2016 SIERRA LEONE MALARIA INDICATOR SURVEY
HOUSEHOLD QUESTIONNAIRE
SIERRA LEONE
MINISTRY OF HEALTH AND SANITATION, NATIONAL MALARIA CONTROL PROGRAMME
STATISTICS SIERRA LEONE
CATHOLIC RELIEF SERVICES
LOCALITY NAME __
NAME OF HOUSEHOLD HEAD __
CLUSTER NUMBER __
DISTRICT __
PROVINCE __
CHIEFDOM __
SECTION __
ENUMERATION AREA __
URBAN-RURAL (RURAL = 1, URBAN = 2) __
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 2016
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 INTERIVEW** __
NATIVE LANGUAGE OF RESPONDENT** __
TRANSLATOR USED (YES =1 , NO =2) __
LANGUAGE OF QUESTIONNAIRE** ENGLISH
**LANGUAGE CODES:
KRIO 02
MENDE 03
TEMNE 04
MADINGO 05
LOKO 06
SHERBRO 07
LIMBA 08
KISSI 09
KONO 10
SUSU 11
FULLAH 12
KRIM 13
YALUNKA 14
KORANKO 15
VAI 16
OTHER 96
SUPERVISOR
NAME __
NUMBER __
Hello. My name is _________________________________. I am working with the Ministry of Health and Sanitations (MoHS). We are conducting a survey about malaria all over Sierra Leone. The information we collect will help the government to plan health services. Your household was selected for 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 any of the people listed on this card.
GIVE CARD WITH CONTACT INFORMATION
2016 SLMIS Principle Investigator: Dr. Foday Sahr; +232 76 480288; Email: fodaysahr1@gmail.com
Chairman of Ethics Committee: Professor Hector G. Morgan; +232 76 629251; Email: hmorg2007@yahoo.com
Director of Policy, Planning, and Information: Dr. Samuel A.S. Kargbo; +232 76 603274; Email: saskargbo@gmail.com
National Malaria Control Programme (NMCP): Dr. Samuel Juana Smith; +232 76 611042; Email: samueljuana@yahoo.com
Catholic Relief Services: Mr. Ebrima Jarjou; +232 79 250636; Email: ebrima.jarjou@crs.org
As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. As part of this survey, we are asking that children all over the country take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or disease. This survey will help the government to develop programs to prevent and treat Anemia. As part of this survey, we are asking that children all over the country take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by a mosquito bite. If the malaria test is positive, treatment will be offered. This survey will help the government to develop programs to prevent malaria. Participation in the survey is completely voluntary. 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 you will participate in the survey because 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 INTERVIEW ______________________________ 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 the 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 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.
__
CODES FOR Q.3: RELATIONSHIP TO HEAD OF HOUSEHOLD
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
NIECE/NEPHEW BY BLOOD 09
NIECE/NEPHEW BY MARRIAGE 10
OTHER RELATIVE 11
ADOPTED/FOSTER/STEPCHILD 12
NOT RELATED 13
CO-WIFE 14
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',
ELIGIBILITY
(8) CIRCLE LINE NUMBER OF ALL WOEN AGE 15-49 YEARS
(9) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5 YEARS
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
WATER SACHETS 92
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
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
WOOD 08
STRAWS/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
109. How many rooms in this household are used for sleeping?
109A. How many sleeping facilities are currently in use in this household, including any beds, mattresses, mats, or rugs?
ASK FOR BOTH INSIDE AND OUTSIDE OF DWELLING.
IF THE NUMBER IS MORE THAN 25, RECORD 95.
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) Other cattle?
c) Horses, donkeys, or mules?
d) Goats?
e) Sheep?
f) Chickens or other poultry?
g) Pigs?
b) OTHER CATTLE __
c) HORSES/DONKEYS/MULES __
d) GOATS __
e) SHEEP __
f) CHICKENS/POULTRY __
g) PIGS __
112. Does any member of your household own any agricultural land?
NO 2 (SKIP TO 114)
113. How many acres of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '950'.
95 OR MORE ACRES 950
DON'T KNOW 998
114. Does your household have:
b) A radio?
c) A television?
d) A non-mobile telephone?
e) A computer?
f) A refridgerator?
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/village savings and loans/osusu?
NO 2
117. At any time in the past 12 months, has anone come into your dwelling to spray the interior walls against mosquitoes?
NO 2 (SKIP TO 118A)
DON'T KNOW 8 (SKIP TO 118A)
118. Who sprayed the dwelling?
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER X (SPECIFY) __
DON'T KNOW Z
118A. Now I would like to talk to you about mosquito nets. What shape of mosquito nets do you prefer, conical or rectangular?
SHOW PHOTO OF NETS
RECTANGULAR 2
EITHER 3
DON'T KNOW 8
118B. If you have a choice, what color of mosquito nets do you prefer?
BLUE 2
GREEN 3
OTHER 6
118C. Do you prefer a mosquito net where the material is soft (MADE OF POLYESTER) or hard (MADE OF POLYETHYLENE)?
SHOW SAMPLES PIECES
HARD (POLYETHYLENE) 2
DON'T KNOW 8
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 HANGING 2
NOT HANGING 4
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 BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.
OLYSET 12 (SKIP TO 126)
DURANET 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 the June-July 2014 mass distribution campaign, during an antenatal care visit, or during an immunization visit?
YES, ANC 2 (SKIP TO 128)
YES, IMMUNIZATION VISIT3 (SKIP TO 128)
NO 4
127. Where did you get the net?
MOBILE CLINIC 02
COMMUNITY HEALTH WORKER 03
PVT HOSPITAL/CLINIC 04
MISSION/FAITH-BASED HOSPITAL 05
MISSION/FAITH-BASED CLINIC 06
PHARMACY 07
PVT MOBILE CLINIC 08
NGO 09
SCHOOL 10
SHOP 11
TRADITIONAL HEALER 12
DON'T KNOW 98
OTHER 96 (SPECIFY) __
128. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 130)
NOT SURE 8 (SKIP TO 130)
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. __
LINE NO. __
LINE NO. __
LINE NO. __
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 ADOE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
WATTLE 35
WOOD PLANKS/SHINGLES 36
ZINC 37
MINUTES __
INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW: __
COMMENTS ON SPECIFIC QUESTIONS: __
ANY OTHER COMMENTS: __