FORMATTING DATE: 29 SEP. 2016
ENGLISH LANGUAGE: 29 SEP. 2016
2016 GHANA MALARIA INDICATOR SURVEY BIOMARKER QUESTIONNAIRE
MINISTRY OF HEALTH
GHANA STATISTICAL SERVICES
IDENTIFICATION
LOCALITY NAME _____________________
NAME OF HOUSEHOLD HEAD ____________________
CLUSTER NUMBER ____
HOUSEHOLD NUMBER ____
VISITS 1, 2, AND 3
FIELDWORKER TECH'S NAME ___________
NEXT VISIT:
TIME _______
FINAL VISIT:
MONTH _____
YEAR 2016
TOTAL NUMBER OF VISITS ____________
TOTAL ELIGIBLE CHILDREN ____________
LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
AKAN 02
GA 03
EWE 04
OTHER _________________(SPECIFY) 06
AKAN 02
GA 03
EWE 04
OTHER _________________(SPECIFY) 06
NO 2
NUMBER ____________
HEMOGLOBIN MEASUREMENT AND MALARIA TESTING FOR CHILDREN AGE 0-5
101. CHECK COLUMN 9 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 102; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
102. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 9
NAME _________
103. COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM HOUSEHOLD SCHEDULE. IF COMPLETE DATE OF BIRTH NOT PROVIDED ASK:
What is (NAME)'s date of birth?
MONTH ________
YEAR _______
104. CHECK 103: CHILD BORN IN 2011-2016?
NO 2 (SKIP TO 130)
105. CHECK 103: CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?
OLDER 2
106. NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD.
107. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT.
As part of this survey, we are asking children 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 ask that all children born in 2011 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 bbeen 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 or no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?
108. CIRCLE THE CODE AND SIGN YOUR NAME
REFUSED 2
NOT PRESENT/OTHER 3
109. 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 test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by a mosquito bite. This survey will assist the government to develop programs to prevent malaria.
We ask that all children born in 2011 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. One blood drop will be tested for malaria immediately, and the result will be told to you right away. A few blood drops will be collected on slide(s) and taken to a laboratory for testing. You will not be told the results of the laboratory testing. All results 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 or no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the malaria test?
110. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
REFUSED 2
NOT PRESENT/OTHER 3
111. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S)
112. PLACE BAR CODE LABEL FOR MALARIA LAB TEST
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RDT, THE 3RD ON THE SLIDE AND THE 4TH ON THE TRANSMITTAL FORM.
113. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA AND MALARIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
114. CIRCLE THE CODE FOR THE MALARIA RDT.
NOT PRESENT 2 (SKIP TO 116)
REFUSED 3 (SKIP TO 116)
OTHER 6 (SKIP TO 116)
115. RECORD THE RESULT OF THE MALARIA RDT HERE AND IN THE ANEMIA AND MALARIA PAMPHLET.
POSITIVE, PAN 2 (SKIP TO 118)
POSITIVE, Pf and PAN 3 (SKIP TO 118)
NEGATIVE 4
OTHER 6
116. CHECK 113. HEMOGLOBIN RESULT
7.0 G/DL OR ABOVE 2 (SKIP TO 130)
NOT PRESENT 3 (SKIP TO 130)
REFUSED 4 (SKIP TO 130)
OTHER 6 (SKIP TO 130)
RECORD THE RESULT OF THE ANEMIA TEST ON THE REFFERAL FORM.
The anemia test shows that (NAME OF CHILD) has severe anemia. Your child is very ill and must be taken to a health facility immediately. (SKIP TO 130)
118. Does (NAME) suffer from any of the following illnesses or symptoms:
NO 2
b) Inability to drink or breastfeed?
NO 2
c) Vomiting everything?
NO 2
d) Loss of consciousness?
NO 2
e) Deep and laboured breathing?
NO 2
f) Multiple convulsions?
NO 2
g) Abnormal spontaneous bleeding?
NO 2
h) Yellow eyes/jaundice?
NO 2
119. CHECK 118: ANY 'YES' CIRCLED?
NO
120. CHECK 113: HEMOGLOBIN RESULT
7.0 G/DL OR ABOVE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
121. In the past two weeks has (NAME) taken or is taking ACT given by a doctor or health center to treat the malaria?
VERIFY BY ASKING TO SEE TREATMENT
NO 2 (SKIP TO 124)
RECORD THE RESULT OF THE MALARIA RDT ON THE REFERRAL FORM.
The malaria test shows that (NAME OF CHILD) has malaria. Your child also has symptoms of severe malaria. The malaria treatment I have will not help your child, and I cannot give you the medication. Your child is very ill and must be taked to a health facility right away. (SKIP TO 128)
123. ALREADY TAKING ACT REFERRAL STATEMENT
You have told me that (NAME OF CHILD) had already received ACT for malaria. Therefore, I cannot give you additional ACT. However, the test shows that he/she has malaria. If your child has a fever for two days after the last dose of ACT, you should take the child to the nearest health facility for further examination. (SKIP TO 130)
124. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT/OTHER
The malaria test shows that your child has malaria. We can give you free medicine. The medicine is called ACT. ACT is very effective and in a few days it should get rid of the fever and other symptoms. You do not have to give the child the medicine. This is up to you. Please tell me whether you accept the medicine or not.
125. CIRCLE THE APPOPRIATE CODE AND SIGN YOUR NAME.
REFUSED 2
OTHER 6
126. CHECK 125: MEDICATION ACCEPTED
REFUSED 2 (SKIP TO 130)
OTHER 6 (SKIP TO 130)
127. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT/OTHER ADULT.
TREATMENT WITH ARTESUNATE-AMODIAGUINE (AA)
Weight (in kg) - Approximate age
? 4.5 kg to 9 kg (under 1 year)
> 9 kg - Less than 18 kg (age 1-5 years)
Dosage
1 tablet AS- AQ (25 mg/67.5 mg) daily for 3 days
1 tablet AS-AQ (50 mg/135 mg) daily for 3 days
Give the child one tablet each day for three consecutive days. Take the medicine with fatty food or drinks like milk or breast milk. For smaller children, put the tablet in a little water, mix water and tablet well, and give to the child. If your child vomits within an hour of taking the medicine, repeat the dose and get additional tablets.
ALSO TELL THE PARENT/OTHER ADULT: If (NAME OF CHILD) has any of the following symptoms, you should take him/her to a health professional for further assessment and treatment right away:
- A high temperature or fever
- Fast or difficulty breathing
- Not able to drink or breastfeed
- Gets sicker or does not get better in two days
(SKIP TO 130)
128. CHECK 113: HEMOGLOBIN RESULT
7.0 G/DL OR ABOVE 2 (SKIP TO 130)
NOT PRESENT 3 (SKIP TO 130)
REFUSED 4 (SKIP TO 130)
OTHER 6 (SKIP TO 130)
RECORD THE RESULT OF THE ANEMIA TEST ON THE REFERRAL
The anemia test shows that (NAME OF CHILD) has severe anemia. Your child is very ill and must be taken to a health facility immediately.
130. GO BACK TO 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, END INTERVIEW.
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
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