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GHANA DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE 2008

MINISTRY OF HEALTH, GHANA GHANA STATISTICAL SERVICE

Questionnaire serial no.______________

SEPTEMBER 2008

IDENTIFICATION

LOCALITY NAME _______________
NAME OF HOUSEHOLD HEAD ______________
EA NUMBER _______
STRUCTURE NUMBER _____
HOUSEHOLD NUMBER _____
REGION ____
DISTRICT ____

URBAN/RURAL ___

URBAN 1
RURAL 2

CITY/LARGE TOWN/SMALL TOWN/VILLAGE ___

CITY 1
LARGE TOWN 2
SMALL TOWN 3
VILLAGE 4

HOUSEHOLD SELECTED FOR INDIVIDUAL INTERVIEW(S)

YES 1
NO 2

PERSON TO BE INTERVIEWED WITH THE DV MODULE IN THIS HOUSEHOLD

WOMAN 1
MAN 2
NO ONE 3

INTERVIEWER VISITS 1
DATE______
INTERVIEWER'S NAME_______
RESULT*_________

NEXT VISIT:
DATE______
TIME ______

INTERVIEWER VISITS 2
DATE______
INTERVIEWER'S NAME_______
RESULT*_________

NEXT VISIT:
DATE______
TIME ______

INTERVIEWER VISITS 3
DATE______
INTERVIEWER'S NAME_______
RESULT*_________

FINAL VISIT
DAY _____
MONTH_____
YEAR 2008
INT. NUMBER_____
RESULT_____

TOTAL NO. OF VISITS_____

TOTAL PERSONS IN HOUSEHOLD______

TOTAL ELIGIBLE WOMEN______

TOTAL ELIGIBLE MEN______

TOTAL ELIGIBLE DEATHS FOR VERBAL AUTOPSY______

LINE NO. OF RESP TO HH QUESTION______

RESULT _____
*RESULT CODES:

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _________

LANGUAGE OF QUESTIONNAIRE: 1

LANGUAGE OF INTERVIEW: ___

LANGUAGE OF RESPONDENT ___

TRANSLATOR USED:

YES 1
NO 2

LANGUAGE CODES:

ENGLISH 1
AKAN 2
GA 3
EWE 4
NZEMA 5
DAGBANI 6
OTHER (SPECIFY) 7

SUPERVISOR
NAME ____
DATE ____

FIELD EDITOR
NAME ____
DATE ____

OFFICE EDITOR
NAME____

KEYED BY
NAME ____

Introduction and Consent

Hello. My name is _______________________________________ and I am working for Ghana Statistical Service and Ministry of Health.

We are conducting a national survey about various health issues.

We would very much appreciate your participation in this survey. The survey usually takes between 10 and 20 minutes to complete.

As part of the survey we would first like to ask some questions about your household.
All of the answers you give will be confidential and will not be seen by anyone other than members of our survey team.

Participation in the survey is completely voluntary.

If we should come to any question you don't want to answer, just let me know and 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.

At this time, 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)

HOUSEHOLD SCHEDULE

1. LINE NO.

__

2. USUAL RESIDENTS AND VISITORS

Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

_________

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-32 FOR EACH PERSON.

3. RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?

RELATIONSHIP TO HEAD OF HOUSEHOLD:

01 = HEAD
02 = WIFE/HUSBAND/PARTNER
03 = SON OR DAUGHTER
04 = SON-IN-LAW OR DAUGHTER-IN-LAW
05 = GRANDCHILD
06 = PARENT
07 = PARENT-IN-LAW
08 = BROTHER OR SISTER
09 = NIECE/NEPHEW BY BLOOD
10 = NIECE/NEPHEW BY MARRIAGE
11 = OTHER RELATIVE
12 = ADOPTED/FOSTER STEPCHILD
13 = NOT RELATED
98 = DON'T KNOW

4. SEX: Is (NAME) male or female?

YES 1
NO 2

RESIDENCE

5. Does (NAME) usually live here?

YES 1
NO 2

6. Did (NAME) stay here last night?

YES 1
NO 2

7. AGE: How old is (NAME)?

IN YEARS ____

IF AGE 15 OR OLDER

8. MARITAL STATUS: What is (NAME'S) current marital status?

1 = MARRIED OR LIVING TOGETHER
2 = DIVORCED/SEPARATED
3 = WIDOWED
4 = NEVER-MARRIED AND NEVER LIVED TOGETHER

ELIGIBILITY

9. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-54.

11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.

2A) Just to make sure that I have a complete listing. Are there any other persons such as small children or infants that we have not listed?

YES __ (ADD TO TABLE)
NO __

2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?

YES __ (ADD TO TABLE)
NO __

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

YES __ (ADD TO TABLE)
NO __

IF AGE 0-17 YEARS

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

13. Is (NAME)'s biological mother alive?

Y 1
N 2 (GO TO 16)
DK 8 (GO TO 16)

14. Does (NAME)'s biological mother usually live in this household or was she a guest last night? IF YES, What is her name?

RECORD MOTHER'S LINE NUMBER. IF NO, RECORD '00'.

______

16. Is (NAME)'s biological father alive?

Y 1
N 2 (GO TO 23)
DK 8 (GO TO 23)

17. Does (NAME)'s biological father usually live in this household or was he a guest last night? IF YES, What is his name?

RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.

_____

IF AGE 3 YEARS OR OLDER

EVER ATTENDED SCHOOL

23. Has (NAME) ever attended school?

Y 1
N 2 (GO TO 32)

CODES FOR Qs.24, 26 AND 28: EDUCATION LEVEL:

0 = PRE-SCHOOL
1 = PRIMARY
2 = MIDDLE/JSS/JHS
3 = SECONDARY/SSS/SHS/TECH/VOC
4 = HIGHER
8 = DON'T KNOW

GRADE:

00 = LESS THAN 1 YEAR COMPLETED (UES '00' FOR Q.24 ONLY. THIS CODE IS NOT ALLOWED FOR QS. 26 AND 28)
98 = DON'T KNOW

24. What is the highest level of school (NAME) has attended? SEE CODES BELOW. What is the highest grade (NAME) completed at that level?

LEVEL ___
GRADE ______

IF AGE 3-24 YEARS

CURRENT/RECENT SCHOOL ATTENDANCE

25. Did (NAME) attend school at any time during the current school year, that is, 2008-2009?

Y 1
N 2 (GO TO 27)

26. During this school year, what level and grade is (NAME) attending? SEE CODES BELOW.

LEVEL____
GRADE _______

27. Did (NAME) attend school at any time during the previous school year, that is, 2007-2008?

Y 1
N 2 (GO TO 32)

28. During that school year, what level and grade did (NAME) attend? SEE CODES BELOW.

LEVEL___
GRADE____

IF AGE 0-4 YEARS

BIRTH REGISTRATION

32. Has (NAME) ever been registered with the civil authority?

1=HAS CERTIFICATION
2=REGISTERED
3=NEITHER
8=DON'T KNOW

INFORMATION ABOUT DEATHS IN THE HOUSEHOLD IN THE PREVIOUS 5 YEARS

32A. Now I would like to ask you about any deaths that occurred in this household in the last 5 years. Since January 2003 has any usual member of this household died?

Y 1
N 2 (GO TO 101)

32B. How many deaths occurred to usual residents in this household in the last 5 years?

____

32C. LINE NO.

32D. What were the names of the people who died in the last 5 years?

_______

32E. Was (NAME) male or female?

MALE 1
FEMALE 2

32F. In what month and year did (NAME) die? IF MONTH DON'T KNOW RECORD '98'

MONTH ____
YR 200__

32G. How old was (NAME) when he/she died?

RECORD IN DAYS. IF LESS THAMONTH; RECORD IN MONTH. IF LESS THAN 6 YEARS; OTHERWISE, RECORD IN YEARS.

DAYS 1 ____
MONTHS 2 ____
YEARS 3_____

We would like to get more information on the circumstances surrounding the deaths of children under the age of 5 years so that the government can provide health services to help reduce these deaths. If you don't mind, another member of our team will be coming later to interview members of the household about the death(s) you have just told me about.

CHECK HERE IF RESPONDENT DOES NOT AGREE TO THE VERBAL AUTOPSY VISIT. GO TO Q.101 IF THE RESPONDENT DOES NOT AGREE TO THE VISIT. OTHERWISE PROCEED WITH Q.33.

33. CHECK COLS. 32F AND 32 RECORD NUMBER OF DEATHS TO CHILDREN UNDER YEARS (AGE 0 to 71 MONTHS) SINCE JANUARY 2005.

RECORD THIS NUMBER ON THE COVER PAGE AND ON THE INTERVIEWER'S ASSIGNMENT SHEET FOR TOTAL DEATHS ELIGIBLE FOR VERBAL AUTOPSY

HOUSEHOLD CHARACTERISTICS

101. What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING/INDOOR 11 (GO TO 106)
PIPED TO YARD/PLOT 12 (GO TO 106)
PUBLIC TAP/STANDPIP 13 (GO TO 103)
TUBE WELL OR BOREHOLE 21 (GO TO 103)
DUG WELL
PROTECTED WELL 31 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)

WATER FROM SPRING
PROTECTED SPRING 41 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
RAINWATER 51 (GO TO 106)
TANKER TRUCK 61 (GO TO 103)
CART WITH SMALL TANK 71 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 103)
BOTTLED WATER 91 (GO TO 103)
SACHET WATER 92 (GO TO 103)
OTHER (SPECIFY) _____ 96 (GO TO 103)

102. What is the main source of water used by your household for other purposes such as cooking and hand washing?

PIPED WATER
PIPED INTO DWELLING/INDOOR 11 (GO TO 106)
PIPED TO YARD/PLOT 12 (GO TO 106)
PUBLIC TAP/STANDPIP 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 106)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
SACHET WATER 92
OTHER (SPECIFY) _____ 96

103. Where is that water source located?

IN OWN DWELLING 1 (GO TO 106)
IN OWN YARD/PLOT 2 (GO TO 106)
ELSEWHERE 3

104. How long does it take to go there, get water, and come back?

MINUTES ___
DON'T KNOW 998

105. Who usually goes to this source to fetch the water for your household?

ADULT WOMAN 01
ADULT MAN 02
FEMALE CHILD UNDER 15 YEARS OLD 03
MALE CHILD UNDER 15 YEARS OLD 04
FEMALE AGE 15-17 YEARS OLD 05
MALE AGE 15-17 YEARS OLD 06
OTHER (SPECIFY) ____ 96

106. Do you do anything to the water to make it safer to drink?

YES 1
NO 2 (GO TO 108)
DON'T KNOW 8 (GO TO 108)

107. What do you usually do to make the water safer to drink? Anything else?
RECORD ALL MENTIONED.

BOIL A
ADD BLEACH/CHLORINE/ALLOY B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) ____ X
DON'T KNOW Z

108. What kind of toilet facility do members of your household usually use?

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET/PAN 31
COMPOSTING TOILET 41
NO FACILITY/BUSH/FIELD 61 (GO TO 111)
OTHER (SPECIFY) _____ 96

109. Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 111)

110. How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10 0__
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

111. Does your household have:

Electricity?
A wall clock?
A radio?
A black/white television?
A color television?
A mobile telephone?
A land-line telephone?
A refrigerator?
A freezer?
Electric generator/Invertor(s)?
Washing machine?
Computer?
Digital photo-camera?
Non-digital photo-camera?
Video deck?
DVD/VCD?
Sewing machine?
Bed?
Table?
Cabinet/Cupboard?

ELECTRICITY
YES 1
NO 2
CLOCK
YES 1
NO 2
RADIO
YES 1
NO 2
BLACK/WHITE TELEVISION
YES 1
NO 2
COLOR TELEVISION
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2
LAND-LINE TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
FREEZER
YES 1
NO 2
GENERATOR/INVERTOR
YES 1
NO 2
WASHING MACHINE
YES 1
NO 2
COMPUTER
YES 1
NO 2
DIGITAL CAMERA
YES 1
NO 2
NON-DIGITAL CAMERA
YES 1
NO 2
VIDEO DECK
YES 1
NO 2
DVD/VCD
YES 1
NO 2
SEWING MACHINE
YES 1
NO 2
BED
YES 1
NO 2
TABLE
YES 1
NO 2
CABINET/CUPBOARD
YES 1
NO 2

112. What type of fuel does your household mainly use for cooking?

ELECTRICITY 01 (GO TO 113A)
LPG 02 (GO TO 113A)
NATURAL GAS 03 (GO TO 113A)
BIOGAS 04 (GO TO 113A)
KEROSENE 05
CHARCOAL 06
WOOD/FIREWOOD 07
STRAW/SHRUBS/GRASS 08
AGRICULTURAL CROP RESIDUE 09
ANIMAL DUNG 10
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 117)
OTHER (SPECIFY) _____ 96

113. In this household, is food cooked on an open fire, an open stove or closed stove?

OPEN FIRE 1`
COAL PIT 2
OPEN STOVE 3
CLOSED STOVE/COAL POT WITH CHIMNEY 4
OTHER (SPECIFY) _____ 6

113A. What type of oil does your household mainly use for cooking?

PALM OIL 01
FRYTOL/FORTIFIED VEGETABLE OIL 02
OTHER VEGETABLE OIL 03
LARD OR SUET 04
BUTTER OR MARGARINE 05
SHEA BUTTER 06
OTHER (SPECIFY) ____ 96

115. Is the cooking usually done in the house, in a separate building, or outdoors?

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 117)
OUTDOORS 3 (GO TO 117)
OTHER (SPECIFY) ____ 6 (GO TO 117)

116. Do you have separate room which is used a kitchen?

YES 1
NO 2

117. MAIN MATERIAL OF THE FLOOR IN THE DWELLING. RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES/TERRAZO 33
CEMENT 34
WOOLEN CARPET/SYNTHETIC CARPET 35
LINOLEUM/RUBBER CARPET 36
OTHER (SPECIFY) _____ 96

118. MAIN MATERIAL OF THE ROOF IN THE DWELLING. RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PAL LEAF/SOD 12
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
METAL 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES/BRICK TILES 34
CEMENT 35
ROOFING SHINGLES 36
ASBESTOS/SLATE ROOFING SHEETS 37
OTHER (SPECIFY) _____ 96

119. MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 24
REUSED WOOD 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) _____ 96

120. How many rooms in this household are used for sleeping?

ROOMS ____

121. Does any member of this household own:

A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor?
A boat without a motor?

BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2
BOAT WITH MOTOR
YES 1
NO 2
BOAT WITHOUT MOTOR
YES 1
NO 2

122. Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 124)

123. How many hectares, acres or poles of agricultural land do members of this household own?

HECTARES 1 ___
ACRES 2 ___
POLES 3 ___
95 OR MORE 995
DON'T KNOW 998

124. Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
NO 2

125. How many of the following animals does this household own?

IF NONE, ENTER '00'.
IF MORE THAN 95, ENTER '95'.
IF UNKNOWN, ENTER '98'.

Cattle?
Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Pigs?
Rabbits?
Grasscutter?
Chickens?
Other poultry? (SPECIFY) ________
Other? (SPECIFY) ________

CATTLE ___
COWS/BULLS ___
HORSES/DONKEYS/MULES ___
GOATS ___
SHEEP ___
PIGS ___
RABBITS ___
GRASSCUTTER ___
CHICKENS ___
OTHER POULTRY ___
OTHER ___

126. Does any member of this household have a bank account?

YES 1
NO 2

126A. How many household members are covered by health insurance?
IF NONE, RECORD '00'.

PERSONS ___
DON'T KNOW/NOT SURE 98

127. Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 137A)

128. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

NUMBER OF NETS ___

129. ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

NET OBSERVED 1
NET NOT OBSERVED 2

130. How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'.

MONTHS AGO ___
37 OR MORE MONTHS AGO 95
NOT SURE 98

131. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

LONG LASTING NET
OLYSET 10 (GO TO 135)
PERMANET 11 (GO TO 135)
INTERCEPTOR 12 (GO TO 135)
NETPROTECT 13 (GO TO 135)
DURANET 14 (GO TO 135)
ICON LIFE 15 (GO TO 135)
OTHER /DK BRAND 16 (GO TO 135)
'PRETREATED' NET
DAWA PLUS 21 (GO TO 133)
OTHER/DK BRAND 26 (GO TO 133)
LOCALLY SEWN NETS 31
OTHER 41
DK BRAND 98

131A. Where did you get this net?

PUBLIC SECTOR
GOVT. HOSPITAL/POLYCLINIC 11
GOVT. HEALTH CENTER 12
GOVT. HEALTH POST/CHIPS 13
FIELDWORKER/OUTREACH/PEER EDUCATOR 14
CAMPAIGN 15
OTHER PUBLIC (SPECIFY) ______ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY/CHEMICAL/DRUG STORE 22
OTHER PRIVATE MEDICAL (SPECIFY) ____ 26
OTHER SOURCE
NGO 31
SHOP/MARKET 32
STREET VENDOR 33
PETROL STATION/MOBILE MART 34
OTHER (SPECIFY) _____ 36
DON'T KNOW 98

131B. Was a voucher used to purchase this net?

YES 1
NO 2
DON'T KNOW 98

132. When you got the net, was it treated with an insecticide to kill or repel mosquitos?

YES 1
NO 2
NOT SURE 8

133. Since you got the mosquito net, was it ever soaked or dipped liquid to kill or repel mosquitos?

YES 1
NO 2 (GO TO 135)
NOT SURE 8 (GO TO 135)

134. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH, RECORD '00'.

MONTHS AGO ___.__
25 OR MORE MONTHS AGO 95
NOT SURE 98

135. Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 137)
NOT SURE 8 (GO TO 137)

136. Who slept under this mosquito net last night?
RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME ______
LINE NO. _____

137. GO BACK TO 129 FOR NEXT NET OR, IF NO MORE NETS CONTINUE TO Q. 137A.

137A. In the past 12 months, have you seen or heard any messages telling you that:

a) The Ghana Health Service recommends Artesunate and Amodiaquine a drug for malaria?
b) Treatment should be sought from health facility within 24hrs of onset of fever, especially for a child under 5years?
c) The full course of the malaria drug Artesunate and Amodiaquine should be completed?
d) Pregnant women should attend ANC and take 3 doses of SP/Fansidar during pregnancy to prevent malaria?
e) Families should sleep under an insecticide treated mosquito net to protect them from mosquito bites that lead to malaria, especially pregnant women and children under 5 years?

GHS RECOMMENDATION
YES 1
NO 2
SEEKING URGENT CARE
YES 1
NO 2
COMPLETING FULL COURSE
YES 1
NO 2
ATTENDING ANC
YES 1
NO 2
SLEEPING UNDER NET
YES 1
NO 2

137B. In the past 12 months, have you seen or heard any of the messages about malaria:

a) On the television?
b) On the radio?
c) In a newspaper or magazine?
d) From a poster?
e) From leaflets or brochures?
f) From a health worker?
g) From a Community volunteer?

TELEVISION
YES 1
NO 2
RADIO
YES 1
NO 2
NEWSPAPER/MAGAZINE
YES 1
NO 2
POSTER
YES 1
NO 2
LEAFLET/BROCHURE
YES 1
NO 2
HEALTH WORKER
YES 1
NO 2
VOLUNTEER
YES 1
NO 2

137C. Have you ever listened to the radio program ''He Ha Ho"?

YES 1
NO 2

SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE

138. ONLY ONE PERSON PER HOUSEHOLD SHOULD BE SELECTED FOR DV MODULE

LOOK AT THE IDENTIFICATION PANEL ON THE COVER OF THE HOUSEHOLD QUESTIONNAIRE, CHECK WHETHER A WOMAN OR A MAN IS TO BE INTERVIEWED WITH THE DOMESTIC VIOLENCE MODULE IN THIS HOUSEHOLD:

WOMAN: ___

USE THE TABLE BELOW TO SELECT ONE WOMAN TO BE INTERVIEWED WITH DV MODULE IN THIS HH.

NAME OF SELECTED WOMAN______________

HH LINE NUMBER___

GO TO COL.9 IN THE HH SCHEDULE AND WRITE 'DV' NEXT TO THE LINE NUMBER OF THE WOMAN SELECTED

MAN: ___

USE THE TABLE BELOW TO SELECT ONE MAN TO BE INTERVIEWED WITH DV MODULE IN THIS HH

NAME OF SELECTED MAN______________

HH LINE NUMBER____

GO TO COL. 10 IN THE HH SCHEDULE AND WRITE 'DV' NEXT TO THE LINE NUMBER OF THE MAN SELECTED

HOW TO USE THE TABLE FOR SELECTION OF RESPONDENTS FOR DV

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE.

THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE FEMALES (COLUMN 9) OR MALES (COLUMN 10) IN THE HOUSEHOLD SCHEDULE.

THIS IS THE COLUMN YOU SHOULD GO TO. THE CELL WHERE THE ROW AND THE COLUMN MEET IS THE NUMBER OF THE SELECTED WOMAN OR MAN FOR THE DOMESTIC VIOLENCE MODULE IN THE HOUSEHOLD SCHEDULE.

FOR EXAMPLE, THE HOUSEHOLD WAS SELECTED TO INTERVIEW A WOMAN WITH THE DV MODULE AND THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 (LINE NUMBERS 02, 04, AND 05).

IF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '216', THE LAST DIGIT IS "6", THEREFORE GO TO ROW '6'.

THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD, THEREFORE GO TO COLUMN '3'.

FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER WHERE THE ROW AND COLUMN MEET ('2') AND CIRCLE THE BOX.

NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER "04" IN OUR EXAMPLE).

WRITE HER LINE NUMBER ABOVE IN THE BOXES INDICATED.

TABLE FOR SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE

TABLE COLUMN HEADING: LAST DIGIT OF THE HOUSEHOLD Q-RE SERIAL NUMBER
LAST DIGIT OF THE HOUSEHOLD Q-RE SERIAL NUMBER.

TABLE ROW HEADING: TOTAL NUMBER OF ELIGIBLE WOMEN 15-49, MEN 15-59 IN THE HOUSEHOLD

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

501. CHECK COLUMN 11.

RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 502.

IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 508 AND FOR THE ANEMIA PROCEDURE IN 513.

502. LINE NUMBER FROM COLUMN 11.
NAME FROM COLUMN 2.

CHILD LINE NUMBER ___
CHILD NAME ____

503. IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?

CHILD BIRTHDATE
DAY ___
MONTH ___
YEAR ___

504. CHECK 503:
CHILD BORN IN JANUARY 2003 OR LATER?

YES 1
NO 2 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 515)

505. WEIGHT IN KILOGRAMS

CHILD WEIGHT
KG ____.__

506. HEIGHT IN CENTIMETERS

CHILD HEIGHT
CM ____.__

507. MEASURED LYING DOWN OR STANDING UP?

CHILD MEASURED STYLE
LYING DOWN 1
STANDING UP 2

508. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

CHILD MEASUREMENT RESULT
CHILD MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

509. CHECK 503:
IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

CHILD AGE
0-5 MONTHS 1 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 515)
OLDER 2

510. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (COLUMN 1).
RECORD '00' IF NOT LISTED.

PARENT'
LINE NUMBER ___

511. READ CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

CHILD CONSENT
GRANTED 1 (SIGN) _____
REFUSED 2 (IF REFUSED, GO TO 513)

512. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

CHILD HEMOGLOBIN LEVEL
G/DL ____.__

513. RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT

CHILD HEMOGLOBIN MEASUREMENT RESULT
MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

514. GO BACK TO 503 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 515.

CONSENT STATEMENT FOR ANEMIA FOR CHILDREN
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.

We request that all children born in 2003 or later participate in the anemia testing part of this survey and give a few drops of blood from finger. The equipment used in taking 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 told to you right away. The result will be kept confidential and will not be seen by 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 allow (NAME(S) OF CHILD(REN) to participate in the anemia test?

WEIGHT, HEIGHT AND HIV TESTING FOR WOMEN AGE 15-49

515. CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 516. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 519 AND FOR THE HIV TEST PROCEDURE IN 528.

516. LINE NUMBER (COLUMN 9). NAME (COLUMN 2).

WOMAN LINE NUMBER ___
WOMAN NAME ____

517. WEIGHT IN KILOGRAMS

WOMAN WEIGHT
KG _____.__

518. HEIGHT IN CENTIMETERS

WOMAN HEIGHT
CM _____.__

519. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

WOMAN MEASUREMENT RESULT
MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

520. AGE: CHECK COLUMN 7.

WOMAN AGE GROUP
15-17 YEARS 1
18-49 YEARS 2

521. MARITAL STATUS: CHECK COLUMN 8.

WOMAN MARITAL STATUS
CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 523)

522. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ___

523. READ ANEMIA TEST CONSENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

GRANTED 1 (SIGN)______
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____
RESPONDENT REFUSED 3 (SIGN) _____
(IF REFUSED, GO TO 528)

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 523 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF SHE REFUSES.

FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT.

CIRCLE CODE '2' IN 523 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of the survey we also 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 test, we need a few drops of blood from a finger. The equipment used in taking 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 told to you right away. The result will be kept confidential and will not be seen by 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 allow (NAME OF ADOLESCENT) to take the anemia test?

LINE NUMBER (COLUMN 9)
NAME (COLUMN 2)

WOMAN LINE NUMBER __
WOMAN NAME ___

524. PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant

WOMAN PREGNANT
YES 1
NO 2
DK 8

526. CHECK 523 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 528 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

527. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

WOMAN HEMOGLOBIN LEVEL
G/DL ____.__

528. RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.

WOMAN
MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

530D. GO BACK TO 517 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE, END