IDENTIFICATION (1)

PLACE NAME_____
NAME OF HOUSEHOLD HEAD_____
CLUSTER NUMBER_____
HOUSEHOLD NUMBER_____

INTERVIEW VISITS:

INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____

RESULT____

NEXT VISIT
DATE_____
TIME_____

FINAL VISIT
DAY_____
MONTH_____
YEAR_____
INT. NUMBER_____
RESULT_____

TOTAL NUMBER OF VISITS_____

*RESULT CODES

COUNTRY-SPECIFIC INFORMATION:
LANGUAGE OF QUESTIONNAIRE
LANGUAGE OF INTERVIEW NATIVE LANGUAGE OF RESPONDENT, AND WHETHER TRANSLATOR USED

SUPERVISOR
NAME_____

FIELD EDITOR
NAME_____

OFFICE EDITOR_____

KEYED BY_____

(1) This section should be adapted for country-specific survey design.
Note: Questions with blue highlighting in the question number column are HIV related questions that may be deleted in some circumstances (see footnotes). Questions with pink highlighting in the question number column are malaria related questions that may be deleted in some circumstances (see footnotes). Questions with yellow highlighting in the question number column are other questions that may be deleted in some circumstances (see footnotes). (see footnotes).

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is __________. I am working with (NAME OF ORGANIZATION). We are conducting a survey about health all over (NAME OF COUNTRY). The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.
Do you have any questions? May I begin the interview now?

SIGNATURE IF INTERVIEWER: ___________
DATE: ______
RESPONDENT AGREES TO BE INTERVIEWED 1(GO TO NO. 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

101) RECORD THE TIME

102) IN WHAT MONTH AND YEAR WERE YOU BORN?

103) HOW OLD WERE YOU AT YOUR LAST BIRTHDAY?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT

104) HAVE YOU EVER ATTENDED SCHOOL?

105) WHAT IS THE HIGHEST LEVEL OF SCHOOL YOU ATTENDED: PRIMARY. SECONDARY, OR HIGHER? (1)

106) WHAT IS THE HIGHEST (GRADE/FORM/YEAR) YOU COMPLETED AT THAT LEVEL? (1)
IF COMPLETED LESS THAT ONE YEAR AT THAT LEVEL, RECORD '00'.
(1)

107) CHECK 105:

108) NOW I WOULD LIKE YOU TO READ THIS SENTENCE TO ME.
SHOW CARD TO RESPONDENT. (2)

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: CAN YOU READ ANY PART OF THE SENTENCE TO ME?

109) CHECK 108:

110) DO YOU READ A NEWSPAPER OR MAGAZINE AT LEAST ONCE A WEEK, LESS THAN ONCE A WEEK OR NOT AT ALL?

111) DO YOU LISTEN TO THE RADIO AT LEAST ONCE A WEEK, LESS THAN ONCE A WEEK OR NOT AT ALL?

112) DO YOU WATCH TELEVISION AT LEAST ONCE A WEEK, LESS THAN ONCE A WEEK OR NOT AT ALL?

113) COUNTRY-SPECIFIC QUESTION ON RELIGION, IF APPROPRIATE.

114) COUNTY-SPECIFIC QUESTION ON ETHNICITY, IF APPROPRIATE.

115) (3) IN THE LAST 12 MONTHS, HOW MANY TIMES HAVE YOU BEEN AWAY FROM HOME FOR ONE OR MORE NIGHTS?

116) (3) IN THE LAST 12 MONTHS, HAVE YOU BEEN AWAY FROM HOME FOR MORE THAN ONE MONTH AT A TIME?

(1) Revise according to the local education system.
(2) Each card should have four simple sentences appropriate to the country (e.g., "Parents love their children.", "Farming is hard work.", "The child is reading a book.", "Children work hard at school."). Cards should be prepared for every language in which respondents are likely to be literate.
(3) The question may be considered for deletion in countries with a very low HIV prevalence.

SECTION 2. REPRODUCTION

201) Now I would like to ask you about all the births you have had during your life. Have you ever given birth?

202) DO YOU HAVE ANY SONS OR DAUGHTERS TO WHOM YOU HAVE GIVEN BIRTH WHO ARE NOW LIVING WITH YOU?

203) HOW MANY SONS LIVE WITH YOU?
AND HOW MANY DAUGHTERS LIVE WITH YOU?

IF NONE, RECORD '00'

204) DO YOU HAVE ANY SONS OR DAUGHTERS TO WHOM YOU HAVE GIVEN BIRTH WHO ARE ALIVE BUT DO NOT LIVE WITH YOU?

205) HOW MANY SONS ARE ALIVE BUT DO NOT LIVE WITH YOU?
AND HOW MANY DAUGHTERS ARE ALIVE BUT DO NOT LIVE WITH YOU?

IF NONE, RECORD '00'

206) HAVE YOU EVER GIVEN BIRTH TO A BOY OR GIRL WHO WAS BORN ALIVE BUT LATER DIED?
IF NO PROBE: ANY BABY WHO CRIED OR SHOWED SIGNS OF LIFE BUT DID NOT SURVIVE?

207) HOW MANY BOYS HAVE DIED?
AND HOW MANY GIRLS HAVE DIED?

IF NONE, RECORD '00'

208) SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
IF NONE, RECORD '00'

209) CHECK 208:
JUST TO MAKE SURE THAT I HAVE THIS RIGHT, YOU HAVE HAD IN TOTAL ____ BIRTHS DURING YOUR LIFE. IS THAT CORRECT?

210) CHECK 208:

211) NOW I WOULD LIKE TO RECORD THE NAMES OF ALL YOUR BIRTHS, WHETHER STILL ALIVE OR NOT, STARTING WITH THE FIRST ONE YOU HAD.

RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS. (IF THERE ARE MORE THAN 12 BIRTHS, USE ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW).

212) WHAT NAME WAS GIVEN TO YOUR (FIRST/NEXT) BABY?

213) IS (NAME) A BOY OR GIRL?

214) WERE ANY OF THESE BIRTHS TWINS?

215) IN WHAT MONTH AND YEAR WAS (NAME) BORN?
PROBE: WHEN IS HIS/HER BIRTHDAY?

216) IS (NAME) STILL ALIVE?

217) IF ALIVE: How old was (NAME) at his/her last birthday?
RECORD AGE IN COMPLETED YEARS.

218) IF ALIVE:
IS (NAME) LIVING WITH YOU?

219) IF ALIVE:
RECORD HOUSEHOLD LINE NUMBER OF CHILD

RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD

220) IF DEAD:
HOW OLD WAS (NAME) WHEN HE/SHE DIED?

IF '1 YR', PROBE: HOW MANY MONTHS OLD WAS (NAME)?

RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IS LESS THAN TWO YEARS; OR YEARS.

221) WERE THERE ANY OTHER LIVE BIRTHS BETWEEN (NAME OF PREVIOUS BIRTH) AND (NAME), INCLUDING ANY CHILDREN WHO DIED AFTER BIRTH?

222) HAVE YOU HAD ANY LIVE BIRTHS SINCE THE BIRTH OF (NAME OF LAST BIRTH)?

IF YES, RECORD BIRTH(S) IN TABLE.

223) COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

224) CHECK 215:
ENTER THE NUMBER OF BIRTHS IN 2005(1) OR LATER.

225) C
FOR EACH BIRTH SINCE JANUARY 2005 (1), ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226) ARE YOU PREGNANT NOW?

227) HOW MANY MONTHS PREGNANT ARE YOU?
RECORD NUMBER OF COMPLETED MONTHS.
C
ENTER 'P's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS

228) WHEN YOU GOT PREGNANT, DID YOU WANT TO GET PREGNANT AT THE TIME?

229) DID YOU WANT TO HAVE A BABY LATER ON OR DID YOU NOT WANT ANY (MORE) CHILDREN?

230) HAVE YOU EVER HAD A PREGNANCY THAT MISCARRIED, WAS ABORTED, OR ENDED IN STILLBIRTH?

231) When did the last such pregnancy end?

232) CHECK 231:

233) How many months pregnant were you when the last such pregnancy ended?

RECORD NUMBER OF COMPLETED MONTHS. ENTER "T" IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

234) Since January 2005, (1) have you had any other pregnancies that did not result in a live birth?

235) ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2005. (1)

C
ENTER 'T' IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236) Did you have any miscarriages, abortions or stillbirths that ended before 2005 ? (1)

237) When did the last such pregnancy that terminated before 2005 (1) end?

238) When did your last menstrual period start?

239) From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant?

240) Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods?

(1) Year of fieldwork is assumed to be 2010. For fieldwork beginning in 2011 or 2012, the year should be 2006 or 2007, respectively.

SECTION 3. CONTRACEPTION

301) Now I would like to talk about family planning-the various ways or methods that a couple can use to delay or avoid pregnancy.
Have you ever heard (METHOD)? (1)

302) CHECK 226:

303) Are you currently doing something or using any method to delay or avoid getting pregnant?

304) Which method are you using? (4)

CIRCLE ALL MENTIONED.

IF MORE THAN ONE METHOD MENTIONED, FOLLOW GO INSTRUCTIONS FOR HIGHEST METHOD IN LIST.

305) What is the brand name of the pills you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

306) What is the brand name of the condoms you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

307) In what facility did the sterilization take place? (5)
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

308) In what month and year was the sterilization performed?

308A) Since what month and year have you been using (CURRENT METHOD) without stopping?

PROBE: For how long have you been using (CURRENT METHOD) now without stopping?

309) CHECK 308/308A, 215 AND 231:
ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 308/308A

GO BACK TO 308/308A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION).

310) CHECK 308/308A:

311) I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.

USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2005. (6)
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

C
IN COLUMN 1, ENTER METHOD USE CODE OR '0' FOR NONUSE IN EACH BLANK MONTH.

ILLUSTRATIVE QUESTIONS:
* When was the last time you used a method? Which method was that?
* When did you start using that method? How long after the birth of (NAME)?
* How long did you use the method then?

IN COLUMN 2, ENTER CODES FOR DISCONTINUATION NEXT TO THE LAST MONTH OF USE. NUMBER OF CODES IN COLUMN 2 MUST BE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1.

ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK
WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT.

ILLUSTRATIVE QUESTIONS:
* Why did you stop using the (METHOD)? Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason?
* IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK: How many months did it take you to get pregnant after you stopped using (METHOD)? AND ENTER '0' IN EACH SUCH MONTH IN COLUMN 1.

312) CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH

313) Have you ever used anything or tried in any way to delay or avoid getting pregnant?

314) CHECK 304:

CIRCLE METHOD CODE:

IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

315) You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time? (5)

Where did you learn how to use the rhythm/lactational amenorrhea method?

PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

316) CHECK 304:

CIRCLE METHOD CODE.

IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR THE HIGHEST METHOD IN THE LIST.

317) At that time, were you told about side effects or problems you might have with the method?

317A) When you got sterilized, were you told about side effects or problems you might have with the method?

318) Were you ever told by a health or family planning worker about side effects or problems you might have with the method?

319) Were you told what to do if you experienced side effects or problems?

320) CHECK 317:

CODE '1' CIRCLED: At that time, were you told about other methods of family planning that you could use?

CODE '1' NOT CIRCLED: when you obtained (CURRENT METHOD FROM 307 OR 315), where you told about other methods of family planning that you could use?

321) Were you ever told by a health or family planning worker about other methods of family planning that you could use?

322) CHECK 304:
CIRCLE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

323) Where did you obtain (CURRENT METHOD) the last time? (5)

PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

324) Do you know of a place where you can obtain a method of family planning?

325) Where is that? (5)

Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

326) In the last 12 months, were you visited by a fieldworker who talked to you about family planning? (8)

327) In the last 12 months, have you visited a health facility for care for yourself (or your children)?

328) Did any staff member at the health facility speak to you about family planning methods?

(1) If Standard Days Method is commonly used, it may be added to the table before Lactational Amenorrhea. "Standard Days Method (use local term, such as CycleBeads? , as appropriate) PROBE: A woman uses a string of colored beads to know the days she can get pregnant. On the days she can get pregnant, she uses a condom or does not have sexual intercourse." If Standard Days Method is added to Q. 301,
it should also be added before LAM to Qs. 304, 314, 316, 322, and Column 1 of the calendar.
(2) The LAM method should be deleted in countries that do not have a LAM program. In these countries, LAM should also be deleted as a coding category in Qs. 304, 314, 316, 322, and Column 1 of the calendar. A description of LAM should not be provided in Q. 301.
(3) Studies have indicated emergency contraception can be effective up to five days. Verify country program recommendations and modify wording if appropriate.
(4) Other commonly used methods may be added to the list, such as contraceptive patch, contraceptive vaginal ring, or sponge. Any codes added in Q. 304 must also be added to Qs. 314, 316, 322, and Column 1 of the calendar. These methods should not be added to Q. 301.
(5) Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.
(6) Year of fieldwork is assumed to be 2010. For fieldwork beginning in 2011 or 2012, the year should be 2006 or 2007, respectively.
(7) Year of fieldwork is assumed to be 2010. For fieldwork beginning in 2011 or 2012, the year should be 2005 or 2006, respectively.
(8) In countries without national fieldworker programs that include family planning, Q. 326 should be deleted

SECTION 4: PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2005 (1) OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

Now I would like to ask some questions about your children born in the last five years. (We will talk about each separately.)

403) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

404) FROM 212 AND 216

405) When you got pregnant with (NAME), did you want to get pregnant at that time?

406) Did you want to have a baby later on, or did you not want any (more) children?

407) How much longer did you want to wait?

408) Did you see anyone for antenatal care for this pregnancy?
[Most recent birth within the last five years]

409) WHOM DID YOU SEE? (2)
Anyone else?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
[Most recent birth within the last five years]

410) Where did you receive antenatal care for this pregnancy? (2)
Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
[Most recent birth within the last five years]

411) How many months pregnant were you when you first received antenatal care for this pregnancy?
[Most recent birth within the last five years]

412) How many times did you receive antenatal care during this pregnancy?
[Most recent birth within the last five years]

413) As part of your antenatal care during this pregnancy, were any of the following done at least once:

Was your blood pressure measured?
Did you give a urine sample?
Did you give a blood sample?
[Most recent birth within the last five years]

414) During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy?
[Most recent birth within the last five years]

415) During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth? (3)
[Most recent birth within the last five years]

416) During this pregnancy, how many times did you get a tetanus injection?
[Most recent birth within the last five years]

417) CHECK 416:

418) At any time before this pregnancy, did you receive any tetanus injections?
[Most recent birth within the last five years]

419) Before this pregnancy, how many times did you receive a tetanus injection?

IF 7 OR MORE TIMES, RECORD '7'.
[Most recent birth within the last five years]

420) How many years ago did you receive the last tetanus injection before this pregnancy?
[Most recent birth within the last five years]

421) During this pregnancy, were you given or did you buy any iron tablets or iron syrup? (4)

SHOW TABLETS/SYRUP.
[Most recent birth within the last five years]

422) During the whole pregnancy, for how many days did you take the tablets or syrup? (4,5)

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.
[Most recent birth within the last five years]

423) During this pregnancy, did you take any drug for intestinal worms?
[Most recent birth within the last five years]

424) (6)
During this pregnancy, did you take any drugs to keep you from getting malaria?
[Most recent birth within the last five years]

425) (6) What drugs did you take?

RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.
[Most recent birth within the last five years]

426) (6)

CHECK 425:

SP/FANSIDAR TAKEN FOR MALARIA PREVENTION.

427) (6) How many times did you take (SP/Fansidar) during this pregnancy?

428) (6) CHECK 409:

ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

429) (6) Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility or from another source?

430) When (NAME) was born, was he/she very large, larger than average, average, smaller than average, or very small? (REPEAT FOR NEXT-TO-LAST BIRTH AND SECOND-FROM LAST BIRTH)

431) Was (NAME) weighed at birth? (REPEAT FOR NEXT-TO-LAST BIRTH AND SECOND-FROM LAST BIRTH)

432) How much did (NAME) weigh?

RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE.

433) Who assisted with the delivery of (NAME)? (2)

Anyone else?

PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED

IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY

434) Where did you give birth to (NAME)? (2)

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

434A) How long after (NAME) was delivered did you stay there?

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS
[Most recent birth within the last five years]

435) Was (NAME) delivered by caesarean, that is, did they cut your belly open to take the baby out? (REPEAT FOR NEXT-TO-LAST BIRTH AND SECOND-FROM LAST BIRTH)

436) I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health while you were still in the facility?

437) Did anyone check on your health after you left the facility?
[Most recent birth within the last five years]

438) I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)?
[Most recent birth within the last five years]

439) Who checked on your health at that time? (2)

PROBE FOR MOST QUALIFIED PERSON
[Most recent birth within the last five years]

440) How long after delivery did the first check take place?

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS
[Most recent birth within the last five years]

442) In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health?
[Most recent birth within the last five years]

443) How many hours, days or weeks after the birth of (NAME) did the first check take place?

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.
[Most recent birth within the last five years]

444) Who checked on (NAME)'s health at that time? (2)

PROBE FOR MOST QUALIFIED PERSON.
[Most recent birth within the last five years]

445) Where did this first check of (NAME) take place? (2)

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE

IF UNABLE TO IDENTIFY IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
[Most recent birth within the last five years]

446) In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)?

SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS
[Most recent birth within the last five years]

447) Has your menstrual period returned since the birth of (NAME)?
[Most recent birth within the last five years]

448) Did your period return between the birth of (NAME) and your next pregnancy?
[Repeat questions for all children born in the last five years, excluding the most recent birth]

449) For how many months after the birth of (NAME) did you not have a period?

450) CHECK 226:
IS RESPONDENT PREGNANT?

451) Have you had sexual intercourse since the birth of (NAME)?
[Most recent birth within the last five years]

452) For how many months after the birth of (NAME) did you not have sexual intercourse?

453) Did you ever breastfeed (NAME)?

454) CHECK 404:
IS CHILD LIVING?

455) How long after birth did you first put (NAME) to the breast?

IF LESS THAN 1 HOUR, RECORD '00' HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS.
[Most recent birth within the last five years]

456) In the first three days after delivery, was (NAME) given anything to drink other than breast milk?
[Most recent birth within the last five years]

457) What was (NAME) given to drink?
Anything else?

RECORD ALL LIQUIDS MENTIONED
[Most recent birth within the last five years]

458) CHECK 404:

459) Are you still breastfeeding (NAME)?
[Most recent birth within the last five years]

460) Did (NAME) drink anything from a bottle with a nipple yesterday or last night?

461) GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501

(1) Year of fieldwork is assumed to be 2010. For fieldwork beginning in 2011 or 2012, the year should be 2006 or 2007, respectively.
(2) Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.
(3) Vaccination practices may vary; this question should specify where the injection is given, e.g. arm or shoulder.
(4) Syrup should be deleted in countries where syrup is not used.
(5) In countries where it is important to know the number of iron tablets taken per day, an appropriate question may be added.
(6) The question should be deleted in surveys in countries where there is no program for intermittent preventive treatment against malaria during pregnancy.

SECTION 5. CHILD IMMUNIZATION, HEALTH AND NUTRITION

501) ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2005 (1) OR LATER.
ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

502) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

503) FROM 212 AND 216

504) Do you have a card where (NAME)'s vaccinations are written down? (2)

IF YES:
May I see it please?

505) Did you ever have a vaccination card for (NAME)? (2)

506) (1) COPY DATES FROM THE CARD. (2)

(2) WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

507) CHECK 506:

BCG TO MEASLES
ALL RECORDED (3)

508) Has (NAME) had any vaccinations that are not recorded on this card, including vaccinations given in a national immunization day campaign?

RECORD 'YES' ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 506 THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

509) Did (NAME) ever have any vaccinations to prevent him/her from getting diseases,
including vaccinations received in a national immunization day campaign?

510) Please tell me if (NAME) had any of the following vaccinations: (4)

510A) A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar? (5)

510B) Polio vaccine, that is, drops in the mouth?

510C) Was the first polio vaccine given in the first two weeks after birth or later? (6)

510D) How many times was the polio vaccine given?

510E) A DPT vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops? (5)

510F) How many times was the DPT vaccination given?

510G) A measles injection or an MMR injection - that is, a shot in the arm at the age of 9 months or older - to prevent him/her from getting measles? (7)

511) Within the last six months, was (NAME) given a vitamin A dose like (this/any of these)?

SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS.

512) In the last seven days, was (NAME) given iron pills, sprinkles with iron, or iron syrup like (this/any of these)?

SHOW COMMON TYPES OF PILLS/SPRINKLES/SYRUPS

513) Was (NAME) given any drug for intestinal worms in the last six months?

514) Has (NAME) had diarrhea in the last 2 weeks? (8)

515) Was there any blood in the stools?

516) Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk).

Was he/she given less than usual to drink, about the same amount, or more than usual to drink?

IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

517) When (NAME) had diarrhea, 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?

518) Did you seek advice or treatment for the diarrhea from any source?

519) Where did you seek advice or treatment? (9)

Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

520) CHECK 519:

521) Where did you first seek advice or treatment?

USE LETTER CODE FROM 519.

522) Was he/she given any of the following to drink at any time since he/she started having the diarrhea:

a) A fluid made from a special packet called [LOCAL NAME FOR ORS PACKET]?
b) A pre-packaged ORS liquid? (10)
c) A government-recommended homemade fluid? (11)

523) Was anything (else) given to treat the diarrhea?

524) What (else) was given to treat the diarrhea?

Anything else?

RECORD ALL TREATMENTS GIVEN.

525) Has (NAME) been ill with a fever at any time in the last 2 weeks?

526) (12) At any time during the illness, did (NAME) have blood taken from his/her finger or heel for testing?

527) Has (NAME) had an illness with a cough at any time in the last 2 weeks?

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

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

530) CHECK 525:
HAD FEVER?

531) Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough).

Was he/she given less than usual to drink, about the same amount, or more than usual to drink?

IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

532) When (NAME) had a (fever/cough), 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?

533) Did you seek advice or treatment for the illness from any source?

534) Where did you seek advice or treatment? (9)

Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

535) CHECK 534:

536) Where did you first seek advice or treatment?

USE LETTER CODE FROM 534

537) At any time during the illness, did (NAME) take any drugs for the illness?

538) What drugs did (NAME) take?

Any other drugs?

RECORD ALL MENTIONED

539) CHECK 538:

ANY CODE A-F CIRCLED?

540) CHECK 538:

541) How long after the fever started did (NAME) first take (SP/Fansidar)?

542) CHECK 538:

CHLOROQUINE ('B') GIVEN

543) How long after the fever started did (NAME) first take chloroquine?

544) CHECK 538:

AMODIAQUINE ('C') GIVEN

545) How long after the fever started did (NAME) first take amodiaquine?

546) CHECK 538:

QUININE ('D') GIVEN

547) How long after the fever started did (NAME) first take quinine?

548) CHECK 538:

COMBINATION WITH ARTEMISININ ('E') GIVEN

549) How long after the fever started did (NAME) first take (COMBINATION WITH
ARTEMISININ)?

550) CHECK 538:

OTHER ANTIMALARIAL ('F') GIVEN

551) How long after the fever started did (NAME) first take (OTHER ANTIMALARIAL)?

552) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553.

553) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2005 (1)

554) The last time (NAME FROM 553) passed stools, what was done to dispose of the stools?

555) CHECK 522(a) AND 522(b), ALL COLUMNS:

556) Have you ever heard of a special product called [LOCAL NAME FOR ORS PACKET OR PRE-PACKAGED ORS LIQUID] you can get for the treatment of diarrhea?

557) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2008

RECORD THE NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE WITH 558

558) Now I would like to ask you about liquids or foods that (NAME FROM 557) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods.

Did (NAME FROM 557) (drink/eat):

a) Plain water?
b) Juice or juice drinks?
c) Clear broth?
d) Milk such as tinned, powdered, or fresh animal milk?
IF YES: How many times did (NAME) drink milk?
IF 7 OR MORE TIMES, RECORD '7'.
e) Infant formula?
IF YES: How many times did (NAME) drink infant formula?
IF 7 OR MORE TIMES, RECORD '7'.
f) Any other liquids?
g) Yogurt?
IF YES: How many times did (NAME) eat yogurt?
IF 7 OR MORE TIMES, RECORD '7'.
h) Any [BRAND NAME OF COMMERCIALLY FORTIFIED BABY FOOD, E.G., Cerelac]? (17)
i) Bread, rice, noodles, porridge, or other foods made from grains? (18)
j) Pumpkin carrots squash or sweet potatoes that are yellow or orange inside? (19)
k) White potatoes, white yams, manioc, cassava, or any other foods made from roots?
l) Any dark green, leafy vegetables? (20)
m) Ripe mangoes, papayas, or [INSERT ANY OTHER LOCALLY AVAILABLE VITAMIN A-RICH FRUITS]?
n) Any other fruits or vegetables?
o) Liver, kidney, heart or other organ meats?
p) Any meat, such as beef, pork, lamb, goat, chicken, or duck?
q) Eggs?
r) Fresh or dried fish or shellfish?
s) Any foods made from beans, peas, lentils, or nuts?
t) Cheese or other food made from milk?
u) Any other solid, semi-solid, or soft food?

559) CHECK 558 (CATEGORIES "g" THROUGH "u"):

560) Did (NAME) eat any solid, semi-solid, or soft foods yesterday during the day or at night?
IF 'YES' PROBE: What kind of solid, semi-solid or soft foods did (NAME) eat?

561) How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night?

IF 7 OR MORE TIMES, RECORD '7'.

(1) Year of fieldwork is assumed to be 2010. For fieldwork beginning in 2011 or 2012, the year should be 2006 or 2007, respectively.
(2) To be developed locally since immunization practices may vary from country to country, as may the terms used for the written record and for the vaccinations. Add yellow fever, rubella, MMR, Hib (3 doses), and hepatitis B (3 doses) in Q. 506 in countries where these vaccinations are listed on the vaccination card.
(3) Filter should reflect the vaccination list in Q. 506.
(4) To be developed locally since immunization practices may vary from country to country, as may the terms used for the vaccinations. Include question on pentavalent injection or injections for yellow fever, rubella,MMR, Hib, and Hepatitis B where these are included in Q. 506.
(5) Adapt question locally after determining the most common injection site.
(6) Delete this question in countries where Polio 0 is not part of the immunization schedule.
(7) Adapt question locally, some countries do not give measles vaccination until 12-15 months of age.
(8) The term(s) used for diarrhea should encompass the expressions used for all forms of diarrhea, including bloody stools (consistent with dysentery), watery stools, etc.
(9) Coding categories to be developed locally and revised based on the pretest; however, the broad categories
must be maintained.
(10) Include in the question the common names/brands for pre-packaged ORS liquids. If pre-packaged ORS liquids are not available in the country, this item should be deleted.
(11) This item should be adapted to include the terms used locally for the recommended home fluid. The ingredients
promoted by the government for making the recommended home fluid should be reflected in the category. If the government does not recommend a homemade fluid, then the word "government" should be dropped from the question.
(12) The question should be deleted in countries that are not affected by malaria.
(13) Coding categories to be developed locally and revised based on the pretest. All antimalarials commonly used in the country should be included in the response categories. Common brand names of drugs, such as Bayer, Tylenol or Paracetamol, should be added to the response categories for aspirin, acetaminophen, or ibuprofen as appropriate.
(14) Delete "OR PRE-PACKAGED ORS LIQUID" in countries where such liquid is not available.
(15) Year of fieldwork is assumed to be 2010. For fieldwork beginning in 2011 or 2012, the year should be 2009 or 2010, respectively.
(16) A separate category: "Foods made with red palm oil, palm nut, or palm nut pulp sauce" must be added in countries where these items are consumed. A separate category: "Grubs, snails, insects or other small protein food" must be added in countries where these items are eaten. Items in each food group should be modified to include only those foods that are locally available and/or consumed in the country. Local terms should be used.
(17) In the case of fortified foods, the interviewer should ask to see the package and/or brand label (if available), to confirm that the food is fortified.
(18) Grains include millet, sorghum, maize, rice, wheat, or other local grains. Start with local foods, e.g. ugali, nshima, fufu, chapati, then follow with bread, rice, noodles, etc.
(19) Items in this category should be modified to include only vitamin A rich tubers, starches, or red, orange, or yellow vegetables that are consumed in the country.
(20) These include cassava leaves, bean leaves, kale, spinach, pepper leaves, taro leaves, amaranth leaves, or other dark green, leafy vegetables.

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

601) Are you currently married or living together with a man as if married?

602) Have you ever been married or lived together with a man as if married?

603) What is your marital status now: are you widowed, divorced, or separated?

604) Is your (husband/partner) living with you now or is he staying elsewhere?

605) RECORD THE HUSBAND'S/PARTNER'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

606) (1) Does your (husband/partner) have other wives or does he live with other women as if married?

607) (1) Including yourself, in total, how many wives or live-in partners does he have?

608) Are you the first, second, ? wife?

609) Have you been married or lived with a man only once or more than once?

610) CHECK 609:
IF MARRIED/LIVED WITH MAN ONLY ONCE: In what month and year did
you start living with your (husband/partner)?

IF MARRIED/LIVED WITH MAN MORE THAN ONCE: Now I would like to ask about
your first (husband/partner). In what month and year did you start living with him?

611) How old were you when you first started living with him?

612) CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY

613) Now I would like to ask some questions about sexual activity in order to gain a better understanding of some important life issues.

How old were you when you had sexual intercourse for the very first time?

614) Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question.

615) When was the last time you had sexual intercourse?

IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS OR MONTHS. IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

616) When was the last time you had sexual intercourse with this person?
[Exclude last sexual partner]

617) The last time you had sexual intercourse (with this second/third person), was a condom used? (2)

618) Was a condom used every time you had sexual intercourse with this person in the last 12 months?

619) What was your relationship to this person with whom you had sexual intercourse?

IF BOYFRIEND: Were you living together as if married?

IF YES, CIRCLE '2'

IF NO, CIRCLE '3'.

620) CHECK 609:

621) CHECK 613:

622) How long ago did you first have sexual intercourse with this (second/third) person?

623) How many times during the last 12 months did you have sexual intercourse with this person?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, WRITE '95'.

624) How old is this person?

625) Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?
[Exclude third to-last -sexual partner]

626) In total, with how many different people have you had sexual intercourse in the last 12 months?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95'.

627) In total, with how many different people have you had sexual intercourse in your lifetime?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95'.

628) PRESENCE OF OTHERS DURING THIS SECTION

629) Do you know of a place where a person can get condoms?

630) Where is that? (3)

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

631) If you wanted to, could you yourself get a condom?

632) (4) Do you know of a place where a person can get female condoms?

633) (4)
Where is that? (3)

Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

634) (4) If you wanted to, could you yourself get a female condom?

(1) The question should be deleted in countries where polygyny is not practiced.
(2) In countries with an active female condom program, the wording of the question should be modified to include
reference to both the male and female condom.
(3) Coding categories to be developed locally and revised based on the pretest; however, the broad categories
must be maintained.
(4) The question should be deleted in countries where female condoms are not actively promoted.

SECTION 7. FERTILITY PREFERENCES

701) CHECK 304:

702) CHECK 226:

703) Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?

704) Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

705) CHECK 226:
IF NOT PREGNANT OR UNSURE:___
How long would you like to wait from now before the birth of (a/another) child?

IF PREGNANT:___
After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?

706) CHECK 226:

707) CHECK 303: USING A CONTRACEPTIVE METHOD?

708) CHECK 705:

709) CHECK 704:
WANTS TO HAVE A/ANOTHER CHILD____
You have said that you do not want (a/another) child soon. Can you tell me why you are
not using a method to prevent pregnancy?

Any other reason?

WANTS NO MORE/NONE____
You have said that you do not want any (more) children. Can you tell me why you are not
using a method to prevent pregnancy?

Any other reason?

RECORD ALL REASONS MENTIONED.

710) CHECK 303: USING A CONTRACEPTIVE METHOD?

711) Do you think you will use a contraceptive method to delay or avoid pregnancy at any time in the future?

712) CHECK 216:

HAS LIVING CHILDREN___
If you could go back to the time you did not have any children and could choose
exactly the number of children to have in your whole life, how many would that be?

NO LIVING CHILDREN___
If you could choose exactly the number of children to have in your whole life, how many would
that be?

PROBE FOR NUMERIC RESPONSE

713) How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter if it's a boy or a girl?

714) In the last few months have you:

Heard about family planning on the radio?
Seen anything about family planning on the television?
Read about family planning in a newspaper or magazine?

715) COUNTRY-SPECIFIC QUESTIONS ON MEDIA MESSAGES ABOUT FAMILY PLANNING.

716) CHECK 601:

717) CHECK 303: USING A CONTRACEPTIVE METHOD?

718) Would you say that using contraception is mainly your decision, mainly your (husband's/partner's) decision, or did you both decide together?

719) CHECK 304:

720) Does your (husband/partner) want the same number of children that you want, or does he want more or fewer than you want?

SECTION 8. HUSBAND'S BACKGROUND AND WOMAN'S WORK

801) CHECK 601 AND 602:

802) How old was your (husband/partner) on his last birthday?

803) Did your (last) (husband/partner) ever attend school?

804) What was the highest level of school he attended: primary, secondary, or higher? (1)

805) What was the highest (grade/form/year) he completed at that level? (1)

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

806) CHECK 801:
CURRENTLY MARRIED/LIVING WITH A MAN____
What is your (husband's/partner's) occupation? That is, what kind of work does he mainly do?

FORMERLY MARRIED/LIVED WITH A MAN____
What was your (last) (husband's/ partner's) occupation? That is, what kind of work did he do?

807) Aside from your own housework, have you done any work in the last seven days?

808) As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work?

809) Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, maternity leave, or any other such reason?

810) Have you done any work in the last 12 months?

811) What is your occupation, that is, what kind of work do you mainly do?

812) Do you do this work for a member of your family, for someone else, or are you self-employed?

813) Do you usually work throughout the year, or do you work seasonally, or only once in a while?

814) Are you paid in cash or kind for this work or are you not paid at all?

815) CHECK 601:

816) CHECK 814:

817) Who usually decides how the money you earn will be used: you, your (husband/partner), or you and your (husband/partner) jointly?

818) Would you say that the money that you earn is more than what your (husband/partner) earns, less than what he earns, or about the same?

819) Who usually decides how your (husband's/partner's) earnings will be used: you, your (husband/partner), or you and your (husband/partner) jointly?

820) Who usually makes decisions about health care for yourself: you, your (husband/partner), you and your (husband/partner) jointly, or someone else?

821) Who usually makes decisions about making major household purchases?

822) Who usually makes decisions about visits to your family or relatives?

823) Do you own this or any other house either alone or jointly with someone else?

824) Do you own any land either alone or jointly with someone else?

825) PRESENCE OF OTHERS AT THIS POINT (PRESENT AND LISTENING, PRESENT BUT NOT LISTENING, OR NOT PRESENT)

826) In your opinion, is a husband justified in hitting or beating his wife in the following situations:

If she goes out without telling him?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

SECTION 9. HIV/AIDS

901) Now I would like to talk about something else. Have you ever heard of an illness called AIDS?

902) Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

903) (1) Can people get the AIDS virus from mosquito bites?

904) Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?

905) (1) Can people get the AIDS virus by sharing food with a person who has AIDS?

906) (1) Can people get the AIDS virus because of witchcraft or other supernatural means?

907) Is it possible for a healthy-looking person to have the AIDS virus?

908) Can the virus that causes AIDS be transmitted from a mother to her baby:

During pregnancy?
During delivery?
By breastfeeding?

909) CHECK 908:

910) Are there any special drugs that a doctor or a nurse can give to a woman infected with the AIDS virus to reduce the risk of transmission to the baby?

911) (2) CHECK 208 AND 215:

912) (2) CHECK 408 FOR LAST BIRTH:

913) (2) CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

914) (2) During any of the antenatal visits for your last birth were you given
any information about:

Babies getting the AIDS virus from their mother?
Things that you can do to prevent getting the AIDS virus?
Getting tested for the AIDS virus?

915) (2) Were you offered a test for the AIDS virus as part of your antenatal care?

916) (2) I don't want to know the results, but were you tested for the AIDS virus as part of your antenatal care?

917) (2) Where was the test done? (4)

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

918) (2) I don't want to know the results, but did you get the results of the test?

919) (2) All women are supposed to receive counseling after being tested. After you were tested, did you receive counseling?

920) (2) CHECK 434 FOR LAST BIRTH:

921) (2) Between the time you went for delivery but before the baby was born, were you offered a test for the AIDS virus?

922) I don't want to know the results, but were you tested for the AIDS virus at that time?

923) (2) I don't want to know the results, but did you get the results of the test?

924) (2) Have you been tested for the AIDS virus since that time you were tested during your pregnancy?

925) (2) How many months ago was your most recent HIV test?

926) I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?

927) How many months ago was your most recent HIV test?

928) I don't want to know the results, but did you get the results of the test?

929) Where was the test done? (4)

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

930) Do you know of a place where people can go to get tested for the AIDS virus?

931) Where is that? (4)

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

932) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?

933) If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?

934) If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?

935) In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?

936) (2) Should children age 12-14 be taught about using a condom to avoid getting AIDS?

937) CHECK 901:
___IF HEARD ABOUT AIDS: Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

___NOT HEARD ABOUT AIDS: Have you heard about infections that can be transmitted through sexual contact?

938) CHECK 613:

939) CHECK 937: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

940) Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact?

941) Sometimes women experience a bad-smelling abnormal genital discharge. During the last 12 months, have you had a bad-smelling abnormal genital discharge?

942) Sometimes women have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?

943) CHECK 940, 941, AND 942:

944) The last time you had (PROBLEM FROM 940/941/942), did you seek any kind of advice or treatment?

945) Where did you go? (4)
Any other place?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

946) (2) If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

947) Is a wife justified in refusing to have sex with her husband when she knows he has sex with other women? (5)

948) (2) CHECK 601:

949) (2) Can you say no to your (husband/partner) if you do not want to have sexual intercourse?

950) (2) Could you ask your (husband/partner) to use a condom if you wanted him to?

(1) If Qs. 903, 905 and/or 906 do not apply to the local context, replace the question using a specific local misconception. At least two questions related to misconceptions are needed.
(2) The question may be considered for deletion in countries with a very low HIV prevalence.
(3) Year of fieldwork is assumed to be 2010. For fieldwork in 2011 or 2012, the year should be 2009 and 2010, respectively.
(4) Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.
(5) In polygynous societies, the phrase 'other women' should be replaced by the phrase 'women other than his wives.'

SECTION 10. OTHER HEALTH ISSUES

1001) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?

IF YES: How many injections have you had?

IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1002) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?

IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1003) The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

1004) Do you currently smoke cigarettes?

1005) In the last 24 hours, how many cigarettes did you smoke?

1006) Do you currently smoke or use any (other) type of tobacco? (1)

1007) What (other) type of tobacco do you currently smoke or use? (1)

RECORD ALL MENTIONED.

1008) Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not?

Getting permission to go to the doctor?
Getting money needed for advice or treatment?
The distance to the health facility?
Not wanting to go alone?

1009) Are you covered by any health insurance? (2)

1010) What type of health insurance are you covered by? (2)

RECORD ALL MENTIONED.

1011) RECORD THE TIME

INTERVIEWER'S OBSERVATION
TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:
_____________

COMMENTS ON SPECIFIC QUESTIONS:
_____________

ANY OTHER COMMENTS:
_____________

SUPERVISOR'S OBSERVATION
_______________

NAME OF SUPERVISOR:__________
DATE:_________

EDITOR'S OBSERVATION
__________________

NAME OF EDITOR:__________
DATE:________

INSTRUCTIONS:
ONLY ONE CODE SHOULD APPEAR IN ANY BOX
COLUMN 1 REQUIRES A CODE IN EVERY MONTH

INFORMATION TO BE CODED FOR EACH COLUMN

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE **
B BIRTHS
P PREGNANCIES

0 NO METHOD
1 FEMALE STERILIZATION
2 MALE STERILIZATION
3 IUD
4 INJECTABLES
5 IMPLANTS
6 PILL
7 CONDOM
8 FEMALE CONDOM
9 DIAPHRAGM
J FOAM JELLY
K LACTATIONAL AMENORRHEA METHOD
L RHYTHM METHOD
M WITHDRAWAL
X OTHER MODERN METHOD
Y OTHER TRADITIONAL METHOD

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE
0 INFREQUENT SEX/HUSBAND AWAY
1 BECAME PREGNANT WHILE USING
3 HUSBAND/PARTNER DISAPPROVED
4 WANTED MORE EFFECTIVE METHOD
5 SIDE EFFECTS/HEALTH CONCERNS
6 LACK OF ACCESS/TOO FAR
7 COSTS TOO MUCH
8 INCONVENIENT TO USE
F UP TO GOD/FATALISTIC
A DIFFICULT TO GET PREGNANT/MENOPAUSAL
D MARITAL DISSOLUTION /SEPARATION
X OTHER (SPECIFY)________
Z DON'T KNOW