MALARIA INDICATORS SURVEY ("EIP 2020")
HOUSEHOLD QUESTIONNAIRE
REPUBLIC OF SENEGAL
Ministry of the Economy, Planning, and Cooperation
Ministry of Health and Social Action
NAME OF LOCALITY ______
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) ______
(Repeat for up to 3 visits)
DATE _____
NAME OF INTERVIEWER ______
RESULT ______
NEXT VISIT
DATE ______
TIME ______
FINAL VISIT
DAY ______
MONTH ______
YEAR 202______
INTERVIEWER NUMBER ______
RESULT ______
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 PEOPLE IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN ______
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE ______
LANGUAGE OF QUESTIONNAIRE 01
LANGUAGE OF QUESTIONNAIRE FRENCH
LANGUAGE OF INTERVIEW ______
NATIVE LANGUAGE OF RESPONDENT ______
INTERPRETER (YES = 1, NO = 2) ______
CODE:
01 FRENCH
02 WOLOF
03 PULAR
04 SERER
05 MANDINKA
06 DIOLA
07 OTHERS
TEAM LEADER
NAME ______
NUMBER ______
DATE ______
THIS PAGE IS INTENTIONALLY LEFT BLANK
INTRODUCTION AND CONSENT REQUEST
(2)
Hello. My name is ______. I work for the National Agency of Statistics and Demographics ("ANSD") in collaboration with the Ministry of Health and Social Action ("MSAS"). We are conducting a national survey of malaria in Senegal. The information that we collect will help the government improve health services. Your household was selected for this survey. We would like to ask you a few questions about your household. The questions usually take about 15 to 20 minutes. All the information that you give us is strictly confidential and will not be shared with anyone other than members of the survey team. You are not obligated to participate in this survey, but we hope that you will accept to answer our questions for your opinion is very important. If I happen to ask a question that you do not want to answer, tell me and I will go on to the next question. If you want more information about the survey, you can also contact the people named on this card.
GIVE THE CARD WITH CONTACT INFORMATION FOR THESE PEOPLE
Do you have any questions to ask me?
May I begin the interview now?
SIGNATURE OF INTERVIEWER ______
DATE ______
1 RESPONDENT AGREES TO BE INTERVIEWED (Continue to 100)
2 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED (Skip to END)
100. RECORD THE TIME.
MINUTES ______
(Repeat Q.1 - 9 for up to 10 household members)
01
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.
(Name) ______
AFTER ASKING QUESTIONS 2 - 7 FOR EACH PERSON, ASK QUESTIONS 2A - 2C TO MAKE SURE THAT THE LIST IS COMPLETE.
3. RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.
(Relationship code) ______
CODES FOR Q. 3: RELATIONSHIP TO HEAD OF 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 IN-LAW
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED/FOSTER/STEPCHILD
11 NO RELATION
12 CO-WIFE
98 DK
4. GENDER
Is (NAME) male or female?
1 MALE
2 FEMALE
5. RESIDENCE
Does (NAME) usually live here?
1 YES
2 NO
6. RESIDENCE
Did (NAME) stay here last night?
1 YES
2 NO
IF 95 OR OLDER, RECORD '95'
IN YEARS ______
8. ELIGIBILITY
CIRCLE THE LINE NUMBERS OF ALL WOMEN AGE 15 - 49
01
9. ELIGIBILITY
CIRCLE THE LINE NUNBER OF ALL CHILDREN AGE 0 - 5
01
2A) Just to be sure that I have a complete list: are there any other people like small children or infants whom we have not listed?
YES ______ (ADD TO TABLE)
NO ______
2B) Are there any people who are perhaps not family members, such as servants, renters or friends who usually live here?
YES ______ (ADD TO TABLE)
NO ______
2C) Do you have any guests or temporary visitors who are in your home, or other people who slept here last night and were not listed?
YES ______ (ADD TO TABLE)
NO ______
101. Where does the drinking water used by members of your household mainly come from?
11 IN DWELLING (Skip to 105)
12 IN YARD/PLOT (Skip to 105)
13 AT NEIGHBOR'S (Skip to 105)
14 PUBLIC FAUCET/FIRE HYDRANT (Skip to 103)
21 PUMP WELL/BOREHOLE (Skip to 103)
DUG WELL
31 PROTECTED WELL (Skip to 103)
32 UNPROTECTED WELL (Skip to 103)
SPRING WATER
41 PROTECTED SPRING
42 UNPROTECTED SPRING
51 RAINWATER
61 TANKER TRUCK WATER
71 CART WITH CISTERN/BARREL
81 SURFACE WATER (RIVER/DAM/LAKE/POND/CANAL/IRRIGATION CANAL)
91 BOTTLED WATER/INDUSTRIAL BAG WATER
96 OTHER (SPECIFY) ______ (Skip to 103)
[###translator's note: Skip instructions unclear for 14 - 42]
102. Where does your household's water for other uses such as cooking or handwashing mainly come from?
11 IN DWELLING (Skip to 105)
12 IN YARD/PLOT (Skip to 105)
13 AT NEIGHBOR'S (Skip to 105)
14 PUBLIC FAUCET/FIRE HYDRANT
21 PUMP WELL/BOREHOLE
DUG WELL
31 PROTECTED WELL
32 UNPROTECTED WELL
SPRING WATER
41 PROTECTED SPRING
42 UNPROTECTED SPRING
51 RAINWATER
61 TANKER TRUCK WATER
71 CART WITH CISTERN/BARREL
81 SURFACE WATER (RIVER/DAM/LAKE/POND/CANAL/IRRIGATION CANAL)
96 OTHER (SPECIFY) ______
103. Where is this water source located?
2 IN YOUR YARD/PLOT (Skip to 105)
3 ELSEWHERE
104. How long does it take to go there, fetch water, and come back?
998 DK
105. What kind of toilets do members of your household usually use?
IF UNABLE TO DETERMINE TYPE OF TOILET, ASK TO SEE THE FACILITY.
11 FLUSH CONNECTED TO SEWER
12 FLUSH CONNECTED TO SEPTIC TANK
13 FLUSH CONECTED TO LATRINES
14 FLUSH CONNECTED TO SOMETHING ELSE
15 FLUSH CONNECTED TO UNKNOWN PLACE
PIT LATRINES
21 VENTILATED IMPROVED PIT LATRINES
22 PIT LATRINE WITH SLAB
23 PIT LATRINE WITHOUT SLAB, OPEN PIT
31 COMPOSTING TOILET
41 BUCKETS/PAILS
51 SUSPENDED TOILETS/LATRINES
61 NO TOILET/NATURE (Skip to 109)
96 OTHER (SPECIFY) ______
106. Do you share these toilets with other households?
2 NO (Skip to 108)
107. Including your own household, how many households use these toilets?
95 10 OR MORE HOUSEHOLDS
98 DK
108. Where are these toilets located?
2 IN YOUR YARD/PLOT
3 ELSEWHERE
109. In this household, what kind of stove is usually used for cooking?
02 SOLAR OVEN (Skip to 111)
03 LIQUID PROPANE GAS ("GPL") STOVE (Skip to 111)
04 STOVE CONNECTED TO NATURAL GAS (Skip to 111)
05 BIOGAS STOVE (Skip to 111)
06 LIQUID FUEL STOVE
07 MANUFACTURED SOLID FUEL STOVE
08 TRADITIONAL SOLID FUEL STOVE
09 THREE STONE FIREPLACE/OPEN HEARTH
95 NO KITCHEN IN HOUSEHOLD (Skip to 111)
96 OTHER (SPECIFY) ______
110. What kind of fuel or energy does this stove use?
02 GAS/DIESEL
03 PARAFFIN/OIL
04 CHARCOAL
05 FIREWOOD
06 STRAW/BRANCHES/GRASSES
07 AGRICULTURAL PRODUCTS
08 ANIMAL DUNG/WASTE
09 PROCESSED BIOMASS FUELS (PELLETS)
10 WOOD PELLETS
11 TRASH/PLASTIC
12 SAWDUST
96 OTHER (SPECIFY) ______
111. How many rooms are used for sleeping in this household?
112. Does your household own any livestock, herds, other farm animals, or poultry?
2 NO (Skip to 114)
113. How many of the following animals does your household own?
IF NONE, MARK '00'.
IF 95 OR MORE, MARK '95'.
IF DON'T KNOW, MARK '98'.
a) Milk cows or bulls?
b) Camels?
c) Horses, donkeys, or mules?
d) Goats?
e) Sheep?
f) Pigs?
g) Chickens or other poultry?
h) Rabbits or other leporids?
i) Other farm animals?
b) CAMELS ______
c) HORSES, DONKEYS, OR MULES ______
d) GOATS ______
e) SHEEP ______
f) PIGS ______
g) CHICKENS/OTHER POULTRY ______
h) RABBITS OR OTHER LEPORIDS ______
i) OTHER FARM ANIMALS ______
114. Does any member of your household own any agricultural land?
2 NO (Skip to 116)
115. How many hectares of agricultural land is owned by household members?
IF 95 OR MORE, CIRCLE '950'.
950 95 HECTARES OR MORE
998 DK
116. In this household, do you have:
a) Electricity?
b) A radio set?
c) A television?
d) An MMDS/TV5 antenna?
e) CANAL+ subscription?
f) A landline phone?
g) A washing machine?
h) A refrigerator?
i) A gas or electric hotplate/stove?
j) An improved stove?
k) A VCR/CD/DVD player?
l) An air-conditioner?
m) A computer?
n) Internet access at home?
[###translator's note: CANAL+ and TV5 are both French television channels]
1 YES
2 NO
b) RADIO SET
1 YES
2 NO
c) TELEVISION
1 YES
2 NO
d) TV5 ANTENNA
1 YES
2 NO
e) CANAL+
1 YES
2 NO
f) TELEPHONE
1 YES
2 NO
g) WASHING MACHINE
1 YES
2 NO
h) REFRIGERATOR
1 YES
2 NO
i) HOT PLATE/STOVE
1 YES
2 NO
j) IMPROVED STOVE
1 YES
2 NO
k) CD/DVD/VCR
1 YES
2 NO
l) AIR CONDITIONER
1 YES
2 NO
m) COMPUTER
1 YES
2 NO
n) INTERNET
1 YES
2 NO
117. Does any member of your household own:
a) A watch?
b) A cell phone?
c) A bicycle?
d) A motorcycle/scooter/moped?
e) An animal-drawn cart?
f) A business car or small truck?
g) A motorboat?
h) A personal car?
i) A plow?
j) A dugout canoe/fishing net?
1 YES
2 NO
b) CELL PHONE
1 YES
2 NO
c) BICYCLE
1 YES
2 NO
d) MOTORCYCLE/SCOOTER/MOPED
1 YES
2 NO
e) ANIMAL-DRAWN CART
1 YES
2 NO
f) BUSINESS CAR OR SMALL TRUCK
1 YES
2 NO
g) MOTOR BOAT
1 YES
2 NO
h) PERSONAL CAR
1 YES
2 NO
i) PLOW
1 YES
2 NO
j) DUGOUT CANOE/FISHING NET
1 YES
2 NO
118. Does any member of the household have an account in a bank or in another financial institution?
2 NO
119. Does any member of this household use a cell phone to carry out financial transactions such as sending or receiving money, paying bills, buying goods or services, or receiving a salary?
2 NO
119A. At any time in the last 12 months has anyone come to your home to spray the interior walls for mosquitos?
2 NO (Skip to 119C)
8 DK (Skip to 119C)
119B. Who sprayed the walls of the dwelling?
B PRIVATE COMPANY
C NON-GOVERNMENTAL ORGANIZATION (NGO)
X OTHER (SPECIFY) ______
Z DK
119C. Do the windows of the rooms for residential use have screens to prevent mosquitos from entering?
2 NO
8 DK
119D. Do the doors of the rooms for residential use have screens or curtains to prevent mosquitos from entering?
2 NO
8 DK
120. Does your household have mosquito nets?
2 NO (Skip to 132)
121. How many mosquito nets does your household have?
IF SEVEN OR MORE MOSQUITO NETS, RECORD '7'.
ASK RESPONDENT TO SHOW YOU ALL THE MOSQUITO NETS IN THE HOUSEHOLD. OBSERVE AND ASK QUESTIONS ABOUT EACH MOSQUITO NET, ONE BY ONE.
122. ASSIGN EACH MOSQUITO NET A SEQUENTIAL NUMBER AND RECORD THE NUMBER HERE.
MOSQUITO NET NUMBER ______
123. WAS THIS MOSQUITO NET OBSERVED?
2 NOT OBSERVED
124. How many months has your household had the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'.
95 MORE THAN 36 MONTHS
98 UNSURE
125. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET. IF BRAND IS NOT KNOWN AND YOU CANNOT SEE THE MOSQUITO NET, SHOW RESPONDENT PHOTOS OF COMMON BRANDS AND TYPES OF MOSQUITO NETS.
[###translator's note: Unclear skip instructions for 11 - 16]
11 PERMANET
12 OLYSET-NET
13 DAWA PLUS
14 ICONLIFE
15 INTERCEPTOR
16 OTHER (SPECIFY) ______
17 DON'T KNOW BRAND (LLIN)
OTHER TREATED MOSQUITO NET (NOT LLIN)
(21 - 26 skip to 125 B)
21 K-ONET
22 NETTO
23 SENTINELLE
26 OTHER (SPECIFY) ______
30 MADE BY A TAILOR
31 OTHER
98 DK TYPE/UNSURE
125A. When you got this mosquito net, had it already been treated by the manufacturer with an insecticide that kills or repels mosquitos?
2 NO
8 UNSURE/DK
125B. Since you have had the mosquito net, has it been soaked or dipped in a liquid to kill or repel mosquitos?
2 NO (Skip to 126)
8 UNSURE (Skip to 126)
125C. How many months ago was the mosquito net soaked or dipped for the last time?
IF LESS THAN ONE MONTH, RECORD '00'.
95 MORE THAN 24 MONTHS
98 UNSURE
126. Did you get this mosquito net during a mass distribution campaign, an antenatal visit, a visit to a health facility, or through a community based organization?
2 YES, ANTENATAL VISIT
3 YES, VISIT TO HEALTH FACILITY (Skip to 128)
4 THROUGH COMMUNITY BASED ORGANIZATION (Skip to 128)
5 NO (Skip to 128)
127. Where did you get the mosquito net?
02 PRIVATE HEALTH FACILITY
03 PHARMACY
04 SHOP/MARKET
05 COMMUNITY HEALTH AGENT
06 RELIGIOUS INSTITUTION
07 SCHOOL
08 DISTRIBUTION CAMPAIGN POINT
09 RELATIVE/NEIGHBOR/FRIEND
96 OTHER
98 DK
128. Last night, did anyone sleep under this mosquito net?
2 NO (Skip to 130)
8 UNSURE (Skip to 131)
129. Who slept under this mosquito net last night?
RECORD PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.
NAME ______
LINE NUMBER ______
(Skip to 131)
130. What is the main reason that this mosquito net was not used last night?
02 DON'T LIKE SHAPE/COLOR/SIZE OF MOSQUITO NET
03 DON'T LIKE SMELL
04 TORN
05 UNABLE TO HANG IT
06 SLEPT OUTSIDE
07 NO LONGER EFFECTIVE
08 USUAL PERSON TO USE IT DID NOT SLEEP HERE LAST NIGHT
09 NO MOSQUITOS
10 EXTRA MOSQUITO NET/KEPT FOR LATER
96 OTHER (SPECIFY) ______
131. RETURN TO 122 FOR NEXT MOSQUITO NET; IF NO MORE MOSQUITO NETS, CONTINUE TO 132.
OTHER CHARACTERISTICS OF DWELLING
132. OBSERVE MAIN MATERIAL OF FLOOR OF DWELLING.
RECORD OBSERVATION.
11 EARTH/SAND
12 DUNG
RUDIMENTARY MATERIAL
21 WOOD PLANKS
22 PALMS/BAMBOU
FINISHED MATERIAL
31 PARQUET OR POLISHED WOOD
32 VINYL OR ASPHALT STRIPS
33 TILES
34 CEMENT
35 CARPET
96 OTHER (SPECIFY) ______
133. OBSERVE MAIN MATERIAL OF DWELLING'S ROOF.
RECORD OBSERVATION.
11 NO ROOF
12 THATCH/PALM LEAVES/LEAVES
13 CLUMPS OF EARTH
RUDIMENTARY MATERIAL
21 MATS
22 PALMS/BAMBOU
23 WOOD PLANKS
24 CARDBOARD
FINISHED MATERIAL
31 METAL
32 WOOD
33 ZINC/CEMENT FIBER
34 TILES
35 CEMENT
36 SHINGLES
96 OTHER (SPECIFY) ______
134. OBSERVE MAIN MATERIAL OF DWELLING'S EXTERIOR WALLS.
RECORD OBSERVATION.
11 NO WALLS
12 BAMBOU/CANE/PALMS/TRUNKS
13 EARTH
RUDIMENTARY MATERIAL
21 BAMBOU WITH MUD
22 STONES WITH MUD
23 UNFINISHED ADOBE
24 PLYWOOD
25 CARDBOARD
26 SALVAGED WOOD
FINISHED MATERIAL
31 CEMENT
32 STONES WITH LIME/CEMENT
33 BRICKS
34 CEMENT BLOCKS
35 FINISHED ADOBE
36 WOODEN PLANKS/SHINGLES
96 OTHER (SPECIFY) ______
MINUTES ______
TO BE FILLED OUT ONCE THE INTERVIEW IS COMPLETED
COMMENTS ABOUT THE INTERVIEW:
______
COMMENTS ABOUT PARTICULAR QUESTIONS:
______
OTHER COMMENTS:
______
OBSERVATIONS OF TEAM LEADER
______
(1) This section must be adapted according to the country's specific survey plan.
(2) Omit the section to register the name and ID number of CAPI controller if there is not a team leader who specifically takes care of CAPI in the survey.
(3) Increase the time length of interview that is stated to respondents if modules are added to the questionnaire.
(4) The countries that use bagged water (little plastic bags filled with water) as a source of drinking water must add the separate category BAG WATER after BOTTLED WATER and follow the same skip instruction as for households that use BOTTLED WATER (ask Q. 102, source of water for other uses). Also, countries that have water kiosks must add a separate category WATER KIOSK and follow the same skip instruction as for households that use BOTTLED WATER.
(5) Codes must be developed locally; however, the broad categories should be maintained.
(6) Add any other animal specific to the country such as zebus, water buffalo, camels, llamas, alpacas, pigs, ducks, geese, or elephants.
(7) Each country must add at least 5 types of furniture to the list (like a table, chair, sofa, bed, armoire or closet). In addition, each country must add at least 4 electric appliances so that the list includes at least 3 appliances that even a poor household might own, 3 appliances that a middle income household might own and at least 3 appliances that a wealthier household might own. For example, the following appliances could be added: an alarm clock/clock, water pump, grain mill, fan, mixer, water heater, generator, washing machine, microwave oven, DVD player, cassette or CD player, a movie camera, air conditioning or an air
conditioner, or a sewing machine.
(8) The question must be adapted locally by using the name of the mass distribution campaign.
(9) Adapt the list of response codes to the context of the country when necessary.