2016 LIBERIA MALARIA INDICATOR SURVEY
HOUSEHOLD QUESTIONNAIRE
NATIONAL MALARIA CONTROL PROGRAM-MINISTRY OF HEALTH
LIBERIA INSTITUTE OF STATISTICS AND GEO-INFORMATION SERVICES
PLACE NAME
NAME OF HOUSEHOLD HEAD
LMIS CLUSTER NUMBER
HOUSEHOLD NUMBER
DATE
INTERVIEWER'S NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
TOTAL NUMBER OF VISITS
TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
SUPERVISOR
NAME
NUMBER
OFFICE EDITOR
NUMBER
KEYED BY
NUMBER
Hello. My name is__. I am working with the Ministry of Health. We are conducting a survey about malaria all over Liberia. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don?t have to be in the survey, but we hope you will agree to answer the questions because your views are important. If I ask you any question you don?t want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the survey, you may contact the person listed on this card. GIVE FACT SHEET WITH CONTACT INFORMATION. Do you have any questions? May I begin the interview now?
SIGNATURE OF INTERVIEWER__
DATE__
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES__
1. LINE NUMBER
2. 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 5-15 FOR EACH PERSON.
2A. Just to make sure that I have a complete listing: are there any other people such as small children or infants that we have not listed?
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?
NO
2C. Are there any guests or temporary visitors staying here, or anyone who stayed here last night, who have not been listed?
NO
RELATIONSHIP TO HEAD OF HOUSEHOLD
3. What is the relationship of (NAME) to the head of household? SEE CODES BELOW
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER/STEPCHILD 10
NOT RELATED 11
CO-WIFE 12
DON?T KNOW 98
4. Is (NAME) male or female?
FEMALE 2
5. Does (NAME) usually live here?
NO 2
6. Did (NAME) stay here last night?
NO 2
7. How old is (NAME)? IF 95 OR MORE, RECORD '95'.
8. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
9. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
10. In the last 4 weeks, has (NAME) been sick with a fever at any time?
NO 2 (NEXT LINE)
DON?T KNOW 8 (NEXT LINE)
11. Did (NAME) get any treatment for the fever in the last 4 weeks?
NO 2 (NEXT LINE)
DON?T KNOW 8 (NEXT LINE)
12. Where did (NAME) go for treatment? USE CODES BELOW. IF MORE THAN ONE PLACE, RECORD FIRST PLACE TREATMENT WAS SOUGHT.
GOVERNMENT HEALTH CENTER 02
GOVERNMENT HEALTH CLINIC 03
PRIVATE HOSPITAL/CLINIC 04
PHARMACY 05
PRIVATE DOCTOR 06
MOBILE CLINIC 07
MEDICINE STORE/DRUG STORE 08
TRADITIONAL PRACTITIONER 09
BLACK BAGGER, DRUG PEDDLER 10
OTHER 96
DOES NOT KNOW 98
13. How much did the treatment cost? INCLUDE COST OF DOCTOR, NURSE, DRUGS, TESTS. IF GREATER THAN 9990 LIBERIAN DOLLARS, RECORD '9990'. IF 'FREE', RECORD '9995'. IF 'DON?T KNOW', RECORD '9998'
14. Did (NAME) get tested for malaria?
NO 2 (NEXT LINE)
DON?T KNOW 8 (NEXT LINE)
15. Did (NAME) get told the results?
NO 2 (NEXT LINE)
DON?T KNOW 8 (NEXT LINE)
TICK HERE IF CONTINUATION SHEET USED.
101. What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (SKIP TO 105)
PIPED TO NEIGHBOR 13 (SKIP TO 105)
PUBLIC TAP/STANDPIPE 14 (SKIP TO 103)
DUG WELL
UNPROTECTED WELL 32 (SKIP TO 103)
UNPROTECTED SPRING 42 (SKIP TO 103)
TANKER TRUCK 61 (SKIP TO 103)
CART WITH SMALL TANK 71 (SKIP TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (SKIP TO 103)
BOTTLED WATER 91
MINERAL WATER IN SACHET 92
OTHER (SPECIFY) 96 (SKIP TO 103)
102. What is the main source of water used by your household for other purposes such as cooking and handwashing?
PIPED INTO YARD/PLOT 12 (SKIP TO 105)
PIPED TO NEIGHBOR 13 (SKIP TO 105)
PUBLIC TAP/STANDPIPE 14
DUG WELL
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
OTHER (SPECIFY) 96
103. Where is that water source located?
IN OWN YARD/PLOT 2 (SKIP TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON?T KNOW 998
105. What kind of toilet facility do members of your household usually use? IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON?T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (SKIP TO 108)
OTHER 96
106. Do you share this toilet facility with other households?
NO 2 (SKIP TO 108)
107. Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON?T KNOW 98
108. What type of fuel foes your household mainly use for cooking? PROBE: By what means do you cook your food?
GES CYLINDER 02
KEROSENE STOVE 03
FIRE COAL/CHARCOAL 04
WOOD 05
NO FOOD COOKED IN HOUSEHOLD 95
OTHER (SPECIFY) 98
109. How many rooms in this household are used for sleeping?
110. Does this household own any livestock, herds, other farm animals, or poultry like chickens, ducks, or guinea fowl?
NO 2 (SKIP TO 112)
111. How many of the following animals does this household own? IF NONE, RECORD '00'. IF 95 OR MORE, RECORD '95'. IF UNKNOWN, RECORD '98'.
112. Does any member of your household farm any agricultural land?
NO 2 (SKIP TO 114)
113. How many acres of agricultural land do members of this household farm? IF 95 OR MORE, CIRCLE '950'
95 OR MORE ACRES 950
DON?T KNOW 998
114. Does your household have:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
115. Does any member of this household own:
NO 2
NO 2
NO 2
NO 2
NO 2
116. Does any member of this household have a bank account?
NO 2
117. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitos?
NO 2 (SKIP TO 119)
DON?T KNOW 8 (SKIP TO 119)
118. Who sprayed the dwelling?
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY) X
DON?T KNOW Z
119. Does your household have any mosquito nets?
NO 2
119A. Why doesn?t your household have any mosquito nets?
NOT AVAILABLE B (SKIP TO 130A)
DON?T LIKE TO USE NETS C (SKIP TO 130A)
TOO EXPENSIVE D (SKIP TO 130A)
DID NOT RECEIVE E (SKIP TO 130A)
SPOILED F (SKIP TO 130A)
HAVE WINDOW SCREENS G (SKIP TO 130A)
OTHER (SPECIFY) X (SKIP TO 130A)
120. How many mosquito nets does your household have? IF 7 OR MORE NETS, RECORD '7'.
121. ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
122. How many months ago did your household get the mosquito net? IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
123. OBSERVE OR ASK BRAND/TYPE OF MOSQUITO NET. IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.
PERMANET 12 (SKIP TO 126)
BASF NET 13 (SKIP TO 126)
DURANET 14 (SKIP TO 126)
OTHER/DON?T KNOW BRAND BUT LLIN 16 (SKIP TO 126)
DON?T KNOW TYPE 98
124. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?
NO 2 (SKIP TO 126)
NOT SURE 8 (SKIP TO 126)
125. How many months ago was the net last soaked or dipped? IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 24 MONTHS AGO 95
NOT SURE 98
126. Did you get the net through a mass distribution campaign, during an antenatal care visit, or during a delivery in a health facility?
YES, ANC 2 (SKIP TO 127A)
YES, HEALTH FACILITY 3 (SKIP TO 127A)
NO 4
127. Where did you get the net?
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
CHW 05
RELIGIOUS INSTITUTION 06
PRIVATE DOCTOR 07
MOBILE CLINIC 08
MEDICINE/DRUG STORE 09
TRADITIONAL PRACTITIONER 10
STREET CORNER 11
NEIGHBOR/FRIEND RELATIVE 12
OTHER 96
DON?T KNOW 98
127A. Did you buy the net or was it given to you for free?
FREE 2 (SKIP TO 128)
DON?T KNOW 8 (SKIP TO 128)
127B. How much did you pay for the net? IF 995 OR MORE, RECORD '995'.
128. Did anyone sleep under this mosquito net last night?
NO 2
NOT SURE 8 (SKIP TO 130)
128A. What are some of the reasons why this mosquito net was not used? CIRCLE ALL THAT APPLY.
SIZE OF BED B (SKIP TO 130)
NOT HUNG UP/STORED AWAY C (SKIP TO 130)
NET NOT IN GOOD CONDITION D (SKIP TO 130)
MATERIAL IS TOO HARD/ROUGH E (SKIP TO 130)
CHILD DOESN?T LIKE F (SKIP TO 130)
SKIN IRRITATION/ITCHING G (SKIP TO 130)
BAD FOR HEALTH H (SKIP TO 130)
SUPERSTITION/WITCHCRAFT I (SKIP TO 130)
TOO WEAK TO HANG J (SKIP TO 130)
CHEMICAL SMELL/TOXIC K (SKIP TO 130)
SAVING FOR LATER L (SKIP TO 130)
NO MOSQUITOES M (SKIP TO 130)
USUAL USER(S) DID NOT SLEEP HERE N (SKIP TO 130)
OTHER (SPECIFY) X (SKIP TO 130)
DON?T KNOW Z (SKIP TO 130)
129. Who slept under this mosquito net last night? RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.
LINE NUMBER__
130. GO BACK TO 121 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 130B.
130A. In the last 12 months, did any member of your household have a mosquito net?
NO 2 (SKIP TO 130F)
DON?T KNOW 8 (SKIP TO 130F)
130B. In the last 12 months has any member of your household disposed of a mosquito net?
NO 2 (SKIP TO 130F)
DON?T KNOW 8 (SKIP TO 130F)
130C. Now I want to talk about the last net that was disposed of. For how long did the household member use this net?
2-4 YEARS 2
MORE THAN 4 YEARS 3
DON?T KNOW 8
130D. What was the main reason the household member disposed of this mosquito net?
NO LONGER REPELLED MOSQUITOES 12
GOT A NEW ONE 13
PUT TO THE STORAGE/END OF RAINY SEASON 14
INSTALLED SCREENS 15
ITCHING/SKIN IRRITATION/HEALTH PROBLEMS 16
CAN'T BREATHE/TOO HOT 17
TOXIC CHEMICALS 18
OTHER (SPECIFY) 96
DON?T KNOW 98
130E. Was this a soft mosquito net or a hard mosquito net?
HARD 2
DON?T KNOW 8
130F. If you had a choice, would you like to have a soft mosquito net or a hard mosquito net?
HARD 2
NO PREFERENCE 3
DON?T KNOW 4
ADDITIONAL HOUSEHOLD CHARACTERISTICS
131. OBSERVE THE MAIN MARERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION.
FLOOR MAT, LINOLEUM, VINYL 32
CERAMIC TILES/TERRAZO 33
CONCRETE, CEMENT 34
CARPET 35
132. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING. RECORD OBSERVATION.
PALM/BAMBOO 22
WOOD PLANKS 23
TARPAULIN, PLASTIC 24
WOOD 32
CERAMIC TILES 34
CONCRETE/CEMENT 35
ASBESTOS SHEETS/SHINGLES 36
133. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING. RECORD OBSERVATION.
CANE/PALM/TRUNKS 12
STRAW/THATCH MATS 13
PLYWOOD 22
CARDBOARD/PLASTIC 23
REUSED WOOD 24
CEMENT 32
STONE BLOCKS 33
BRICKS 34
WOOD PLANKS/SHINGLES 35
MINUTES__
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW
COMMENTS ON SPECIFIC QUESTIONS
ANY OTHER COMMENTS
SUPERVISOR'S OBSERVATIONS
EDITOR'S OBERVATIONS