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DEMOGRAPHIC AND HEALTH SURVEY-MALAWI 2004-
HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PLACE NAME ________________________

DISTRICT ____________________

CLUSTER NUMBER __

HOUSEHOLD NUMBER ___

URBAN/RURAL ___

URBAN l
RURAL 2

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE ___

LARGE CITY 1
SMALL CITY 2
TOWN 3
COUNTRYSIDE 4

HOUSEHOLD SELECTED FOR MALE SURVEY AND BLOOD WORK?

YES 1
NO 2

NAME OF HOUSEHOLD HEAD ___

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER'S NAME ___________
RESULT* _____________

COMPLETED 1
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 ___
INTERVIEWER CODE ____
RESULT* _____

TOTAL NUMBER OF VISITS __

TOTAL PERSONS IN HOUSEHOLD __

TOTAL WOMEN 15-49__

TOTAL MEN 15-54 __

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __

LANGUAGE OF QUESTIONNAIRE***:

ENGLISH 3

LANGUAGE OF INTERVIEW***:

CHICHEWA 1
TUMBUKA 2
ENGLISH 3
OTHER (SPECIFY) __________________ 4

NATIVE LANGUAGE OF RESPONDENT***:

CHICHEWA 1
TUMBUKA 2
ENGLISH 3
OTHER (SPECIFY) __________________ 4

WAS A TRANSLATOR USED?

YES 1
NO 2

SUPERVISOR
NAME ________
DATE ________

FIELD EDITOR
NAME ________
DATE ________

OFFICE EDITOR____

KEYED BY____

HOUSEHOLD SCHEDULE

1) LINE NO.

LINE NUMBER___

2) USUAL 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.

NAME__________

3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?*

HEAD 01
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
CO-WIFE 09
OTHER RELATIVE 10
ADOPTED/FOSTER/ STEPCHILD 11
NOT RELATED 12
DON'T KNOW 98

4) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

5) RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

7) AGE: How old is (NAME)?

IN YEARS __

ELIGIBILITY:

8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

8A) CIRCLE LINE NUMBER OF WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE.

9) CIRCLE LINE NUMBER OF ALL MEN AGE 15-54.

10) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6.

10A) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 5-14.

11) IF AGE 5-54 YEARS: Has (NAME) been very sick for at least three months during the past 12 months? By very sick, I mean that (NAME) was too sick to work or do normal activities around the house for at least three of the past 12 months.

YES 1
NO 2

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD**

12) Is (NAME)'s natural mother alive?

YES 1
NO 2 (GO TO 14)
DON'T KNOW 8 (GO TO 14)

13) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER

LINE NUMBER___

14) Is (NAME)'s natural father alive?

YES 1
NO 2 (GO TO 16)
DON'T KNOW 8 (GO TO 16)

15) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER

LINE NUMBER___

EDUCATION:

16) IF AGE 5 YEARS OR OLDER: Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

17) What is the highest level of school (NAME) has attended? ***
What is the highest class (NAME) completed at that level? ***

LEVEL ____
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
CLASS ____
LESS THAN 1 YEAR COMPLETED 00
DON'T KNOW 98

18) IF AGE 5-24 YEARS: Is (NAME) currently attending school?

YES 1 (GO TO 20)
NO 2

19) During the current school year, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO 21)

20) During the current school year, what level and class [is/was] (NAME) attending? ***

LEVEL ____
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
CLASS ____
DON'T KNOW 98

21) During the previous school year, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO NEXT LINE)

22) During that school year, what level and class did (NAME) attend?

LEVEL ____
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
CLASS ____
DON'T KNOW 98

** CODES FOR Q.12 THROUGH Q.15
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
IN Q.13 AND Q.15, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.

TICK HERE IF CONTINUATION SHEET USED __

Just to make sure that I have a complete listing:

1) Are there any other persons such as small children or infants that we have not listed?

YES (ENTER EACH IN TABLE)
NO

2) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?

YES (ENTER EACH IN TABLE)
NO

3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?

YES (ENTER EACH IN TABLE)
NO

23. What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 25)
PIPED INTO YARD/PLOT 12 (GO TO 25)
COMMUNITY STAND PIPE 13
WATER FROM OPEN WELL
OPEN WELL IN YARD /PLOT 22 (GO TO 25)
OPEN PUBLIC WELL 23
WATER FROM COVERED WELL OR BOREHOLE
PROTECTED WELL IN YARD/PLOT 32 (GO TO 25)
PROTECTED PUBLIC WELL 33
SURFACE WATER
SPRING 41
RIVER/STREAM 42
POND/LAKE 43
DAM 44
RAINWATER 51 (GO TO 25)
TANKER TRUCK/BOWSER 61
BOTTLED WATER 71 (GO TO 25)
OTHER (SPECIFY) ______ 96

24. How long does it take you to go there, get water, and come back?

MINUTES ___
ON PREMISES 996

25. What kind of toilet facilities does your household have?

FLUSH TOILET 11
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/BUSH/FIELD 31 (GO TO 27)
OTHER (SPECIFY) ____ 96

26. Do you share these facilities with other households?

YES 1
NO 2

27. Does your household have:

Electricity?
YES 1
NO 2
A paraffin lamp?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A cellular phone?
YES 1
NO 2
A telephone (landline)?
YES 1
NO 2
A bed with a mattress?
YES 1
NO 2
A sofa set?
YES 1
NO 2
A table and chair(s)?
YES 1
NO 2
A refrigerator?
YES 1
NO 2

28. What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
LPG/NATURAL GAS 02
BIOGAS 03
PARAFFIN/KEROSENE 04
COAL, LIGNITE 05
CHARCOAL 06
FIREWOOD, STRAW 07
DUNG 08
OTHER (SPECIFY) ______ 96

29. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
BROKEN BRICKS 23
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) _________________ 96

29A. How many rooms in your household are used for sleeping?

ROOMS ____

29B. Does this household own any agricultural land?

YES 1
NO 2 (GO TO 29D)

29C. How much agricultural land does this household own?

SIZE AND UNIT_____________
ACRES ___.___
DON'T KNOW 9998

29D. Does this household own any livestock?

YES 1
NO 2 (GO TO 30)

29E. How many of the following types of animals are owned by this household?

Goats?
NUMBER OF GOATS ___
Pigs?
NUMBER OF PIGS ___
Cattle?
NUMBER OF CATTLE ___
Sheep?
NUMBER OF SHEEP ___
Chickens?
NUMBER OF CHICKENS ___

30. Does any member of your household own:

A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
A car or truck?
YES 1
NO 2

31. Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 36)

32. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

NUMBER OF NETS ___

33. ASK THE RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2 (GO TO 33C)

33A. OBSERVE THE CONDITION OF THE MOSQUITO NET:
DOES THE NET HAVE HOLES IN IT (HOLES THE SIZE OF THE TIP OF YOUR THUMB OR LARGER)?

YES 1
NO 2

33B. OBSERVE (OR ASK) THE COLOR OF THE MOSQUITO NET.

BLUE 1
GREEN 2
WHITE 3
OTHER 4

33C. OBSERVE (OR ASK) THE SHAPE OF THE MOSQUITO NET.

CONICAL 1
RECTANGLE 2

34. How long ago did your household obtain the mosquito net?

MONTHS AGO___
MORE THAN 3 YEARS AGO 96

35. Where did you get this mosquito net?

HEALTH FACILITY 1
COMMUNITY-DISTRIBUTED 2
PRIVATE SHOP 3
OTHER (SPECIFY) _____________ 4

35A. When you got the net, did it come with an insecticide treatment kit?

YES 1
NO 2
NOT SURE 8

35B. Since you got the mosquito net, was it ever soaked or dipped in an insecticide to kill or repel mosquitos?

YES 1
NO 2 (GO TO 35D)
NOT SURE 8 (GO TO 35D)

35C. How long ago was the net last soaked or dipped?
IF LESS THAN 1 MONTH, RECORD '00'.

MONTHS AGO __
MORE THAN 3 YEARS AGO 96
NOT SURE 98

35D. Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 35F)
NOT SURE 8 (GO TO 35F)

35E. Who slept under this mosquito net last night?
RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME ____________
LINE NUMBER __

35F. GO BACK TO 33 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 36.

36. What color of mosquito net do you prefer?

BLUE 1
GREEN 2
WHITE 3
OTHER (SPECIFY) ______________ 4
DON'T KNOW/NO PREFERENCE 8

37. What shape of mosquito net do you prefer?

CONICAL 1
RECTANGULAR 2
DON'T KNOW/NO PREFERENCE 8

CHILD LABOUR

Now I would like to ask you about any work children in this household may do.

39) LINE NO.
COPY LINE NUMBER OF CHILDREN AGE 5-14 FROM COLUMN (1)

LINE NUMBER_____

40) CHILD'S NAME
COPY THE NAMES OF THE CHILDREN AGE 5-14 FROM COLUMN (2)

NAME_____

41) During the past week, did (NAME) do any kind of work for someone who is not a member of this household?
IF YES: For pay?

PAID 1
UNPAID 2
NO 3 (GO TO 43)

42) Since last (DAY OF THE WEEK), about how many hours did he/she do this work for someone who is not a member of the household?*
* IF MORE THAN ONE JOB, INCLUDE ALL HOURS AT ALL JOBS.

HOURS_____

43) During the past week, did (NAME) help with house-keeping chores such as cooking, shopping, cleaning, washing clothes, fetching water, or caring for children?

YES 1
NO 2 (GO TO 45)

44) Since last (DAY OF THE WEEK), about how many hours did he/she spend doing these chores?

HOURS_____

45) During the past week, did (NAME) do any other family work on the farm or in a business?

YES 1
NO 2 (GO TO NEXT LINE)

46) Since last (DAY OF THE WEEK), about how many hours did he/she do this work?

HOURS_____

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE NUMBER OF THE ROW YOU SHOULD GO TO.
CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. THIS IS THE NUMBER OF THE COLUMN YOU SHOULD GO TO.
FIND THE BOX WHERE THE ROW AND THE COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE NUMBER OF THE WOMAN WHO WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
THEN, GO TO COLUMN 8A IN THE HOUSEHOLD SCHEDULE AND CIRCLE THE LINE NUMBER OF THE ELIGIBLE WOMAN.

FOR EXAMPLE, IF THE QUESTIONNAIRE NUMBER IS '36716', GO TO ROW '6'.
IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'.
FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE BOX ('2').
SUPPOSE THE LINE NUMBERS OF THE THREE WOMEN ARE '02', '03', AND '07', THEN THE ELIGIBLE WOMAN FOR DOMESTIC VIOLENCE QUESTIONS IS THE SECOND ONE, I.E., THE ONE ON LINE '03'.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)
TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD (COLUMN)

1 2 3 4 5 6 7 8
0 1 2 2 4 3 6 5 4
1 1 1 3 1 4 1 6 5
2 1 2 1 2 5 2 7 6
3 1 1 2 3 1 3 1 7
4 1 2 3 4 2 4 2 8
5 1 1 1 1 3 5 3 1
6 1 2 2 2 4 6 4 2
7 1 1 3 3 5 1 5 3
8 1 2 1 4 1 2 6 4
9 1 1 2 1 2 3 7 5

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT

CHECK COLUMN (10): RECORD THE LINE NUMBER, NAME AND AGE OF ALL CHILDREN UNDER AGE 6.

CHILDREN UNDER AGE 6:

47) LINE NUMBER FROM COLUMN (10)

LINE NUMBER_____

48) NAME FROM COLUMN (2)

NAME_____

49) AGE FROM COLUMN (7)

AGE_____

50) What is (NAME'S) date of birth?*
*FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM 215 IN MOTHER'S BIRTH HISTORY AND ASK DAY.

DAY ___
MONTH ___
YEAR ___

WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1999 OR LATER

51) WEIGHT (KILOGRAMS)

WEIGHT_____.__

52) HEIGHT (CENTIMETERS)

HEIGHT_____.__

53) MEASURED LYING DOWN OR STANDING UP

LYING 1
STANDING 2

54) RESULT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

TICK HERE IF CONTINUATION SHEET USED __

HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN 1999 OR LATER

56) LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

LINE NUMBER___

57) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)

GRANTED 1
SIGN _________
REFUSED 2 (GO TO NEXT LINE)

58) HEMOGLOBIN LEVEL (G/DL)

LEVEL____._

60) RESULT

MEASURED 1
REFUSED 2
NOT PRESENT 3
OTHER 6

*CONSENT STATEMENT

As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem.
You do not have to participate; however, if you do, it will help the government to develop programs to prevent and treat anemia.

We request that you agree to let me test (NAME OF CHILDREN BORN IN 1999 OR LATER) for anemia.
For the test, I will take a few drops of blood from a finger or from the heel of the child.
The test uses disposable sterile instruments that are clean and completely safe.
The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.

Do you have any questions? Do you agree to have the test done?

61) CHECK 58 AND 59:
NUMBER OF CHILDREN WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT*
*The cutoff point is 7 g/dl for children.

ONE OR MORE (GIVE EACH PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND CONTINUE WITH 62. **)
NONE (GIVE EACH PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND END HOUSEHOLD INTERVIEW.)

**If more than one child is below the cutoff point, read the statement in Q.62 to each woman who is below the cutoff point and to each parent/responsible adult of a child who is below the cutoff point.

62) We detected a low level of hemoglobin in the blood of (NAME OF CHILD(REN)).
This indicates that (NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem.
We would like to inform the doctor at ________________ about the condition of (NAME OF CHILD(REN)).
This will assist you in obtaining appropriate treatment for the condition.
Do you agree that the information about the level of hemoglobin in the blood of (NAME OF CHILD(REN)) may be given to the doctor?

NAME OF CHILD WITH HEMOGLOBIN BELOW THE CUTOFF POINT

NAME______

NAME OF PARENT/RESPONSIBLE ADULT

NAME______

AGREES TO REFERRAL?

YES 1
NO 2