2014 UGANDA MALARIA INDICATOR SURVEY
HOUSEHOLD QUESTIONNAIRE
UGANDA
IDRC/MOH/UBOS
REGION __
DISTRICT __
COUNTY __
SUBCOUNTY/TOWN __
PARISH/LC2 NAME __
EA NAME __
UMIS NUMBER __
URBAN = 1, PERI URBAN = 2, RURAL = 3 __
NAME OF HEAD OF HOUSEHOLD __
HOUSEHOLD NUMBER __
HOUSEHOLD SAMPLE NUMBER __
FIRST VISIT
INTERVIEWER'S NAME __
RESULT* __
NEXT VISIT:
TIME __
SECOND VISIT
INTERVIEWER'S NAME __
RESULT* __
NEXT VISIT:
TIME __
THIRD VISIT
INTERVIEWER'S NAME __
RESULT* __
FINAL VISIT
MONTH __
YEAR __
INTERVIEWER NUMBER __
RESULT __
TOTAL NUMBER OF VISITS __
*RESULT CODES:
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER 9 (SPECIFY) __
TOTAL ELIGIBLE PERSONS IN HOUSEHOLD __
TOTAL ELIGIBLE WOMEN __
TOTAL ELIGIBLE CHILDREN __
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __
LANGUAGE OF THE QUESTIONNAIRE 7
LANGUAGE USED IN THE INTERVIEW __
NATIVE LANGUAGE OF RESPONDENT __
TRANSLATOR USED (NOT AT ALL = 1; SOMETIMES = 2; ALL THE TIME = 3) __
LANGUAGE OF THE QUESTIONNAIRE ENGLISH
LANGUAGE USED:
LUGANDA 2
LUGBARA 3
LUO 4
RUNYANKORE-RUKIGA 5
RUNYORO-RUTORO 6
ENGLISH 7
OTHER 8 (SPECIFY) __
SUPERVISOR NAME __
OFFICE EDITOR __
KEYED BY __
Hello. My name is _________________________________________. I am working with the Ministry of Health. We are conducting a survey about malaria all over Uganda. 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 15 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 answers, 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 CONTACT INFORMATION
Do you have any questions?
May I begin the interview now?
SIGNATURE OF INTERVIEWER ______________________________ DATE: ____________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
START TIME:
MINUTES __
LINE NO.
USUAL RESIDENTS AND VISITORS
2. 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.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPRORIATE QUESTIONS IN COLUMNS 5-9 FOR EACH PERSON.
2A. Just to make sure that I have a complete listing: are there any other persons such as small children or infants that we have not listed?
NO
2B. Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?
NO
2C. Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
RELATIONSHIP TO HEAD OF HOUSEHOLD
3. What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.
CODES FOR Q.3: RELATIONSHIP TO HEAD OF HOUSEHOLD
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER/STEPCHILD 10
NOT RELATED 11
DON'T KNOW 98
SEX
4. Is (NAME) male or female?
FEMALE 2
RESIDENCE
5. Does (NAME) usually live here?
NO 2
6. Did (NAME) stay here last night?
NO 2
IF 95 OR MORE, RECORD '95'.
WOMEN AGE 15-49
8. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
CHILDREN AGE 0-5
9. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (SKIP TO 104)
PUBLIC TAP/STANDPIPE 13
PUBLIC BOREHOLE 22
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
RAINWATER 51 (SKIP TO 104)
TANKER TRUCK 61
VENDOR 62
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
102. Where is that water located?
IN OWN YARD/PLOT 2 (SKIP TO 104)
ELSEWHERE 3
103. How long does it take to go there, get water, and come back?
DON'T KNOW 998
104. What kind of toilet facility do members of your household usually use?
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
COVERED PIT LATRINE WITH SLAB 22
COVERED PIT LATRINE WITHOUT SLAB/OPEN PIT 23
UNCOVERED PIT LATRINE WITH SLAB 24
UNCOVERED PIT LATRINE WITHOUT SLAB 25
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD/BAGS/BUCKET 61 (SKIP T 107)
OTHER 96 (SPECIFY) __
105. Do you share this toilet facility with other households?
NO 2 (SKIP TO 107)
106. How many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
107. Does your household have:
b. A radio?
c. A cassette player?
d. A television?
e. A mobile telephone?
f. A non-mobile telephone?
g. A refrigerator?
h. A table?
i. A chair?
j. A sofa set?
k. A bed?
l. A cupboard?
m. A clock?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
108. What type of fuel does your household mainly use for cooking?
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE/PARAFFIN 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95
OTHER 96 (SPECIFY) __
109. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
SAND AND DUNG 12
PALM 22
MOSAIC OR TILE 33
CEMENT 34
STONES 36
BRICKS 37
110. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.
THATCHED 12
MUD 13
PALM 22
WOOD PLANKS 23
WOOD 32
CEMENT FIBER 33
TILES 34
CEMENT 35
ROOFING SHINGLES 36
ASBESTOS 37
111. MAIN MATERIAL OF THE EXTERIOR WALLS/
RECORD OBSERVATION.
THATCHED/STRAW 12
DIRT 13
STONE WITH MUD 22
REUSED WOOD 26
UNBURNT BRICKS 27
UNBURNT BRICKS WITH PLASTER 28
UNBURNT BRICKS WITH MUD 29
STONE WITH LIME/CEMENT 32
BURNT BRICKS WITH CEMENT 33
CEMENT BLOCKS 34
WOOD PLANKS/SHINGLES 36
112. How many rooms in this household are used for sleeping?
113. Does any member of this household own:
b. A bicycle?
c. A motorcycle or motor scooter?
d. An animal-drawn cart?
e. A car or truck?
f. A boat with a motor?
g. A boat without a motor?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
114. Does any member of this household own any agricultural land?
NO 2 (SKIP TO 116)
115. How many acres of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '950'.
(1 DECIMAL = 00.1 ACRES)
95 OR MORE ACRES 950
DON'T KNOW 958
116. Does this household own any livestock, herds, other farm animals or poultry?
NO 2 (SKIP TO 118)
117. How many of the following animals does this household own?
IF NONE, ENTER '00'.
IF 95 OR MORE, ENTER '95'.
IF UNKNOWN, ENTER '98'.
b. Milk cows or bulls?
c. Horses, donkeys, or mules?
d. Goats?
e. Sheep?
f. Chicken?
g. Pigs?
b. COWS/BULLS __
c. HORSES/DONKEYS/MULES __
d. GOATS __
e. SHEEP __
f. CHICKENS __
g. PIGS __
118. Does any member of this household have a bank account?
NO 2
119. At any time in the past 6 months, as anyone come into your dwelling to spray the interior walls against mosquitoes?
NO 2 (SKIP TO 120B)
DON'T KNOW 8 (SKIP TO 120B)
119A. How many months ago was the dwelling last sprayed?
IF LESS THAN ONE MONTH, RECORD '0' MONTHS AGO.
120. Who sprayed the dwelling?
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATIO (NGO) C
OTHER X (SPECIFY) __
DON'T KNOW Z
120A. Did you pay for your dwelling to be sprayed?
NO 2
DON'T KNOW 8
120B. Is there a community worker or community medicine distributor (CMD) who distributes malaria medicines in your village or community?
NO 2 (SKIP TO 121)
DON'T KNOW 8 (SKIP TO 121)
120C. Does the community health worker currently have malaria medicines available?
NO 2
DON'T KNOW 8
121. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (SKIP TO 201)
122. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.
123. ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
124. How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
124A. Where did you get the mosquito net from?
GOV'T HEALTH CENTER 02
HEALTH CENTER 04
PHARMACY 06
OPEN MARKET 08
HAWKER 09
CAMPAIGN 10
CHURCH 11
DOES NOT KNOW 98
124B. CHECK 124A. THE NET WAS OBTAINED THROUGH THE CAMPAIGN?
CODE '10' NOT CIRCLED (SKIP TO 125)
124C. What is the campaign's date?
MONTH __
YEAR __
DON'T KNOW 98
125. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS UNKOWN AND YOU CANNT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS.
DURANET 12 (SKIP TO 128)
INTEREPTOR 13 (SKIP TO 128)
NETPROJECT 14 (SKIP TO 128)
OLYSET 15 (SKIP TO 128)
DAWNET 16 (SKIP TO 128)
ICONLIFE 17 (SKIP TO 128)
YORKOOL 18 (SKIP TO 128)
DK BRAND 19 (SKIP TO 128)
OTHER 20 (SPECIFY) __ (SKIP TO 128)
DK BRAND 98
126. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?
NO 2 (SKIP TO 128)
NOT SURE 8 (SKIP TO 128)
127. How months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 24 MONTHS AGO 95
NOT SURE 98
128. Did anyone sleep under this mosquito net last night?
NO 2
NOT SURE 8 (SKIP TO 130)
128A. What are some of the reasons why this net was not used?
DIDN'T LIKE SMELL B (SKIP TO 130)
NO MOSQUITOES C (SKIP TO 130)
NET TOO OLD/TOO MANY HOLES D (SKIP TO 130)
NET NOT HUNG E (SKIP TO 130)
OTHER X (SPECIFY) __ (SKIP TO 130)
DON'T KNOW Z (SKIP TO 130)
129. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NO. __
NAME __
LINE NO. __
NAME __
LINE NO. __
NAME __
LINE NO. ___
130. GO BACK TO 123 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 131.
MINUTES __
HEMOGLOBIN MEASUREMENT AND MALARIA TESTING FOR CHILDREN AGE 0-5
201. CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN AGE 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
202. LINE NUMBER FORM COLUMN 9
NAME FROM COLUMN 2
NAME __
203. IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK ADAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth date?
MONTH __
YEAR __
204. CHECK 203: CHILD BORN IN JANUARY 2009 OR LATER?
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, END INTERVIEW)
206. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF THE HOUSEHOLD SCHEDULE.) RECORD '00' IF NOT LISTED.
207. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 206 AS RESPONSIBLE FOR CHILD.
As part of this survey, we are asking children all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. We ask that all children born in 2009 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?
208. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
REFUSED 2 (SIGN) __
NOT PRESENT 5
OTHER 6
209. ASK CONSENT FOR MALARIA TEST FROM PARENT.OTHER ADULT IDENTIFIED IN 206 AS RESPONSIBLE FOR CHILD.
As part of this survey, we are asking that children all over the country take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by a mosquito bite. This survey will help the government to develop programs to prevent malaria.
We ask that all children born in 2009 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. (We will use blood from the same finger or heel prick made for the anemia test). One blood drop will be tested for malaria immediately, and the result will be told to you right away. A few blood drops will be collected on a slide(s) and taken to a laboratory for testing. You will not be told the results of the laboratory testing. All results will be kept strictly confidential and will not be shared with anyone other than members of our survey team?
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the malaria testing?
210. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
REFUSED 2 (SIGN) __
NOT PRESENT 5
OTHER 6
211. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
212. BAR CODE LABEL FOR MALARIA TEST
PUT THE 1ST BAR CODE LABEL HERE.
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE ON THE RDT, THE 3RD ON THE THICK SMEAR SLIDE, THE 4TH ON THE THIN SMEAR SLIDE AND THE 5TH ON THE TRANSMITTAL FORM.
213. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA AND MALARIA BROCHUDRE.
NOT PRESENT 994
REFUSED 995
OTHER 996
214. RECORD RESULT CODE OF THE MALARIA RDT.
NOT PRESENT 2 (SKIP TO 216)
REFUSED 3 (SKIP TO 216)
OTHER 6 (SKIP TO 216)
215. RECORD THE RESULT OF THE MALARIA RDT HERE AND IN THE ANEMIA AND MALARIA BROCHURE.
NEGATIVE 2
OTHER 6
216. CHECK 213: HEMOGLOBIN RESULT
8.0 G/DL OR ABOVE 2 (SKIP TO 229)
NOT PRESENT 4 (SKIP TO 229)
REFUSED 5 (SKIP TO 229)
OTHER 6 (SKIP TO 229)
217. SEVERE ANEMIA REFERRAL STATEMENT
The anemia test shows that (NAME OF CHILD) has severe anemia. Your child is very ill and must be taken to a health facility immediately.
SKIP TO 229
218. Does (NAME) suffer from any of the following illnesses or symptoms:
b. Heart problems?
c. Loss of consciousness?
d. Rapid or difficult breathing?
e. Seizures?
f. Abnormal bleeding?
g. Jaundice or yellow skin?
h. Dark urine?
IF NONE OF THE ABOVE SYMPTOMS, CIRCLE CODE Y
HEART PROBLEMS B
LOSS OF CONCIOUSNESS C
RAPID BREATHING D
SEIZURES E
BLEEDING F
JAUNDICE G
DARK URINE H
NONE OF THE ABOVE SYMPTOMS Y
219. CHECK 218: ANY CODE A-H CIRCLED?
ANY CODE A-H CIRCLED 2 (SKIP TO 222)
220. CHECK 213: HEMOGLOBIN RESULT
8.0 G/DL OR ABOVE 2
NOT PRESENT 4
REFUSED 5
OTHER 6
221. In the past two weeks has (NAME) taken or is taking COARTEM/ACT given by a doctor or a health center to treat the malaria?
VERIFY BY ASKING TO SEE TREATMENT.
NO 2 (SKIP TO 223A)
222. SEVERE MALARIA REFERRAL STATEMENT
The malaria test shows that (NAME OF CHILD) has malaria. Your child also has symptoms of severe malaria. The malaria treatment I have will not help your child, and I cannot give you the medication. Your child is very ill and must be taken to a health facility right away.
SKIP TO 228
223. ALREADY TAKING (FIRST LINE MEDICATION) REFERRAL STATEMENT
You have told me that (NAME OF CHILD) has already received COARTEM/ACT for malaria. Therefore, I cannot give you additional COARTEM/ACT. However, the test shows that he/she has malaria. If your child has a fever for two days after the last dose of COARTEM/ACT, you should take the child to the nearest health facility for further examination.
SKIP TO 228
223A. CHECK 203: IS CHILD AGE 0-3 MONTHS, I.E. WAS CHILD BORN IN MONTH OF INTERVIEW OR THREE PREVIOUS MONTHS?
OLDER 2 (SKIP TO 224)
223B. UNDER 4 MONTHS MALARIA REFERRAL STATEMENT
The malaria test shows that (NAME OF CHILD) has malaria. Your child is also younger than 4 months old and therefore requires special treatment from a health facility. Your child is ill and must be taken to a health facility right away.
SKIP TO 228
224. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD.
The malaria test shows that your child has malaria. We can give you free medicine. The medicine is called COARTEM/ACT. COARTEM/ACT is a very effective and in a few days it should get rid of the fever and other symptoms. You do not have to give the child the medicine. This is up to you. Please tell me whether you accept the medicine or not.
225. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
REFUSED 2 (SIGN) __
OTHER 7
226. CHECK 225: MEDICATION ACCEPTED
REFUSED 2 (SKIP TO 228)
OTHER 6 (SKIP TO 228)
227. TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TESTS
First day starts by taking first dose followed by the second one 8 hours later; on subsequent days the recommendation is simply 'morning' and 'evening' (usually around 12 hours apart). Take the medicine (crushed for smaller children) with high fat food or drinks like milk.
Make sure that the FULL 3 days treatment is taken at the recommended times, otherwise the infection may return. If your child vomits within an hour of taking the medicine, you will need to get additional tablets and repeat the dose.
ALSO TELL THE PARENT/ADULT RESPONSIBLE FOR THE CHILD: If (NAME) has a high fever, fast or difficult breathing, is not able to drink or breastfeed, gets sicker or does not get better in two days you should take him/her to a health professional for treatment right away.
228. RECORD THE RESULT CODE OF MALARIA TREATMENT OR REFERRAL
MEDS REFUSED 2
SEVERE MALARIA REFERRAL 3
ALREADY TAKING ACTS REFERRAL 4
UNDER 4 MONTHS REFERRAL 5
OTHER 6
229. GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, END INTERVIEW.