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SIXTH DEMOGRAPHIC AND HEALTH SURVEY IN MALI (EDSM-VI 2018)
BIOMARKER QUESTIONNAIRE

PLACE NAME
NAME OF HEAD OF HOUSEHOLD
PLOT NUMBER
CLUSTER NUMBER
HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS
1 2 3
DATE

INTERVIEWER'S NAME
RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7

FINAL VISIT
DAY
MONTH
YEAR 2018
INT. NUMBER
RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7

NEXT VISIT
DATE
TIME

TOTAL NO. OF VISITS

NOTES

TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE CHILDREN

LANGUAGE OF QUESTIONNAIRE: FRENCH 01

LANGUAGE OF INTERVIEW

FRENCH 01
BAMBARA/MALINKE 02
SONRAI/DJERMA 03
PEUHL/FOULFOULDE 04
SENOUFO 05
MARKA/SONINKE 06
MINIANKA 08
TAMACHECK 09
BOBO/DAFING 10
BOZO/SOMONO 11
OTHER (SPECIFY) 96

NATIVE LANGUAGE OF RESPONDENT

FRENCH 01
BAMBARA/MALINKE 02
SONRAI/DJERMA 03
PEUHL/FOULFOULDE 04
SENOUFO 05
MARKA/SONINKE 06
MINIANKA 08
TAMACHECK 09
BOBO/DAFING 10
BOZO/SOMONO 11
OTHER (SPECIFY) 96

TRANSLATOR USED

YES 1
NO 2

LANGUAGE OF QUESTIONNAIRE: FRENCH 01

SUPERVISOR
NAME
DATE

WEIGHT, HEIGHT, HEMOGLOBIN, AND MALARIA TEST FOR CHILDREN AGE 0-5

101) Check column 11 of the household schedule. Record the line number and the name for all eligible children 0-5 years in q. 102; if more than six children, use additional questionnaire(s).

CHILD 1
CHILD 2
CHILD 3

102) CHECK LINE NUMBER FROM COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE

LINE NUMBER
NAME

103) IF MOTHER INTERVIEWED, COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM BIRTH HISTORY. IF MOTHER NOT INTERVIEWED, ASK: What is (name)'s date of birth?

DAY
MONTH
YEAR

104) CHECK 103: Child born 2013-2018?

YES 1
NO 2 (SKIP TO 136)

105) WEIGHT IN KILOGRAMS

KG
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

106) HEIGHT IN CENTIMETERS

CM ___
NOT PRESENT 9994 (SKIP TO 108)
REFUSED 9995 (SKIP TO 108)
OTHER 9996 (SKIP TO 108)

107) Measured lying down or standing up?

LYING DOWN 1
STANDING UP 2

108) MEASURER: ENTER YOUR INTERVIEWER NUMBER

INTERVIEWER NUMBER

110) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN Q. 102; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

CHILD 1
CHILD 2
CHILD 3

102) CHECK LINE NUMBER FROM COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE

LINE NUMBER
NAME

109) CHECK 103:
If child age 0-5 months, i.e. was child born in month of interview or five previous months?

0-5 MONTHS 1 (SKIP TO 136)
OLDER 2

110) LINE NUMBER FROM PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD 00 IF NOT LISTED.

LINE NUMBER

111) Ask consent for anemia test from parent/other adult

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 and set up programs to prevent and treat anemia. We ask that all children born in 2013 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 been 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 member 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 child) to participate in the anemia test?

112) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
REFUSED 2 (SIGN)
NOT PRESENT/OTHER 3

113) Ask consent for malaria test from parent/other adult

As part of this survey, we are asking people all over the country to take a malaria test. Malaria is a serious health problem caused by a parasite transmitted by mosquito bites. This survey will assist the government to develop and set up programs to prevent and treat malaria.

We ask that all children born in 2013 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. We will use the blood from the anemia test. A drop of blood will be tested for malaria immediately, and you will receive the results right away. A treatment will be proposed for children who have simple malaria if they aren't already receiving treatment. Children with serious malaria will be referred to a health care establishments.
The result will be kept strictly confidential and will not be shared with anyone other than member 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 child) to participate in the malaria test?

114) Circle the appropriate code, sign your name, and record your interviewer number

GRANTED 1 (SIGN AND RECORD YOUR FIELD AGENT NUMBER)
REFUSED 2 (SIGN AND RECORD YOUR FIELD AGENT NUMBER)
NOT PRESENT/OTHER 3

115) Prepare the equipment and supplies for the test(s) for which consent has been obtained and proceed with the test(s).

116) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA AND MALARIA PAMPHLET.
G/DL

NOT PRESENT 994
REFUSED 995
OTHER 996

117) RECORD TDR MALARIA RESULT CODE [TDR=Rapid Diagnostic Test]

TESTED 1
NOT PRESENT 2 (SKIP TO 119)
REFUSED 3 (SKIP TO 119)
OTHER 6 (SKIP TO 119)

118) RECORD TDR MALARIA RESULT CODE HERE AND IN ANEMIA AND MALARIA PAMPHLET.

POSITIVE, PF 1 (SKIP TO 121)
NEGATIVE 2
OTHER 6

119) CHECK 116: Hemoglobin level

BELOW 7.0 G/DL SEVERE ANEMIA 1
7.0 G/DL OR HIGHER 2
NOT PRESENT 4
REFUSED 5
OTHER 6
2-6 (SKIP TO 136)

120) REFERENCE DECLARATION FOR SEVERE ANEMIA
RECORD THE RESULT OF THE ANEMIA TEST ON THE REFERENCE SHEET
The anemia diagnostic test show that (name of child) has severe anemia. You child is seriously ill and must be taken to a health care establishment immediately.

SKIP TO 114

121) Did (name) suffer from any of the following illness or present one or more of the following symptoms?

EXTREME WEAKNESS?
YES 1
NO 2
LOSS OF APPETITE?
YES 1
NO 2
VOMITING?
YES 1
NO 2
LOSS OF CONSCIOUSNESS?
YES 1
NO 2
RAPID OR DIFFICULTY BREATHING?
YES 1
NO 2
MULTIPLE CONVULSIONS?
YES 1
NO 2
ABNORMAL BLEEDING?
YES 1
NO 2
JAUNDICE/YELLOW SKIN?
YES 1
NO 2

122) CHECK 121: Any "Yes" code circled?

NO
YES (SKIP TO 125)

123) CHECK 116: HEMOGLOBIN LEVEL

UNDER 7.0 G/DL 1-SKIP TO 125
7.0 D/DL OR HIGHER 2
NOT PRESENT 4
REFUSED 5
OTHER 6

124) In the last two weeks, has (name) taken or is (name) taking CTA given to him/her by a doctor, a health care establishment. or a community health agent to treat malaria?
CHECK BY ASKING TO SEE THE TREATMENT

YES 1 (SKIP TO 126)
NO 2 (SKIP TO 127)

125) REFERENCE DECLARATION FOR SERIOUS MALARIA
RECORD THE RESULT OF THE MALARIA TEST IN THE REFERENCE SHEET.
The diagnostic test for malaria shows that (name of child) has malaria. Your child has the symptoms of serious malaria. The antimalarial drugs that I have will not help your child, and I cannot give him/her treatment. Your child is seriously ill and must be taken to a health care establishment immediately.

SKIP TO 131

126) REFERENCE DECLARATION FOR CHILDREN ALREADY TAKING CTA DRUG.
You told me that (NAME OF CHILD) already received CTA for malaria. I cannot give you extra CTA. However, the test shows that he/she has malaria. If your child had a fever in the two days after the last dose of CTA, you must bring the child to the closest health care establishment for further testing.

SKIP TO 131

127) READ INFORMATION FOR MALARIA TREATMENT AND THE DECLARATION OF CONSENT TO THE PARENTS OR OTHER ADULT RESPONSIBLE FOR THE CHILD.
The malaria test shows that your child has malaria. We can give you free drugs. The drug is called CTA. CTA is very effective and in a few days, he/she will not have a fever or any other symptoms. You are not obligated to give the drug to the child. It is up to you to decide. Please tell me, do you accept the drug or not?

128) CIRCLE THE APPROPRIATE CODE AND SIGN.

DRUG ACCEPTED 1 (SIGNATURE)
REFUSED 2
OTHER 6

129) CHECK 128: Drug accepted

DRUG ACCEPTED 1
REFUSED 2 (SKIP TO 131)
OTHER 6 (SKIP TO 131)

130) Treatment for children with positive malaria test
Treatment with Artemether / Lumefantrine (AL)

CHILD LESS THAN THREE YEARS OLD
(ROSE STRIPED BROCHURE)
DAY 1: 1 TABLE TWICE A DAY
DAY 2: 1 TABLE TWICE A DAY
DAY 3: 1 TABLE TWICE A DAY
CHILD AGE 3-5
(PURPLE STRIPED BROCHURE)
DAY 1: 2 TABLE TWICE A DAY
DAY 2: 2 TABLE TWICE A DAY
DAY 3: 2 TABLE TWICE A DAY

Tell the parents/adult responsible for child: If (name) has a high fever, difficulty or rapid breathing, if he/she cannot drink or breastfeed, if his/her condition worsens or if he/she doesn't get better in two days, you must take him/her to a health professional for treatment immediately.

SKIP TO 136

131) CHECK 116: Hemoglobin level

BELOW 7.0 G/DL SEVERE ANEMIA 1
7.0 G/DL OR HIGHER 2
NOT PRESENT 4
REFUSED 5
OTHER 6
2-6 SKIP TO 136

132) REFERENCE DECLARATION FOR SEVERE ANEMIA
RECORD THE RESULT OF THE ANEMIA TEST ON THE REFERENCE SHEET
The anemia diagnostic test show that (name of child) has severe anemia. You child is seriously ill and must be taken to a health care establishment immediately.

136) GO BACK TO Q 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR THE FIRST COLUMN OF THE NEXT PAGE. IF NO MORE CHILDREN, GO TO 201.

WEIGHT, HEIGHT AND HEMOGLOBIN FOR WOMEN AGE 15-49

201) CHECK COLUMN 9 OF THE HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AND MARITAL STATUS FOR ALL WOMEN ELIGIBLE FOR Q 202, 203, AND 204. IF MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

WOMEN 1
WOMEN 2
WOMEN 3

202) CHECK HOUSEHOLD QUESTIONNAIRE:

LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2
LINE NUMBER
NAME

203) CHECK HOUSEHOLD QUESTIONNAIRE: Column 7 (age)

15-17 YEARS 1
18-49 YEARS 2

204) CHECK HOUSEHOLD SCHEDULE: Column 8 (marital status)

CODE 4 (NEVER IN UNION) 1
OTHER 2

205) WEIGHT IN KILOGRAMS

KG ___
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

206) HEIGHT IN CENTIMETERS

CM ___
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

207) MEASURER: ENTER YOUR INTERVIEW NUMBER

INTERVIEWER NUMBER

208) CHECK 203: AGE

15-17 YEARS 1
18-49 YEARS 2 (SKIP TO 210)

209) CHECK 204: MARITAL STATUS

CODE 4 (NEVER IN UNION) 1 (SKIP TO 216)
OTHER 2

ADULT RESPONDENT CONSENT FOR ANEMIA TEST

210) Ask for consent for anemia test .

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.

For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take 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 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 to the test, or you can say no. It is up to you to decide.

Will you take the anemia test?

211) CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
RESPONDENT REFUSED 2 (SIGN THEN SKIP TO 229)
NOT PRESENT 3 (SKIP TO 229)

211a) CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1 (SKIP TO 229)
NO 2 (SKIP TO 229)
DON'T KNOW 8 (SKIP TO 229)

216) RECORD THE LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT.
LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT.

RECORD 00 IF NOT LISTED

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST

217) Ask for consent for anemia test from parent/other adult.

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.

For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take 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 will be told to you and (name of minor) 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 to the test, or you can say no. It is up to you to decide.

Will you allow (name of minor) to take the anemia test?

218) Circle the appropriate code and sign.

GRANTED 1 (SIGN)
PARENT/OTHER RESPONSIBLE ADULT REFUSED (IF REFUSED, SKIP TO 229)
NOT PRESENT 3 (SKIP TO 229)

MINOR RESPONDENT CONSENT FOR ANEMIA TEST

219) Ask for consent for anemia test from respondent.

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.

For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take 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 will be told to you and (name of parent/responsible adult) 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 to the test, or you can say no. It is up to you to decide.

Will you take the anemia test?

220) CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
MINOR RESPONDENT REFUSED 2 (IF REFUSED, SKIP TO 229)
NOT PRESENT 3 (SKIP TO 229)

220a) CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: are you pregnant?

YES 1
NO 2
DON'T KNOW 8

229) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

231) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL
ABSENT 994
REFUSED 995
OTHER 996

236) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, END THE INTERVIEW.

INTERVIEWER'S OBSERVATIONS

To be filled in after completing interview

SUPERVISOR'S OBSERVATIONS

_______________________
_______________________
_______________________