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REPUBLIC OF ANGOLA

WOMAN’S QUESTIONNAIRE

STATISTICAL CONFIDENTIALITY: BY THE TERMS GIVEN IN ARTICLE 11 OF THE LAW NO. 3/11, FROM THE 14TH OF JANUARY, LAW OF THE NATIONAL STATISTICS SYSTEM, ALL INDIVIDUAL DATA COLLECTED BY OFFICIAL STATISTICS ORGANIZATIONS, IN THIS CASE THE INE, ARE STRICTLY CONFIDENTIAL. COLLECTED DATA IS PROTECTED FROM ANY NON-STATISTICAL PURPOSES OR FROM ANY UNAUTHORIZED DISSEMINATION, ONLY TO BE USED FOR THE PRODUCTION OF OFFICIAL STATISTICS.

IDENTIFICATION

PLACE NAME ________
NAME OF HOUSEHOLD HEAD_______
PROVINCE_______
MUNICIPALITY_____
COMMUNITY_______
NEIGHBORHOOD/VILLAGE______
CENSUS SECTION______
AREAS OF RESIDENCE

URBAN 1
RURAL 2

CLUSTER NUMBER (ID. IIMS)______
HOUSEHOLD NUMBER_______
NAME AND LINE NUMBER OF WOMAN_______
THE WOMAN WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT
DATE_________
DAY___
MONTH___
INTERVIEWER’S NAME_________
RESULT*

COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7

NEXT VISIT:
DATE_________
TIME_________

SECOND VISIT
DATE____
DAY____
MONTH____
INTERVIEWER’S NAME____
RESULT*

COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7

NEXT VISIT:
DATE____
TIME____

THIRD VISIT
DATE____
DAY____
MONTH____
INTERVIEWER’S NAME____
RESULT*

COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7

FINAL VISIT
DAY_________
MONTH_________
YEAR_____
INT. NO._________
RESULT*

COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7

TOTAL NUMBER OF VISITS_________

LANGUAGE OF QUESTIONNAIRE______

PORTUGUESE 1
CHOKWE/KIOKO 2
FIOTE 3
KIKONGO/UKONGO 4
KIMBUNDU 5
KWANHAMA 6
LUVALE 7
MUHUMBI 8
NGANGUELA 9
NHANECA 10
UMBUNDU 11
OTHER (SPECIFY)____ 96

TRANSLATOR USED (YES =1, NO=2) ____

SUPERVISOR
NAME_________
NUMBER_________

INTRODUCTION AND CONSENT
Good morning/afternoon. My name is _________. I am working with the Institute of National Statistics and here is my identification (SHOW YOUR ID BADGE). We are conducting a survey about health all over the country. The information we collect will help the government to plan health services. Your household was selected for the survey. All of the answers you give will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Your participation in the survey is voluntary if I ask you a 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. We hope that you will participate in this survey since your views are important. In case that you need more information about the survey, you may contact INE [INS] or the province delegate of Statistics.

Do you have any questions? May I begin the interview now?

SIGNATURE OF INTERVIEWER:____________ DATE:________________

RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

SECTION 1: WOMAN’S BASIC CHARACTERISTICS

101) RECORD THE TIME

HOUR_____
MINUTES____

102) In what month and year were you born?

MONTH ____
DON’T KNOW MONTH 98
YEAR ____
DON’T KNOW YEAR 9998

103) How old were you at your last birthday?
COMPARE AND CORRECT 102 AND 103 IF INCONSISTENT

AGE IN COMPLETED YEARS_____

104) Have you ever attended school?

YES 1
NO 2 (GO TO 108)

105) What is the highest level of school you attended?

INITIAL EDUCATION 90
LITERACY 91
PRIMARY/SECONDARY
1ST GRADE
2ND GRADE
3RD GRADE
4TH GRADE
5TH GRADE
6TH GRADE
7TH GRADE
8TH GRADE
9TH GRADE
10TH GRADE
11TH GRADE
12TH GRADE
13TH GRADE
HIGHER EDUCATION
1ST YEAR
2ND YEAR
3RD YEAR
4TH YEAR
5TH YEAR
6TH YEAR

106) Have you completed that year successfully?

YES 1
NO 2

106A) What level is the year you completed?

LITERACY 00
PRE-PRIMARY 01
PRIMARY 02
SECONDARY 1ST CYCLE 03
SECONDARY 2ND CYCLE 04
HIGH SCHOOL 05
BACHELOR’S DEGREE 06
MASTER’S DEGREE 07
DOCTORATE 08

107) CHECK 106A:

CODES ‘00 TO 04’ RECORDED ___
CODES ‘05 TO 08’ RECORDED ___ (GO TO 112)

108) Can you read?

YES 1
NO 2

109) Can you write?

YES 1
NO 2

110) Now I would like you to read this sentence to me.
SHOW CARD TO RESPONDENT
IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE:
Can you read any part of the sentence to me?

CANNOT READ AT ALL 1
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE)_____ 4
BLIND/VISUALLY IMPAIRED 5

111) CHECK 110:

CODE ‘2’, ‘3’ OR ‘4’ CIRCLED______
CODE ‘1’ OR ‘5’ CIRCLED ____ (GO TO 113)

112) Do you read the newspaper or magazine at least once a week, less than once a week or not at all?

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

113) Do you listen to the radio at least once a week, less than once a week or not at all?

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

114) Do you watch television at least once a week, less than once a week or not at all?

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

115) Do you own a mobile telephone?

YES 1
NO 2

116) Have you ever used the internet?

YES 1
NO 2 (GO TO 119)

117) In the last 12 months, have you used the internet?
IF NECESSARY, PROBE FOR USE FROM ANY LOCATION, WITH ANY EVIDENCE

YES 1
NO 2 (GO TO 119)

118) During the last 30 days, how often did you use the internet: almost every day, at least once a week, less than once a week, or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

119) What is your religion?

CATHOLIC 01
METHODIST 02
ASSEMBLY OF GOD 03
UNIVERSAL 04
JEHOVAH’S WITNESS 05
PROTESTANT 06
ISLAMIC 07
ANIMIST 08
NO RELIGION 09
OTHER (SPECIFY) _____96

120) How often do you go to the church?

ONCE A MONTH 1
TWICE A MONTH 2
ONCE A WEEK 3
MORE THAN ONCE A WEEK 4
ONLY DURING HOLIDAY 5
NEVER 6

121) Usually what language do you speak in the household?
IF MORE THAN ONE LANGUAGE IS MENTIONED, PROBE TO IDENTIFY THE MAIN LANGUAGE

PORTUGUESE 01
CHOWKE/KIOKO 02
FIOTE 03
KIKONGO/UKONGO 04
KIMBUNDU 05
KWANHAMA 06
LUVALE 07
MUHUMBI 08
NGANGUELA 09
NHANECA 10
UMBUNDU 11
GESTURAL 12
OTHER (SPECIFY) _____96

122) In the last 12 months, how many times have you been away from home for one or more nights?

NUMBER OF TIMES____
NONE 00 (GO TO 124)

123) In the last 12 months, have you been away from home for one month or more at a time?

YES 1
NO 2

124) How long have you lived in this province?
IF LESS THAN A YEAR, RECORD ‘00’ YEARS

YEARS____
ALWAYS 95 (GO TO 201)
VISITOR 96 (GO TO 201)

125) In which province or country did you live before moving here?

CABINDA 01
ZAIRE 02
UIGE 03
LUANDA 04
NORTHERN CUANZA 05
SOUTHERN CUANZA 06
MALANJE 07
NORTHERN LUNDA 08
BENGUELA 09
HUAMBO 10
BIE 11
MOXICO 12
CUANDO CUBANGO 13
NAMIBE 14
HUILA 15
CUNENE 16
SOUTHERN LUNDA 17
BENGO 18
OTHER COUNTRY (COUNTRY)_____96

SECTION 2. REPRODUCTION

201) Now I would like to ask about all the children [sons and daughters] that you have had in your whole life. Have you ever given birth?

YES 1
NO 2 (GO TO 206)

202) Do you have any sons or daughters that live with you?

YES 1
NO 2 (GO TO 204)

203) How many sons live with you?
And how many daughters live with you?
IF NONE, RECORD ‘00’

SONS AT HOME ____
DAUGHTERS AT HOME_____

204) Do you have any sons or daughters who don’t live with you?

YES 1
NO 2 (GO TO 206)

205) How many sons are alive and living away from home?
And how many daughters are alive and living away from home?
IF NONE, RECORD ‘00’

SONS ELSEWHERE_____
DAUGHTERS ELSEWHERE_____

206) Have you ever given birth to a boy or a girl who was born alive but later died?
IF NO, PROBE: Any baby who cried, tried to breath, moved in some way or showed signs of life, even if only for a short time?

YES 1
NO 2 (GO TO 208)

207) How many sons have died?
And how many daughters have died?
IF NONE, RECORD ‘00’

SONS DEAD____
DAUGHTERS DEAD____

208) ADD UP RESPONSES TO 203, 205 AND 207. RECORD THE TOTAL
IF NONE, RECORD ‘00’

TOTAL SONS AND DAUGHTERS______

209) CHECK 208:
Just to make sure that I understood correctly: In your entire life, you have had a TOTAL of _____ children. Is that right?

YES
NO (PROBE AND CORRECT 201-208 IF NECESSARY.)

210) CHECK 208:

ONE OR MORE BIRTHS_____
NO BIRTHS____ (GO TO 226)

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 IN 212, THE NAMES OF ALL CHILDREN BORN ALIVE. (Even if the child is no longer alive or is not a child of the current partner.) RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (IF THERE ARE MORE THAN 10 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW)

212) What is the name of your (first/next) baby?
RECORD THE NAME.

NAME____

213) Is (NAME) a male or female?

MALE 1
FEMALE 2

214) Is (NAME) a twin?

SINGLE 1
MULTIPLE 2

215) In what day, month and year was (NAME) born?

DAY ____
MONTH____
YEAR____

216) Is (NAME) alive?

YES 1
NO 2 (GO TO 220)

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

AGE IN YEARS_____

218) IF ALIVE: Is (NAME) living with you?

YES 1
NO 2

219) IF ALIVE: RECORD HOUSEHOLD LINE NUMBER OF CHILD FROM HOUSEHOLD SURVEY. RECORD ‘00’ IF CHILD WAS NOT LISTED.

LINE NUMBER_______ (GO NEXT BIRTH)

220) IF DEAD: How old was (NAME) when he/she died?
IF ‘12 MONTHS’ OR ‘1 YEAR’, ASK: Did (NAME) have his/her first birthday?
AND THEN ASK: How many months old was (NAME) when he/she died?
RECORD DAYS IF LESS THAN A MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

DAYS 1 _____
MONTHS 2 _____
YEARS 3 _____

221) Were there any other births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth?

YES 1 (ADD BIRTH)
NO 2 (NEXT BIRTH)

222) Have you given birth to another child since the birth of (NAME OF LAST BIRTH)?

YES 1 (RECORD BIRTH(S) IN TABLE)
NO 2

223) COMPARE 208 WITH NUMBER OF BIRTHS IN THE BIRTH RECORD.

NUMBERS ARE THE SAME____
NUMBERS ARE DIFFERENT _____ (PROBE AND RECONCILE)

224) CHECK 215: ENTER THE NUMBER OF BIRTHS OCCURRING SINCE JANUARY 2010.

NUMBER OF BIRTHS______
NONE 0 (GO TO 226)

225) C FOR EACH BIRTH SINCE JANUARY 2010, ENTER ‘B’ IN THE MONTH OF BIRTH IN THE CALENDAR AND RECORD THE CHILD’S NAME TO THE LEFT OF THE CODE ‘B’. FOR EACH BIRTH, ASK THE NUMBER OF COMPLETE MONTHS THAT THE WOMAN WAS PREGNANT, AND RECORD ‘P’ IN EACH OF THE MONTHS PRIOR TO THE BIRTH. (NOTE: THE NUMBER OF ‘P’s MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226) Are you pregnant now?

YES 1
NO 2 (GO TO 230)
DON’T KNOW 8 (GO TO 230)

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.

MONTHS________

228) When you got pregnant, did you want/hope to get pregnant at that time?

YES 1 (GO TO 230)
NO 2

229) CHECK 208: TOTAL NUMBER OF BIRTHS

ONE OR MORE: Did you want to have a baby later on or did you not want any more children?
LATER 1
DIDN’T WANT TO HAVE ANY (MORE) CHILDREN 2
NONE: Did you want to have a baby later on or did you not want any children?
LATER 1
DIDN’T WANT TO HAVE ANY (MORE) CHILDREN 2

230) Did you ever have a pregnancy where you lost the baby (miscarriage or stillbirth)?

YES 1
NO 2 (GO TO 239)

231) In what month and year did the last such pregnancy end?

MONTH____
YEAR_____

232) CHECK 231:

LAST PREGNANCY ENDED IN JANUARY 2010 OR LATER_________ (GO TO 234)
LAST PREGNANCY ENDED IN 2009 OR EARLIER_______ (GO TO 239)

233) In what month and year did that pregnancy end?

MONTH____
YEAR_____

234) How many months pregnant were you when the miscarriage occurred?

NUMBER OF MONTHS _____

235) Since January 2010, did you have any pregnancy that ended in miscarriage?

YES 1 (GO TO NEXT LINE)
NO 2 (236)

236) C FOR EACH PREGNANCY THAT ENDED IN MISCARRIAGE SINCE JANUARY 2010, RECORD ‘T’ IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND ‘P’ FOR THE REMAINING NUMBER OF COMPLETED MONTHS OF PREGNANCY.

IF THERE WERE MORE THAN FOUR PREGNANCIES THAT ENDED IN MISCARRIAGE, USE AN ADDITIONAL SURVEY, BEGINNING ON THE SECOND LINE.

237) Before 2010, did you have any pregnancy that terminated, in miscarriage or stillbirth?

YES 1
NO 2 (GO TO 239)

238) In what year and month did the last such pregnancy that terminated before 2010 end?

MONTH_____
YEAR_____

239. When did your last menstrual period start?

(DATE, IF GIVEN)____
DAYS AGO 1___
WEEKS AGO 2___
MONTHS AGO 3____
YEARS AGO 4_____
IN MENOPAUSE/HAS HAD HYSTERECTOMY 994
BEFORE THE LAST BIRTH 995
NEVER MENSTRUATED 996

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

YES 1
NO 2 (GO TO 242)
DON’T KNOW (GO TO 242)

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

JUST BEFORE HER PERIOD 1
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER: (SPECIFY)___ 6
DON’T KNOW 8

242) After the birth of a child, can a woman become pregnant before her menstrual period has returned?

YES 1
NO 2
DON’T KNOW 8

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. Which ways or methods have you heard about?
For methods not mentioned spontaneously, ask: Have you heard of (read: METHOD)?

01 Female Sterilization. (Tubal ligation). PROBE: Women can have an operation to avoid having any more children.
YES 1
NO 2
02 Male Sterilization. (Vasectomy).PROBE: Men can have an operation to avoid having any more children.
YES 1
NO 2
03 IUD. PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse to avoid pregnancy
YES 1
NO 2
04 Injectables. PROBE: Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months.
YES 1
NO 2
05 Implants. PROBE: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2
06 Pill. PROBE: Women can take pill everyday to avoid pregnancy.
YES 1
NO 2
07 Condom. PROBE: Men can put a rubber sheath on their penis during sexual intercourse.
YES 1
NO 2
08 Female Condom. PROBE: Women can place a sheath on their vagina before sexual intercourse.
YES 1
NO 2
09 Emergency Contraception. PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
YES 1
NO 2
10 Standard Days Method. 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.
YES 1
NO 2
11 Lactational Amenorrhea Method (LAM). PROBE: Up to 6 months after childbirth, a woman can use a method that requires that she breastfeeds frequently, day and night, and that her menstrual period has not returned.
YES 1
NO 2
12 Periodic Abstinence. PROBE: Every month that a women is sexually active she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
13 Withdrawal. PROBE: Men can be careful and pull out before climax ejaculating outside of the vagina.
YES 1
NO 2
14 Other Methods. ROBE: Couples can use other methods or ways to avoid pregnancy. Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES 1 (SPECIFY) ______
NO 2

302) CHECK 226:

NOT PREGNANT OR UNSURE_____
PREGNANT____ (GO TO 311)

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

YES 1
NO 2 (GO TO 311)

304) Which method are you using?
RECORD ALL ANSWERS. IF MORE THAN ONE METHOD MENTIONED, FOLLOW GO INSTRUCTION FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION A (GO TO 306)
MALE STERILIZATION B (GO TO 306)
IUD C (GO TO 308)
INJECTABLES D (GO TO 308)
IMPLANTS E (GO TO 308)
PILL F
CONDOM G (GO TO 308)
FEMALE CONDOM H (GO TO 308)
EMERGENCY CONTRACEPTION I (GO TO 308)
STANDARD DAYS METHOD J (GO TO 308)
LACTATIONAL AMEN. METHOD K (GO TO 308)
PERIODIC ABSTINENCE L (GO TO 308)
WITHDRAWAL M (GO TO 308)
OTHER MODERN METHOD X (GO TO 308)
OTHER TRADITIONAL METHODS Y(GO TO 308)

305) What is the brand name of the pills you are using?

IF DON’T KNOW THE BRAND, ASK TO SEE THE PACKAGE

MICROGYNON 01 (GO TO 308)
NOGESTOL 02 (GO TO 308)
MICROLUT 03 (GO TO 308)
OTHER (SPECIFY)____96 (GO TO 308)
DON’T KNOW 98 (GO TO 308)

306) In what facility did the sterilization take place?

IF SOURCE IS HOSPITAL, OR HEALTH CENTER, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE)____
PUBLIC SECTOR
CENTRAL HOSPITAL 11
HOSPITAL IN PROVINCE 12
HOSPITAL IN RURAL AREA 13
OTHER: (SPECIFY)____ 16
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL 21
PRIVATE HEALTH CENTER 22
OTHER: (SPECIFY)____ 26
OTHER: (SPECIFY)____96
DON’T KNOW 98

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

MONTH___ (GO TO 309)
YEAR___ (GO TO 309)

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

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

MONTH___
YEAR___

309) CHECK 307 AND 308, 215 AND 231:

ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 307 OR 308

NO_____
YES _____ (GO BACK TO 307 OR 308, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION))

310) CHECK 307/308:

YEAR IS 2010 OR LATER _______
C ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND IN EACH MONTH BACK TO THE DATE STARTED USING
THEN CONTINUE
YEAR IS 2009 OR EARLIER _____
C ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND IN EACH MONTH BACK TO JANUARY 2010
THEN GO TO 324.

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

C USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2010. USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE
POINTS.

312A) MONTH AND YEAR OF START CONTRACEPTIVE METHOD

MONTH____
YEAR_____

312B) Between (EVENT) in (MONTH/YEAR) and (EVENT), did you or your partner use any method of contraception?

YES 1
NO 2 (GO TO 312I)

312C) Which method was that?

METHOD CODE _____

312D) How many months after (EVENT) in (MONTH/YEAR) did you start to use (METHOD)?

CIRCLE ‘95’ IF RESPONDENT GIVES THE DATE OF STARTING TO USE METHOD.

IMMEDIATELY 00 (GO TO 312F)
MONTHS____ (GO TO 312F)
DATE GIVEN 95

312E) RECORD THE MONTH AND YEAR RESPONDENT STARTED USING METHOD.

MONTH____
YEAR_____

312F) For how many months did you use (METHOD)?

CIRCLE ‘95’ IF RESPONDENT GIVES THE DATE OF TERMINATION OF USE

MONTHS____ (GO TO 312H)
DATE GIVEN 95

312G) RECORD MONTH AND YEAR RESPONDENT STOPPED USING METHOD.

MONTH____
YEAR_____

312H) Why did you stop using (METHOD)?

REASON STOPPED_____

312I) GO BACK TO 312A IN NEXT COLUMN; OR, IF NO MORE GAPS, GO TO 313.

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

NO METHOD USE____
ANY METHOD USE___ (GO TO 315)

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

YES 1 (GO TO 326)
NO 2 (GO TO 326)

315) CHECK 304:

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

NO CODE CIRCLED 00 (GO TO 326)
FEMALE STERILIZATION 01 (GO TO 319)
MALE STERILIZATION 02 (GO TO 327)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
FEMALE CONDOM 08
EMERGENCY CONTRACEPTION 09
STANDARD DAYS METHOD 10
LACTATIONAL AMEN. METHOD 11 (GO TO 323)
PERIODIC ABSTINENCE 12 (GO TO 323)
WITHDRAWAL 13 (GO TO 323)
OTHER MODERN METHOD 95
OTHER TRADITIONAL METHODS 96

316) You first started using (CURRENT METHOD) in (DATE FROM 307 OR 308). Where did you get it at that time?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)___________
PUBLIC SECTOR
CENTRAL HOSPITAL 11
HOSPITAL IN PROVINCE 12
HOSPITAL IN RURAL AREA 13
HEALTH CENTER 14
MATERNITY WARD 15
MOBILE CLINIC 16
OTHER: (SPECIFY)____ 17
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC 21
PHARMACY 22
HEALTH CENTER 23
OTHER: (SPECIFY)____26
OTHER SOURCE
MARKET/STORE 31
FRIEND/RELATIVE 32
OTHER: (SPECIFY)____96

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

IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07 (GO TO 323)
FEMALE CONDOM 08 (GO TO 322)
EMERGENCY CONTRACEPTION 09 (GO TO 322)
STANDARD DAYS METHOD 10 (GO TO 322)
OTHER MODERN METHOD 95 (GO TO 322)
OTHER TRADITIONAL METHODS 96 (GO TO 323)

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

YES 1 (GO TO 321)
NO 2 (GO TO 320)

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

YES 1 (GO TO 321)
NO 2

320) Were you ever told by a health or family planning worker about side effects or problems you my half with the method?

YES 1
NO 2 (GO TO 322)

321) Were you told what to do if you experience side effects or problems?

YES 1
NO 2

322) CHECK 318 AND 319:

ANY ‘YES’: At that time, were you told about other methods of family planning that you could use?
YES 1 (GO TO 324)
NO 2
OTHER: When you obtain (CURRENT METHOD FROM 315) from (SOURCE OF METHOD FROM 307 OR 306), where you told about other methods of family planning that you could use?
YES 1 (GO TO 324)
NO 2

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

YES 1
NO 2

324) CHECK 304:

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

FEMALE STERILIZATION 01 (GO TO 327)
MALE STERILIZATION 02 (GO TO 327)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
FEMALE CONDOM 08
FEMALE CONDOM 08
EMERGENCY CONTRACEPTION 09
STANDARD DAYS METHOD 10
LACTATIONAL AMEN. METHOD 11 (GO TO 327)
PERIODIC ABSTINENCE 12 (GO TO 327)
WITHDRAWAL 13 (GO TO 327)
OTHER MODERN METHOD 95
OTHER TRADITIONAL METHODS 96 (GO TO 327)

325) Where did you obtain (CURRENT METHOD) the last time?
PROBE TO IDENTIFY THE TYPE OF SOURCE
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE)_______
PUBLIC SECTOR
CENTRAL HOSPITAL 11 (GO TO 327)
HOSPITAL IN PROVINCE 12 (GO TO 327)
HOSPITAL IN RURAL AREA 13 (GO TO 327)
HEALTH CENTER 14 (GO TO 327)
MATERNITY WARD 15 (GO TO 327)
MOBILE CLINIC 16 (GO TO 327)
OTHER: (SPECIFY)____ 17 (GO TO 327)
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC 21 (GO TO 327)
PHARMACY 22 (GO TO 327)
HEALTH CENTER 23 (GO TO 327)
OTHER: (SPECIFY)____26 (GO TO 327)
OTHER SOURCE
MARKET/STORE 31 (GO TO 327)
FRIEND/RELATIVE 32 (GO TO 327)
OTHER: (SPECIFY)____96 (GO TO 327)

326) Do you know if the place where you can obtain a method of family planning?

YES 1
NO 2

327) CHECK 202: LIVING CHILDREN

YES: In the last 12 months, have you visited a health facility for care for yourself or your children?
YES 1
NO 2 (GO TO 401)
NO: In the last 12 months, have you visited a health facility for care for yourself?
YES 1
NO 2 (GO TO 401)

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

YES 1
NO 2

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

ONE OR MORE BIRTHS IN JANUARY 2010 OR LATER______
NO BIRTHS IN JANUARY 2010 OR LATER______ (GO TO 648)

402) CHECK 215: RECORD THE BIRTH HISTORY NUMBER IN 403 AND THE NAME AND SURVIVAL STATUS IN 404, FOR EACH BIRTH SINCE JANUARY 2010.
ASK THE QUESTIONS ABOUT ALL THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRE.

Now I would like to ask you some more questions about the health of all your children born in the past five years. (We will talk about one child at a time.)

403) LINE NUMBER FROM QUESTION 212 IN BIRTH HISTORY.

BIRTH HISTORY NUMBER______

404) FROM 212 AND 216:

NAME____
ALIVE____
DEAD___

405) At the time you became pregnant with (NAME), did you want to get pregnant at that time?

YES 1 (GO TO 408)
NO 2

406) CHECK 208:

ONLY ONE BIRTH: Did you want to have a baby later on, or did you not want any children?
LAST BIRTH
LATER 1
NO MORE/NONE 2 (GO TO 408)
MORE THAN ONE BIRTH: Did you want to have a baby later on, or did you not want any more children?
LAST BIRTH
LATER 1
NO MORE/NONE 2 (GO TO 408)

407) How much longer would you like to have waited?

MONTHS 1 _____
YEARS 2 _____
DON’T KNOW 998

408) Did you see anyone for antenatal care for this pregnancy?

YES 1
NO 2 (GO TO 415)

409) Whom did you see?
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PERSONNEL
DOCTOR A
NURSE B
MIDWIFE C
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT D
OTHER: (SPECIFY) ______X

410) Where did you received antenatal care for this pregnancy?
Anywhere else?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
CENTRAL HOSPITAL A
HOSPITAL IN PROVINCE B
HOSPITAL IN RURAL AREA C
HEALTH CENTER/POST D
MATERNITY WARD E
MOBILE CLINIC F
OTHER PUBLIC SECTOR: (SPECIFY)____ G
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL H
HEALTH CENTER I
OTHER PRIVATE MEDICAL SECTOR: (SPECIFY)____J
OTHER: (SPECIFY) ______ X

411) How many months pregnant were you when you first received antenatal care?

MONTHS_____
DON’T KNOW 98

412) How many antenatal appointments did you have during this pregnancy?

NUMBER OF TIMES____
DON’T KNOW 98

413) As part of your antenatal care during this pregnancy, were any of the following done at least once?
A) Was your blood pressure measured?
B) Did you give a urine sample?
C) Did you give a blood sample?

BLOOD PRESSURE
YES 1
NO 2
URINE SAMPLE
YES 1
NO 2
BLOOD SAMPLE
YES 1
NO 2

414) During (any of) your antenatal care visit(s), were you told about the signs of pregnancy complications?

YES 1
NO 2

415) When you were pregnant were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?

YES 1
NO 2 (GO TO 418)
DON’T KNOW 8 (GO TO 418)

416) During this pregnancy, how many times did you get this injection?

NUMBER OF TIMES____
DON’T KNOW 8

417) CHECK 416:

2 OR MORE TIMES ____(GO TO 421)
OTHER____

418) At any times before this pregnancy, did you receive any tetanus injections?

YES 1
NO 2 (GO TO 421)
DON’T KNOW 8 (GO TO 421)

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

IF 7 OR MORE TIMES, RECORD ‘7’.

TIMES ______
DON’T KNOW 8

420) CHECK 419:

ONLY ONE: How many years ago did you receive that tetanus injection?
YEARS AGO ___
MORE THAN ONE: How many years ago did you receive that tetanus injection prior to this pregnancy?
YEARS AGO ___

421) During this pregnancy, were you given or did you buy any iron tablets or iron syrup?
SHOW TABLET/SYRUP

YES 1
NO 2 (GO TO 423)
DON’T KNOW 8 (GO TO 423)

422) During the whole pregnancy, for how many days did you take the tablets or syrup?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS

NUMBER OF DAYS_____
DON’T KNOW 998

423) During this pregnancy, did you take any drug for intestinal worms?

YES 1
NO 2
DON’T KNOW 8

424) During this pregnancy, did you take SP/Fansidar to keep you from getting malaria?

YES 1
NO 2 (GO TO 427)
DON’T KNOW 8 (GO TO 427)

425) How many times did you take SP/Fansidar during this pregnancy?

TIMES_____

426) Did you get the SP/Fansidar during any antenatal care visit, during another visit to a health facility or from another source?
IF MORE THAN ONE SOURCE, RECORD THE HIGHEST ON THE LIST.

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6

427) When (NAME) was born, was (NAME), very large, larger than average, average, smaller than average, or very small?

VERY LARGE 1
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON’T KNOW 8

428) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 430)
DON’T KNOW (GO TO 430)

429) How much did (NAME) weigh?
RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE.

KILOGRAMS FROM CARD 1____
KILOGRAMS FROM RECALL 2____
DON’T KNOW 9998

430) Who assisted with the delivery of (NAME)?
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.

HEALTH PROFESSIONAL
DOCTOR A
NURSE B
MIDWIFE C
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT D
FRIENDS/RELATIVES E
OTHER: (SPECIFY) ______X
NO ONE Y

431. Where did you give birth to (NAME)?

PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
HOME
YOUR HOME 11 (GO TO 435)
OTHER HOME 12 (GO TO 435)
PUBLIC SECTOR
CENTRAL HOSPITAL 21
HOSPITAL IN PROVINCE 22
HOSPITAL IN RURAL AREA 23
HEALTH CENTER/POST 24
MATERNITY WARD 25
OTHER: (SPECIFY)____ 26
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL 31
HEALTH CENTER 32
HEALTH POST 33
OTHER: (SPECIFY)____36
OTHER: (SPECIFY) ___96 (GO TO 435)

432) How long after (NAME) was delivered did you stayed there?

IF LESS THAN ONE DAY, RECORD HOURS; IF LESS THAN ONE WEEK, RECORD DAYS

HOURS 1 ___
DAYS 2___
WEEKS 3 ____
DON’T KNOW 998

433) Was (NAME) delivered by caesarean, that is, did they cut your belly open to take the baby out?

YES 1
NO 2 (GO TO 435)

434) When was the decision made to have the caesarean section? Was it before or after your labor pains started?

BEFORE 1
AFTER 2

435) Immediately after birth, was (NAME) put directly on the bare skin of your chest?

YES 1
NO 2
DON’T KNOW 8

436) CHECK 431: PLACE OF DELIVERY

CODE 11, 12 OR 96 CIRCLED______ (GO TO 451)
OTHER _____

437) I would like to talk to you about checks on your health after delivery. Before you were discharged after (NAME) was born, did anyone check on your health while you were still in the facility?

YES 1
NO 2 (GO TO 440)

438) How long after delivery did the first check take place?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1__
DAYS 2__
WEEKS 3__
DON’T KNOW 998

439) Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL
DOCTOR 11
NURSE 12
MIDWIFE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
OTHER: (SPECIFY)___9

440) Now I would like to talk to you about check on (NAME)’s health after delivery. Did anyone check on (NAME)’s health while you were still in the facility?

YES 1
NO 2 (GO TO 443)
DON’T KNOW 8 (GO TO 443)

441) How long after delivery was (NAME)’s health first check?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN A WEEK, RECORD DAYS.

HOURS 1___
DAYS 2___
WEEKS 3___
DON’T KNOW 998

442) Who checked on (NAME)’s health at that time?
PROBE FOR MOST QUALIFIED PERSON

HEALTH PERSONNEL
DOCTOR 11
NURSE 12
MIDWIFE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
OTHER: (SPECIFY)____96

443) Now I would like to talk to you about what happened after you left the facility. Did anyone check on your health after you left the facility?

YES 1
NO 2 (GO TO 447)

444) How long after delivery did that check take place?

IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN A WEEK, RECORD DAYS.

HOURS 1___
DAYS 2___
WEEKS 3___
DON’T KNOW 998

445) Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON

HEALTH PERSONNEL
DOCTOR 11
NURSE 12
MIDWIFE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
OTHER: (SPECIFY)____96

446) Where did the check take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
CENTRAL HOSPITAL 21
HOSPITAL IN PROVINCE 22
HOSPITAL IN RURAL AREA 23
HEALTH CENTER/POST 24
MATERNITY WARD 25
OTHER PUBLIC SECTOR: (SPECIFY)____ 26
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL 31
HEALTH CENTER 32
HEALTH POST 33
OTHER PRIVATE MEDICAL SECTOR: (SPECIFY)____36
OTHER: (SPECIFY)___96

447) Did any health care provider or a traditional birth attendant check on (NAME)’s health in the two months after you left (FACILITY IN 431)?

YES 1
NO 2 (GO TO 459)
DON’T KNOW 8 (GO TO 459)

448) How long after the birth of (NAME) did that check take place?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN A WEEK, RECORD DAYS.

HOURS 1___
DAYS 2___
WEEKS 3___
DON’T KNOW 998

449) Who checked on (NAME)’s health at that time?
PROBE FOR MOST QUALIFIED PERSON

HEALTH PERSONNEL
DOCTOR 11
NURSE 12
MIDWIFE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
OTHER: (SPECIFY)____96

450) Where did this check of (NAME) take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
CENTRAL HOSPITAL 21 (GO TO 459)
HOSPITAL IN PROVINCE 22 (GO TO 459)
HOSPITAL IN RURAL AREA 23 (GO TO 459)
HEALTH CENTER/POST 24 (GO TO 459)
MATERNITY WARD 25 (GO TO 459)
OTHER PUBLIC SECTOR: (SPECIFY)____ 26 (GO TO 459)
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL 31 (GO TO 459)
HEALTH CENTER 32 (GO TO 459)
HEALTH POST 33 (GO TO 459)
OTHER PRIVATE MEDICAL SECTOR: (SPECIFY)____36 (GO TO 459)
OTHER: (SPECIFY)___96 (GO TO 459)

451) I would like to talk to you about checks on your health after delivery. Did anyone check on your health after you gave birth to (NAME)?

YES 1
NO 2 (GO TO 455)

452) How long after delivery did the first check take place?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN A WEEK, RECORD DAYS.

HOURS 1___
DAYS 2___
WEEKS 3___
DON’T KNOW 998

453) Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON

HEALTH PERSONNEL
DOCTOR 11
NURSE 12
MIDWIFE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
OTHER: (SPECIFY)____96

454) Where did the first check take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
CENTRAL HOSPITAL 21
HOSPITAL IN PROVINCE 22
HOSPITAL IN RURAL AREA 23
HEALTH CENTER/POST 24
MATERNITY WARD 25
OTHER PUBLIC SECTOR: (SPECIFY)____ 26
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL 31
HEALTH CENTER 32
HEALTH POST 33
OTHER PRIVATE MEDICAL SECTOR: (SPECIFY)____36
OTHER: (SPECIFY)___96

455) In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on (NAME)’s health?

YES 1
NO 2 (GO TO 459)
DON’T KNOW (GO TO 459)

456) How long after the birth of (NAME) did the first check take place?

HOURS AFTER BIRTH 1___
DAYS AFTER BIRTH 2___
WEEKS AFTER BIRTH 3___
DON’T KNOW 998

457) Who checked on (NAME)’s health at that time?
PROBE FOR MOST QUALIFIED PERSON

HEALTH PERSONNEL
DOCTOR 11
NURSE 12
MIDWIFE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
OTHER: (SPECIFY)____96

458) Where did this check of (NAME) take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
CENTRAL HOSPITAL 21 (GO TO 459)
HOSPITAL IN PROVINCE 22 (GO TO 459)
HOSPITAL IN RURAL AREA 23 (GO TO 459)
HEALTH CENTER/POST 24 (GO TO 459)\
MATERNITY WARD 25 (GO TO 459)
OTHER PUBLIC SECTOR: (SPECIFY)____ 26 (GO TO 459)
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL 31 (GO TO 459)
HEALTH CENTER 32 (GO TO 459)
HEALTH POST 33 (GO TO 459)
OTHER PRIVATE MEDICAL SECTOR: (SPECIFY)____36 (GO TO 459)
OTHER: (SPECIFY)___96 (GO TO 459)

459) During the first two days after (NAME)’s birth, did any health care provider do the following:

A) Examine the cord?
B) Measure (NAME)’s temperature?
C) Counsel you on danger signs for newborns?
D) Counsel you on breastfeeding?
E) Observe (NAME) breastfeeding?

A) CORD
YES 1
NO 2
DON’T KNOW 8
B) TEMPERATURE
YES 1
NO 2
DON’T KNOW 8
C) SIGNS
YES 1
NO 2
DON’T KNOW 8
D) COUNSEL BREASTFEED
YES 1
NO 2
DON’T KNOW 8
E) OBSERVE BREASTFEED
YES 1
NO 2
DON’T KNOW 8

460) Has your period returned since the birth of (NAME)?

YES 1 (GO TO 462)
NO 2 (GO TO 463)

461) Did your period return between the birth of (NAME) and your next pregnancy?

YES 1
NO 2 (GO TO 465)

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

MONTHS_____
DON’T KNOW 98

463) CHECK 226: IS RESPONDENT PREGNANT?

NOT PREGNANT______
PREGNANT OR UNSURE___(GO TO 465)

464) Have you resumed sexual relations since the birth of (NAME)?

YES 1
NO 2 (GO TO 466)

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

MONTHS_____
DON’T KNOW 98

466) Did you ever breastfeed (NAME)?

YES 1 (GO TO 468)
NO 2

467) CHECK 404: IS CHILD LIVING?

LIVING __(GO TO 473)
DEAD ___(GO TO 474)

468) 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.

IMMEDIATELY 000
HOURS____ 1
DAYS____ 2

469) In the first three days after delivery, before your milk began flowing regularly, was (NAME) given anything to drink other than breast milk?

YES 1
NO 2 (GO TO 471)

470) What was (NAME) given to drink before your milk began flowing regularly?
PROBE: Anything else?
RECORD ALL LIQUIDS MENTIONED.

MILK (OTHER THAN BREAST MILK) A
POWDER FORMULA B
PLAIN WATER C
SUGAR OR GLUCOSE WATER D
SUGAR WATER SOLUTION E
FRUIT JUICE F
INFANT FORMULA F
PORRIDGE G
TEA H
HONEY I
OTHER: (SPECIFY)___X

471) CHECK 404:
IS CHILD LIVING?

LIVING ____
DEAD____ (GO TO 474)

472) Are you still breastfeeding (NAME)?

YES 1
NO 2

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

YES 1
NO 2
DON’T KNOW 8

474) GO BACK TO 405 IN NEXT COLUMN, OR, IF NO MORE BIRTHS, GO TO 501A.

SECTION 5A. CHILD IMMUNIZATION (LAST BIRTH)

501A) CHECK 215 IN THE BIRTH HISTORY: ANY BIRTHS SINCE JANUARY 2012?

ONE OR MORE BIRTHS SINCE JANUARY 2012_____
NO BIRTHS SINCE JANUARY 2012___

502A) RECORD THE NAME AND BIRTH HISTORY NUMBER FROM 212 OF THE LAST CHILD BORN SINCE JANUARY 2012.

NAME OF LAST BIRTH ______
BIRTH HISTORY NUMBER_____

503A) CHECK 216 FOR CHILD:

LIVING ___
DEAD __(GO TO 501B)

504A) Do you have a card or other document where (NAME)’s vaccination are written down?

YES, HAS ONLY A CARD 1 (GO TO 507A)
YES, HAS ONLY AN OTHER DOCUMENT 2
YES, HAS CARD AND OTHER DOCUMENT 3 (GO TO 507A)
NO, NO CARD AND NO OTHER DOCUMENT 4

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

YES 1
NO 2

506A) CHECK 504A:

CODE ‘2’ CIRCLED_____
CODE ‘4’ CIRCLED ________ (GO TO 511A)

507A) May I see the card or other document where (NAME)’s vaccination are written down?

YES, ONLY CARD SEEN 1
YES, ONLY OTHER DOCUMENT SEEN 2
YES, CARD AND OTHER DOCUMENT SEEN 3
NO CARD AND NO OTHER DOCUMENT SEEN 4 (GO TO 511A)

508A) COPY THE DATES FROM THE CARD
WRITE ‘44’ IN ‘DAY’ COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED

AT BIRTH

POLIO:
DAY_
MONTH_
YEAR_
BCG:
DAY_
MONTH_
YEAR_
HEPATITIS B:
DAY_
MONTH_
YEAR_

AT TWO MONTHS

POLIO 1:
DAY_
MONTH_
YEAR_
PENTAVALENT 1:
DAY_
MONTH_
YEAR_
PNEUMOCOCCAL 1:
DAY_
MONTH_
YEAR_
ROTAVIRUS 1:
DAY_
MONTH_
YEAR_

AT FOUR MONTHS

POLIO 2:
DAY_
MONTH_
YEAR_
PENTAVALENT 2:
DAY_
MONTH_
YEAR_
PNEUMOCOCCAL 2:
DAY_
MONTH_
YEAR_
ROTAVIRUS 2:
DAY_
MONTH_
YEAR_

AT SIX MONTHS

POLIO 3:
DAY_
MONTH_
YEAR_
PENTAVALENT 3:
DAY_
MONTH_
YEAR_
PNEUMOCOCCAL 3:
DAY_
MONTH_
YEAR_
VITAMIN A 1:
DAY_
MONTH_
YEAR_

AT NINE MONTHS (15 MONTHS FOR MEASLES)

MEASLES 1:
DAY_
MONTH_
YEAR_
YELLOW FEVER ONLY DOSE:
DAY_
MONTH_
YEAR_
VITAMIN A 2:
DAY_
MONTH_
YEAR_
MEASLES 2:
DAY_
MONTH_
YEAR_

509A) CHECK 508A: ALL VACCINES FROM ‘POLIO’ TO ‘MEASLES’ 2 RECORDED?

NO___
YES ___(GO TO 526A)

510A) In addition to what is recorded on (this document/these documents), did (NAME) receive any other vaccinations, including vaccinations received in campaigns or immunization days or child health days?
RECORD ‘YES’ ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 508A THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

YES 1 (PROBE FOR VACCINATIONS AND WRITE ‘66’ IN THE CORRESPONDING DAY COLUMN 508A) (GO TO 526A)
NO 2 (GO 526A)
DON’T KNOW 8 (GO 526A)

511A) Did (NAME) ever receive any vaccinations to prevent (NAME) from getting diseases, including vaccinations received in campaigns or immunization days or child health days?

YES 1
NO 2 (GO 526A)
DON’T KNOW 8 (GO 526A)

512A) Has (NAME) ever received 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

513A) Within 24 hours after birth, did (NAME) receive a Hepatitis B vaccination, that is, an injection in the thigh to prevent Hepatitis B?

YES 1
NO 2
DON’T KNOW 8

514A) Has (NAME) received oral polio vaccines, that is, about two drops in the mouth to prevent polio?

YES 1
NO 2 (GO TO 517A)
DON’T KNOW 8 (GO TO 517A)

515A) Did (NAME) receive the first oral polio vaccine in the first two weeks after birth or later?

FIRST TWO WEEKS 1
LATER 2

516A) How many times did (NAME) receive the oral polio vaccine?

NUMBER OF TIMES____

517A) Has (NAME) ever received a pentavalent vaccination, that is, an injection given in the thigh sometimes at the same time as polio drops?

YES 1
NO 2 (GO TO 519A)
DON’T KNOW 8 (GO TO 519A)

518A) How many times did (NAME) receive the pentavalent vaccine?

NUMBER OF TIMES____

519A) Has (NAME) ever received a pneumococcal vaccination, that is an injection in the thigh to prevent pneumonia?

YES 1
NO 2 (GO TO 521A)
DON’T KNOW 8 (GO TO 521A)

520A) How many times did (NAME) receive the pneumococcal vaccine?

NUMBER OF TIMES____

521A) Has (NAME) ever received a rotavirus vaccination, that is liquid in the mouth to prevent diarrhea?

YES 1
NO 2 (GO TO 523A)
DON’T KNOW 8 (GO TO 523A)

522A) How many times did (NAME) receive the rotavirus vaccine?

NUMBER OF TIMES____

523A) Has (NAME) ever received a measles vaccination, that is, an injection in the arm to prevent measles?

YES 1
NO 2 (GO TO 526A)
DON’T KNOW 8 (GO TO 526A)

524A) How many times did (NAME) receive the measles vaccine?

NUMBER OF TIMES____

525A) Has (NAME) ever received a yellow fever vaccination?

YES 1
NO 2
DON’T KNOW 8

526A) In the last seven days, was (NAME) given:

Ferrous sulfate like this (SHOW IMAGES OF PILLS OR VIAL)?
Pill for intestinal worms (SHOW IMAGES OF PILLS)?
Any nutritional supplement with whole food formula?

FERROUS SULFATE
YES 1
NO 2
DON’T KNOW 8
PILL FOR INTESTINAL WORMS
YES 1
NO 2
DON’T KNOW 8
NUTRITIONAL SUPPLEMENT
YES 1
NO 2
DON’T KNOW 8

527A) CONTINUE WITH 501B.

SECTION 5B. CHILD IMMUNIZATION (NEXT-TO-LAST BIRTH)

501B) CHECK 215 IN THE BIRTH HISTORY: ANY BIRTHS SINCE JANUARY 2012?

ONE OR MORE BIRTHS SINCE JANUARY 2012_____
NO BIRTHS SINCE JANUARY 2012___ (GO TO 601)

502B) RECORD THE NAME AND BIRTH HISTORY NUMBER FROM 212 OF THE LAST CHILD BORN SINCE JANUARY 2012.

NAME OF LAST BIRTH ______
BIRTH HISTORY NUMBER_____

503B) CHECK 216 FOR CHILD:

LIVING ___
DEAD __ (GO TO 527B)

504B) Do you have a card or other document where (NAME)’s vaccination are written down?

YES, HAS ONLY A CARD 1 (GO TO 507B)
YES, HAS ONLY AN OTHER DOCUMENT 2
YES, HAS CARD AND OTHER DOCUMENT 3 (GO TO 507B)
NO, NO CARD AND NO OTHER DOCUMENT 4

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

YES 1
NO 2

506B) CHECK 504B:

CODE ‘2’ CIRCLED_____
CODE ‘4’ CIRCLED ________ (GO TO 511B)

507B) May I see the card or other document where (NAME)’s vaccination are written down?

YES, ONLY CARD SEEN 1
YES, ONLY OTHER DOCUMENT SEEN 2
YES, CARD AND OTHER DOCUMENT SEEN 3
NO CARD AND NO OTHER DOCUMENT SEEN 4 (GO TO 511B)

508B) COPY THE DATES FROM THE CARD
WRITE ‘44’ IN ‘DAY’ COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED

AT BIRTH

POLIO:
DAY_
MONTH_
YEAR_
BCG:
DAY_
MONTH_
YEAR_
HEPATITIS B:
DAY_
MONTH_
YEAR_

AT TWO MONTHS

POLIO 1:
DAY_
MONTH_
YEAR_
PENTAVALENT 1:
DAY_
MONTH_
YEAR_
PNEUMOCOCCAL 1:
DAY_
MONTH_
YEAR_
ROTAVIRUS 1:
DAY_
MONTH_
YEAR_

AT FOUR MONTHS

POLIO 2:
DAY_
MONTH_
YEAR_
PENTAVALENT 2:
DAY_
MONTH_
YEAR_
PNEUMOCOCCAL 2:
DAY_
MONTH_
YEAR_
ROTAVIRUS 2:
DAY_
MONTH_
YEAR_

AT SIX MONTHS

POLIO 3:
DAY_
MONTH_
YEAR_
PENTAVALENT 3:
DAY_
MONTH_
YEAR_
PNEUMOCOCCAL 3:
DAY_
MONTH_
YEAR_
VITAMIN A 1:
DAY_
MONTH_
YEAR_

AT NINE MONTHS (15 MONTHS FOR MEASLES)

MEASLES 1:
DAY_
MONTH_
YEAR_
YELLOW FEVER ONLY DOSE:
DAY_
MONTH_
YEAR_
VITAMIN A 2:
DAY_
MONTH_
YEAR_
MEASLES 2:
DAY_
MONTH_
YEAR_

509B) CHECK 508B: ALL VACCINES FROM ‘POLIO’ TO ‘MEASLES’ 2 RECORDED?

NO___
YES ___ (GO TO 526B)

510B) In addition to what is recorded on (this document/these documents), did (NAME) receive any other vaccinations, including vaccinations received in campaigns or immunization days or child health days?

RECORD ‘YES’ ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 508A THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

YES 1 (PROBE FOR VACCINATIONS AND WRITE ‘66’ IN THE CORRESPONDING DAY COLUMN 508B) (GO TO 526B)
NO 2 (GO 526B)
DON’T KNOW 8 (GO 526B)

511B) Did (NAME) ever receive any vaccinations to prevent (NAME) from getting diseases, including vaccinations received in campaigns or immunization days or child health days?

YES 1
NO 2 (GO 526B)
DON’T KNOW 8 (GO 526B)

512B) Has (NAME) ever received 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

513B) Within 24 hours after birth, did (NAME) receive a Hepatitis B vaccination, that is, an injection in the thigh to prevent Hepatitis B?

YES 1
NO 2
DON’T KNOW 8

514B) Has (NAME) received oral polio vaccines, that is, about two drops in the mouth to prevent polio?

YES 1
NO 2 (GO TO 517B)
DON’T KNOW 8 (GO TO 517B)

515B) Did (NAME) receive the first oral polio vaccine in the first two weeks after birth or later?

FIRST TWO WEEKS 1
LATER 2

516B) How many times did (NAME) receive the oral polio vaccine?

NUMBER OF TIMES____

517B) Has (NAME) ever received a pentavalent vaccination, that is, an injection given in the thigh sometimes at the same time as polio drops?

YES 1
NO 2 (GO TO 519B)
DON’T KNOW 8 (GO TO 519B)

518B) How many times did (NAME) receive the pentavalent vaccine?

NUMBER OF TIMES____

519B) Has (NAME) ever received a pneumococcal vaccination, that is an injection in the thigh to prevent pneumonia?

YES 1
NO 2 (GO TO 521B)
DON’T KNOW 8 (GO TO 521B)

520B) How many times did (NAME) receive the pneumococcal vaccine?

NUMBER OF TIMES____

521B) Has (NAME) ever received a rotavirus vaccination, that is liquid in the mouth to prevent diarrhea?

YES 1
NO 2 (GO TO 523B)
DON’T KNOW 8 (GO TO 523B)

522B) How many times did (NAME) receive the rotavirus vaccine?

NUMBER OF TIMES____

523B) Has (NAME) ever received a measles vaccination, that is, an injection in the arm to prevent measles?

YES 1
NO 2 (GO TO 526B)
DON’T KNOW 8 (GO TO 526B)

524B) How many times did (NAME) receive the measles vaccine?

NUMBER OF TIMES____

525B) Has (NAME) ever received a yellow fever vaccination?

YES 1
NO 2
DON’T KNOW 8

526B) In the last seven days, was (NAME) given:

Ferrous sulfate like this (SHOW IMAGES OF PILLS OR VIAL)?
Pill for intestinal worms (SHOW IMAGES OF PILLS)?
Any nutritional supplement with whole food formula?

FERROUS SULFATE
YES 1
NO 2
DON’T KNOW 8
PILL FOR INTESTINAL WORMS
YES 1
NO 2
DON’T KNOW 8
NUTRITIONAL SUPPLEMENT
YES 1
NO 2
DON’T KNOW 8

527B) CHECK 215 IN BIRTH HISTORY: ANY MORE BIRTHS SINCE JANUARY 2012?

MORE BIRTHS SINCE JANUARY 2012 _____ (GO TO 502B IN AN ADDITIONAL QUESTIONNAIRE)
NO MORE BIRTHS SINCE JANUARY 2012___ (GO TO 601)

SECTION 6. CHILD HEALTH AND NUTRITION

601) CHECK 224:

ONE OR MORE BIRTHS SINCE JANUARY 2010_____
NO BIRTHS SINCE JANUARY 2010___ (GO TO 649)

602) CHECK 215: RECORD THE BIRTH HISTORY NUMBER IN 603 AND THE NAME AND SURVIVAL STATUS IN 604 FOR EACH BIRTH SINCE JANUARY 2010. ASK THE QUESTIONS ABOUT ALL THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
IF THERE ARE MORE THAN 2 BIRTHS USE THE LAST COLUMN OF ADDITIONAL QUESTIONNAIRE
Now I would like to ask some questions about your children born in the last five years. (we will talk about each separately).

603) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

BIRTH HISTORY NUMBER__

604) FROM 212 AND 216:

NAME___
LIVING___
DEAD ___(GO TO 647)

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

YES 1
NO 2 (GO TO 615)
DON’T KNOW 8 (GO TO 615)

606) CHECK 466: WAS (NAME) EVER BREASTFEED?

YES: Now I would like to know how much (NAME) was given to drink during the diarrhea including breastmilk. Was (NAME) given less than usual to drink, about the same amount or more than usual to drink? IF LESS PROBE: Was she/he given much less than usual to drink or somewhat less?
MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON’T KNOW 8
NO: Now I would like to know how much (NAME) was given to drink during the diarrhea. Was (NAME) given less than usual to drink, about the same amount or more than usual to drink? IF LESS PROBE: Was she/he given much less than usual to drink or somewhat less?
MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON’T KNOW 8

607) 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 she/he given much less than usual to eat or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON’T KNOW 8

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

YES 1
NO 2 (GO TO 612)

SECTION 6. CHILD HEALTH AND NUTRITION

609) Where did you seek advice or treatment?
Anywhere else?

PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
CENTRAL HOSPITAL A
HOSPITAL IN PROVINCE B
HOSPITAL IN RURAL AREA C
HEALTH CENTER/POST D
MOBILE CLINIC E
OTHER PUBLIC SECTOR: (SPECIFY)____ F
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL G
PHARMACY H
HEALTH CENTER/POST I
OTHER PRIVATE MEDICAL SECTOR: (SPECIFY)____J
OTHER SOURCE
TRADITIONAL PRACTITIONER K
MARKET L
OTHER: (SPECIFY) ______ X

610) CHECK 609:

TWO OR MORE CODES CIRCLED ____
ONLY ONE CODE CIRCLED ___(GO TO 612)

611) Where did you first seek advice or treatment?
USE LETTER CODE FROM 609.

FIRST PLACE_____

612) Was (NAME) given any of the following to drink at any time since (NAME) started having the diarrhea:

a) A fluid made from a special packet called Oral Rehydration Salts (ORS)?
b) A pre-packaged ORS liquid?
c) A homemade sugar-salt-water solution?
d) Iron tablets or syrup?
e) Rice water?

A) FLUID FROM ORS PACKET
YES 1
NO 2
DON’T KNOW 8
B) ORS LIQUID
YES 1
NO 2
DON’T KNOW 8
C) HOMEMADE FLUID
YES 1
NO 2
DON’T KNOW 8
D) IRON
YES 1
NO 2
DON’T KNOW 8
E) RICE WATER
YES 1
NO 2
DON’T KNOW 8

613) CHECK 612:

ANY ‘YES’: What else was given to treat diarrhea?
YES 1
NO 2 (GO TO 615)
DON’T KNOW 8 (GO TO 615)
ALL ‘NO’ OR ‘DK’: What was given to treat diarrhea?
YES 1
NO 2 (GO TO 615)
DON’T KNOW 8 (GO TO 615)

614. CHECK 612:

ANY ‘YES’: What else was given to treat diarrhea? Anything else? RECORD ALL TREATMENTS GIVEN
PILLS OR SYRUP
ANTIBIOTIC A
ANTIMOTILITY B
OTHER (NO ANTIBIOTIC OR ANTIMOTILITY) C
UNKNOWN PILL OR SYRUP D
INJECTION
ANTIBIOTIC E
ANTIMOTILITY F
UNKNOWN INJECTION G
(I.V) INTRAVENOUS H
HOME REMEDIES/HERBAL MEDICINES I
OTHER: (SPECIFY) ______ X
ALL ‘NO’ OR ‘DON’T KNOW’: What was given to treat diarrhea? Anything else?
RECORD ALL TREATMENTS GIVEN
PILLS OR SYRUP
ANTIBIOTIC A
ANTIMOTILITY B
OTHER (NO ANTIBIOTIC OR ANTIMOTILITY) C
UNKNOWN PILL OR SYRUP D
INJECTION
ANTIBIOTIC E
ANTIMOTILITY F
UNKNOWN INJECTION G
(I.V) INTRAVENOUS H
HOME REMEDIES/HERBAL MEDICINES I
OTHER: (SPECIFY) ______ X

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

YES 1
NO 2 (GO TO 639)
DON’T KNOW 8 (GO TO 639)

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

YES 1
NO 2
DON’T KNOW 8

617) Did you seek advice or treatment at that time?

YES 1
NO 2 (GO TO 622)

618) Where did you seek advice or treatment?
Anywhere else?

PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
CENTRAL HOSPITAL A
HOSPITAL IN PROVINCE B
HOSPITAL IN RURAL AREA C
HEALTH CENTER/POST D
MOBILE CLINIC E
OTHER PUBLIC SECTOR: (SPECIFY)____ F
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL G
PHARMACY H
HEALTH CENTER/POST I
OTHER PRIVATE MEDICAL SECTOR: (SPECIFY)____J
OTHER SOURCE
TRADITIONAL PRACTITIONER K
OTHER: (SPECIFY) ______ X

619) CHECK 618:

TWO OR MORE CODES CIRCLED ____
ONLY ONE CODE CIRCLED ___(GO TO 621)

620) Where did you first seek advice or treatment?
USE LETTER CODE FROM 618.

FIRST PLACE_____

621) How many days after the illness began did you first seek advice or treatment for (NAME)?
IF THE SAME DAY RECORD ‘00’

DAYS___

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

YES 1
NO 2 (GO TO 639)
DON’T KNOW 8 (GO TO 639)

623) What drugs did (NAME) take?
Any other drugs?
RECORD ALL MENTIONED

ANTIMALARIAN DRUGS
ARTEMISININ COMBINATION THERAPY (ACT) A
SP/FANSIDAR B
CHLOROQUINE C
AMODIAQUINE D
QUININE PILLS E
INJECTION/IV F
COARTEM G
OTHER ANTIMALARIAN: (SPECIFY)___H
ANTIBIOTIC DRUGS
SYRUP I
INJECTION/IV J
OTHER DRUGS
ASPIRIN K
ACETAMINOPHEN L
IBUPROFEN M
OTHER: (SPECIFY)___X
DON’T KNOW Z

624) CHECK 623: ANY CODE A-H CIRCLED?

YES____
NO___ (GO TO 639)

625) CHECK 623: ARTEMISININ COMBINATION THERAPY (‘A’) GIVEN

CODE ‘A’ CIRCLED____
CODE ‘A’ NOR CIRCLED___ (GO TO 627)

626) How long after the fever started did (NAME) first take combination with artemisinin (ACT)?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER 3
DON’T KNOW 8

627) CHECK 623: SP/FANSIDAR (‘B’) GIVEN

CODE ‘B’ CIRCLED__
CODE ‘B’ NOT CIRCLED___ (GO TO 629)

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

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER 3
DON’T KNOW 8

629) CHECK 623:
CHLOROQUINE (‘C’) GIVEN

CODE ‘C’ CIRCLED__
CODE ‘C’ NOT CIRCLED___ (GO TO 631)

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

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER 3
DON’T KNOW 8

631) CHECK 623:
AMODIAQUINE (‘D’) GIVEN

CODE ‘D’ CIRCLED__
CODE ‘D’ NOT CIRCLED___ (GO TO 633)

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

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER 3
DON’T KNOW 8

633) CHECK 623:
QUININE (‘E’ OR ‘F’) GIVEN

CODE ‘E’ OR ‘F’ CIRCLED__
CODE ‘E’ OR ‘F’ NOT CIRCLED___ (GO TO 635)

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

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER 3
DON’T KNOW 8

635) CHECK 623:
COARTEM (‘G’) GIVEN

CODE ‘G’ CIRCLED__
CODE ‘G’ NOT CIRCLED___ (GO TO 637)

636) How long after the fever started did (NAME) first take coartem?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER 3
DON’T KNOW 8

637) CHECK 623:
OTHER ANTIMALARIAL (‘H’) GIVEN

CODE ‘H’ CIRCLED__
CODE ‘H’ NOT CIRCLED___ (GO TO 639)

638) How long after the fever started did (NAME) first take other antimalarial?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER 3
DON’T KNOW 8

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

YES 1
NO 2
DON’T KNOW 8

640) In the last 2 weeks did (NAME) breathe faster than usual with short, rapid breaths or have difficulty breathing?

YES 1
NO 2 (GO TO 642)
DON’T KNOW 8 (GO TO 642)

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

CHEST ONLY 1
NOSE ONLY 2
BOTH 3
OTHER: (SPECIFY) ______ 6
DON’T KNOW 8

642) CHECK 639:
HAD A COUGH?

YES____
NO OR DON’T KNOW ___(GO TO 647)

643) Did you seek advice or treatment at that time when (NAME) had a cough?

YES 1
NO 2 (GO TO 645)

644) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
CENTRAL HOSPITAL A
HOSPITAL IN PROVINCE B
HOSPITAL IN RURAL AREA C
HEALTH CENTER/POST D
MOBILE CLINIC E
OTHER PUBLIC SECTOR: (SPECIFY)____ F
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL G
PHARMACY H
HEALTH CENTER/POST I
OTHER PRIVATE MEDICAL SECTOR: (SPECIFY)____J
OTHER SOURCE
TRADITIONAL PRACTITIONER K
OTHER: (SPECIFY) ______ X

645) At any time during the illness with the cough, did (NAME) take any drugs for the illness?

YES 1
NO 2 (GO TO 647)
DON’T KNOW 8

646) What drugs did (NAME) take?
Any other drugs?
RECORD ALL MENTIONED

ANTIMALARIAN DRUG A
ANTIBIOTIC DRUGS
PILLS B
SYRUP C
INJECTION/IV D
OTHER DRUGS
ASPIRIN E
ACETAMINOPHEN F
IBUPROFEN G
OTHER: (SPECIFY)___X

647)
GO BACK TO 604 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 648.

648. CHECK 612(a) AND 612(b), ALL COLUMNS:

NO CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID___
ANY CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID___ (GO TO 650)

649) Have you ever heard of a special product called (Oral Rehydration Salts) or a pre-packaged ORS liquid you can get for the treatment of diarrhea?

YES 1
NO 2

650) CHECK 215 AND 218, ALL ROWS: NUMBER OF CHILDREN BORN SINCE JANUARY 2013 LIVING WITH THE RESPONDENT

ONE OR MORE____(NAME OF YOUNGEST CHILD LIVING WITH HER)
NONE___ (GO TO 701)

651) Now I would like to ask you about liquids or foods (NAME FROM Q. 649) 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 649) (drink/eat):

A) PLAIN WATER?
YES 1
NO 2
DON’T KNOW 8
B) JUICE OR JUICE DRINKS?
YES 1
NO 2
DON’T KNOW 8
C) CLEAR BROTH?
YES 1
NO 2
DON’T KNOW 8
D) MILK SUCH AS TINNED, POWDERED OR FRESH ANIMAL MILK?
YES 1
NO 2
DON’T KNOW 8
IF YES: How many times did (NAME) drink milk?
IF 7 OR MORE TIMES, RECORD ‘7’
NUMBER OF TIMES DRANK MILK___
E) INFANT FORMULA?
YES 1
NO 2
DON’T KNOW 8
IF YES: How many times did (NAME) drink infant formula?
IF 7 OR MORE TIMES, RECORD ‘7’
NUMBER OF TIMES DRANK INFANT FORMULA ___
F) ANY OTHER LIQUIDS?
YES 1
NO 2
DON’T KNOW 8
G) YOGURT?
YES 1
NO 2
DON’T KNOW 8
IF YES: How many times did (NAME) eat yogurt?
IF 7 OR MORE TIMES, RECORD ‘7’
NUMBER OF TIMES ATE YOGURT___
H) ANY CERELAC?
YES 1
NO 2
DON’T KNOW 8
I) RICE, CORN, WHEAT, NOODLES, OR OTHER FOODS MADE FROM GRAINS?
YES 1
NO 2
DON’T KNOW 8
J) SQUASH, CARROTS, OR SWEET POTATOES THAT ARE YELLOW OR ORANGE INSIDE?
YES 1
NO 2
DON’T KNOW 8
K) WHITE POTATOES, WHITE YAMS, MANIOC, CASSAVA, OR ANY OTHER FOODS MADE FROM ROOTS?
YES 1
NO 2
DON’T KNOW 8
L) ANY DARK GREEN, LEAFY VEGETABLES?
YES 1
NO 2
DON’T KNOW 8
M) RIPE MANGOES OR PAPAYAS?
YES 1
NO 2
DON’T KNOW 8
N) ANY OTHER FRUITS OR VEGETABLES (RIPE BANANA, APPLE, TOMATO, LIMES, ORANGE, TANGERINE, GUAVA, GRAPES, CAULIFLOWER)?
YES 1
NO 2
DON’T KNOW 8
O) LIVER, KIDNEY, HEART OR OTHER ORGAN MEATS?
YES 1
NO 2
DON’T KNOW 8
P) ANY MEAT, SUCH AS BEEF, PORK, LAMB, GOAT, CHICKEN, OR DUCK?
YES 1
NO 2
DON’T KNOW 8
Q) EGGS?
YES 1
NO 2
DON’T KNOW 8
R) FRESH OR DRIED FISH OR SHELLFISH?
YES 1
NO 2
DON’T KNOW 8
S) ANY FOODS MADE FROM BEANS, PEAS, LENTILS, OR NUTS?
YES 1
NO 2
DON’T KNOW 8
T) CHEESE, YOGURT OR OTHER MILK PRODUCTS?
YES 1
NO 2
DON’T KNOW 8
U) PALM OIL, ANY OILS, FATS OR BUTTER, OR FOODS MADE WITH ANY OF THESE?
YES 1
NO 2
DON’T KNOW 8
V) ANY OTHER SOLID OR SEMI-SOLID FOOD?
YES 1
NO 2
DON’T KNOW 8

652) CHECK 651 (CATEGORIES "g" THROUGH "v")

AT LEAST ONE ‘YES’_____
NOT A SINGLE ‘YES’_______ (GO TO 654)

653) Did (NAME FROM 649) 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 FROM 649) eat?

YES 1 (GO BACK TO 651 TO RECORD FOOD EATEN YESTERDAY) (THEN CONTINUE TO 654)
NO 2 (GO TO 655)

654) How many times did (NAME FROM 649) eat solid, semisolid or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD ‘7’.

NUMBER OF TIMES____
DON’T KNOW 8

655) The last time (NAME FROM 649) passed stools, what was done to dispose of the stools?

CHILD USED TOILET OR LATRINE 01
PUT/RINSED INTO TOILET OR LATRINE 02
THROWN INTO GARBAGE 03
THROWN INTO YARD 04
BURIED IN YARD 05
LEFT IN THE OPEN 06
OTHER: (SPECIFY)___96

SECTION 7. MARRIAGE AND SEXUAL ACTIVITY

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

YES, CURRENTLY MARRIED 1 (GO TO 704)
YES, LIVING WITH A MAN 2 (GO TO 704)
NO, NOT IN UNION 3

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

YES, FORMERLY MARRIED 1
YES, LIVED WITH A MAN 2
NO 3 GO (712)

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

WIDOWED 1 (GO TO 709)
DIVORCED 2 (GO TO 709)
SEPARATED 3 (GO TO 709)

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

LIVES WITH HER 1
STAYING ELSEWHERE 2

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

NAME_________
LINE NUMBER________

706) Does your husband/partner have any other wives or does he live with other women as if married?

YES 1
NO 2 (GO TO 709)
DON’T KNOW 8 (GO TO 709)

707) Including yourself, in total, how many other wives or partners does your husband live with now as if married?

TOTAL NUMBER OF WIVES AND LIVE-IN PARTNERS_____
DON’T KNOW 98

708) Are you the first, second… wife?

RANK_______

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

ONCE 1
MORE THAN ONCE 2

710) CHECK 709:

MARRIED/LIVED WITH A MAN ONLY ONCE: In what month and year did you start living with your husband/partner?
MONTH_____
DON’T KNOW MONTH 98
YEAR_____(GO TO 712)
DON’T KNOW YEAR 9998
MARRIED/LIVED WITH A MAN MORE THAN ONCE: Now we will talk about your first husband/partner. In what month and year did you start living with your husband/partner?
MONTH_____
DON’T KNOW MONTH 98
YEAR_____(GO TO 712)
DON’T KNOW YEAR 9998

711) How old were you when you started living with him?

AGE_______

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

713) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues. 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.
How old were you when you had sexual intercourse for the very first time?

NEVER HAD SEXUAL INTERCOURSE 00 (GO TO 731)
AGE IN YEARS ______

714) Now I would like to ask some questions about your recent sexual activity.
When was the last time you had sexual intercourse?

IF ANSWER IS IN LESS THAN 12 MONTHS, RECORD IN DAYS, WEEKS OR MONTHS. IF IS 12 OR MORE MONTHS RECORD IN YEARS.

DAYS AGO 1____ (GO TO 716)
WEEKS AGO 2___(GO TO 716)
MONTHS AGO 3____ (GO TO 716)
YEARS AGO 4_____ (GO TO 727)

715) When was the last time you had sexual intercourse with this person?

DAYS 1 ____
WEEKS 2_____
MONTHS 3____

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

YES 1
NO 2 (GO 718)

717) Did you use a condom every time you had sexual intercourse with this person in the last 12 months?

YES 1
NO 2

718) 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’

HUSBAND 1
LIVE-IN PARTNER 2
BOYFRIEND NOT LIVING WITH RESPONDENT 3
CASUAL ACQUAINTANCE 4
CLIENT/SEX WORKER 5
OTHER: (SPECIFY)_____ 6

719) How long ago did your first have sexual intercourse with this person?

DAYS AGO 1 __
WEEKS AGO 2 __
MONTHS AGO 3 __
YEARS AGO 4 __

720) 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’

NUMBER OF TIMES__

721) How old is this person?

AGE OF PARTNER______
DON’T KNOW 98

722) Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?

YES 1 (GO BACK TO 715 IN NEXT COLUMN)
NO 2 (GO TO 724)

723) 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 TIMES IS 95 OR MORE, WRITE ‘95’

NUMBER OF PARTNERS LAST 12 MONTHS___
DON’T KNOW 98

724) CHECK 106:

AGE 15-24___
AGE 25-49 __(GO TO 727)

725) CHECK 701:

NOT IN A UNION___
CURRENTLY MARRIED/LIVING WITH A MAN____(GO TO 727)

726) In the past 12 months have you had sex or been sexually involved with anyone because he gave you or told you he would give you gifts, cash, or anything else?

YES 1
NO 2

727) 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 GREATER THAN 95, WRITE ‘95’

NUMBER OF PARTNERS IN LIFETIME_____
DON’T KNOW 98

728) CHECK 716, MOST RECENT PARTNER (FIRST COLUMN):

YES, CONDOM USED ___
NO CONDOM NOT USED___ (GO TO 731)
NOT ASKED___ (GO TO 731)

729) You told me that a condom was used the last time you had sex. What is the brand name of the condom used at that time?
IF BRAND NOR KNOWN, ASK TO SEE THE PACKAGE

BILLY BOY 01 [ALL BRAND NAMES]
CONDOMI 02
CONTROL 03
DUREX 04
HARMONY 05
KAMA SUTRA 06
LEGAL 07
PRUDENCE 08
ROCK 09
SENSUAL 10
OTHER (SPECIFY)____96
DON’T KNOW 98

730) From where did you obtain the condom last time?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
CENTRAL HOSPITAL 11
HOSPITAL IN PROVINCE 12
HOSPITAL IN RURAL AREA 13
HEALTH CENTER 14
MATERNITY WARD 15
MOBILE CLINIC 16
OTHER: (SPECIFY)____ 17
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC 21
HEALTH CENTER 22
PHARMACY 23
OTHER: (SPECIFY)____26
OTHER SOURCE
MARKET/STORE 31
CHURCH 32
FRIEND/RELATIVE 33
NGOs 34
OTHER: (SPECIFY)____96
DON’T KNOW 98

731) PRESENCE OF OTHERS DURING THIS SECTION

CHILDREN UNDER 10
YES 1
NO 2
MALE ADULTS
YES 1
NO 2
FEMALE ADULTS
YES 1
NO 2

SECTION 8. FERTILITY PREFERENCES

801) CHECK 304:

NEITHER STERILIZED _____
HE OR SHE STERILIZED ______ (GO TO 813)

802) CHECK 226:

PREGNANT_____ (GO TO NEXT QUESTION)
NOT PREGNANT OR UNSURE _____ (GO TO 804)

803) 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?

HAVE ANOTHER CHILD 1 (GO TO 805)
NO MORE 2 (GO 812)
UNDECIDED/DON’T KNOW 8 (GO TO 812)

804. 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?

HAVE (A/ANOTHER) CHILD 1
NO MORE 2 (GO TO 807)
SAYS SHE CAN’T GET PREGNANT 3 (GO TO 813)
UNDECIDED/DON’T KNOW (GO TO 811)

805) CHECK 226:

NOT PREGNANT OR UNSURE: How long would you like to wait from now before the birth of (a/another) child?
MONTHS____ 1
YEARS____ 2
SOON/NOW 993 (GO TO 811)
SAYS SHE CAN’T GET PREGNANT 994 (GO TO 813)
AFTER MARRIAGE 995 (GO TO 811)
OTHER: (SPECIFY) ______ 996 (GO TO 811)
DON’T KNOW 998 (GO TO 811)
PREGNANT: After the child you are expecting now, how long would you like to wait from now before the birth of another child?
MONTHS____ 1
YEARS____ 2
SOON/NOW 993 (GO TO 811)
SAYS SHE CAN’T GET PREGNANT 994 (GO TO 813)
AFTER MARRIAGE 995 (GO TO 811)
OTHER: (SPECIFY) ______ 996 (GO TO 811)
DON’T KNOW 998 (GO TO 811)

806) CHECK 226:

NOT PREGNANT OR UNSURE _____
PREGNANT_____ (GO TO 812)

807) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT CURRENTLY USING ______
CURRENTLY USING ____ (GO TO 813)

808) CHECK 805:

NOT ASKED_____
‘24’ OR MORE MONTHS OR ‘02’ OR MORE YEARS _____
‘00-23’ MONTHS OR ‘00-01’ YEAR______ (GO TO 812)

809) CHECK 714:

DAYS, WEEKS OR MONTHS AGO___
YEARS AGO___ (GO TO 811)
NOT ASKED___ (GO TO 811)

810) CHECK 804:

WANTS TO HAVE ANOTHER CHILD: You have said that you do not want (a/another) child soon, but you are not using any method to avoid pregnancy.
Can you tell me why you are not using a method?
Any other reason? RECORD ALL REASONS MENTIONED.
NOT MARRIED/HAS NOT PARTNER A
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
INFECUND/STERILE E
CAN’T GET PREGNANT NOT MENSTRUATED SINCE LAST BIRTH F
BREASTFEEDING G
UP TO GOD/FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
HEALTH CONCERNS/SIDE EFFECTS O
LACK OF ACCESS/TOO FAR P
COST TOO MUCH Q
PREFERRED METHOD NOT AVAILABLE R
NO METHOD AVAILABLE S
INCONVENIENT TO USE T
INTERFERES WITH BODY’S NORMAL PROCESSES U
OTHER: (SPECIFY) ______X
DON’T KNOW Z
WANTS NO MORE/NONE: You have said that you do not want any (more) child, but you are not using any method to avoid pregnancy.
Can you tell me why you are not using a method?
Any other reason? RECORD ALL REASONS MENTIONED.
NOT MARRIED/HAS NOT PARTNER A
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
INFECUND/STERILE E
CAN’T GET PREGNANT NOT MENSTRUATED SINCE LAST BIRTH F
BREASTFEEDING G
UP TO GOD/FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
HEALTH CONCERNS/SIDE EFFECTS O
LACK OF ACCESS/TOO FAR P
COST TOO MUCH Q
PREFERRED METHOD NOT AVAILABLE R
NO METHOD AVAILABLE S
INCONVENIENT TO USE T
INTERFERES WITH BODY’S NORMAL PROCESSES U
OTHER: (SPECIFY) ______X
DON’T KNOW Z

811) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT ASKED____
NOT CURRENTLY USING ______
CURRENTLY USING ____ (GO TO 813)

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

YES 1
NO 2
DON’T KNOW 8

813) 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? PROBE FOR A NUMERIC RESPONSE
NONE 00 (GO TO 815)
NUMBER____
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 A NUMERIC RESPONSE
NONE 00 (GO TO 815)
NUMBER____

814) How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter?

NUMBER BOYS ____
NUMBER GIRLS _____
NUMBER EITHER ____

815) In the last 6 months have you:

a) Heard about family planning on the radio?
b) Seen about family planning on the television?
c) Read about family planning in a newspaper or magazine?
d) Received a voice or text message about family planning on a mobile phone?
e) Read about family planning from a poster?
f) Read about family planning from leaflets or brochures?

A) RADIO
YES 1
NO 2
B) TELEVISION
YES 1
NO 2
C) NEWSPAPER OR MAGAZINE
YES 1
NO 2
D) MOBILE PHONE
YES 1
NO 2
E) POSTER
YES 1
NO 2
F) LEAFLETS OR BROCHURES
YES 1
NO 2

816) CHECK 701:

YES, CURRENTLY MARRIED_____
YES, LIVING WITH A MAN_____
NO, NOT IN UNION_____ (GO TO 901)

817) CHECK 304:

NEITHER STERILIZED _____
HE OR SHE STERILIZED ______ (GO TO 901)

818) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT CURRENTLY USING ______
CURRENTLY USING ____ (GO TO 820)
NOT ASKED ___ (GO TO 820)

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

MAINLY RESPONDENT 1 (GO TO 821)
MAINLY HUSBAND/PARTNER 1 (GO TO 821)
JOINT DECISION 3 (GO TO 821)
OTHER: (SPECIFY)_____6 (GO TO 821)

820) Would you say that not using contraception is mainly your decision, mainly your husband’s/partner’s decision, or did you both decide together?

MAINLY RESPONDENT 1
MAINLY HUSBAND/PARTNER 1
JOINT DECISION 3
OTHER: (SPECIFY)_____6

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

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DON’T KNOW 8

SECTION 9. HUSBAND’S BACKGROUND AND GENDER

901) CHECK 701:

CURRENTLY MARRIED/LIVING WITH A MAN_______
NOT IN UNION_____(GO TO 913)

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

AGE IN COMPLETED YEARS____

903) Did your husband/partner ever attend school?

YES 1
NO 2 (GO TO 906)
DON’T KNOW (GO TO 906)

904) What was the highest level of school he attended?

INITIAL EDUCATION 90
LITERACY 91
PRIMARY/SECONDARY
1ST GRADE 01
2ND GRADE 02
3RD GRADE 03
4TH GRADE 04
5TH GRADE 05
6TH GRADE 06
7TH GRADE 07
8TH GRADE 08
9TH GRADE 09
10TH GRADE 10
11TH GRADE 11
12TH GRADE 12
13TH GRADE 13
HIGHER EDUCATION
1ST YEAR 14
2ND YEAR 15
3RD YEAR 16
4TH YEAR 17
5TH YEAR 18
6TH YEAR 19
DON’T KNOW 98 (GO TO 906)

905) Did your spouse/partner completed that level successfully?

YES 1
NO 2
DON’T KNOW 8

905A) What was the highest grade/year he completed at that level?

LITERACY 00
PRE-PRIMARY 01
PRIMARY 02
SECONDARY 1 YEAR 03
SECONDARY 2 YEAR 04
HIGH SCHOOL 05
BACHELOR’S DEGREE 06
MASTER’S DEGREE 07
DOCTORATE 08

906) CHECK P.59 OR P.72 FOR THE CORRESPONDING LINE NUMBER OF THE HOUSEHOLD QUESTIONNAIRE:

CODE ‘1’ OR ‘2’ CIRCLED____
OTHER___ (GO TO 909)

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
OTHER (SPECIFY)_____6

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

MORE THAN HIM 1
LESS THAN HIM 2
ABOUT THE SAME 3
HUSBAND/PARTNER DOESN’T BRING IN ANY MONEY 4 GO (910)
DON’T KNOW 8

909) Who usually decides how your husband/partner’s earnings will be used: you, your husband/partner, you and your husband/partner jointly?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
HUSBAND/PARTNER HAS NO EARNINGS 4
OTHER (SPECIFY)_____6

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE DECIDES 4
OTHER (SPECIFY) 6

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE DECIDES 4
OTHER (SPECIFY) 6

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE DECIDES 4
OTHER (SPECIFY) 6

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

CHILDREN UNDER 10
PRESENT/ LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
HUSBAND
PRESENT/ LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
OTHER MALES
PRESENT/ LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
OTHER FEMALES
PRESENT/ LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3

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

a) If she goes out without telling him?
b) If she neglects the children?
c) If she argues with him?
d) If she refuses to have sex with him?
e) If she burn the food?

A) GOES OUT
YES 1
NO 2
DON’T KNOW 8
B) NEGLECTS CHILDREN
YES 1
NO 2
DON’T KNOW 8
C) ARGUES
YES 1
NO 2
DON’T KNOW 8
D) REFUSES SEX
YES 1
NO 2
DON’T KNOW 8
E) BURNS FOOD
YES 1
NO 2
DON’T KNOW 8

915) Do you know whether or not laws exist to protect people from abuse and violence in Angola?

YES, LAWS EXIST 1
NO, LAWS DON’T EXIST 2
DON’T KNOW 8

SECTION 10. HIV/AIDS

1001) Now I would like to talk about something else.
Have you ever heard of an illness called HIV or AIDS?

YES 1
NO 2 (GO TO 1037)

1002) Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

YES 1
NO 2
DON’T KNOW 8

1003) Can people get the AIDS virus from mosquito bites?

YES 1
NO 2
DON’T KNOW 8

1004) Can people reduce their chances of getting the AIDS virus by using a condom every time they have sex?

YES 1
NO 2
DON’T KNOW 8

1005) Can people get the AIDS virus by sharing food with a person who has AIDS?

YES 1
NO 2
DON’T KNOW 8

1006) Is it possible for a healthy-looking person to have the AIDS virus?

YES 1
NO 2
DON’T KNOW 8

1007) Can the virus that causes AIDS be transmitted from mother to a child:
a) During pregnancy?
b) During delivery?
c) By breastfeeding?

A) DURING PREGNANCY
YES 1
NO 2
DON’T KNOW 8
B) DURING DELIVERY
YES 1
NO 2
DON’T KNOW 8
C) BREASTFEEDING
YES 1
NO 2
DON’T KNOW 8

1008) CHECK 1007:

AT LEAST ONE ‘YES’ ______
OTHER_____ (GO TO 1010)

1009) 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?

YES 1
NO 2
DON’T KNOW 8

1010) CHECK 208 AND 215:

LAST BIRTH SINCE JANUARY 2013 OR LATER_______
NO BIRTHS_______ (GO TO 1020)
LAST BIRTH IN OR BEFORE 2012_______ (GO TO 1020)

1011) CHECK 408 FOR LAST BIRTH:

HAD ANTENATAL CARE_______
NO ANTENATAL CARE_____ (GO TO 1020)

1012) CHECK FOR PRESENCE OF OTHERS, BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

1013) During any of the antenatal visits for your last birth, did anyone talk to you about:
a) Babies getting the AIDS virus from their mother?
b) Things that you can do to prevent getting the AIDS virus?
c) Getting tested for the AIDs virus?

A) AIDS FROM MOTHER
YES 1
NO 2
DON’T KNOW 8
B) THINGS TO DO
YES 1
NO 2
DON’T KNOW 8
C) TESTED FOR AIDS
YES 1
NO 2
DON’T KNOW 8

1014) Were you offered a test for the AIDS virus as part of your antenatal care?

YES 1
NO 2

1015) Were you tested for HIV as part of your antenatal care?

YES 1
NO 2 (GO TO 1020)

1016) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE)_____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
REGIONAL HOSPITAL 12
MUNICIPAL HOSPITAL 13
CATV (Office for Advice and Voluntary Testing of HIV/AIDS) 14
HEALTH CENTER 15
PTV 16
OTHER PUBLIC: (SPECIFY)____ 17
PRIVATE SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR 21
CATV 22
PHARMACY 23
OTHER PRIVATE: (SPECIFY)____ 26
OTHER: (SPECIFY)____ 96

1017) Did you get the results?

YES 1
NO 2

1018) Did you get another HIV test after the test during antenatal care?

YES 1 (GO TO 1021)
NO 2

1019) How long ago did you get your last HIV test?

LESS THAN ONE MONTH 00 (GO TO 1024)
BETWEEN 1 AND 23 MONTHS _____ (GO TO 1024)
TWO YEARS OR MORE 95 (GO TO 1024)

1020) Did you ever have an HIV test?

YES 1
NO 2 (GO TO 1031)

1021) How long ago did you get your last HIV test?

LESS THAN ONE MONTH 00
BETWEEN 1 AND 23 MONTHS _____
TWO YEARS OR MORE 95

1022) Where was the test done?
PROBE TO IDENTIFY THE PLACE.
IF IT IS NOT POSSIBLE TO DETERMINE IF THE PLACE IS PUBLIC OR PRIVATE, RECORD THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
REGIONAL HOSPITAL 12
MUNICIPAL HOSPITAL 13
CATV (Office for Advice and Voluntary Testing of HIV/AIDS) 14
HEALTH CENTER 15
PTV 16
OTHER PUBLIC: (SPECIFY)____ 17
PRIVATE SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR 21
CATV 22
PHARMACY 23
OTHER PRIVATE: (SPECIFY)____ 26
OTHER: (SPECIFY)____ 96

1023) Did you get the results?

YES 1
NO 2

1024) CHECK 1017 OR 1023:

ANY CODE 1 MARKED (GO TO 1025)
NO CODE 1 MARKED (GO TO 1033)

1025) You said that you have had an HIV test done. What was the result of your last HIV test?

POSITIVE 1
NEGATIVE 2 (GO TO 1033)
INCONCLUSIVE 3 (GO TO 1033)
REFUSES TO ANSWER 4 (GO TO 1033)
NOT SURE 8 (GO TO 1033)

1026) AFTER RECEIVING YOUR POSITIVE RESULTS, WERE YOU DIRECTED TO MAKE AN APPOINTMENT WITH AN HIV SPECIALIST?

YES 1
NO 2 (GO TO 1028)
NOT SURE 8 (GO TO 1028)

1027) Did you go to this medical appointment?

YES 1
NO 2

1028) At any time were you directed to take antiretroviral medications on a daily basis?

YES 1
NO 2 (GO TO 1033)

1029) Did you, in fact, take antiretroviral medications to protect you from the effects of HIV?

YES 1
NO 2 (GO TO 1033)

1030) At any time in the last 30 days, did you miss at least one day of taking your antiretroviral medication?

YES 1 (GO TO 1033)
NO 2 (GO TO 1033)

1031) Do you know of any place where people can go to get an HIV test done?

YES 1
NO 2 (GO TO 1033)

1032) Where?
Any other place?
MULTIPLE CHOICES
PROBE TO IDENTIFY THE PLACE.
IF IT IS NOT POSSIBLE TO DETERMINE IF THE PLACE IS PUBLIC OR PRIVATE, RECORD THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
REGIONAL HOSPITAL B
MUNICIPAL HOSPITAL C
CATV (Office for Advice and Voluntary Testing of HIV/AIDS) D
HEALTH CENTER E
PTV F
OTHER PUBLIC: (SPECIFY)____ G
PRIVATE SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR H
CATV I
PHARMACY J
OTHER PRIVATE: (SPECIFY)____ K
OTHER: (SPECIFY)____ X

1033) Would you buy fresh vegetables from a vendor, if you knew that he or she was carrying HIV?

YES 1
NO 2
NOT SURE/DON’T KNOW/DEPENDS 8

1034) In your opinion, should it be permitted for a professor to continue teaching in a school, if he/she has HIV, but is not sick?

YES 1
NO 2
NOT SURE/DON’T KNOW/DEPENDS 8

1035) Do you think that children infected with HIV should attend school with children who are not infected with the virus?

YES 1
NO 2
NOT SURE/DON’T KNOW/DEPENDS 8

1036) Are you scared of getting HIV through contact with the saliva of someone infected with HIV?

YES 1
NO 2
SHE SAYS THAT SHE HAS HIV 3
NOT SURE/DON’T KNOW/DEPENDS 8

1037) CHECK 1001:

HAS HEARD OF HIV OR AIDS: In addition to HIV, she has heard of other illnesses that can be sexually transmitted?
YES 1
NO 2
NEVER HEARD OF HIV OR AIDS: Has at some time heard of illnesses that can be sexually transmitted?
YES 1
NO 2

1038) CHECK 713:

HAS HAD SEXUAL INTERCOURSE____
NEVER HAD SEXUAL INTERCOURSE____ (GO TO 1046)

1039) CHECK 1037: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

YES __
NO___ (GO TO 1041)

1040) Now I would like to ask you about your health in the last 12 months:
During the last 12 months, have you had a disease which you got through sexual contact?

YES 1
NO 2
DON’T KNOW 8

1041) Sometimes women experience a bad smelling abnormal genital discharge. During the last 12 months, have you had a bad smelling abnormal genital discharge?

YES 1
NO 2
DON’T KNOW 8

1042) Sometimes women have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?

YES 1
NO 2
DON’T KNOW 8

1043) CHECK 1040, 1041 AND 1042:

HAS HAD AN INFECTION (ANY ‘YES’)______
HAS NOT HAD AN INFECTION OR DOES NOT KNOW_____ (GO TO 1046)

1044. The last time you had those problems (PROBLEMS MENTIONED IN 1040/1041/1042), did you seek advice or treatment?

YES 1
NO 2 (GO TO 1046)

1045) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
PUBLIC SECTOR
CENTRAL HOSPITAL A
HOSPITAL IN PROVINCE B
HOSPITAL IN RURAL AREA C
MATERNITY WARD D
GATV E
HEALTH CENTER/POST F
MOBILE CLINIC G
OTHER: (SPECIFY)____ H
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL/DOCTOR I
GATV J
PHARMACY K
OTHER PRIVATE SECTOR: (SPECIFY) ______ L
OTHER SOURCE
TRADITIONAL HEALER M
FRIEND/RELATIVE N
OTHER: (SPECIFY)____X

1046) 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?

YES 1
NO 2
DON’T KNOW 8

1047) Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women?

YES 1
NO 2
DON’T KNOW 8

1048) CHECK 701:

CURRENTLY MARRIED/LIVING WITH A MAN______
NOT IN UNION_____ (GO TO 1101)

1049) Can you say no to your husband/partner if you do not want to have sexual intercourse?

YES 1
NO 2
DEPENDS/NOT SURE 8

1050) Can you ask your husband/partner to use a condom if you wanted him to?

YES 1
NO 2
DEPENDS/NOT SURE 8

SECTION 11. OTHER HEALTH ISSUES

1101) Now I would like to ask you some 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 GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD ‘90’.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS_____
NONE 00 (GO TO 1104)

1102) Among these injections, how many were administered by a health worker (a doctor, a nurse, a pharmacy clerk, dentist, or other health worker)?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD ‘90’.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS_____
NONE 00 (GO TO 1104)

1103) The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

YES 1
NO 2
DON’T KNOW 8

1104) Do you currently smoke cigarettes everyday, occasionally, or not at all?

EVERYDAY 1
OCCASIONALLY 2 (GO TO 1106)
NOT AT ALL 3 (GO TO 1106)

1105) How many cigarettes did you smoke, daily?

NUMBER OF CIGARETTES______

1106) Do you currently smoke or use any other type of tobacco everyday, occasionally, or not at all?

EVERYDAY 1
OCCASIONALLY 2
NOT AT ALL 3 (GO TO 1108)

1107) What (other) type of tobacco do you currently smoke or use?
RECORD ALL ANSWERS MENTIONED.

CIGARETTE A
HAND ROLLED CIGARETTE B
PIPE C
CIGAR D
SNUFF E
CHEWING TOBACCO F
OTHER (SPECIFY) ______X

1108) Currently, do you drink beer, wine or other alcoholic beverage everyday, occasionally, or not at all?

EVERYDAY 1
OCCASIONALLY 2
NOT AT ALL 3

1109) 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?

a) Getting permission to go?
b) Getting money needed for treatment?
c) The distance to the health facility?
d) Not wanting to go alone?

A) PERMISSION TO GO
BIG PROBLEM 1
NOT A BIG PROBLEM 2
B) GETTING MONEY
BIG PROBLEM 1
NOT A BIG PROBLEM 2
C) DISTANCE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
D) GO ALONE
BIG PROBLEM 1
NOT A BIG PROBLEM 2

1110) Are you covered by any medical assistance or health insurance?

YES 1
NO 2

1111) In the last 30 days, have you sought medical treatment for an illness or accident?

YES 1
NO 2 (GO TO 1201)

1112) During the last 30 days, have you sought medical treatment only one time, or more than one time?

ONLY ONE TIME 1
MORE THAN ONE TIME 2

1113) Where did you obtain medical treatment (the last time)?

GOVERNMENT HOSPITAL 11
REGIONAL HOSPITAL 12
MUNICIPAL HOSPITAL 13
HEALTH CENTER 14
MOBILE HEALTH UNIT 15
OTHER PUBLIC (SPECIFY)____ 16
PRIVATE SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR 21
HEALTH CENTER 22
PHARMACY 23 (GO TO 1201)
OTHER PRIVATE (SPECIFY)____ 26 (GO TO 1201)
OTHER LOCAL
HEALER 31 (GO TO 1201)
FRIEND/FAMILY MEMBER (GO TO 1201)
OTHER (SPECIFY) ______ 96

1114) The last time you went to the (HEALTH CARE UNIT SPECIFIED IN 1113), how long did it take to be seen by a health care professional?

IMMEDIATELY 000 (GO TO 1116)
MINUTES 1 _____
HOURS 2 _____
NOT SURE 998

1115) While you were waiting to be seen, were you standing or were you seated?

STANDING 1
SEATED 2
SEATED AND STANDING 3

1116) At the time of your last medical appointment, could you understand the health care personnel easily, with difficulty, or not at all?

EASILY 1
WITH DIFFICULTY 2
NOT AT ALL 3

1117) Did the last person who saw you speak the same language as you normally use or did they speak a different language?

SPOKE THE SAME LANGUAGE 1
SPOKE A DIFFERENT LANGUAGE 2

1118) In general, were you very satisfied, reasonably satisfied, unsatisfied or very unsatisfied with the treatment you received at this last appointment?

VERY SATISFIED 1
REASONABLY SATISFIED 2
UNSATISFIED 3
VERY UNSATISFIED 4
NO OPINION 5

SECTION 12: MATERNAL MORTALITY

1201) Now I would like to talk about your brothers and sisters, in other words, all the children born by your mother, including those that live with you, those that live elsewhere, and those who have died.

How many children did your mother have, including yourself?

NUMBER OF CHILDREN THAT MOTHER HAD ____

1202) CHECK 1201:

TWO OR MORE BIRTHS (GO TO 1203)
ONLY ONE BIRTH (ONLY THE INTERVIEWEE) (GO TO NEXT SEC.)

1203) How many of these births did your mother have before you were born?

NUMBER OF PRECEEDING BIRTHS______

1204) Please tell me the name of each of your brothers and sisters, either living or dead, beginning with the oldest?

NAME_____________

1205) Is (NAME) male or female?

MALE 1
FEMALE 2

1206) Is (NAME) alive?

YES 1
NO 2 (GO TO 1208)
DON’T KNOW 8 (GO TO NEXT BIRTH)

1207) How old is (NAME)?

AGE____ (GO TO NEXT BIRTH)

1208) How many years ago did (NAME) die?

YEARS AGO____

1209) How old was (NAME) when s/he died?

AGE OF DEATH____ (IF MALE OR FEMALE THAT DIED BEFORE 12 YEARS OF AGE GO TO NEXT BIRTH)

1210) Was (NAME) pregnant when she died?

YES 1 (GO TO 1213)
NO 2

1211) Did (NAME) die during labor?

YES 1 (GO TO 1213)
NO 2

1212) Did (NAME) die within two months after labor or after losing the child?

YES 1 (GO TO 1214)
NO 2

1213) Did she die due to pregnancy complications, abortion or labor?

YES 1
NO 2
DON’T KNOW 8

1214) Did (NAME) die at home, on the way to the hospital, in the hospital or in another place?

AT HOME 1
ON THE WAY TO THE HOSPITAL 2
AT THE HOSPITAL 3
OTHER (SPECIFY)____ 6
DON’T KNOW 8

1215) How many born live children did (NAME) give birth to during her lifetime?

NUMBER OF BIRTHS__________ (GO TO NEXT BIRTH)

IF THERE ARE NO OTHER BROTHERS OR SISTERS, GO TO THE NEXT SECTION.

SECTION 13. DOMESTIC VIOLENCE MODULE

1300) CHECK HOUSEHOLD QUESTIONNAIRE COVER PAGE,

WOMAN WAS SELECTED FOR THIS SECTION (GO TO 1301)
WOMAN WAS NOT SELECTED (GO TO 1340)

1301) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.

PRIVACY OBTAINED 1 (GO TO 1302)
NO PRIVACY 2 (GO TO 1339)

1302) READ TO THE RESPONDENT
Now I would like to ask you questions about some other important aspects of a woman’s life. I know that some of these questions are very personal. However, your answers are crucial for helping to understand the conditions of women’s lives in Angola. Let me assure you that your answers are completely confidential, that is, they will not be told to anyone and no one else in your household will know that you answered these questions.

1303) CHECK 701 AND 702:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 1304)
WAS MARRIED/LIVED WITH A MAN (READ IN THE PAST TENSE AND ASK THE QUESTIONS ABOUT THE LAST HUSBAND/PARTNER) (GO TO 1304)
NEVER MARRIED/NEVER LIVED WITH A MAN (GO TO 1319)

1304) First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband/partner?

A) He is(was) jealous or angry if you talk(talked) to other men?
B) He frequently accuses(accused) you of being unfaithful?
C) He does(did) not allow you to meet with your female friends?
D) He tries(tried) to limit your contact with your family?
E) He insists(insisted) on knowing where you are(were) at all times?
F) He does(did) not trust you to manage money?

JEALOUS
YES 1
NO 2
DON’T KNOW 8
ACCUSES(ED)
YES 1
NO 2
DON’T KNOW 8
NOT ALLOWED TO MEET
YES 1
NO 2
DON’T KNOW 8
LIMIT CONTACT WITH
YES 1
NO 2
DON’T KNOW 8
KNOWING WHERE YOU ARE
YES 1
NO 2
DON’T KNOW 8
MANAGE MONEY
YES 1
NO 2
DON’T KNOW 8

1305) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner.

A. Does (did) your (last) husband/partner ever:

A) Say or do something to humiliate you in front of others?
B) Threaten to hurt or harm you or someone close to you?
C) Insult you or make you feel bad about yourself?

A) HUMILIATE
AT ANY TIME
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
B) THREATEN/HARM
AT ANY TIME
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
C) INSULT
AT ANY TIME
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)

B) How often did this happen during the last 12 months: often, only sometimes, or never?

A) HUMILIATE
OFTEN 1
SOMETIMES 2
NEVER 3
B) THREATEN/HARM
OFTEN 1
SOMETIMES 2
NEVER 3
C) INSULT
OFTEN 1
SOMETIMES 2
NEVER 3

1306. A. (Does/did) your (last) husband/partner ever:

A) PUSH YOU, SHAKE YOU, OR THROW SOMETHING AT YOU?
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
B) SLAP YOU?
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
C) TWIST YOUR ARM OR PULL YOUR HAIR?
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
D) PUNCH YOU WITH HIS FIST OR WITH SOMETHING THAT COULD HURT YOU?
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
E) KICK YOU, DRAG YOU OR BEAT YOU UP?
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
F) TRY TO CHOKE YOU OR BURN YOU ON PURPOSE?
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
G) THREATEN OR ATTACK YOU WITH A KNIFE, GUN OR ANY OTHER WEAPON?
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
H) PHYSICALLY FORCE YOU TO HAVE SEXUAL INTERCOURSE WITH HIM AGAINST YOUR WILL?
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
I) FORCE YOU TO PERFORM ANY OTHER SEXUAL ACTS AGAINST YOUR WILL?
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)
J) THREATEN YOU IN SOME OTHER WAY TO PERFORM A SEXUAL ACT AGAINST YOUR WILL?
YES 1 (GO TO PART B)
NO 2 (GO TO NEXT QUESTION)

B. How often did this happen during the last 12 months: often, only sometimes, or not at all?

A) PUSH YOU, SHAKE YOU, OR THROW SOMETHING AT YOU?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
B) SLAP YOU?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
C) TWIST YOUR ARM OR PULL YOUR HAIR?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
D) PUNCH YOU WITH HIS FIST OR WITH SOMETHING THAT COULD HURT YOU?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
E) KICK YOU, DRAG YOU OR BEAT YOU UP?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
F) TRY TO CHOKE YOU OR BURN YOU ON PURPOSE?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
G) THREATEN OR ATTACK YOU WITH A KNIFE, GUN OR ANY OTHER WEAPON?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
H) PHYSICALLY FORCE YOU TO HAVE SEXUAL INTERCOURSE WITH HIM AGAINST YOUR WILL?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
I) FORCE YOU TO PERFORM ANY OTHER SEXUAL ACTS AGAINST YOUR WILL?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
J) THREATEN YOU IN SOME OTHER WAY TO PERFORM A SEXUAL ACT AGAINST YOUR WILL?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1307. CHECK 1306 (a-j):

AT LEAST ONE ‘YES’ (GO TO 1308)
NOT A SINGLE ‘YES’ (GO TO 1310)

1308. How long after you (first got married to/started living together) did that thing(s) you just mentioned first happen?
IF LESS THAN 1 YEAR, RECORD ‘00’.

NUMBER OF YEARS_______
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95

1309) Did the following ever happen as a result of the actions of your (last) husband/partner:
Did you have cuts, bruises or pain?
Did you have eye injuries, sprains, dislocations, or burns?
Did you have deep wounds, broken bones, broken teeth or any other serious injury?

A) PAIN
YES 1
NO 2
B) SMALL INJURIES
YES 1
NO 2
C) SERIOUS INJURY
YES 1
NO 2

1310) Have you ever hit, slapped, kicked or done anything else to physically hurt your husband/partner at times when he was not already beating or physically hurting you?

YES 1
NO 2 GO (1312)

1311) How often did you do this to your (last) husband/partner during the last 12 months: often, only sometimes, rarely or not at all?

OFTEN 1
SOMETIMES 2
RARELY 3
NOT AT ALL 4

1312) Does (did) your husband/partner drink alcohol?

YES 1
NO 2 (GO TO 1316)

1313) How often does (did) he get drunk: often, only sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

1314) Some men can become violent when they drink alcohol and get drunk. Has your husband/partner become violent after drinking alcoholic beverages?

YES 1
NO 2 (GO TO 1316)

1315) In the last 12 months, how many times did your husband/partner became violent after drinking alcoholic beverages: often, only sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

1316) Do/did you fear your husband/partner most of the time, sometimes, or never?

MOST OF THE TIME 1
SOMETIMES 2
NEVER 3

1317) CHECK 709:

MARRIED MORE THAN ONE TIME (GO TO 1318)
MARRIED ONLY ONE TIME (GO TO 1319)

1318) Until now, we have spoke about the behavior of your (last/current) husband/partner. Now I would like to ask you some questions about your previous husband(s)/partner(s).
Did any previous (husband/partner) hit, slap, kick, or hurt you in any other way?
AT ANY TIME

YES 1 (GO TO PART B)
NO 2 (GO TO QUESTION b)

B) How long ago did this occur?

0 TO 11 MONTHS 1
12 OR MORE MONTHS 2
DOES NOT REMEMBER 3

b) Did any previous (husband/partner) physically force you to have sexual intercourse or any other sexual act against your will?
AT ANY TIME

YES 1 (GO TO PART B)
NO 2 (GO TO QUESTION 1319)

B) How long ago did this occur?

0 TO 11 MONTHS 1
12 OR MORE MONTHS 2
DOES NOT REMEMBER 3

1319) CHECK 701 AND 702:

EVER MARRIED/LIVED WITH A MAN: From the time you were 15 years old has anyone other than your (current/last) husband/partner hit, slapped, kicked or done anything else to hurt you physically?
YES 1
NO 2 (GO TO 1322)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1322)
NEVER MARRIED/NEVER LIVED WITH A MAN: From the time you were 15 years old has anyone hit, slapped, kicked or done anything else to hurt you physically?
YES 1
NO 2 (GO TO 1322)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1322)

1320) Who hurt you?
Anyone else?
RECORD ALL ANSWERS MENTIONED

MOTHER/STEP-MOTHER A
FATHER/STEP-FATHER B
SISTER/ BROTHER C
DAUGHTER/SON D
OTHER RELATIVE E
CURRENT BOYFRIEND F
FORMER BOYFRIEND G
MOTHER-IN-LAW H
FATHER-IN-LAW I
ANOTHER RELATIVE OF PARTNER J
TEACHER K
EMPLOYER/SOMEONE AT WORK L
POLICE/SOLDIER M
OTHER:(SPECIFY)___ X

1321) In the past 12 months, how often were you hurt by this(these) person(people): often, only sometimes or never?

OFTEN 1
SOMETIMES 2
ONCE 3
NEVER 4

1322) CHECK 201, 226 AND 230:

EVER BEEN PREGNANT (YES ON 201 OR 226 OR 230) (GO TO 1323)
NEVER BEEN PREGNANT (GO TO 1325)

1323) Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

YES 1
NO 2 (GO TO 1325)

1324) When you were pregnant, who hurt you in this way?
Anyone else?
MULTIPLE RESPONSES

CURRENT HUSBAND/BOYFRIEND A
MOTHER/STEP-MOTHER B
FATHER/STEP-FATHER C
SISTER/ BROTHER D
DAUGHTER/SON E
OTHER RELATIVE F
FORMER HUSBAND/PARTNER G
CURRENT BOYFRIEND H
FORMER BOYFRIEND I
MOTHER-IN-LAW J
FATHER-IN-LAW K
ANOTHER RELATIVE OF PARTNER L
TEACHER M
EMPLOYER/SOMEONE AT WORK N
POLICE/SOLDIER O
OTHER (SPECIFY)___ X

1325) CHECK 701 AND 702:

EVER MARRIED/EVER LIVED WITH A MAN____
NEVER MARRIED/NEVER LIVED WITH A MAN____ (GO TO 1327)

1326) Now I want to ask you about things that may have been done to you by someone other than (your/any) (husband/partner). At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts?

YES 1 (GO TO 1328)
NO 2 (GO TO 1330)
REFUSED TO ANSWER/NO RESPONSE 3 (GO TO 1330)

1327) At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts?

YES 1
NO 2 (GO TO 1332)
REFUSED TO ANSWER/NO RESPONSE 3 (GO TO 1332)

1328) Who was the person who was forcing you the very first time this happened?

CURRENT HUSBAND/PARTNER 01
FORMER HUSBAND/PARTNER 02
CURRENT/FORMER BOYFRIEND 03
FATHER/STEPFATHER 04
BROTHER/STEP-BROTHER 05
OTHER RELATIVES 06
OTHER IN-LAW 07
OWN FRIEND/ACQUAINTANCE 08
FAMILY FRIEND 09
TEACHER 10
EMPLOYER 11
POLICE/SOLDIER 12
PASTOR/RELIGIOUS LEADER 13
STRANGER 14
OTHER (SPECIFY)___ 96

1329) CHECK 701 AND 702:

EVER MARRIED/EVER LIVED WITH A MAN: In last 12 months, has anyone other than (your/any) (husband/partner) physically forced you to have sexual intercourse when you did not want to?
YES 1 (GO TO 1331)
NO 2 (GO TO 1331)
NEVER MARRIED/NEVER LIVED WITH MAN: In last 12 months, has anyone physically forced you to have sexual intercourse when you did not want to?
YES 1 (GO TO 1331)
NO 2 (GO TO 1331)

1330) CHECK 1306 (h-j) AND 1318A(b)

AT LEAST ONE ‘YES’___
NOT A SINGLE ‘YES’___ (GO TO 1332)

1331) CHECK 701 AND 702:

EVER MARRIED/EVER LIVED WITH A MAN: How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts by anyone, including (your/any) husband/partner?
AGE IN COMPLETED YEARS ___
DON’T KNOW 98
NEVER MARRIED/NEVER LIVED WITH MAN: How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?
AGE IN COMPLETED YEARS ___
DON’T KNOW 98

1332) CHECK 1306 (a-j), 1318 (a, b), 1319, 1326 AND 1327:

AT LEAST ONE ‘YES’ ______
NOT A SINGLE ‘YES’ ‘_____ (GO TO 1337)

1333) Thinking about what you yourself have experienced among different things we have been talking about, have you ever tried to seek help to stop (the/these) person(s) from doing this to you again?

YES 1
NO 2 (GO TO 1335)

1334) From whom have you sought help?
Anyone else?
RECORD ALL MENTIONED.

OWN FAMILY A (GO TO 1336)
HUSBAND/PARTNER’S FAMILY B (GO TO 1336)
CURRENT/LAST/LATE HUSBAND/PARTNER C (GO TO 1336)
CURRENT/FORMER BOYFRIEND D (GO TO 1336)
FRIEND E (GO TO 1336)
NEIGHBOR F (GO TO 1336)
RELIGIOUS LEADER (GO TO 1336)
DOCTORAL/MEDICAL PERSONNEL H (GO TO 1336)
POLICE I (GO TO 1336)
LAWYER J (GO TO 1336)
SOCIAL SERVICE ORGANIZATION K (GO TO 1336)
MINISTRY OF FAMILY AFFAIRS AND WOMEN L (GO TO 1336)
WOMEN’S ORGANIZATION M (GO TO 1336)
OTHER (SPECIFY)___ X (GO TO 1336)

1335. What was the reason you did not seek any help?

RECORD ALL MENTIONED.

FEAR OF RETALIATION A (GO TO 1337)
THOUGHT THAT THE VIOLENCE WILL NEVER OCCUR AGAIN B (GO TO 1337)
FEAR OF ABANDONMENT BY HUSBAND/PARTNER C (GO TO 1337)
THOUGHT YOU COULD PROTECT YOURSELF ALONE D (GO TO 1337)
DID NOT THINK THAT OTHER PEOPLE COULD HELP E (GO TO 1337)
DOES NOT TRUST AUTHORITIES F (GO TO 1337)
OTHER:(SPECIFY)___ X (GO TO 1337)

1336) Have you ever told anyone else about this?

YES 1
NO 2

1337) As far as you know, did your father ever beat your mother?

YES 1
NO 2
DON’T KNOW 8

THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER ABOUT THE CONFIDENTIALITY OF HER ANSWERS. FILL OUT THE QUESTIONS BELOW REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

1338) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

HUSBAND/PARTNER
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3
OTHER MALE ADULT
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3
FEMALE ADULT
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3

1339) INTERVIEWER’S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE ________________________________________________________________________________________________________________________________________________________

1340) RECORD TIME

HOURS _____
MINUTES____

INTERVIEWER’S OBSERVATIONS
To be filled in after completing interview

COMMENT ABOUT THE INTERVIEW: __________
COMMENTS ON SPECIFIC QUESTIONS __________
ANY OTHER COMMENTS________

SUPERVISOR’S OBSERVATIONS ________________

INSTRUCTIONS: ONLY ONE CODE SHOULD APPEAR IN ANY BOX. ALL MONTHS SHOULD BE FILLED IN.

INFORMATION TO BE CODED FOR EACH COLUMN

COLUMN 1: BIRTHS AND PREGNANCIES, CONTRACEPTIVE USE

B BIRTHS
P PREGNANCIES
T TERMINATIONS

0 NO METHOD
1 FEMALE STERILIZATION
2 MALE STERILIZATION
3 IUD
4 INJECTABLES
5 IMPLANTS
6 PILL
7 CONDOM
8 FEMALE CONDOM
9 EMERGENCY CONTRACEPTION
J STANDARD DAYS METHOD
K LACTATIONAL AMENORRHEA METHOD
L RHYTHM, PERIODIC ABSTINENCE
M WITHDRAWAL
X OTHER MODERN METHODS.
Y OTHER TRADITIONAL METHODS.

COLUMN 2: NOT USING CONTRACEPTIVE METHODS
0 IRREGULAR SEXUAL RELATIONS/ABSENT PARTNER
1 GOT PREGNANT WHILE USING A METHOD
2 STOPPED METHOD TO GET PREGNANT
3 HUSBAND/PARTNER REFUSED TO USE A METHOD
4 WANTED A MORE EFFICIENT METHOD
5 SECONDARY EFFECTS
6 NOT ACCESSIBLE/LONG DISTANCE
7 HIGH PRICE
8 INCONVENIENT METHOD
F GOD’S WILL/FATALISTIC
A DIFFICULT TO GET PREGNANT IN MENOPAUSE
D DIVORCED/SEPARATED/WIDOW
X OTHER (SPECIFY) ______

Z DON’T KNOW
COL 1. COL. 2
2016
12 DEC ___ 01
11 NOV ___02
10 OCT ___03
09 SEP ___04
08 AGO__05
07 JUL ___06
06 JUN ___07
05 MAY ___08
04 APR ___09
03 MAR ___10
02 FEB ___11
01 JAN ___12

2015
12 DEC ___ 13
11 NOV ___14
10 OCT ___15
09 SEP ___16
08 AGO__17
07 JUL ___18
06 JUN ___19
05 MAY ___20
04 APR ___21
03 MAR ___22
02 FEB ___23
01 JAN ___24

2014
12 DEC ___ 25
11 NOV ___26
10 OCT ___27
09 SEP ___28
08 AGO__29
07 JUL ___30
06 JUN ___31
05 MAY ___32
04 APR ___33
03 MAR ___34
02 FEB ___35
01 JAN ___36

2013
12 DEC ___ 37
11 NOV ___38
10 OCT ___39
09 SEP ___40
08 AGO__41
07 JUL ___42
06 JUN ___43
05 MAY ___44
04 APR ___45
03 MAR ___46
02 FEB ___47
01 JAN ___48

2012
12 DEC ___ 49
11 NOV ___50
10 OCT ___51
09 SEP ___52
08 AGO__53
07 JUL ___54
06 JUN ___55
05 MAY ___56
04 APR ___57
03 MAR ___58
02 FEB ___59
01 JAN ___60

2011
12 DEC ___ 61
11 NOV ___62
10 OCT ___63
09 SEP ___64
08 AGO__65
07 JUL ___66
06 JUN ___67
05 MAY ___68
04 APR ___69
03 MAR ___70
02 FEB ___71
01 JAN ___72

2010
12 DEC ___ 73
11 NOV ___74
10 OCT ___75
09 SEP ___76
08 AGO__77
07 JUL ___78
06 JUN ___79
05 MAY ___80
04 APR ___81
03 MAR ___82
02 FEB ___83
01 JAN ___84