MALAWI

IDENTIFICATION

PLACE NAME:

NAME OF HOUSEHOLD HEAD:

CLUSTER NUMBER:

HOUSEHOLD NUMBER:

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

HOUSEHOLD SELECTED FOR MICRONUTRIENT'S STUDY?

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY
MONTH
YEAR
INTERVIEW NUMBER
RESULT*

TOTAL NUMBER OF VISITS

TOTAL PERSONS IN HOUSEHOLD

TOTAL ELIGIBLE WOMEN

TOTAL ELIGIBLE MEN

LINE NUMBER OF RESPONDENT TO THE HOUSEHOLD QUESTIONNAIRE

LANGUAGE OF QUESTIONNAIRE

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

SUPERVISOR
NAME
NUMBER

OFFICE EDITOR
NUMBER

KEYED BY
NUMBER

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with The National Statistical Office. We are conducting a survey about health and other topics all over Malawi. 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 since 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 CARD WITH CONTACT INFORMATION

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

SIGNATURE OF INTERVIEWER ___
DATE ___

100. RECORD THE TIME.

HOUSEHOLD SCHEDULE

1. LINE NUMBER

2. USUAL RESIDENTS AND VISITORS: Please give me the names of all 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 QUESTION IN COLUMNS 5-20 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?

2B. Are there any other people who may not be members of you family, such as domestic servants, lodgers, or friends who usually live here?

2C. Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

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

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

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

6. Did (NAME) stay here last night?

7. AGE: How old is (NAME)?

IF 95 OR MORE, RECORD '95'.

IF AGE 15 OR OLDER

8. MARITAL STATUS: What is (NAME)'s current marital status?

9. ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

10. IF HOUSEHOLD IS SELECTED FOR MAN'S SURVEY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-54.

11. IF HOUSEHOLD SELECTED FOR MAN'S SURVEY: CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.

IF AGE 0-17, SURVIVORSHIP AND RESIDENCE OR BIOLOGICAL PARENTS

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

13. Does (NAME)'s natural mother usually live in this household or was she a guest last night?

IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER.

IF NO, RECORD '00'.

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

15. Does (NAME)'s natural father usually live in this household or was he a guest last night?

IF YES: What is his name?

RECORD FATHER'S LINE NUMBER.

IF NO, RECORD '00'.

IF AGE 5 YEARS OR OLDER, EVER ATTENDED SCHOOL

16. Has (NAME) ever attended school?

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

IF AGE 5-24 YEARS, CURRENT OR RECENT SCHOOL ATTENDANCE

18. Did (NAME) attend school at any time during the (2015-16) school year?

19. During (this/that) school year, what level and grad (is/was) (NAME) attending?

IF AGE 0-4, BIRTH REGISTRATION

20. Does (NAME) have a birth certificate?

IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

21. IF QUESTION 20 WAS CODE 1 OR 2: Was (NAME)'s birth registered with the district commissioner, hospital, registrar general's office or the traditional village chief?

SELECTION OF WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS

CHECK FRONT COVER

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER OF THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 9 SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO THE ROW '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HER NAME AND LINE NUMBER IN

30. NAME OF SELECTED WOMAN ___
HOUSEHOLD LINE NUMBER OF SELECTED WOMAN ___

HOUSEHOLD CHARACTERISTICS

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

102. What is the main soured of water used by your household for other purposes such as cooking and hand washing?

103. Where is that water source located?

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

105. CHECK 101 AND 102: CODE '14' OR '21' CIRCLED?

106. In the past two weeks, was the water from this source not available for at least one full day?

107. Do you do anything to the water to make it safer to drink?

108. What do you usually do to make the water safer to drink? Anything else?

RECORD ALL MENTIONED.

109. What kind of toilet facility do members of your household usually use?

IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.

110. Do you share this toilet facility with other households?

111. Including your own household, how many households use this toilet facility?

112. Where is this toilet facility located?

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

114. Is the cooking usually done in the house, in separate building, or outdoors?

115. Do you have a separate room which is used as a kitchen?

116. How many rooms in this household are used for sleeping?

117. Does this household own any livestock, herds, other farm animals, or poultry?

118. How many of the following animals does this household own?

IF NONE, RECORD '00'.

IF 95 OR MORE, RECORD '95'.

IF UNKNOWN, RECORD '98'.

119. Does any member of this household own any agricultural land?

120. How many hectares of agricultural land do members of this household own?

IF 95 OR MORE, CIRCLE '950'.

121. Does your household have:

122. Does any member of this household own:

123. Does any member of this household have a bank account?

124. How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less often than once a month, or never?

125. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

126. Who sprayed the dwelling?

127. Does your household have any mosquito nets?

128. How many mosquito nets does your household have?

IF 7 OR MORE NETS, RECORD '7'.

MOSQUITO NETS

129. ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD.

IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

129A. Is the net hanging for sleeping?

130. How many months ago did your household get the mosquito net?

IF LESS THAN ONE MONTH AGO, RECORD '00'.

131. 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.

132. Since you go the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

133. How many months ago was the net last soaked or dipped?

IF LESS THAN ONE MONTH AGO, RECORD '00'.

134. Did you get the net through the 2014-15 mass campaign, during an antenatal care visit, at birth, or first immunization visit?

135. Where did you get the net?

136. Did anyone sleep under this mosquito net last night?

137. Who slept under this mosquito net last night?

RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.

138. GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 139.

ADDITIONAL HOUSEHOLD CHARACTERISTICS

139. We would like to learn about the places that households use to wash their hands. Can you please show me where members of your household most often wash their hands?

140. OBSERVE PRESENCE OF WATER AT THE PLACE FOR HAND WASHING.

RECORD OBSERVATION.

141. OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HAND WASHING.

RECORD OBSERVATION.

142. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING.

RECORD OBSERVATION

143. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.

RECORD OBSERVATION.

144. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.

RECORD OBSERVATION.

145. I would like to check whether the salt used in your household is iodized. May I have a sample of the salt used to cook meals in your household?

TEST SALT FOR IODINE.

CHILD FUNCTIONING AND DISABILITY (AGE 2-9)

200. CHECK COLUMN 5 AND 7 IN THE LIST OF HOUSEHOLD MEMBERS AND WRITE THE TOTAL NUMBER OF CHILDREN AGE 2-9 YEARS WHO USUALLY LIVE IN THE HOUSEHOLD. (COLUMN 5 CODE 1)

201. CHECK NUMBER OF CHILDREN IN 200:

202. CHECK COLUMNS 1, 2, 4, AND 7 IN THE LIST OF HOUSEHOLD MEMBERS. LIST BELOW EACH OF CHILDREN AGE 2-9 YEARS WHO USUALLY LIVE IN THE HOUSEHOLD. RECORD THE LINE NUMBER, NAME, SEX, AND AGE FOR EACH OF THE CHILDREN. IF MORE THAN FOUR CHILDREN, USE ADDITIONAL QUESTIONNAIRE (S).

Now I would like to talk to you about the health condition of children age 2-9 who usually live her. We will talk about each separately. This will take only a few minutes. All the information you give me will remain strictly confidential and your answers will never be shared with those outside of our team.

203. LINE NUMBER FROM COLUMN 1. NAME FROM COLUMN 2.

204. CHILD SEX FROM COLUMN 4.

205. CHILD AGE FROM COLUMN 7.

206. Compared with other children, does or did (NAME) have any serious delay in sitting, standing, or walking?

207. Compared with other children, does (NAME) have difficulty seeing, either in the daytime or at night?

208. Does (NAME) appear to have any difficulty hearing (uses hearing aid, hears with difficulty or completely deaf?

209. When you tell (NAME) to do something, does he or she seem to understand what you are saying?

210. Does (NAME) have difficulty in walking or moving his or her arms or does he or she have weakness and/or stiffness in the arms or legs?

211. Does (NAME) sometimes have fits, become rigid, or lose consciousness?

212. Does (NAME) learn to do things like other children his or her age?

213. Does (NAME) speak at all (can he or she make him or herself understood in words; can he or she say any recognizable words)?

214. CHECK 206: CHILD AGE

215. Is (NAME)'s speech in any way different from normal (not clear enough to be understood by people other than the immediate family)?

216. Can (NAME) name at least one object (for example, an animal, a toy, a cup, a spoon)?

217. Compared with other children of the same age, does (NAME) appear in any way mentally backward, dull or slow?

218. GO BACK TO 206 IN NEXT COLUMN OF THIS QUESTIONNAIRE; IF NO MORE CHILDREN, GO TO 300.

CHILD FUNCTIONING AND DISABILITY (AGE 10-17)

300. CHECK COLUMN 5 AND 7 IN THE LIST OF HOUSEHOLD MEMBERS AND WRITE THE TOTAL NUMBER OF CHILDREN AGE 10-17 YEARS WHO USUALLY LIVE IN THE HOUSEHOLD. (COLUMN 5 CODE 1)

301. CHECK THE NUMBER OF CHILDREN IN 300:

302. CHECK COLUMN 1, 2, 4, AND 7 IN THE LIST OF HOUSEHOLD MEMBERS. LIST BELOW EACH OF CHILDREN AGE 10-17 YEARS WHO USUALLY LIVE IN THE HOUSEHOLD. RECORD THE LINE NUMBER, NAME, SE, AND AGE FOR EACH OF THE CHILDREN. IF MORE THAN FOUR CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

Now I would like to talk to you about the health condition of children age 10-17 who usually live her. We will talk about each separately. This will take only a few minutes. All the information you give me will remain strictly confidential and your answers will never be shared with those outside of our team.

303. LINE NUMBER FROM COLUMN 1. NAME FROM COLUMN 2.

304. CHILD SEX FROM COLUMN 4.

305. CHILD AGE FROM COLUMN 7.

306. Does (NAME) wear glasses or contact lenses?

307. Does (NAME) have difficulty seeing even if he or she is wearing glasses or contact lenses?

308. Would you say that (NAME) has some difficulty seeing, a lot of difficult, or can he or she not see at all?

309. Does (NAME) have difficulty seeing?

310. Would you say that (NAME) as some difficulty seeing, a lot of difficulty, or can he or she not see at all?

311. Does (NAME) use a hearing aid?

312. Does (NAME) have difficulty hearing even if he or she is using a hearing aid?

313. Would you say that (NAME) has some difficulty hearing, a lot of difficulty, or can he or she not hear at all?

314. Does (NAME) have difficulty hearing?

315. Would you say that (NAME) has some difficulty hearing, a lot of difficulty, or can he or she not hear at all?

316. Does (NAME) have difficulty communicating using his or her usual language, for example understanding or being understood?

317. Would you say that (NAME) has some difficulty communicating, a lot of difficulty, or can she not communicate at all?

318. Does (NAME) have difficulty remembering or concentrating?

319. Would you say that (NAME) has some difficulty remembering or concentrating, a lot of difficulty, or can he or she not remember of concentrate at all?

320. Does (NAME) have difficulty walking or climbing steps?

321. Would you say that (NAME) has some difficulty walking or climbing steps, a lot of difficulty, or can he or she not walk or climb steps at all?

322. Does (NAME) have difficulty washing all over or dressing?

323. Would you say (NAME) has some difficulty washing all over or dressing, a lot of difficulty, or can he or she not wash all over or dress at all?

324. GO BACK TO 306 IN NEXT COLUMN OF THIS QUESTIONNAIRE; IF NO MORE CHILDREN, GO TO 401.

ELIGIBILITY AND CONSENT FOR THE MICRONUTRIENT SURVEY

401. CHECK FRONT COVER

402.

403. PERMISSION TO REVISIT THE HOUSEHOLD BY THE MICRONUTRIENT TEAM

In the next few days, my colleagues who are working with the ministry of health would like to revisit your household to conduct a micronutrient study. The micronutrient team will collect samples of sugar, oil, and slat used in the household; conduct a brief interview to assess individual and household-level exposures to nutrition interventions; and collect venous blood and urine samples to evaluate micronutrient status of children aged 6-59 months, school-age children (6-14), women age 15-49 years, and men age 20-54. You don't have to permit the visit, but we hope you will agree since your household participation is very important. In case you need more information about the revisit, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION.

Do you have any questions?
Do you agree for your household to be revisited?

SIGNATURE OF INTERVIEWER ___
DATE ___

404. RECORD THE TIME.

INTERVIEWERS OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

SUPERVISOR'S OBSERVATIONS:

EDITOR'S OBSERVATIONS: