UGANDA BUREAU OF STATISTICS
2009 UGANDA MALARIA INDICATOR SURVEY
HOUSEHOLD QUESTIONNAIRE -- ENGLISH
REGION_
DISTRICT_
COUNTY_
SUBCOUNT/TOWN_
PARISH/LC2 NAME_
EA NAME_
UMIS NUMBER_
URBAN=1, PERI URBAN=2, RURAL=3_
NAME OF HEAD OF HOUSEHOLD_
HOUSEHOLD NUMBER_
HOUSEHOLD SAMPLE NUMBER_
SECTION 1B: INTERVIEWER VISITS
FIRST VISIT
2. INTERVIEWER'S NAME_
3. RESULT*
4. NEXT VISIT: DATE_
5. TIME_
2. INTERVIEWER'S NAME_
3. RESULT*
4. NEXT VISIT: DATE_
5. TIME_
2. INTERVIEWER'S NAME_
3. RESULT*
2. MONTH_
3. YEAR_
4. INT. NUMBER_
5. RESULT_
6. TOTAL NUMBER OF VISITS_
7. TOTAL PERSONS IN HOUSEHOLD_
8. TOTAL ELIGIBLE WOMEN_
9. TOTAL ELIGIBLE CHILDREN_
10. LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE_
*RESULT CODES
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 9 (SPECIFY) __
2. LANGUAGE USED IN THE INTERVIEW_
3. NATIVE LANGUAGE OF RESPONDENT_
4. TRANSLATOR USED (NOT AT ALL=1; SOMETIMES=2; ALL THE TIME=3)_
LANGUAGE USED:
ATESO-KARAMOJONG 1
LUGANDA 2
LUGBARA 3
LUO 4
RUNYANKORE-RUKIGA 5
RUNYORO-RUTORO 6
ENGLISH 7
OTHER 8
DATE_
FIELD EDITOR
DATE_
OFFICE EDITOR_
KEYED BY_
Hello. My name is_. I am working with UBOS in collaboration with MOH. We are conducting a national survey about malaria and would very much appreciate your participation in this survey. This information will help the government to plan health services. As part of the survey we would first like to ask some questions about your household. These questions will take about 15 minutes to complete. Whatever information you provide will be kept strictly confidential, and will not be shared with anyone other than members of our survey team.
Participation in this survey is voluntary, and 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 since your views are important.
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 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED (END)
START TIME:
END TIME:
LINE NO.
(1)_
USUAL RESIDENTS AND VISITORS:
(2) 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. 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 QUESTIONS IN COLUMNS 5-7 FOR EACH PERSON.
2A) Just to make sure that I have a complete listing. Are there any other persons such as small children or infants that are not listed?
NO_
2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?
NO_
2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO_
RELATIONSHIP TO HEAD OF HOUSEHOLD
(3) What is the relationship of (NAME) to the head of the household? SEE CODES BELOW.
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
NIECE/NEPHEW BY BLOOD = 09
NIECE/NEPHEW BY MARRIAGE = 10
OTHER RELATIVE = 11
ADOPTED/FOSTER/STEPCHILD = 12
NOT RELATED = 13
DON'T KNOW = 98
SEX
(4) Is (NAME) male or female?
FEMALE 2
RESIDENCE
(5) Does (NAME) usually live here?
NO 2
(6) Did (NAME) stay here last night?
NO 2
ELIGIBILITY
(8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 YEARS
(9) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-4 YEARS (0-59 MONTHS)
SECTION 3: HOUSEHOLD CHARACTERISTICS
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/COMPOUND 12
PUBLIC TAP 13
OPEN PUBLIC WELL 22
PROTECTED PUBLIC WELL 32
BOREHOLE 33
UNPROTECTED SPRING 42
RIVER/STREAM 43
POND/LAKE 44
DAM 45
WATER TRUCK 61
BOTTLED WATER 71
OTHER 96 (SPECIFY)_
102. What kind of toilet facility do members of your household usually use?
VIP LATRINE 02
COVERED PIT LATRINE NO SLAB 03
COVERED PIT LATRINE W/SLAB 04
UNCOVERED PIT LATRINE NO SLAB 05
UNCOVERED PIT LATRINE W/SLAB 06
COMPOSTING TOILET 07
NO FACILITY/BUSH/FIELD 08
OTHER 96 (SPECIFY)_
104. Does your household have:
a) Electricity?
b) A radio?
c) A cassette player?
d) A television?
e) A mobile phone?
f) A fixed phone?
g) A refrigerator?
h) A table?
i) A chair?
j) A sofa set?
k) A bed?
l) A cupboard?
m) A clock?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
105. What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02
BIOGAS 03
PARAFFIN/KEROSENE 04
CHARCOAL 05
FIREWOOD 06
STRAW/SHRUBS/GRASS 07
ANIMAL DUNG 08
NO FOOD COOKED IN HOUSEHOLD 09
OTHER 96 (SPECIFY)_
106. What is the main source of energy for lighting in the household?
SOLAR 02
GAS 03
PARAFFIN-HURRICANE LAMP 04
PARAFFIN-PRESSURE LAMP 05
PARAFFIN-WICK 06
FIREWOOD 07
CANDLES 08
OTHER 96 (SPECIFY)_
107. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION. MARK ONLY ONE.
EARTH AND DUNG 12
MOSIAC OR TILES 33
BRICKS 34
CEMENT 35
STONES 36
108. MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION. MARK ONLY ONE.
MUD 12
IRON SHEETS 22
ASBESTOS 23
TILES 24
TIN 25
CEMENT 26
109. MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION. MARK ONLY ONE.
UN-BURNT BRICKS 22
UN-BURNT BRICKS WITH PLASTER 23
BURNT BRICKS WITH MUD 24
STONE 32
TIMBER 33
BURNT BRICKS WITH CEMENT 34
110. How many rooms in your household are used for sleeping? (INCLUDING ROOMS OUTSIDE THE MAIN DWELLING)
111. How many sleeping spaces like mats, mattresses, or beds are available in your household?
112. Does any member of your household own or have:
a) A watch?
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor
A boat without a motor
e) A bank account?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
113. How many acres of agricultural land do members of this household own?
9995 OR MORE ACRES 9995.0
DON'T KNOW 9999.8
114. How many of the following animals/birds does this household own? IF NONE, ENTER '00'. IF MORE THAN 95, ENTER '95'. IF UNKNOWN, ENTER '98'.
Local Cattle?
Exotic/Cross Cattle?
Goats?
Sheep?
Pigs?
Chickens?
EXOTIC/CROSS CATTLE_
GOATS_
SHEEP_
PIGS_
CHICKENS_
115. How far is it to the nearest market place? WRITE '00' IF LESS THAN ONE KILOMETRE. IF MORE THAN 95 KM, WRITE 95. CIRCLE '98' IF DON'T KNOW.
DON'T KNOW 98
116. Now I would like to ask you about the food your household eats. How many meals does your household usually have per day?
117. In the past week, on how many days did the household eat meat?
118. How often in the last year did you have problems in satisfying the food needs of the household?
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5
119. How far is it to the nearest health facility? WRITE '00' IF LESS THAN ONE KILOMETRE. IF MORE THAN 95 KM, WRITE 95. CIRCLE '98' IF DON'T KNOW.
DON'T KNOW 98
120. If you were to go to this facility, how would you most likely go there?
PUBLIC TRANSPORT (BUS, TAXI) 2
ANIMAL/ANIMAL CART 3
WALKING 4
BICYCLE 5
OTHER 6 (SPECIFIY)_
121. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?
NO 2 (SKIP TO 121D)
DON'T KNOW 8 (SKIP TO 121D)
121A. How many months ago was the dwelling last sprayed? IF LESS THAN ONE MONTH, RECORD '00' MONTHS AGO.
121B. Who sprayed the dwelling?
PRIVATE COMPANY 2
NGO 3
OTHER 6 (SPECIFY) (SPECIFY)_
DON'T KNOW 8
121C. Did you pay for your dwelling to be sprayed?
NO 2
DON'T KNOW 8
121D. Is there a community worker or community medicine distributor (CMD) who distributes malaria medicines in your village or community?
NO 2 (SKIP TO 122)
DON'T KNOW 8 (SKIP TO 122)
121E. Does the community health worker currently have malaria medicines available?
NO 2
DON'T KNOW 8
122. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (SKIP TO 201)
123. How many mosquito nets does your household have?
124. May I have a look at (all) the net(s) to establish the brand?
NOT OBSERVED 2
125. How many months ago did your household obtain the mosquito net? IF LESS THAN ONE MONTH, WRITE '00'.
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
126. Where did you get the mosquito net from?
GOV'T HEALTH CENTER 02
PHARMACY 04
OPEN MARKET 06
HAWKER 07
PROJECT/NGO 08
CAMPAIGN 09
CHURCH 10
DOES NOT KNOW 98
127. OBSERVE OR ASK THE BRAND OR TYPE OF MOSQUITO NET.
DURANET 12 (SKIP TO 131)
INTERCEPTOR 13 (SKIP TO 131)
NETPROTECT 14 (SKIP TO 131)
OLYSET 15 (SKIP TO 131)
DAWANET 16 (SKIP TO 131)
ICONLIFE 17 (SKIP TO 131)
KOOPER NET 22
ICONET 23
SAFI NET 24
BAMBOO HUT 32
CENTURY 33
LUCKY NET 34
VICTORIA 35
OTHER 96 (SPECIFY)_
DK BRAND 98
129. Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitoes or bugs?
NO 2 (SKIP TO 131)
NOT SURE 8 (SKIP TO 131)
130. How many months ago was the net last soaked or dipped? IF LESS THAN 1 MONTH, RECORD '00'.
25 OR MORE MONTHS AGO 95
NOT SURE 98
131. Did anyone sleep under this mosquito net last night?
NO 2
NOT SURE 8 (SKIP TO 133)
131A. What are some of the reasons why this net was not used?
DON'T LIKE SMELL B
NO MOSQUITOES C
NET TOO OLD/TOO MANY HOLES D
NET NOT HANG E
OTHER X (SPECIFY)_
DON'T KNOW Z
(ALL SKIP TO 133)
132. Who slept under this mosquito net last night? RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE
LINE NUMBER_
133. GO BACK TO 124 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 201.
SECTION 4: ANEMIA AND MALARIA TESTING FOR CHILDREN AGE 0-4 (0-59 MONTHS)
201. CHECK COLUMN 9. WRITE THE LINE NUMBER AND NAME FOR ALL CHILDREN 0-4 YEARS IN Q. 202 IN ORDER BY LINE NUMBER. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRES
BE SURE TO FILL Qs. 209 AND 211
202. LINE NUMBER FROM COLUMN 9. NAME FROM COLUMN 2
NAME_
203. IF MOTHER INTERVIEWED, COPY CHILD'S MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?
MONTH_
YEAR_
204. CHECK 203: CHILD BORN IN OCTOBER 2004 OR LATER?
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE, GO TO 215)
206. LINE NUMBER OF PARENT OR ADULT RESPONSIBLE FOR CHILD. RECORD '00' IF NOT LISTED.
207. READ ANEMIA CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.
REFUSED 2
208. READ MALARIA CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.
REFUSED 2
CONDUCT TESTS FOR WHICH CONSENT IS GRANTED AND CONTINUE TO 209
209. RECORD RESULT CODE OF ANEMIA TEST.
NOT PRESENT 2 (SKIP TO 211)
REFUSED 3 (SKIP TO 211)
OTHER 6 (SKIP TO 211)
210. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.
211. RECORD RESULT CODE OF MALARIA TEST
NOT PRESENT 2 (SKIP TO 215)
REFUSED 3 (SKIP TO 215)
OTHER 6 (SKIP TO 215)
212. BAR CODE LABEL. PASTE BAR CODE HERE AND ON SLIDE AND ON TRANSMITTAL FORM.
NEGATIVE 2 (SKIP TO 215)
OTHER 6 (SKIP TO 215)
214. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD. ASK ABOUT ANY TREATMENT THE CHILD HAS ALREADY RECEIVED.
REFUSED 2
ALREADY HAS ACT 3
NOT ELIGIBLE 4
OTHER 6
215. GO BACK TO 203 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST
COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, END INTERVIEW.
CONSENT STATEMENT FOR ANEMIA TEST
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.
We request that all children under 5 years participate in the anemia testing part of this survey and give a few drops of blood from a finger. The equipment used in taking 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 confidential.
Do you have any questions about the anemia test?
You can say yes to the test or you can say no. It is up to you to decide.
Will you allow [NAME(S) OF CHILD(REN)] to participate in the anemia test?
CONSENT STATEMENT FOR MALARIA TEST
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. This survey will help the government to develop programs to prevent malaria.
We request that all children under 5 years participate in the malaria testing part of this survey and give a few drops of blood from a finger. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test. (We will use blood from the same finger prick made for the anemia test).
The blood will be tested for malaria immediately and the result will be told to you right away. The result will be kept confidential.
Do you have any questions about the malaria test?
You can say yes to the test or you can say no. It is up to you to decide.
Will you allow [NAME(S) OF CHILD(REN)] to participate in the malaria test?
TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TESTS
IF MALARIA TEST IS POSITIVE: The malaria test shows that your child has malaria. We can give you free medicine.
The medicine is called COARTEMACT. COARTEM/ACT is very effective and in a few days it should get rid of the fever and other symptoms.
BEFORE PROVIDING COARTEM/ACT, FIRST ASK IF THE CHILD IS ALREADY TAKING OTHER MEDICINES AND IF SO, ASK TO SEE THEM. IF CHILD IS ALREADY TAKING COARTEM/ACT, CHECK ON THE DOSE ALREADY AVAILABLE. FOLLOW THE NATIONAL TREATMENT GUIDELINE FOR MALARIA. BE CAREFUL NOT TO OVERTREAT.
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.
TREATMENT WITH COARTEM/ACT
Weight (in Kg) -- Approximate Age
5 kgs. to less than 15 kgs. (under 3 years)
Dosage
1 tablet twice daily for 3 days
Weight (in Kg) -- Approximate Age
15 kgs. to less than 25 kgs. (3 -8 years)
Dosage
2 tablets twice daily for 3 days
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). Take the medicine (crushed for smaller children) with high fat food or drinks like 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, you will need to get get additional tablets and repeat the dose.
ALSO TELL THE PARENT/CARE TAKER:
If [NAME] has any of the following symptoms, you should take him/her to a health professional for treatment immediately:
-- High fever
-- Fast or difficult breathing
-- Not able to drink or breastfeed
-- Gets sicker or does not get better in 2 days
TO BE FILLED IN AFTER COMPLETING INTERVIEW COMMENTS ABOUT RESPONDENT:
COMMENTS ABOUT RESPONDENT_
COMMENTS ON SPECIFIC QUESTIONS_
ANY OTHER COMMENTS_
NAME OF SUPERVISOR_
DATE_