QUESTIONNAIRE

This questionnaire is prepared to be used on assessment of prevalence of malnutrition and

associated risk factors among under five children in Rukwa region. It consists four main sections,
basing on the objectives. It is confidential and adhere to all ethical issues during the field.
DATE: ……………….. ; ASSESER’S NAME: …………………………………..
SECTION A: DEMOGRAPHIC DATA
Instructions: Put a tick in the box for correct answer
Example: Sex; A) Male
B) Female
DEMOGRAPHIC DATA CHILD’S SIDE GUARDIAN’S SIDE
(To be filled by guardian)
1. Age A. 0 – 6 months [ ] C. 18 – 25 years [ ]
B. 1 – 3 years [ ] D. 26 – 40 years [ ]
C. 3 – 5 years [ ] E. Over 40 years [ ]

2. Sex A. Male [ ] A. Male [ ]

B. Female [ ] B. Female [ ]

3. Area of residence A. Urban [ ]

B. Rural [ ]

4. Marital status
A. Married [ ]
B. Divorce [ ]
C. Single [ ]
D. Widow [ ]

5. Religion
A. Christian [ ]
B. Muslim [ ]
C. Others [ ]

6. Level of A. Kindagarten [ ]
education B. Nursery [ ] A. First school leaving
certificates [ ]
B. Ordinary level [ ]
C. Advance level [ ]
D. Others [ ]
DEMOGRAPHIC DATA CHILD’S SIDE GUARDIAN’S SIDE
(To be filled by the guardian)
7. Occupation A. Farmer [ ]
B. Teacher [ ]
C. House keeper [ ]
D. Others [ ]

8. Number of A. One [ ]
children B. Two [ ]
C. Three [ ]
D. More than three [ ]

SECTION B: GENERAL INFORMATION ON A CHILD’S NUTRITION

Instruction: To be filled by the guardian
1. How many meals does a child eat per day?
A. One meal [ ]
B. Two meals [ ]
C. Three meals [ ]
D. More than three meals [ ]

2. If once or twice times meal, what is the reason?

………………………………………………………………………………………………
………………………………………………………………………………………………

3. Does a child still on breast feeding?

A. Yes [ ]
B. No [ ]

4. Apart from breast feeding, what other kind of foods does the child eat on daily basis?
A. Cereals [ ]
B. Proteins [ ]
C. Cow milk [ ]
D. Fruits [ ]

5. Does the child eat well without hesitation?

A. Yes [ ]
B. No [ ]
6. How long did/ do you breast feed your child/ children?
a) 6 months [ ]
b) 1 year [ ]
c) 2 years [ ]
d) Does not [ ]
e) Other ………….

7. How long do you exclusively breast feed your child? ……………….

8. Do you know any advantages of breast feeding, to your child? If yes go to question 4
a) Yes [ ]
b) No [ ]

9. Mention any advantage(s) ………………………….

……………………………………….
………………………………………………………………………

10. What kinds of food do you consume? Mention any;

……………………………..
…………………………….
……………………………..
……………………………..
……………………………..
…………………………….

11. How many times do eat in a day? …………………………..

12. Who decides how much your child/children should eat?

A. Your child [ ]
B. You [ ]
C. The father ( )
SECTION C: GUARDIAN’S KNOWLEDGE ON MALNUTRITION
1. What will happen if the child is malnourished?
A. The child will be strong [ ]
B. The child’s health will deteriorates [ ]
C. Child will be prone to infections [ ]
D. I do not know [ ]

2. Are you aware on malnutrition?

A. Yes [ ]
B. No [ ]

3. What makes a child malnourished?

A. Poor feeding [ ]
B. Proper feeding [ ]
C. I do not know [ ]

SECTION D: RELATIONSHIP BETWEEN DISEASES AND MALNUTRITION

1. Does a child have any underlying disease?
A. Yes [ ]
B. No [ ]
C. I do not know [ ]

2. Is the disease associated with malnutrition?

A. Yes [ ]
B. No [ ]
C. I do not know [ ]

3. Does your child have recurrent infections?

A. Yes [ ]
B. No [ ]

4. When your child is sick, do you bring him or her to the hospital?
A. Yes [ ]
B. No [ ]