KPC Survey, CH Project, Guatemala, June 2010
Community Name
No. of the Conglomerate
Sector Number
Name of Mother
Name of Supervisor
Name of Interviewer
Date: Day___/Month_____Year_____
1
2
1
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KPC Survey, CH Project, Guatemala, June 2010
Introduction:
Hello. My name is ______________________________, and I am working with Medical Teams
International We are conducting a survey and would appreciate your participation. I would like
to ask you about your health and the health of your youngest child under the age of two. May I
ask (Selection Criteria: Ask the following 4 questions):
1) Is there a child or children under 24 months living in this household?
2) Is there a child or children under 24 months present now?
3) Is the mother of that child or the mother(s) of those children present now?
Consent: If there is an eligible mother and child or children, read the consent form: If it is the same
person that you read the above introduction to, just say: “As I was saying,” instead of “Hello” again.
Hello. My name is ______________________________, and I am working with Medical Teams
International. We are conducting a survey and would appreciate your participation. I would like
to ask you about your health and the health of your youngest child under the age of two. This
information will help Medical Teams International to plan health services and assess whether it
is meeting its goals to improve children’s health. The survey usually takes 30 minutes to
complete. Whatever information you provide will be kept strictly confidential and will not be
shown to other persons.
Participation in this survey is voluntary and you can choose not to answer any individual
question or all of the questions. However, we hope that you will participate in this survey since
your views are important.
At this time, do you want to ask me anything about the survey?
Respondent agrees to be interviewed (Yes or No) _______
Signature of interviewer: _____________________________________ Date: ____________
Selecting a Child:
At this time, if there is more than 1 eligible child under two years of age; ask the mother if she
could bring the children. Give each child a number, and explain to the mother that you will
randomly choose one of the children to ask the questions about.
Randomly choose the child.
Then ask the mother if she has a Child Health Card for this child available, and also an
Antenatal Care or TT Card for herself. Ask her to please bring these cards now so they are
available for the interview.
QUESTIONNAIRE - ALL QUESTIONS ARE TO BE ADDRESSED TO MOTHERS WITH A
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KPC Survey, CH Project, Guatemala, June 2010
CHILD LESS THAN 24 MONTHS OF AGE.
1. How old are you?
Record age of Mother in Years:_____________
2. How many children do you have? ________________
3. How many of these children are your biological children? _________________
4. What is the name and date of birth of the youngest child?”
NAME
The selected child
SEX
DATE OF BIRTH
1 - Male
2 -Female
AGE IN MONTHS
__ __ / __ __ / __ __
DD MM YY
All subsequent questions pertain to the selected child under age two.
Anthropometry
5. May I weigh (Name)? If the mother agrees, weigh the child and record the weight below. Record to
the nearest tenth.
____ Pounds _____Ounces
6. May I measure (Name)? If the mother agrees, measure the child and record the height
below. Record to the nearest tenth.
_____ ______ . ______ Centimeters
7.
Do you have a Child Health Card where the child’s birth weight is written down?
MARK ONLY 1 ANSWER
1. YES, SEEN BY INTERVIEWER
2. YES, SEEN BY INTERVIEWER, BUT NO BIRTHWEIGHT REGISTERED
3. YES, NOT SEEN  SKIP TO Q. 9
4. NO CARD  SKIP TO Q. 9
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KPC Survey, CH Project, Guatemala, June 2010
8. LOOK AT THE CARD TO ENSURE THAT IT IS FOR THIS CHILD AND
RECORD THE CHILD’S BIRTH WEIGHT
_____ ______lbs . ______Onz
Maternal and Newborn Care
BEFORE ASKING THESE QUESTIONS, PLEASE ASK THE MOTHER IF SHE HAS
A MATERNAL HEALTH CARD
LOOK AT THE CARD TO SEE IF SHE HAS HAD PRENATAL CARE AND TO
VERIFY THE NUMBER OF TIMES SHE HAD PRENATAL CARE (Q. 10). IF THE
NUMBER SHE GIVES YOU IN Q. 10 IS DIFFERENT THAN THE CARD
INDICATES, PLEASE ASK HER WHICH IS CORRECT AND ENTER THAT
NUMBER FOR Q. 10
9. Did you see anyone for prenatal care while you were pregnant with (NAME)?
YES CONTINUE
NO SKIP TO Q. 10
IF YES: Whom did you see?
PROBE FOR THE TYPE OF PERSON AND
RECORD ALL PERSONS MENTIONED BY THE MOTHER.
HEALTH PROFESSIONAL
1.
DOCTOR
2.
NURSE
3.
TRADITIONAL TRAINED MIDWIFE
4.
AUXILIARY NURSE
5.
COMMUNITY FACILITATOR
6.
HEALTH VIGILANT
7.
MOTHER COUNSELOR
OTHER PERSON
8.
TRADITIONAL MIDWIFE
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KPC Survey, CH Project, Guatemala, June 2010
9.
10.
11.
99.
MEDICINE MAN
MEDICATION SALESMAN
OTHER_______________________________
(Specify)
NO ONE
10. How many times did you see someone for care during the pregnancy?
1 NUMBER OF TIMES…………………….|___|
8. DON’T KNOW
11. During your pregnancy with (NAME) did you receive an injection in the arm to prevent the baby
from getting tetanus, that is, convulsions after birth?
1.
YES
2.
NO  SKIP TO Q. 13
88. Don’t Know  SKIP TO Q. 13
12. While pregnant with (name), how many times did you receive such an injection?
If 7 or more times, record 7
1. Times…….|___|
88. Don’t Know
13. Did you receive any tetanus toxoid injection at any time before that pregnancy, including
during a previous pregnancy or between pregnancies?
1.
YES
2. NO - SKIP TO Q. 15
88. Don’t Know- SKIP TO Q. 15
14. Before the pregnancy with (Name), how many times did you receive a tetanus injection?
If 7 or more times, record 7
1. Times…….|___|
88. Don’t Know
15. When you were pregnant with (NAME), did you receive or buy any
iron tablets or iron syrup?
SHOW TABLET/SYRUP.
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KPC Survey, CH Project, Guatemala, June 2010
1.
YES
2. NO - SKIP TO Q. 17
88. DON’T KNOW - SKIP TO Q. 17
16. How many weeks did you take the tablets or syrup?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER
OF DAYS.
1. Number of Weeks…….|___|
88. Don’t Know
17. In the first two months after delivery, did you receive Folic Acid tablets like this?*
*SHOW AMPULE/CAPSULE/SYRUP.
1. YES
2.
NO- SKIP TO Q. 19
3. Don’t Know- SKIP TO Q. 19
18. How many weeks did you take Folic Acid?
NUMBER OF WEEKS…….|___|
88. DON’T KNOW
19. When (name of child) was born, where did they attend your delivery?
1. HOSPITAL
2. CAP (HEALTH CENTER)
3. HEALTH POST
4. CONVERGENCE CENTER
5. IN THE HOME
6. OTHERS (SPECIFY WHERE:______________________________
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KPC Survey, CH Project, Guatemala, June 2010
20. Who assisted you with the delivery of (Name)?
HEALTH PERSONNEL
1.
2.
3.
4.
DOCTOR
NURSE
TRAINED TRADITIONAL MIDWIFE
AUXILIARY NURSE
OTHER PERSON
5. TRADITIONAL MIDWIFE (MALE OR FEMALE)
6. COMMUNITY HEALTH WORKER (Community facilitator, Health
vigilants)
7. FAMILY MEMBER/FRIEND
8. OTHER_____________________________________(SPECIFY)
9. NO ONE
Questions 21-24 refer to the mother after the delivery of this child
21. Did a health care provider or a traditional birth attendant check on your health after the
delivery of this child, either at a health facility, home or other location?
1.
YES
2.
NO - SKIP TO Q. 25
22. Where did they do the consultation?
1. HOSPITAL
2. CAP (HEALTH CENTER)
3. HEALTH POST
4. CONVERGENCE CENTER
5. IN THE HOME
6. OTHERS (SPECIFY WHERE: ______________________________
23. Who checked your health at that time?
Probe for the most qualified person.
HEALTH PERSONNEL
1. DOCTOR
2. NURSE OR CLINICAL OFFICER
3. MIDWIFE
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KPC Survey, CH Project, Guatemala, June 2010
4. AUXILLIARY NURSE/MIDWIFE
5. TRADITIONAL BIRTH ATTENDANT (MIDWIFE) _______________
(NAME)
OTHER PERSON
6. COMMUNITY HEALTH WORKER
7. RELATIVE/FRIEND
8. OTHER: ____________________________________(NAME)
24. How long after the delivery did the first check take place?
If less than one day, record hours, if less than one week, record days.
Hours ___ ___
Days ___ ___
Weeks ___ ___
Don’t Know: 88
25. What are the signs of danger after giving birth indicating the need for you to seek health
care?
RECORD ALL MENTIONED.
1.
2.
3.
4.
5.
FEVER
EXCESSIVE BLEEDING (HEMORRAGING)
SMELLY VAGINAL DISCHARGE
DIFFICULTY BREATHING
STRONG HEAD ACHES THAT DO NOT END WITH
MEDICATION.
6. STRONG PAIN IN THE STOMACH
7.
7. OTHER_________________________
(SPECIFY)
8. DOES NOT KNOW
Questions 26-29 refer to this child shortly after birth.
26. After (Name) was born, did any health care provider or traditional birth attendant check on (Name’s)
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KPC Survey, CH Project, Guatemala, June 2010
health?
1.
YES
2.
NO  SKIP TO Q. 30
27. If the answer to the previous question is YES, ASK: Where did they do the consult?
1. HOSPITAL
2. CAP (HEALTH CENTER)
3. HEALTH POST
4. CONVERGENCE CENTER
5. IN THE HOME
6. OTHER (SPECIFY WHERE):______________________________
28. Who checked on (Child’s Name) health at that time?
Probe for the most qualified person.
HEALTH PERSONNEL
1. DOCTOR
2. NURSE OR CLINICAL OFFICER
3. MIDWIFE
4. NURSING ASSISTANT (AUXILLIARY NURSE)
5. TRADITIONAL BIRTH ATTENDANT _______________
(NAME)
OTHER PERSON
6. COMMUNITY HEALTH WORKER
7. RELATIVE/FRIEND
8. OTHER____________________________________ (NAME)
29. How long after the birth of (Name) did the first check take place?
If less than one day, record hours, if less than one week, record days.
Hours ___ ___
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KPC Survey, CH Project, Guatemala, June 2010
Days ___ ___
Weeks___ ___
Don’t Know: 99
30. What are the danger signs for newborns?
DON’T READ THE ANSWERS
CIRCLE THE LETTERS THAT CORRESPOND TO THE RESPONSES THAT THE MOTHER GIVES
1. CONVULSIONS………………..………………A
2. FEVER…………………………........................B
3. NOT BREASTFEEDING WELL O VOMITING EVERYTHING
…………………C
4. DIFFICULTY BREATHING ……………………D
5. THE BEBE BECOMES COLD …...……..…………….E
6. THE BEBE IS VERY SMALL …………………………...F
7. YELLOW PALMS/EYES....................G
8. WEAK, LETHARGIC, UNCONSCIOUS…………………...H
9. IS PURPLE …………………………………….I
10. HAS PUS OR REDNESS IN THE NAVEL, EYES OR SKIN
………………..…………………………………..J
11. MALFORMATIONS OR CONGENITAL ANOMALIES THAT COULD
PUT THE NEWBORN’S LIFE AT RISK ……….K
121. WRITE OTHER ANSWERS (THAT ARE NOT ON THE LIST ABOVE)
HERE: _________________________________
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KPC Survey, CH Project, Guatemala, June 2010
31. Are you currently doing something or using any method to delay or avoid getting pregnant?
1.
YES
2.
No  SKIP TO Q. 33
32. Which method are you (or your husband/ partner) using?
DO NOT READ RESPONSES
CIRCLE ONLY ONE RESPONSE
IF MORE THAN ONE METHOD IS MENTIONED, ASK,
What is your MAIN method that you (or your husband/ partner) use to delay or avoid
getting pregnant?”
IF RESPONDENT MENTIONS BOTH CONDOMS AND STANDARD DAYS
METHOD, CODE “12” FOR STANDARD DAYS METHOD.
IF RESPONDENT MENTIONS BREASTFEEDING, CODE “15” FOR OTHER AND
RECORD BREASTFEEDING.
IF RESPONDENT MENTIONS ABSTINENCE OR ISOLATION, CODE “15” FOR
OTHER AND RECORD RESPONSE IN SPACE PROVIDED.
HYSTERECTOMY……………………………………….1
VASECTOMY………………………………..…….2
PILLS/TABLETS……………………………………..……..3
IUD (intrauterine device in shape of T)..………………4
HORMONAL INJECTION (Depo Provera)....……………5
HORMONAL IMPLANT (Jadelle).……………….............6
MALE CONDOM …………..……………………………….7
FEMALE CONDOM ……………………………………………..8
DIAPHRAM………………………………………………………….9
SPERMICIDES….…………………………………………………10
BREASTFEEDING METHOD AND AMENORRHEA ….11
NATURAL CICLE METHOD……………………………………………..12
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KPC Survey, CH Project, Guatemala, June 2010
NATURAL METHODS (OTHERS APART FROM THE NATURAL
CICLE)……………….…….……………...……13
PULLING OUT …………..………………….....14
OTHER……………………………………………………..….……….15
(SPECIFY)
Breastfeeding and Young Child Feeding
33. Did you ever breastfeed (NAME)?
1.
YES
2.
NO  SKIP TO Q. 35
34. How long after birth did you first put (NAME) to the breast?
If less than 1 hour, record 00 hours, if less than 24 hours, record the hours, Otherwise
record days.
Hours ___ ___
Days ___ ___
Weeks ___ ___
Don’t Know: 88
35. In the first three days after delivery, was (NAME) given anything else to eat or drink other
than breast milk?
1.
YES
2.
NO
88. Don’t Know
36. Are you currently (still) breastfeeding (NAME)?
1.
YES → SKIP TO Q. 38
2.
No
37. For how many months did you breastfeed (NAME)?
Months …….|___|___
38. Now I would like to ask you about the types of liquids and foods that (NAME) had yesterday
during the day or at night (THE LAST 24 HOURS). Did (NAME) have. . .
READ EACH OF THE FOLLOWING AND PLACE A CHECK MARK IN THE BOX NEXT TO
EACH ITEM CONSUMED.
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KPC Survey, CH Project, Guatemala, June 2010
1
2
3
4
LIQUID/FOOD
Breastmilk?
Plain water?
CONSUMED IN LAST 24 HOURS?
Commercially produced infant
formula?
Any fortified, commercially
available infant and young
child food” [e.g. Cerelac]?
5
Any (other) porridge or gruel
oatmeal?
6
7
Rice with water
Other baby food with carrot,
potato, beans, and tortillas,
bananas, and other fruits and
vegetables.
39. How many times did (NAME) eat solid, semi-solid, or soft foods other than liquids yesterday
during the day and at night?
Number of Times: _________
Don’t Know: 88
40. PLEASE FILL IN THE FOLLOWING TABLE: Now I would like to ask you in more detail about any liquids or foods that
(NAME) may have had yesterday during the day or at night. I am interested in whether your child had the item even if it
was combined with other foods.
1. DAIRY
A
B
C
YES NO DK
Commercially produced Infant formula __________________?
Milk such as tinned, powdered, or fresh animal milk?
Cheese, yogurt, or other milk products?
2. GRAIN
YES NO DK
D
E
F
G
Cerelac
Any (other) porridge?
Bread, rice, noodles, or other foods made from grains?
White potatoes, white yams, manioc, cassava, or any other foods
made from roots?
3. VITAMIN A RICH VEGETABLES
YES NO DK
Pumpkin, carrots, squash, or sweet potatoes that are yellow or
H
orange inside?
Any dark green leafy vegetable (pumpkin leaves, greens,
I
spinach)?
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KPC Survey, CH Project, Guatemala, June 2010
Ripe mangoes, papayas or jack fruit?
Foods made with palm nut oil?
4. OTHER FRUITS/VEGETABLES)
Any other fruits or vegetables like oranges, grapefruit or
l
pineapple, banana, eggplant, tomatoes, peppers, cabbage?
5. EGGS
Eggs?
M
6. MEAT, POULTRY, FISH)
Liver, kidney, heart or other organ meats?
N
Any meat, such as beef, pork, lamb, goat, chicken, duck, sheep,
O
pigeon?
Fresh or dried fish or shellfish?
P
Grubs, snails, insects, other small protein food?
Q
J
K
7. LEGUMES & NUTs
R
YES NO DK
YES NO DK
YES NO DK
Any foods made from beans, peas, lentils, groundnuts, or soya
nuts?
8. OILS & FATS
S
YES NO DK
YES NO DK
Any oils, fats, or butter, or foods made with any of these?
CHECK 15A – 15S: HOW MANY FOOD GROUPS (GROUPS 1-8 IN ABOVE TABLE)
HAVE AT LEAST 1 ‘YES’ CIRCLED?
Number of Groups
________
________________________________________________________________________________
_END OF FOOD GROUPS_____________________________________________________________
9. OTHER FOODS-
*DOES NOT COUNT TOWARD FOOD GROUPS)
YES NO DK
U
V
W
X
Tea or coffee?
Any other liquids?
Any sugary foods, such as chocolates, candy, sweets, pastries,
cakes, or biscuits?
Any other solid or soft food?
41. Has (Name) ever received a Vitamin A dose (like this/any of these)?
Show common types of ampules, capsules, and syrups.
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KPC Survey, CH Project, Guatemala, June 2010
1.
Yes
2.
No  SKIP TO Q. 43
88. Don’t Know  SKIP TO Q. 43
42. Did (Name) receive a Vitamin A dose within the last 6 months?
IF SHE HAS THE HEALTH CARD, VERIFY THE DATE
1.
Yes
2.
No
88. Don’t Know
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KPC Survey, CH Project, Guatemala, June 2010
Child Immunization
43. Do you have a Child Health Card where (NAME’S) vaccinations are written down?
3. YES, SEEN BY INTERVIEWER→ Copy Card in spaces provided below
2. YES, NOT SEEN  SKIP TO Q. 44
3. NO CARD  SKIP TO Q. 44
44. Record information exactly as it appears on (name’s) vaccination card.
DAY
MONTH
YEAR
DPT 1
DPT 3
MEASLES
VITAMIN A
(most recent)
45. Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations
given during immunization campaigns?
1.
Yes
2.
No→SKIP TO Q. 54
88. Don’t Know →SKIP TO Q. 54
Even though you have copied the card, you will now ask the mother about her recall of
immunizations-in case some were not marked on her card
Q 46-48: “PLEASE TELL ME IF (NAME) RECEIVED ANY OF THE FOLLOWING
VACCINATIONS”:
46. A PENTAVLAENT vaccination, that is, an injection given in the thigh or buttocks,
sometimes at the same time as polio drops?
YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
NO  SKIP TO Q. 48 . . . . . . . . . . . . . . . . 2
DON’T KNOW  SKIP TO Q. 48.. . . . . . 8
47. How many times was the DPT vaccine received?
NUMBER OF TIMES __________
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KPC Survey, CH Project, Guatemala, June 2010
48. Did (NAME) ever receive an injection in the arm to prevent Measles?
1.
Yes
2.
No
88. Don’t Know
Diarrhea
49. Has (NAME) had diarrhea in the last 2 weeks?
1.
Yes
2.
No  SKIP TO Q. 59
88. Don’t Know  SKIP TO Q. 59
50. If yes, at any time when your child had diarrhea, were the stools mostly or entirely liquid?
1. Yes
2. No  GO TO QUESTION 52
51. If yes, what did the stool look like? (SHOW THE BRISTOL STOOL CHART)
TYPE 1 ………………………………………1
TYPE 2 ………………………………..…….2
TYPE 3 ………………………………..…….3
TYPE 4 ………………………………..…….4
TYPE 5 ………………………………..…….5
TYPE 6 ………………………………..…….6
TYPE 7 ………………………………..…….7
52. When your child had diarrhea, how many stools did he/she have each day? _
NUMBER OF STOOLS _________
53. Was s/he given any of the following to drink at any time since s/he started having diarrhea?
YES NO
DK
ORS packet..................................1
2
88
A sugar, salt solution...................1
2
88
Coconut or rice water .................1
2
88
54. Was anything else given to treat the diarrhea?
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KPC Survey, CH Project, Guatemala, June 2010
1.
Yes
2.
No  SKIP TO Q. 56
88. Don’t Know  SKIP TO Q. 56
55. What ELSE was given to treat the diarrhea?
RECORD ALL MENTIONED
If the answer is a pill or syrup, show local packaging for zinc and ask if the child received this
medicine.
Pill or Syrup
1. Antibiotic
2. Immodium-Antimotility
3. Zinc
4. Other (not antibiotic, antimotility or Zinc
5. Unknown Pill or syrup
Injection
6. Antibiotic
7. Non antibiotic
8. Unknown injection
9. ((IV) Intravenous
10. Herbal medicine: __________
11. Other:___________________________________
56. When (NAME) had diarrhea, did you breastfeed him/her less than usual, about the same amount, or
more than usual?
1. LESS
2. SAME
3. MORE
4. CHILD NOT BREASTFED AT THIS TIME
88. DON’T KNOW
57. When (NAME) had diarrhea, was he/she offered less than usual to drink, about the same amount, or
more than usual to drink?
1. LESS
2. SAME
3. MORE
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KPC Survey, CH Project, Guatemala, June 2010
4. NOTHING-EXCLUSIVE BREAST FEEDING
88. DON’T KNOW
58. Was (NAME) offered less than usual to eat, about the same amount, or more than usual to eat?
1. LESS
2. SAME
3. MORE
4. NOTHING TO EAT-EXCLUSIVELY BREASTFEEDING
88. DON’T KNOW
ARI Recognition and Management
59. Has (NAME) had an illness with a cough that comes from the chest at any time in the last two
weeks?
1.
Yes
2.
No  SKIP TO Q. 66
88. Don’t Know  SKIP TO Q. 66
60. When (NAME) had an illness with a cough, did he/she have trouble breathing or breathe faster than
usual with short, fast breaths?
1.
Yes
2.
No  SKIP TO Q. 66
88. Don’t Know SKIP TO Q. 66
61. Did you seek advice or treatment for the cough/fast breathing?
1.
2.
Yes
No  SKIP TO Q. 65
62. How long after you noticed (NAME’s) cough and fast breathing did you seek treatment?
0. SAME DAY
1. NEXT DAY
2. TWO OR MORE
63. Where did you go for advice or treatment for your child’s cough/fast breathing?
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KPC Survey, CH Project, Guatemala, June 2010
HEALTH FACILITY - IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE
THE NAME OF THE PLACE, AND ALSO CHECK THE CORRECT BOX:
______________________________________
(NAME OF PLACE)
1. HOSPITAL
2. HEALTH CENTER
3. HEALTH POST
4. CONVERGENCE CENTER
5. PRIVATE CLINIC
6. HOUSE OF A COMMUNITY HEALTH WORKER (CF, HV)
7. OTHER ASSISTANCE CENTER ________________________________
8. MEDICINE MAN
9. STORE
10. PHARMACY
11. COMMUNITY SELLER OF MEDICATIONS
12. FAMILY MEMBER/FRIEND
88. OTHER_________________________.
64. Who gave you advice or treatment?
RECORD ALL MENTIONED
Anyone else?
.
1. DOCTOR
2. NURSE
3. AUXILIARY NURSE
4. TRAINED COMMUNITY HEALTH WORKER
5. OTHER
65. Which medicines were given to (NAME)?
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KPC Survey, CH Project, Guatemala, June 2010
1. NOTHING
2. ASPIRIN
3. PANADOL /ACTION/ MAXADOL/ HEADEX/PIRITON
4. AMOXICILLIN, SEPTRIN, PEN.V (TABLET),
5. CHLORAMPHENICOL
6. ERYTHROMYCIN
7. AZITHROMYCIN
8. UNKNOWN PILL/TABLET
9. UNKNOWN SYRUP
10. OTHER: ________________________
88. Don’t Know
66. Do you have an improved stove?
1. YES
2. NO
67. Where do you cook your meals?
1. INSIDE THE HOUSE
2. INSIDE THE HOUSE IN A SEPARATE KITCHEN/COOKING AREA
3. OUTSIDE OF THE HOUSE—SKIP TO Q. 69
68. If you cook INSIDE the house, which methods do you use to cook your food?
CIRCLE ALL METHODS MENTIONED. FOR EACH METHOD SELECTED, MARK NUMBER OF
TIMES USED PER WEEK.
1.
2.
3.
4.
5.
6.
OPEN FIRE INSIDE THE HOUSE
____(number of days per week)
Polletón (unimproved stove)
____(number of days per week)
VENTILATED STOVE
____(number of days per week)
GAS STOVE
____(number of days per week)
In the dirt
____ (number of days per week)
OTHER____________(Specify) ____(number of days per week)
IF THE MOTHER ANSWERS BOTH THE OPEN FIRE OR POLLETON AND THE IMPROVED STOVE,
ASK QUESTION #69. IF NOT, THEN SKIP TO QUESTION #70.
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KPC Survey, CH Project, Guatemala, June 2010
69. If you have an improved stove and you are still using an open fire in your home, why do you
still use the open fire?
CIRCLE ALL MENTIONED. DO NOT READ THE ANSWERS
1.
2.
3.
4.
To cook
To heat the home
To dry the corn and beans
Other ___________________
(please list)
70. What features of a stove are most important to you?
DO NOT READ THE ANSWERS.
MARK ALL RESPONSES MENTIONED.
1. SIZE OF THE COOKING SURFACE
2. ABILITY TO HEAT THE ROOM
3. AMOUNT OF WOOD REQUIRED
4. LACK OF SMOKE INSIDE THE HOUSE
5. OTHER ___________________ (SPECIFY)
Hand-washing Practices
71. Now we would like to ask you something concerning hygiene and sanitation. Do you sometimes
wash your hands?
1.
Yes
2.
No  SKIP TO Q. 74
72. Can you show me where you usually wash your hands and WHAT YOU USUALLY USE
TO WASH YOUR HANDS?
OBSERVATION ONLY: IS THERE SOAP OR DETERGENT OR LOCALLY USED
CLEANSING AGENT? THIS ITEM SHOULD BE EITHER IN PLACE OR
BROUGHT BY THE INTERVIEWEE WITHIN ONE MINUTE. IF THE ITEM IS NOT
PRESENT WITHIN ONE MINUTE CHECK NONE, EVEN IF BROUGHT OUT
LATER.
1. SOAP
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KPC Survey, CH Project, Guatemala, June 2010
2. DETERGENT
3. ASH
4. MUD/SAND LEAVES/GRASS/BRUSH/PLANTS
5. NONE
6. OTHER______________________________________
73. When do you wash your hands?
DO NOT PROMPT (do not read the answers to the mother/caretaker-let her answer on her own).
CIRCLE ALL MENTIONED.
ASK: “ANY OTHER TIME?”
1. NEVER
2. BEFORE FOOD PREPARATION
3. BEFORE FEEDING CHILDREN
4. AFTER DEFECATION
5. AFTER ATTENDING TO A CHILD WHO HAS DEFECATED
6. OTHER __________________________
Water and Sanitation
74. What is the main source of drinking water for members of your household?
1.
PIPED WATER INTO DWELLING
2.
PIPED WATER INTO YARD/PLOT/BUILDING
3.
PUBLIC TAP/STANDPIPE
4.
TUBEWELL/BOREHOLE
5.
PROTECTED DUG WELL
6.
UNPROTECTED DUG WELL
7.
PROTECTED SPRING
8.
UNPROTECTED SPRING
9.
RAIN WATER COLLECTION
10. CART WITH SMALL TANK/DRUM (BUS THAT SELLS WATER)
TANKER TRUCK
11. BOTTLED WATER
12. SURFACE WATER (RIVER /POND/LAKE/DAM/STREAM/CANAL/IRRIGATION CHANNELS
88. OTHER _________________________________________
75. Do you treat your water in any way to make it safer for drinking?
1. YES
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KPC Survey, CH Project, Guatemala, June 2010
2.
NO  SKIP TO Q. 77
88. DON’T KNOW  SKIP TO Q. 77
76. IF YES, what do you usually do to the water to make it safer to drink?
ONLY CHECK MORE THAN ONE RESPONSE, IF SEVERAL METHODS ARE USUALLY
USED TOGETHER, FOR EXAMPLE, CLOTH FILTRATION AND CHLORINE
1. TABLET/AQUAFRESH
2. BOIL
3. ADD BLEACH/CHLORINE
4. WATER FILTER (CERAMIC, SAND, COMPOSITE)
5. SOLAR DISINFECTION
6. LET IT STAND AND SETTLE/SEDIMENTATION
7. STRAIN IT THROUGH CLOTH
8. OTHER_____________________________________
88. DON’T KNOW
77. What kind of toilet does most members of your household use?
1. TOILET WITH SEPTIC TANK
2. VENTILATED IMPROVED PIT LATRINE (VIP)
3. SIMPLE PIT LATRINE WITH SLAB
4. PIT LATRINE WITHOUT SLAB/OPEN PIT
5. COMPOSTING/DRY TOILET
6. SERVICE OR BUCKET LATRINE
7. HANGING LATRINE OR OPEN AIR
8. NO FACILITY, FIELD, BUSH, PLASTIC BAG
9. OTHER (SPECIFY)
Health Messaging
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KPC Survey, CH Project, Guatemala, June 2010
78. Have you received messages about improving the health of your children and family?
1. YES
2. No (Go to question 85
79. From who have you received the messages about improving your health?
1. Mother Counselors
2. Midwives
3. Community facilitators (telephone facilitators)
4. Staff from the Ministry of Health
3. Religious leaders (catechist, evangelical pastors)
4. By the radio or other media
5. Other leaders (Specify)
80. Do you have a radio in the house?
1. YES (GO TO 80)
2. No (IF THE ANSWER IS NO, THANK HER FOR HER COLLABORATION AND END
THE INTERVIEW)
81. How many radios do you have in the house?
WRITE THE NUMBER OF RADIOS IN GOOD CONDITION
:______________________
Who listens to the radio?
1. The woman
2. Her husband
3. Both
4.The children
4. Other. Specify who? __________________________________
81. What radio stations do you listen to most?
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KPC Survey, CH Project, Guatemala, June 2010
READ THE FOLLOWING AND ENTER THE STATION THEY LISTEN TO THE MOST
1. (put a station choice here)
2. (put 2nd station choice here)
3. Put a 3rd station choice here)
4. Put a 4th station choice here
88. Other (List)________________________
99. Don’t know/ no specific station
82. What days do you listen to the radio the most?
READ THE FOLLOWING AND ENTER THE DAYS THAT THEY LISTEN THE MOST
1............................ Monday – Friday
2............................ Saturday
3............................ Sunday
83. At what time do you listen to the radio?
READ THE FOLLOWING CHOICES AND ENTER THE TIME THEY LISTEN THE MOST
1.
2.
3.
4.
Early morning
Late morning-early afternoon
Late afternoon
Evening
84. What program do you listen to the most?
READ THE FOLLOWING AND ENTER THE PROGRAM THEY LISTEN TO THE MOST
1. (put a program choice here)
2. (put 2nd program choice here)
3. Put a 3rd program choice here)
4. Put a 4th program choice here
88. Other (list) _____________________________________
99. Don’t know/ no specific program
85. What health topics would you like to hear on the radio?
DO NOT READ THE CHOICES
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KPC Survey, CH Project, Guatemala, June 2010
CIRCLE ANY CHOICES MENTIONED
1. Put a health topic you think they might mention here
2. Put a 2nd health topic you think they might mention here
3. Put a 3rd health topic you think they might mention here
4. Put a 4th health topic you think they might mention here
5. Put a 5th health topic you think they might mention here
6. Put a 6th health topic you think they might mention here
7. Put a 7th health topic you think they might mention here
8. Put a 8th health topic you think they might mention here
88. Other (List)__________________________________
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