MALARIA INDICATORS SURVEY
EIP-TOGO 2017
WOMAN'S SURVEY

MINISTRY OF HEALTH AND SOCIAL WELFARE
NATIONAL INSTITUTE OF STATISTICS AND ECONOMIC AND DEMOGRAPHIC STUDIES (INSEED)

IDENTIFICATION

PLACE NAME ______
NAME OF THE LOCALITY ____
NAME OF HOUSEHOLD HEAD ____________
CLUSTER NUMBER _____
HOUSEHOLD NUMBER ____

WOMAN'S NAME AND LINE NUMBER _____

INTERVIEWER VISITS

VISITS 1, 2, 3
DATE ____________
INTERVIEWER'S NAME ____________
RESULT ____*

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7

FINAL VISIT

DAY ______
MONTH ______
YEAR 2017
INTERVIEWER NUMBER _________
RESULT ____*

*RESULT CODES

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
UNABLE 6
OTHER _____ (SPECIFY) 7

NEXT VISIT:
DATE ___________
HOUR ____________

TOTAL NUMBER OF VISITS _______________

QUESTIONNAIRE LANGUAGE (LANGUAGE CODE) **: ____

QUESTIONNAIRE LANGUAGE (NAME OF LANGUAGE): ____

LANGUAGE OF INTERVIEW: ____

**LANGUAGE CODES

FRENCH 01
EWE/MINA 02
KABYE 03
KOTOKOLI/TEM 04
AKPOSSO/AKEBOU 05
IFE/ANA 06
MOBA-GOURMA 07
TCHOKOSSI 08
BASSAR/KONKOMBA 09
OTHER NATIONAL LANGUAGE ________________(SPECIFY) 96
OTHER FOREIGN LANGUAGE _______________(SPECIFY) 97

NATIVE LANGUAGE OF RESPONDENT: ____

TRANSLATOR USED?

YES 1
NO 2

FIELD EDITOR

NAME _______________
NUMBER _____________

INTRODUCTION AND CONSENT STATEMENT

Hello. I am working with the National Institute of Statistics. We are conducting a survey about malaria all over Togo. 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 10 or 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than the 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 you decide not to be in the survey, there will be no changes in the services you can access through health programs. 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.

GIVE CARD WITH INFORMATION.

Do you have any questions?
May I begin the interview?

SIGNATURE OF INTERVIEWER_____
DATE_____

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END INTERVIEW)

SECTION 1. SOCIODEMOGRAPHIC CHARACTERISTICS OF RESPONDENT

101. RECORD THE TIME.

HOUR ______________
MINUTES ____________

102. In what month and year were you born?

MONTH _____
DON'T KNOW MONTH 98

YEAR _____
DON'T KNOW YEAR 9998

103. How old were you at your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

AGE IN COMPLETED YEARS_____

104. Have you ever attended school?

YES 1
NO 2 (GO TO 108)

105. What is the highest level of school you attended: primary, middle, secondary, or higher?

PRIMARY 1
MIDDLE 2
SECONDARY 3
HIGHER 4

106. What is the highest (grade/form/year) you completed at this level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '0'.

GRADE/FORM/YEAR _____

PRIMARY 1

LESS THAN ONE YEAR COMPLETED 0

ONE YEAR 1
TWO YEARS 2
THREE YEARS 3
FOUR YEARS 4
FIVE YEARS 5
SIX YEARS 6

MIDDLE 2

LESS THAN ONE YEAR COMPLETED 0

6TH 1
7TH 2
8TH 3
9TH 4

SECONDARY 3

LESS THAN ONE YEAR COMPLETED 0

10TH 1
11TH 2
12TH 3

HIGHER 4

LESS THAN ONE YEAR COMPLETED 0
ONE YEAR 1
TWO YEARS 2
THREE YEARS 3
FOUR YEARS OR MORE 4

107. CHECK 105:

PRIMARY (GO TO 108)
MIDDLE (GO TO 108)
SECONDARY (GO TO 108)
HIGHER (GO TO 109)

108. Now I would like you to read this sentence to me.

SHOW CARD TO RESPONDENT.

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

CANNOT READ AT ALL 1
ABLE TO READ ONLY PART OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) _____ 4
BLIND/VISUALLY IMPAIRED 5

109. What is your religion?

TRADITIONAL/ANIMIST 01
MUSLIM 02
CATHOLIC 03
PRESBYTERIAN EVANGELICAL 04
METHODIST 05
ASSEMBLY OF GOD 06
BAPTIST 07
PENTECOSTAL 08
JEHOVAH'S WITNESS 09
ADVENTIST 10
OTHER CHRISTIAN 11
NO RELIGION 12
OTHER ________________(SPECIFY) 96

110. What is your ethnicity?

ADJA-EWE/MINA 01
KABYE/TEM 02
AKPOSSO/AKEBOU 03
ANA-IFE 04
PARA-GOURMA/AKAN 05
OTHER TOGOLESE _____________(SPECIFY) 95
FOREIGNER ___________(SPECIFY) 96

111. Now I would like to ask you some questions about malaria. How do you think people can get malaria?

RECORD ALL MENTIONED

UNHYGIENIC ENVIRONMENT A
MOSQUITO BITE B
NOT TAKING PRESCRIBED PREVENTATIVE DRUGS C
PHYSICAL EXERTION/FATIGUE D
EXPOSURE TO DIRECT SUNLIGHT DURING WORK E
STAYING IN THE RAIN F
SUDDEN CHANGE OF WEATHER G
MALNUTRITION H
EATING FRUIT I
POOR BODILY HYGIENE J
BY BRUSH K

OTHER ____ (SPECIFY) W
OTHER ____ (SPECIFY) X

DON'T KNOW Z

112. What do you think is the main symptom of malaria?

FEVER 01
LACK OF APPETITE/VOMITING 02
HIGH TEMPERATURE WITH CONVULSIONS 03
HIGH TEMPERATURE WITH FAINTING 04
PERSISTENT HIGH TEMPERATURE 05
CONVULSIONS 06
JAUNDICE 07

OTHER ____ (SPECIFY) 96
DON'T KNOW 98

113. What are effective ways of preventing malaria?

SLEEPING UNDER A MOSQUITO NET A
SLEEPING UNDER AN INSECTICIDAL MOSQUITO NET B
SLEEPING UNDER AN INSECTICIDAL MOSQUITO NET EVERY NIGHT OF THE YEAR C
TAKING PREVENTATIVE DRUGS (TPI) D
TAKING PILLS DURING PREGNANCY E
USING INSECTICIDE/DIFFUSERS/CREAMS/LOTIONS/REPELLANTS F
USING A MOSQUITO COIL G
AVOIDING GETTING A COLD H
AVOIDING EXPOSURE TO DIRECT SUNLIGHT I
KEEPING SURROUNDINGS CLEAN J
INTRA-HOUSEHOLD SPRAYING (CAID) K

OTHER ____ (SPECIFY) W
OTHER ____ (SPECIFY) X

DON'T KNOW Z

114. In the last six months, have you heard or seen messages about malaria?

YES 1
NO 2 (GO TO 201)

115.

a) In the last six months, have you heard messages about malaria from a community health worker?

YES 1
NO 2

b) In the last six months, have you heard messages about malaria on the radio?

YES 1
NO 2

c) In the last six months, have you seen messages about malaria on the television?

YES 1
NO 2

d) In the last six months, have you seen messages about malaria on a poster or in a brochure?

YES 1
NO 2

e) In the last six months, have you seen or heard messages about malaria as part of a large outdoor event?

YES 1
NO 2

f) In the last six months, have you heard messages about malaria from a village/district official?

YES 1
NO 2

g) In the last six months, have you seen messages about malaria while visiting a health facility?

YES 1
NO 2

h) In the last six months, have you seen messages about malaria from another source?

YES 1
NO 2

116. What message did you hear or see about malaria in the last six months?

PROBE: Any other message?

RECORD ALL MENTIONED

MALARIA PREVENTION

LONG-LASTING INSECTICIDE MOSQUITO NET (LLIN) A
INTRA-HOUSEHOLD SPRAY CAMPAIGN (CAID) B
INTERMITTENT PREVENTATIVE TREATMENT FOR PREGNANT WOMEN (TPI) C

OTHER ____ (SPECIFY) D

MALARIA TREATMENT

SEEKING EARLY CARE IN CASE OF FEVER IN CHILDREN YOUNGER THAN 5 YEARS E
USE OF RAPID DIAGNOSTIC TEST (RDT) F
TREATMENT WITH ACT G

OTHER ____ (SPECIFY) X

SECTION 2. REPRODUCTION

201. Now I would like to ask you about all the births you have had during your life. Have you ever given birth?

YES 1
NO 2 (GO TO 206)

202. Do you have any sons or daughters to whom you have given birth who are now living with you?

YES 1
NO 2 (GO TO 204)

203. How many sons live with you? And how many daughters live with you?
IF NONE, RECORD '00'.

SONS AT HOME_____

DAUGHTERS AT HOME_____

204. Do you have any sons or daughters to whom you have given birth and are alive but do not live with you?

YES 1
NO 2 (GO TO 206)

205.

a) How many sons are alive but do not live with you?
b) And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'.

SONS ELSEWHERE_____
DAUGHTERS ELSEWHERE_____

206. Have you ever given birth to a boy or girl who was born alive but later died?

IF NO, PROBE: Any baby who cried, who made any movement, sound, or effort to breathe, or who showed any other signs of life even if for a very short time?

YES 1
NO 2 (GO TO 208)

207. How many boys have died? And how many girls have died?
IF NONE, RECORD '00'.

BOYS DEAD_____
GIRLS DEAD______

208. SUM ANSWERS TO 203, 205, AND 207 AND ENTER TOTAL.
IF NONE, RECORD '00'.

TOTAL NUMBER OF BIRTHS______

209. CHECK 208: Just to makes sure that I have this right: you have had in TOTAL ____births during your life. Is that correct?

YES (GO TO 210)
NO (PROBE AND CORRECT 201-208 AS NECESSARY)

210. CHECK 208:

ONE OR MORE BIRTHS (GO TO 211)
NO BIRTHS (GO TO 225)

211. Now I would like to ask you about your most recent births. How many births have you had in 2012-2017?

ENTER TOTAL NUMBER OF BIRTHS IN 2012-2017.

TOTAL IN 2012-2017 ____
NONE 00 (GO TO 225)

212. Now I would like to record the names of all your births you had in 2012-2017, whether still alive or not, starting with the first one you had.

ENTER NAMES OF ALL THE BIRTHS IN 2012-2017 IN 213. ENTER TWINS AND TRIPLETS ON SEPARATE LINES.

IF THERE ARE MORE THAN 10 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.

213. What name was given to your (first/next) baby?

RECORD NAME ____

RECORD BIRTH HISTORY NUMBER ____

214. Is (NAME) a boy or a girl?

BOY 1
GIRL 2

215. Is (NAME) a single or multiple birth?

SING 1
MULT 2

216. In what day, month, and year was (NAME) born?

DAY ____________
MONTH _____________
YEAR _____________

217. Is (NAME) still alive?

YES 1
NO 2 (IF FIRST BIRTH, GO TO NEXT BIRTH; IF OTHER BIRTH, GO TO 221)

218. IF ALIVE: How old was (NAME) on his/her last birthday?
RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS______

219. IF ALIVE: Is (NAME) living with you?

YES 1
NO 2

220. IF ALIVE: RECORD HOUSEHOLD LINE NUMBER OF CHILD.
RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD.
FIRST BIRTH: GO TO NEXT BIRTH

HOUSEHOLD LINE NUMBER_____ (GO TO 221)

221. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth?

[DO NOT ASK FOR FIRST BIRTH]

YES 1 (ADD BIRTH)
NO 2 (GO TO NEXT BIRTH)

222. Did you have any other live births between (NAME OF PREVIOUS BIRTH)?

YES 1 (ADD BIRTH)
NO 2

223. COMPARE 211 WITH THE NUMBER OF BIRTHS IN THE BIRTH TABLE.

NUMBERS ARE THE SAME (GO TO 224)
NUMBERS ARE DIFFERENT (PROBE AND CORRECT)

224. CHECK 216: ENTER THE NUMBER OF BIRTHS IN 2012-2017.

NUMBER OF BIRTHS_____
NONE 0

225. Are you pregnant now?

YES 1
NO 2 (GO TO 227)
NOT SURE 8 (GO TO 227)

226. How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.

MONTHS ____________________________

227. CHECK 224:

ONE BIRTH OR MORE IN 2012-2017 (GO TO 301)
NO BIRTHS 2012-2017 (GO TO 435)
224 NOT ASKED (GO TO 435)

SECTION 3. PREGNANCY AND INTERMITTENT PREVENTATIVE TREATMENT

301. RECORD THE NAME AND SURVIVAL STATE OF THE LAST BIRTH FROM 213 AND 217.

LAST BIRTH:

NAME ____

LIVING (GO TO 302)
DEAD (GO TO 302)

302. Now I would like to ask you some questions about your last birth.

When you were pregnant with (NAME), Did you see anyone for antenatal care for this pregnancy?

YES 1
NO 2 (GO TO 304)

303. Whom did you see? Anyone else?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PERSONNEL

DOCTOR A
MEDICAL ASSISTANT B
NURSE/MIDWIFE C
DELIVERY NURSE D

OTHER PERSON

TRADITIONAL MIDWIFE E
TRAINED TRADITIONAL BIRTH ATTENDANT F
VILLAGE COMMUNITY HEALTH WORKER G

OTHER ____ (SPECIFY) X

304. During this pregnancy, did you take SP/Fansidar to keep you from getting malaria?

YES 1
NO 2 (GO TO 307)
DON'T NOW 8 (GO TO 307)

305. How many times did you take SP/Fansidar during this pregnancy?

NUMBER OF TIMES ____

306. Did you get the SP/Fansidar during any antenatal care visit, during another visit to a health facility or from another source?

IF MORE THAN ONE SOURCE, ENTER THE HIGHEST SOURCE ON THE LIST.

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
COMMUNITY HEALTH WORKER 3
OTHER SOURCE ____ (SPECIFY) 6

307. CHECK 216 AND 217:

ONE LIVING CHILD OR MORE BORN IN 2012-2017 (GO TO 401)
NO LIVING CHILD BORN IN 2012-2017 (GO TO 435)

SECTION 4. FEVER IN CHILDREN

401. CHECK 213: ENTER THE BIRTH NUMBER IN 402 AND THE NAME AND SURVIVAL STATE IN 403 FOR EACH LIVING CHILD BORN IN 2011 OR LATER. ASK QUESTIONS FOR ALL BIRTHS, STARTING WITH THE LAST BIRTH. IF THERE ARE MORE THAN TWO BIRTHS, USE THE LAST COLUMN OF AN ADDITIONAL QUESTIONNAIRE(S).

Now I would like to ask you some questions about the health of your children since January 2012. (We will talk about each one separately.)

402. LINE NUMBER FROM BIRTH TABLE IN 213 IN BIRTH HISTORY.

LINE NUMBER FROM BIRTH TABLE ____

403. FROM 213 AND 217:

NAME ____

LIVING (GO TO 403A)
DEAD (GO TO 434)

403A. CHECK THE REGION ON FRONT PAGE OF SURVEY.

CENTRAL KARA SAVANA (GO TO 403B)
OTHER (GO TO 404)

403B. Between August and November 2016, did (NAME) take medication each month for three to four consecutive months to prevent malaria?

YES 1
NO 2 (GO TO 403E)
DON'T KNOW 8 (GO TO 403E)

403C. What medication did (NAME) take?

SULFADOXINE-PYRIMETHAMINE AND L'AMODIAQUINE (SP+AQ) 1
OTHER ____ (SPECIFY) 6

403D. How many times did (NAME) take this medication?

NUMBER OF TIMES ____ (GO TO 403F)

403E. What is the main reason that (NAME) did not take the medication to prevent malaria?

WAS SERIOUSLY ILL 01
ALREADY HAD MALARIA 02
ALREADY TAKING AN ANTIMALARIAL 03
WAS NOT AT HOME 05
PARENTS/CHILDREN REFUSED 06
OTHER ____ (SPECIFY) 96
DON'T KNOW 98

403F. From August 2017 to present, did (NAME) take medication each month to prevent malaria?

YES 1
NO 2 (GO TO 404)
DON'T KNOW 8 (GO TO 404)

403G. What medication did (NAME) take?

SULFADOXINE-PYRIMETHAMINE AND AMODIAQUINE (SP+AQ) 1
OTHER ____ (SPECIFY) 6

404. Has (NAME) been ill with a fever at any time in the last two weeks?

YES 1
NO 2 (GO TO 434)
DON'T KNOW 8 (GO TO 434)

405. At any time during the illness, did (NAME) have blood taken from (NAME)'s finger or heel for testing?

YES 1
NO 2
DON'T KNOW 8

406. Did you seek advice or treatment for the fever from any source?

YES 1
NO 2 (GO TO 411)

407. Where did you seek advice or treatment?

Anywhere else?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

NAME OF PLACE _____

PUBLIC SECTOR

GOVERNMENT HOSPITAL A
SOCIAL MEDICAL CENTER B
DISPENSARY C
PRESIDENT'S MALARIA INITIATIVE (PMI) D
GOVERNMENT HEALTH POST E
MOBILE CLINIC F
COMMUNITY HEALTH WORKER (CHW) G
OTHER PUBLIC SECTOR ____ (SPECIFY) H

PRIVATE MEDICAL SECTOR

PRIVATE CLINIC/HOSPITAL I
PHARMACY J
PRIVATE DOCTOR'S OFFICE K
OTHER PRIVATE MEDICAL SECTOR ____ (SPECIFY) L

OTHER SOURCE

SHOP M
TRADITIONAL HEALER N
MARKET O
TRAVELING DRUG SELLER P

OTHER ____ (SPECIFY) X

408. CHECK 407:

TWO OR MORE CODES CIRCLED (GO TO 409)
ONLY ONE CODE CIRCLED (GO TO 410)

409. Where did you first go for advice or treatment?

USE LETTER CODES FROM 407.

FIRST PLACE ____

410. How many days after the illness began did you first seek advice or treatment for (NAME)?

IF SAME DAY, RECORD '00'.

DAYS ____

411. At any time during the illness, did (NAME) take any drugs for the fever?

YES 1
NO 2 (GO TO 434)
DON'T KNOW (GO TO 434)

412. What drugs did (NAME) take?

Any other drugs?

RECORD ALL MENTIONED.

ANTIMALARIAL

ARTEMETHER-LUMEFANTRINE (AL) A
ARTESUNATE-AMODIAQUINE (ASAQ) B
DIHYDROARTEMISININE-PIPERAQUINE (DHAPQ) C
ARTESUNATE MEFLOQUINE D
SP/FANSIDAR E
CHLOROQUINE F
AMODIAQUINE G

QUININE

TABLETS H
INJECTION/IV I

ARTESUNATE

RECTAL INSERTION J
INJECTION/IV K
OTHER ANTIMALARIAL ____ (SPECIFY) L

ANTIBIOTICS

TABLETS/SYRUP M
INJECTION/IV N

OTHER DRUGS

ASPIRIN O
ACETAMINOPHEN P
IBUPROFEN Q

OTHER ____ (SPECIFY) X
DON'T KNOW Z

413. CHECK 412: CODE A-L CIRCLED?

YES 1 (GO TO 414)
NO 2 (GO TO 434)

414. CHECK 412: ARTEMETHER-LUMEFANTRINE ('A') GIVEN

CODE 'A' CIRCLED (GO TO 415)
CODE 'A' NOT CIRCLED (GO TO 416)

415. How long after the fever started did (NAME) first take the combination Artemether-Lumefantrine (AL)?