Module 4: Questionnaire for use with women with

Children 24-59.9 months children from 24-59.9 months

UF1 Questionnaire Number which include the
Region code, Cluster & Household Number |_____|_____[____|_____|_____|
(to be numbered before interview)
REGION________ ZONE ________ WOREDA ________

CLUSTER _______ HOUSEHOLD _______

UF2 Date of visit

[_____|_____| ______|
DD |MM |YYYY
T1 Time at beginning of interview
____:____

Background of the Mother/Caretaker

UF3 How old were you on your last birthday?

Age in years………….._________
UF4 Are you able to read or write a simple Yes……….1
sentence? No……….2
UF5 Did you ever attend formal school? Yes……….1

No……….2 Skip
to UF7
UF6 If yes, what is the highest grade you
Grade _________
completed?
UF7 What is your current marital status? Single 1
Married 2
Divorced/Separated 3
Widowed 4
Background of the Child
UF8 What is the name of your child?

UF9 Boy………..1
Sex of Child
Girl………. 2
UF10
What is the age of your child?
[____|____] MONTHS
UF11
What is the birth date of [NAME]? [______/______/______]
DAY / MONTH / YEAR
UF12 Card seen, date of birth verified……………...1
Card seen, date of birth different.…………...2
Verify child’s date of birth by asking to see the
Record DOB from card [______/______/______]
Family Health card or vaccination card.
DAY / MONTH / YEAR
Not possible to verify……………………..3
UF13 Look at the age sheet and enter the child’s
age in months
[____|____] MONTHS
Check that the child is 24-59.9 months. If so
continue with interview.

LINKAGES Ethiopia Module 4: Children from 24-59.9 Months 1

Section 1: Child Health, Nutrition During Illness, and Care Seeking
UF101 Has (NAME) been ill at any time in the Yes…………….1
last 2 weeks? No..…………...2 Skip to
UF108
UF102 If yes, did (NAME) have….: (Y = YES, N = NO)
If no
Y N diarrhea
READ OUT THE LIST
Circle “1” for yes, and “2” for no. a) Diarrhea….................................……………1 2 mentioned
in UF102
b) Cough..…………………………………… 1 2 skip to
question
c) Rapid/Difficulty Breathing…………………1 2 UF104
d) Fever….................................………………1 2
e)Other……….............................……………1 2

Other (Specify) _____________________________

UF103 If the child had diarrhea: was (NAME) (Y = yes, N = no, DK = don’t know) Ask UF103
given any of the following to drink: Y N DK only if
a) Fluid from an ORS packet…….1 2 8 diarrhea
mentioned
Fluid from ORS packet? b) Home made sugar and salt
in UF102
Home made sugar and salt? solution...........................…….…. 1 2 8
Other home made fluid? c) Other home made fluid ……….1 2 8
d) Other …………………………1 2 8
READ OUT LIST
Other (specify)_______________________
RECORD ALL MENTIONED
UF104 How much was (NAME) offered to drink Less……………...…..1
during the illness? Was (NAME) offered About the same….…..2
less than usual to drink, about the same More than usual……..3
amount, or more than usual to drink? Nothing offered to drink…..…4
Child only breastfeeds, so no fluid given……..5
Don’t Know……..…..8
UF105 During illness, were the ‘number of Less……………...…..1
meals’ offered to [NAME] less than usual, About the same….…..2
about the same amount, or more than More than usual……..3
usual than before the illness? Nothing to eat……..…4
Child has not yet started complementary foods……….5
Don’t Know……..…..8

UF106 Is (NAME) still ill? Yes…………….1 Skip to

UF108
No..…………...2
UF107 After illness, were the ‘number of meals’ Less……………...…..1
offered to [NAME] less than usual, about About the same….…..2
the same amount, or more than usual than More than usual……..3
before the illness? Child has not yet started complementary foods……….4
Don’t Know……..…..8

UF108 Did you own a bed net? Yes…………….1

Skip to
No..…………...2 UF201
UF109 Did (NAME OF CHILD) sleep under a Yes…………….1
bed net last night? No..…………...2
UF110 Did you sleep under a bed net last night? Yes…………….1
No..…………...2

LINKAGES Ethiopia Module 4: Children from 24-59.9 Months 2

Section 2: Vitamin A
UF201 Did [NAME] receive a dose of vitamin Yes…………….1
A in the last 6 months? [Show Vitamin
No..…………...2 Skip to
A Capsule]
UF301
Do not know…..8
Skip to
UF301

UF202 If yes, where did your child receive the

vitamin A?
Routine Immunizations..…………...1
EOS ..……………………….……...2
Sick child visit…………….………..3
Well child/growth monitoring……...4
Other..……………………………...5
Other (specify) _________________________________

SECTIONE 3: Behavioral Change Communication (BCC)/Community Mobilization

UF301 Have you heard any child health related
messages in a radio? Yes…………….1
No…………..2 Skip to
UF303
Can’t remember……….8 Skip to
UF303
UF302 IF Yes, then what main points do you (M = mentioned, N = not mentioned)
remember from the radio message(s)? M N
a) Immunize your child before first birthday.……... 1 2
READ OUT THE LIST b) Immunization prevents from the 6 killer diseases….
Circle “1” for yes, and “2” for no. ……………………...…………………. 1 2
c) The father should get involved in immunization
of his children …………………….......……. 1 2
d) Bring your child’s immunization card…….……. 1 2
e) Other………………………………….......……. 1 2
Other (Specify) _________________________
Breastfeeding
M N
f) Early Initiation.………………………………….... 1 2
g) Feed Colostrum………………………………….... 1 2
h) EBF to 6 months……………………..………..….. 1 2
i) Frequently feed, 10-12 times ………..………..….. 1 2
j) Finish one breast before switching ………….….... 1 2
k) Continue BF until 24 months & beyond …….….... 1 2
l) other………………………………….......………. 1 2
Other (Specify) _________________________
Complementary Feeding
M N
m) Introduce CF at 6 months…….…..…………….... 1 2
n) Start with thick porridge………………………... 1 2
o) Give Variety of Foods……….….…………..…... 1 2
p)Progressively increase amount as child gets older..1 2
q) At 12 months child should eat “family foods”…. 1 2
r) Feeding frequency……………….………. .……. 1 2
s) Other…………………………………....……….. 1 2
Other (Specify) _________________________

LINKAGES Ethiopia Module 4: Children from 24-59.9 Months 3

UF303 In the last 6 months were you visited by
Yes…………….1
a field worker who talked to you about
immunizations and/or feeding practices No..…………...2 Skip to
for your child? UF305
UF304 If yes, who did you speak with? (Y = yes, N = no)

(Multiple Responses Possible) Y N

a) Health Worker……………………..... 1 2
b) Health Extension Worker. .…. …...... 1 2
c) CBRHA…………………………...... 1 2
d) Community Health Promoter……..…1 2
e) Other………………….…………......1 2
Other (Specify) ____________________________

UF305 Have you heard about the FHC? Yes…………….1

No..…………...2
Skip to
UF308
UF306 If yes, how did you hear about it? (Y = yes, N = no)

(Multiple Responses Possible) Y N

a) Health Worker...………..………….. 1 2
b) Health Extension Worker…. ……..... 1 2
c) CBRHA…………………………...... 1 2
d) Community Health Promoter……..…1 2
e) Neighbor, Friend, Family…..……..…1 2
f) Other………………….…………......1 2
Other (Specify) ____________________________

UF307 Does your child have a Family Health Yes…………….1

Card?
No..…………...2
UF308 Have you heard about the Yes…………….1
Immunization Diploma (Show
No..…………...2
Diploma)? End of
Interview
UF309 If yes, how did you hear about it? (Y = yes, N = no)

(Multiple Responses Possible) Y N

a) Health Worker...………..………….. 1 2
b) Health Extension Worker…. ……..... 1 2
c) CBRHA…………………………...... 1 2
d) Community Health Promoter……..…1 2
e) Neighbor, Friend, Family…..……..…1 2
f) Other………………….…………......1 2
Other (Specify) ____________________________

T2
Time at end of interview ____:____

LINKAGES Ethiopia Module 4: Children from 24-59.9 Months 4