MALARIA INDICATOR SURVEY
HOUSEHOLD QUESTIONNAIRE
RWANDA
MALARIA AND OTHER PARASITIC DISEASES DIVISION
PLACE NAME __
NAME OF HOUSEHOLD HEAD __
CLUSTER NUMBER __
HOUSEHOLD NUMBER __
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:
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER 9 (SPECIFY) __
TOTAL PERSONS IN HOUSEHOLD __
TOTAL ELIGIBLE WOMEN __
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __
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 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 or 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.
Do you have any questions?
May I begin the interview now?
SIGNATURE OF INTERVIEWER ______________________________ DATE ____________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES __
LINE NO.
(1) __
USUAL RESIDENTS AND VISITORS
(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 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 5-9 FOR EACH PERSON.
2A) 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
2B) 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
2C) 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.
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
__
SEX
(4) Is (NAME) male or female?
FEMALE 2
RESIDENCE
(5) Does (NAME) usually live here?
NO 2
(6) Did (NAME) stay here last night?
NO 2
IF 95 OR MORE, RECORD '95'.
IF AGE 15 OR OLDER
MARITAL STATUS
7A. What is (NAME's) current marital status?
DIVORCED/SEPARATED = 2
WIDOWED = 3
NEVER MARRIED AND NEVER LIVED TOGETHER = 4
__
ELIGIBILITY
(8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
(9) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-14
(10) CIRCLE LINE NUMBER OF ALL MEMBERS AGE 15+
INSURANCE
(11) Is (NAME) covered by any health insurance?
NO 2 (NEXT LINE)
DON'T KNOW 8 (NEXT LINE)
(12) What is (NAME) main type of health insurance?
RAMA = 2
MMI = 3
PRIVATE/COMMERCIAL = 4
OTHER = 5
DON'T KNOW = 8
WEALTH LEVEL
(13) What is (NAME) wealth level?
__
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (SKIP TO 105)
PIPED TO NEIGHBOR 13 (SKIP TO 105)
PUBLIC TAP/STANDPIPE 14 (SKIP TO 103)
UNPROTECTED WELL 32 (SKIP TO 103)
UNPROTECTED SPRING 42 (SKIP TO 103)
TANKER TRUCK 61 (SKIP TO 103)
CART WITH SMALL TANK 71 (SKIP TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (SKIP TO 103)
BOTTLED WATER 91
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 (SKIP TO 105)
PIPED TO NEIGHBOR 13 (SKIP TO 105)
PUBLIC TAP/STANDPIPE 14
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
OTHER 96 (SPECIFY) __
103. Where is that water source located?
IN OWN YARD/PLOT 2 (SKIP TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
105. What kind of toilet facility do members of your household usually use?
IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (SKIP TO 108)
106. Do you share this toilet facility with other households?
NO 2 (SKIP TO 108)
107. Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
108. What type of fuel does your household mainly use for cooking?
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOD 08
STRAW/SHRUB/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95
OTHER 96 (SPECIFY) __
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 (SKIP 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'.
b) Milk cows (modern)?
c) Bulls?
d) Goats?
e) Sheep?
f) Chickens or other poultry?
g) Pigs?
h) Rabbits?
i) Horses, donkeys, or mules?
b) MILK COWS __
c) BULLS __
d) GOATS __
e) SHEEPS __
f) CHICKENS __
g) PIGS __
h) RABBITS __
i) HORSES/DONKEYS/MULES __
112. Does any member of your household own any agricultural land?
NO 2 (SKIP 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 95.0
DON'T KNOW 98.0
114. Does your household have:
b) A radio?
c) A television?
d) A non-mobile telephone?
e) A computer?
f) A refrigerator?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
115. Does any member of this household own:
b) A mobile phone?
c) A bicycle?
d) A motorcycle or motor scooter?
e) An animal-drawn cart?
f) A car or truck?
g) A boat with a motor?
h) A boat without a motor?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
116. Does any member of this household have a bank account?
NO 2
117. 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 119)
DON'T KNOW 8 (SKIP TO 119)
118. Who sprayed the dwelling?
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER X (SPECIFY) __
DON'T KNOW Z
119. Does your household have any mosquito nets?
NO 2 (SKIP TO 131)
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 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NET #1
NOT OBSERVED 2
121A. CHECK THE YEAR OF MANUFACTURING
NOT AVAILABLE 9998
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
123. OBSERVE OR ASK BRANK/TYPE OF MOSQUITO NET.
IF BRAND IS UNKOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.
DCT 12 (SKIP TO 126)
OLYSET 13 (SKIP TO 126)
OTHER/DON'T KNOW BRAND 16 (SKIP TO 126)
DON'T KNOW TYPE 98
124. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?
NO 2 (SKIP TO 126)
NOT SURE 8 (SKIP TO 126)
125. 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
126. Did you get the net through a mass distribution campaign, during an antenatal care visit, or during an immunization visit/
YES, ANC 2 (SKIP TO 127A)
YES, IMMUNIZATION VISIT 3 (SKIP TO 127A)
NO 4
127. Where did you get the net?
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
CHW 05
RELIGIOUS INSTITUTION 06
SCHOOL 07
OTHER 96
DON'T KNOW 98
127A. OBSERVE IF THE NET HAVE AT LEAST ONE HOLE EQUAL TO OR LARGER THAN THE THUMB
NO 2
127B. OBSERVE THE SHAPE OF THE MOSQUITO NET.
RECTANGULAR 2
127C. OBSERVE THE COLOUR THE NET
GREEN 2
BLUE 3
RED 4
OTHER 6 (SPECIFY) __
127D. OBSERVED IF THE NET IS HANGED
NO 2
127E. Why don't you hang this net?
USE FOR OTHER PURPOSES 2
THE NET IS BEING WASHED 3
HANG ONLY IN THE EVENING 4
THE NET IS TOO OLD 5
OTHER 6 (SPECIFY) __
128. Did anyone sleep under this mosquito net last night?
NO 2
NOT SURE 8
128A. Why did no one sleep under this net last night?
TOO COLD 2
NET USED FOR OTHER PURPOSES 3
NET NOT HANGED 4
BUGS IN NET 5
OTHER 6 (SPECIFY) __
129. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.
LINE NO. __
LINE NO. __
LINE NO. __
129A. Which material of the net do you prefer?
POLYETHYLENE 2
129B. How many times did you wash this mosquito net since you have had it?
95+ TIMES 95
DON'T KNOW 98
130. GO BACK TO 121 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 131.
ADDITIONAL HOUSEHOLD CHARACTERISTICS
131. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING.
RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
132. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.
THATCH/PALM LEAF 12
SOD 13
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
133. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.
CANE/PALM/TRUNKS 12
DIRT 13
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
MINUTES __
INTERVIEWER'S OBSERVATIONS
__
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW: __
COMMENTS ON SPECIFIC QUESTIONS: __
ANY OTHER COMMENTS: __