IDENTIFICATION
PLACE NAME ______________________

NAME OF THE LOCALITY _______________________

NAME OF HOUSEHOLD HEAD ______________________________

CLUSTER NUMBER _____________________________

HOUSEHOLD NUMBER ______________________________

REGION ____

DISTRICT ____

COMMUNE ____

MILIEU

INTERVIEWER VISITS:

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

NEXT VISIT

FINAL VISIT

TOTAL NUMBER OF VISITS ______

*RESULT CODES

QUESTIONNAIRE LANGUAGE** ____

QUESTIONNAIRE LANGUAGE** ____

LANGUAGE OF INTERVIEW** ____

NATIVE LANGUAGE OF RESPONDENT** ___

TRANSLATOR USED

**LANGUAGE CODES

SUPERVISOR

INTRODUCTION AND CONSENT

Hello. My name is _______________________________________. I am working with National Institute of Statistics. We are conducting a survey about malaria all over Madagascar. 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 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 since your views are important. If you decide not to be in the survey, there will be no changes in the services you can access through health programs. 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 CARD WITH CONTACT INFORMATION

Mr. RABEZA Victor, Institut National des Statistiques (INSTAT). Tel: 0340755850
Pr. RATSIMBASOA Arsène, Programme National de Lutte contre le Paludisme (PNLP). Tel: 0340541965

Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER ____
DATE ____

SECTION 1. RESPONDENT'S BACKGROUND

101) RECORD THE TIME

102) In what month and year were you born?

103) How old were you on your last birthday?

COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

104) Have you ever attended school?

105) What is the highest level of school you attended: primary, secondary, or higher?

106) What is the highest [GRADE/FORM/YEAR] you completed at that level?

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, ENTER '0'.

LEVEL OF EDUCATION

107) CHECK 105:

108) Now I would like you to read this sentence to me.

SHOW CARD TO RESPONDENT.

IF RESPONDENT CANNOT READ WHOLE SENTENCE,
PROBE: Can you read any part of the sentence to me?

109) What is your religion?

111) In the past six months, have you seen or heard any messages about malaria?

112) Have you seen or heard these messages:

SECTION 2. REPRODUCTION

201) Now I would like to ask about all the births you have had during your life. Have you ever given birth?

202) Do you have any sons or daughters to whom you have given birth who are now living with you?

203)

204) Do you have any sons or daughters to whom you have given birth who are alive but do not live with you?

205)

206) Have you ever given birth to a boy or girl who was born alive but later died?

IF NO, PROBE: Any baby who cried, who made any movement, sound, or effort to breathe, or who showed any other signs of life even if for a very short time?

207)

208) TOTAL RESPONSES 203, 205, AND 207, AND ENTER THE TOTAL. IF NONE, ENTER '00'.

209) CHECK 208:

Just to make sure that I have this right: you have had in TOTAL _____ births during your life. Is that correct?

210) CHECK 208:

211) Now I would like to ask you about your most recent births. How many births have you had in 2011-2016?

212) Now I would like to record the names of all your births you had in 2011-2016, whether still alive or not, starting with the first one you had.

ENTER NAMES OF ALL THE BIRTHS IN THE LAST SIX YEARS IN 213. ENTER TWINS AND TRIPLETS ON SEPARATE LINES.

IF THERE ARE MORE THAN 10 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.

213) What name was given to your (first/next) baby?

RECORD NAME.

BIRTH HISTORY NUMBER.

214) Were any of these births twins?

215) Is (NAME) a boy or a girl?

216) In what day, month, and year was (NAME) born?

217) Is (NAME) still alive?

218) IF ALIVE:

How old was (NAME) at (NAME)'s last birthday?

RECORD THE NAME IN COMPLETED YEARS.

219) IF ALIVE:

Is (NAME) living with you?

220) IF ALIVE:

HOUSEHOLD LINE NUMBER ____ (GO TO NEXT BIRTH)

221) Did you have any other live births between (NAME OF PREVIOUS BIRTH), including children that died after birth?

222) Did you have any other live births between (NAME OF LAST BIRTH), including children that died after birth?

223) COMPARE 211 TO THE NUMBER OF BIRTHS IN THE BIRTH TABLE

224) CHECK 216: ENTER THE NUMBER OF BIRTHS IN 2011-2016

225) Are you currently pregnant?

226) How many months have you been pregnant?

RECORD THE NUMBER OF COMPLETE MONTHS.

227) CHECK 224:

SECTION 3. PREGNANCY AND INTERMITTENT PREVENTATIVE TREATMENT

301) RECORD THE NAME AND SURVIVAL STATE OF THE LAST BIRTH FROM 213 AND 217.

LAST BIRTH

302) Now I would like to ask you some questions about your children born in the last six years. (We will talk about each one separately).

When you were pregnant with (NAME), Did you see anyone for antenatal care for this pregnancy?

303) Whom did you see? Anyone else?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

303A) Do you have a medical card?

IF YES: Can I see it?

IF CARD AVAILABLE, CHECK IF IT CONTAINS INFORMATION ON PREVENTATIVE MALARIA TREATMENT DURING PREGNANCY.

303B) How many months pregnant were you when you first received antenatal care for this pregnancy?

303C) How many times did you receive antenatal care during this pregnancy?

303D) During this pregnancy, were you given or did you buy any iron tablets or iron syrup?

SHOW TABLETS/SYRUP.

303E) During the whole pregnancy, for how many days did you take the tablets or syrup?

RECORD '00' IF SHE DID NOT TAKE MEDICATION.

304) During this pregnancy, did you take SP/Fansidar to keep you from getting malaria?

304A) How many months pregnant were you when you first took SP/Fansidar?

305) How many times did you take SP/Fansidar during this pregnancy?

307) Did you get the SP/Fansidar during any antenatal care visit, during another visit to a health facility or from another source?

IF MORE THAN ONE SOURCE, ENTER THE HIGHEST SOURCE ON THE LIST.

308) CHECK 216 AND 217:

SECTION 4. FEVER IN CHILDREN

401) CHECK 213: ENTER IN THE TABLE THE NAME AND LINE NUMBER FROM 403 FOR EACH LIVING CHILD BORN IN 2011 OR LATER. ASK QUESTIONS ON ALL BIRTHS, STARTING WITH THE LAST BIRTH. IF THERE ARE MORE BIRTHS, USE THE LAST COLUMN OF AN ADDITIONAL QUESTIONNAIRE(S).

Now I would like to ask you some questions about the health of all your children younger than 5 years old. (We will talk about each one separately.)

402) LINE NUMBER FROM BIRTH TABLE IN 213 IN BIRTH HISTORY.

403) FROM 213 AND 217:

404) Has (NAME) been ill with a fever at any time in the last two weeks?

404A) How many days ago did the fever start?

IF LESS THAN ONE DAY, RECORD '00'.

405) At any time during the illness, did (NAME) have blood taken from (NAME)'s finger or heel for testing?

405A) What was the result?

406) Did you seek advice or treatment for the fever from any source?

407) Where did you seek advice or treatment?

Anywhere else?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

NAME OF PLACE _____

408) CHECK 407:

409) Where did you first go for advice or treatment?

USE LETTER CODES FROM 407.

409A) How many days after the fever began did you first seek advice or treatment for (NAME)?

IF SAME DAY, RECORD '00'.

410) At any time during the illness, did (NAME) take any drugs for the fever?

411) What drugs did (NAME) take?

Any other drugs?

411A) Did you have to pay out of pocket for drugs and services you received related to (NAME)'s fever?

RECORD COST IN ARIARY. IF MORE THAN 99 000 ARIARY, RECORD 99 000.

412) CHECK 411: CODE A-O CIRCLED?

413) CHECK 411: CODE A-J (COMBINATION WITH ARTEMISININE) CIRCLED?

414) How long after the fever started did (NAME) first take (DRUG A-J CIRCLED IN 411)?

415) For how many days did (NAME) take (DRUG A-J CIRCLED IN 411)?

IF 7 DAYS OR MORE, RECORD '7'.

416) How many tablets of (DRUG A-J CIRCLED IN 411) did (NAME) take per day?

IF 7 TABLETS OR MORE, RECORD '7'.

417) CHECK 411: SP/FANSIDAR ('K') GIVEN

418) How long after the fever started did (NAME) first take SP/Fansidar?

419) For how many days did (NAME) take SP/Fansidar?

IF 7 DAYS OR MORE, RECORD '7'.

420) How many tablets of SP/Fansidar did (NAME) take per day?

IF 7 TABLETS OR MORE, RECORD '7'.

421) CHECK 411: CHLOROQUINE ('L') GIVEN

422) How long after the fever started did (NAME) first take Chloroquine?

423) For how many days did (NAME) take Chloroquine?

IF 7 DAYS OR MORE, RECORD '7'.

424) How many tablets of Chloroquine did (NAME) take per day?

IF 7 TABLETS OR MORE, RECORD '7'.

425) CHECK 411: AMODIAQUINE ('M') GIVEN

426) How long after the fever started did (NAME) first take amodiaquine?

427) For how many days did (NAME) take amodiaquine?

IF 7 DAYS OR MORE, RECORD '7'.

428) How many tablets of amodiaquine did (NAME) take per day?

IF 7 TABLETS OR MORE, RECORD '7'.

429) CHECK 411: QUININE ('N') GIVEN

430) How long after the fever started did (NAME) first take quinine?

431) For how many days did (NAME) take quinine?

IF 7 DAYS OR MORE, RECORD '7'.

432) How many tablets of quinine did (NAME) take per day?

IF 7 TABLETS OR MORE, RECORD '7'.

433) CHECK 411: OTHER ANTIMALARIAL ('O') GIVEN

434) How long after the fever started did (NAME) first take (OTHER ANTIMALARIAL)?

435) For how many days did (NAME) take (OTHER ANTIMALARIAL)?

IF 7 DAYS OR MORE, RECORD '7'.

436) How many tablets of (OTHER ANTIMALARIAL) did (NAME) take per day?

IF 7 TABLETS OR MORE, RECORD '7'.

437) Did (NAME) take all the anti-fever drugs prescribed to him/her?

438) Why did (NAME) not take all the drugs prescribed to him/her?

439) Did (NAME) have any of the following symptoms?

440) Has (NAME) ever been hospitalized because of severe malaria?

441) For how many days?

IF 7 DAYS OR MORE, RECORD '7'.

442) GO BACK TO 404 IN THE NEXT COLUMN; OR IF THERE ARE NO MORE BIRTHS, GO TO 443.

443) When your child/children have a fever, how important or unimportant is it to seek antimalarial treatment immediately?

Is it extremely important, very important, a little important, or not at all important?"

IF IMPORTANT: Is it extremely important or very important?

IF NOT IMPORTANT: Is it a little important or not at all important?

444) When your child/children have a fever, do you agree or disagree that the child should first be treated with medicinal herbs or other practices?

IF YES (AGREE): Do you strongly agree or agree?

IF NO (DISAGREE): Do you strongly disagree or disagree?

445) When your child/children had a fever, how affordable or unaffordable was treatment? Was it very affordable, affordable, unaffordable, or very unaffordable?

446) When your child/children have a fever, are anti-malarial drugs available or not available?

IF AVAILABLE: Are they always available or sometimes available?

IF NOT AVAILABLE: Are they rarely available or never available?

447) Do you keep partial doses of antimalarial drugs for possible future use?

SECTION 5. KNOWLEDGE OF MALARIA

501) How can people get malaria?

PROBE: Any other ways?

RECORD ALL MENTIONED.

502) What do you think is the main symptom of malaria?

503) What are effective ways of preventing malaria?

PROBE: Any other way?

RECORD ALL MENTIONED.

504) Which people are most likely to get a serious case of malaria?

PROBE: Anyone else?

RECORD ALL MENTIONED.

504A) During the months of September, October, and November of 2015, did you hear or receive messages about the long-lasting insecticidal mosquito net (LLIN) distribution campaign?

504B) Did you hear or receive these messages BEFORE the distribution campaign?

504C) How did you hear or receive these messages?

Any other ways?

RECORD ALL MENTIONED.

504D) Did you hear or receive messages DURING the distribution campaign?

504E) How did you hear or receive these messages?

Any other ways?

RECORD ALL MENTIONED.

504F) Did you hear or receive messages AFTER the distribution campaign?

504G) How did you hear or receive these messages?

Any other ways?

RECORD ALL MENTIONED.

504H) What messages did you hear or receive (before, during, or after the distribution campaign)?

Any other messages?

RECORD ALL MENTIONED.

504I) In the last 12 months, how many times did you hear messages on malaria awareness?

IF 6 OR MORE TIMES, RECORD '6'.

505) In the last 12 months, have you:

506) In the last 12 months, have you received messages on malaria treatment regarding:

507) In the last 12 months, have you:

508) In the last 12 months, have you received messages about LLINs for malaria prevention regarding:

509) In the last 12 months, have you received messages about the intra-household spraying campaign (CAID) for malaria prevention regarding:

510) In the last 12 months, have you received messages about malaria prevention for pregnant women regarding:

510A) In the last 12 months, have you attended any malaria control information sessions in a public place, given by a community health worker such as, for example, information sessions in small groups during market days?

510B) What were the topics of the information session?

Any other topic?

RECORD ALL MENTIONED

510C) In the last 12 months, has your household been visited by a community health worker to discuss malaria control?

510D) What topics did you discuss?

Any other topic?

RECORD ALL MENTIONED

510E) In the last 12 months, have you attended a large outdoor event about malaria control?

510F) What types of events?

Any other events?

RECORD ALL MENTIONED

511) Do you know of a place where you can obtain antimalarial drugs?

512) Does a child with a fever need to go to a health center or see a community health worker, or can he/she stay home to receive treatment?

512A) Does a pregnant woman with a fever need to go to a health center or see a community health worker or can she stay home to receive treatment?

513) Have you heard of:

514) What do you think is the most effective antimalarial for treating pregnant women with malaria symptoms?

DO NOT READ ANSWERS

515) What do you think is the most effective antimalarial for treating children younger than 5 years old?

DO NOT READ ANSWERS

516) What does a pregnant woman need to do to prevent malaria?

RECORD ALL MENTIONED

517) Where does a pregnant woman need to go to receive doses of intermittent preventative treatment (SP) during her pregnancy?

518) Do you agree or disagree with the following statement: Your friends or neighbors encourage pregnant women to obtain SP tablets from health centers to prevent malaria?

IF AGREE: Do you strongly agree or agree?

IF DISAGREE: Do you strongly disagree or disagree?

519) What do you think are the advantages of sleeping under an insecticidal mosquito net?

PROBE: Any other advantages?

DO NOT READ ANSWERS

RECORD ALL MENTIONED

520) What do you think are the disadvantages of sleeping under an insecticidal mosquito net?

DO NOT READ ANSWERS

RECORD ALL MENTIONED

521) For how many months or seasons of the year do people need to sleep under an insecticidal mosquito net?

522) Do you think that a mosquito net sold for 3000 ariary is affordable?

523) Do you have conversations with friends or neighbors about malaria often, rarely, or never?

524) How important do you think it is for your children to sleep under an insecticidal net: extremely important, very important, a little important, or not important?

525) Do you ever use mosquito nets for anything other than sleeping under them?

526) Now I would like to know what you think about certain statements. I ask that you try to say what you really think. The questions may seem repetitive, but I will ask them to get a clear picture of your opinion.

527) Do you agree or disagree with the following statement: insecticidal mosquito nets have negative health effects.

Do you agree or disagree?

IF AGREE: Do you strongly agree or agree?

IF DISAGREE: Do you strongly disagree or disagree?

528) Do you agree or disagree with the following statement: You can hang a mosquito net anywhere people sleep in your home.

Do you agree or disagree?

IF AGREE: Do you strongly agree or agree?

IF DISAGREE: Do you strongly disagree or disagree?

529) Do you agree or disagree with the following statement: You are only likely to contract malaria during the rainy season.

Do you agree or disagree?

IF AGREE: Do you strongly agree or agree?

IF DISAGREE: Do you strongly disagree or disagree?

530) What places do you know where you can get a LLIN for your family?

Anywhere else?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

NAME OF PLACE _____

531) What places do you know where you can get a LLIN for pregnant women?

Anywhere else?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

NAME OF PLACE _____

532) RECORD THE TIME.

FIELDWORKER OBSERVATIONS.

TO BE COMPLETED AFTER INTERVIEW.

COMMENTS ON THE INTERVIEW:

____

COMMENTS ON SPECIFIC QUESTIONS:

____

OTHER COMMENTS:

____

SUPERVISOR OBSERVATIONS

_____

EDITOR OBSERVATIONS

____