MALARIA INDICATORS SURVEY ("EIP 2020")
WOMAN'S QUESTIONNAIRE
REPUBLIC OF SENEGAL
Ministry of the Economy, Planning, and Cooperation
Ministry of Health and Social Action
NAME OF REGION ______
NAME AND NUMBER OF HEAD OF HOUSEHOLD ______
CONCESSION NUMBER ______
CLUSTER NUMBER ______
REGION ______
DEPARTMENT ______
HEALTH DISTRICT ______
URBAN/RURAL (URBAN = 1, RURAL = 2) ______
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL
(DAKAR = 1, REGIONAL CAPITAL = 2, OTHER CITY = 3, RURAL = 4)______
NAME AND LINE NUMBER OF WOMAN ______
(Repeat up to 3 visits)
DATE ______
NAME OF INTERVIEWER ______
RESULT ______
NEXT VISIT:
DATE ______
TIME ______
FINAL VISIT
DAY ______
MONTH ______
YEAR 202______
RESPONDENT NUMBER______
RESULT CODE ______
TOTAL NUMBER OF VISITS ______
RESULT CODES:
1 COMPLETED
2 NOT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ______
LANGUAGE OF QUESTIONNAIRE 1
LANGUAGE OF INTERVIEW ______
NATIVE LANGUAGE OF RESPONDENT ______
INTERPRETER (YES = 1, NO = 2) ______
LANGUAGE OF QUESTIONNAIRE FRENCH
LANGUAGE CODES:
01 FRENCH
02 WOLOF
03 PULAR
04 SERER
05 MANDINKA
06 DIOLA
07 OTHERS
TEAM LEADER
NAME ______
NUMBER ______
DATE ______
INTRODUCTION AND CONSENT REQUEST
Hello. My name is ______. I work for the National Agency of Statistics and Demographics ("ANSD") along with the Ministry of Health and Social Action ("MSAS"). We are carrying out a national survey on malaria in Senegal. The information that we gather will help our government to improve health services. Your household was selected for this survey. The questions usually take between 15 and 20 minutes. All the information that you give us will remain strictly confidential and will not be shared with anyone other than survey team members. You do not have to participate in this survey but we hope that you will accept to answer my questions because your opinion is very important. If I happen to ask a question that you do not wish to answer, tell me and I will go on to the next question; you can also stop the interview at any time.
If you would like more information about the survey, you can contact the person whose name is on the card that was already given to your household.
Do you have any questions to ask me?
May I begin the interview now?
INTERVIEWER'S SIGNATURE: ______
DATE: ______
1 RESPONDENT AGREES TO BE INTERVIEWED (Continue to 101)
2 RESPONDENT DECLINES TO BE INTERVIEWED (Skip to END)
SECTION 1: SOCIODEMOGRAPHIC BACKROUND OF RESPONDENT
MINUTES ______
102. In what month and what year were you born?
98 DK MONTH
YEAR ______
9998 DK YEAR
103. How old were you on your last birthday?
COMPARE AND CORRECT 102 AND/0R 103 IF INCONSISTENT.
104. Have you ever attended school?
2 NO (Skip to 108)
105. What is the highest level of studies you reached: primary, secondary, or higher?
2 MIDDLE
3 SECONDARY
4 HIGHER
6 OTHER (SPECIFY) ______
106. What is the highest (YEAR/GRADE) that you completed at this level?
IF LESS THAN ONE YEAR WAS COMPLETED AT THIS LEVEL, RECORD '00'.
PRIMARY, MIDDLE OR SECONDARY ______ (Continue to 108)
HIGHER ______ (Skip to 110)
108. Now I would like you to read this sentence to me.
SHOW CARD TO RESPONDENT.
IF RESPONDENT CANNOT READ THE WHOLE SENTENCE, PROBE:
Can you read part of the sentence?
2 CAN READ PARTS OF THE SENTENCE
3 CAN READ ENTIRE SENTENCE
4 NO CARD IN RESPONDENT'S LANGUAGE (SPECIFY LANGUAGE) ______
5 BLIND/VISUALLY IMPAIRED
CODE '2', '3', OR '4' CIRCLED ______ (Continue to 110)
CODE '1' OR '5' CIRCLED ______ (Skip to 111)
110. Do you read a newspaper or magazine at least once a week, less than once a week, or not at all?
2 LESS THAN ONCE A WEEK
3 NOT AT ALL
111. Do you listen to the radio at least once a week, less than once a week, or not at all?
2 LESS THAN ONCE A WEEK
3 NOT AT ALL
112. Do you watch television at least once a week, less than once a week, or not at all?
2 LESS THAN ONCE A WEEK
3 NOT AT ALL
113. Do you have a mobile phone?
2 NO (Skip to 115)
114. Is your mobile phone a smart phone?
2 NO
115. Have you ever used the internet from any place or any device?
2 NO (Skip to 118)
116. In the last 12 months, have you used the internet?
IF NECESSARY, PROBE TO DETERMINE IF USED IN ANY PLACE WITH ANY DEVICE.
2 NO (Skip to 118)
117. In the last month, how many times have you used the internet: almost every day, at least once a week, less than once a week or not at all?
2 AT LEAST ONCE A WEEK
3 LESS THAN ONCE A WEEK
4 NOT AT ALL
02 CHRISTIAN
03 ANIMIST
WITHOUT RELIGION
96 OTHER (SPECIFY) ______
[###translator's note: number code omitted for "WITHOUT RELIGION"]
119. What is your ethnicity?
02 PULAR
03 SERER
04 MANDINKA
05 DIOLA
06 SONINKE
96 OTHER (SPECIFY) ______
201. Now I would like to ask you some questions about all the births you have had in your lifetime. Have you ever given birth?
2 NO (Skip to 206)
202. Do you have any sons or daughters to whom you gave birth who are currently living with you?
2 NO (Skip to 204)
203. a) How many sons live with you?
b) How many daughters live with you?
IF NONE, RECORD '00'.
b) DAUGHTERS AT HOME ______
204. Do you have any sons or daughters to whom you gave birth who are still living but do not live with you?
2 NO (Skip to 206)
205. a) How many sons are living but do not live with you?
b) How many daughters are living 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 who later died?
IF NO, PROBE: No baby who cried, made a sound, tried to breathe, or showed other signs of life for a short time?
2 NO (Skip to 208)
207. a) How many boys died?
b) How many girls died?
IF NONE, RECORD '00'.
b) DECEASED GIRLS ______
208. TOTAL UP THE ANSWERS TO 203, 205, AND 207 AND RECORD THE TOTAL.
IF NONE, RECORD '00'.
I would like to be sure I understood correctly: you have had a TOTAL of ______ births in your life. Is that correct?
NO ______ PROBE AND CORRECT 201 - 208 AS NECESSARY
ONE OR MORE BIRTHS ______ (Continue to 211)
NONE ______ (Skip to 224)
211. Now I would like to ask you questions about your most recent births. How many births did you have between 2015 - 2020?
00 NONE (Skip to 224)
212. Now I would like to record the names of all the births you had in 2015 - 2020, whether they are still living or not, beginning with the most recent birth.
RECORD THE NAME OF ALL BIRTHS IN 2015 - 2020 IN Q.213. RECORD TWINS/TRIPLETS ON SEPARATE LINES. IF THERE ARE MORE THAN 5 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, BEGINNING ON THE SECOND ROW.
(Repeat 213 - 221 for up to 5 births)
213. What name was given to your (last/preceding) baby?
RECORD THE NAME.
NUMBER IN BIRTH HISTORY.
01 ______
214. Is (NAME) a boy or a girl?
1 BOY
2 GIRL
215. Is (NAME) a single or multiple birth?
1 SINGLE
2 MULTIPLE
216. On what day, month, and year was (NAME) born?
DAY ______
MONTH ______
YEAR ______
1 YES
2 NO (Go to NEXT BIRTH)
218. IF LIVING:
How old was (NAME) on his/her last birthday?
RECORD AGE IN COMPLETED YEARS.
AGE IN YEARS ______
219. IF LIVING:
Does (NAME) live with you?
1 YES
2 NO
RECORD CHILD'S LINE NUMBER FROM HOUSEHOLD SCHEDULE.
RECORD '00' IF CHILD IS NOT LISTED IN HOUSEHOLD.
LINE NUMBER FROM HOUSEHOLD SCHEDULE ______ (Go to NEXT BIRTH)
221.Were there other live births between (NAME OF PRECEDING BIRTH) and (NAME), including babies who died after birth?
1 YES (ADD BIRTH)
2 NO (GO TO NEXT BIRTH)
222. Have you had other live births since that of (NAME OF LAST BIRTH)?
2 NO
223. COMPARE 211 WITH NUMBER OF BIRTHS IN BIRTH HISTORY
NUMBERS ARE EQUAL ______ (Continue to 224)
NUMBERS ARE DIFFERENT ______ (PROBE AND CORRECT)
2 NO (Skip to 301)
8 UNSURE (Skip to 301)
225. How many weeks or months pregnant are you?
RECORD THE NUMBER OF COMPLETED WEEKS OR MONTHS.
2 MONTHS ______
SECTION 3. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT
ONE OR MORE BIRTHS IN THE PERIOD 0 - 35 MONTHS BEFORE SURVEY ______ (Continue to 302)
NO BIRTHS IN PERIOD 0 - 35 MONTHS BEFORE SURVEY ______ (Skip to 401)
302. RECORD NAME OF LAST BIRTH FROM 213, ROW 01:
NAME: ______
303. Now I would like to ask you some questions about your last pregnancy that ended in a live birth.
When you were pregnant with (NAME), did you see anyone for antenatal care during this pregnancy?
2 NO
304. Whom did you see?
Anyone else?
PROBE TO DETERMINE EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
A DOCTOR
B MIDWIFE
C NURSE/HEAD NURSE
OTHER PERSONNEL
D TRADITIONAL BIRTH ATTENDANT
E VILLAGE MIDWIFE "MATRONE"
X OTHER (SPECIFY) ______
305. Where did you receive antenatal care for this pregnancy?
No other place?
PROBE TO DETERMINE TYPE OF PLACE.
IF UNABLE TO DETERMINE IF PLACE IS PUBLIC OR PRIVATE SECTOR, OR AN NGO, RECORD 'X' AND WRITE THE NAME OF THE PLACE.
A HER HOME
B OTHER HOME
PUBLIC MEDICAL SECTOR
CIVILIAN PUBLIC
C HOSPITAL
D HEALTH CENTER
E RURAL HEALTH POST
F VILLAGE HEALTH CENTER
G HOME HEALTH CARE PROVIDER/COMMUNITY AGENT
MILITARY PUBLIC
H HOSPITAL
I HEALTH CENTER
J RURAL HEALTH POST
K VILLAGE HEALTH CENTER
L HOME HEALTH CARE PROVIDER/COMMUNITY AGENT
PARAMILITARY PUBLIC
M HEALTH CENTER
N RURAL HEALTH POST
O OTHER PUBLIC SECTOR (SPECIFY) ______
PRIVATE MEDICAL SECTOR
PRIVATE DENOMINATIONAL
P HOSPITAL
Q RURAL HEALTH POST
PRIVATE NON-DENOMINATIONAL
R CLINIC
S MEDICAL OFFICE
T PARAMEDICAL OFFICE
PRIVATE NGO
U NGO HOSPITAL
V NGO CLINIC
W OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ______
OTHER PLACE
X TRADITIONAL PRACTITIONER
Y OTHER (SPECIFY) ______
306. How many weeks or months pregnant were you when you received your first antenatal care for this pregnancy?
2 MONTHS ______
998 DK
307. During this pregnancy, how many times did you receive antenatal care?
98 DK
308. During this pregnancy, did you take SP/Fansidar to prevent malaria?
2 NO (Skip to 401)
8 DK (Skip to 401)
309. During this pregnancy, how many times did you take SP/Fansidar?
310. Were you given the SP/Fansidar during an antenatal visit, during another visit to a health facility, or did you get it elsewhere?
IF MORE THAN 1 SOURCE, RECORD THE FIRST SOURCE ON THE LIST.
2 OTHER TYPE OF VISIT/NOT ANTENATAL
3 HOME HEALTH CARE PROVIDER/COMMUNITY AGENT
6 ELSEWHERE
401. CHECK 216, 217, AND 218 IN BIRTH HISTORY: ANY SURVIVING CHILDREN BORN 0 - 59 MONTHS BEOFRE SURVEY?
ONE OR MORE SURVIVING CHILDREN BORN 0 - 59 MONTHS BEFORE SURVEY ______ (Continue to 402)
NO SURVIVING CHILDREN BORN 0 - 59 MONTHS BEFORE SURVEY ______ (Skip to 417)
402. Now I would like to ask you some questions about the health of your children born in the last 5 years. We will talk about one child at a time, beginning with the youngest.
403. RECORD THE NAME AND BIRTH HISTORY NUMBER FROM 213 OF SURVIVING CHILDREN BORN 0 - 59 MONTHS BEFORE SURVEY, BEGINNING WITH THE LAST-BORN.
NAME OF CHILD ______
BIRTH HISTORY NUMBER ______
404. In the last two weeks, has (NAME) been sick with a fever at any time?
2 NO
8 DK
[###translator's note: unclear skip instructions]
405. Did anyone draw blood from (NAME)'s finger or heel at any time during (NAME)'s illness?
2 NO
8 DK
[###translator's note: unclear skip instructions]
406. Did a health care provider tell you that (NAME) had malaria?
2 NO
8 DK
407. Did you seek out any advice or treatment for the illness?
2 NO (Skip to 412)
408. Where did you go to seek advice or treatment?
Anywhere else?
PROBE TO DETERMINE TYPE OF PLACE.
IF UNABLE TO DETERMINE IF PLACE IS PUBLIC OR PRIVATE SECTOR OR AN NGO, RECORD 'X' AND WRITE THE NAME OF THE PLACE.
CIVILIAN PUBLIC
A HOSPITAL
B HEALTH CENTER
C RURAL HEALTH POST
D VILLAGE HEALTH CENTER
E HOME HEALTH CARE PROVIDER/COMMUNITY AGENT
MILITARY PUBLIC
F HOSPITAL
G HEALTH CENTER
H RURAL HEALTH POST
I VILLAGE HEALTH CENTER
J HOME HEALTH CARE PROVIDER/COMMUNITY AGENT
PARAMILITARY PUBLIC
K HEALTH CENTER
L RURAL HEALTH POST
M OTHER PUBLIC SECTOR (SPECIFY) ______
PRIVATE MEDICAL SECTOR
PRIVATE DENOMINATIONAL
N HOSPITAL
O RURAL HEALTH POST
PRIVATE NON-DENOMINATIONAL
P CLINIC
Q MEDICAL OFFICE
R PARAMEDICAL OFFICE
PRIVATE NGO
S NGO HOSPITAL
T NGO CLINIC
U OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ______
OTHER SOURCE
V SHOP
W TRADITIONAL PRACTITIONER
X MARKET
Y ITINERANT MEDICINE PEDDLAR
Z OTHER (SPECIFY) ______
TWO OR MORE CODES CIRCLED ______ (Continue to 410)
ONLY ONE CODE CIRCLED ______ (Skip to 411)
410. Where did you go first to seek advice or treatment?
USE LETTER CODES FROM 408.
411. How many days after the illness began did you seek advice or treatment for (NAME)?
IF SAME DAY, RECORD '00'.
412. Did (NAME) take medicine for the illness at any time during the illness?
2 NO (Skip to 416)
8 DK (Skip to 416)
413. What medicine did (NAME) take?
No other medicine?
RECORD ALL MENTIONED.
IF MEDICINE IS NOT KNOWN, ASK TO SEE THE BOX OR PRESCRIPTION.
A ACT ARTEMISININ COMBINATION THERAPY
B SP/FANSIDAR
C CHLOROQUINE
D AMODIAQUINE
QUININE
E TABLETS
F INJECTION/IV
ARTESUNATE
G RECTAL TREATMENT
H INJECTION/IV
I OTHER ANTIMALARIAL (SPECIFY) ______
ANTIBIOTICS
J AMOXICILLIN
K COTRIMOXAZOLE
L OTHER TABLET/SYRUP
M OTHER INJECTION/IV
OTHER MEDICATION
N ASPIRIN
O PARACETAMOL/PANADOL/ACETAMINOPHEN
P IBUPROFEN
X OTHER (SPECIFY) ______
Z DK
[###translator's note: incomplete skip instructions]
414. CHECK 413: ACT ARTEMISININ COMBINATION THERAPY ('A') GIVEN
CODE 'A' CIRCLED ______ (Continue to 415)
CODE 'A' NOT CIRCLED ______ (Skip to 416)
415. How soon after the fever began did (NAME) start to take ACT artemisinin combination therapy?
1 NEXT DAY
2 TWO DAYS AFTER THE FEVER
3 THREE OR MORE DAYS AFTER THE FEVER
8 DK
416. CHECK 216 AND 217 IN BIRTH HISTORY: IS THERE A SURVIVING CHILD BORN 0 - 59 MONTHS BEFORE THE SURVEY?
NO OTHER SURVIVING CHILDREN BORN 0 - 59 MONTHS BEFORE SURVEY ______ (Continue to 417)
OTHER SURVIVING CHILDREN BORN 0 - 59 MONTHS BEFORE SURVEY ______ (Go to 403)
MINUTES ______
TO BE FILLED OUT ONCE THE INTERVIEW IS FINISHED
COMMENTS ON THE INTERVIEW: ______
COMMENTS ON PARTICULAR QUESTIONS: ______
OTHER COMMENTS: ______
OBSERVATIONS OF TEAM LEADER
______
REFERENCE DATES
YEAR OF SURVEY: 2020
FIVE YEARS BEFORE SURVEY: 2015
CHILDREN OVER FIVE YEARS OLD: 2014
CHILDREN UNDER FOUR: 2017
CHILDREN UNDER 3: 2018
CHILDREN UNDER 16: 2005