PERSONAL CHARACTERISTIC

Name
Date of birth d m y
Age y m
Weight kg
Height cm
W/A
H/A
W/H

Child Factors
Variable Score
Preterm Y N
Birth weight <2.5 >2.5
Feeding methods Breast feed Bottle feed Mixed
Age when <4 moths 4-6 months >6 months
breastfeeding
ceased
Age when <3 months 3-4 months 5-6 months >6 months
complementary
feeding introduced
Number of meals <3 3-4 >4
per day
Immunization Complete Incomplete Up to date
Birth spacing <1 year 1-2 years >2 years
between patient
and sibling before
Child drank plain Yes No
water yesterday
Child drank milk Yes No
yesterday
Child ate vitamin Yes No
yesterday
Child illness in the Yes No
last 2 weeks
Child diarrhea in Yes No
the last 30 days
DDS Poor Med Good
(Dietary diversity (1-3) (4-6) (7+)
score)
 Birth interval of Below 36 36 months or
children months above
Antenatal check up No 1-3 ANC 4 or more
Place of delivery Health facility Home
Postnatal check up Yes No
Growth monitoring Yes No
in previous 6
months before
interview
Total

Maternal Factors
Variable Score
Maternal age Less than >20 yo
at first 20 yo
Marital Married Single Separated
Status
Education No formal Grade 1-3 Grade 4-6 Secondray Tertiary
Level education
Occupation House Wife Domestic Market Semi- Skilled Professional
Help Seller Skilled
Health Status Healthy Pregnant On
Medical
Treatment
Alcohol Yes No
Consumption
Smoker Yes No
Summary of Low High
maternal
decision
making
power
matrix
Decision Respondent Jointly Husband Husband
making on alone and alone
small another
household person
purchase
Decision Respondent Jointly Husband Husband
making on alone and alone
large another
household person
purchase
 Decision Respondent Jointly Husband Husband
making on alone and alone
mother and another
child person
healthcare
Decision Respondent Jointly Husband Husband
making on alone and alone
right another
quantity and person
type of foods
to be given
to children
Decision Respondent Jointly Husband Husband
making on alone and alone
family another
planning person
Decision Respondent Jointly Husband Husband
making on alone and alone
participating another
on work to person
earn money
Total

Paternal Factors
Variable Score
Paternal age
Education No formal Grade 1-3 Grade 4- Secondray Tertiary
Level Education 6
Occupation Unemployed Market Semi- Skilled Professioonal
Seller skilled
Alcohol Yes No
Consumption
Smoker Yes No
Total
 Household,environmental and socio-economic factors
Variable Score
Total Number of <3 4-6 >7
People in
Household
Total Number of <UMR UMR >UMR
income earners in
household
Area of Residence Rural village Urban village Settlement Town
Type of Housing Permanent Semi Shanty Bush
Permanent Material
Area of land Landless Up to 0.5 More than 0.5
owned Hectors H
Number of <2 rooms >2 rooms
sleeping room
Type of toilet Flush Pit Bush Sea
Soap used in Yes No
previous 24h
before interview
Water Supply Running water Communal tap Others (well, No water
in house river, tank) supply
Water purified in Boiling Filtration No treatment
last 24 h
Food sufficiency Yes No
around the year
Types of cooking Solid fuel Liquid fuel
fuel
Total