NIGERIA MALARIA INDICATOR SURVEY
WOMAN'S QUESTIONNAIRE

NATIONAL MALARIA ELIMINATION PROGRAM
NATIONAL POPULATION COMMISSION
NATIONAL BUREAU OF STATISTICS

IDENTIFICATION

STATE __
LOCAL GOVT. AREA __
LOCALITY __
ENUMERATION AREA __
URBAN/RURAL (URBAN = 1, RURAL = 2) __
CLUSTER NUMBER __
BUILDING NUMBER __
HOUSEHOLD HEAD NAME/HOUSEHOLD NUMBER __
NAME AND LINE NUMBER OF WOMAN __

INTERVIEWER VISITS

FIRST VISIT

DATE __
INTERVIEWER'S NAME __
RESULT* __

NEXT VISIT:

DATE __
TIME __

SECOND VISIT

DATE __
INTERVIEWER'S NAME __
RESULT* __

NEXT VISIT:

DATE __
TIME __

THIRD VISIT

DATE __
INTERVIEWER'S NAME __
RESULT* __

FINAL VISIT

DAY __
MONTH __
YEAR 2015
INT NO. __
RESULT* __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

COMPLETED 1
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

HAUSA 1
YORUBA 2
IGBO 3
ENGLISH 4
OTHER 6 (SPECIFY) __

SUPERVISOR/EDITOR
NAME __
DATE __

NUMBER __

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 (NPopC) and the National Malaria Elimination Program (NMEP). 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/01/01/2007-11/05/2015, for the study period of September 2015 to November 2015. Your household was selected for this survey. We would very much appreciate your participation in this survey. This information you provide will help the government to plan health services. The survey usually takes between 20 and 30 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):

NMEP Contact Person: Dr. Nnenna Ezeigwe, National Coordinator; Email:; Phone: 08033000296
NPC CONTACT PERSON: Mr. Bolajj Akinsulie, Project Director, Email:; Phone: 08023307806
NHREC Contact Person(s): Secretary, NHREC; Email:; Phone: 09523867; Desk Officer, NHREC; Email:; Phone: -----

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 AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

101. RECORD THE TIME.

HOUR __
MINUTES __

102. In what month and year were you born?

MONTH __
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.

AGE IN COMPLETED YEARS __

104. Have you ever attended school?

YES 1
NO 2 (SKIP TO 108)

105. What is the highest level of school you attended: primary, secondary, or higher?

PRIMARY 1
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'.

CLASS/FORM/YEAR __

107. CHECK 106:

PRIMARY OR SECONDARY (CONTINUE)
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?

CANNOT READ AT ALL 1
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

109. What is your religion?

CHRISTIANITY 1
ISLAM 2
TRADITIONAL RELIGION 3
NO RELIGION 4
OTHER 6 (SPECIFY) __

110. What is your ethnic group?

SECTION 2. REPRODUCTION

201. Now I would like to ask about all the births you have had during your life. Have you ever born a child?

YES 1
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?

YES 1
NO 2 (SKIP TO 204)

203. How many sons live with you?
And how many daughters live with you?

IF NONE, RECORD '00'.

SONS AT HOME __
DAUGHTERS AT HOME __

204. Do you have any children you born who are alive but do not live with you?

YES 1
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'.

SONS ELSEWHERE __
DAUGHTERS ELSEWHERE __

206. Have you ever born a child who was born alive but later died?

IF NO, PROBE: Any baby who cried, who made any movement, sound, or effort to breathe, or who showed any other signs of life even if for a very short time?

YES 1
NO 2 (SKIP TO 208)

207. How many boys have died?
And how many girls have died?

IF NONE, RECORD '00'.

BOYS DEAD __
GIRLS DEAD __

208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'.

TOTAL BIRTHS __

209. CHECK 208:

Just to make sure that I have this right: you have had in TOTAL ________ births in your life. Is that correct?

YES (CONTINUE)
NO (PROBE AND CORRECT 201-208 AS NECESSARY)

209A. CHECK 208:

ONE OR MORE BIRTHS (CONTINUE)
NO BIRTHS (SKIP TO 224)

210. Now I'd like to ask you about your more recent births. How many births have you had in the last 6 years?

RECORD ALL BIRTHS IN 2010 OR LATER

IF NONE, CIRCLE '00'.

TOTAL IN THE LAST 6 YEARS __
NONE 00 (SKIP TO 224)

211. Now I would like to record the names of all your births in the last six years, whether still alive or not, starting with the most recent one you had.

RECORD NAMES OF ALL THE BIRTHS IN 2010 OR LATER IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. IF THERE ARE MORE THAN 5 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.

212. What name was given to your (most recent/previous) baby?

RECORD NAME.

BIRTH HISTORY NUMBER

01__

213. Is (NAME) a boy or a girl?

BOY 1
GIRL 2

214. Were any of these births twins?

SINGLE 1
MULTIPLE 2

215. In what month and year was (NAME) born?

DAY__
MONTH __
YEAR __

216. Is (NAME) still living?

YES 1
NO 2 (NEXT BIRTH)

217. IF ALIVE: How old was (NAME) at (NAME)'s last birthday?

RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS __

218. IF ALIVE: Is (NAME) still living with you?

YES 1
NO 2

219. IF ALIVE:

RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD).

HOUSEHOLD LINE NUMBER __ (NEXT BIRTH)

220. Were there any other live births between (NAME) and (NAME OF PREVIOUS BIRTH), including any children who died after birth?

YES 1 (ADD BIRTH)
NO 2 (NEXT BIRTH)

221. Have you had any live births since the birth of (NAME OF MOST RECENT BIRTH)?

IF YES, RECORD BIRTH(S) IN BIRTH TABLE.

YES 1
NO 2

222. COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY:

NUMBERS ARE SAME (CONTINUE)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

223. CHECK 215: ENTER THE NUMBER OF BIRTHS IN 2010 OR LATER.

NUMBER OF BIRTHS__
NONE 0

224. Are you pregnant now?

YES 1
NO 2 (SKIP TO 226)
UNSURE 8 (SKIP TO 226)

225. How many months pregnant are you?

RECORD NUMBER OF COMPLETED MONTHS.

MONTHS __

226A. CHECK 223:

ONE OR MORE BIRTHS IN 2010 OR LATER (GO TO 300)
NO BIRTHS IN 2010 OR LATER (GO TO 501)
Q. 223 IS BLANK (GO TO 501)

SECTION 3. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT

300. CHECK 212: ENTER IN THE TABLE THE NAME AND SURVIVAL STATUS OF THE MOST RECENT BIRTH.

Now I would like to ask some questions about your last pregnancy that resulted in a live birth.

301. FROM 212 AND 216, LINE 01:

MOST RECENT BIRTH

NAME __
LIVING (CONTINUE)
DEAD (CONTINUE)

302. When you were pregnant with (NAME) did you see anyone for antenatal care for this pregnancy?

YES 1
NO 2 (SKIP TO 304)

303. Whom did you see?
Anyone else?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PERSONNEL

DOCTOR A
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
COMMUNITY HEALTH EXTENSION WORKER (CHEW) D

OTHER PERSON

TRADITIONAL BIRTH ATTENDANT E
VILLAGE HEALTH WORKER (VHW) F
RURAL MODEL CAREGIVER (RMC) G
COMMUNITY DIRECTED DISTRIBUTOR (CDD) H

OTHER X (SPECIFY) __

304. During this pregnancy, did you SP/Fansidar to keep you from getting malaria?

YES 1
NO 2 (SKIP TO 311)
DON'T KNOW 8 (SKIP TO 311)

307. How many times did you take SP/Fansidar during this pregnancy?

TIMES__

308. CHECK 303:

ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

CODE 'A', 'B', 'C', OR 'D' CIRCLED (CONTINUE)
OTHER (SKIP TO 311)

309. CHECK 304: ANTENATAL CARE FROM HEALTH PROFESSIONAL RECEIVED DURING THIS PREGNANCY?

CODE 'A', 'B', 'C', OR 'D' CIRCLED (CONTINUE)
OTHER (SKIP TO 312)

310. Did you get the SP/Fansidar during an antenatal care visit, during another visit to a health facility or from another source?

IF MORE THAN ONE SOURCE, RECORD THE HIGHEST SOURCE ON THE LIST.

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
COMMUNITY HEALTH EXTENSION WORKER 3
OTHER SOURCE 6

310. Did you receive a mosquito net during an antenatal care visit?

YES 1
NO 2

311. CHECK 215 AND 216:

ONE OR MORE LIVING CHILDREN BORN IN 2010 OR LATER (GO TO 401)
NO LIVING CHILDREN BORN IN 2010 OR LATER (SKIP TO 501)

SECTION 4. FEVER IN CHILDREN

401. CHECK 212: RECORD THE BIRTH HISTORY NUMBER IN 402 AND THE NAME AND SURVIVAL STATUS IN 403 FOR EACH BIRTH IN 2010-2015. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS, BEGIN WITH THE LAST BIRTH.

Now I would like to ask some questions about the health of your children born since January 2010. (We will talk about each separately.)

402. BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

MOST RECENT BIRTH

BIRTH HISTORY NUMBER __

403. FROM 212 and 216

NAME__
LIVING (CONTINUE)
DEAD (GO TO 403 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 425)

404. Has (NAME) been ill with a fever at any time in the last 2 weeks?

YES 1
NO 2 (GO TO 403 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 425)
DON'T KNOW 8 (GO BACK TO 403 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 425)

404A. Did you suspect that (NAME) had malaria?

YES 1
NO 2
DON'T KNOW 8

405. At any time during the illness, did (NAME) have a drop of blood taken from his/her finger or heel for testing?

YES 1
NO 2
DON'T KNOW 8

405A. Was (NAME) tested for malaria?

YES 1
NO 2 (SKIP TO 406)
DON'T KNOW 8 (SKIP TO 406)

405B. What was the result of the malaria test?

POSITIVE 1
NEGATIVE 2
DON'T KNOW 8

406. Did you seek advice or treatment for the fever from any source?

YES 1
NO 2 (SKIP TO 410)

407. Where did you seek advice or treatment?
Anywhere else?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
_______________________________
(NAME OF PLACE)

PUBLIC SECTOR

GOVT HOSPITAL A
GOVT HEALTH CENTER B
GOVT HEALTH POST C
FREE MOBILE CLINIC D
ROLE MODEL CAREGIVER/COMMUNITY WORKER E
OTHER PUBLIC F (SPECIFY) __

PRIVATE MEDICAL SECTOR

PVT HOSPITAL/CLINIC G
PHARMACY H
CHEMIST/PMV I
PVT DOCTOR J
PVT MOBILE CLINIC K
OTHER PRIVATE L (SPECIFY) __

OTHER SOURCE

SHOP M
TRADITIONAL PRACTITIONER N
DRUG HAWKER O
OTHER X (SPECIFY) __

408. CHECK 407:

TWO OR MORE CODES CIRCLED (CONTINUE)
OTHER (SKIP TO 409A)

409. Where did you first seek advice or treatment?

USE LETTER CODE FROM 407.

FIRST PLACE__

409A. How many days after the illness began did you first seek advice or treatment for (NAME)?

IF SAME DAY, RECORD '00'.

DAYS __

410. At any time during this illness, did (NAME) take any drugs for the illness?

YES 1
NO 2 (GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 425)
DON'T KNOW 8 (GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 425)

411. What drugs did (NAME) take?

Any other medicine?

RECORD ALL MENTIONED.

ANTIMALARIAL DRUGS

SP/FANSIDAR/AMALAR/MALOXINE A
CHLOROQUINE B
AMODIAQUINE C
ARTESUNATE RECTAL D
INJECTION/IV E
QUININE PILLS F
INJECTION/IV G
ARTEMISININ COMBINATION THERAPY (ACT) H
OTHER ANTIMALARIAL I (SPECIFY) __

ANTIBIOTIC DRUGS

PILL/SYRUP J
INJECTION K

OTHER DRUGS

PARACETAMOL L
ASPIRIN M
ACETAMINOPHEN N
IBUPROFEN O

OTHER X (SPECIFY) __
DON'T KNOW Z

412. CHECK 411: ANY CODE A-I CIRCLED?

YES (CONTINUE)
NO (GO BACK TO 315 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 425)

413. CHECK 411: SP/FANSIDAR/AMALAR/MALOXINE ('A') GIVEN

CODE 'A' CIRCLED (CONTINUE)
CODE 'A' NOT CIRCLED (SKIP TO 415)

414. How long after the fever started did (NAME) first take (SP/Fansidar)?