Date of interview: ___ /_____/______ House ID :_____________________

Interviewers: [] 1 [] 2 [] 3 Children : [] 0 active TB [] 1 without TB

A. Parents/guardian sociodemographic and other characteristics

No Questions Code
A1 Gender 1[ ] female 2[ ] male
A2 Date of birth (dd / mm / yyyy) (_____/________/________)
A3 Marital status?
1[] single 2[] married 3[] widowed 4[] divorced
A4 Ethnicity ?
1[] Minangkabau 2[] Javanese 3[] batak 4[] other, specify ___________
A5 What is your highest education ?
1[] don’t have education 2[] primary school
3[] junior high school 4[] senior high school
5[] bachelor 6[] above bachelor
A6 what is your current occupation ?
1[] housewife / house keeper 2[] entrepreneur / self employed
3[] agriculture /farmer 4[] fisherman
5[] lecturer 6[] civil servant
7[] private employees 8[] retired
9[] other , specify___________
A7 How many hours of work per day
________ hour
A8 Average monthly household income (IDR) ?
1[] < 1,000,000 2[] 1,000,000 – 3,000,000
3[] 4,000,000 – 5,000,000 4[] > 5,000,000
A9 Spending on food per month
1[] ≤ 1,000,000 2[] 1,000,000 – 2,000,000 3[] ≥ 2,0000,000
A10 How many people living in your house including yourself ?
______ (specify)
A11 How many children <15 yo living there ?
______ (specify)
A12 What is your relationship with the child ?
1[] mother 2[] father 3[] grandparents 4[] relatives 5[] other, __________
A13 Have you ever received nutritional counselling?
0[] No 1[] Yes 88[] not sure
B. Household Smoking behavior
No Questions Code
B1 Are you smoking ? 1[] Yes, current 2[] No, never 3[] former
B1.1 If yes, how many pack perdays ? ________ cigarettes/packs per day
B1.2 How long you have been smoking? ________ years
B1.3 Do you use to smoke inside house ? 1[] yes 2[] No 3[] sometimes
B2 If No, is there anyone in your house smoke in the last 6 months ?
0[] yes 1[] No how many people ? __________ specify
B2.1 If yes, how many pack perdays ? ________ cigarettes/packs per day
B2.2 How long they have been smoking? ________ years
B.2.3 Where do they usually smoke ? 1[] inside house 2[] outside house 3[] both

C. Parents health (if this section completed already by hospital based data, than skip)
No Questions Code
C1 What is your relationship with the child ?
1[] mother 2[] father 3[] grandparents
4[] siblings 5[] relatives 6[] other, specify _______________
C2 Do you have any underlying diseases (diagnosed by doctor) ?
may choose more than one
1[] Hypertension 2[] Diabetes 3[] COPD
4[] Asthma 5[] Cancer 6[] HIV
7[] Other, specify____________
8[] don’t have
C3 Have you ever been diagnosed, now or on the past that you had tuberculosis ?
0[] Yes 1[] No
C3.1 If yes, do you complete your treatment ? 1[] No 2[] Yes 3[]current on-going
C4 Do you know any person that have history of active TB ?
0[] No 1[] Yes
C4.1 If yes, what is her relationship with your child ?
1[] father / mother 2[] grandparents 3[] siblings
4[] family 5[] neighbours 6[] others, specify____________
C4.2 Do you know when s/he got TB diagnosed ? Specify : ________ month ______year
88[] don’t know
C4.3 Do you know her/his TB treatment status?
1[] cure 2[] completion 3[] treatment interruption
4[] lost to follow up 5[] death 6[] not evaluated 88[] don’t know

D. Child TB risk factors

No Questions Code
D1 Child gender 1[] female 2[] male
D2 Date of birth (dd/mm/yyyy) ______/________/________
D3 Child current education
1[] no education 2[] kindergarden
3[] elementary school 4[] junior high school

D4 Has your child previously received the BCG vaccine? 0[] No 1[] Yes
Has your child ever been diagnosed with tuberculosis? 0[] yes 1[] No
D5
If Not, TPT history? 1[] completed 2[] on going 3[] not received
D5.1
If yes, When was she/he diagnosed with tuberculosis? _______ month ________ year
D5.2
D5.3 What is following symptoms s/he have ? (multiple answer)
1 [] Cough 2 [] Fever 3 [] Night sweats
4 [] Loss of appetite 5 [] Less playful (not energetic) 6 [] Weight loss
7 [] Other, specify__________
Your child treatment status?
D5.4
1[] cure 2[] completion 3[] treatment interruption
4[] lost to follow up 5[] death 6[] not evaluated
88[] don’t know
Since how many months has your child been receiving tuberculosis treatment?
D5.5
1 [] 1-2 2 [] 3-4 3 [] 5-6 4 [] >6 88 [] don’t know
Type of index case contact
D6
1[] household contact 2[] close contact 3[] unknown

D7 Is your child sleep in the same room with index case ? 0[] yes 1[] No
D8 Is s/he has any underlying disease ?
1[] Hypertension 2[] Diabetes 3[] COPD
4[]Asthma 5[] Cancer 6[] Psychiatric problem
7[] HIV 8[] Other (specify)________________
9[] don’t have
PRACTICE related Nutrition

No Questions Code
1 Who determines your child's daily menu?
1[] Mother 2[] Father 3[] Caregiver
4[] Grandparent 5[] Helper 6[] Other, specify ________________
2 What are the considerations in choosing a menu for your child? (more than one)
1[] Nutrition
2[] Price/financial aspect
3[] Availability of ingredients
4[] Child's preference
5[] Other, specify ___________________
3 How often does your family eat together at home?
1[] Almost always, every day 2[] Often, not every day
3[] Sometimes, only on special occasions 4[] Rarely, once a week
4 Was the child ever breastfed ? 0 [] No 1 [] yes
(if NO, END questions about BF)
5 Exclusive breast feeding (only) for the first 6 months ? 0 [] No 1 [] Yes

5.1 If no, what type of milk/liquid you give to your child ? Multiple choices
[] 1 formula milk [] 2 evaporated milk [] 3 animal milk
[] 4 plants / soy milk [] 5 plain water [] 6 tea /coffee
[] 7 fruit juice [] 8 honey [] 9 other ___________________
6 Are you continuing / will breastfeeding to your child until 12 – 23 months ?
[] 0 No [] 1 Yes
7 What is your difficulties to give exclusive breastfeeding ?
Multiple choices
[] 1 painful breast by anycause [] 2 insufficient breastmilk production
[] 3 lack of support [] 4 short maternity leave periods
[] 5 emotional stress [] 6 lack of knowledge
[] 7 cultural influence [] 8 mother unable to breastfeeding
[] 9 other, specify________________
8 At what time you give complementary food ?
1[] < 6 months 2[] > 6 months
9 How many times did (name of the baby) eat foods, that is meals and snacks other than
liquids yesterday?
_______ number of times [] 88 don’t know
Minimum Dietary Diversity
Group Food lists code
Group 1 : Breast Milk Breast Milk (direct to mother breast or bottle feeding)
(only for infant parent) [] 0 No [] 1 yes
Group 2 : Grains, roots Porridge, bread, rice, lontong, noodles or other foods made from grains
and tubers [] 0 No [] 1 yes
White potatoes, white yams, cassava or any other foods made from roots
[] 0 No [] 1 yes
Group 3: Legumes and Any foods made from beans, peas, lentils, nuts or seeds (beans, long
nuts beans, gadang beans, soybeans, peanuts)
[] 0 No [] 1 yes
Group 4: Dairy products Infant formula, such as ®bebelac, ®dancow [] 0 No [] 1 yes
How many times ? ____
Milk, such as tinned, powdered or fresh animal milk [] 0 No [] 1 yes
How many times ? ____
Cheese or other dairy products [] 0 No [] 1 yes
Group 5: Flesh foods Liver, kidney, heart or other organ meats [] 0 No [] 1 yes
Any meat, such as beef, lamb, goat, chicken or duck [] 0 No [] 1 yes
Fresh or dried fish (bandeng, nil/mujair, lele), seafood
[] 0 N
o [] 1 yes
Group 6: Eggs Eggs [] 0 No [] 1 yes
Group 7: Vitamin A Pumpkin, carrots, squash or sweet potatoes that are yellow or orange
fruits and vegetables inside
[] 0 No [] 1 yes
Any dark green vegetables (kang kong, spinach, cassava leaves, broccoli,
mustard, cabbage, )
[] 0 No [] 1 yes
Ripe mangoes, papaya, banana, star fruit, langsat, watermelon (rich vit A
fruits)
[] 0 No [] 1 yes
Group 8: Other fruits Any other fruits or vegetables [] 0 No [] 1 yes
and vegetable
Others (not counted in Any oil, fats, or butter or foods made with any of these (rempeyek,
the dietary diversity gorengan, karupuak) [] 0 yes [] 1 no
score)
Any sugary foods, such as chocolates, sweets, candies, pastries, cakes or
biscuits (martabak, donat, brownis, bolu) [] 0 yes [] 1 no
Condiments for flavour, such as chillies, spices, herbs or fish powder
[] 0 yes [] 1 no
 Instant drinks (®popice, ®marimas, ®nutrisari) and Soft drinks
(®cocacola, ®sprite, ®fanta) [] 0 yes [] 1 no
No Questions code
1 What is your difficulties to give divers food ? Multiple choices
[] 1 financial difficulties
[] 2 child is picky eater
[] 3 lack of knowledge
[] 4 have no time / busy
[] 5 lack of child appetite [
] 6 unhealthy food preference
[] 7 other ________

KNOWLEDGE related to Nutrition

No Questions Code
1 Have you ever heard about exclusive breast feeding? [] 0 No [] 1 yes
2 An infant should exclusively breastfeed for the first 6 months
[] 0 No [] 1 yes [] 88 don’t know
3 How long is it recommended that a woman breastfeeds her child?
1[] Six months or less 2[] 6–11 months 3[] 12–23 months
4[] 24 months and more 5[] Other 88[] Don’t know
4 An infants should start complementary food at 6 months
[] 0 No [] 1 yes [] 88 don’t know
5 Which foods or types of food can be added to rice porridge make it more nutritious?
multiple choices
[] 1 protein-rich foods (meat, poultry, fish, liver/organ meat, eggs, etc.)
[] 2 Pulses and nuts: flours of groundnut and other legumes (peas, beans, lentils, etc.),
[] 3 Vitamin-A-rich fruits and vegetables (carrot, orange- yellow pumpkin, mango, etc.)
[] 4 Green leafy vegetables (e.g. kangkung, bayam, etc)
[] 5 rich sugary and strong flavor food
[] 6 Other, specify______________________[] 88 Don’t know
6 Why is it bad to eat too many sweets and candies for child ?
[]1 Because they can cause tooth decay []2 Because they are not nutritious
[]3 Because they interfere with appetite []4 Other,____________________
[] 88 Don’t know
7 Do health experts recommend that people should be eating more, the same amount, or less of
the following foods? (tick one box per food)
1. Vegetables 1[]More 2[]Same 3[]Less 4[]Not Sure
2. Food and drinks with added sugar 1[]More 2[]Same 3[]Less 4[]Not Sure
3. Meat 1[]More 2[]Same 3[]Less 4[]Not Sure
 4. Grains 1[]More 2[]Same 3[]Less 4[]Not Sure
5. Fatty food 1[]More 2[]Same 3[]Less 4[]Not Sure
6. Fruits 1[]More 2[]Same 3[]Less 4[]Not Sure
7. Salty foods 1[]More 2[]Same 3[]Less 4[]Not Sure
8. Water 1[]More 2[]Same 3[]Less 4[]Not Sure

8 How many times per week do experts recommend that people eat breakfast?
1[] 3 times per week 2[]4 times per week 3[] Every day 88[]Don't know
9 Healthy foods contain the following nutrients, except...
1[] Carbohydrates 2[]Protein 3[]Vitamins 4[]Fat 5[]gorengan 88[]Don't know
10 Which of the following is not a carbohydrate food source...
1[]Rice 2[]Cassava 3[]Meat 4[]Corn 88[]Don't know
11 The following food contains protein...
1[]Tempeh 2[]Wheat 3[] potato 4[]Meat 88[]Don't know
12 Vegetables and fruits are rich in... multiple choice
1[]Protein 2[]Vitamins 3[]Carbohydrates 4[]Minerals 88[]Don't know
13 Young children who often have mouth ulcers and bleeding gums are caused by a deficiency o
f the following nutrients...
1[]Iron 2[]Vitamin C 3[]Vitamin K 4[]Minerals 88[]Don't know
14 Inadequate nutrition can cause to infection include TB ?
1[] not true 2[] true 3[] don’t know
15 How can you recognize that your child is not having enough food/nutrition ?
Multiple choices
[] 1 Lack of energy/weakness: cannot work, study or play as normal (disability)
[] 2 Weakness of the immune system (becomes ill easily or becomes seriously ill)
[] 3 Loss of weight/thinness
[] 4 Children do not grow as they should (growth faltering)
[] 5 Other [] 88 Don’t know

E. Child Eating behavior (for children age more 2 years old)

1= never, 2= rarely, 3= sometimes, 4= often, 5= always
No Questions Code
E1 My child is always asking for food/eat too much
E2 My child eats more when upset/grumphy
E3 My child loves food and enjoys when eating
 E4 My child gets full before his/her meal is finished and get full up easily
E5 My child is difficult to please with meals
E6 My child eats slowly ,more than 30 minutes

Home Food availability (past 7 days)

Group subgroup Availability in home
1[] always 2[] often 3[] rarely
Grains, roots and tubers Rice, bread, rice, noodles or other foods mad
e from grains
Legumes and nuts beans, peas, lentils, nuts or seeds (buncis, ka
cang panjang, kacang gadang)
Dairy products Milk
Flesh foods Any meat, such as beef, lamb, goat, chicken
or duck, Fresh or dried fish, shellfish or seafo
od
Eggs eggs
fruits Any fruits
vegetables Any vegetables
Others (not counted in Oil, fat, butter foods
the dietary diversity candies
score) beverages

PRACTICE related TB
No Questions Code
1 Have you ever heard anything about tuberculosis (TB)? [] 0 NO (if No, interview END) [] 1
yes
2 For cases : Hand-shaking with anybody when child got TB diagnosed
For control : Hand-shaking with anybody who having TB
1[] Not at all 2[] Sometimes 3[] Most of the time 4[] Always
3 For cases : Put on a mask on child when child is suspect or active for TB
For control : Put on a mask on child when together people with TB
1[] Not at all 2[] Sometimes 3[] Most of the time 4[] Always
4 For cases : Sharing of utensils between child whose active TB with other family member
For control : Sharing of utensils between whose active TB with the child
1[] Always 2[] Most of the time 3[] Sometimes 4[] Not at all
5 Avoiding child to not contacts in public buildings
1[] Always 2[] Most of the time 3[] Sometimes 4[] Not at all
6 Opening windows in your bed/living room
1[] Always 2[] Most of the time 3[] Sometimes 4[] Not at all
7 Have a good diet especially when child is suspecting TB symptoms or child currently is ill with
 TB
1[] Always 2[] Most of the time 3[] Sometimes 4[] Not at all
8 Visit health facility when having TB symptoms
1[] Always 2[] Most of the time 3[] Sometimes 4[] Not at all

Knowledge related TB
No Questions Code
1 Where do you usually go if your children sick ?
1[] puskesmas 2[] hospital 3[] private clinic 4[] alternative / traditional medicine
5[] other, specify_____________
2 Where did you first hear about tuberculosis? 1[] family/friends 2[] health worker
3[] social media 4[] other, specify____________________
3 How can an individual contract to TB? ( Chose all that apply)
1[] Hand shake 2[] Smoking 3[] Sharing utensils
4[] Drink fresh milk without boiling
5[] Contact handles in public places
6[] From mother to unborn child
7[] Through air transmission from an infected person (cough or sneezing)
8[] Other (mention)..................................................88[] Don’t know
4 What are the signs and symptoms of TB that you know ? ( Choose all that apply)
1[] Loss of appetite 2[] Unexplained fevers of more than seven days
3[] Chest pains 4[] Prolonged cough of more than two weeks…
5[] Difficulty in breathing 6[] Night sweats.
7[] Weight loss. 8[] Coughing some blood
9[] Constant fatigue
10[]Other (mention)................................................. 88[] Don’t know
5 Will you go to a health facility if your child have fever, cough, night sweat ? [] 0 No [] 1 yes
6 If no, why ? 1[] Cost 2[] Difficulties with transportation/distance to clinic
3[] Do not trust medical workers 4[] Do not like attitude of medical workers
5[] Cannot leave work 6[] Do not want to find out that something is really wrong
7[] Other, specify____________
7 Do you know that TB medication in Indonesia is free ? [] 0 No [] 1 yes