TANZANIA MALARIA INDICATOR SURVEY
MODEL WOMEN'S QUESTIONNAIRE
UNITED REPUBLIC OF TANZANIA
NATIONAL BUREAU OF STATISTICS
DISTRICT_
WARD_
NAME OF HOUSEHOLD HEAD_
CLUSTER NUMBER_
HOUSEHOLD NUMBER_
NAME AND LINE NUMBER OF WOMAN_
FIRST VISIT
INTERVIEWER'S NAME_
RESULT*_
NEXT VISIT
TIME_
INTERVIEWER'S NAME_
RESULT*_
NEXT VISIT
TIME_
INTERVIEWER'S NAME_
RESULT*_
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
NUMBER_
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
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 (SKIP TO 108)
105. What is the highest level of school you attended: primary, secondary, or higher?
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'.
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?
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?
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?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
201. Now I would like to ask about all the births you have had during your life. Have you ever given birth?
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?
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'
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?
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'
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?
NO 2 (SKIP TO 208)
207.
a) How many boys have died?
b) And how many girls have died?
IF NONE, RECORD '00'.
b) GIRLS DEAD_
208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'.
209. CHECK 208: Just to make sure that I have this right: you have had in TOTAL births during your life. Is that correct?
NO (PROBE AND CORRECTLY ANSWER 201-208 AS NECESSARY)
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.
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?
GIRL 2
215. Were any of these births twins?
MULT 2
216. On what day, month, and year was (NAME) born?
MONTH_
YEAR_
NO 2 (SKIP TO NEXT BIRTH)
218. IF ALIVE: How old was (NAME) at (NAME)'s 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.
221. Were there any other live births between (NAME) and (NAME OF PREVIOUS BIRTH), including any children who died after birth?
NO 2 (NEXT BIRTH)
222. Have you had any live births since the birth of (NAME OF MOST RECENT BIRTH)?
NO 2
223. COMPARE 211 WITH NUMBER OF BIRTHS IN BIRTH HISTORY.
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)
224. CHECK 216: ENTER THE NUMBER OF BIRTHS IN 2012-2017.
NONE 0
NO 2 (SKIP TO 227)
UNSURE (SKIP TO 227)
226. How many months pregnant are you? RECORD NUMBER OF COMPLETED MONTHS.
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.
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?
NO 2 (SKIP TO 304)
303. Whom did you see? Anyone else? PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
COMMUNITY/VILLAGE HEALTH WORKER E
303A. How many times did you receive antenatal care during this?
DON'T KNOW 8
303B. Did you receive a bed net at an antenatal care visit for this pregnancy?
NO 2
DON'T KNOW 8
304. During this pregnancy, did you take SP/Fansidar to keep you from getting malaria?
NO 2 (SKIP TO 306D)
DON'T KNOW 8 (SKIP TO 306D)
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, RECORD THE HIGHEST SOURCE ON THE LIST.
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6
306a. Did you buy SP/Fansidar or was it given to you free?
FREE (SKIP TO 307)
DON'T KNOW (SKIP TO 307)
306b. How much did you pay for SP/Fansidar? IF DK, WRITE '99998'.
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.
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
NO LIVING CHILDREN BORN IN 2012-2017 (SKIP TO 501)
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.
BIRTH HISTORY NUMBER_
LIVING (CONTINUE)
DEAD (SKIP TO 428)
404. Has (NAME) been ill with a fever at any time in the last 2 weeks?
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?
NO 2
DON'T KNOW 8
406. Did you seek advice or treatment for the illness from any source?
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_
REFERRAL REGIONAL HOSP. B
REGIONAL HOSPITAL C
DISTRICT HOSPITAL D
HEALTH CENTRE E
DISPENSARY F
CLINIC G
CHW H
DISTRICT HOSPITAL J
HOSPITAL K
HEALTH CENTRE L
DISPENSARY M
CLINIC N
HOSPITAL P
HEALTH CENTRE Q
DISPENSARY R
CLINIC S
PHARMACY T
ADDO U
NGO V
OTHER (SPECIFY_) X
407a. Did you pay for the advice or treatment for this illness?
NO 2 (SKIP TO 408)
DON'T KNOW 999998
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
ONLY ONE CODE CIRCLED (SKIP TO 410)
409. Where did you first seek advice or treatment? USE LETTER CODE FROM 407.
410. How many days after the illness began did you first seek advice or treatment for (NAME)? IF THE SAME DAY RECORD '00'.
411. At any time during the illness, did (NAME) take any drugs for the illness?
NO 2 (SKIP TO 428)
DON'T KNOW 8
412. What drugs did (NAME) take? Any other drugs? RECORD ALL MENTIONED
SP/FANSIDAR B
CHLOROQUINE C
AMODIAQUINE D
INJECTION/IV F
INJECTION/IV H
INJECTION/IV K
ACETAMINOPHEN M
IBUPROFEN N
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)_
REFERRAL REGIONAL HOSP B
REGIONAL HOSPITAL C
DISTRICT HOSPITAL D
HEALTH CENTRE E
DISPENSARY F
CLINIC G
CHW H
DISTRICT HOSPITAL J
HOSPITAL K
HEALTH CENTRE L
DISPENSARY M
CLINIC N
HOSPITAL P
HEALTH CENTRE Q
DISPENSARY R
CLINIC S
ADDO U
NGO V
OTHER (SPECIFY_) X
413. CHECK 412: ANY CODE A-I CIRCLED?
NO (SKIP TO 428)
414. CHECK 412: ARTEMISININ COMBINATION THERAPY ('A') GIVEN.
CODE 'A' NOT CIRCLED (SKIP TO 416)
415. How long after the fever started did (NAME) first take an artemisinin combination therapy?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
416. CHECK 412: SP/FANSIDAR ('B') GIVEN.
CODE 'B' NOT CIRCLED (SKIP TO 418)
417. How long after the fever started did (NAME) first take SP/Fansidar?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
418. CHECK 412: CHLOROQUINE ('C') GIVEN.
CODE 'C' NOT CIRCLED (SKIP TO 420)
419. How long after the fever started did (NAME) first take chloroquine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
420. CHECK 412: AMODIAQUINE ('D') GIVEN.
CODE 'D' NOT CIRCLED (SKIP TO 422)
421. How long after the fever started did (NAME) first take amodiaquine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
422. CHECK 412: QUININE ('E' OR 'F') GIVEN.
CODE 'E' OR 'F' NOT CIRCLED (SKIP TO 424)
423. How long after the fever started did (NAME) first take quinine?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
424. CHECK 412: ARTESUNATE ('G' OR 'H') GIVEN.
CODE 'G' OR 'H' NOT CIRCLED (SKIP TO 426)
425. How long after the fever started did (NAME) first take artesunate?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
426. CHECK 412: OTHER ANTIMALARIAL ('I') GIVEN.
CODE 'I' NOT CIRCLED (SKIP TO 428)
427. How long after the fever started did (NAME) first take (OTHER ANTIMALARIAL)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8
428. GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE.
501. In your opinion, what is the most serious health problem in your country?
TUBERCULOSIS 02
MALARIA 03
MALNUTRITION 04
DIABETES 05
CANCER 06
FLU 07
ROAD TRAFFIC ACCIDENTS 08
DIARRHEA 09
HEART DISEASE 10
OTHER (SPECIFY_) 96
DON'T KNOW 98
502. Can you tell me the signs or symptoms of malaria in a young child? RECORD ALL MENTIONED.
FEELING COLD B
CHILLS C
PERSPIRATION/SWEATIN D
HEADACHE E
BODY ACHES F
POOR APPETITE G
VOMITING H
DIARRHEA I
WEAKNESS J
COUGHING K
OTHER (SPECIFY_) X
DOES NOT KNOW ANY Z
503. Are there ways to avoid getting malaria?
NO 2 (SKIP TO 505)
504. What are the ways to avoid getting malaria? RECORD ALL MENTIONED.
USE MOSQUITO COILS B
USE INSECTICIDE SPRAY C
INDOOR RESIDUAL SPRAYING (IRS D
KEEP DOORS/WINDOWS CLOSE E
USE INSECT REPELLANT F
KEEP SURROUNDINGS CLEA G
CUT THE GRASS H
REMOVE STANDING WATER I
INTERMITTENT PREVENTATIVE TREATMENT (IPTP) J
HOUSE SCREENING K
OTHER (SPECIFY_) X
505. Can ACTs such as Alu/Coartem/Artesunate-Amodiaquine or other be obtained at your nearest health facility or pharmacy (duka la dawa muhimu)?
NO 2
DON'T KNOW 8
506A. In the past year, have you seen or heard any messages about malaria prevention?
NO 2
506B. In the past year, have you seen or heard any messages about malaria treatment?
NO 2
ZANZIBAR (SKIP TO 508B)
508A. Have you ever heard or seen the phrase "Malaria Haikubaliki"?
NO 2 (SKIP TO 508C)
508B. In the past year, have you ever heard or seen the phrase "Maliza Malaria"?
NO 2
508C. Have you ever heard or seen the phrase "Sio kila homa ni malaria"?
NO 2 (SKIP TO 510)
509. Where did you hear or see this phrase? RECORD ALL MENTIONED.
BILLBOARD B
POSTER C
T-SHIRT D
LEAFLET/FACT SHEET/ BROCHURE E
TELEVISION F
MOBILE VIDEO UNI G
SCHOOL H
HEALTH CARE WORKER I
COMMUNITY EVENT/PRESENTATIO J
FRIEND/NEIGHBOR/FAMILY MEMBE K
OTHER (SPECIFY_) X
DON'T KNOW Z
510. In the past six months, were you visited by a health worker or volunteer who talked to you about malaria?
NO 2
511. Now I am going to read some statements and I would like you to tell me how much you agree or disagree with them. After I read each statement, please tell me whether you strongly agree with it, somewhat agree with it, somewhat disagree with it or strongly disagree with it. If you don't know, say, Don't know.
512. I can easily get treatment if my child gets malaria. Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree?
SOMEWHAT AGREE 2
SOMEWHAT DISAGREE 3
STRONGLY DISAGREE 4
DON"T KNOW/UNCERTAIN 8
513. My family rarely gets malaria. Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree?
SOMEWHAT AGREE 2
SOMEWHAT DISAGREE 3
STRONGLY DISAGREE 4
DON"T KNOW/UNCERTAIN 8
514. It is important to take the entire course of malaria medicine to make sure the disease will be fully cured. Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree?
SOMEWHAT AGREE 2
SOMEWHAT DISAGREE 3
STRONGLY DISAGREE 4
DON"T KNOW/UNCERTAIN 8
515. ACTs can be obtained at nearest health facility or duka la dawa muhimu. Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree?
SOMEWHAT AGREE 2
SOMEWHAT DISAGREE 3
STRONGLY DISAGREE 4
DON"T KNOW/UNCERTAIN 8
516. The only way to be sure someone has malaria is to test their blood. Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree?
SOMEWHAT AGREE 2
SOMEWHAT DISAGREE 3
STRONGLY DISAGREE 4
DON"T KNOW/UNCERTAIN 8
MINUTES_
TO BE FILLED AFTER COMPLETING THE INTERVIEW
COMMENTS ON SPECIFIC QUESTIONS:_
ANY OTHER COMMENTS:_
EDITOR'S OBSERVATIONS_