NATIONAL SURVEY ON MALARIA ("ENPS, 2006")
HOUSEHOLD QUESTIONNAIRE
Republic of Senegal
Ministry of Health and Medical Prevention
ORC Macro
Center of Research for Human Development ("CRDH")
NAME OF LOCALITY ______
NAME OF HEAD OF HOUSEHOLD______
HOUSEHOLD NUMBER ______
CONCESSION NUMBER ______
CLUSTER NUMBER ______
REGION ______
URBAN/RURAL (URBAN = 1, RURAL = 2) ENVIRONMENT ______
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL DETAILED ENVIRONMENT
(DAKAR = 1, REGIONAL CAPITAL = 2, OTHER CITY = 3, RURAL = 4) ______
CLUSTER NUMBER DHS-IV 2005 ______
HOUSEHOLD SURVEYED IN DHS-IV 2005? (YES = 1, NO = 2) ______
HOUSEHOLD NUMBER IN DHS-IV 2005 ______
(Repeat for up to 3 visits)
DATE _____
NAME OF INTERVIEWER ______
RESULT ______
NEXT VISIT
DATE ______
TIME ______
FINAL VISIT
DAY ______
MONTH ______
YEAR 2006
INTERVIEWER NUMBER ______
RESULT CODE ______
TOTAL NUMBER OF VISITS ______
RESULT CODES:
1 COMPLETED
2 NO FAMILY MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR LONG PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR NO DWELLING AT ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ______
TOTAL IN HOUSEHOLD ______
TOTAL NUMBER OF ELIGIBLE WOMEN ______
RESPONDENT'S LINE NUMBER FOR HOUSEHOLD QUESTIONNAIRE ______
TEAM LEADER
NAME ______
DATE ______
SUPERVISOR
NAME ______
DATE ______
OFFICE EDITOR
______
KEYED BY
______
(Repeat Q. 1 - 10 for up to 32 household members)
Now we would like some information about the people who usually live in your household or who are currently living in your household.
2. HABITUAL RESIDENTS AND VISITORS
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.
3. RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
01 HEAD OF HOUSEHOLD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW/DAUGHTER-IN-LAW
05 GRANDSON/GRANDDAUGHTER
06 FATHER/MOTHER
07 FATHER-IN-LAW/MOTHER-IN-LAW
08 BROTHER OR SISTER
09 CO-WIFE
10 OTHER RELATIVES
11 ADOPTED/FOSTER/STEPCHILD
12 NO FAMILY RELATION
98 DK
4. GENDER
Is (NAME) male or female?
2 FEMALE
5. RESIDENCE
Does (NAME) usually live here?
2 NO
6. RESIDENCE
Did (NAME) stay here last night?
2 NO
8. USE OF MOSQUITO NET
Did (NAME) sleep under a mosquito net last night that had been soaked or treated in the last 6 months?
2 NO
9. ELIGIBILITY
CIRCLE THE LINE NUMBERS OF ALL WOMEN AGE 15 - 49.
10. CURRENTLY PREGNANT
FOR ALL ELIGIBLE WOMEN, ASK: Is (NAME) pregnant now?
2 NO
11. Where does the drinking water used by members of your household mainly come from?
11 IN DWELLING
12 IN YARD/CONCESSION
13 PUBLIC FAUCET
OPEN WELL
21 OPEN WELL IN DWELLING
22 IN YARD/CONCESSION
23 OPEN PUBLIC WELL
COVERED WELL OR BOREHOLE
31 PROTECTED WELL IN DWELLING
32 IN YARD/CONCESSION
33 PUBLIC PROTECTED WELL
SURFACE WATER
41 SPRING
42 RIVER
43 POND/LAKE
44 DAM
51 RAINWATER
61 TANKER TRUCK WATER
71 BOTTLED WATER (Skip to 13)
96 OTHER (SPECIFY) ______
12. Do you do anything to make the water cleaner before drinking it? For example, do you boil it or filter it or do you add any product to it before using it as drinking water?
2 BOIL
3 FILTER WITH CLOTH
4 WATER FILTER
5 ADD BLEACH/CHLORINE
6 OTHER (SPECIFY) ______
13. What kind of toilets does your household have?
12 FLUSH CONNECTED TO PIT
21 RUDIMENTARY PIT/LATRINE
22 IMPROVED PIT LATRINE
31 NO TOILET/IN NATURE (Skip to 16)
96 OTHER (SPECIFY) ______
14. Do you share these toilets with other households?
2 NO (Skip to 16)
15. How many other households use these toilets?
IF 5 OR MORE HOUSEHOLDS, RECORD '5'.
16. In your household, is there:
Electricity?
A radio?
A television?
An MMDS/TV5 antenna?
A CANAL subscription?
A landline phone?
A cell phone?
A washing machine?
A refrigerator?
An electric hot plate/stovetop or gas stovetop?
An improved stove?
A CD/DVD player?
An air conditioner?
A computer?
Internet at home?
1 YES
2 NO
RADIO
1 YES
2 NO
TELEVISION
1 YES
2 NO
TV5 ANTENNA
1 YES
2 NO
CANAL
1 YES
2 NO
TELEPHONE
1 YES
2 NO
CELL PHONE
1 YES
2 NO
WASHING MACHINE
1 YES
2 NO
REFRIGERATOR
1 YES
2 NO
HOT PLATE/STOVETOP
1 YES
2 NO
IMPROVED STOVE
1 YES
2 NO
CD/DVD PLAYER
1 YES
2 NO
AIR CONDITIONER
1 YES
2 NO
COMPUTER
1 YES
2 NO
INTERNET
1 YES
2 NO
17. In your household, what kind of fuel do you mainly use for cooking?
2 BOTTLED GAS
3 CHARCOAL
4 FIREWOOD, STRAW
5 ANIMAL DUNG
6 OTHER (SPECIFY) ______
18. MAIN MATERIAL OF FLOOR
RECORD OBSERVATION.
11 EARTH/SAND
12 DUNG
MODERN MATERIAL
31 PARQUET OR POLISHED WOOD
32 VINYL OR LINOLEUM/ASPHALT
33 TILES
34 CEMENT
35 CARPETING
96 OTHER (SPECIFY) ______
19. Of all the rooms in your household, how many are generally used for sleeping by household members?
20. In your household, is there anyone who owns:
Bicycles?
Mopeds or motorcycles?
Personal car?
Business car or truck?
Wagons?
Plows?
Horses?
Cattle?
Camels?
Donkeys?
Sheep/goats?
Flat-bottom boats/fishing nets?
Poultry?
1 YES
2 NO
MOPED/MOTORCYCLE
1 YES
2 NO
PERSONAL CAR
1 YES
2 NO
CAR/TRUCK
1 YES
2 NO
WAGON
1 YES
2 NO
PLOW
1 YES
2 NO
HORSE
1 YES
2 NO
CATTLE
1 YES
2 NO
CAMELS
1 YES
2 NO
DONKEYS
1 YES
2 NO
SHEEP/GOATS
1 YES
2 NO
FLAT-BOTTOM BOATS/NETS
1 YES
2 NO
POULTRY
1 YES
2 NO
20A. What is your ethnicity (what is head of household's ethnicity)?
02 PULAR
03 SERER
04 MANDINKA
05 DIOLA
06 SONINKE
96 OTHER (SPECIFY) ______
21. In the past 12 months, has anyone sprayed the interior walls of your dwelling for mosquitos?
2 NO (Skip to 24)
8 DK (Skip to 24)
22. How long ago was the interior of your house sprayed?
IF LESS THAN ONE MONTH, RECORD '00' MONTHS.
23. Who sprayed the walls of your dwelling?
2 PRIVATE COMPANY
3 HOUSEHOLD MEMBER
6 OTHER (SPECIFY) ______
8 DK
23A. Since the walls of your dwelling were sprayed, have you touched them up, for example by applying lime or paint, applying a coating or washing them?
2 NO
8 NO/DON'T REMEMBER
24. In your household, do you have any mosquito nets that can be used for sleeping?
2 NO (Skip to END)
25. How many mosquito nets do you have in your household?
IF 7 OR MORE MOSQUITO NETS, RECORD '7'.
26. ASK RESPONDENT TO SHOW YOU THE MOSQUITO NETS. ASK THE FOLLOWING QUESTIONS ABOUT EACH MOSQUITO NET. IF MORE THAN 3 MOSQUITO NETS, USE AN ADDITIONAL QUESTIONNAIRE.
MOSQUITO NET 1
1 SEEN
2 NOT SEEN
27. How long has your household owned the mosquito net?
96 3 OR MORE YEARS
28. OBSERVE OR ASK THE BRAND OF MOSQUITO NET.
21 PRETREATED MOSQUITO NET (Skip to 30)
31 OTHER
98 DK/UNSURE
29. When you got this mosquito net, had the manufacturer already treated it with an insecticide that kills or repels mosquitos?
2 NO
8 UNSURE/DK
30. Since you have had this mosquito net, has it been soaked or dipped in a liquid that kills or repels mosquitos or insects?
2 NO (Skip to 32)
8 UNSURE/DK (Skip to 32)
31. How long has it been since the last time the mosquito was soaked or dipped in a liquid insecticide?
IF LESS THAN 1 MONTH, RECORD '00'.
IF LESS THAN 2 YEARS, RECORD NUMBER OF MONTHS.
95 2 OR MORE YEARS
98 UNSURE/DK
32. Did anyone sleep under this mosquito net last night?
2 NO (Skip to 34)
8 DK (Skip to 34)
33. Who slept under this mosquito net last night?
CARRY OVER THE LINE NUMBER FROM HOUSEHOLD SCHEDULE.
(Repeat for up to 5 people)
LINE NUMBER ______
34. Where did this mosquito net come from?
12 RURAL HEALTH POST (Skip to 36)
13 VILLAGE HEALTH CENTER
14 OTHER HEALTH CENTER
21 PHARMACY
22 COMMUNITY-BASED ORGANIZATION
23 GAS STATION/MARKET
31 PUBLIC MARKET
41 OTHER (SPECIFY) ______
98 DK
35. How was this mosquito net acquired?
2 FREE
8 DK
36. Was a coupon given to you at the Health Center/Health Post to get this mosquito net?
IF NECESSARY, SHOW A COUPON TO THE RESPONDENT
2 NO
8 DK
37. RETURN TO 26 FOR NEXT MOSQUITO NET; OR, IF NO MORE MOSQUITO NETS IN HOUSEHOLD: END HOUSEHOLD QUESTIONNAIRE.