SURVEY OF MALARIA INDICATORS IN BURKINA FASO
(EIPBF - 2017)
WOMAN'S QUESTIONNAIRE

BURKINA FASO
NATIONAL INSTITUTE OF STATISTICS AND DEMOGRAPHY (INSD)
PROGRAM TO SUPPORT HEALTH DEVELOPMENT (PADS)
NATIONAL PROGRAM IN FIGHT AGAINST MALARIA (PNLP)

IDENTIFICATION (1)

NAME OF LOCALITY ______
NAME OF HEAD OF HOUSEHOLD ______
CLUSTER NUMBER ______
CONCESSION NUMBER ______
HOUSEHOLD NUMBER ______
ADMINISTRATIVE REGION ______
PROVINCE ______
HEALTH DISTRICT ______
AREA (URBAN = 1, RURAL = 2) ______
SPECIFIC AREA (OUAGADOUGOU = 1, OTHER CITY = 2, RURAL = 3) ______
NAME AND LINE NUMBER OF WOMAN ______

INTERVIEWER VISITS

(Repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT

DATE ______
TIME ______

FINAL VISIT

DAY ______
MONTH ______
YEAR 2017
INTERVIEWER NUMBER ______
RESULT ______

TOTAL NUMBER OF VISITS ______

RESULT CODES:

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

LANGUAGE OF QUESTIONNAIRE 01
LANGUAGE OF INTERVIEW ______
NATIVE LANGUAGE OF RESPONDENT ______
TRANSLATOR (YES = 1, NO = 2) ______
LANGUAGE OF QUESTIONNAIRE FRENCH

LANGUAGE CODES:

01 FRENCH
02 MOORE
03 PEUHL/FULFUDE
04 DIOULA
05 GULMANTCHEMA
06 BISSA
07 DAGARA
08 OTHERS

TEAM LEADER

NAME ______

FIELD EDITOR

NAME ______

DATA ENTRY AGENT

NAME ______

INTRODUCTION AND CONSENT REQUEST

Hello. My name is ______ and I work for the National Institute of Statistics and Demography (INSD). We are conducting a national survey on malaria throughout the country. The information that we collect will help your government to improve health services. Your household was selected for this survey. The questions usually take between 20 and 30 minutes. All the information you give us is strictly confidential and will not be shared with anyone other than members of the survey team.
You do not have to participate in this survey but we hope you will agree to participate because your opinion is very important. If you decide not to participate, there will be no changes in the services you can receive from health programs. If I happen to ask a question that you do not want to answer, tell me and I will move on to the next question; you can also stop the interview at any time.

If you would like more information about any aspect of the survey, you can contact the person whose name is on the card that was already given to your household.

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

SIGNATURE OF INTERVIEWER ______
DATE ______

1 RESPONDENT AGREES TO BE INTERVIEWED (Continue to 101)
2 RESPONDENT REFUSES TO BE INTERVIEWED (Skip to END)

SECTION 1. SOCIODEMOGRAPHIC BACKGROUND OF RESPONDENT

101. RECORD THE TIME.

HOUR ______
MINUTES ______

102. In what month and what year were you born?

MONTH ______
98 DK MONTH
YEAR ______
9998 DK YEAR

103. How old were you on your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

AGE IN COMPLETED YEARS ______

104. Have you ever been to school?

1 YES
2 NO (Skip to 108)

105 (2). What is the highest level of education you have reached: primary, post primary (grades 7 - 10), secondary (grades 11 - 13 (Terminale)), or higher?

1 PRIMARY
2 POST PRIMARY
3 SECONDARY
4 HIGHER

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

IF LESS THAN ONE YEAR WAS COMPLETED AT THIS LEVEL, RECORD '0'.

[###translator's note: unable to translate "FPP" and "FPB" below]
(Table)

LEVEL

1 PRIMARY
2 POST PRIMARY
3 SECONDARY
4 HIGHER

PRIMARY GRADES

1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
6 6TH GRADE

POST PRIMARY GRADES

1 7TH GRADE
2 8TH GRADE
3 9TH GRADE
4 10TH GRADE
5 "FPP"

SECONDARY GRADES

1 11TH GRADE
2 12TH GRADE
3 "TERMINALE" COLLEGE PREP EXAMS
4 "FPB"

HIGHER

1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR
4 5TH YEAR AND HIGHER

CLASS/YEAR ______

107. CHECK 105:

PRIMARY, POST PRIMARY OR SECONDARY ______ (Continue to 108)
HIGHER ______ (Skip to 109)

108 (3). Now I would like you to read this sentence to me.

SHOW CARD TO RESPONDENT.

IF RESPONDENT CANNOT READ THE WHOLE SENTENCE, PROBE:
Can you read part of the sentence?

1 CANNOT READ AT ALL
2 CAN ONLY READ PARTS OF THE SENTENCE
3 CAN READ ENTIRE SENTENCE
4 NO CARD IN RESPONDENT'S LANGUAGE (SPECIFY LANGUAGE) ______
5 BLIND/VISUALLY IMPAIRED

109. What is your religion?

01 MUSLIM
02 CATHOLIC
03 PROTESTANT
04 TRADITIONAL/ANIMIST
05 NO RELIGION/NONE
96 OTHER (SPECIFY) ______

110. What is your ethnicity (for Burkinabés)/your nationality (for foreigners)?

ETHNIC CODE (FOR BURKINABÉS)

01 BOBO
02 DIOULA
03 FULFULDE/PEULH
04 GOURMANTCH
05 GOUROUNSI
06 LOBI
07 MOSSI
08 SENOUFO
09 TOUAREG/BELLA
10 DAGARA
11 BISSA

NATIONALITY CODE (FOR FOREIGNERS)

12 ECOWAS COUNTRY
13 OTHER AFRICAN COUNTRY
14 OTHER NATIONALITY

96 OTHER ETHNICITY (SPECIFY) ______
98 DK

111. In the last 6 months, have you heard or received any messages about malaria?

1 YES
2 NO (Skip to 115)

112. Did you hear or receive messages:

a) On the radio?
B) On T.V.?
C) On a poster/flyer/picture box?
D) From a community health worker?
E) At a community event/town crier?
F) Health centres?
G) Facilitators?
H) Elsewhere?

RADIO

1 YES
2 NO

TELEVISION

1 YES
2 NO

POSTER/FLYER/PICTURE BOX

1 YES
2 NO

COMMUNITY HEALTH WORKER

1 YES
2 NO

COMMUNITY EVENT/TOWN CRIER

1 YES
2 NO

HEALTH CENTRES

1 YES
2 NO

FACILITATORS

1 YES
2 NO

ELSEWHERE

1 YES
2 NO

115. In your opinion, what is the main cause of malaria?

[###Translator's note: possibly should read: If respondent replies "mosquito bite", then Probe]

MOSQUITO BITE

PROBE: Any other way?

RECORD ALL MENTIONED

A MOSQUITO BITE
B OVER CONSUMPTION OF OIL
C TIRED DUE TO WORK
D INSUFFICIENT SLEEP
E DIRECT EXPOSURE TO SUN
F EATING MANGOS/SUGARY FRUIT
G DRINKING MILK
X OTHER (SPECIFY) _______
Z DK

117. In your opinion, what are the symptoms of malaria?

PROBE: Other symptoms?

RECORD ALL MENTIONED.

A FEVER
B LACK OF APPETITE AND VOMITING
C HIGH FEVER WITH CONVULSIONS
D HIGH FEVER WITH FAINTING
E PERSISTANT FEVER
F CONVULSIONS
G JAUNDICE
X OTHER (SPECIFY) ______
Z DK

118. What are effective methods for preventing malaria?

PROBE: Any other method?

RECORD ALL MENTIONED.

A SLEEPING UNDER A MOSQUITO NET (UNTREATED)
B SLEEPING UNDER AN INSECTICIDE-TREATED MOSQUITO NET (TREATED)
C TAKING PREVENTIVE MEDICINE
D USING INSECTICIDE/DIFFUSERS/CREAMS/LOTIONS/REPELLANTS
E USING AN ANTI-MOSQUITO COIL
F PLANT OR ROOT JUICE DECOCTION TO DRINK AS PREVENTIVE
G BY CLEANING SURROUNDINGS
H INDOOR RESIDUAL SPRAYING
I SCREENS ON WINDOWS
J USING A FUMIGATING COIL
K USING ELECTRIC PLATES
L AIR CONDITIONERS/FANS
M POWDER (APPLICATION)
N COVERING UP BODY
W OTHER (SPECIFY) ______
X OTHER (SPECIFY) ______
Z DK

119. What are effective methods of treating malaria in children?

PROBE: Any other method?

RECORD ALL MENTIONED.

ANTIMALARIALS

A ACT COMBINATION THERAPY
B SP/FANSIDAR
C CHLOROQUINE
D AMODIAQUINE
E QUININE TABLETS
F QUININE INJECTION/IV/INTRAMUSCULAR
G RECTAL ARTESUNATE
H ARTESUNATE INJECTION/IV/INTRAMUSCULAR
I ARTEMETHER (INJECTION)
J SP/FANSIDAR AND AMODIAQUINE (COMBINATION)
K OTHER ANTIMALARIAL (SPECIFY) ______

ANTIBIOTICS

L PILLS/SYRUP
M INJECTION/IV

OTHER MEDICINE

N PARACETAMOL/ASPIRIN
O ACETAMINOPHEN
P IBUPROFEN

X OTHER (SPECIFY) ______
Z DK

SECTION 2. REPRODUCTION

201. Now I would like to ask you some questions about all the births you have had in your lifetime. Have you ever given birth?

1 YES
2 NO (Skip to 206)

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

1 YES
2 NO (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 gave birth who are still living but do not live with you?

1 YES
2 NO (Skip to 206)

205. a) How many sons are living but do not live with you?
b) How many daughters are living 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 who later died?

IF NO, PROBE: No baby who cried or moved, made a noise, tried to breathe or showed signs of life for a short time?

1 YES
2 NO (Skip to 208)

207. a) How many boys died?
b) How many girls died?

IF NONE, RECORD '00'.

a) DECEASED BOYS ______
b) DECEASED GIRLS ______

208. TOTAL UP THE ANSWERS TO 203, 205, AND 207 AND RECORD THE TOTAL.
IF NONE, RECORD '00'.

TOTAL BIRTHS ______

209. CHECK 208:

I would like to be sure I understood correctly: you have had a TOTAL of ______ births in your life. Is that correct?

YES ______ (Continue to 210)
NO ______ (PROBE AND CORRECT 201 - 208 AS NECESSARY)

210. CHECK 208:

ONE OR MORE BIRTHS ______ (Continue to 211)
NONE ______ (Skip to 225)

211. Now I would like to ask you some questions about your most recent births. How many births did you have between 2010 - 2017?

RECORD THE TOTAL NUMBER OF BIRTHS IN 2012 - 2017.

TOTAL IN 2012 - 2017 ______
00 NONE (Skip to 225)

SECTION 2. REPRODUCTION

212. Now I would like to record the names of all the births you had between 2012 - 2017, whether they are still living or not, beginning with the most recent birth.

RECORD THE NAMES OF ALL BIRTHS BETWEEN 2012 - 2017 IN 213. RECORD TWINS/TRIPLETS ON SEPARATE LINES. IF THERE ARE MORE THAN 10 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, BEGINNING ON THE SECOND LINE.

213. What name was given to your (last/preceding) child?

RECORD THE NAME.
BIRTH HISTORY NUMBER.

(NAME) ______

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

1 BOY
2 GIRL

215. Is (NAME) a single birth or a multiple birth?

1 SINGLE
2 MULTIPLE

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

DAY ______
MONTH ______
YEAR ______

217. Is (NAME) still alive?

1 YES
2 NO (Go to next birth)

218. IF ALIVE:

How old was (NAME) on his/her last birthday?

RECORD AGE IN COMPLETED YEARS

AGE IN YEARS ______

219. IF ALIVE:

Does (NAME) live with you?

1 YES
2 NO

220. IF ALIVE:

NOTE THE CHILD'S LINE NUMBER FROM HOUSEHOLD SCHEDULE.
RECORD '00' IF CHILD IS NOT LISTED IN HOUSEHOLD.

LINE NUMBER FROM HOUSEHOLD SCHEDULE ______ (Go to next birth)

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

1 YES (Add birth)
2 NO (Go to next birth)

222. Have you had other live births since that of (NAME OF LAST BIRTH)?

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

223. COMPARE 211 TO THE NUMBER OF BIRTHS IN THE BIRTH TABLE

NUMBERS ARE SAME ______ (Continue to 224)
NUMBERS OF DIFFERENT ______ (PROBE AND CORRECT)

224 (4). CHECK 216: RECORD THE NUMBER OF BIRTHS BETWEEN 2012 - 2017

NUMBER OF BIRTHS ______
0 NONE

225. Are you pregnant now?

1 YES
2 NO (Skip to 227)
8 NOT SURE (Skip to 227)

226. How many months pregnant are you?

RECORD THE NUMBER OF COMPLETED MONTHS.

MONTHS ______

227 (4). CHECK 224:

ONE OR MORE BIRTHS IN 2012 OR LATER ______ (Continue to 301)
NO BIRTHS BETWEEN 2012 - 2017 ______ (Skip to 429)
224 IS NULL ______ (Skip to 429)

SECTION 3. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT

301. NOTE THE NAME AND SURVIVAL STATUS OF THE LAST BIRTH ACCORDING TO 213 AND 217.

LAST BIRTH:

NAME ______
LIVING ______ (Continue to 302)
DECEASED ______ (Continue to 302)

302. Now I would like to ask you some questions about your last pregnancy.

When you were pregnant with (NAME), did you see anyone for antenatal care?

1 YES
2 NO (Skip to 304)

303 (5). Whom did you see?

Anyone else?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PROFESSIONAL

A DOCTOR
B NURSE
C MIDWIFE
D LICENSED BIRTH ATTENDANT/MIDWIFE ASSISTANT
E VILLAGE MIDWIFE "MATRONE"

OTHER PERSONNEL

F TRADITIONAL/VILLAGE BIRTH ATTENDANT
G COMMUNITY HEALTH AGENT
X OTHER (SPECIFY) ______

304. During this pregnancy, did you take SP/Fansidar to prevent malaria?

SHOW MEDICATION PACKAGE IF POSSIBLE

1 YES
2 NO (Skip to 307)
8 DK (Skip to 307)

305. During this pregnancy, how many times did you take SP/Fansidar?

NUMBER OF TIMES ______

305A. How many times did you take SP/Fansidar in presence of a health agent?

NUMBER OF TIMES ______

306. Were you given the SP/Fansidar during an antenatal visit, at a different visit in a health facility, during a community health agent's visit, or did you obtain it elsewhere?

IF MORE THAN ONE SOURCE, RECORD THE FIRST SOURCE ON THE LIST.

1 ANTENATAL VISIT
2 OTHER VISIT IN HEALTH FACILITY
3 COMMUNITY HEALTH AGENT
6 OTHER SOURCE (SPECIFY) ______

307 (4). CHECK 216 AND 217:

ONE OR MORE LIVING CHILDREN BORN BETWEEN 2012 - 2017 ______ (Continue to 401)
NO LIVING CHILDREN BORN BETWEEN 2012 - 2017 ______ (Skip to 428)

SECTION 4. FEVER IN CHILDREN

401. CHECK 213: RECORD THE BIRTH HISTORY NUMBER IN 402 AND NAME AND SURVIVAL STATUS IN 403 FOR EACH BIRTH BETWEEN 2012 - 2017. ASK QUESTIONS ON ALL THESE BIRTHS. START WITH THE LAST BIRTH. IF THERE ARE MORE BIRTHS, USE THE LAST COLUMN OF ADDITIONAL QUESTIONNAIRE(S).

Now I would like to ask you some questions about the health of your children since January 2012. (We will talk about one child at a time).

402. NUMBER FROM BIRTH HISTORY IN 213

LAST BIRTH

BIRTH HISTORY NUMBER ______

SECOND TO LAST BIRTH

BIRTH HISTORY NUMBER ______

403. FROM QUESTIONS 213 AND 217:

(Repeat Q. 403 - 428 for additional births)

NAME ______
LIVING ______ (Continue to 404)
DECEASED ______ (Skip to 428)

404. Was (NAME) sick with a fever at any time in the last 2 weeks?

1 YES
2 NO (Skip to 428)
8 DK (Skip to 428)

405. At any time during his/her illness, was blood taken from (NAME)'s finger or heel?

1 YES
2 NO
8 DK

406. Have you sought out any advice or treatment for the illness?

1 YES
2 NO (Skip to 411)

407 (5). Where did you go for advice or treatment?

Anywhere else?

PROBE TO DETERMINE THE KIND OF PLACE.

IF UNABLE TO DETERMINE IF PLACE IS PUBLIC SECTOR OR PRIVATE SECTOR, RECORD THE NAME OF THE PLACE.

(NAME OF PLACE) ______

PUBLIC SECTOR

A GOVERNMENT HOSPITAL/UNIVERSITY HOSPITAL/REGIONAL HOSPITAL
B GOVERNMENT HEALTH CENTRE/MEDICAL CENTER WITH SURGICAL UNIT/MEDICAL CENTER
C HEALTH AND SOCIAL WELFARE CENTER/DISPENSARY/MATERNITY UNIT
D COMMUNITY HEALTH AGENT
E OTHER PUBLIC SECTOR (SPECIFY) ______

PRIVATE MEDICAL SECTOR

F PRIVATE HOSPITAL/CLINIC
G PHARMACY
H PRIVATE DOCTOR/DOCTOR'S OFFICE
I MOBILE CLINIC
J COMMUNITY HEALTH AGENT
K OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ______

OTHER PLACE

L SHOP
M TRADITIONAL PRACTITIONER
N MARKET
O STREET VENDOR
X OTHER (SPECIFY) ______

408. CHECK 407:

TWO OR MORE CODES CIRCLED ______ (Continue to 409)
ONLY ONE CODE CIRCLED ______ (Skip to 410)

409. Where did you go first for advice or treatment?

USE LETTER CODES FROM 407.

FIRST PLACE ______

410. How many days after the onset of the illness did you seek out advice or treatment for (NAME)?
IF SAME DAY, RECORD '00'.

DAYS ______

411. Did (NAME) take medicine for the illness at any time during the course of the illness?

1 YES
2 NO (Skip to 427)
8 DK (Skip to 427)

412. What medication did (NAME) take?

Any other medication?

RECORD ALL MENTIONED.

ANTIMALARIALS

A ACT (ARTEMISININ-BASED COMBINATION THERAPY)
B SP/FANSIDAR
C CHLOROQUINE
D AMODIAQUINE
QUININE
E PILLS
F INJECTION/IV/INTRAMUSCULAR
ARTESUNATE
G RECTAL ARTESUNATE
H INJECTION/IV/INTRAMUSCULAR
I ARTEMETHER (INJECTION)
J SP/FANSIDAR AND AMODIAQUINE (COMBINED)

K OTHER ANTIMALARIAL (SPECIFY) ______

ANTIBIOTICS

L PILLS/SYRUP
M INJECTION/IV

OTHER MEDICINE

N PARACETAMOL/ ASPIRIN
O ACETAMINOPHEN
P IBUPROFEN
X OTHER (SPECIFY) ______
Z DK

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

YES ______ (Continue to 414)
NO ______ (Skip to 428)

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

CODE 'A' CIRCLED ______ (Continue to 415)
CODE 'A' NOT CIRCLED ______ (Skip to 416)

415. How soon after the onset of the fever did (NAME) start taking ACT?

0 SAME DAY
1 NEXT DAY
2 TWO DAYS AFTER FEVER
3 THREE DAYS AFTER FEVER
8 DK

416. CHECK 412:

SP ('B') GIVEN

CODE 'B' CIRCLED ______ (Continue to 417)
CODE 'B' NOT CIRCLED ______ (Skip to 418)

417. How soon after the onset of the fever did (NAME) start taking (SP/Fansidar)?