to stop the interview at any time.
If you need additional information about the survey, you can speak to my supervisor here or
contact INS/MISAU through the numbers 823991494 (Mr. Acácio Sabonete) or 827573630 (Mrs. Mariana da Silva). In case of bad behavior on my part, you can contact the National Committee of Bioethics for Health (CNBS) through his secretary, Mrs Cristina Chissico at 824066350.
GIVE CARD WITH CONTACT INFORMATION
Any questions?
Can I start the interview?
INTERVIEWER SIGNATURE ___
DATE ___
RESPONDENT REFUSES TO BE INTERVIEWED 2 (END THE INTERVIEW)
MINUTES __ __
REGULAR RESIDENTS AND VISITORS
1. ORDER NUMBER
2 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 APPROPRIATE QUESTIONS IN COLUMNS 5-11 FOR EACH PERSON
2 A) 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
2 B) 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
2 C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
RELATIONSHIP TO HEAD OF HOUSEHOLD
3 What is the relationship of (NAME) to the head of the household? SEE CODES BELOW
SEX
4 Is (NAME) male or female?
F 2
RESIDENCE
5 Does (NAME) usually live here?
NO 2
6 Did (NAME) stay here last night?
NO 2
AGE
7 How old is (NAME)? IF 95 OR MORE, RECORD '95'
8 CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
9 CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
10 In the past 2 weeks, did (NAME) have a fever at any time?
NO 2 (GO TO NEXT LINE)
DK 8 (GO TO NEXT LINE)
11 CIRCLE THE ORDER NUMBER OF EVERYONE WHO HAD A FEVER
CHECK HERE IN CASE YOU NEED TO USE A SUPPLEMENTARY SHEET ___
CODES FOR P. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD
02 = WIFE OR HUSBAND
03 = SON OR DAUGHTER
04 = SON-IN-LAW OR DAUGHTER-IN-LAW
05 = GRANDCHILD
06 = PARENT
07 = PARENT-IN-LAW
08 = BROTHER OR SISTER
09 = OTHER RELATIVE
10 = ADOPTED/FOSTER/STEPCHILD
11 = NOT RELATED
98 = DON'T KNOW
101 What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 105)
PIPED TO NEIGHBOR 13 (GO TO 105)
PUBLIC TAP/STANDPIPE 14 (GO TO 103)
TUBE WELL OR BOREHOLE 21 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
TANK TRUCK 61 (GO TO 103)
TANK WAGON 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 TO YARD/PLOT 12 (GO TO 105)
PIPED TO NEIGHBOR 13 (GO TO 105)
PUBLIC TAP/STANDPIPE 14
DUG WELL
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANK TRUCK 61
TANK WAGON 71
SURFACE WATER (RIVER/DAM/ LAKE/POND/STREAM/CANAL/ IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) 96
103 Where is that water source located?
YARD/PLOT 2 (GO TO 105)
SOMEWHERE ELSE 3
104 How long does it take to go there, get water, and come back?
DK 998
105 What kind of toilet facility do members of your household usually use?
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH T SOMEWHERE ELSE 14
FLUSH, DK WHERE 15
TRADITIONAL IMPROVED PIT LATRINE (WITH CONCRETED FLOOR) 22
NOT IMPROVED LATRINE 23
BUCKET TOILET 41
NO FACILITY/BUSH/FIELD 51 (GO TO 108)
OTHER (SPECIFY) 96
106 Do you share this toilet facility with other households?
NO 2 (GO TO 108)
107 Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DK 98
108 In your household, what type of cookstove is mainly used for cooking?
NATURAL GAS 02
OIL/PARAFFIN/KEROSENE 03
COAL/LIGNITE 04
CHARCOAL 05
WOOD 06
STRAW/SHRUBS/GRASS 07
AGRICULTURAL CROPS 08
ANIMAL DUMG/WASTE 09
NO FOOD COOKED IN HOUSEHOLD 95
OTHER (SPECIFY) ___ 96
109 How many rooms in this household are used for sleeping?
110 Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (GO TO 112)
111 How many of the following animals does this household own? IF NONE, RECORD '00'. IF 95 OR MORE, RECORD '95'. IF UNKNOWN, RECORD '98'.
112 Does any member of this household own any agricultural land?
NO 2 (GO TO 114)
113 How many hectares of agricultural land do members of this household own? IF 95 OR MORE, CIRCLE '950'.
95 OR MORE HECTARES 950
DK 998
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
115 Does any member of this household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
116 Does any member of this household have an account in a bank or other financial institution?
NO 2
DK 8
116A During the last 12 months, did someone come to your community to spray the walls against mosquitoes?
NO 2 (GO TO 119)
DK 8 (GO TO 119)
NO 2
DK 8 (GO TO 119)
IT WAS HARD TO PREPARE B
NOBODY CAME C
HOUSE WAS FULL D
'PIDOM'/SPRAY METHOD DID NOT WORK E
RESPONDENT AFRAID OF CHEMICALS F
PIDOM ATTRACTS MOSQUITOES G
PIDOM CAUSES ITCHY SKIN H
THERE IS A BABY/SICK PERSON AT HOME I
OTHER (SPECIFY) X
DK Z
119 Does your household have any mosquito nets?
NO 2 (GO TO 149)
120 How many mosquito nets does your household have? IF 7 OR MORE NETS, RECORD 7.
121 ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF MORE THAN 3, USE AN ADDITIONAL QUESTIONNAIRE
OBSERVED, WITHOUT HOLES 2
NOT OBSERVED 3
121A OBSERVE (OR ASK) THE COLOR OF THE MOSQUITO NET
LIGHT BLUE 2
BLUE-LIGHT 3
RED 4
PINK 5
WHITE 6
OTHER (SPECIFY) 96
121B OBSERVE (OR ASK) THE COLOR OF THE MOSQUITO NET
RECTANGULAR 2
OTHER (SPECIFY) 6
DK 8
121C OBSERVE (OR ASK) THE SIZE OF THE MOSQUITO NET
INDIVIDUAL 2
DOUBLE 3
TRIPLE 4
OTHER (SPECIFY) 6
DK 8
122 How many months ago did your household get the mosquito net? IF LESS THAN ONE MONTH AGO, RECORD '00'
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
122A DID YOU BUY THE MOSQUITO NET OR IT WAS GIVEN TO YOU FOR FREE?
FREE (GO TO 123)
DK (GO TO 123)
122B HOW MUCH DID YOU PAY FOR IT? IF DK, RECORD 9998
123 OBSERVE OR ASK BRAND/TYPE OF MOSQUITO NET. IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.
NET PROTECT 2
OLYSET 3
NOT TREATED 4
OTHER ___ 6
DK TYPE/DK 8
126 Did you get the net through a [LOCAL NAME OF MASS DISTRIBUTION CAMPAIGN], during an antenatal care visit, or during an immunization visit?
YES, ANTENATAL CARE VISIT 2 (GO TO 128)
IMMUNIZATION VISIT 3 (GO TO 128)
NO 4
127 Where did you get the net?
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
HEALTH COMMUNITY WORKER 05
RELIGIOUS INSTITUTION 06
SCHOOL 07
OTHER 96
DON'T KNOW 98
128 Did anyone sleep under this mosquito net last night?
NO 2 (GO TO 129)
NOT SURE 8 (GO TO 130)
128A What was the main reason this net was not used last night?
NO MALARIA 2 (GO TO 130)
TOO HOT 3 (GO TO 130)
UNABLE TO HANG NET 4 (GO TO 130)
NET SMELLS BAD 5 (GO TO 130)
FEELS RESTRICTED OR CONFINED 6 (GO TO 130)
NET IS OLD, TORN OR HAS HOLES 7 (GO TO 130)
NET IS TOO DIRTY 8 (GO TO 130)
NET WAS BEING WASHED 9 (GO TO 130)
NET CONTAMINATED WITH HAZARDOUS CHEMICALS 10 (GO TO 130)
NET CAUSES COUGH 11 (GO TO 130)
NET CAUSES ITCHING 12 (GO TO 130)
BURN IN THE FACE 13 (GO TO 130)
USUAL USER DIDN'T SLEEP HERE LAST NIGHT 14 (GO TO 130)
NET WAS NOT NECESSARY 15 (GO TO 130)
NO SPACE TO HANG NET 16 (GO TO 130)
OTHER (SPETIFY) 96 (GO TO 130)
DK 98 (GO TO 130)
129 Who slept under this mosquito net last night? RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.
LINE NUMBER __ __
130 GO BACK TO 121 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 130D.
130A Why doesn't your household have a mosquito net? RECORD ALL MENTIONED
DOES NOT LIKE USING IT B
COSTS TOO MUCH C
NO MOSQUITOES D
OTHER (SPECIFY)
130B In the past, has your household ever had a mosquito net?
NO (GO TO 130D)
DK 8
130C WHAT HAPPENED TO THE NET?
IT WAS DESTROYED ACCIDENTALLY 2
IT WAS SOLD 3
IT WAS ADAPTED TO A DIFFERENT PURPOSE 4
IT WAS GIVEN TO SOMEONE 5
THROWN AWAY 6
OTHER (SPECIFY) 96
DK 98
130D Does your household currently have a mosquito net that is not used to sleep?
NO 2 (GO TO 130I)
130E Is there a brand new mosquito net, still wrapped in plastic, or little used?
NO 2 (GO TO 130G)
130F What are you going to do with the new net?
SELL IT IN THE MARKET 2
GIVE IT TO SOMEONE (SPECIFY) 96
DK 98
130G Do you have an old or damaged mosquito net that has been adapted for another purpose?
NO 2 (GO TO 130I)
TO COVER THE WINDOWS 2
TO PROTECT HARVEST 3
TO FISH 4
TO BE USED AS A ROPE 5
OTHER (SPECIFY) 96
DK 98
SOMEONE HAD FEVER ___ (GO TO 130IA)
130Ia HOUSEHOLD MEMBER WHO HAD FEVER IN THE PAST 2 WEEKS
LINE NUMBER __ __
130J Did you search for advice or treatment when (NAME) had a fever?
NO 2 (GO TO 130L)
DK 8 (GO TO 130M)
130K Where did you search for treatment first?
PROVINCIAL HOSPITAL 2 (GO TO 130M)
DISTRICT/RURAL HOSPITAL 3 (GO TO 130M)
HEALTH POST/CENTER 4 (GO TO 130M)
MOBILE HEALTH UNIT 5 (GO TO 130M)
PHARMACY 6 (GO TO 130M)
APE 7 (GO TO 130M)
PRIVATE PHARMACY 9 (GO TO 130M)
PRIVATE DOCTOR 10 (GO TO 130M)
TRADITIONAL HEALER 12 (GO TO 130M)
FRIENDS/RELATIVES 13 (GO TO 130M)
OTHER (SPECIFY) 96 (GO TO 130M)
130L. Why did he/she not search for treatment? RECORD ALL MENTIONED
COSTS TOO MUCH B
TOO DISTANT C
NO TRANSPORTATION D
HAD A LOT OF WORK TO DO E
FEVER WAS NOT SERIOUS F
HAD NOT PERMISSION G
OTHER (SPECIFY) X
130M Was (NAME) tested for malaria?
NO 2 (GO TO 130O)
DK 8
NEGATIVE 2
DK 8
130O Has (NAME) taken any medication for fever or malaria in the last 2 weeks?
NO 2 (GO TO 130Q)
DK 8
130P What medication has (NAME) taken? RECORD ALL MENTIONED
SP/FANSIDAR B
CHLOROQUINE C
AMODIAQUINE D
QUININE
PILLS E
INJECTION/IV F
ARTESUNATE
SUPPOSITORY G
INJECTION/IV H
PILLS/SYRUP J
INJECTION/IV K
PARACETAMOL M
IBUPROFEN N
DK Z
130Q GO BACK TO 130Ia FOR THE NEXT MEMBER; OR IF THERE A NO MORE MEMBERS, GO TO 131.
131 OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION.
ADOBE (DIRT FLOOR) 11
EARTH/SAND 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) 96
132. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING. RECORD OBSERVATION
GRASS/PALM 12
SOD 13
GRASS/BAMBOO/PALM 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CEMENT FIBER 33
CERAMIC TILES 34
CONCRETE 35
ROOFING SHINGLES 36
133. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING. RECORD OBSERVATION.
CANE/PALM/TRUNKS/BAMBOO 12
DIRT 13
STONE WITH MUD 22
ADOBE 23
PLYWOOD 24
TIN/CARDBOARD/PAPER/BAG MATERIAL/BARK 25
DISCARDED WOOD 26
ZINC 27
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
MINUTES
INTERVIEWERS OBSERVATIONS
TO BE FILLED OUT AFTER THE INTERVIEW
INTERVIEWER COMMENTS
COMMENTS ABOUT SPECIFIC QUESTIONS
OTHER COMMENTS