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 ___

CITY/LARGE TOWN/SMALL TOWN/VILLAGE ___

HOUSEHOLD SELECTED FOR INDIVIDUAL INTERVIEW(S)

PERSON TO BE INTERVIEWED WITH THE DV MODULE IN THIS HOUSEHOLD

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:

LANGUAGE OF QUESTIONNAIRE: 1

LANGUAGE OF INTERVIEW: ___

LANGUAGE OF RESPONDENT ___

TRANSLATOR USED:

LANGUAGE CODES:

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:

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

RESIDENCE

5. Does (NAME) usually live here?

6. Did (NAME) stay here last night?

7. AGE: How old is (NAME)?

IF AGE 15 OR OLDER

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

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?

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?

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

IF AGE 0-17 YEARS

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

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

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?

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?

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

GRADE:

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

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?

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

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

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

IF AGE 0-4 YEARS

BIRTH REGISTRATION

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

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?

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?

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

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.

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?

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

103. Where is that water source located?

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

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

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

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

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

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

110. How many households use this toilet facility?

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?

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

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

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

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

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

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

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

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

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

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?

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

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

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

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) ________

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

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

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

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

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

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

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

131A. Where did you get this net?

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

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

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

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

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

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

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?

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?

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

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.

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?

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

505. WEIGHT IN KILOGRAMS

506. HEIGHT IN CENTIMETERS

507. MEASURED LYING DOWN OR STANDING UP?

508. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

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

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

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

512. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

513. RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT

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).

517. WEIGHT IN KILOGRAMS

518. HEIGHT IN CENTIMETERS

519. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

520. AGE: CHECK COLUMN 7.

521. MARITAL STATUS: CHECK COLUMN 8.

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

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.

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)

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

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

528. RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.

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