SEPTEMBER 2015
MALARIA INDICATORS SURVEY IN MALI ("EIPM" 2015)
HOUSEHOLD QUESTIONNAIRE
MALI
NATIONAL INSTITUTE OF STATISTICS ("INSTAT")
NATIONAL PROGRAM IN FIGHT AGAINST MALARIA ("PNLP")
INFO-STAT ICF INTERNATIONAL
IDENTIFICATION
NAME OF LOCALITY ______
NAME OF HEAD OF HOUSEHOLD ______
CLUSTER NUMBER ______
CONCESSION NUMBER ______
HOUSEHOLD NUMBER ______
ADMINISTRATIVE REGION ______
ENVIRONMENT (URBAN = 1, RURAL = 2) ______
DETAILED ENVIRONMENT (BAMAKO = 1, OTHER CITY = 2, RURAL = 3) ______
INTERVIEWER VISITS
(Repeat for up to 3 visits)
DATE _____
NAME OF INTERVIEWER ______
RESULT ______
TIME ______
MONTH ______
YEAR 2015
INTERVIEWER NUMBER ______
RESULT ______
2 NO FAMILY MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR LONG PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR NO DWELLING AT ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ______
TOTAL IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN ______
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE ______
INTRODUCTION AND INFORMED CONSENT
Hello. My name is ______. I work for the National Program in the Fight Against Malaria "PNLP", the National Institute of Statistics "INSTAT", and INFO-STAT. We are conducting a national survey of malaria over the entire country. The information that we collect will help the government improve health services. Your household was selected for this survey. We would like to ask you a few questions about your household. The questions usually take about between 5 and 10 minutes. All the information that you give us is strictly confidential and will not be shared with anyone other than members of the survey team. You are not obligated to participate in this survey, but we hope that you will accept to answer our questions for your opinion is very important. If I happen to ask a question that you do not want to answer, tell me and I will go on to the next question; you can also stop the interview at any time.
If you would like more information about the survey, you can also contact the persons named on this card.
GIVE THE CARD WITH CONTACT INFORMATION FOR THESE PERSONS
May I begin the interview now?
DATE ______
2 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED (Skip to END)
HOUSEHOLD SCHEDULE
(Repeat Q.1 - 11 for up to 20 household members)
1. LINE NUMBER
2. HABITUAL 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 GENDER FOR EACH PERSON, ASK QUESTIONS 2A - 2C TO MAKE SURE THAT THE LIST IS COMPLETE. THEN ASK THE APPROPRIATE QUESTIONS IN COLUMNS 5 - 11 FOR EACH PERSON.
3. RELATIONSHIP TO HEAD OF HOUSEHOLD
What is (NAME)'s relationship to the head of the household?
SEE CODES BELOW.
CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW/DAUGHTER-IN-LAW
05 GRANDSON/GRANDDAUGHTER
06 FATHER/MOTHER
07 IN-LAWS
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED/FOSTER
11 STEPCHILD
12 CO-WIFE
13 NO RELATION
98 DK
4. GENDER
Is (NAME) male or female?
2 FEMALE
2A) Just to be sure that I have a complete list: are there any other people like small children or infants whom we have not listed?
NO ______
2B) Are there any people who are perhaps not family members, such as servants, renters or friends who usually live here?
NO ______
2C) Do you have any guests or temporary visitors who are in your home, or other people who slept here last night and were not listed?
NO ______
5. RESIDENCE
Does (NAME) usually live here?
2 NO
6. RESIDENCE
Did (NAME) stay here last night?
2 NO
IF 95 OR OLDER, RECORD '95'
8. IF 15 OR OLDER
MARITAL STATUS
What is (NAME)'s current marital status?
2 DIVORCED/SEPARATED
3 WIDOWED
4 NEVER MARRIED AND NEVER LIVED WITH ANYONE
______
9. WOMAN AGE 15 - 49
ELIGIBILITY
CIRCLE THE LINE NUMBER OF ALL WOMEN AGE 15 - 49.
11. CHILD AGE 0 - 5
CIRCLE THE LINE NUMBER OF ALL CHILDREN AGE 0 - 5
CHECK HERE IF ADDITIONAL PAGE IS USED ______
HOUSEHOLD CHARACTERISTICS
102. Where does the drinking water used by members of your household mainly come from?
12 FAUCET IN YARD/PLOT (Skip to 107)
13 PUBLIC FAUCET/FIRE HYDRANT FAUCET AT NEIGHBOR'S
14 FAUCET AT NEIGHBOR'S
31 PROTECTED WELL
32 UNPROTECTED WELL
42 UNPROTECTED SPRING
61 TANKER TRUCK
71 CART WITH SMALL CISTERN/BARREL
81 SURFACE WATER (RIVERS/DAMS/LAKES/PONDS/IRRIGATION CANALS)
91 BOTTLED WATER
96 OTHER (SPECIFY) ______
103. Where is this water source located?
2 IN YOUR YARD/PLOT (Skip to 107)
3 ELSEWHERE
104. How long does it take to go there, fetch water, and come back?
998 DK
107. What kind of toilets do members of your household usually use?
12 FLUSH CONNECTED TO SEPTIC TANK
13 FLUSH CONECTED TO LATRINE
14 FLUSH CONNECTED TO SOMETHING ELSE
15 FLUSH CONNECTED TO UNKNOWN PLACE
22 PIT LATRINE WITH SLAB
23 PIT LATRINE WITHOUT SLAB, OPEN PIT
41 BUCKET/PAIL
51 SUSPENDED TOILETS/LATRINES
61 NO TOILET/NATURE (Skip to 110)
96 OTHER (SPECIFY) ______
108. Do you share these toilets with other households?
2 NO (Skip to 110)
109. How many households use these toilets?
95 10 OR MORE HOUSEHOLDS
98 DK
110. In this household, do you have: (4)
Electricity?
A radio set?
A television?
A cell phone?
A landline phone?
A refrigerator?
A table?
Chair?
Wardrobe/Bookcase?
Stove/Hot plate?
Freezer?
Hunting rifle?
Plow?
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 NO
111. What kind of fuel does your household mainly use for cooking?
02 GAS/OIL
07 CHARCOAL
08 WOOD
95 NO MEALS PREPARED IN HOUSEHOLD
96 OTHER (SPECIFY) ______
114. MAIN MATERIAL OF FLOOR
RECORD OBSERVATION.
12 DUNG/GRAVEL
33 TILE
34 CEMENT
115. MAIN MATERIAL OF ROOF.
RECORD OBSERVATION.
116. MAIN MATERIAL OF EXTERIOR WALLS.
RECORD OBSERVATION.
13 EARTH
22 STONES WITH MUD
23 UNFINISHED ADOBE
32 STONES WITH LIME/CEMENT
33 BRICKS
34 CEMENT BLOCKS
35 FINISHED ADOBE
36 WOODEN PLANKS
117. How many rooms are used for sleeping in this household?
95 UNDER TREE/OPEN AIR
118. Does any member of your household own:
A flat-bottomed boat?
A watch?
A bicycle?
A motorcycle or scooter?
An animal-drawn cart?
A car or small truck?
A motorboat?
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
2 NO
119. Does any member of your household own any agricultural land?
2 NO (Skip to 121)
120. How many hectares of agricultural land is owned by household members?
IF 95 OR MORE, CIRCLE '950'.
950 95 HECTARES OR MORE
998 DK
121. Does your household own any cattle, herds, other farm animals, or poultry?
1 YES
2 NO (Skip to 123)
122. How many of the following animals does your household own?
IF NONE, MARK '00'.
IF 95 OR MORE, MARK '95'.
IF DON'T KNOW, MARK '98'.
Horses, donkeys, or mules?
Goats?
Pigs?
Sheep?
Poultry (Chickens/Ducks, etc.)?
HORSES/DONKEYS/ MULES ______
GOATS ______
PIGS ______
SHEEP ______
CHICKENS/DUCKS ______
123. Does any member of the household have a bank account?
2 NO
124. At any time in the last 12 months has someone come to your dwelling to spray the interior walls for mosquitos?
2 NO (Skip to 126)
8 DK (Skip to 126)
125. Who sprayed the walls of the dwelling?
RECORD ALL MENTIONED.
B PRIVATE COMPANY
C NONGOVERNMENTAL ORGANIZATION (NGO)
X OTHER (SPECIFY) ______
Z DK
125A. Has the number of mosquitos in your dwelling decreased since it got sprayed?
2 NO
126. Does your household have any mosquito nets that can be used for sleeping?
2 NO (Skip to 137)
127. How many mosquito nets does your household have?
IF 7 OR MORE MOSQUITO NETS, RECORD '7'.
128. ASK RESPONDENT TO SHOW YOU THE HOUSEHOLD'S MOSQUITO NETS.
IF MORE THAN 3 MOSQUITO NETS, USE ADDITIONAL QUESTIONNAIRE(S).
(Repeat 128 - 136 for up to 3 nets)
2 NOT OBSERVED
129. How many months have you had the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'.
95 MORE THAN 36 MONTHS
98 UNSURE
130. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET
IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE MOSQUITO NET, SHOW RESPONDENT A PHOTO OF A COMMON MOSQUITO NET.
11 OLYSET
12 PERMANET
13 INTERCEPTOR
14 SERENA
16 OTHER/DK BRAND
26 DK BRAND
98 DK BRAND
131. When you got this mosquito net, had it already been treated with an insecticide to kill or repel mosquitos?
2 NO
8 UNSURE
131A. What is the shape of this mosquito net?
2 RECTANGULAR
131B. Where did you get this mosquito net?
2 ANTENATAL CONSULTATION
3 CHILD VACCINATION
4 MARKET
5 PHARMACY
6 OTHER ______
131C. Is the mosquito net hanging up?
2 NO (Skip to 136)
2 INSTALLATION AGENT
3 NEIGHBOR
8 DK
134. Last night, did anyone sleep under this mosquito net?
2 NO (Skip to 136)
8 UNSURE (Skip to 136)
135. Who slept under this mosquito net last night?
135A. RECORD PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.
135AA. At what point did (NAME) go to sleep under the mosquito net last night?
CIRCLE THE RESPONSE CATEGORY THAT CORRESPONDS TO ANSWER GIVEN BY RESPONDENT.
AFTER EVENING MEAL/AFTER TV NEWS/AFTER "SAFO" PRAYERS :
2 20:30 TO 23:00
3 23:00 TO 1 IN MORNING
4 AFTER 1 IN MORNING
8 DK
[###translator's note: unable to translate "SAFO"; it is the name of a village in Mali but no further information]
135B. Who else slept under this mosquito net last night?
LINE NUMBER
LINE NUMBER ______
135BB. At what point did (NAME) go to sleep under the mosquito net last night?
CIRCLE THE RESPONSE CATEGORY THAT CORRESPONDS TO ANSWER GIVEN BY RESPONDENT.
AFTER EVENING MEAL/AFTER TV NEWS/AFTER "SAFO" PRAYERS:
2 20:30 TO 23:00
3 23:00 TO 1 IN MORNING
4 AFTER 1 IN MORNING
8 DK
135C. Who else slept under this mosquito net last night?
LINE NUMBER
LINE NUMBER ______
135CC. At what point did (NAME) go to sleep under the mosquito net last night?
CIRCLE THE RESPONSE CATEGORY THAT CORRESPONDS TO ANSWER GIVEN BY RESPONDENT.
AFTER EVENING MEAL/AFTER TV NEWS/AFTER "SAFO" PRAYERS:
2 20:30 TO 23:00
3 23:00 TO 1 IN MORNING
4 AFTER 1 IN MORNING
8 DK
135D. Who else slept under this mosquito net last night?
LINE NUMBER
LINE NUMBER ______
135DD. At what point did (NAME) go to sleep under the mosquito net last night?
CIRCLE THE RESPONSE CATEGORY THAT CORRESPONDS TO ANSWER GIVEN BY RESPONDENT.
AFTER EVENING MEAL/AFTER TV NEWS/AFTER "SAFO" PRAYERS:
2 20:30 TO 23:00
3 23:00 TO 1 IN MORNING
4 AFTER 1 IN MORNING
8 DK
136. GO BACK TO 128 FOR NEXT MOSQUITO NET, OR, IF NO MORE MOSQUITO NETS, CONTINUE TO 137.
137. Before the last distribution campaign in 2015, did your household receive any treated nets during other distribution campaigns?
2 NO (Skip to 144)
138. How many of these mosquito nets from distribution campaigns did your household own before the last 2015 campaign?
98 DK
138A. Of these mosquito nets, did you get some of them during
2 NO (Continue to "2")
2 NO (Continue to "3")
2 NO (Continue to "4")
2 NO (Continue to "5")
2 NO
138B. How many mosquito nets did you receive during this campaign?
Campaign 2 ______
Campaign 3 ______
Campaign 4 ______
Campaign 5 ______
138C. Of the mosquito nets received during this campaign:
Campaign 2 ______
Campaign 3 ______
Campaign 4 ______
Campaign 5 ______
Campaign 2 ______
Campaign 3 ______
Campaign 4 ______
Campaign 5 ______
139A. TOTAL NUMBER OF MOSQUITO NETS OBTAINED
CHECK COLUMN 138B
ADD UP ALL THE MOSQUITO NETS RECORDED IN COLUMN 138B AND RECORD THE TOTAL NUMBER IN THIS BOX.
IF "DK" CODE '98' WAS RECORDED IN Q. 138, RETURN TO Q. 138 TO RECORD THE TOTAL NUMBER OBTAINED IN Q. 139A.
139B. TOTAL NUMBER OF MOSQUITO NETS ALREADY USED
ADD UP ALL THE MOSQUITO NETS RECORDED IN COLUMN 138CA AND RECORD THE TOTAL NUMBER IN THIS BOX
139C. TOTAL NUMBER OF MOSQUITO NETS CURRENTLY USED
CHECK COLUMN 138CB
RECORD THE TOTAL NUMBER IN THIS BOX
SEVERAL MOSQUITO NETS (Q 139A IS EQUAL TO 2 OR MORE) ______ (Skip to 142)
ANY SINGLE MOSQUITO NET USED (Q 139B = 1) ______ (Skip to 144)
141. Why didn't your household use this mosquito net?
RECORD ALL MENTIONED.
A MOSQUITO NET NOT EFFECTIVE
B SOME HOUSEHOLD MEMBERS DON'T LIKE MOSQUITO NETS
C SIZE IS NOT SATISFACTORY
D SHAPE IS NOT SATISFACTORY
E BAD SMELL
F CAUSES IRRITATIONS/COUGH
G MAKES SICK
H MAKES NAUSEOUS
I DANGEROUS CHEMICAL PRODUCTS
J CAN SUFFOCATE/BREATHING DIFFICULTIES
K HEAT
L MOSQUITO NET GETS DIRTY QUICKLY
M ALREADY USING OTHER MOSQUITO NETS
N NO REASON
X OTHER (SPECIFY) ______
Z DK
CHECK IF ALL MOSQUITO NETS RECORDED IN 139A WERE USED IN 139B
2 YES, SOME (Q 139A GREATER THAN Q 139B)
3 NO, NONE (Q 139B = 0)
B SOME HOUSEHOLD MEMBERS DON'T LIKE MOSQUITO NETS
C SIZE IS NOT SATISFACTORY
D SHAPE IS NOT SATISFACTORY
E BAD SMELL
F CAUSES IRRITATIONS/COUGH
G MAKES SICK
H MAKES NAUSEOUS
I DANGEROUS CHEMICAL PRODUCTS
J CAN SUFFOCATE/BREATHING DIFFICULTIES
K HEAT
L MOSQUITO NET GETS DIRTY QUICKLY
M ALREADY USING OTHER MOSQUITO NETS
N NO REASON
X OTHER (SPECIFY) ______
Z DK
144. Did your household receive the treated mosquito nets during the distribution campaign of 2015?
2 NO (Skip to 146)
145. How many mosquito nets did your household receive?
98 DK
146. Did anyone visit your household after the campaign to talk to you about mosquitos?
2 NO (Skip to 201)
2 Explain the importance of sleeping under an LLIN every night?
1 HOW TO HANG LLIN
2 NO
8 DK
2 IMPORTANCE OF SLEEPING UNDER LLIN
2 NO
8 DK
201. CHECK COLUMN 11 OF HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL CHILDREN AGE 0 - 5 YEARS IN Q. 202 IN ORDER ACCORDING TO THE LINE NUMBER. IF THERE ARE MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
NO CHILDREN AGE 0 - 5 ______ (Skip to END)
(Repeat 202 - 206 for up to 3 children)
202. LINE NUMBER FROM COLUMN 11
NAME ______
203. IF MOTHER IS RESPONDENT, COPY MONTH AND YEAR OF CHILD'S BIRTH FROM BIRTH HISTORY AND ASK THE DAY; IF MOTHER IS NOT RESPONDENT, ASK:
What is (NAME)'s birth date?
MONTH ______
YEAR ______
2 NO (GO TO 203 FOR NEXT CHILD, OR IF NO MORE CHILDREN, END INTERVIEW)
2 OLDER
206. LINE NUMBER OF CHILD'S PARENT/OTHER RESPONSIBLE ADULT (FROM COLUMN 1 IN HOUSEHOLD SCHEDULE).
RECORD '00' IF NOT LISTED.
207. ASK CONSENT OF PARENT/OTHER RESPONSIBLE ADULT AS IDENTIFIED IN 206 FOR ANEMIA TEST:
In this survey, we are asking children all over the country to participate in anemia testing. Anemia is a serious health problem that generally results from poor nutrition, infections, or chronic illnesses. The results of this survey will help the government develop programs for preventing and treating anemia.
We are asking all children born in 2010 or later to participate in the anemia test included in this survey by giving a few drops of blood from a finger or heel. For this test, we use clean and risk-free equipment. It has never been used before and will be thrown out after each test.
The blood will be tested for anemia immediately and you will know the results right away. The results are strictly confidential and will not be shared with anyone outside of the survey team.
Do you have any questions to ask me?
You can say 'yes' to the test or you can say 'no'. It is your decision.
Will you give (NAME OF CHILD) permission to participate in the anemia test?
208. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGNATURE) ______
2 REFUSED (Go to signature)
5 ABSENT
6 OTHER
209. ASK CONSENT OF CHILD'S PARENT/OTHER RESPONSIBLE ADULT AS IDENTIFIED IN 206 FOR MALARIA TEST.
As part of this survey, we are asking children all over the country to participate in a test to see if they have malaria or not. Malaria is a serious health problem caused by a parasite transmitted by a mosquito bite. This survey will help the government develop programs to prevent malaria.
We are asking all children born in 2010 or later to participate in the malaria test included in this survey by giving a few drops of blood from a finger or heel. For this test, we use clean and risk-free equipment. It has never been used before and it will be thrown away after each test. (We will use the blood from the same finger stick as for the anemia test).
A drop of blood will be tested immediately for malaria and you will be told the results right away. A few drops will be placed on one or more slides and sent to a laboratory for testing. The laboratory test results will not be shared with you. The results are strictly confidential and will not be given to anyone outside of the survey team.
Do you have any questions to ask me?
You can say 'yes' to the test or you can say 'no'. It is your decision.
Will you give (NAME) permission to participate in the malaria test?
210. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
2 REFUSED (Go to signature)
5 ABSENT
6 OTHER
211. PREPARE THE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH PERMISSION WAS GRANTED AND CONTINUE WITH THE TEST(S).
212. BARCODE STICKER FOR MALARIA TEST
ATTACH THE 1ST BARCODE STICKER HERE ______
99995 REFUSED
99996 OTHER
ATTACH THE 2ND BARCODE STICKER ON THE SLIDE AND THE 3RD ON THE TRANSMISSION SHEET.
213. RECORD THE HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA AND MALARIA BROCHURE.
994 ABSENT
995 REFUSED
996 OTHER
214. RECORD THE RESULT CODE FOR THE MALARIA RAPID TEST.
2 ABSENT (Skip to 216)
3 REFUSED (Skip to 216)
6 OTHER (Skip to 216)
215. RECORD THE RESULT OF THE MALARIA RAPID TEST HERE AND IN THE ANEMIA AND MALARIA BROCHURE.
2 SPECIES POSITIVE (OMV/PAN) (Skip to 218)
3 FP POSITIVE (OMV/PAN) (Skip to 218)
4 NEGATIVE
6 OTHER
HEMOGLOBIN LEVEL
2 8.0 G/DL OR HIGHER (Skip to 228)
4 ABSENT (Skip to 228)
5 REFUSED (Skip to 228)
6 OTHER (Skip to 228)
217. REFERRAL STATEMENT FOR SEVERE ANEMIA
SKIP TO 228
218. Does (NAME) suffer from any of the following illnesses or present any of these symptoms:
Cardiac problems?
Loss of consciousness?
Fast respiration or difficulty breathing?
Convulsions?
Abnormal bleeding?
Jaundice/yellow skin?
Dark urine?
NONE OF THE ABOVE SYMPTOMS, CIRCLE CODE Y.
B CARDIAC PROBLEMS
C LOSS OF CONSCIOUSNESS
D FAST BREATHING
E CONVULSIONS
F BLEEDING
G JAUNDICE
H DARK URINE
Y NONE OF THE ABOVE SYMPTOMS
ANY CODE A - H CIRCLED?
2 ONLY CODE Y CIRCLED
2 6.0 G/DL OR HIGHER (Skip to 222)
4 ABSENT (Skip to 222)
5 REFUSED (Skip to 222)
6 OTHER (Skip to 222)
[###translator's note: error? in Q. 216, amount was 8.0 G/DL]
221. In the last two weeks, did (NAME) take or is (NAME) taking ACT given by a doctor or health center to treat the malaria?
2 NO (Skip to 221B)
221A. ADVICE AND REFERRAL STATEMENT FOR CHILDREN ALREADY TAKING AN ACT MEDICATION.
You have told me that (NAME OF CHILD) has these symptoms that you just cited and you also just said that he/she has already been given ACT for malaria. I cannot give you any additional ACT. If your child has a fever or continues to have symptoms in the two days after the last ACT dose, you must take the child to the nearest health center for further examination.
SKIP TO 227
221B. REFERRAL STATEMENT FOR SEVERE MALARIA.
The diagnostic test for malaria shows that (NAME OF CHILD) has malaria. Your child also shows symptoms of serious malaria. The medication that I have for malaria will not help your child, and I cannot give him/her a treatment. Your child is seriously ill and must be taken to a health facility immediately.
SKIP to 227
222. In the last two weeks, did (NAME) take or is (NAME) taking ACT given by a doctor or a health center to treat the malaria?
2 NO (Skip to 224)
223. REFERRAL STATEMENT FOR CHILDREN ALREADY TAKING AN ACT MEDICATION.
You have told me that (NAME OF CHILD) has already received ACT for malaria. I cannot give you additional ACT. However, the test shows that he/she does have malaria. If your child has a fever for 2 days after the last dose of ACT, you must take the child to the nearest health facility for further treatment.
SKIP TO 227.
224. READ THE INFORMATION FOR THE TREATMENT OF MALARIA AND CONSENT STATEMENT TO CHILD'S PARENT OR OTHER RESPONSIBLE ADULT.
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 within a few days, he/she will no longer have a fever or any other symptoms. You are not obligated to give the medicine to the child. It's your decision. Please tell me whether you accept the medication or not.
225. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGNATURE) ______
2 REFUSED (Skip to 227)
6 OTHER (Skip to 227)
226. TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TEST.
Children under age of 3
Artemether-lumefantrine Tablet (AL)
(Packet with Pink Stripe)
Day 2 (1 tablet two times a day)
Day 3 (1 tablet two times a day)
Children age 3 - 5
Artemether-lumefantrine Tablet (AL)
(Packet with Purple Stripe)
Day 2 (2 tablets two times a day)
Day 3 (2 tablets two times a day)
ALSO TELL CHILD'S PARENT/RESPONSIBLE ADULT: If (NAME) has a high fever, difficult or fast breathing, if he/she cannot drink or nurse, if his/her condition worsens or doesn't improve in two days, you should take him/her immediately to see a health professional for treatment.
227. RECORD THE RESULT CODE FOR MALARIA TREATMENT OR REFERENCE SHEET
2 MEDICATION REFUSED
3 REFERRED FOR SEVERE MALARIA
4 REFERRED FOR CHILD ALREADY TAKING ACT
6 OTHER
228. RETURN TO 202 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR THE 1ST COLUMN OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, END INTERVIEW.
INTERVIEWER'S OBSERVATIONS
TO BE FILLED OUT ONCE INTERVIEW IS COMPLETED
______
COMMENTS ABOUT PARTICULAR QUESTIONS
______
OTHER COMMENTS
______
TEAM LEADER'S OBSERVATIONS
______
DATE: ______
SUPERVISOR'S OBSERVATIONS
______
DATE: ______