Assessment of equity in provision and utilization of maternal and child health programs in butajira, southern ethiopia

Annexes

Annex 1: Questionnaire for household survey

Identification number of the questionnaire _____/_____/_____

Date of the interview: dd/mm/yy_______/_____/____

Name and signature of interviewer ___________________

PART 1. ADDRESS

QES#	Questions	Response	Go to	Code
101	Kebeles [peasant association]	1. Butajira UDA 2. Meskan 3. Bido 4. Dirama 5. Yeteker 6. Wrib 7. Mijarda 8. Bati 9. Dobena 10. Hobe
102	House number of the household	--------------------
103	Name of head of household	--------------------------
104	What is your family size?	-----

PART II. GENERAL SOCIODEMOGRAPHIC INFORMATION

Qes#	Question	Response	Go to	Code
201	What is your Age? [in years]__________	1 Age in year------- 2 Don’t know
202	Sex of the head of household	Male 2. Female
203	What is occupation of the head of household	Farmer Daily laborer Government employee Merchant Student Unemployed Other (specify
204	Do you have occupation other than that of husband?	1Yes 2.No
205	What is your religion?	Muslim Orthodox Catholic Protestant Other (specify)
206	What is your ethnicity?	Sodo Dobi Meskan Mareko Silti Amhara Oromo Other (specify)________
207	What is your current marital status?	Single Married Widowed Divorced
208	do your husband have another wife other than you?	1.yes 2. No
209	What is your educational status?	Illiterate Read and write only Grade 1-6 Grade 7-8 Grade 9-12 Above grade 12
210	What is your husband’s educational status?	Illiterate Read and write only Literate; Grade ____

PART III. Mothers Utilization of Health services

Qes#	Question	Response	Go to	Code
301	What is the type of the nearest modern health facility, which your family uses for routine care?	Health post Clinic Health center Hospital Drug vendor/drug shop/pharmacy Others(specify)_____
302	How far is the nearest health facility from your house?	On foot_____minutes. By animals__ minutes by vehicle ___minutes I don’t know
303	What means of transport do you use to travel there often?	Walking Horse/ mule Private Vehicle Public transport (bus, taxi) Cart Other (Specify) ____
304	In the family who usually make decision about using maternal and child health services?	You Your husband Both of you Your parents Others I don’t know
305	Regarding maternal and child health services which one is the major source of information for you?	Health facility/HW Radio/television News paper, bulletins or books TBA/ CHA Friends or neighbors Husband or partner Other (specify)
306	Have you ever heard about modern contraceptives?	Yes No	If 2; 310
307	When was the time that you heard or got the information about modern contraceptive methods for the first time?	Less than one year More than one year Don’t know
308	Using modern contraceptives,	1. Leads to loss of confidence between couples 2. Leads to conflict in marriage 3. Leads to infertility 4. I don't know
309	Which of the following modern contraceptive methods do you know?	Pills IUCD Injectables Implants/Norplant Condom
310	Have you ever heard of ANC?	Yes No	If 2; 315
311	When was the time that you heard or got the information about ANC follow up for the first time?	Less than one year More than one year Don’t know
312	Regarding ANC follow up is important for whom?	It is important for all pregnant woman It is important only for pregnant women who are sick It is useless and is waste of time Don’t know
313	At what month of the pregnancy should mothers start attending ANC?	Early (before 4th Month) Middle (5th-7th month) Late (after 7th month) Don’t know
314	How much amount of money is paid for ANC services at public health facilities?	Amount in birr------- Free Don’t know
315	In your opinion where should pregnant mothers give birth?	Health facility Home
316	Have you ever heard of check up of mothers after they gave birth?	Yes No	If 2; 320
317	When was the time that you heard or got the information about PNC follow up for the first time?	Less than one year More than one year Don’t know
318	Do you think mothers should visit health facility within six weeks after they gave birth?	Yes No Don’t know
319	How much amount of money is paid for PNC services at public health facilities?	Amount in birr--- Free Don’t know
320	Have you ever heard of immunization service for children	Yes No	If 2; part 4
321	When was the time that you heard or got the information about child immunization services for the first time?	Less than one year More than one year Don’t know
322	Immunization makes child	More weak More healthy Susceptible to disease No use
323	When do you think is the preferable time for child immunization?	1. < 1 year of age 2. 3- 5 year of age 3. > 5 year of age 4. Don’t know
324	How much amount of money is paid for child immunization services at public health facilities?	1. Amount in birr------- 2. Free 3. Don’t know

Part IV. General Socioeconomic Informations

Qes#	Question	Response	Go to	Code
401	What is the average annual income of your household [in Birr]?	Amount in birr---- Don’t know
402	What is the main source of income for the family?	Farming Trade Monthly salary from gov’t or NGO Daily labor Production of handcrafts Other (specify)____________
403	What is the food crop usually produced by the household only for rural (select only one)?	Teff Maize Millet Barley Legumes Wheat Other (specify
404	On average how much quintal do you produce annually?	____
405	Do you have the following cultivation /plantation in your farm or backyard garden?	1.Coffee 1.Yes 2.No 2.‘Chat’ 1.Yes 2.No 3.Pepper 1.Yes 2.No
406	Does the family/ household own the following?	1. Own home 1.Yes 2.No 2. Own land 1.Yes ,-----timad 2.No 3.Cattle 1.Yes (#___) 2.No 4. Piped water 1.Yes 2.No 5. Private latrine 1.Yes 2.No 6.Radio 1.Yes 2.No 7. Electricity 1.Yes 2.No 8.TV 1.Yes 2.No 9. Refrigerator 1.Yes 2.No 10 .own car 1.Yes 2.No
407	Compared to your neighbors, how do you classify the family’s economic status?	Very poor Poor Average Well to do Rich