2016 SIERRA LEONE MALARIA INDICATOR SURVEY
WOMAN'S QUESTIONNAIRE

SIERRA LEONE
MINISTRY OF HEALTH AND SANITATION, NATIONAL MALARIA CONTROL PROGRAMME
STATISTICS SIERRA LEONE
CATHOLIC RELIEF SERVICES

IDENTIFICATION

LOCALITY NAME __
NAME OF HOUSEHOLD HEAD __
CLUSTER NUMBER __
HOUSEHOLD NUMBER __
NAME AND LINE NUMBER OF WOMAN __

INTERVIEWER VISITS

FIRST VISIT

DATE __
INTERVIEWER'S NAME __
RESULT* __

NEXT VISIT:

DATE __
TIME __

SECOND VISIT

DATE __
INTERVIEWER'S NAME __
RESULT* __

NEXT VISIT:

DATE __
TIME __

THIRD VISIT

DATE __
INTERVIEWER'S NAME __
RESULT* __

FINAL VISIT

DAY __
MONTH __
YEAR 2016
INT. NO. __
RESULT* __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

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

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __
NATIVE LANGUAGE OF RESPONDENT** __
TRANSLATOR USED (YES = 1, NO = 2) __
LANGUAGE OF QUESTIONNAIRE** ENGLISH

**LANGUAGE CODES:

ENGLISH 01
KRIO 02
MENDE 03
TEMNE 04
MADINGO 05
LOKO 06
SHERBRO 07
LIMBO 08
KISSI 09
KONO 10
SUSU 11
FULLAH 12
KRIM 13
YALUNKA 14
KORANKO 15
VAI 16
OTHER 96

SUPERVISOR
NAME __
NUMBER __

INTRODUCTION AND CONSENT

Hello. My name is ___________________________________. I am working with the Ministry of Health and Sanitations (MoHS). We are conducting a survey about malaria all over Sierra Leone. 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 INFROMATION

2016 SLMIS Principle Investigator: Dr. Foday Sahr; +232 76 480288; Email: fodaysahr1@gmail.com
Chairman of Ethics Committee: Profesor Hector G. Morgan; +232 76 629251; Email: hmorg2007@yahoo.com
Director of Policy, Planning, and Information: Dr. Samuel A.S. Kargbo; +232 76 603274; Email: saskargbo@gmail.com
National Malaria Control Programme (NMCP): Dr. Samuel Juana Smith; +232 76 611042; Email: samueljuana@yahoo.com
Catholic Relief Services: Mr. Ebrima Jarjou; +232 79 250636; Email: ebrima.jarjou@crs.org

As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. As part of this survey, we are asking that children all over the country take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or disease. This survey will help the government to develop programs to prevent and treat anemia. As part of this survey, we are asking that children all over the country take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by a mosquito bite. If the malaria test is positive, treatment will be offered. This survey will help the government to develop programs to prevent malaria. Participation in the survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

SIGNATURE OF INTERVIEWER _____________________________ DATE _____________

RESPONDENT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 1 (END)

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE TIME.

HOURS __
MINUTES __

102. In what month and year were you born?

MONTH __
DON'T KNOW MONTH 98
YEAR __
DON'T KNOW YEAR 998

103. How old were you at your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

AGE IN COMPLETED YEARS __

104. Have you ever attended school?

YES 1
NO 2 (SKIP TO 108)

105. What is the highest level of school you attended: primary, junior secondary, senior secondary, vocational, commercial, nursing, technical, teaching or higher?

PRIMARY 1
JUNIOR SECONDARY 2
SENIOR SECONDARY 3
VOCATIONAL/COMMERCIAL/NURSING/TECHNICAL/TEACHING 4
HIGHER 5

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

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

GRADE/FORM/YEAR __

107. CHECK 105:

PRIMARY (CONTINUE)
SECONDARY OR HIGHER (SKIP TO 109)

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?

CANNOT READ AT ALL 1
ABLE TO READ ONLY PART OF THE SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE 4 (SPECIFY LANGUAGE) __
BLIND/VISUALLY IMPAIRED 5

109. What is your religion?

CHRISTIAN 1
MUSLIM 2
TRADITIONAL 3
NONE 4
OTHER 96 (SPECIFY) __

110. What is your ethnicity?

KRIO 01
MENDE 02
TEMNE 03
MADINGO 04
LOKO 05
SHERBRO 06
LIMBA 07
KISSI 08
KONO 09
SUSU 10
FULLAH 11
KRIM 12
YALUNKA 13
KORANKO 14
VAI 15
OTHER 96 (SPECIFY) __

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?

YES 1
NO 2 (SKIP TO 206)

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

YES 1
NO 2 (SKIP TO 204)

203. a.) How many sons live with you?
b.) And how many daughters live with you?

IF NONE, RECORD '00'.

a.) SONS AT HOME __
b.) DAUGHTERS AT HOME __

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

YES 1
NO 2 (SKIP TO 206)

205. a.) How many sons are alive but do not live with you?
b.) And how many daughters are alive but do not live with you?

IF NONE, RECORD '00'.

a) SONS ELSEWHERE
b) DAUGHTERS ELSEWHERE

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?

YES 1
NO 2 (SKIP TO 206)

207. a.) How many boys have died?
b.) And how many girls have died?

IF NONE, RECORD '00'.

a) BOYS DEAD __
b) GIRLS DEAD __

208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'.

TOTAL BIRTHS __

209. CHECK 208: Just to make sure I have this right: you have had in TOTAL __ births during your life. Is that correct?

YES (CONTINUE)
NO (PROBE AND CORRECT 201-208 AS NECESSARY)

210. CHECK 208:

ONE OR MORE BIRTHS (CONTINUE)
NO BIRTHS (SKIP TO 225)

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

RECORD NUMBER OF LIVE BIRTHS 2011-2016

TOTAL IN 2011-2016 __
NONE 00 (SKIP TO 225)

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

RECORD NAMES OF ALL THE BIRTHS BORN IN 2011-2016 IN 213. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS. IF THERE ARE MORE THAN 5 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE STARTING WITH THE SECOND ROW.

213. What name was given to your (most recent/previous) baby?

RECORD NAME.

NAME __
BIRTH HISTORY NUMBER __

214. Is (NAME) a boy or a girl?

BOY 1
GIRL 2

215. Were any of these births twins?

SINGLE 1
MULTIPLE 2

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

DAY __
MONTH __
YEAR __

217. Is (NAME) still alive?

YES 1
NO 2 (NEXT BIRTH)

218. IF ALIVE: How old was (NAME) at (NAME)'s last birthday?

RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS __

219. IF ALIVE: Is (NAME) living with you?

YES 1
NO 2

220. IF ALIVE: RECORD HOUSEHOLD LINE NUMBER OF CHILD.

RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD.

HOUSEHOLD LINE NUMBER __ (NEXT BIRTH)

221. Were there any other live births between (NAME) and (NAME OF PREVIOUS BIRTH), including any children who died after birth?

YES 1 (ADD BIRTH)
NO 2 (NEXT BIRTH)

222. Have you had any live births since the birth of (NAME OF LAST BIRTH)?

YES 1 (RECORD BIRTH(S) IN TABLE)
NO 2

223. COMPARE 211 WITH NUMBER OF BIRTHS IN BIRTH HISTORY

NUMBERS ARE SAME (CONTINUE)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

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

NUMBER OF BIRTHS __
NONE 0

225. Are you pregnant now?

YES 1
NO 2 (SKIP TO 227)
UNSURE 8 (SKIP TO 227)

226. How many months pregnant are you?

RECORD NUMBER OF COMPLETED MONTHS.

MONTHS __

227. CHECK 224:

ONE OR MORE BIRTHS IN 2011-2016 (GO TO 301)
NO BIRTHS IN 2011-2016 (SKIP TO 501)
Q.224 IS BLANK (SKIP TO 501)

SECTION 3. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT

301. RECORD THE NAME AND SURVIVAL STATUS OF THE MOST RECENT BIRTH FROM 213 AND 217

MOST RECENT BIRTH

NAME __
LIVING __
DEAD __

302. Now I would like to ask you some questions about your last pregnancy that resulted in a live birth. When you got pregnant with (NAME), did you see anyone for antenatal care for this pregnancy?

YES 1
NO 2 (SKIP TO 304)

303. Whom did you see?
Anyone else?

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

HEALTH PERSONNEL

DOCTOR A
NURSE/MIDWIFE B
MCH AIDE C
COMMUNITY HEALTH OFFICER D
COMMUNITY HEALTH ASSISTANT E

OTHER PERSON

TRADITIONAL BIRTH ATTENDANT F
COMMUNITY HEALTH WORKER G

OTHER X (SPECIFY) __

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

PROBE AND SHOW PHOTOS.

YES 1
NO 2 (SKIP TO 307)
DON'T KNOW 8 (SKIP TO 307)

305. How many tomes did you take SP/Fansidar during this pregnancy?

TIMES __

306. 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 SOURC, RECORD THE HIGHEST SOURCE ON THE LIST.

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
TRADITIONAL BIRTH ATTENDANT 3
COMMUNITY HEALTH WORKER 4
OTHER SOURCE 6

307. CHECK 216 AND 217:

ONE OR MORE LIVING CHILDREN BORN IN 2011-2016 (GO TO 401)
NO LIVING CHILDREN BORN IN 2011-2016 (SKIP TO 501)

SECTION 4. FEVER IN CHILDREN

401. CHECK 213: RECORD THE BIRTH HISTORY NUMBER IN 402 AND THE NAME AND SURVIVAL STATUS IN 403 FOR EACH BIRTHIN 2011-2016. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNAIRE(S).

Now I would like to ask some questions about the health of your children born from 2011-2016. (We will talk about each separately.)

402. BIRTH HISTORY NUMBER FROM 213 IN BIRTH HISTORY.

LAST BIRTH

BIRTH HISTORY NUMBER __

403. FROM 213 AND 217:

NAME __

LIVING (CONTINUE)
DEAD (SKIP TO 430)

404. Has (NAME) been ill with a fever at any time in the last 2 weeks?

YES 1
NO 2 (SKIP TO 430)
DON'T KNOW 8 (SKIP TO 430)

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

YES 1
NO 2
DON'T KNOW 8

406. Did you seek advice or treatment for the illness from any source?

YES 1
NO 2 (SKIP TO 411)

407. Where did you seek advice or treatment?

Anywhere else?
PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE(S).

__________________________________________
(NAME OF PLACE)

PUBLIC SECTOR

GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
MOBILE CLINIC C
COMMUNITY HEALTH WORKER D
OTHER PUBLIC SECTOR E (SPECIFY) __

PRIVATE SECTOR

PRIVATE HOSPITAL F
PRIVATE CLINIC G
MISSION/FAITH-BASED CLINIC I
PHARMACY J
MOBILE CLINIC K
OTHER PRIVATE MEDICAL SECTOR L (SPECIFY) __

OTHER SOURCE

SHOP M
TRADITIONAL HEALER N
DRUG PEDDLER O

OTHER X (SPECIFY) __

408. CHECK 407:

TWO OR MORE CODES CIRCLED (CONTINUE)
ONLY ONE CODE CIRCLED (SKIP TO 410)

409. Where did you first seek advice or treatment?

USE LETTER CODE FROM 407.

FIRST PLACE __

410. How many days after the illness began did you first seek advice or treatment for (NAME)?

IF THE SAME DAY, RECORD '00'.

DAYS __

411. At any time during the illness, did (NAME) take any drugs for the illness?

YES 1
NO 2 (SKIP TO 430)
DON'T KNOW 8 (SKIP TO 430)

412. What drugs did (NAME) take?
Any other drugs?

RECORD ALL MENTIONED.

ANTIMALARIAL DRUGS

ARTESUNATE + AMODIAQUINE (ASAQ) (ACT) A
ARTMETHER + LUMEFANTRINE (AL) (ACT) B
SP/FANSIDAR C
CHLOROQUINE D
AMODIAQUINE E
QUININE F
ARTESUNATE G
OTHER ANTI-MALARIAL H (SPECIFY) __

ANTIBIOTIC DRUGS

AMPICILLIN I
AMOXICILLIN J
SEPTRIN K
INJECTION, CRYSTALINE PENACILLIN L
OTHER ANTIBIOTIC M (SPECIFY) __

ANTIPYRETIC

ASPIRIN N
PARACETAMOL/PANADOL O
NOVALGINE P
IBUPROFEN Q

OTHER X (SPECIFY) __
DON'T KNOW Z

413. CHECK 412: ANY CODE A-H CIRCLED?

YES (CONTINUE)
NO (SKIP TO 430)

414. CHECK 412: ARTESUNATE + AMODIAQUINE ('A') GIVEN

CODE 'A' CIRCLED (CONTINUE)
CODE 'A' NOT CIRCLED (SKIP TO 416)

415. How long after the fever started did (NAME) first take artesunate + amodiaquine?