ANGOLA
COSEP-CONSULTORIA, LDA/CONSAÚDE

IDENTIFICATION

PLACE NAME

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD NUMBER

REGION

URBAN/RURAL

MALARIA ENDEMIC REGION

NAME AND LINE NUMBER OF WOMAN

INTERVIEWER VISITS

FIRST VISIT

DATE

INTERVIEWER'S NAME

RESULT

NEXT VISIT

DATE

TIME

FINAL VISIT

DAY

MONTH

YEAR

NAME

RESULT

TOTAL NO. OF VISITS

COUNTRY-SPECIFIC INFORMATION: LANGUAGE OF QUESTIONNAIRE, LANGUAGE OF INTERVIEW, NATIVE LANGUAGE OF RESPONDENT, AND WHETHER TRANSLATOR USED

SUPERVISOR

NAME

DATE

OFFICE EDITOR

KEYED BY

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is and I am working with (NAME OF ORGANIZATION). We are conducting a national survey about malaria. We would very much appreciate your participation in this survey. The information you provide will help the government to plan health services. The survey usually takes between 10 and 20 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer: ___
Date: ___

101. RECORD THE TIME.

102. In what month and year were you born?

103. How old were you at your last birthday? COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

104. Have you ever attended school?

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

106. What is the highest (grade/form/year) you completed at that level?

107. CHECK 105:

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?

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?

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

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

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

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

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 or showed signs of life but did not survive?

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

208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.

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

210. CHECK 208:

211. Now I would like to record the names of all your births in the last six years (since 2001), whether still alive or not, starting with the first one you had. RECORD NAMES OF ALL THE BIRTHS IN THE LAST SIX YEARS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.

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

213. Were any of these births twins?

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

215. In what month and year was (NAME) born? PROBE: What is his/her birthday?

216. Is (NAME) still alive?

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

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

219. IF ALIVE: RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD)

220. IF DEAD: How old was (NAME) when he/she died? IF '1 YR', PROBE: How many months old was (NAME)? RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

221. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)?

222. Have you had any live births since the birth of (NAME OF MOST RECENT BIRTH)? IF YES, RECORD BIRTH(S) IN BIRTH TABLE.

223. COMPARE 210 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

NUMBERS ARE SAME (CHECK: FOR EACH BIRTH YEAR OF BIRTH IS RECORDED. FOR EACH LIVING CHILD CURRENT AGE IS RECORDED)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

224. CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2001 OR LATER. IF NONE, RECORD '0'.

225. Are you pregnant now?

226. IF YES, RECORD NUMBER OF COMPLETED MONTHS AND WEEKS OF PREGNANCY.

227. VERIFY 224:

227A. VERIFY 215 AND 216:

227B. VERIFY Q.220 AND ENTER NUMBER OF CHILDREN WHO DIED BEFORE THE AGE OF 29 DAYS. IF NONE, ENTER '0.'

2207C. VERIFY Q.220 AND ENTER NUMBER OF CHILDREN WHO DIED BETWEEN THE AGE OF 29 DAYS AND FIVE YEARS. IF NONE, ENTER '0.'

Section 3 - VERBAL AUTOPSY - DEATH OF A CHILD UNDER 29 DAYS

228. I would like to ask you some questions concerning symptoms that the deceased child(dren) who died before s/he (they) was (were) 29 days old had or showed when s/he was ill. Some of these questions may be painful and you can choose not to answer them; also they may not appear to be directly related to his/her death. Please bear with me and answer all the questions as best as you can. They will help us to get a clearer picture of all possible symptoms that the deceased had.

228A. WRITE THE NAME AND LINE NUMBER OF THE CHILD FROM Q. 212

228B. How is your health now?

228C. Was (NAME's) birth a difficult birth?

228D. Did you have fits before giving birth to (NAME)?

228E. Did/does you have high blood pressure?

228F. Did you have a febrile illness at the time of delivery of (NAME)?

228G. Did you suffer from any of the conditions during your pregnancy with (NAME)?

DIABETES

HEART DISEASE

TB

EPILEPSY

229. Did you have any antenatal care during your pregnancy with (NAME)?

229A. Where did you give birth to (NAME)?

229B. Who assisted the birth?

229C. Had you received TT vaccination when you were pregnant with (NAME)?

229D. If yes, how many TT injections did you receive?

229E. Was (NAME) a singleton or a twin?

229F. Was it a forceps or vacuum delivery?

229G. Was it a caesarean delivery?

229H. How many hours was the labour?

229I. Did waters break 1 day or more before delivery of (NAME)?

229J. Was (NAME) born premature?

229K. If yes, at how many months or weeks of pregnancy?

229L. Did (NAME) play or move in the womb before labour?

229M. If no, did (NAME) breathe at all after delivery?

229N. Was (NAME) dead at birth?

229O. Did the umbilical cord come before (NAME) was born?

ASK THESE QUESTIONS IF THE CHILD WAS BORN ALIVE

230. Did (NAME) cry immediately after birth?

230A. Was(NAME) able to breastfeed soon after birth?

230B. If no, was the problem with (NAME) or with you?

230C. Was (NAME) weighed after being born?

230D. If yes, how much did (NAME) weigh?

230E. Were there any bruises or signs of injury on (NAME)'s body after birth?

230F. What was the colour of (NAME)'s skin after being born?

230G. Did (NAME)'s arms/legs have strength?

230H. Did (NAME) have any malformation at birth?

230I. Did the eye color change to yellow (jaundice)?

230J. If yes, how many days after being born?

230K. Did (NAME) have any problem with the umbilical cord?

230L. Did (NAME) have a fever?

230L2. If yes, for how many days?

230M. Did (NAME) have convulsions?

230N. During the period of illness did (NAME) have areas of skin that were red, peeling or skin rash with blisters containing pus?

230O. Was (NAME) coughing?

230P. Did (NAME) have difficulty breathing?

230Q. If yes, did s/he have fast breathing?

230R. Did s/he have indrawing of the chest while breathing?

230S. Was (NAME) vomiting?

230T. Did s/he have diarrhea?

230U. Was (NAME) unable to breastfeed when s/he was ill?

230V. Was there a bulge in (NAME)'s fontanel?

230W. Did (NAME) have an:

230X. If the answer to question ?is 1 or 2, what kind of injury or accident?

230Y. During the illness that led to death, did (NAME) become unconscious?

230Z. PLACE OF DEATH

230Z1. DATE OF DEATH

230Y1. VERIFY 215, 216 AND 220:

230Y2. VERIFY Q.220 AND WRITE THE NUMBER OF CHILDREN WHO DIED BETWEEN AGE 29 DAYS AND FIVE YEARS AND CONTINUE TO Q.231. IF NONE, WRITE '0' AND CONTINUE TO Q. 301

Section 4 - VERBAL AUTOPSY - DEATH OF A CHILD AGED 29 DAYS TO UNDER 5 YEARS

231. I would like to ask you some questions concerning symptoms that the deceased child(dren) (who died between 29 days old but before turning 5 years) had or showed when s/he was ill. Some of these questions may be painful and you can choose not to answer them; also they may not appear to be directly related to his/her death. Please bear with me and answer all the questions as best as you can. They will help us to get a clearer picture of all possible symptoms that the deceased had.

232. WRITE THE NAME AND LINE NUMBER OF THE CHILD FROM Q. 212

SYMPTOMS

233. Was (NAME) small at birth?

234. Was (NAME) born premature?

235. If yes, how many months or weeks of pregnancy?

236. Was (NAME) breastfeeding?

237. If yes, did (NAME) stop feeding just before death?

238. Did s/he have fever?

239. If yes, was the fever continuous or off and on?

240. Did s/he have convulsions?

241. Did s/he have a cough?

242. If yes, was the cough dry, productive or with blood?

243. Did s/he have breathing difficulties?

244. If yes, did s/he have fast breathing?

245. Did s/he have indrawing of chest while breathing?

246. Did s/he vomit?

247. If yes, did s/he vomit blood?

248. Did s/he have a mass in the abdomen?

249. Did s/he have abdominal distension?

250. If yes, did the distension start suddenly or gradually as the days went on?

251. Did s/he have diarrhea?

252. If yes, did s/he have bloody diarrhea?

253. Did s/he have abdominal pain?

254. Did s/he have weight loss?

255. Did s/he have mouth sores?

256. Did s/he look pale? (on fingers or feet soles)

257. Did the child's lips grow darker in color?

258. Did s/he have puffiness of the face?

259. Did s/he have swelling of the whole body

260. Did the eye color change to yellow (jaundice)?

261. Did s/he have ankle swelling? (show that part of the body)

262. Did s/he have swelling of joints?

263. Did s/he have measles?

264. Did s/he have any other skin disease?

265. Was s/he unusually sleepy?

266. Did s/he have neck pain?

267. Did s/he have a headache?

268. Did s/he develop stiffness of the whole body (before death)?

269. Did s/he have loss of consciousness?

270. Did s/he have fainting fits?

271. Did s/he have paralysis of both legs?

272. Was s/he unable to pass urine?

273. Did s/he pass blood in urine?

274. Did a dog bite him/her?

275. Was s/he bitten by another animal or insect?

276. If yes, what type of animal/insect? (Write the name)

277. Was s/he injured in a road accident?

278. Did s/he suffer any other accidental injuries before death?

279. Was s/he injured intentionally by someone?

Section 5. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT

301. ENTER IN 302 THE NAME AND SURVIVAL STATUS OF THE MOST RECENT BIRTH. Now I would like to ask you some questions about your last pregnancy that ended in a live birth, in the last 6 years.

302. FROM QUESTIONS 212 AND 213 (LINE 01)

303. When you were pregnant with (NAME), did you see anyone for antenatal care?1 IF YES: Whom did you see? Anyone else? PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN.

304. During this pregnancy, did you take any drugs in order to prevent you from getting malaria?

305. Which drugs did you take to prevent malaria? RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

306. CHECK 305: DRUGS TAKEN FOR MALARIA PREVENTION

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

308. CHECK 303: ANTENATAL CARE FROM A HEALTH PROFESSIONAL RECEIVED DURING THIS PREGNANCY?

309. Did you get the SP/Fansidar during an antenatal visit, during another visit to a health facility, or from some other source?

309A. Who assisted with the delivery of (NAME)? Anyone else? PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED. IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY

309B. Where did you give birth to (NAME)? PROBE TO IDENTIFY THE TYPE OF PLACE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICATL, WRITE THE NAME OF THE PLACE

NAME OF THE PLACE

Now I would like to ask you some questions about "Paludismo"

309C. Is there a difference between Paludismo and Malaria?

309D. What is Paludismo? (DESCRIBE)

309D1. What is Malaria? (DESCRIBE)

309E. Have you attended meetings in your community about the prevention of paludismo?

310. VERIFY IF RESPONDENT HAS A CHILD UNDER AGE 5 YEARS. IF YES, CONTINUE TO SECTION 6: FEVER IN CHILDREN.

SECTION 6. FEVER IN CHILDREN

311. FROM Qs. 212 AND 213, ENTER IN THE TABLE THE LINE NUMBER AND NAME OF EACH LIVING CHILD BORN IN 20011 OR LATER. (IF THERE ARE MORE THAN 2 LIVING CHILDREN BORN IN 20011 OR LATER, USE ADDITIONAL QUESTIONNAIRES). Now I would like to ask you some questions about the health of all your children less than 5 years old. (We will talk about each one separately.)

312. NAME AND LINE NUMBER FROM 212 AND 213

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

314. How many days ago did the fever start? IF LESS THAN ONE DAY, RECORD '00'

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

316. Where did you seek advice or treatment? Anywhere else? RECORD ALL SOURCES MENTIONED.

316A. How many days after the fever began did you first seek treatment for (NAME)? IF THE SAME DAY, RECORD '00'.

317. Is (NAME) still sick with a fever?

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

319. What drugs did (NAME) take?1 Any other drugs? RECORD ALL MENTIONED. ASK TO SEE DRUG(S) IF TYPE OF DRUG IS NOT KNOWN. IF TYPE OF DRUG IS STILL NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

320. CHECK 319: ANY CODE A-F CIRCLED?

320A. CHECK 319: SP/FANSIDAR ('A') GIVEN?

321. How long after the fever started did (NAME) first take SP/Fansidar?

322. For how many days did (NAME) take the SP/Fansidar? IF 7 OR MORE DAYS, RECORD '7'.

323. Did you have the SP/Fansidar at home or did you get it from somewhere else? IF SOMEWHERE ELSE, PROBE FOR SOURCE. IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the SP/Fansidar first?

324. CHECK 319: WHICH MEDICINES?

325. How long after the fever started did (NAME) first take chloroquine?

326. For how many days did (NAME) take chloroquine? IF 7 OR MORE DAYS, RECORD '7'

327. Did you have the chloroquine at home or did you get it from somewhere else? IF SOMEWHERE ELSE, PROBE FOR SOURCE. IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the chloroquine first?

328. CHECK 319: WHICH MEDICINES?

329. How long after the fever started did (NAME) first take Amodiaquine?

330. For how many days did (NAME) take Amodiaquine? IF 7 OR MORE DAYS, RECORD '7'.

331. Did you have the Amodiaquine at home or did you get it from somewhere else? IF SOMEWHERE ELSE, PROBE FOR SOURCE. IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the Amodiaquine first?

332. CHECK 319: WHICH MEDICINES?

333. How long after the fever started did (NAME) first take Quinine?

334. For how many days did (NAME) take Quinine? IF 7 OR MORE DAYS, RECORD '7'.

335. Did you have the Quinine at home or did you get it from somewhere else? IF SOMEWHERE ELSE, PROBE FOR SOURCE. IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the Quinine first?

336. CHECK 319: WHICH MEDICINES?

337. How long after the fever started did (NAME) first take Coartem?

338. For how many days did (NAME) take Coartem? IF 7 OR MORE DAYS, RECORD '7'

339. Did you have the Coartem at home or did you get it from somewhere else? IF SOMEWHERE ELSE, PROBE FOR SOURCE. IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the ACT first?

340. CHECK 319: WHICH MEDICINES?

341. How long after the fever started did (NAME) first take (NAME OF OTHER ANTIMALARIAL)?

342. For how many days did (NAME) take (NAME OF OTHER ANTIMALARIAL)? IF 7 OR MORE DAYS, RECORD '7'.

343. Did you have the (NAME OF OTHER ANTIMALARIAL) at home or did you get it from somewhere else? IF SOMEWHERE ELSE, PROBE FOR SOURCE. IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the (NAME OF OTHER ANTIMALARIAL) first?

344. GO BACK TO 313 IN NEXT COLUMN, OR, IF NO MORE CHILDREN, GO TO 345.

345. RECORD THE TIME.

GO BACK TO THE HOUSEHOLD QUESTIONNAIRE TO PROCEED WITH THE ANEMIA AND MALARIA TESTING, IF THERE ARE ELIGIBLE INDIVIDUALS. AFTER COMPLETING ALL TESTING, RETURN TO THE HOUSEHOLD QUESTIONNAIRE TO RECORD THE RESULTS OF YOUR VISIT.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT

COMMENTS ON SPECIFIC QUESTIONS

ANY OTHER COMMENTS

SUPERVISOR'S OBSERVATIONS

NAME OF THE SUPERVISOR

DATE