Woman Has No Vaccination Card

Module 3:
Children 12-23.9 months / Questionnaire for use with women with children from 12-23.9 months

SY1

/ Questionnaire Number which include the Region code, Cluster & Household Number(to be numbered before interview) / |_____|_____[____|_____|_____|
Region______Zone ______Woreda ______
Cluster ______Household ______
SY2 / Date of visit / [_____|_____| ______|
dd |mm |yyyy
T1 / Time at beginning of interview / ____:____
Background of the Caretaker/Mother
SY3 / How old were you on your last birthday? / Age in years…………..______
SY4 / Are you able to read or write a simple sentence? / Yes……….1
No……….2
SY5 / Did you ever attend formal school? / Yes……….1
No……….2 / Skip to SY7
SY6 / If yes, what is the highest grade you completed? / Grade ______
SY7 / What is your current marital status? / Single 1
Married 2
Divorced/Separated 3
Widowed 4
Background of the Child

SY8

/ What is the name of your child?

SY9

/ Sex of Child / Boy………..1
Girl………. 2

SY10

/ What is the age of your child? / [____|____] MONTHS

SY11

/ What is the birth date of [NAME]? / [______/______/______]
DAY / MONTH / YEAR

SY12

/ Verify child’s date of birth by asking to see the Family Health card or vaccination card. / Card seen, date of birth verified……………...1
Not possible to verify……………………..3

SY13

/ Look at the age sheet and enter the child’s age in months
Check that the child is 12-23.9 months. If so continue with interview. / [____|____] MONTHS
SECTION 1: Immunizations
SY101 / Do you have a card where (Name’s) vaccinations are written down?
If Yes, May I see it? / Yes…………….1
No..…………...2 / Skip to SY103
SY102 / Did you ever have a vaccination card for (NAME)? / Yes…………….1
No..…………...2 / Skip to SY106
Skip to SY106
WOMAN HAS CHILD’S VACCINATION CARD
SY103 / Does the child have a scar from BCG vaccination?
CHECK FOR BCG SCAR. / Yes…………….1
No..…………...2
SY104 / Copy vaccination date for each vaccine from the card
Write “44” in “Year” column if card shows that a vaccination was given, but no date is recorded
a) BCG
b) Polio 0
c) Polio 1
d) Polio 2
e) Polio 3
f) DPT 1
g) DPT 2
h) DPT 3
i) Measles / Day Month Year
BCG [___|___][___|___][___||___]
Polio 0 [___|___][___|___][___||___]
Polio 1 [___|___][___|___][___||___]
Polio 2 [___|___][___|___][___||___]
Polio 3 [___|___][___|___][___||___]
DPT 1 [___|___][___|___][___||___]
DPT 2 [___|___][___|___][___||___]
DPT 3 [___|___][___|___][___||___]
Measles [___|___][___|___][___||___] / If fully vaccinated, then skip to SY116
SY105 / Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in a national immunization day campaign?
PROBE FOR VACCINATIONS AND WRITE “66” IN THE CORRESPONDING DAY COLUMN OF SY104 / Yes…………….1
No.…………...2
IF YES, PROBE FOR VACCINATIONS AND WRITE “66” IN THE CORRESPONDING DAY COLUMN
ABOVE IN SY104. THEN SKIP TO SY116. / If yes, then fill SY104
If no, then skip to SY115

WOMAN HAS NO VACCINATION CARD

SY106 / Did (Name) ever receive any vaccinations to prevent him/her from getting diseases, including vaccinations received in a national immunization day campaign? / Yes…………….1
No..…………...2
Don’t Know…..8 / Skip to SY115
Skip to SY115
Please tell me if (Name) received any of the following vaccinations:
Read questions SY107 – 114
SY107 / A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar? / Yes…………….1
No..…………...2
Don’t Know…..8
SY108 / CHECK FOR BCG SCAR. / Yes…………….1
No..…………...2
SY109 / Polio vaccine, that is, drops in the mouth? / Yes…………….1
No..…………...2
Don’t Know…..8 / Skip to SY112
Skip to SY112
SY110 / When was the first polio vaccine received, just after birth (within 2 weeks) or later? / Just after birth…………….1
Later than two weeks..…………...2
SY111 / How many times was the polio vaccine received? / Number……..______
Don’t Know…..8
SY112 / DPT vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops. / Yes…………….1
No..…………...2
Don’t Know…..8 /
Skip to SY114
Skip
to SY114
SY113 / How many times was the DPT vaccine received? / Number……..______
Don’t Know…..8
SY114 / An injection to prevent measles, given around 9 months of age? / Yes…………….1
No..…………...2
Don’t Know…..8 / If child fully immunized, skip to SY116
SY115 / Look back at the information on the child’s immunization card or the information given by the mother
If child never immunized or not fully immunized, ask the following question:
Why was the child not fully immunized?
Do Not Read Out List.
MULTIPLE RESPONSES POSSIBLE / Lack of Information M NM
a) Unaware of need for immunization…………1 2
b) Unaware of need to return for 2nd or
3rd dose…………………………….…….….1 2
c) Place and/or time of immunization
unknown ……………………………………1 2
d) Fear of side reactions………………………..1 2
e) Wrong ideas about contra-indications……....1 2
f) Postponed until another time………………...1 2
g) No faith in immunization……………………1 2
Obstacles
h) Place of immunization too far………………..1 2
i) Time of immunization inconvenient…………1 2
j) Vaccinators absent…………………..………..1 2
k) Vaccine not available………………………...1 2
l) Mother too busy……………………………….1 2
m) Child ill-- not brought…………….………….1 2
n) Child ill—brought but not given immunization.1 2
o) Long Waiting time……………………..……..1 2
p) Other…….…………………….………..…….1 2
Specify other ______/ All answers skip to SY201
SY116 / Since your child is fully immunized, did (NAME) receive the immunization diploma?
(Show Immunization Diploma) / Yes…………….1
No..…………...2 / Skip to SY201
SY117 / If no, did your child complete the full series of immunizations before his/her first birthday? / Yes…………….1
No..…………...2
Section 2: Child Health, Nutrition During Illness, and Care Seeking
SY201 / Has [NAME] been ill at any time in the last 2 weeks? / Yes…………….1
No..…………...2 / Skip to SY210
SY202 / If yes, did [NAME] have….:
READ OUT THE LIST
Circle “1” for yes, and “2” for no. / (Y = yES, N = NO)
y N
a) Diarrhea…...... ……………1 2
b) Cough..…………………………………… 1 2
c) Rapid/Difficulty Breathing…………………1 2
d) Fever…...... ………………1 2
e)Other….……...... ……………1 2
Other (Specify) ______/ If no diarrhea mentioned in SY202 skip to question SY204
SY203 / If the child had diarrhea: was [NAME] given any of the following to drink:
READ OUT LIST
RECORD ALL MENTIONED / (Y = yes, N = no,)

Y N

a) Fluid from an ORS packet…….1 2
b) Home made sugar and salt solution...... ……..1 2
c) Other home made fluid ……….1 2
d) Other ………………………….1 2
Other (specify)______/ Ask SY203 only if diarrhea mentioned in SY202
SY204 / How much did you breastfeed during the illness? Did you breastfeed less than usual, about the same amount, or more than usual? / Less……………...…..1
About the same….…..2
More than usual……..3
Did not breastfeed..…4
Child weaned…..……5
Don’t Know……..…..8
SY205 / How much was [NAME] offered to drink during the illness? Was [NAME] offered less than usual to drink, about the same amount, or more than usual to drink? / Less……………...…..1
About the same….…..2
More than usual……..3
Nothing offered to drink…..…4
Child only breastfeeds, so no fluid given……..5
Don’t Know……..…..8
SY206 / During illness, were the ‘number of meals’ offered to [NAME] less than usual, about the same amount, or more than usual than before the illness? / Less……………...…..1
About the same….…..2
More than usual……..3
Nothing to eat……..…4
Child has not yet started complementary foods……….5
Don’t Know……..…..8
SY207 / Is [NAME] still ill? / Yes…………….1
No..…………...2 / Skip to SY210
SY208 / If NO: How much did you breastfeed after the illness? Did you breastfeed less than usual, about the same amount, or more than usual? / Less……………...…..1
About the same….…..2
More than usual……..3
Child weaned…..……4
Don’t Know……..…..8
SY209 / After illness, were the ‘number of meals’ offered to [NAME] less than usual, about the same amount, or more than usual than before the illness? / Less……………...…..1
About the same….…..2
More than usual……..3
Child has not yet started complementary foods……….4
Don’t Know……..…..8
SY210 / Did you own a bed net? / Yes…………….1
No..…………...2 / Skip to SY301
SY211 / Did [NAME] sleep under a bed net last night? / Yes…………….1
No..…………...2
SY212 / Did you sleep under a bed net last night? / Yes…………….1
No..…………...2
Section 3: Child Feeding & Preparation Practices:
SY301 / Have you ever breastfed[NAME]? / Yes…………….1
No..…………...2 / Skip to
SY307
SY302 / Are you still breastfeeding [NAME]? / Yes…………….1
No..…………...2 / Skip to SY304
SY303 / Why did you stop breastfeeding [NAME]?
Skip to Question SY307. / Mother ill/weak….…………….…01
Child ill/weak….…………………02
Nipple/breast problem……………03
Not enough milk…………………04
Mother working………………….05
Child refused…………….……….06
Weaning age/age to stop…………07
Became pregnant………….……..08
Started using contraception………09
Other……….…………………….10
Specify other______/ For all responses skip to SY307
SY304 / Up to what age do you intend to breastfeed [NAME]? / Months ______
Don’t Know…………..…98
SY305 / Since you breastfeed, are the ‘number of meals’ you eat more than usual, the same as usual, or less than usual? / More………….1
Same………….2
Less…………..3
Don’t Know…..8
SY306 / How many times did you breastfeed [NAME], between sunrise yesterday and sunrise today?
If response is not numeric, probe for a numeric response / Number ______
Don’t Know…………..…98
SY307 / Did [NAME] drink anything from a bottle between sunrise yesterday and sunrise today? / Yes……………..1
No……………..2
Don’t Know……8
SY308 / At what age did you first introduce liquids or foods (semi-solid or solid) other than breastmilk to the baby? / Months ______
Don’t Know…………..…98
Not yet started………………97 /
Skip to SY310
SY309 / How many times did you feed [NAME] solid and/or semi-solid food between sunrise yesterday and sunrise today?
If response is not numeric, probe for a numeric response / Number of feedings of solids and/or semi-solid foods ______
Don’t Know…………..…98
SY310 / I would like to ask you about the types of foods [NAME] has been fed over the past 24 hours, from sunrise yesterday to sunrise today. Did [NAME] have:
READ OUT THE LIST
Circle “1” for mentioned and “2” for not mentioned / (M = mentioned, NM= not mentioned)
M NM
a) Breastmilk……………..……………...1 2
b) Water……………………..………..….1 2
c) Formula…………………….……...….1 2
d) Animal milk………………..……...….1 2
e) Fruit Juice.………………………...…..1 2
f) Other liquids (sugar water, coffee,
tea, broth, soft drinks).…..……..….1 2
g) Any food made from grains (millet
(sorghum, maize, rice, wheat, teff) ……...1 2
h) Any other food made from roots or
tubers? (white potatoes, cassava, enset,
or other local roots or tubers)…..…….1 2
i) Any food made from pumpkins,
carrots, red sweet potatoes, mango,
papaya………….…...………………..1 2
j.) Green leafy vegetables………………1 2
k) Any other fruits? (e.g., bananas,
apples, avocados, tomatoes...... 1 2
l.) Any other vegetables?
m) Meat , Poultry, Fish …………..……..1 2
n.) Eggs……………………………...…..1 2
o.) Cheese or yoghurt ……………….….1 2
p) Any food made from legumes or nuts
(e.g. lentils, beans, soybeans,
pulses, or peanuts)?…………..……...1 2
q) Any food made with oil, fat
or butter?………………………..……1 2
SY311 / The last time you prepared food/meal for (NAME) did you wash your hands with soap/ash? / Yes…………….1
No..…………...2
SY312 / The last time you had to clean (name) after he/she defecated, did you wash your hands with soap/ash immediately afterwards? / Yes…………….1
No..…………...2
SECTION 4: Vitamin A
SY401 / Did [NAME] receive a dose of vitamin A in the last 6 months? [Show Vitamin A Capsule] / Yes…………….1
No..…………...2
Do not know…..8 / Skip to SY501
Skip to SY501
SY402 / 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 ______
SECTION 5: Message Recall: TIBF
SY501 / How long after birth do you think a baby should start breastfeeding? / Immediately………...…………………00
Hours………………………….______
Days.…………………………. ______
Don’t Know………………………….98
SY502 / Did you hear a message to put your baby on the breast immediately after birth? / Yes……………1
No……………..2
Can’t remember…….8 / Skip to SY506

Skip to SY506
SY503 / From whom did you hear this message? / (M=Mentioned NM= Not mentioned)
M NM
a.) Health Worker….…………..….1 2
b.) Health Extension Worker…..…1 2
c.) CBRHA……………………..…1 2
d.) Community Health Promoter.…1 2
e.) Family/friend…….…………….1 2
f.) Radio/TV………….………..….1 2
g.) Community leader….…………1 2
h.)Other……….…….……………1 2
Other (specify) ______
SY504 / When or how did you hear these messages? During: / (M=Mentioned NM= Not mentioned)
M NM
a.) Pregnancy………………….1 2
b.) Delivery……………………1 2
c.) Post natal/family planning…1 2
d.) Sick child contacts…………1 2
e.) Well child contacts………. .1 2
f.) Immunizations…………..…1 2
g.) EOS contact ………..…… 1 2
h.) Other……….……..…….…1 2
Other (specify) ______
SY505 / Where did you hear these messages? / (M=Mentioned NM= Not mentioned)
M NM
a.) Health facility……..1 2
b.) Community event…1 2
c.)Home….…………….. 2
d.)Other….…………….. 2
Other (specify) ______
MESSAGE RECALL: EBF
SY506 / For how long do you think a baby should receive only breastmilk and nothing else? / Enter age in months:______
Don’t know…….98
SY507 / Did you hear a message to feed your baby only breast milk for the first six months of life, not even giving water? / Yes……………1
No……………..2
Can’t remember…….8 / Skip to SY511

Skip to SY511
SY508 / From whom did you hear this message? / (M=Mentioned NM= Not mentioned)
M NM
a.) Health Worker……………..….1 2
b.) Health Extension Worker…..…1 2
c.) CBRHA……………………..…1 2
d.) Community Health Promoter…1 2
e.) Family/friend………………….1 2
f.) Radio/TV…………………..….1 2
g.) Community leader……………1 2
h.)Other……….…………………1 2
Other (specify) ______
SY509 / When or how did you hear these messages? During: / (M=Mentioned NM= Not mentioned)
M NM
a.) Pregnancy………………….1 2
b.) Delivery……………………1 2
c.) Post natal/family planning…1 2
d.) Sick child contacts…………1 2
e.) Well child contacts………. .1 2
f.) Immunizations…………..…1 2
g.) EOS contact ………..…… 1 2
h.) Other……….……..…….…1 2
Other (specify) ______
SY510 / Where did you hear these messages? / (M=Mentioned NM= Not mentioned)
M NM
a.) Health facility……..1 2
b.) Community event….1 2
c.)Home….……………1 2
d.)Other….…………….1 2
Other (specify) ______
MESSAGE RECALL: TCF
SY511 / How long after birth do you think a baby should start to receive semi-solid and solid foods? / Age in months ______
SY512 / Did you hear a message on introducing complementary foods at six months of age, such as soft porridge 2-3 times per day? / Yes……………1
No……………..2
Can’t remember…….8 / Skip to SY601

Skip to SY601
SY513 / From whom did you hear this message? / (M=Mentioned NM= Not mentioned)
M NM
a.) Health Worker……………..….1 2
b.) Health Extension Worker…..…1 2
c.) CBRHA……………………..…1 2
d.) Community Health Promoter…1 2
e.) Family/friend………………….1 2
f.) Radio/TV…………………..….1 2
g.) Community leader……………1 2
h.)Other……….…………………1 2
Other (specify) ______
SY514 / When or how did you hear these messages? During: / (M=Mentioned NM= Not mentioned)
M NM
a.) Pregnancy………………….1 2
b.) Delivery……………………1 2
c.) Post natal/family planning…1 2
d.) Sick child contacts…………1 2
e.) Well child contacts………. .1 2
f.) Immunizations…………..…1 2
g.) EOS contact ………..…… 1 2
h.) Other……….……..…….…1 2
Other (specify) ______
SY515 / Where did you hear these messages? / (M=Mentioned NM= Not mentioned)
M NM
a.) Health facility……..1 2
b.) Community event….. 2
c.)Home….…………….. 2
d.)Other….…………….. 2
Other (specify) ______
Section 6: Behavioral Change Communication (BCC)/Community Mobilization
SY601 / Have you heard about immunization when listening to the radio? / Yes…………….1
No…………..2
Can’t remember……….8 / Skip to FY603
Skip to FY603
SY602 / IF Yes, then what main points do you remember from the radio message(s)?
Circle “1” for yes, and “2” for no. / (M = mentioned, N = not mentioned)

M N

a) Immunize your child before first birthday.……... 1 2
b) Immunization prevents from the 6 killer diseases….……………………...……. 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) ______
SY603 / In the last 6 months, were you visited by a field worker who talked to you about immunizations? / Yes…………….1
No..…………...2
Can’t remember……….8 / Skip to UF605
Skip to UF605
SY604 / If yes, who did you speak with?
(Multiple Responses Possible) / (Y = yes, N = no)

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) ______
SY605 / Have you heard about the FHC? / Yes…………….1
No..…………...2 / Skip to FY608
SY606 / If yes, how did you hear about it?
(Multiple Responses Possible) / (Y = yes, N = no)

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) ______
SY607 / Does your child [Name] have a FHC? / Yes…………….1
No..…………...2
SY608 / Have you heard about the Immunization Diploma (Show Diploma)? / Yes…………….1
No..…………...2 /
End of Interview
SY609 / If yes, how did you hear about it?
(Multiple Responses Possible) / (Y = yes, N = no)

Y N

LINKAGES Ethiopia Module 3: Infants 12-23.9 months old1