MALARIA INDICATOR SURVEY
WOMAN'S QUESTIONNAIRE
RWANDA
MALARIA AND OTHER PARASITIC DISEASES DIVISION
PLACE NAME __
NAME OF HOUSEHOLD HEAD __
CLUSTER NUMBER __
HOUSEHOLD 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 __
INT. NO. __
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** 01
LANGUAGE OF INTERVIEW** __
NATIVE LANGUAGE OF RESPONDENT** __
TRANSLATOR USED (YES = 1, NO = 2) __
LANGUAGE OF QUESTIONNAIRE** ENGLISH
**LANGUAGE CODES:
KINYARWANDA 02
SUPERVISOR
NAME __
NUMBER __
OFFICE EDITOR
NUMBER __
KEYED BY
NUMBER __
Hello. My name is _____________________________. I am working with the Ministry of Health. We are conducting a survey about malaria all over Rwanda. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 10 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 the card that has already been given to your household.
Do you have any questions?
May I begin this interview now?
SIGNATURE OF INTERVIEWER ________________________________ DATE __________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
SECTION 1. RESPONDENT'S BACKGROUND
102. RECORD THE TIME.
MINUTES __
102. In what month and year were you born?
DON'T KNOW MONTH 98
YEAR __
DON'T KNOW YEAR 998
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?
POST-PRIMARY/VOCATIONAL 2
SECONDARY 3
TERTIARY 4
PRE-PRIMARY 5
106. What is the highest grade/form/year you completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.
HIGHER (SKIP TO 109)
108. Now I would like you to read this sentence to me.
SHOW CARD TO RESPONDENT.
IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?
ABLE TO READ ONLY PART OF THE SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE 4 (SPECIFY LANGUAGE) __
BLIND/VISUALLY IMPAIRED 5
PROTESTANT 2
ADVENTIST 3
MUSLIM 4
TRADITIONAL 5
OTHER 6 (SPECIFY) __
NO RELIGION 7
109A. Have you ever heard an illness called malaria?
NO 2 (SKIP TO 201)
109B. Can you tell me the main sign of symptom of malaria?
MULTIPLE RESPONSES POSSIBLES PROBE ONCE (ANYTHING ELSE?)
FEELING COLD B
HEADACHE C
NAUSEA AND VOMITING D
DIARRHEA E
DIZZINESS F
LOSS OF APPETITE G
BODY ACHE OR JOINT PAIN H
PALE EYES I
SALTY TASTING PALMS J
BODY WEAKNESS K
REFUSING TO EAT OR DRINK L
OTHER X (SPECIFY) __
109C. In your opinion, what causes malaria?
MULTIPLE RESPONSES POSSIBLE PROBE ONCE (ANYTHING ELSE?)
EATING IMMATURE SUGACANE B
EATING DIRTY FOOD C
DRINKING DIRTY WATER D
GETTING SOAKED WITH RAIN E
COLD OR CHANGING WEATHER F
WITCHCRAFT G
OTHER X (SPECIFY) __
DON'T KNOW Z
109D. How can someone protect themselves against malaria?
MULTIPLE RESPONSES POSSIBLE PROBE ONCE (ANYTHING ELSE?)
SLEEP UNDER AN INSECTICIDE TREATED MOSQUITO NET B
USE MOSQUITO REPELLANT C
AVOID MOSQUITO BITES D
TAKE PREVENTATIVE MEDICATION E
SPRAY HOUSE WITH INSECTICIDE F
USE MOSQUITO COILS G
CUT THE GRASS AROUND THE HOUSE H
FILL IN PUDDLES (STAGNANT WATER) I
KEEP HOUSE SURROUNDINGS CLEAN J
BURN LEAVES K
DON'T DRINK DIRTY WATER L
DON'T EAT BAD FOOD M
PUT MOSQUITO SCREENS ON THE WINDOWS N
DON'T GET SOAKED WITH RAIN O
OTHER X (SPECIFY) __
DON'T KNOW Z
109E. Where can someone receive treatment for malaria?
MULTIPLE RESPONSES POSSIBLE PROBE ONCE (ANYTHING ELSE?)
DIST. HOSPITAL B
HEALTH CENTER C
HEALTH POST D
OUTREACH E
COMMUNITY HEALTH WORKER F
OTHER PUBLIC FACILITY G (SPECIFY) __
CLINIC I
DISPENSARY J
PHARMACY K
OTHER PRIVATE MEDICAL FACILITY L (SPECIFY) __
TRADITIONAL PRACTITIONER N
CHURCH O
FRIEND/RELATIVE P
DON'T KNOW Z
111. In the past six months, have you seen or heard any messages about malaria?
NO 2 (SKIP TO 201)
112. Have you seen or heard these messages:
b) On the television?
c) On a poster or billboard?
d) From a community health worker?
e) At a community event?
f) Anywhere else?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
201. Now I would like to ask about all the births you have had during your life. Have you ever given birth?
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. a) How many sons live with you?
b) And how many daughters live with you
b) DAUGHTERS AT HOME __
204. Do you have any sons or daughters to whom you have given birth who are alive but do not live with you?
NO 2 (SKIP TO 206)
205. a) How many sons are alive but do not live with you?
b) And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'.
b) DAUGHTERS ELSEWHERE __
206. Have you ever given birth to a boy or girl 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?
NO 2 (SKIP TO 208)
207. a) How many boys have died?
b) And how many girls have died?
IF NONE, RECORD '00'.
b) 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 __ births during your life. Is that correct?
NO (PROBE AND CORRECT 201-208 AS NECESSARY)
NO BIRTHS (SKIP TO 225)
211. Now I'd like to ask you about your more recent births. How many births have you had in 2012-2017?
RECORD NUMBER OF LIVE BIRTHS IN 2012-2015
NONE 00 (SKIP TO 225)
212. Now I would like to record the names of all your births in 2012-2017, whether still alive or not, starting with the most recent one you had.
RECORD IN 213 THE NAMES OF ALL THE BIRTHS BORN IN 2012-2017. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS. IF THERE ARE MORE THAN 5 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE STARTING WITH THE SECOND ROW.
213. What name was given to your (most recent/previous)?
RECORD NAME.
BIRTH HISTORY NUMBER.
01
214. Is (NAME) a boy or a girl?
GIRL 2
215. Were any of these births twins?
MULTIPLE 2
216. On what day, month, and year was (NAME) born?
MONTH __
YEAR __
NO 2 (NEXT BIRTH)
How old was (NAME) at (NAME)'s last birthday?
RECORD AGE IN COMPLETED YEARS
219. IF ALIVE: Is (NAME) living with you?
NO 2
220. IF ALIVE: RECORD HOUSEHOLD LINE NUMBER OF CHILD. RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD.
221. Were there any other live births between (NAME) and (NAME OF PREVIOUS BIRTH), 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)?
NO 2
223. COMPARE 211 WITH NUMBER OF BIRTHS IN BIRTH HISTORY
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)
224. CHECK 216: ENTER THE NUMBER OF BIRTHS IN 2012-2017
NONE 0
NO 2 (SKIP TO 227)
UNSURE 8 (SKIP TO 227)
226. How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.
NO BIRTHS IN 2012-2017 (SKIP TO 429)
Q. 224 IS BLANK (SKIP TO 429)
SECTION 3. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT
301. RECORD THE NAME AND SURVIVAL STATUS OF THE MOST RECENT BIRTH FROM 213 AND 217.
MOST RECENT BIRTH
LIVING __
DEAD __
302. Now I would like to ask you some questions about your last pregnancy that resulted in a live birth.
When you got pregnant with (NAME), did you see anyone for antenatal care for this pregnancy?
NO 2 (SKIP TO 307)
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
COMMUNITY/VILLAGE HEALTH WORKER E
NO LIVING CHILDREN BORN IN 2012-2017 (SKIP TO 429)
401. CHECK 213: RECORD THE BIRTH HISTORY NUMBER IN 402 AND THE NAME AND SURVIVAL STATUS IN 403 FOR EACH BIRTH IN 2012-2017. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE MOST RECENT BIRTH. IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNAIRE(S).
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 213 IN BIRTH HISTORY.
MOST RECENT BIRTH
LIVING __
DEAD __ (SKIP TO 428)
404. Has (NAME) been ill with a fever at any time in the last 2 weeks?
NO 2 (SKIP TO 428)
DON'T KNOW 8 (SKIP TO 428)
405. At any time during the illness, did (NAME) have blood taken from (NAME)'s finger or heel for testing?
NO 2
DON'T KNOW 8
406. Did you seek advice or treatment for the illness from any source?
NO 2 (SKIP TO 411)
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(S).
_________________________________
(NAME OF PLACE)
PROV/DIST. HOSPITAL B
HEALTH CENTER C
HEALTH POST D
OUTREACH E
COMMUNITY HEALTH WORKER F
OTHER PUBLIC FACILITY G (SPECIFY) __
CLINIC I
DISPENSARY J
PHARMACY K
OTHER PRIVATE MEDICAL FACILITY L (SPECIFY) __
TRADITIONAL HEALER N
CHURCH O
FRIEND/RELATIVE P
ONLY ONE CODE CIRCLED (SKIP TO 410)
409. Where did you first seek advice or treatment?
USE LETTER CODE FROM 407
410. How many days after the illness began did you first seek advice or treatment for (NAME)?
IF THE SAME DAY, RECORD '00'.
411. At any time during the illness, did (NAME) take any drugs for the illness?
NO 2 (SKIP TO 428)
DON'T KNOW 8 (SKIP TO 428)
412. What drugs did (NAME) take?
Any other drugs?
RECORD ALL MENTIONED.
QUININE PILLS B
INJECTION/IV C
ARTESUNATE RECTAL D
INJECTION/IV E
OTHER ANTIMALARIAL F (SPECIFY) __
INJECTION/IV H
ACETAMINOPHEN J
IBUPROFEN K
DON'T KNOW Z
413. CHECK 412: ANY CODE A-F CIRCLED?
NO (SKIP TO 428)
414. CHECK 412: ARTEMISININ COMBINATION THERAPY ('A') GIVEN
CODE 'A' NOT CIRCLED (SKIP TO 416)
415. How long after the fever started did (NAME) first take an artemisinin combination therapy?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
416. CHECK 412: QUININE ('B' OR 'C') GIVEN
CODE 'B' OR 'F' NOT CIRCLED (SKIP TO 418)
417. How long after the fever started did (NAME) first take Quinine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
418. CHECK 412: ARTESUNATE ('D' OR 'E') GIVEN
CODE 'D' OR 'E' NOT CIRCLED (SKIP TO 420)
419. How long after the fever started did (NAME) first take artesunate?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
420. CHECK 412: OTHER ANTIMALARIAL ('F') GIVEN
CODE 'F' NOT CIRCLED (SKIP TO 428)
421. How long after the fever started did (NAME) first take (OTHER ANTIMALARIAL)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
428. GO BACK TO 402 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 429.
429. RECORD THE TIME.
MINUTES __
INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW: __
COMMENTS ON SPECIFIC QUESTIONS: __
ANY OTHER COMMENTS: __