REPUBLIC OF BURUNDI

MINISTRY OF PUBLIC HEALTH AND THE FIGHT AGAINST AIDS (MSPLS)

MINISTRY OF FINANCE AND ECONOMIC DEVELOPMENT PLANNING (MFPDE)

SURVEY OF MALARIA INDICATORS IN BURUNDI (2012 EDITION)
EIPBU 2012
WOMAN'S QUESTIONNAIRE

Implementing agency:
INSTITUTE OF STATISTICS AND ECONOMIC STUDIES OF BURUNDI (ISTEEBU)

Technical assistance:
ICF International

SURVEY OF MALARIA INDICATORS IN BURUNDI
EIPBU 2012
WOMAN'S QUESTIONAIRE

REPUBLIC OF BURUNDI

MINISTRY OF PUBLIC HEALTH AND THE FIGHT AGAINST AIDS (MSPLS)

MINISTRY OF FINANCE AND ECONOMIC DEVELOPMENT PLANNING (MFPDE)

INSTITUTE OF STATISTICS AND ECONOMIC STUDIES OF BURUNDI (ISTEEBU)

IDENTIFICATION

NAME OF LOCALITY/SUB-HILL (COLLINE) ______
NAME OF HEAD OF HOUSEHOLD ______
PROVINCE ______
COMMUNE ______
NAME AND NUMBER OF HILL (COLLINE) ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER ______
URBAN-RURAL AREA (1 = URBAN, 2 = RURAL) ______
WOMAN'S NAME AND LINE NUMBER ______

INTERVIEWER VISITS

(Repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT
DAY ______
MONTH ______
YEAR 20______
INTERVIEWER NUMBER ______
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 (FRENCH AND KIRUNDI = 1)
LANGUAGE OF INTERVIEW
INTERPRETER (YES = 1, NO = 2)

LANGUAGE CODES
1 KIRUNDI
2 FRENCH
6 OTHERS

LANGUAGE OF QUESTIONNAIRE 1
INTERVIEW LANGUAGE ______
INTERPRETER ______

TEAM LEADER
NAME ______

FIELD EDITOR
(NUMBER) ______

DATA ENTRY BY
(NUMBER) ______

[###translator's note: Throughout this survey, all questions or statements that are directly addressed to the respondent are given in Kirundi language as well as French]

SECTION 1. SOCIODEMOGRAPHIC BACKGROUND OF RESPONDENT

[###translator's note: Text given only in Kirundi. Used English text of Introduction and Consent Request from Standard MIS survey]

INTRODUCTION AND CONSENT REQUEST

Hello. My name is ______ and I work for the Institute of Statistics and Economic Studies of Burundi (ISTEEBU). 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 DECLINES TO BE INTERVIEWED (Skip to END)

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 ______

IF UNDER AGE 15 OR OLDER THAN 49, STOP THE INTERVIEW

104. Have you ever been to school?

1 YES
2 NO (Skip to 108)

105. What is the highest level of education you have reached: primary, secondary 1, secondary 2, or higher?

1 PRIMARY
2 SECONDARY 1
3 SECONDARY 2
4 HIGHER

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

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

CLASS/YEAR ______

(1) CLASS/YEAR
PRIMARY GRADES
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
6 6TH GRADE

SECONDARY 1ST CYCLE GRADES
1 7TH GRADE
2 8TH GRADE
3 9TH GRADE
4 10TH GRADE

SECONDARY 2ND CYCLE GRADES
1 11TH GRADE
2 12TH GRADE
3 13TH GRADE
4 14TH GRADE

HIGHER
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR OR HIGHER

107. CHECK 105:

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

108. 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 CATHOLIC
02 PROTESTANT
03 MUSLIM
04 ADVENTIST
05 JEHOVAH'S WITNESS
06 TRADITIONAL/ANIMIST
07 NO RELIGION/NONE
08 SECT
96 OTHER (SPECIFY) ______

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

1 YES
2 NO (Skip to 113)

111A. Have you seen or heard messages about:

Sleeping under an LLIN (long-lasting insecticidal net)?
Cleaning the area (around dwellings)?
Indoor residual spraying?
Getting treated at a health centre as soon as first symptoms appear?
Taking medicine as prescribed by health care provider?

SLEEPING UNDER LLIN
1 YES
2 NO

CLEANING AREA
1 YES
2 NO

INDOOR RESIDUAL SPRAYING
1 YES
2 NO

GETTING CARE AT FIRST SIGN OF SYMPTOMS
1 YES
2 NO

TAKING MEDICINE AS PRESCRIBED
1 YES
2 NO

112. Have you seen or heard these messages:

On the radio?
On the television?
On a poster or billboard?
From a community health agent?
At the health centre?
At hill meetings?
At a travelling film festival screening?
Somewhere else?

RADIO
1 YES
2 NO

TELEVISION
1 YES
2 NO

POSTER/BILLBOARD
1 YES
2 NO

HEALTH CENTRE
1 YES
2 NO

HILL MEETING
1 YES
2 NO

FILM FESTIVAL
1 YES
2 NO

ELSEWHERE
1 YES
2 NO

113. Did you sleep under a mosquito net last night?

1 YES (Skip to 201)
2 NO

114. What is the main reason you did not sleep under a mosquito net last night?

11 DIDN'T SLEEP HERE LAST NIGHT
12 NOT ENOUGH MOSQUITO NETS
13 NO MOSQUITO NETS/BAD CONDITION/RUINED
14 NO ONE SICK
15 NOT NECESSARY
16 DON'T LIKE TO SLEEP UNDER MOSQUITO NET
17 NOT AFRAID OF MOSQUITOS
18 HOT WEATHER
19 KEEPING MOSQUITO NET FOR FUTURE USE
96 OTHER
98 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. How many sons live with you?
How many daughters live with you?

IF NONE, RECORD '00'.

SONS AT HOME ______
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. How many sons are living but do not live with you?
How many daughters are living but do not live with you?

IF NONE, RECORD '00'.

SONS ELSEWHERE ______
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 showed signs of life but who didn't survive?

1 YES
2 NO (Skip to 208)

207. How many boys died?
How many girls died?

IF NONE, RECORD '00'.

DECEASED BOYS ______
DECEASED GIRLS ______

208. TOTAL UP THE ANSWERS TO 203, 205, AND 207 AND RECORD THE TOTAL.

TOTAL BIRTHS ______

209. CHECK 208:

I would like to be sure I understood correctly: you have had a TOTAL of ______ births (number from 208) in your life. Is that correct?

YES ______ (Continue to 209A)
NO ______ (PROBE AND CORRECT 201 - 208 AS NECESSARY)

209A. CHECK 208:

AT LEAST ONE BIRTH ______ (Continue to 210)
NO BIRTHS ______ (Skip to 224)

210. Now I would like to ask you some questions about your recent births. How many births have you had in the last six years?

IF NONE, CIRCLE '00'.

TOTAL IN LAST SIX YEARS ______
00 NONE (Skip to 224)

211. Now I would like to record the names of all the births you have had since January 2006 or after (in the last six years), whether they are still living or not, beginning with the most recent birth.

RECORD THE NAME OF ALL THE BIRTHS SINCE JANUARY 2006 OR LATER (IN THE LAST SIX YEARS) IN Q. 212. RECORD TWINS/TRIPLETS ON SEPARATE LINES.

(Repeat 212 - 220 for up to 7 births)

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

(NAME)
01 ______

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

1 BOY
2 GIRL

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

1 SINGLE
2 MULTIPLE

215. In what month and what year was (NAME) born?

PROBE: What is his/her birthdate?

MONTH ______
YEAR ______

216. Is (NAME) still alive?

1 YES
2 NO (Go to next birth)

217. IF ALIVE:
How old was (NAME) on his/her last birthday?

RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS ______

218. IF ALIVE:
Does (NAME) live with you?

1 YES
2 NO

219. IF ALIVE:

NOTE THE LINE NUMBER OF CHILD FROM HOUSEHOLD SCHEDULE

(RECORD '00' IF CHILD IS NOT LISTED IN HOUSEHOLD)

LINE NUMBER ______ (Go to next birth)

220. Were there any other 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)

221. Have you had any other live births since (NAME OF LAST BIRTH)?
IF YES, RECORD THE BIRTH(S) IN BIRTH TABLE.

1 YES
2 NO

222. COMPARE 210 TO THE NUMBER OF RECORDED BIRTHS IN TABLE BELOW AND MAKE A CHECK MARK:

NUMBERS ARE EQUAL ______ (Continue to 223)
NUMBERS ARE DIFFERENT ______ (PROBE AND CORRECT)

223. CHECK 215.
RECORD THE NUMBER OF BIRTHS IN 2007 OR LATER.

IF NONE, CIRCLE '0'.

NUMBER OF BIRTHS ______
0 NONE

224. Are you currently pregnant?

1 YES
2 NO (Skip to 226)
8 NOT SURE (Skip to 226)

225. How many months pregnant are you?

RECORD THE NUMBER OF COMPLETED MONTHS.

MONTHS ______

226. CHECK 223:

ONE OR MORE BIRTHS IN 2007 OR LATER ______ (Continue to 301)
NO BIRTHS IN 2007 OR LATER ______ (Skip to 501)
Q. 223 NOT ASKED ______ (Skip to 501)

SECTION 3. PREGNANCY: MALARIA AND ANEMIA PREVENTION

301. NOTE THE NAME AND SURVIVAL STATUS OF THE LAST BIRTH IN 301A.
Now I would like to ask you some questions about your last pregnancy which ended with a live birth in January 2007 or later.

301A. ACCORDING TO Q. 212 AND Q. 216 (LINE 01) FROM BIRTH HISTORY

LAST BIRTH:
NAME: ______
LIVING ______ (Continue to 302)
DECEASED ______ (Continue to 302)

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

1 YES
2 NO (Skip to 304)

303. Whom did you see?

Anyone else?

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

HEALTH PROFESSIONAL
A DOCTOR
B NURSE/MIDWIFE
C ASSISTANT MIDWIFE

OTHER PERSON
D TRAINED TRADITIONAL BIRTH ATTENDANT
E COMMUNITY HEALTH AGENT

X OTHER (SPECIFY) ______
Y NO ONE

304. During this pregnancy, did you take any medication to prevent malaria?

1 YES
2 NO (Skip to 309A)
8 DK (Skip to 309A)

305. What medication did you take to prevent malaria?

RECORD ALL MENTIONED.
IF TYPE OF MEDICATION IS NOT DETERMINED, SHOW COMMON ANTIMALARIALS TO RESPONDENT.

A SP/FANSIDAR
B CHLOROQUINE
C COARTEM
D QUININE
E ARTESUNATE AMODIAQUINE COMBINATION
F OTHER ANTIMALARIAL
X OTHER (SPECIFY) ______
Z DK

305A. CHECK 305:

CIRCLE CODE OF ANTIMALARIAL:

IF MORE THAN ONE CODE IS CIRCLED IN 305, CIRCLE THE CODE OF THE FIRST MEDICATION ON THE LIST

01 SP/FANSIDAR
02 CHLOROQUINE
03 COARTEM
04 QUININE
05 ARTESUNATE AMODIAQUINE COMBINATION
06 OTHER ANTIMALARIALS
96 OTHER (SPECIFY) ______
98 DK

307. How many times did you take (MEDICINE CIRCLED IN 305A) during this pregnancy?

NUMBER OF TIMES ______

308. CHECK 303:

RECEIVED ANTENATAL CARE FROM A HEALTH PROFESSIONAL DURING THIS PREGNANCY?

CODE 'A', 'B', OR 'C' CIRCLED ______ (Continue to 309)
OTHER ______ (Skip to 309A)

309. Did you receive (MEDICATION CIRCLED IN 305A) during an antenatal visit, during a different visit to a health facility, or from another source?

1 ANTENATAL VISIT
2 OTHER VISIT TO HEALTH FACILITY
6 OTHER SOURCE (SPECIFY) ______

309A. During this pregnancy did you receive a mosquito net to protect yourself against mosquito bites?

1 YES
2 NO

309B. During this pregnancy did you take any iron tablets or syrup/gelcaps containing iron?

1 YES
2 NO (Skip to 310)
8 DK (Skip to 310)

309C. During the entire pregnancy, how many days did you take these tablets or syrup/gelcaps?

IF NON-NUMERIC RESPONSE, PROBE TO GET AN APPROXIMATE NUMBER OF DAYS

DAYS ______
998 DK

310. CHECK 215 AND 216:

ONE OR MORE LIVE BIRTHS IN 2007 OR LATER ______ (Continue to 401)
NO LIVE BIRTH IN 2007 OR LATER ______ (Skip to 501)

SECTION 4. FEVER IN CHILDREN

401. CHECK Q. 225
IN THE TABLE, NOTE THE LINE NUMBER, NAME AND SURVIVAL STATUS OF EACH CHILD BORN IN 2007 OR LATER. ASK QUESTIONS ABOUT ALL THESE BIRTHS, BEGINNING WITH THE LAST BIRTH. (IF MORE THAN 3 BIRTHS BORN IN 2007 OR LATER, USE AN ADDITIONAL QUESTIONNAIRE).

Now I would like to ask you some questions about the health of all your children born since January 2007. (We will talk about one child at a time).

402. LINE NUMBER FROM 212 IN BIRTH HISTORY.

(Repeat 403 - 425 for up to 3 births)

LAST BIRTH (SECOND TO LAST BIRTH) (THIRD TO LAST BIRTH)

BIRTH HISTORY NUMBER ______

403. FROM QUESTIONS 212 AND 216

NAME ______
LIVING ______ (Continue to 404)
DECEASED ______ (Go to next column of 403 or, if no more births, skip to 501)

404. Has (NAME) had a fever at any time in the last two weeks?

1 YES
2 NO (Go to next column of 403 or, if no more births, skip to 501)
8 DK (Go to next column of 403 or, if no more births, skip to 501)

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

1 YES
2 NO (Skip to 410)

407. Where did you go for advice or treatment?

Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE ALL MENTIONED.
IF DIFFICULT TO DETERMINE WHETHER PRIVATE OR PUBLIC SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE(S))______

PUBLIC SECTOR
A GOVERNMENT HOSPITAL
B GOVERNMENT HEALTH CENTRE
C HEALTH POST
D MOBILE CLINIC
E HEALTH AGENT
F OTHER PUBLIC (SPECIFY) ______

PRIVATE SECTOR
MEDICAL
G PRIVATE HOSPITAL/CLINIC
H PHARMACY
I PRIVATE DOCTOR
J HEALTH CENTRE
K HEALTH AGENT
L OTHER PRIVATE (SPECIFY) ______

OTHER SOURCE
M SHOP
N TRADITIONAL HEALER
O MARKET
X OTHER (SPECIFY) ______

407A. At any time during the illness, was blood taken from (NAME)'s finger or heel?

1 YES
2 NO (Skip to 408)
8 DK (Skip to 408)

407B. Was the test result positive or negative?

1 POSITIVE
2 NEGATIVE
3 OTHER

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. At any time during the illness, did (NAME) take any medicine whatsoever?

1 YES
2 NO (Go to next column in 403, or, if no more births, skip to 501)
8 DK (Go to next column in 403, or, if no more births, skip to 501)

411. What medication did (NAME) take?
No other medication?

RECORD ALL MENTIONED.
ASK TO SEE THE MEDICATION(S) IF TYPE OF MEDICATION IS NOT KNOWN.
IF MEDICATION CANNOT BE IDENTIFIED, SHOW COMMON ANTIMALARIALS TO RESPONDENT.

ANTIMALARIALS
1 SP/FANSIDAR
B CHLOROQUINE
C COARTEM
D QUININE
E ARTESUNATE AMODIAQUINE COMBINATION
F OTHER ANTIMALARIALS (SPECIFY) ______

ANTIBIOTICS
G PILL/SYRUP
H INJECTION

OTHER MEDICINE
I ASPIRIN
J ACETAMINOPHEN
K IBUPROFEN
X OTHER (SPECIFY) ______
Z DK

412. CHECK 411

ANY CODE A - F CIRCLED?

YES ______ (Continue to 413)
NO ______ (Return to next column in 403; or, if no more births, skip to 501)

413. CHECK 411

SP/FANSIDAR ('A') GIVEN

CODE 'A' CIRCLED ______ (Continue to 414)
CODE 'A' NOT CIRCLED ______ (Skip to 415)

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