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)
PLACE NAME ______
NAME OF THE LOCALITY ____
NAME OF HOUSEHOLD HEAD ____________
CLUSTER NUMBER _____
HOUSEHOLD NUMBER ____
WOMAN'S NAME AND LINE NUMBER _____
VISITS 1, 2, 3
DATE ____________
INTERVIEWER'S NAME ____________
RESULT ____*
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
FINAL VISIT
MONTH ______
YEAR 2017
INTERVIEWER NUMBER _________
RESULT ____*
*RESULT CODES
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
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: ____
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
TRANSLATOR USED?
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 DOES NOT AGREE TO BE INTERVIEWED 2 (END INTERVIEW)
SECTION 1. SOCIODEMOGRAPHIC CHARACTERISTICS OF RESPONDENT
101. RECORD THE TIME.
MINUTES ____________
102. In what month and year were you born?
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.
104. Have you ever attended school?
NO 2 (GO TO 108)
105. What is the highest level of school you attended: primary, middle, secondary, or higher?
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'.
ONE YEAR 1
TWO YEARS 2
THREE YEARS 3
FOUR YEARS 4
FIVE YEARS 5
SIX YEARS 6
6TH 1
7TH 2
8TH 3
9TH 4
10TH 1
11TH 2
12TH 3
ONE YEAR 1
TWO YEARS 2
THREE YEARS 3
FOUR YEARS OR MORE 4
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?
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
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
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
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) X
112. What do you think is the main symptom of malaria?
LACK OF APPETITE/VOMITING 02
HIGH TEMPERATURE WITH CONVULSIONS 03
HIGH TEMPERATURE WITH FAINTING 04
PERSISTENT HIGH TEMPERATURE 05
CONVULSIONS 06
JAUNDICE 07
DON'T KNOW 98
113. What are effective ways of preventing malaria?
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) X
114. In the last six months, have you heard or seen messages about malaria?
NO 2 (GO TO 201)
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
116. What message did you hear or see about malaria in the last six months?
PROBE: Any other message?
RECORD ALL MENTIONED
INTRA-HOUSEHOLD SPRAY CAMPAIGN (CAID) B
INTERMITTENT PREVENTATIVE TREATMENT FOR PREGNANT WOMEN (TPI) C
USE OF RAPID DIAGNOSTIC TEST (RDT) F
TREATMENT WITH ACT G
201. Now I would like to ask you about all the births you have had during your life. Have you ever given birth?
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?
NO 2 (GO TO 204)
203. How many sons live with you? And how many daughters live with you?
IF NONE, RECORD '00'.
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?
NO 2 (GO TO 206)
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'.
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?
NO 2 (GO TO 208)
207. How many boys have died? And how many girls have died?
IF NONE, RECORD '00'.
GIRLS DEAD______
208. SUM ANSWERS TO 203, 205, AND 207 AND ENTER TOTAL.
IF NONE, RECORD '00'.
209. CHECK 208: Just to makes sure that I have this right: you have had in TOTAL ____births during your life. Is that correct?
NO (PROBE AND CORRECT 201-208 AS NECESSARY)
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.
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 BIRTH HISTORY NUMBER ____
214. Is (NAME) a boy or a girl?
GIRL 2
215. Is (NAME) a single or multiple birth?
MULT 2
216. In what day, month, and year was (NAME) born?
MONTH _____________
YEAR _____________
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.
219. IF ALIVE: Is (NAME) living with you?
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
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]
NO 2 (GO TO NEXT BIRTH)
222. Did you have any other live births between (NAME OF PREVIOUS BIRTH)?
NO 2
223. COMPARE 211 WITH THE NUMBER OF BIRTHS IN THE BIRTH TABLE.
NUMBERS ARE DIFFERENT (PROBE AND CORRECT)
224. CHECK 216: ENTER THE NUMBER OF BIRTHS IN 2012-2017.
NONE 0
NO 2 (GO TO 227)
NOT SURE 8 (GO TO 227)
226. How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.
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:
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?
NO 2 (GO TO 304)
303. Whom did you see? Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
MEDICAL ASSISTANT B
NURSE/MIDWIFE C
DELIVERY NURSE D
TRAINED TRADITIONAL BIRTH ATTENDANT F
VILLAGE COMMUNITY HEALTH WORKER G
304. During this pregnancy, did you take SP/Fansidar to keep you from getting malaria?
NO 2 (GO TO 307)
DON'T NOW 8 (GO TO 307)
305. How many times did you take SP/Fansidar during this pregnancy?
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.
ANOTHER FACILITY VISIT 2
COMMUNITY HEALTH WORKER 3
OTHER SOURCE ____ (SPECIFY) 6
NO LIVING CHILD BORN IN 2012-2017 (GO TO 435)
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.
DEAD (GO TO 434)
403A. CHECK THE REGION ON FRONT PAGE OF SURVEY.
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?
NO 2 (GO TO 403E)
DON'T KNOW 8 (GO TO 403E)
403C. What medication did (NAME) take?
OTHER ____ (SPECIFY) 6
403D. How many times did (NAME) take this medication?
403E. What is the main reason that (NAME) did not take the medication to prevent malaria?
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?
NO 2 (GO TO 404)
DON'T KNOW 8 (GO TO 404)
403G. What medication did (NAME) take?
OTHER ____ (SPECIFY) 6
404. Has (NAME) been ill with a fever at any time in the last two weeks?
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?
NO 2
DON'T KNOW 8
406. Did you seek advice or treatment for the fever from any source?
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 _____
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
PHARMACY J
PRIVATE DOCTOR'S OFFICE K
OTHER PRIVATE MEDICAL SECTOR ____ (SPECIFY) L
TRADITIONAL HEALER N
MARKET O
TRAVELING DRUG SELLER P
ONLY ONE CODE CIRCLED (GO TO 410)
409. Where did you first go for advice or treatment?
USE LETTER CODES FROM 407.
410. How many days after the illness began did you first seek advice or treatment for (NAME)?
IF SAME DAY, RECORD '00'.
411. At any time during the illness, did (NAME) take any drugs for the fever?
NO 2 (GO TO 434)
DON'T KNOW (GO TO 434)
412. What drugs did (NAME) take?
Any other drugs?
RECORD ALL MENTIONED.
ARTESUNATE-AMODIAQUINE (ASAQ) B
DIHYDROARTEMISININE-PIPERAQUINE (DHAPQ) C
ARTESUNATE MEFLOQUINE D
SP/FANSIDAR E
CHLOROQUINE F
AMODIAQUINE G
INJECTION/IV I
INJECTION/IV K
OTHER ANTIMALARIAL ____ (SPECIFY) L
INJECTION/IV N
ACETAMINOPHEN P
IBUPROFEN Q
DON'T KNOW Z
413. CHECK 412: CODE A-L CIRCLED?
NO 2 (GO TO 434)
414. CHECK 412: ARTEMETHER-LUMEFANTRINE ('A') GIVEN
CODE 'A' NOT CIRCLED (GO TO 416)
415. How long after the fever started did (NAME) first take the combination Artemether-Lumefantrine (AL)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
416. CHECK 412: ARTESUNATE-AMODIAQUINE ('B') GIVEN
CODE 'B' NOT CIRCLED (GO TO 418)
417. How long after the fever started did (NAME) first take the combination Artesunate-Amodiaquine (ASAQ)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
418. CHECK 412: DIHYDROARTEMISININE-PIPERAQUINE ('C') GIVEN
CODE 'C' NOT CIRCLED (GO TO 420)
419. How long after the fever started did (NAME) first take the combination Dihydroartemisinine-Piperaquine (DHAPQ)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
420. CHECK 412: ARTESUNATE MEFLOQUINE ('D') GIVEN
CODE 'D' NOT CIRCLED (GO TO 422)
421. How long after the fever started did (NAME) first take the combination Artesunate-Mefloquine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
422. CHECK 412: SP/FANSIDAR ('E') GIVEN
CODE 'E' NOT CIRCLED (GO TO 424)
423. How long after the fever started did (NAME) first take SP/Fansidar?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
424. CHECK 412: CHLOROQUINE ('F') GIVEN
CODE 'F' NOT CIRCLED (GO TO 426)
425. How long after the fever started did (NAME) first take Chloroquine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
426. CHECK 412: AMODIAQUINE ('G') GIVEN
CODE 'G' NOT CIRCLED (GO TO 428)
427. How long after the fever started did (NAME) first take amodiaquine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
428. CHECK 412: QUININE ('H-I') GIVEN
CODE 'H-I' NOT CIRCLED (GO TO 430)
429. How long after the fever started did (NAME) first take quinine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
430. CHECK 412: ARTESUNATE ('J-K') GIVEN
CODE 'J-K' NOT CIRCLED (GO TO 432)
431. How long after the fever started did (NAME) first take artesunate?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
432. CHECK 412: OTHER ANTIMALARIAL ('L') GIVEN
CODE 'L' NOT CIRCLED (GO TO 434)
433.How long after the fever started did (NAME) first take (OTHER ANTIMALARIAL)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
434. GO BACK TO THE NEXT COLUMN OF 403; OR, IF THERE ARE NO MORE BIRTHS, GO TO 435.
MINUTES ____
INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW.
INTERVIEW COMMENTS:
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COMMENTS ON SPECIFIC ISSUES:
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OTHER COMMENTS:
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FIELD SUPERVISOR'S OBSERVATIONS:
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