DEMOGRAPHIC AND HEALTH SURVEYS
FISTULA MODULE
MODEL WOMAN'S QUESTIONNAIRE
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF WOMAN __________
(1) This section should be adapted for country-specific survey design.
FIRST VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
SECOND VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
THIRD VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
NEXT VISIT:
DATE ______
TIME ______
FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __ __
RESULT* __
TOTAL NUMBER OF VISITS: __
*RESULT CODES:
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) __________
LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH
**LANGUAGE CODES
02 LANGUAGE 2
03 LANGUAGE 3
04 LANGUAGE 4
05 LANGUAGE 5
06 LANGUAGE 6
SUPERVISOR
NAME ______
NUMBER __ __ __ __
FIELD EDITOR
NAME ______
NUMBER __ __ __ __
OFFICE EDITOR
NUMBER __ __
KEYED BY
NUMBER __ __
F1) Sometimes a woman can have a problem of constant leakage of urine or stool from her vagina during the day and night. This problem usually occurs after a difficult childbirth, but may also occur after a sexual assault or after pelvic surgery.
Have you ever experienced a constant leakage of urine or stool from your vagina during the day and night?
NO 2
F2) Have you ever heard of this problem?
NO 2 (GO TO NEXT SECTION)
F3) Did this problem start after you delivered a baby or had a stillbirth?
AFTER HAD STILLBIRTH 2
NEITHER 3 (GO TO F5)
F4) Did this problem start after a normal labor and delivery, or after a very difficult labor and delivery?
VERY DIFFICULT LABOR/DELIVERY 2 (GO TO F6)
F5) What do you think caused this problem?
PELVIC SURGERY 2
OTHER (SPECIFY) _______ 6
DON'T KNOW 8 (GO TO F7)
F6) How many days after (CAUSE OF PROBLEM FROM F3 OR F5) did the leakage start?
ENTER '90' IF 90 DAYS OR MORE
F7) Have you sought treatment for this condition?
NO 2
F8) Why have you not sought treatment?
PROBE AND RECORD ALL MENTIONED.
DO NOT KNOW WHERE TO GO B (GO TO NEXT SECTION)
TOO EXPENSIVE C (GO TO NEXT SECTION)
TOO FAR D (GO TO NEXT SECTION)
POOR QUALITY OF CARE E (GO TO NEXT SECTION)
COULD NOT GET PERMISSION F (GO TO NEXT SECTION)
EMBARRASSMENT G (GO TO NEXT SECTION)
PROBLEM DISAPPEARED H (GO TO NEXT SECTION)
OTHER (SPECIFY) ____________ X (GO TO NEXT SECTION)
F9) From whom did you last seek treatment?
NURSE/MIDWIFE 2
F10) Did you have an operation to fix the problem?
NO 2
F11) Did the treatment stop the leakage completely?
IF NO: Did the treatment reduce the leakage?
NOT STOPPED BUT REDUCED 2
NOT STOPPED AT ALL 3
DID NOT RECEIVE TREATMENT 4