2015-16 TANZANIA DEMOGRAPHIC AND HEALTH AND MALARIA INDICATORS SURVEYS - BIOMARKER QUESTIONNAIRE

THE UNITED REPUBLIC OF TANZANIA
NATIONAL BUREAU OF STATISTICS

IDENTIFICATION

PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER ____
HOUSEHOLD NUMBER ____

HOUSEHOLD SELECTED FOR MAN'S SURVEY, SALT AND URINE TESTING?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

DATE _____
INTERVIEWER'S NAME __________

NEXT VISIT

DATE _____
TIME _____

FINAL VISIT

DAY _____
MONTH _____
YEAR _____

TOTAL NUMBER OF VISITS _____

TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN _____

NOTES: ________________________________________________

LANGUAGE OF QUESTIONNAIRE

ENGLISH 01
KISWHAILI 02
LANGUAGE 3 03
LANGUAGE 4 04
LANGUAGE 5 05
LANGUAGE 6 06

LANGUAGE OF INTERVIEW ____

ENGLISH 01
KISWHAILI 02
LANGUAGE 3 03
LANGUAGE 4 04
LANGUAGE 5 05
LANGUAGE 6 06

TRANSLATOR

YES 1
NO 2

SUPERVISOR

NAME _____
NUMBER _____

FIELD EDITOR

NAME _____
NUMBER _____

OFFICE EDITOR

NUMBER _____

KEYED BY

NUMBER_____

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

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

102. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 11.

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 IN 2010-2016

YES 1
NO 2 (GO TO 130)

105. WEIGHT IN KILOGRAMS.

KG _____.___

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

106. HEIGHT IN CENTIMETERS.

CM _____.___

NOT PRESENT 9994 (GO TO 109)
REFUSED 9995 (GO TO 109)
OTHER 9996 (GO TO 109)

107. MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2

108. MEASURER: ENTER YOUR FIELDWORKER NUMBER.

FIELDWORKER NUMBER _____

109. CHECK 103: CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?

0-5 MONTHS 1 (GO TO 130)
OLDER 2

110. LINE NUMBER OF 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 programs to prevent and treat anemia. We ask that all children born in 2010 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 members of our survey team. Do you have any questions? You can say yes or no. It is up to you to decide. Will you allow (NAME OF CHILD) to participate in the anemia test?

112. CIRCLE THE CODE AND SIGN YOUR NAME.

(SIGN AND ENTER YOUR FIELDWORKER NUMBER) _______________ ______

GRANTED 1
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 112B)

112A. ASK CONSENT FOR MALARIA TEST FROM PARENT/OTHER ADULT.

As part of this survey, we are asking children all over the country to take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by a mosquito bite. This survey will assist the government to develop programs to prevent malaria.
We ask that all children born in 2010 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. One blood drop will be tested for malaria immediately, and the result will be told to you right away. A few blood drops will be collected on slide(s) and taken to a laboratory for testing. You will not be told the results of the laboratory testing. All results 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 or no. It is up to you to decide. Will you allow (NAME OF CHILD) to participate in the malaria test?

112B. CIRCLE THE CODE AND SIGN YOUR NAME.

(SIGN AND ENTER YOUR FIELDWORKER NUMBER) _______________ ______

GRANTED 1
REFUSED 2
NOT PRESENT/OTHER 3

112D. PLACE BAR CODE LABEL FOR MALARIA LAB TEST.

PUT THE 1ST BAR CODE LABEL HERE.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

PUT THE 2ND BAR CADE LABEL ON THE SLIDE AND THE 3RD ON THE TRANSMITTAL FORM.

113. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

G/DL ____.__

NOT PRESENT 994
REFUSED 995
OTHER 996

114. CIRCLE THE CODE FOR THE MALARIA/RDT.

TESTED 1
NOT PRESENT 2 (GO TO 116)
REFUSED 3 (GO TO 116)
OTHER 6 (GO TO 116)

115. RECORD THE RESULT OF THE MALARIA RDT HERE AND IN THE ANEMIA AND MALARIA PAMPHLET.

POSITIVE 1 (GO TO 117A)
NEGATIVE 2
OTHER 6

116. CHECK 113:
HEMOGLOBIN RESULT

BELOW 7.0 G/DL, SEVERE ANEMIA 1
7.0 G/DL OR ABOVE 2 (GO TO 130)
NOT PRESENT 3 (GO TO 130)
REFUSED 4 (GO TO 130)
OTHER 6 (GO TO 130)

117. SEVERE ANEMIA REFERRAL.
RECORD THE RESULT OF THE ANEMIA TEST ON THE REFERRAL FORM.

The anemia test shows that (NAME OF CHILD) has severe anemia. Your child is very ill and must be taken to a health facility immediately. (GO TO 130)

117A. LOCATION OF INTERVIEW:

ZANZIBAR (GO TO 117B)
MAINLAND TANZANIA (GO TO 118)

117B. MALARIA REFERRAL.
RECORD THE RESULT OF THE MALARIA TEST ON THE REFERRAL FORM.

The malaria test shows that (NAME OF CHILD) has malaria. Your child is ill and must be taken to a health facility immediately (GO TO 130)

118. Does (NAME) suffer from any of the following illnesses or symptoms:

IF NONE OF THE ABOVE SYMPTOMS, CIRCLE CODE Y

EXTREME WEAKNESS A
HEART PROBLEMS B
LOSS OF CONSCIOUSNESS C
RAPID BREATHING D
SEIZURES E
BLEEDING F
JAUNDICE G
DARK URINE H
NONE OF THE ABOVE SYMPTOMS Y

119. CHECK 118:
ANY CODE A-H CIRCLED?

ONLY CODE Y CIRCLED 1
ANY CODE A-H CIRCLED 2 (GO TO 122)

120. CHECK 113:
HEMOGLOBIN RESULT

BELOW 7.0 G/DL, SEVERE ANEMIA 1 (GO TO 122)
7.0 G/DL OR ABOVE 2
NOT PRESENT 3
REFUSED 4
OTHER 6

121. In the past two weeks has (NAME) taken or is taking ALU given by a doctor or health center to treat the malaria?
VERIFY BY ASKING TO SEE TREATMENT

YES 1 (GO TO 123)
NO 2 (GO TO 124)

122. SEVERE MALARIA REFERRAL.
RECORD THE RESULT OF THE MALARIA RDT ON THE REFERRAL FORM.

The malaria test shows that (NAME OF CHILD) has malaria. Your child also has symptoms of severe malaria. The malaria treatment I have will not help your child, and I cannot give you the medication. Your child is very ill and must be taken to a health facility right away.

(GO TO 130)

123. ALREADY TAKING [FIRST LINE MEDICATION] REFERRAL STATEMENT

You have told me that (NAME OF CHILD) had already received ALU for malaria. Therefore, I cannot give you additional ALU. However, the test shows that he/she has malaria. If your child has a fever for two days after the last dose of ALU, you should take the child to the nearest health facility for further examination.

(GO TO 130)

124. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATMENT TO PARENT/OTHER

The malaria test shows that your child has malaria. We can give you free medicine. The medicine is called [FIRST LINE OF MEDICATION]. [FIRST LINE OF MEDICATION] is very effective and in a few days it should get rid of the fever and other symptoms. You do not have to give the child the medicine. This is up to you. Please tell me whether you accept the medicine or not.

125. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

ACCEPTED MEDICINE 1 (SIGN) _______________
REFUSED 2
OTHER 6

126. CHECK 125: MEDICATION ACCEPTED

ACCEPTED MEDICINE 1
REFUSED 2 (GO TO 130)
OTHER 3 (GO TO 130)

127. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT/OTHER ADULT.

Weight (in Kg) - Approximate Age: Dosage *

5 to less than 15 - under 3 years of age: 1 tablet ALu twice daily for 3 days
15 to less than 25 - 3 to 8 years of age: 2 tablets ALu twice daily for 3 days

ALSO TELL THE PARENT/OTHER ADULT: First day starts by taking first dose followed by the second one 8 hours later; on subsequent days the recommendation is simply "morning" and "evening" (usually around 12 hours apart). Put the tablet in a little water, mix water and tablet well, and give to the child with fatty food or drinks like milk or breast milk. Make sure that the FULL 3 days treatment is taken at the recommended times, otherwise the infection may return. If your child vomits within an hour of taking the medicine, repeat the dose and get additional tablets. If [NAME] has a high fever, fast or difficult breathing, is not able to drink or breastfeed, gets sicker or does not get better in two days, you should take him/her to a health professional for treatment right away.
with fatty food or drinks like milk or breast milk. Make sure that the FULL 3 days treatment is taken.

130. GO BACK TO 103 IN NEXT COLUMN OF THIS PAGE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201.

WEIGHT AND HEIGHT MEASUREMENT, HEMOGLOBIN AND URINE (FOR IODINE) TEST FOR WOMEN AGE 15-49

201. CHECK COLUMN 9 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE WOMEN IN 202, 203, AND 204. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

202. CHECK HOUSEHOLD QUESTIONNAIRE:
LINE NUMBER FROM COLUMN 9.

LINE NUMBER _____
NAME __________

203. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7:

15-17 YEARS 1
18-49 YEARS 2

204. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):

CODE 4 (NEVER IN UNION) 1
OTHER 2

204A. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 3 (RELATIONSHIP):

CODE 1 (HEAD OF HH) 1
OTHER 2

205. WEIGHT IN KILOGRAMS.

KG ____.___

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

206. HEIGHT IN CENTIMETERS.

CM ____._

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207. MEASURER: ENTER YOUR INTERVIEWER NUMBER.

INTERVIEWER NUMBER _____

208. CHECK 203: AGE

15-17 YEARS 1
18-49 YEARS (GO TO 210)

209. CHECK 204: MARITAL STATUS

NEVER IN UNION 1
OTHER 2 (GO TO 210)

209. CHECK 204A: RELATIONSHIP

HEAD OF HH 1
OTHER (GO TO 216)

ADULT RESPONDENT CONSENT FOR ANEMIA TEST

210. ASK 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 we take your blood. 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 or no. It is up to you to decide.

211. CIRCLE THE CODE AND SIGN YOUR NAME.

(SIGN AND ENTER YOUR FIELDWORKER NUMBER) __________ _____

GRANTED 1
RESPONDENT REFUSED 2 (GO TO 221)
NOT PRESENT/OTHER 3 (GO TO 221)

211A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?

YES 1 (GO TO 221)
NO 2 (GO TO 221)
DON'T KNOW 8 (GO TO 221)

216. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE _____

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST

217. ASK CONSENT FOR ANEMIA TEST FROM PARENT/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?

218. CIRCLE THE CODE AND SIGN YOUR NAME.

(SIGN AND ENTER YOUR FIELDWORKER NUMBER) _______ _____

GRANTED 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 221)
NOT PRESENT/OTHER 3 (GO TO 221)

MINOR RESPONDENT CONSENT FOR ANEMIA TEST

219. ASK 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 we take your blood. 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.

220. CIRCLE THE CODE AND SIGN YOUR NAME.

(SIGN) ______________

GRANTED 1
MINOR RESPONDENT REFUSED 2 (GO TO 221)
NOT PRESENT/OTHER 3 (GO TO 221)

220A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

221. CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE. HOUSEHOLD SELECTED FOR MAN'S SURVEY AND IODINE

SELECTED 1
NOT SELECTED 2 (GO TO 229B)

222. CHECK 203: AGE

15-17 YEARS 1
18-49 YEARS (GO TO 224)

223. CHECK 204: MARITAL

NEVER IN UNION 1
OTHER 2 (GO TO 224)

223A. CHECK 204A: RELATIONSHIP

HEAD OF HH 1
OTHER 2 (GO TO 226)

ADULT RESPONDENT CONSENT FOR URINARY IODINE TEST

224. ASK CONSENT FOR IODINE TEST.

As part of this survey, we are also asking women all over the country to take test for iodine deficiency. Iodine deficiency is a health problem that usually results from poor nutrition. This survey will assist the government to develop programs to prevent and treat iodine deficiency.
For the iodine test, we need a small amount of urine. The urine will be tested at the Tanzania Food and Nutrition Laboratory. 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 or no. It is up to you to decide.

225. CIRCLE THE CODE AND SIGN YOUR NAME.

(SIGN) __________

GRANTED 1 (GO TO 229B)
RESPONDENT REFUSED 2 (GO TO 229B)
NOT PRESENT/OTHER 3 (GO TO 229B)

226. RECORD LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE _____

PARENTAL/RESPONSIBLE ADULT CONSENT FOR URINARY IODINE TEST

227. ASK CONSENT FOR IODINE TEST FROM PARENT/ADULT

228. CIRCLE THE CODE AND SIGN YOUR NAME.

(SIGN) _______________

GRANTED 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 229B)
NOT PRESENT/OTHER 3 (GO TO 229B)

MINOR RESPONDENT CONSENT FOR URINARY IODINE TEST

229. ASK CONSENT FOR IODINE TEST FROM RESPONDENT

229A. CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1
MINOR RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3

(SIGN) _______________

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

230. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

G/DL ____.__

NOT PRESENT/OTHER 994
REFUSED 995
OTHER 996

231. BAR CODE LABEL: URINARY IODINE

PUT THE 1ST BAR CODE LABEL HERE.

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S COLLECTION CUP AND THE THIRD LABEL ON THE COLLECTION TUBE AND THE FOURTH LABEL ON THE TRANSMITTAL FORM.

232. OUTCOME OF URINARY IODINE TEST PROCEDURE

URINE GIVEN 1
NOT PRESENT/OTHER 2
REFUSED 3

233. GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE ELIGIBLE WOMEN, END THE BIOMARKER COLLECTION.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING BIOMARKERS

_____________________________________________________________

SUPERVISOR'S OBSERVATIONS _____________________________________________

EDITOR'S OBSERVATIONS __________________________________________________

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