Republic of Senegal
Ministry of Health and Medical Prevention

ORC Macro
Research Center for Human Development ("CRDH")

IDENTIFICATION

NAME OF LOCALITY ______
NAME OF HEAD OF HOUSEHOLD ______
HOUSEHOLD NUMBER ______
CONCESSION NUMBER ______
CLUSTER NUMBER ______
HEALTH DISTRICT ______
URBAN/RURAL (URBAN = 1, RURAL = 2) ENVIRONMENT ______
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL
(DAKAR = 1, REGIONAL CAPITAL = 2, OTHER CITY = 3, RURAL = 4) DETAILED ENVIRONMENT ______
NAME AND LINE NUMBER OF WOMAN ______
CLUSTER NUMBER IN DHS-IV 2005 ______
HOUSEHOLD SURVEYED IN DHS-IV 2005? (YES = 1, NO = 2) ______
HOUSEHOLD NUMBER IN DHS-IV 2005 ______
WOMAN SURVEYED IN DHS-IV 2005? (YES = 1, NO = 2) ______
WOMAN'S LINE NUNBER IN DHS-IV ______

INTERVIEWER VISITS

(Repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT
DAY ______
MONTH ______
YEAR 2006
INTERVIEWER NUMBER______
RESULT ______

TOTAL NUMBER OF VISITS ______

RESULT CODES:
1 COMPLETED
2 NOT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ______

LANGUAGE OF QUESTIONNAIRE 1
LANGUAGE OF INTERVIEW ______

LANGUAGE CODES:
1 FRENCH
2 WOLOF
3 PULAR
4 SERER
5 MANDINKA
6 DIOLA
8 OTHERS

INTERPRETER (YES = 1, NO = 2) ______

TEAM LEADER
NAME ______
DATE ______

SUPERVISOR
NAME ______
DATE ______

OFFICE EDITOR ______

KEYED BY ______

SECTION 1. SOCIODEMOGRAPHIC BACKGROUND OF RESPONDENT

INTRODUCTION AND CONSENT REQUEST

INFORMED CONSENT
Hello. My name is ______ and I am working for the Ministry of Health. We are carrying out a national survey on the prevention and care of malaria. We would like you to participate in this survey. I would like to ask you some questions about your household members, and if mosquito nets are owned and used. This information will be useful to the government for planning health services. The interview usually takes between 20 and 25 minutes. The information that you provide us will remain strictly confidential and will not be shared with anyone.

Participation in this survey is voluntary and you can refuse to answer any and all questions. However, we hope that you will accept to participate in this survey because your opinion is very important to us.

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

Interviewer's signature: ______
Date: ______

1 RESPONDENT AGREES TO ANSWER (Continue to 101)
2 RESPONDENT DECLINES TO ANSWER QUESTIONS (Skip to END)

101. RECORD TIME.

102. In what month and year were you born?

103. How old were you on your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

104. Have you ever attended school?

105. What is the highest level of school you attended: primary, secondary 1st cycle, secondary 2nd cycle, higher, or other?

106. What is the last (YEAR/GRADE) you completed at that level?

107. CHECK 105:

PRIMARY: ______ (Continue to 108)
SECONDARY OR HIGHER ______ (Skip to 109)

108. Now I would like you to read this sentence out loud to me; read as much as you can.

SHOW CARD TO RESPONDENT.

IF RESPONDENT CANNOT READ THE WHOLE SENTENCE, PROBE:
Can you read part of the sentence?

(Footnote)
There should be four simple phrases on each card that are adapted to the country (for example: "Parents love their children", "Working the land is hard", "The child is reading a book", "Children work hard at school"). Cards should be prepared in all the languages in which respondents might be literate.

109. What is your religion?

110. Are you Senegalese?

111. What is your ethnicity?

SECTION 2. REPRODUCTION

201. Now I would like to ask you some questions about all the births you have had in your lifetime. Have you ever given birth?

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

203. How many sons live with you?
How many daughters live with you?

IF NONE, RECORD '00'.

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

205. How many sons are living but do not live with you?
How many daughters are living but do not live with you?

IF NONE, RECORD '00'.

206. Have you ever given birth to a boy or girl who was born alive but who later died?

IF NO, PROBE: No baby who cried or showed other signs of life at birth but who did not survive?

207. How many boys died?
How many girls died?

IF NONE, RECORD '00'.

208. TOTAL UP THE ANSWERS TO 203, 205, AND 207 AND RECORD THE TOTAL.
IF NONE, RECORD '00'.

00 NONE (Skip to 224)

TOTAL ______

209. CHECK 208:

I would like to be sure I understood correctly: you have had a TOTAL of ______ births in your life. Is that correct?

210. CHECK 208:

ONE BIRTH______ (Continue to question)
Was this child born in the last six years?
IF NO, CIRCLE '00'.

TWO OR MORE BIRTHS ______ (Continue to question)
How many of these children were born in the last six years?

211. Now I would like to record the names of all the births you have had in the last six years, whether still living or not, beginning with the most recent birth.

RECORD THE NAMES OF ALL BIRTHS IN THE LAST SIX YEARS IN 212.
RECORD TWINS/TRIPLETS ON SEPARATE LINES.

(Repeat 212 - 220 for up to 7 births)

212. What name was given to your (last/previous) child?
01 (NAME) ______

213. Is (NAME) a single or multiple birth?

1 SINGLE
2 MULTIPLE

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

1 BOY
2 GIRL

215. In what month and year was (NAME) born?

PROBE: What is his/her birthdate?

MONTH ______
YEAR ______

216. Is (NAME) still alive?

1 YES
2 NO (Go to NEXT BIRTH)

217. IF ALIVE:
How old was (NAME) on his/her last birthday?

RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS ______

218. IF ALIVE:
Does (NAME) live with you?

1 YES
2 NO

219. IF ALIVE:
RECORD CHILD'S LINE NUMBER FROM HOUSEHOLD SCHEDULE
(RECORD '00' IF CHILD IS NOT LISTED IN HOUSEHOLD)

LINE NUMBER ______ (Go to NEXT BIRTH)

220. Were there other live births between (NAME AND NAME OF NEXT BIRTH)?

1 YES
2 NO

221. Have you had other live births since the birth of (NAME OF LAST BIRTH)?
IF YES, RECORD THE BIRTH(S) IN BIRTH TABLE.

222. COMPARE 210 TO THE NUMBER OF BIRTHS RECORDED IN THE TABLE ABOVE AND CHECK OFF:

NUMBERS ARE EQUAL: ______ (Go to CHECK)
CHECK: FOR EACH BIRTH: YEAR OF BIRTH IS RECORDED ______
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED ______

NUMBERS ARE DIFFERENT ______ (PROBE AND CORRECT)

223. CHECK 215 AND RECORD THE NUMBER OF BIRTHS IN 2001 OR LATER.
IF NONE, RECORD '0'.
______

224. Are you pregnant now?

225. How many months pregnant are you?

RECORD NUMBER OF COMPLETED MONTHS.

226. CHECK 223:

ONE OR MORE BIRTHS IN 2001 OR LATER ______ (Continue to 301)
NO BIRTHS IN 2001 OR LATER: ______ (Skip to 345)

SECTION 3A. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT

301. RECORD NAME AND SURVIVORSHIP OF LAST BIRTH IN 302.
Now I would like to ask you some questions about your last pregnancy that ended in a live birth, in the last 6 years.

302. ACCORDING TO 212 AND 216 (ROW 01)

303. When you were pregnant with (NAME) did you receive any antenatal care?

IF YES: Whom did you see?
Anyone else?

PROBE TO DETERMINE TYPE OF PERSON AND RECORD ALL PEOPLE SEEN.

304. During this pregnancy, did you take any medicine to prevent malaria?

305. What medication did you take?

RECORD ALL MENTIONED.

IF UNABLE TO DETERMINE TYPE OF MEDICATION, SHOW COMMON ANTIMALARIALS TO RESPONDENT.

306. CHECK 305:

MEDICATION TAKEN TO PREVENT MALARIA

CODE 'A' CIRCLED ______ (Continue to 307)
CODE 'A' NOT CIRCLED ______ (Skip to 310)

307. How many times did you take SP/Fansidar during this pregnancy?

308. CHECK 303:

ANTENATAL CARE PROVIDED BY A HEALTH PROFESSIONAL DURING THIS PREGNANCY?

309. Did you get the SP/Fansidar at an antenatal visit, at a different visit to a health facility, or from another source?

310. CHECK 215 AND 216:

ONE OR MORE LIVING CHILDREN BORN IN 2001 OR LATER ______ (Continue to 311)
NO LIVING CHILDREN BORN IN 2001 OR LATER: ______ (Skip to 345)

SECTION 3B. FEVER IN CHILDREN

311. RECORD THE LINE NUMBER AND NAME OF EACH LIVING CHILD BORN IN 2001 OR LATER IN THE TABLE. IF THERE ARE MORE THAN 2 LIVING CHILDREN BORN IN 2001 OR LATER, USE ADDITIONAL QUESTIONNAIRES.

Now I would like to ask you some questions about the health of all your children who are under the age of 6. (We will talk about one child at a time).

312. NAME AND LINE NUMBER FROM 212.

313.(Repeat 313 - 344 for up to two children)

Did (NAME) have a fever at any time in the last 2 weeks?

314. How many days has it been since the start of the fever and today?

IF LESS THAN ONE DAY, RECORD '00'.

315. Did you seek out any advice or a treatment for the fever?

316. Where did you seek out treatment or advice?

Anywhere else?

RECORD ALL SOURCES MENTIONED.

316A. How many days after the fever started did you start looking for a treatment for (NAME)?
IF SAME DAY, RECORD '00'.

317. Does (NAME) still have a fever?

318. During his/her illness, did (NAME) take any medications for the fever?

319. What medications did (NAME) take?

Other medications?

RECORD ALL MENTIONED.
ASK TO SEE THE MEDICATION(S) IF TYPE OF MEDICATION IS UNKNOWN.

IF TYPE OF MEDICATION CANNOT BE IDENTIFIED, SHOW COMMON ANTIMALARIAL MEDICATIONS TO THE RESPONDENT.

(FOOTNOTE) AMONATE TABLET, FALCIMON TABLET AND ARSUCAM TABLET MAKE UP ACT.

320. CHECK 319:

AT LEAST ONE CODE 'A' TO 'F' CIRCLED?

320A. CHECK 319:

WAS ACT GIVEN ('A')?
AMONATE TABLET, FALCIMON TABLET AND ARSUCAM TABLET MAKE UP ACT.

321. How soon after the beginning of the fever did (NAME) start to take tablets of amonate/falcimon/arsucam?

322. For how many days did (NAME) take the amonate/falcimon/arsucam tablets?

IF 7 OR MORE DAYS, RECORD '7'.

323. Did you have the amonate/falcimon/arsucam tablets at your home or did you get them elsewhere?

IF 'ELSEWHERE', PROBE TO DETERMINE THE SOURCE. IF MORE THAN ONE SOURCE IS MENTIONED, ASK: Where did you get these tablets the first time?

324. CHECK 319:

WAS SP/FANSIDAR GIVEN ('B')?

325. How soon after the beginning of the fever did (NAME) start to take chloroquine?

326. For how many days did (NAME) take the SP/FANSIDAR?

IF 7 OR MORE DAYS, RECORD '7'.

327. Did you have the chloroquine at your home or did you get it elsewhere?

IF 'ELSEWHERE', PROBE TO DETERMINE THE SOURCE. IF MORE THAN ONE SOURCE IS MENTIONED, ASK: Where did you get the SP/FANSIDAR the first time?

328. CHECK 319:

WAS CHLOROQUINE ('C') GIVEN?

329. How soon after the beginning of the fever did (NAME) start to take chloroquine?

330. For how many days did (NAME) take the chloroquine?

IF 7 OR MORE DAYS, RECORD '7'.

331. Did you have the chloroquine at your home or did you get it elsewhere?

IF 'ELSEWHERE', PROBE TO DETERMINE THE SOURCE. IF MORE THAN ONE SOURCE IS MENTIONED, ASK: Where did you get the chloroquine the first time?

332. CHECK 319:

WAS AMODIQUINE ('D') GIVEN?

333. How soon after the beginning of the fever did (NAME) start to take amodiaquine?

334. For how many days did (NAME) take the amodiaquine?

IF 7 OR MORE DAYS, RECORD '7'.

335. Did you have the amodiaquine at your home or did you get it elsewhere?

IF 'ELSEWHERE', PROBE TO DETERMINE THE SOURCE. IF MORE THAN ONE SOURCE IS MENTIONED, ASK: Where did you get the amodiaquine the first time?

336. CHECK 319:

WAS QUININE ('E') GIVEN?

337. How soon after the beginning of the fever did (NAME) start to take quinine?

338. For how many days did (NAME) take the quinine?

IF 7 OR MORE DAYS, RECORD '7'.

339. Did you have the quinine at your home or did you get it elsewhere?

IF 'ELSEWHERE', PROBE TO DETERMINE THE SOURCE. IF MORE THAN ONE SOURCE IS MENTIONED, ASK: Where did you get the quinine the first time?

340. CHECK 319:

OTHER MEDICATIONS?

341. How soon after the beginning of the fever did (NAME) start to take (NAME OF OTHER ANTIMALARIAL)?

342. For how many days did (NAME) take the (NAME OF OTHER ANTIMALARIAL)?

IF 7 OR MORE DAYS, RECORD '7'.

343. Did you have the (NAME OF OTHER ANTIMALARIAL) at your home or did you get it elsewhere?

IF 'ELSEWHERE', PROBE TO DETERMINE THE SOURCE. IF MORE THAN ONE SOURCE IS MENTIONED, ASK: Where did you get the (NAME OF OTHER ANTIMALARIAL) the first time?

344. RETURN TO 313 IN NEXT COLUMN, OR, IF LAST CHILD, CONTINUE TO 345.

345. RECORD TIME.

OBSERVATIONS OF INTERVIEWER

TO BE FILLED OUT ONCE THE INTERVIEW IS FINISHED

COMMENTS ON THE RESPONDENT: ______

COMMENTS ON PARTICULAR QUESTIONS: ______

OTHER COMMENTS: ______

OBSERVATIONS OF TEAM LEADER
______

NAME OF TEAM LEADER: ______
DATE: ______

OBSERVATIONS OF SUPERVISOR
______

NAME OF SUPERVISOR:
DATE: ______