Is this your ID?

001b. Enter your ID below.

Please record your ID

Must start with "N7" followed by 3 numbers

002a. Current date and time.

Is this date and time correct?

002b. Record the correct date and time.

The date must be between 2020-09-01 and 2021-09-01.

003a. Region

003b. Province

003c. Commune

003d village

004. Enumeration area

004a. Phase 1 Household list

005. Structure number

Please record the structure number from the household listing form.

Please record the structure number from the household listing form.

006. Household number

Please record the household number from the household listing form.

007a. Are you at the same dwelling unit location from Phase 1?

007b. Do people live in this dwelling unit?

007c. Is at least one of the original P1 members still living in the dwelling unit?

007d. Why are people not living in this dwelling unit?

GO TO 099, ENTER THE RESULT CODE AND SUBMIT THE FORM

007e. What is the status of the original P1 household?

Confirm with the neighbors to know the status

008. Which woman from Phase 1 are you following up?
If you do not see any women in this list, double-check your answers to 004a and 007a

010. CHECK: Why are you resending this form?

Choose all that apply.

011. Is a member of the household and competent respondent present and available to be interviewed today?

INFORMED CONSENT

Find a competent member of the household. Read the greeting on the following screen.

Bonjour. Je m'appelle ________________________________ et je travaille pour l'Institut Supérieur des Sciences de la Population (ISSP) de l'Université Joseph KI-ZERBO. Je vais à présent vous lire une déclaration expliquant l'enquête que nous menons.

Note d'information

L'Institut Supérieur des Sciences de la Population (ISSP) de l'Université Joseph KI-ZERBO en collaboration avec le ministère de la santé du Burkina Faso et l'école de santé publique et de la santé reproductive de l'université Johns Hopkins aux Etats-Unis mène une étude dénommée PMA (Performance Monitoring for Action). Cette étude a pour objectifs de mettre en ?uvre un système de suivi des performances accomplies dans le domaine de la planification familiale et de la santé en général au sein de la population et des structures de santé au Burkina Faso. Les informations que nous recueillerons serviront aussi pour mener des recherches et informer les orientations programmatiques en matière de planification familiale au Burkina Faso.

Consentement

Votre ménage a été sélectionné pour cette enquête. Votre participation dans cette étude nous aiderait beaucoup. Les informations que nous collecterons aideront à informer le gouvernement afin de mieux planifier les services de santé. Toutes les informations que vous nous donnerez resteront strictement confidentielles et ne seront montrées à personne d'autre que les membres de notre équipe.

La participation à cette enquête est volontaire mais nous espérons que vous accepterez d'y participer car votre point de vue est très important. Si vous ne souhaitez pas répondre à une question en particulier, faîtes-le moi savoir et je passerai à la question suivante. Vous pouvez également interrompre l'entretien à tout moment. Nous aimerions ensuite poser une série de questions aux femmes du ménage âgées entre 15 et 49 ans. La participation à l'étude ne présente aucun avantage direct pour vous. Vous ne serez pas rémunérée pour avoir répondu à ce questionnaire. L'enquête prendra environ 1 heure. A la fin de l'enquête un cadeau symbolique constitué d'un paquet de sucre et de deux boules de savon sera remis à votre ménage comme compensation pour le temps que les membres de votre ménage ont consacré pour répondre à nos différents questionnaires.

Avant de continuer, avez-vous des questions sur cette enquête ?

Si vous avez des questions plus tard sur la recherche, contactez
Dr Georges GUIELLA au +226 25 30 25 58

Vos droits en tant que participant
Cette recherche a été examinée et approuvée par le CERS (Comité d'Ethique pour la Recherche en Santé). Si vous avez des questions concernant la façon dont vous avez été traité ou cours de cette étude ou sur vos droits en tant que participante, vous pouvez contacter :
Pr OUEDRAOGO Dieu-Donné au 70324406:

?????????????

Puis-je commencer ?

010a. Read the verbal consent text.

Then, ask:
May I begin the interview now?

010b. Respondent's signature

Please ask the respondent to sign or check the box in agreement of their participation.

011. Interviewer's ID: {your_name}

Mark your ID as a witness to the consent process.

Household Roster Updating

ODK will display the summary of all household members listed in Phase 1. You will then update their information to indicate any changes including births and deaths

Section 1 ? Household Roster

PL102. P1 Household Member

Below are the Phase 1 details for member {P_pos}:

First name: ${hq_firstname_auto}
Relationship to HH head: ${hq_relationship_lab}
Gender: ${hq_gender_lab}
Age: ${hq_age_auto}
Marital Status: ${hq_marital_status_lab}

Is this person the respondent?

If yes, check this box.

PL103. What is the status of this member in the household?

PL104. Household Member

First name: {hq_firstname_auto}
Relationship to HH head: ${hq_relationship_lab}
Gender: ${hq_gender_lab}
Age: ${hq_age_auto}
Marital Status: ${hq_marital_status_lab}

Do you wish to update any of this information?

Section 1 ? Household Roster

I am now going to ask a series of questions about each usual member of the household or anyone who slept in the house last night.

101. Name of household member / visitor

Start with the head of the household.

101a. Is this person the respondent?

If yes, check this box.

102. What is {firstname}'s relationship to the head of household?

103. Is {firstname} male or female?

104. How old was {firstname} at their last birthday?

If less than one year old, record 0

Age must be less than 130 and greater than 0.

105. What is {firstname}'s current marital status?

If not married, probe to determine if they have ever been married and, if so, if they are divorced/separated, or widowed.

106. Does {firstname} usually live here?

107. Did {firstname} stay here last night?

LCL_101. What is the religion of {firstname}?

Only recorded for the head of the household.

LCL_102. What is the ethnicity of {firstname}?

Only recorded for the head of the household.

Are there any other usual members of your household or persons who slept in the house last night that I have not listed here?

109. READ THIS CHECK OUT LOUD: There are {num_HH_members} household members who are named ${names}. Is this a complete list of the household members?

Remember to include all children in the household.

Go back and update the roster.

Section 2 ? Household Characteristics

Now I would like to ask you a few questions about the characteristics of your household.

201. Is this structure/house newly built in the last 12 months?

202. Please tell me about items that your household owns. Does your household have:

Read out all types and select all that apply. Scroll to bottom to see all choices.

If an item is reported broken but said to be out of use only temporarily, select the item. Otherwise, do not select the item.

Cannot select 'no response' or 'none of the above' with other options.

These livestock can be kept anywhere, not necessarily on the homestead.

204. How many of the following animals does this household own?

The household can keep the livestock anywhere, but must own the livestock recorded here.
Zero is a possible answer. Enter -88 for do not know. Enter -99 for no response.

Pigs ___
Cows or bulls ___
Horses, donkeys or mules ___
Goats ___
Sheep ___
Chickens ___
Other ___

Section 3 ? Household Observation

Please observe the floors, roof and exterior walls.

301. Main material of the floor

Observe.

302. Main material of the roof

Observe.

303. Main material of the exterior walls

Observe.

Section 4 ? Water Sanitation and Hygiene

Now I would like to ask you a few questions about water, sanitation and hygiene.

401. We would like to learn about the places that households use to wash their hands. Can you please show me where members of your household most often wash their hands?

402. At the place where the household washes their hands, observe availability of water

403. At the place where the household washes their hands, observe availability of soap or detergent:

404. What is the main source of drinking water for members of your household?

405. What is the main toilet facility used by members of your household?

501. Thank you for the time you have kindly granted us.

Are you willing to provide a phone number for this household where we may reach you in the future to follow up for future research?

502. What is the phone number?

Enter an 8-digit number without the country code. Do not include spaces or dashes.

Invalid number of digits.

503. Can you repeat the number again?

Enter an 8-digit number without the country code. Do not include spaces or dashes.

Number entered must match previously entered number.

504. What is the name of the person who normally answers this phone?

Thank the respondent for his/her time.

The respondent is finished, but there is still more for you to complete outside the home.

Location and Questionnaire result

096. Location

Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6 m.

097. How many times have you visited this household?

098. In what language was this interview conducted?

099. Questionnaire Result

Record the result of the questionnaire.

Check answer to 009 and the consent.