NIGERIA MALARIA INDICATOR SURVEY
WOMAN?S QUESTIONNAIRE
NATIONAL POPULATION COMMISSION
NATIONAL MALARIA CONTROL PROGRAM
STATE __
LOCAL GOVT. AREA __
LOCALITY __
ENUMERATION AREA __
URBAN/RURAL (URBAN = 1, RURAL = 2) __
CLUSTER NUMBER __
BUILDING NUMBER __
HOUSEHOLD HEAD NAME/NUMBER __
NAME AND LINE NUMBER OF WOMAN __
FIRST VISIT
INTERVIEWER?S NAME __
RESULT* __
NEXT VISIT:
TIME __
SECOND VISIT
INTERVIEWER?S NAME __
RESULT* __
NEXT VISIT:
TIME __
THIRD VISIT
INTERVIEWER?S NAME __
RESULT* __
FINAL VISIT
MONTH __
YEAR 2010
INT. NUMBER __
RESULT __
TOTAL NUMBER OF VISITS __
*RESULT CODES:
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY) __
LANGUAGE OF QUESTIONNAIRE** ENGLISH
LANGUAGE OF INTERVIEW** __
NATIVE LANGUAGE OF RESPONDENT** __
TRANSLATOR USED (1 = NOT AT ALL, 2 = SOMETIME, 3 = ALL THE TIME) __
**LANGUAGE CODES
YORUBA 2
IGBO 3
ENGLISH 4
OTHER 6 (SPECIFY) __
SUPERVISOR/EDITOR
NAME __
DATE __
OFFICE EDITOR __
KEYED BY __
SECTION 1. RESPONDENT?S BACKGROUND
INTRODUCTION AND CONSENT
INFORMED CONSENT
Greetings. My name is _____________________________ and I am working with National Population Commission. We are conducting a national survey about malaria all over Nigeria. This study has been reviewed and granted approval by the National Health Research Ethics Committee, assigned number NHREC/01/01/2007, for the study period of September 2010 to September 2011. Your household was selected for this survey. This information you provide will help the government to plan health services. The survey usually takes between 10 and 20 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons. Should you have any questions, feel free to call any of the following contact person(s):
2010 NMIS Contact Person, NPC: Project Director; Email; Phone: 08033708115
NMCP Contact Person: National Coordinator; Email:; Phone: 08037860784
NHREC Contact Person(s): Secretary, NHREC; Email:; Phone: 08033143791; Desk Officer, NHREC; Email; Phone: 08065479926
Participation in this survey is voluntary, and if we should come to 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. However, we hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey?
May I begin the interview now?
Signature of interviewer: ___________________________________ Date: _________________
Signature/thumb print of respondent: __________________________Date: _________________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES __
102. In what month and year were you born?
DON?T KNOW MONTH 98
YEAR __
DON?T KNOW YEAR 9998
103. How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.
104. Have you ever attended school?
NO 2 (SKIP TO 108)
105. What is the highest level of school you attended: primary, secondary, or higher?
SECONDARY 2
HIGHER 3
106. What is the highest (class/form/year) you completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD ?00?.
SECONDARY OR HIGHER (SKIP TO 109)
108. Now I would like you to read this sentence to me.
SHOW SENTENCES ON CARD TO RESPONDENT.
IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE 4 (SPECIFY LANGUAGE) __
BLIND/VISUALLY IMPAIRED 5
ISLAM 2
TRADITIONAL RELIGION 3
NO RELIGION 4
OTHER 6 (SPECIFY) __
110. What is your ethnic group?
201. Now I would like to ask about all the births you have had during your life. Have you ever born a child?
NO 2 (SKIP TO 206)
202. Do you have any sons or daughters to whom you have given birth who are now living with you?
NO 2 (SKIP TO 204)
203. How many sons live with you?
And how many daughters live with you?
IF NONE, RECORD ?00?.
DAUGHTERS AT HOME __
204. Do you have any children you born who are alive but do not live with you?
NO 2 (SKIP TO 206)
205. How many sons are alive but do not live with you?
And how many daughters are alive but do not live with you?
IF NONE, RECORD ?00?.
DAUGHTERS ELSEWHERE __
206. Have you ever born a child who was born alive and later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?
NO 2 (SKIP TO 208)
207. How many boys have died?
And how many girls have died?
IF NONE, RECORD ?00?.
GIRLS DEAD __
208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD ?00?.
Just to make sure that I have this right: you have had in total ________ children in your life. Is that correct?
NO (PROBE AND CORRECT 201-208 AS NECESSARY)
NO BIRTHS Q.208 IS ?00? (SKIP TO 224)
211. Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.
RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.)
212. What name was given to your (first/next) baby?
__
213. Were any of these births twins?
MULTIPLE 2
214. Is (NAME) a boy or a girl?
GIRL 2
215. In what month and year was (NAME) born?
PROBE: What is his/her birthday?
YEAR __
NO 2 (SKIP TO 220)
How old is (NAME)?
RECORD AGE IN COMPLETED YEARS.
Is (NAME) still living with you?
NO 2
RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD ?00? IF CHILD NOT LISTED IN HOUSEHOLD).
How old was (NAME) when he/she died?
IF ?1 YR?, PROBE: How many months old was (NAME)?
RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.
MONTHS 2 __
YEARS 3 __
221. Were there any other live births between (NAME) and (NAME OF BIRTH ON PREVIOUS LINE)? Including any children who died after birth?
NO 2 (NEXT BIRTH)
222. Have you had any live births since the birth of (NAME OF MOST RECENT BIRTH)?
IF YES, RECORD BIRTH(S) IN BIRTH TABLE.
NO 2
223. COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)
224. CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2005 OR LATER.
IF NONE, RECORD ?0? AND CONTINUE TO Q. 225.
NO 2 (SKIP TO 227)
UNSURE 8 (SKIP TO 227)
226. How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.
226A. Have you seen anyone for antenatal care?
NO 2 (SKIP TO 226C)
226B. Whom did you see?
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
COMMUNITY HEALTH EXTENSION WORKER (CHEW) D
COMMUNITY ORIENTED RESOURCE PERSON F
OTHER X (SPECIFY) __
226C. During this current pregnancy, did you take any drugs in order to prevent you from getting malaria?
NO 2 (SKIP TO 227)
DON?T KNOW 8 (SKIP TO 227)
226D. What drugs did you take to prevent malaria?
RECORD ALL MENTIONED.
IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.
CHLOROQUINE B
OTHER X (SPECIFY) __
DON?T KNOW Z
226E. CHECK 226D: SP/FANSIDAR TAKEN FOR MALARIA PREVENTION
CODE ?A? NOT CIRCLED (SKIP TO 227
226F. How many months pregnant were you when you took your first dose of SP/Fansidar?
DON?T KNOW 98
226G. How many times did you take SP/Fansidar during this pregnancy?
NO BIRTHS IN 2005 OR LATER (SKIP TO 401)
SECTION 3. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT
301. CHECK 212 AND 215: ENTER IN 302 THE NAME AND LINE NUMBER OF THE MOST RECENT BIRTH SINCE 2005 EVEN IF THE CHILD ISNO LONGER ALIVE.
Now I would like to ask you some questions about your last pregnancy that ended in a live birth in the last 5 years.
302. NAME AND LINE NUMBER FROM 212.
LINE NUMBER __
LIVING __
DEAD __
303. When you were pregnant with (NAME) did you see anyone for antenatal care?
NO 2 (SKIP TO 305)
304. Whom did you see?
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
COMMUNITY HEALTH EXTENSION WORKER (CHEW) D
COMMUNITY ORIENTED RESOURCE PERSON F
305. During this pregnancy, did you take any drugs in order to prevent you from getting malaria?
NO 2 (SKIP TO 312)
DON?T KNOW 8 (SKIP TO 312)
306. What drugs did you take to prevent malaria?
RECORD ALL MENTIONED.
IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.
CHLOROQUINE B
OTHER X (SPECIFY) __
DON?T KNOW Z
307. CHECK 306: SP/FANSIDAR TAKEN FOR MALARIA PREVENTION
CODE ?A? NOT CIRCLED (SKIP TO 312)
308. How many times did you take SP/Fansidar during this pregnancy?
309. CHECK 304: ANTENATAL CARE FROM HEALTH PROFESSIONAL RECEIVED DURING THIS PREGNANCY?
OTHER (SKIP TO 312)
310. Did you get the (SP/Fansidar) during an antenatal care visit?
NO 2
311. Did you receive a mosquito net during an antenatal care visit?
NO 2
NO LIVING CHILDREN BORN IN 2005 OR LATER (SKIP TO 401)
313. ENTER IN THE TABLE THE LINE NUMBER AND NAME OF EACH LIVING CHILD BORN IN 2005 OR LATER.
IF THERE ARE MORE THAN 3 LIVING CHILDREN BORN IN 2005 OR LATER, USE ADDITIONAL QUESTIONNAIRES.
Now I would like to ask you some questions about the health of your children less than 5 years old.
We will talk about each one separately.
314. NAME AND LINE NUMBER FROM 212
LAST BIRTH
NAME __
NEXT-TO-LAST BIRTH
NAME __
SECOND-FROM-LAST BIRTH
NAME __
315. Has (NAME) been ill with a fever at any time in the last 2 weeks?
NO 2 (GO BACK TO 314 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 401)
DON?T KNOW 8 (GO BACK TO 314 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 401)
316. How many days ago did the fever start?
IF LESS THAN ONE DAY, WRITE ?00?.
DON?T KNOW 98
317. Did you seek advice or treatment for the fever from any source?
NO 2 (SKIP TO 320)
318. Where did you get treatment from?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICA, WRITE THE NAME OF THE PLACE.
_______________________________
(NAME OF PLACE)
GOVT HEALTH CENTER B
GOVT HEALTH POST C
MOBILE CLINIC D
ROLE MODEL CAREGIVER/COMMUNITY WORKER E
OTHER PUBLIC F (SPECIFY) __
PHARMACY H
CHEMIST/PMV I
PVT DOCTOR J
MOBILE CLINIC K
OTHER PRIVATE L (SPECIFY) __
TRADITIONAL PRACTITIONER N
DRUG HAWKER O
319. How many days after the fever began did you first seek treatment for (NAME)?
IF SAME DAY, RECORD ?00?.
320. At any time during the illness, did (NAME) have a drop of blood taken from his/her finger or heel for testing?
NO 2
DON?T KNOW 8
321. At any time during this illness, did (NAME) take any drugs for the illness?
NO 2 (SKIP TO 323)
322. What drugs did (NAME) take?
Any other drugs?
RECORD ALL MENTIONED.
ASK TO SEE DRUG(S) IF TYPE OF DRUG IS NOT KNOWN. IF TYPE OF DRUG IS STILL NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.
CHLOROQUINE B
AMODIAQUINE C
QUININE D
ARTEMISININ COMBINATION THERAPY (ACT) E
OTHER ANTIMALARIAL F (SPECIFY) __
INJECTION H
ASPIRIN J
ACETAMINOPHEN K
IBUPROFEN L
323. CHECK 322: ANY CODE A-F CIRCLED?
NO (GO BACK TO 315 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 401)
324. CHECK 322: SP/FANSIDAR (?A?) GIVEN
CODE ?A? NOT CIRCLED (SKIP TO 327)
325. How long after the fever started did (NAME) first take SP/Fansidar
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS AFTER FEVER 3
FOUR OR MORE DAYS AFTER FEVER 4
DON?T KNOW 8
326. For how many days did (NAME) take this SP/Fansidar?
IF 7 DAYS OR MORE, WRITE ?7?.
DON?T KNOW 8
327. CHECK 322: CHLOROQUINE (?B?) GIVEN
CODE ?B? NOT CIRCLED (SKIP TO 330)
328. How long after the fever started did (NAME) first take chloroquine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS AFTRE FEVER 3
FOUR OR MORE DAYS AFTER FEVER 4
DON?T KNOW 8
329. For how many days did (NAME) take the chloroquine?
IF 7 DAYS OR MORE, WRITE ?7?.
DON?T KNOW 8
330. CHECK 322: AMODIAQUINE (?C?) GIVEN
CODE ?C? NOT CIRCLED (SKIP TO 333)
331. How long after the fever started did (NAME) first take amodiaquine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS AFTER FEVER 3
FOUR OR MORE DAYS AFTER FEVER 4
DON?T KNOW 8
332. For how many days did (NAME) take the amodiaquine?
IF 7 DAYS OR MORE, WRITE ?7?.
DON?T KNOW 8
QUININE (?D?) GIVEN
CODE ?D? NOT CIRCLED (SKIP TO 336)
334. How long after the fever started did (NAME) first take quinine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS AFTER FEVER 3
FOUR OR MORE DAYS AFTER FEVER 4
DON?T KNOW 8
335. For how many days did (NAME) take the quinine?
IF 7 DAYS OR MORE, WRITE ?7?.
DON?T KNOW 8
ACT (?E?) GIVEN
CODE ?E? NOT CIRCLED (SKIP TO 339)
337. How long after the fever started did (NAME) first take ACT?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS AFTER FEVER 3
FOUR OR MORE DAYS AFTER FEVER 4
DON?T KNOW 8
338. For how man days did (NAME) take the ACT?
IF 7 DAYS OR MORE, WRITE ?7?.
DON?T KNOW 8
OTHER ANTIMALARIAL (?F?) GIVEN
CODE ?F? NOT CIRCLED (SKIP TO 342)
340. How long after the fever started did (NAME) first take the (OTHER ANTIMALARIAL)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS AFTER FEVER 3
FOUR OR MORE DAYS AFTER FEVER 4
DON?T KNOW 8
341. For how many days did (NAME) take the (OTHER ANTIMALARIAL)?
IF 7 DAYS OR MORE, WRITE ?7?.
DON?T KNOW 8
342. GO BACK TO 315 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 401.
SECTION 4. KNOWLEDGE OF MALARIA
401. Have you ever heard of an illness called malaria?
NO 2 (SKIP TO 414)
402. What are some things that can happen to you when you have malaria?
CIRCLE ALL MENTIONED
CHILLS/SHIVERING B
HEADACHE C
JOINT PAIN D
POOR APPETITE E
VOMITTING F
CONVULSION G
OTHER X (SPECIFY) __
DON?T KNOW Z
403. Who is most likely to get a serious case of malaria?
CIRCLE ALL MENTIONED.
PREGNANT WOMEN B
ADULTS C
ELDERLY D
EVERYONE E
DON?T KNOW Z
CIRCLE ALL MENTIONED.
STAGNANT WATER B
DIRTY SURROUNDINGS C
BEER D
CERTAIN FOODS E
OTHER X (SPECIFY) __
DON?T KNOW Z
405. Are there ways to avoid getting malaria?
NO 2 (SKIP TO 408)
406. What are the ways to avoid getting malaria?
SLEEP UNDER AN ITN/LLIN B
USE INSECTICIDE SPRAY C
USE MOSQUITO COILS D
KEEP DOORS AND WINDOWS CLOSED E
USE INSECT REPELLANT F
KEEP SURROUNDINGS CLEAN G
CUT THE GRASS H
ELIMINATE STAGNANT WATER AROUND LIVING AREA I
OTHER X (SPECIFY) __
DON?T KNOW Z
407. What can a pregnant woman do to prevent malaria?
CIRCLE ALL MENTIONED.
SLEEP UNDER AN ITN/LLIN B
KEEP ENVIRONMENT CLEAN C
TAKE SP/FANSIDAR GIVEN DURING ANTENATAL CARE D
TAKE DARAPRIM TABLETS (SUNDAY-SUNDAY MEDICINE) E
OTHER X (SPECIFY) __
DON?T KNOW Z
NO 2 (SKIP TO 411)
DON?T KNOW 8 (SKIP TO 411)
409. What drugs are used to treat adults with malaria?
CIRCLE ALL MENTIONED.
CHLOROQUINE B
QUININE C
ACT D
ASPRIRIN, PANADOL, PARACETAMOL E
OTHER X (SPECIFY) __
DON?T KNOW Z
410. What drugs are used to treat children with malaria?
CIRCLE ALL MENTIONED.
CHLOROQUINE B
QUININE C
ACT D
ASPIRIN/PANADOL/PARACETAMOL E
OTHER X (SPECIFY) __
DON?T KNOW Z
411. In the past 4 weeks, have you seen or heard any messages about malaria?
NO 2 (SKIP TO 414)
412. What messages about malaria have you seen or heard?
CIRCLE ALL MENTIONED.
MAN PLAYING DRAFTS WITH MOSQUITO B
MOSQUITO APPEARS IN FAMILY PICTURE C
WOMAN WEARING MOSQUITO NET AS CLOTHES GOING TO MARKET D
MOSQUITO TAKES CHILD AWAY WHILE FAMILY IS SLEEPING F
WOMAN WEARING MOSQUITO NET AS CLOTHES GOING TO MARKET G
WOMAN TELLS HER HUSBAND ?YOU DON BECOME DOCTOR AND YOU SABI BELLE PASS ME?I PITY MALARIA? H
THE KING GETS SLAPPED I
LONART VERSUS MALARIA J
DON?T KNOW Z
413. Where did you hear or see these messages?
CIRCLE ALL MENTIONED.
TELEVISION B
COMMUNITY HEALTH EXTENSION WORKER (CHEW) C
COMMUNITY ORIENTED RESOURCE PERSON (CORP) D
ROLE MODEL CAREGIVER/COMMUNITY WORKER E
MOSQUE/CHURCH F
TOWN ANNOUNCER G
COMMUNITY EVENT H
BILLBOARD I
POSTER J
T-SHIRT K
LEAFLET/FACT SHEET/BROCHURE L
RELATIVE/FRIEND/NEIGHBOR/SCHOOL M
OTHER X (SPECIFY) __
MINUTES __