MALARIA INDICATOR SURVEY IN ANGOLA WOMAN'S QUESTIONNAIRE

COSEP CONSULTORIA - CONSAUDE

IDENTIFICATION

NAME OF LOCALITY

REGION

PROVINCE

MUNICIPALITY

CLUSTERED NUMBER IN AMIS

URBAN / RURAL

URBAN 1
RURAL 2

HOUSEHOLD NUMBER

NAME AND LINE NUMBER OF WOMAN

INTERVIEWER VISITS

DATE

INTERVIEWER'S NAME

RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7

NEXT VISIT

DATE

TIME

LAST VISIT

DAY

MONTH

YEAR: 2011

CODE

RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7

SUPERVISOR

NAME

DATE

FIELD EDITOR

KEYED BY

INTRODUCTION AND CONSENT

Good morning (good afternoon). My name is __ and I'm from COSEP Consultoria. We are doing a survey all over the country about malaria. I would like to ask you some questions and I hope you will agree. The information you give will help the government to plan health services. The survey usually takes about 10 to 20 minutes to complete. The information you give will be kept confidential and will not be shared with anyone other than members of the survey team. You do not have to participate in the survey. If I ask 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. However, we hope you will participate in the survey since your views are important.

Do you want to ask me anything about the survey? May I begin the interview now?

Signature of interviewer: ___
Date: ___

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

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE TIME.

HOUR
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 in your last anniversary? COMPARE AND CORRECT 104 AND/OR 105 IF INCONSISTENT.

AGE IN COMPLETED YEARS ___

104. Have you ever attended school?

YES 1
NO 2 (GO TO 108)

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

BASIC EDUCATION 1
SECONDARY 2
HIGHER 3

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

CLASS/GRADE ___

107. CHECK 105:

BASIC EDUCATION (CONTINUE)
SECONDARY OR HIGHER (GO TO 109)

108. Now I would like you to read this sentence to me. SHOW SENTENCES TO RESPONDENT. IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

1. The child is reading a book
2. Farming is hard work
3. The country should take care of its children
4 The rains were heavy this year

CANNOT READ AT ALL 1
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) 4
BLIND/VISUALLY IMPAIRED

109. What is your religion?

CATHOLIC 1
CHRISTIAN/PROTESTANT 2
ISLAM 3
TRADITIONAL RELIGION 4
NO RELIGION 5
OTHER (SPECIFY) 6

110. In which language did you learn to speak?

PORTUGUESE 01
COQWE 02
KIMBUNDU 03
KIKONGO 04
KWANYAMA 05
NGANGUELA 06
UMBUNDU 07
OTHER (SPECIFY) 96

SECTION 2. REPRODUCTION

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

YES 1
NO 2 (GO TO 206)

202. Do you have any children you born who are living with you? I mean belly born.

YES 1
NO 2 (GO TO 204)

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

SONS AT HOME ___
DAUGHTERS AT HOME ___

204. Do you have any children you born who are alive but do not live with you?

YES 1
NO 2 (GO TO 206)

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'.

SONS ELSEWHERE ___
DAUGHTERS ELSEWHERE ___

206. Have you ever born a child who was born alive and later died? IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

YES 1
NO 2 (GO TO 208)

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

BOYS DEAD ___
GIRLS DEAD ___

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

TOTAL ___

209. CHECK 208: So in all, you have belly born ____ (TOTAL) children in your life. Is that correct?

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

210. CHECK 208:

ONE OR MORE BIRTHS (CONTINUE)
NO BIRTHS (GO TO 224)

211. Now I want the names of all the children you born, whether still alive or not, starting with the first one. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE STARTING WITH THE SECOND ROW).

212. What name was given to your next baby?

NAME ___

213. Were any of these births twins?

SINGLE 1
MULTIPLE 2

214. Is (NAME) a boy or girl?

BOY 1
GIRL 2

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

MONTH ___
YEAR ___

216. Is (NAME) still alive?

YES 1
NO 2 (GO TO 220)

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

AGE IN YEARS ___

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

YES 1
NO 2

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

LINE NUMBER ___ (NEXT BIRTH)

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

DAYS 1 ___
MONTHS 2 ___
YEARS 3 ___

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

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

222. Did you born any child since the birth of (NAME OF LAST BIRTH)? IF YES, RECORD BIRTH(S) IN TABLE.

YES 1
NO 2

223. COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

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

224. CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2006 OR LATER.

NUMBER OF BIRTHS ___

225. Are you pregnant now?

YES 1
NO 2 (GO TO 227)
UNSURE 8 (GO TO 227)

226. How many months pregnant are you?

MONTHS ___

227. CHECK 224:

ONE OR MORE BIRTHS IN 2006 OR LATER (CONTINUE)
NO BIRTHS IN 2006 OR LATER (GO TO 501)

SECTION 3. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT

301. CHECK 212 AND 215: ENTER IN 302 THE NAME AND LINE NUMBER OF THE MOST RECENT BIRTH SINCE 2006 EVEN IF THE CHILD IS NO LONGER ALIVE. Now I would like to ask you some questions about your last pregnancy that ended in a live birth.

302. NAME AND LINE NUMBER FROM 212

NAME OF LAST BIRTH ___
LINE NUMBER ___

303. When you were pregnant with (NAME) did you see anyone for prenatal care for this pregnancy? IF YES: Whom did you see? Anyone else? PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

DOCTOR A
NURSE B
MIDWIFE C
AUXILIARY MIDWIFE D
TRADITIONAL MIDWIFE E
OTHER (SPECIFY) X
NO ONE Y

303A. During this pregnancy, did anyone tell you that pregnant women need to take some kind of medicine to keep them from getting malaria? EMPHASIZE THE WORD 'KEEP'.

YES 1
NO 2
DON'T KNOW 8

304. During this pregnancy, did you take any drugs to keep you from getting malaria? EMPHASIZE 'KEEP'. DO NOT CIRCLE '1' IF SHE WAS ONLY GIVEN DRUGS BECAUSE SHE HAD MALARIA.

YES 1
NO 2 (GO TO 401)
DON'T KNOW 8 (GO TO 401)

305. What drugs did you take to keep from getting malaria? RECORD ALL MENTIONED. IF SHE DOES NOT KNOW THE TYPE OF DRUG, SHOW HER THE TYPICAL ANTIMALARIAL DRUGS.

SP/FANSIDAR A
CHLOROQUINE B
COARTEM B
OTHER (SPECIFY) X
DON'T KNOW Z

306. CHECK 305: DRUGS TAKEN FOR MALARIA PREVENTION

CODE 'A' CIRCLED (CONTINUE)
CODE 'A' NOT CIRCLED (GO TO 401)

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

NUMBER OF TIMES ___

308. CHECK 303: PRENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

CODE 'A', 'B', 'C' OR 'D' CIRCLED (CONTINUE)
OTHER (GO TO 401)

309. Did you get the SP/Fansidar during any prenatal care visit, during another visit to a health facility or from another source?

PRENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE (SPECIFY) 6

SECTION 4. FEVER IN CHILDREN

401. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2006 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE WERE MORE THAN 3 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE FIRST COLUMN). Now I would like to ask you some questions about the health of your children. (We will talk about each one separately.)

402. LINE NUMBER FROM QUESTION 212

LINE NUMBER ___

403. CHECK 212 AND 216

NAME ___
LIVING (CONTINUE)
DEAD (GO TO 403 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 501)

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

YES 1
NO 2 (GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)
DON'T KNOW 8 (GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

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

DAYS AGO ___
DON'T KNOW 98

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

YES 1
NO 2 (SKIP TO 411)

407. Where did you get treatment from? Anywhere else? PROBE TO IDENTIFY EACH. TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

NAME OF PLACE

PUBLIC SECTOR

STATE HOSPITAL A
HEALTH CENTER B
HEALTH POST C
MOBILE CLINIC D
CAMPAIGN WORKER E
PUBLIC COMPANY F
OTHER PUBLIC (SPECIFY) G

PRIVATE SECTOR

HOSPITAL H
CLINIC I
DOCTOR J
PHARMACY K
MOBILE CLINIC L
OTHER PRIVATE (SPECIFY) M

OTHER SOURCE

SHOP N
TRADITIONAL PRACTITIONER O
OTHER (SPECIFY) X

408. CHECK 407:

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

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

FIRST PLACE ___

410. When the fever started, how long it took for you to carry the child for advice or treatment? IF THE SAME DAY, RECORD '00'

DAYS ___

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)
DON'T KNOW 8 (GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

413. What drugs did (NAME) take? Any other drugs? RECORD ALL MENTIONED. IF SHE DOES NOT KNOW THE TYPE OF DRUG, ASK TO SEE THEM. IF THIS IS NOT POSSIBLE OR THE TYPE OF DRUG IS STILL NOT DETERMINED, SHOW HER THE TYPICAL ANTIMALARIAL DRUGS.

ANTIMALARIAL DRUGS

SP/FANSIDAR A
CHLOROQUINE B
QUININE C
COARTEM D
OTHER ANTIMALARIAL (SPECIFY) E

OTHER DRUGS

ASPIRIN F
ACETAMINOPHEN G
PARACETAMOL H
IBUPROFEN I
OTHER (SPECIFY) X
DON'T KNOW Z

414. CHECK 413: ANY CODE 'A'-'E' CRICLED?

YES (CONTINUE)
NO (GO BACK TO 403 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

415. Did you already have (NAME OF DRUG FROM 413) at home when the child became ill? ASK SEPARATELY FOR EACH OF THE DRUGS 'A' THROUGH 'E' THAT THE CHILD IS RECORDED AS HAVING TAKEN IN 413. IF YES FOR NAY DRUG, CIRCLE CODE FOR THAT DRUG. IF NO FOR ALL DRUGS, CIRCLE 'Y'

SP/FANSIDAR A
CHLOROQUINE B
QUININE C
COARTEM D
OTHER ANTIMALARIAL (SPECIFY) E
NO DRUG AT HOME Y

416. CHECK 413: SP/FANSIDAR ('A') GIVEN

CODE 'A' CIRCLED (CONTINUE)
CODE 'A' NOT CIRCLED (SKIP TO 419)

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