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Final Version


Demographic and health survey (EDSB-V-2017)
Biomarker Questionnaire #1

Republic of Benin
Ministry of Planning and Development
National institute of statistics and economic analysis (INSAE)

Identification
Place name
Name of head of household
Plot number
Cluster number
Household number

Household selected for men’s survey? (1=Yes, 2=No)

Yes 1 (continue)
No 2 (Use biomarker questionnaire #2)


Interviewer visits
1 2 3
Date

Interviewer’s name
Result*

Final visit
Day
Month
Year 201

Next visit
Date
Time

Total no. of visits

Notes

Total eligible children

Language of questionnaire 01
Language of interview
Native language of respondent

Translator used (Yes=1, No=2)

Yes 1
No 2

Language of questionnaire: French
Language codes:

01 French
02 Adja
03 Bariba
04 Fon
05 Dendi
06 Ditamari
07 Yoruba
08 Other

Supervisor
Name__
Line Number__

Editor
Name__
Line Number__

Weight and height measurements of children age 0-5

101) Check column 11 of the household schedule. Record the line number and the name for all eligible children 0-5 years in q. 102; if more than six children, use additional questionnaire(s).

Child 1
Child 2
Child 3

102) Check line number from column 11 in household questionnaire

Name from column 2
Line number
Name

103) If mother interviewed, copy child’s date of birth (day, month, and year) from birth history. If mother not interviewed, ask: What is (name)’s date of birth?

Day
Month
Year

104) Check 103:
Child born 2012-2017?

Yes 1
No 2-skip to 111

105) Weight in kilograms

Kg
Not present 9994
Refused 9995
Other 9996

106) Height in centimeters

Cm
Not present 9994-skip to 108
Refused 9995-skip to 108
Other 9996-skip to 108

107) Measured lying down or standing up?

Lying down 1
Standing up 2

108) Measurer: Enter your interviewer number

Interviewer number

110) Line number from parent/other adult responsible for the child (from column 1 of household schedule).

Line number
Record 00 if not listed.

111) Go back to Q 103 in next column of this questionnaire or the first column of the next page. If no more children, end.

[##translator note: questions 102 through 111 repeated for Child 4, 5 and 6]

Interviewer’s observations
To be filled in after completing interview

Supervisor’s observations

Editor’s’ observations

Year of survey: 2017
Five years before survey: 2012
Children older than 5 years: 2011
Children under 4: 2014
Children under 3: 2015
Children under 16: 2002

Final Version


Demographic and health survey (EDSB-V-2017)
Biomarker Questionnaire #2

Republic of Benin
Ministry of Planning and Development
National institute of statistics and economic analysis (INSAE)


Identification

Department
Commune
Urban/rural
Name of head of household
Plot number
Cluster number
Household number

Household selected for men’s survey? (1=Yes, 2=No)

1—continue
2—Use biomarker questionnaire #2

Interviewer visits
1 2 3
Date

Interviewer’s name
Result*

Final visit
Day
Month
Year 201

Next visit
Date
Time

Total no. of visits

Notes

Total eligible women
Total eligible children

Language of questionnaire 01
Language of interview
Native language of respondent

Translator used (Yes=1, No=2)

Yes 1
No 2

Language of questionnaire: French
Language codes:

01 French
02 Adja
03 Bariba
04 Fon
05 Dendi
06 Ditamari
07 Yoruba
08 Other

Supervisor
Name
Number

Editor
Name
Number

Weight, height, hemoglobin, and malaria test for children age 0-5

101) Check column 11 of the household schedule. Record the line number and the name for all eligible children 0-5 years in q. 102; if more than six children, use additional questionnaire(s).

Child 1
Child 2
Child 3

102) Check line number from column 11 in household questionnaire

Name from column 2
Line number
Name

103) If mother interviewed, copy child’s date of birth (day, month, and year) from birth history. If mother not interviewed, ask: What is (name)’s date of birth?

Day
Month
Year

104) Check 103:
Child born 2012-2017?

Yes 1
No 2-skip to 137

105) Weight in kilograms

Kg
Not present 9994
Refused 9995
Other 9996

106) Height in centimeters

Cm
Not present 9994-skip to 107a
Refused 9995-skip to 107a
Other 9996-skip to 107a

107) Measured lying down or standing up?

Lying down 1
Standing up 2

108) Measurer: Enter your interviewer number

Interviewer number

101) Check column 11 of the household schedule. Record the line number and the name for all eligible children 0-5 years in q. 102; if more than six children, use additional questionnaire(s).

Child 1
Child 2
Child 3

102) Check line number from column 11 in household questionnaire

Name from column 2
Line number
Name

109) Check 103: Child age 0-5 months, i.e. was child born in month of interview or 5 previous months?

0-5 months 1-skip to 132
Older 2

110) Line number of parent/other adult responsible for the child from column 1 of household schedule

Line number
(Record 00 if not listed)

111) Ask consent for anemia test from parent/other adult.
As part of this survey, we are asking people 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 and set up programs to prevent and treat anemia. We ask that all children born in 2012 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 member 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?

112) Circle the appropriate code and sign your name.

Granted 1-sign
Refused 2-sign
Not present/Other 3

113) Ask consent for malaria test from parent/other adult

As part of this survey, we are asking children all over the country to take a malaria test. Malaria is a serious health problem caused by a parasite transmitted by mosquito bites. This survey will assist the government to develop and set up programs to prevent and treat malaria.

We ask that all children born in 2012 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. We will use the blood from the anemia test. A drop of blood will be tested for malaria immediately, and you will receive the results right away. A treatment will be proposed for children who have simple malaria if they aren’t already receiving treatment. Children with serious malaria will be referred to a health care establishments. Some drops of blood will be preserved and sent to a laboratory for testing. You will not receive the results of this lab test.
The result will be kept strictly confidential and will not be shared with anyone other than member 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 test?

113) Circle the appropriate code and sign your name.

Granted 1-sign
Refused 2-sign
Not present/Other 3

115) Prepare the equipment and supplies for the test(s) for which consent has been obtained and proceed with the test(s).

116) Place bar code stickers here

Put the 1st bar code here
Not present 99994
Refused 99995
Other 99996
Put the 2nd bar code label on the TDR, the 3rd on the thick smear slide, the 4th [##translator note: text is cut off here]

117) Record hemoglobin level here and in anemia and malaria pamphlet

G/DL
Refused 995
Other 996


118) Record TDR and malaria result code

Tested 1
Absent 2-sip to 120
Refused 3-skip to 120
Other 5-skip to 120

124) Record the TDR and malaria result here and in the brochure on anemia and malaria.

Positive falciparum 1
Positive vivax 2
Positive falciparum and vivax 3
All skip to 122

Negative 4
Other 6

120) Check 122: Hemoglobin level

Below 8.0 g/dl severe anemia 1
8.0 g/dl or higher 2-skip to 132
Absent 3-skip to 132
Refused 4-skip to 132
Other 6-skip to 132

121) Reference declaration for severe anemia
The anemia diagnostic test show that (name of child) has severe anemia. You child is seriously ill and must be taken to a health care establishment immediately.
Skip to 132

122) Did (name) suffer from any of the following illness or present one or more of the following symptoms:

Extreme weakness?
Heart problems?
Loss of consciousness?
Rapid breathing or difficulty breathing?
Has or has had convulsions?
Abnormal bleeding?
Icterus/jaundice?
Dark urine?

If none of the above symptoms, circle code Y.

Extreme weakness A
Heart problems B
Loss of consciousness C
Rapid breathing or difficulty breathing D
Has or has had convulsions E
Abnormal bleeding F
Icterus/jaundice G
Dark urine H

None of above symptoms Y

123) Check 122: Is there a code circled in A-H?

Code A-H circled 1-skip to 125
Only code Y circled 2

124) Check 117: Hemoglobin level

Under 8.0 g/dl 1
8.0 d/dl or higher 2
Not present 4
Refused 5
Other 6
2-6 skip to 126

125) Reference declaration for serious malaria
The diagnostic test for malaria shows that (name of child) has malaria. You child has the symptoms of serious malaria. The antimalarial drugs that I have will not help your child, and I cannot give him/her treatment. You child is seriously ill and must be taken to a health care establishment immediately.
Skip to 131

126) In the last two weeks, has (name) taken or is (name) taking an antimalarial drug given by a doctor, a health care center, or a community health agent to treat malaria?
Check by asking to see the treatment

Yes 1
No 2-skip to 128

127) Reference declaration for children already taking CTA drug.
You told me that (name of child) already received CTA for malaria. I cannot give you extra CTA. However, the test shows that he/she has malaria. If your child had a fever in the two days after the last dose of CTA, you must bring the child to the closest health care establishment for further testing.
Skip to 132

128) Read information for malaria treatment and the declaration of consent to the parents or other adult responsible for the child.
The malaria test shows that your child has malaria. We can give you free drugs. The drug is called CTA. CTA is very effective and in a few days, he/she will not have a fever or any other symptoms. You are not obligated to give the drug to the child. It is up to you to decide. Please tell me, do you accept the drug or not?

129) Circle the appropriate code and sign.

Drug accepted 1-signature
Refused 2-skip to 131
Other 6-skip to 131

130) Treatment for children with positive malaria test
Dosage instructions

Weight (in kg)/Age
4.5 kg to 8kg (6-11 months)
Day 1
1 tablet Artesunate 25 mg tablet and Amodiaquine 67.5 mg of (Rose striped brochure)
Day 2 (1 tablet)
1 tablet Artesunate 25 mg tablet and Amodiaquine 67.5 mg of (Rose striped brochure)
Day 3 (1 tablet)
1 tablet Artesunate 25 mg tablet and Amodiaquine 67.5 mg of (Rose striped brochure)

9-17 kg (1-5 years)
Day 1
Tablet of Artesunate 50 mg and Amodiaquine 135 mg (Purple striped brochure)
Day 2
Tablet of Artesunate 50 mg and Amodiaquine 135 mg (Purple striped brochure)
Day 3
Tablet of Artesunate 50 mg and Amodiaquine 135 mg (Purple striped brochure)

Tell the parents/adult responsible for child: If (name) has a high fever, difficulty or rapid breathing, if he/she cannot drink or breastfeed, if his/her condition worsens or if he/she doesn’t get better in two days, you must take him/her to a health professional for treatment immediately.

131) Record the result code of the malaria treatment or of the reference sheet

Drug given 1
Drug refused 2
Referred for severe malaria 3
Referred because child already took CTA 4
Other 6

132) Go back to 103 in next column of this questionnaire or to the 1st column of the additional questionnaire(s); if there are no more children, go to 201.

[##translator note: question 102-132 repeated for child 4-6]

Weight, height, and hemoglobin measurement for women age 15-49

201) Check column 9 of the household questionnaire. Record the line number, name, and marital status for all women eligible for Q 202, 203, and 204. If more than 3 women, use additional questionnaire(s).

Women 1
Women 2
Women 3

202) Check household questionnaire:

Line number from column 9
Name from column 2
Line number
Name

203) Check household questionnaire:
Column 7 (age):

15-17 years 1
18-49 years 2

204) Check household schedule:

Column 8 (marital status):
Code 4 (never in union) 1
Other 2

205) Weight in kilograms

Kg
Not present 9994
Refused 9995
Other 9996

206) Height in centimeters

cm___
Not present 9994
Refused 9995
Other 9996

207) Measurer: Enter your interviewer number

Interviewer number___

208) Check 203: Age

15-17 years 1
18-49 years 2-skip to 210

209) Check 204: Marital status

Code 4 (never in union) 1-skip to 212
Other 2

Adult respondent consent for anemia test
Adult respondent consent

210) Ask for consent for anemia test.

As part of this survey, we are asking people 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.

For the anemia testing, we will need a few drops of blood from a finger. 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 take the anemia test?

211) Circle the code and sign your name.

Granted 1 (sign)
Refused 2 (sign)-skip to 217
Not present 3-skip to 217

211a) Check 226 in woman’s questionnaire or ask: Are you pregnant?

Yes 1
No 2
Don’t know 8

Consent from parent/other adult responsible for anemia test
Parent/Responsible adult

212) Ask for consent for anemia test from parent/other adult.
As part of this survey, we are asking people 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.
For the anemia testing, we will need a few drops of blood from a finger. 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 and (name of minor) 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.

213) Circle the code and sign your name.

Granted 1 (sign)
Refused 2 (sign)
(If refused, skip to 217)
Not present 3-skip to 217

214) Ask for consent for anemia test from respondent.
As part of this survey, we are asking people 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.
For the anemia testing, we will need a few drops of blood from a finger. 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 and (name of parent/responsible adult) 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.

215) Circle the code and sign your name.

Granted 1 (sign)
Minor respondent refused 2 (sign)
(If refused, skip to 217)
Not present 3-skip to 217

215a) Check 226 in woman’s questionnaire or ask: #NA

Yes 1
No 2
Don’t know 8

216) Record hemoglobin level here and in anemia pamphlet

G/DL
Absent 994
Refused 995
Other 996

217) Go back to 202 in next column of this questionnaire or in the first column of an additional questionnaire. If no more women, end the interview.

Interviewer’s observations
To be filled in after completing interview

Supervisor’s observations

Editor’s’ observations