TANZANIA MALARIA INDICATOR SURVEY
MODEL WOMEN'S QUESTIONNAIRE

UNITED REPUBLIC OF TANZANIA
NATIONAL BUREAU OF STATISTICS

IDENTIFICATION

REGION_
DISTRICT_
WARD_
NAME OF HOUSEHOLD HEAD_
CLUSTER NUMBER_
HOUSEHOLD NUMBER_
NAME AND LINE NUMBER OF WOMAN_

INTERVIEWER VISITS

FIRST VISIT

DATE_
INTERVIEWER'S NAME_
RESULT*_

NEXT VISIT

DATE_
TIME_

SECOND VISIT

DATE_
INTERVIEWER'S NAME_
RESULT*_

NEXT VISIT

DATE_
TIME_

THIRD VISIT

DATE_
INTERVIEWER'S NAME_
RESULT*_

FINAL VISIT

DAY_
MONTH_
YEAR_
INT. NO._
RESULT*_
TOTAL NUMBER OF VISITS_

*RESULT CODES:
1. COMPLETED
2. NOT AT HOME
3. POSTPONED
4. REFUSED
5. PARTLY COMPLETED
6. INCAPACITATED
7. OTHER (SPECIFY)_

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW**_
NATIVE LANGUAGE OF CORRESPONDANT**_
TRANSLATOR USED (YES = 1, NO = 2)_
LANGUAGE OF QUESTIONNAIRE** ENGLISH

** LANGUAGE CODES:
01 ENGLISH
02 KISWAHILI

SUPERVISOR

NAME_
NUMBER_

INTRODUCTION AND CONSENT

Hello. My name is . I am working with the National Bureau of Statistics. We are conducting a survey about malaria all over Tanzania. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 10 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than 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 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 the card that has already been given to your household.

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

SIGNATURE OF INTERVIEWER_
DATE_

RESPONDANT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDANT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

SECTION 1. RESPONDANT'S BACKGROUND

101. RECORD THE TIME

HOURS_
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 COMPLETED IN YEARS_

104. Have you ever attended school?

YES 1
NO 2 (SKIP TO 108)

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

PRE-PRIMARY 0
PRIMARY 1
POST PRIMARY TRAINING 2
SECONDARY 'O' LEVEL 3
POST SECONDARY 'O' LEVEL TRAINING 4
SECONDARY 'A' LEVEL 5
POST SECONDARY 'A' LEVEL TRAINING 6
UNIVERSITY 7
DON'T KNOW 8

106. What is the highest GRADE you completed at that level? IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

[GRADE/FORM/YEAR]_

107. CHECK 105:

PRIMARY OR SECONDARY (CONTINUE)
HIGHER (SKIP TO 111)

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 THE SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPEFICIFY LANGUAGE_) 4
BLIND/VISUALLY IMPAIRED 5

111. In the past six months, have you seen or heard any messages about malaria?

YES 1
NO 2 (SKIP TO 201)

112. Have you seen or heard these messages:

a) On the radio?
b) On the television?
c) On a poster or billboard?
d) From a community health worker?
e) At a community event?
f) Anywhere else?

RADIO

YES 1
NO 2

TELEVISION

YES 1
NO 2

POSTER/BILLBOARD

YES 1
NO 2

COMMUNITY HEALTH WORKER

YES 1
NO 2

COMMUNITY EVENT

YES 1
NO 2

ANYWHERE ELSE

YES 1
NO 2

SECTION 2. REPRODUCTION

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

YES 1
NO 2 (SKIP 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 (SKIP TO 204)

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

a) SONS AT HOME_
b) DAUGHTERS AT HOME_

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

YES 1
NO 2 (SKIP 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'

a) SONS ELSEWHERE_
b) 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 (SKIP TO 208)

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

a) BOYS DEAD_
b) GIRLS DEAD_

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

TOTAL BIRTHS_

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

YES (CONTINUE)
NO (PROBE AND CORRECTLY ANSWER 201-208 AS NECESSARY)

210. CHECK 208:

ONE OR MORE BIRTHS (CONTINUE)
NO BIRTHS (SKIP TO 225)

211. Now I'd like to ask you about your more recent births. How many births have you had in 2012-2017? RECORD NUMBER OF LIVE BIRTHS IN 2012-2017.

TOTAL IN 2012-2017_
NONE 00 (SKIP TO 225)

212. Now I would like to record the names of all your births in 2012-2017, whether still alive or not, starting with the most recent one you had. RECORD IN 213 THE NAMES OF ALL THE BIRTHS BORN IN 2012-2017. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS. IF THERE ARE MORE THAN 5 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE STARTING WITH THE SECOND ROW.

213. What name was given to your (most recent/ previous) baby? RECORD NAME. BIRTH HISTORY NUMER

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

BOY 1
GIRL 2

215. Were any of these births twins?

SING 1
MULT 2

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

DAY_
MONTH_
YEAR_

217. Is (NAME) still alive?

YES 1
NO 2 (SKIP TO NEXT BIRTH)

218. IF ALIVE: How old was (NAME) at (NAME)'s 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.

HOUSEHOLD LINE NUMBER (SKIP TO NEXT BIRTH)_

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

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

222. Have you had any live births since the birth of (NAME OF MOST RECENT BIRTH)?

YES 1 (RECORD BIRTH(S) IN TABLE)
NO 2

223. COMPARE 211 WITH NUMBER OF BIRTHS IN BIRTH HISTORY.

NUMBERS ARE THE SAME (CONTINUE)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

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 (SKIP TO 227)
UNSURE (SKIP TO 227)

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

MONTHS_

227. CHECK 224:

ONE OR MORE BIRTHS IN 2012-2017 (GO TO 301)
NO BIRTHS IN 2012-2017 (SKIP TO 501)
Q. 224 IS BLANK (SKIP TO 501)

SECTION 3. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT

301. RECORD THE NAME AND SURVIVAL STATUS OF THE MOST RECENT BIRTH FROM 213 AND 217.

MOST RECENT BIRTH
NAME_
LIVING (CONTINUE)
DEAD (CONTINUE)

302. Now I would like to ask you some questions about your last pregnancy that resulted in a live birth. When you got pregnant with (NAME), did you see anyone for antenatal care for this pregnancy?

YES 1
NO 2 (SKIP TO 304)

303. Whom did you see? Anyone else? PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PERSONNEL

DOCTOR A
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C

OTHER PERSON

TRADITIONAL BIRTH ATTENDANT D
COMMUNITY/VILLAGE HEALTH WORKER E

OTHER (SPECIFY_) X

303A. How many times did you receive antenatal care during this?

NUMBER OF TIMES_
DON'T KNOW 8

303B. Did you receive a bed net at an antenatal care visit for this pregnancy?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (SKIP TO 306D)
DON'T KNOW 8 (SKIP TO 306D)

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

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, RECORD THE HIGHEST SOURCE ON THE LIST.

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6

306a. Did you buy SP/Fansidar or was it given to you free?

BOUGHT
FREE (SKIP TO 307)
DON'T KNOW (SKIP TO 307)

306b. How much did you pay for SP/Fansidar? IF DK, WRITE '99998'.

COST (TSH)_

306C. How did you pay

CASH (OUT OF POCKET) 1 (SKIP TO 307)
SOCIAL HEALTH INSURANCE SCHEME (eg.NHIF, NSSF, CHF, etc) 2 (SKIP TO 307)
PRIVATE HEALTH INSURANCE SCHEMME (eg.Medex, Jubilee, Metropilan, resolution etc) 3 (SKIP TO 307)
CASH AND HEALTH INSURANCE 4 (SKIP TO 307)

306D. Why did you not take SP/Fansidar to prevent you from getting malaria? PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

NONE AVAILABLE AT FACILITY A
PROVIDER DID NOT OFFER MEDICINE B
PROVIDER REFUSED TO GIVE MEDICINE C
NO WATER AT FACILITY TO TAKE WITH MED D
NO CUP AT FACILITY TO DRINK WATER E
AFRAID OF EFFECTS ON MY HEALTH F
AFRAID OF EFFECTS ON BABY'S HEALTH G
HAD NOT EATEN BEFORE H
AFRAID OF VOMITING I
I DIDN'T HAVE MONEY TO PAY THE SP J
TAKING SEPTRIM K
OTHER (SPECIFY_) X
DON'T KNOW Z

307. CHECK 216 AND 217.

ONE OR MORE LIVING CHILDREN BORN IN 2012-2017 (GO TO 401)
NO LIVING CHILDREN BORN IN 2012-2017 (SKIP TO 501)

SECTION 4. FEVER IN CHILDREN

401. CHECK 213: RECORD THE BIRTH HISTORY NUMBER IN 402 AND THE NAME AND SURVIVAL STATUS IN 403 FOR EACH BIRTH IN 2012-2017. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE MOST RECENT BIRTH. IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNAIRE(S). Now I would like to ask some questions about the health of your children born since January 2012. (We will talk about each separately.)

402. BIRTH HISTORY NUMBER FROM 213 IN BIRTH HISTORY.

MOST RECENT BIRTH
BIRTH HISTORY NUMBER_

403. FROM 213 AND 217:

NAME_
LIVING (CONTINUE)
DEAD (SKIP TO 428)

404. Has (NAME) been ill with a fever at any time in the last 2 weeks?

YES 1
NO 2 (SKIP TO 428)
DON'T KNOW 8 (SKIP TO 428)

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 illness from any source?

YES 1
NO 2 (SKIP TO 411)

407. Where did you seek advice or treatment? Anywhere else? PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE(S). NAME OF PLACE_

GOVERNMENT/PARASTATAL

ZON/REFERRAL/SPEC.HOSPITA A
REFERRAL REGIONAL HOSP. B
REGIONAL HOSPITAL C
DISTRICT HOSPITAL D
HEALTH CENTRE E
DISPENSARY F
CLINIC G
CHW H

RELIGIOUS/VOLUNTARY

REFERAL SPEC.HOSPITA I
DISTRICT HOSPITAL J
HOSPITAL K
HEALTH CENTRE L
DISPENSARY M
CLINIC N

PRIVATE

SPECIALISED HOSPITAL O
HOSPITAL P
HEALTH CENTRE Q
DISPENSARY R
CLINIC S

OTHER
PHARMACY T
ADDO U
NGO V
OTHER (SPECIFY_) X

407a. Did you pay for the advice or treatment for this illness?

YES 1
NO 2 (SKIP TO 408)

407b. How much did you pay?

TSHS_
DON'T KNOW 999998

407C. How did you pay?

CASH (OUT OF POCKET) 1
SOCIAL HEALTH INSURANCE SCHEME (eg.NHIF, NSSF, CHF, etc) 2
PRIVATE HEALTH INSURANCE SCHEMME (eg.Medex, Jubilee, Metropilan, resolution etc) 3
CASH AND HEALTH INSURANCE 4

408. CHECK 407:

TWO OR MORE CODES CIRCLED (CONTINUE)
ONLY ONE CODE CIRCLED (SKIP TO 410)

409. Where did you first seek advice or treatment? USE LETTER CODE FROM 407.

FIRST PLACE_

410. How many days after the illness began did you first seek advice or treatment for (NAME)? IF THE SAME DAY RECORD '00'.

DAYS_

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

YES 1
NO 2 (SKIP TO 428)
DON'T KNOW 8

412. What drugs did (NAME) take? Any other drugs? RECORD ALL MENTIONED

ANTIMALARIAL DRUGS

ARTEMISININ COMBINATION THERAPY (ACT) SUCH AS ALU/COARTEM/ARTESUNATE-AMODIAQUINE OR OTHER A
SP/FANSIDAR B
CHLOROQUINE C
AMODIAQUINE D

QUININE

PILLS E
INJECTION/IV F

ARTESUNATE

RECTAL G
INJECTION/IV H

OTHER ANTIMALARIAL (SPECIFY_) I

ANTIBIOTIC DRUGS

PILL/SYRUP J
INJECTION/IV K

OTHER DRUGS

ASPIRIN L
ACETAMINOPHEN M
IBUPROFEN N

OTHER (SPECIFY_) X
DON'T KNOW Z

412A. Where did you get these drugs from? PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE(S). NAME OF PLACE(S)_

GOVERNMENT/PARASTATAL

ZON/REFERRAL/SPEC.HOSP A
REFERRAL REGIONAL HOSP B
REGIONAL HOSPITAL C
DISTRICT HOSPITAL D
HEALTH CENTRE E
DISPENSARY F
CLINIC G
CHW H

RELIGIOUS/VOLUNTARY

REFERAL SPEC.HOSPITA I
DISTRICT HOSPITAL J
HOSPITAL K
HEALTH CENTRE L
DISPENSARY M
CLINIC N

PRIVATE

SPECIALISED HOSPITAL O
HOSPITAL P
HEALTH CENTRE Q
DISPENSARY R
CLINIC S

OTHER

PHARMACY T
ADDO U
NGO V
OTHER (SPECIFY_) X

413. CHECK 412: ANY CODE A-I CIRCLED?

YES (CONTINUE)
NO (SKIP TO 428)

414. CHECK 412: ARTEMISININ COMBINATION THERAPY ('A') GIVEN.

CODE 'A' CIRCLED (CONTINUE)
CODE 'A' NOT CIRCLED (SKIP TO 416)

415. How long after the fever started did (NAME) first take an artemisinin combination therapy?