[Cuba 2010]

Under-five child information panel: UF

This questionnaire is to be administered to all mothers or caretakers (see Household Listing Form, column HL9) who care for a child that lives with them and is under the age of 5 years (see Household Listing Form, column HL6).
A separate questionnaire should be used for each eligible child.

UF1. Consulting room number: _ _ _

UF2. Household number: _ _

UF3. Child's name:
Name ____

UF4. Child's line number: _ _

UF5. Mother's / caretaker's name:
Name ____

UF6. Mother's / caretakers line number: _ _

UF7. Interviewer name and number
Name ____ _ _

UF8. Day / month / year of interview _ _ / _ _ / _ _ _ _

Repeat greeting if not already read to this respondent:
We are from the Ministry of Public Health. We are working on a project concerned with family health and education. I would like to talk to you about (name)'s health and well-being. The interview will take about 15 minutes. All the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team.

If greeting at the beginning of the household questionnaire has already been read to this person, then read the following:
Now I would like to talk to you more about (child's name from UF3)'s health and other topics. This interview will take about 15 minutes. Again, all the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team.

May I start now?

UF9. Result of interview for children under 5
Codes refer to mother/caretaker.
UF10. Field edited by (name and number)

UF11. Data entry clerk (name and number):

WM12. Record the time.

Age: AG

AG1. Now I would like to ask you some questions about the health of (name).
In what month and year WAS (name) born?
Probe: what is his / her birthday? If the mother/caretaker knows the exact birth date, also enter the day; otherwise, circle 98 for day. Month and year must be recorded.
AG2. How old is (name)?
Probe: how old was (name) at his / her last birthday?
Record age in completed years. Record '0' if less than 1 year. Compare and correct AG1 and/or AG2 if inconsistent.
Breastfeeding: BF

BF1. Has (name) ever been breastfed?

BF2. Is he/she still being breastfed?

BF3. I would like to ask you about liquids that (name) may have had yesterday during the day or the night. I am interested in whether (name) had the item even if it was combined with other foods.
Please include liquids consumed outside of your home.
Did (name) drink plain water yesterday, during the day or night?

BF4. Did (name) drink infant formula yesterday, during the day or night?

BF5. How many times did (name) drink infant formula?

BF6. Did (name) drink milk, such as tinned, powdered or fresh animal milk yesterday, during the day or night?

BF7. How many times did (name) drink tinned, powdered or fresh animal milk?

BF8. Did (name) drink juice or juice drinks yesterday, during the day or night?

BF9. Did (name) drink soup yesterday, during the day or night?

BF10. Did (name) drink or eat vitamin or mineral supplements or any medicines yesterday, during the day or night?

BF11. Did (name) drink ORS (oral rehydration solution) yesterday, during the day or night?

BF12. Did (name) drink any other liquids yesterday, during the day or night?

BF13. Did (name) drink or eat yogurt yesterday, during the day or night?

BF14. How many times did (name) drink or eat yogurt yesterday, during the day or night?

BF15. Did (name) eat thin porridge yesterday, during the day or night?

BF16. Did (name) eat solid or semi-solid (soft, mushy) food yesterday, during the day or night?

BF17. How many times did (name) eat solid or semi-solid (soft, mushy) food yesterday, during the day or night?

BF18. Yesterday, during the day or night, did (name) drink anything from a bottle with a nipple?

Care of illness: CA

CA1. In the last two weeks, has (name) had diarrhoea?

CA2. I would like to know how much (name) was given to drink during the diarrhoea (including breastmilk).
During the time (name) had diarrhoea, was he/she given less than usual to drink, about the same amount, or more than usual?
If less, probe: was he/she given much less than usual to drink, or somewhat less?
CA3. During the time (name) had diarrhoea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
If "less", probe: Was he/she given much less than usual to eat or somewhat less?
CA4. During the episode of diarrhoea, was (name) given to drink any of the following:
Read each item aloud and record response before proceeding to the next item.

[A] A fluid made from a special packet called (local name for ORS packet solution)?

[B] A pre-packaged ORS fluid for diarrhoea?

CA5. Was anything (else) given to treat the diarrhoea?

CA6. What (else) was given to treat the diarrhoea?
Probe: Anything else? Record all treatments given. Write brand name(s) of all medicines mentioned.
(Name) ____

CA7. At any time in the last two weeks, has (name) had an illness with a cough?

CA8. When (name) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?

CA9. Was the fast or difficult breathing due to a problem in the chest or a blocked or runny nose?

CA10. Did you seek any advice or treatment for the illness from any source?

CA11. From where did you seek advice or treatment?
Probe: Anywhere else? Circle all providers mentioned, but do NOT prompt with any suggestions.
Probe to identify each type of source. If unable to determine if public or private sector, write the name of the place.
(Name of place) ____

CA12. Was (name) given any medicine to treat this illness?

CA13. What medicine was (name) given?
Probe: Any other medicine? Circle all medicines given. Write brand name(s) of all medicines mentioned.
(Names of medicines) ____

CA14. Check AG2: Child aged under 3?

CA15. The last time (name) passed stools, what was done to dispose of the stools?

Immunization: IM

If an immunization card is available, copy the dates in IM3 for each type of immunization recorded on the card. IM6-IM17 are for registering vaccinations that are not recorded on the card. IM6-IM17 will only be asked when a card is not available.

IM1A. Check AG2: Is it a child under 3 years of age?
IM1. Do you have a card where (name)'s vaccinations are written down?
(If yes) May I see it please?

IM2. Did you ever have a vaccination card for (name)?

IM3. Date of Immunization

(a) Copy dates for each vaccination from the card.
(b) Write '44' in day column if card shows that vaccination was given but no date recorded.

BCG at birth

HB0 (at birth)

HB1 (1 month, mother tested positive for HBsAG)

HB2 (2 month, mother tested positive for HBsAG)

HB3 (12 month, mother tested positive for HBsAG)

DPT + HB + Hib (2 months)

DPT + HB + Hib (4 months)

DPT + HB + Hib (6 months)

AM-BC1 (3 months)

AM-BC2 (5 months)

PRS (1 year)

DPT1 (2 months, mother tested positive for HBsAG)

DPT2 (4 months, mother tested positive for HBsAG)

DPT3 (6 months, mother tested positive for HBsAG)

Hib1 (2 months, mother tested positive for HBsAG)

Hib2 (4 months, mother tested positive for HBsAG)

Hib3 (6 months, mother tested positive for HBsAG)

Polio 1 (Vaccination campaign from 27/02-05/03 2009 1st dose)

Polio 2 (Vaccination campaign from 24/03-30/04 2009 2nd dose)

Polio 3 (Vaccination campaign from 05-11/03 2010 1st dose)

Polio 4 (Vaccination campaign from 23-29/04 2010 1st dose)

IM4. Check IM3. Are all vaccines (BCG to Polio 4) recorded?
IM5. In addition to what is recorded on this card, did (name) receive any other vaccinations - including vaccinations received in campaigns or immunization days?
Record 'Yes' only if respondent mentions vaccines shown in the table above.
IM6. Has (name) ever received any vaccinations to prevent him/her from getting diseases, including vaccinations received in a campaign or immunization day?

IM7. Has (name) ever received a BCG vaccination against tuberculosis - that is, an injection in the arm or shoulder that usually causes a scar?

IM8. Has (name) ever received any "vaccination drops in the mouth" to protect him/her from getting diseases - that is, polio?

IM9. Was the first polio vaccine received in the first two weeks after birth or later?

IM10. How many times was the polio vaccine received?

IM11. Has (name) ever received a DPT + HB + Hib vaccination ? that is, an injection in the thigh or buttocks known as pentavalent? to prevent him/her from getting tetanus, whooping cough, diphtheria, Hepatitis B and Haempophilus Influenzae B?
Probe by indicating that the Pentavalent vaccination is applied at 2,4 and 6 months of age
IM12. How many times was a Pentavalent vaccine received?

IM13. Has (name) ever been given a Hepatitis B vaccination - that is, an injection in the thigh or buttocks - to prevent him/her from getting Hepatitis B?

IM14. Was the first Hepatitis B vaccine received within 24 hours after birth, or later?

IM15. How many times was a hepatitis B vaccine received?
Probe and indicate that the HepB vaccine is applied at one month, 2, and 12 months of age in children whose mothers tested positive to the HepB antigen
IM16. Has (name) ever received a Measles injection or an MMR injection - that is, a shot in the arm at the age of 12 months or older - to prevent him/her from getting measles?

IM17. Did (name) ever receive the DPT vaccine injections, that is, an injection in the thigh to prevent from diphteria, whooping cough and tetanus?
Probe and indicate that the DPT vaccine is applied at 2,4 and 6 months of age in children whose mothers tested positive for the HepB antigen
IM18. How many times did (name) receive the DPT vaccine?

IM19. Has (name) received the AM-BC vaccine (Meningococcus B and C), that is, an injection in the thigh?
Probe and indicate that the AM-BC vaccine is applied at 3 and 5 months of age
IM20. How many times did (name) receive the AM-BC vaccine?

IM21. Has your doctor ever prescribed (name) with an Iron supplement called "FORFERR"?

IM22. Have you provided (name) with the FORFERR as prescribed by your doctor?

IM23. Why didn't you give (name) the FORFERR?
Mark every mentioned answer
UF13. Record the time.
UF14. Is the respondent the mother or caretaker of another child age 0-4 living in this household?
[] Yes [Indicate to the respondent that you will need to measure the weight and height of the child later. Go to the next questionnaire for children under five to be administered to the same respondent]
[] No [End the interview with this respondent by thanking him/her for his/her cooperation and tell her/him that you will need to measure the weight and height of the child]
Check to see if there are other woman's, man's or under-5 questionnaires to be administered in this household.
Move to another woman's, man's or under-5 questionnair.

Interviewer's observations ________

Field editor's observations ________

Supervisor's observations ________