PROVINCE _____
DEPARTMENT _____
COMMUNE/URBAN CENTER _____
VILLAGE/SECTOR _____
CLUSTER NUMBER _____
NAME OF HEAD OF CONCESSION _____
CONCESSION NUMBER _____
NAME OF HEAD OF HOUSEHOLD _____
HOUSEHOLD UNIT NUMBER _____

URBAN/RURAL:

OUAGA/BOBO/OTHER CITIES/RURAL:

INTERVENTION ZONE:

NAME OF FEMALE RESPONDENT ______

LINE NUMBER OF FEMALE RESPONDENT ______

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____

RESULT _____

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER _____
RESULT _____

TOTAL NUMBER OF VISITS _____

LANGUAGE OF INTERVIEW:

INTERPRETER USED

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____
KEYED BY _____

SECTION 1: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENT

101. RECORD THE TIME.

103. To begin, I would like to ask you questions about yourself. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?

105. In what month and year were you born?

106. How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

106A. Do you understand French?

107. Have you ever attended school?

108. What is the highest level of school you attended: primary, middle school, high school, or higher?

109. What is the highest grade you completed at that level?

110. CHECK 106:

111. Are you currently attending school?

111A. At what age did you stop going to school?

112. What is the main reason you stopped going to school?

113. CHECK 108:

114. Can you read and understand a letter or newspaper easily, with difficulty, or not at all?

114A. Do you read a newspaper or magazine at least once a month?

115. Do you read a newspaper or magazine at least once a week?

115A. Do you listen to the radio?

116. Do you listen to the radio every day?

116A. On what days of the week do you listen to the radio?
RECORD ALL GIVEN RESPONSES. IF THE RESPONSE IS "IT DEPENDS", "WHENEVER" OR "DOESN'T KNOW", YOU SHOULD ONLY CIRCLE ONE CODE.

116B. At what times do you usually listen to the radio?
RECORD ALL GIVEN RESPONSES. IF THE RESPONSE IS "IT DEPENDS", "WHENEVER" OR "DOESN'T KNOW", YOU SHOULD ONLY CIRCLE ONE CODE.

116C. What types of radio programs do you usually listen to?
PROBE TO GET THE TYPES OF SHOWS. RECORD ALL TYPES MENTIONED.

116CA. What radio stations do you usually listen to?
RECORD ALL RESPONSES.

116D. Have you ever had the chance to hear the radio program "Yamba Songo"?

116E. According to you, is this series educational in nature or is it just entertainment?

116F. In your opinion, which problems does "Yamba Songo" discuss?
RECORD ALL RESPONSES. IF THE RESPONSE IS "DOESN'T KNOW", YOU SHOULD ONLY CIRCLE THAT CODE.

116G. Do you watch the television?

117. Do you watch the television at least once a week?

117A. On what days of the week do you watch the television?
RECORD ALL GIVEN RESPONSES. IF THE RESPONSE IS "IT DEPENDS", "WHENEVER" OR "DOESN'T KNOW", YOU SHOULD ONLY CIRCLE ONE CODE.

117B. At what times do you usually watch the television?
RECORD ALL GIVEN RESPONSES. IF THE RESPONSE IS "IT DEPENDS", "WHENEVER" OR "DOESN'T KNOW", YOU SHOULD ONLY CIRCLE ONE CODE.

117C. What types of television programs do you usually watch?
PROBE TO GET THE TYPES OF SHOWS. RECORD ALL TYPES MENTIONED.

117D. What television stations do you usually watch?

118. What is your religion?

118A. What is your nationality?

119. What is your ethnicity?
WRITE DECLARED ETHNICITY, THEN CIRCLE CORRESPONDING CODE.

SECTION 2: REPRODUCTION

Now I would like to ask about all the births you have had during your life.

201. Have you ever given birth?

202. Do you have any sons of daughters to whom you have given birth who are now living with you?

203. How many sons live with you?
How many daughters live with you?
IF NONE, RECORD '00'.

204. Do you have any sons or daughters to whom you have given birth who are alive but do not live with you?

205. How many sons are alive but do not live with you?
How many daughters are alive but do not live with you?
IF NONE, RECORD '00'.

206. Have you ever given birth to a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life at birth but did not survive more than a few hours or days?

207. How many boys have died?
How many girls have died?
IF NONE, RECORD '00'.

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

209. CHECK 208:
Just to make sure that I have this right: you have had in TOTAL _____ births during your life. Is that correct?

210. CHECK 208:

Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.

211. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. REPEAT 212-221 FOR EACH SEPARATE BIRTH.

212. What name was given to your (first/next) baby?

213. Was (NAME) a single birth or part of a multiple birth?

214. Is (NAME) a boy or a girl?

215. In what month and year was (NAME) born?
PROBE: What is his/her birthday? OR: What season was (NAME) born in?

216. Is (NAME) still alive?

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

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

219. IF DEAD: How old was (NAME) when he/she died?
IF '1 YEAR', PROBE: How many months was (NAME)?
RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

220. SUBTRACT THE BIRTH YEAR OF (NAME) FROM THE YEAR OF THE PREVIOUS BIRTH. IS THE DIFFERENCE FOUR OR MORE YEARS?
[DO NOT ASK FOR FIRST BIRTH]

221. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)? [DO NOT ASK FOR FIRST BIRTH]

[GO BACK AND REPEAT 212-221 FOR EACH ADDITIONAL BIRTH]

222. SUBTRACT THE BIRTH YEAR OF THE LAST CHILD FROM THE YEAR OF THE INTERVIEW. IS THE DIFFERENCE FOUR OR MORE YEARS?

223. Have you had any live births since the birth of (NAME OF LAST BIRTH)?

224. COMPARE 208 WITH NUMBER OF BIRTHS REGISTERED IN TABLE ABOVE AND MARK:

225. CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1993:
IF NONE, RECORD '0'.

227. Are you pregnant now?

228. How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.

229. At the time you became pregnant, did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all?

236. When did your last menstrual period start?
RECORD THE DATE, IF IT IS GIVEN.

237. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations?

238. At what point in her menstrual cycle is a woman most likely to become pregnant?

SECTION 3: CONTRACEPTION

300. Now I would like to talk about family planning and the various ways or methods that a couple can use to delay or avoid a pregnancy.

CIRCLE CODE '1' IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 302, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE '2' IF METHOD IS RECOGNIZED AND CODE '3' IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE '1' OR '2' CIRCLED IN 301 OR 302, ASK 303.

301. What are the ways or methods that have you heard about?
302. Have you ever heard of (METHOD)?

303. Have you ever used (METHOD)?
THIS QUESTION IS ASKED ABOUT EACH METHOD IN 301 WITH '1' OR '2' CIRCLED.

304. CHECK 303:

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

307. What have you used or done?
CORRECT 303 AND 304 (AND 302 IF NECESSARY).

Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant.

309. How many living children did you have at that time?
IF NONE, RECORD '00'.

310. The first time you used family planning, was it because you wanted another child, but not until later, or was it because you didn't want any more children at all?

311. CHECK 303:

312. CHECK 227:

313. Are you currently doing something or using any method to delay or avoid getting pregnant?

314. Which method are you currently using?
314A. CIRCLE '06' FOR FEMALE STERILIZATION.

314B. Why do you use the pill over another method?

315. May I see the package of pills you are currently using?
IF THE PACKAGE IS SHOWN, CIRCLE THE CORRESPONDING CODE.

316. What is the brand name of the pills you are currently using?

317. How much does one box (cycle) of pills cost you?

317A. Why did you (or your partner/spouse) choose to have an operation to no longer have children rather than another method?

318. Where did the sterilization take place?

IF IT IS A HOSPITAL, MEDICAL CENTER OR CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

319. Do you regret having (your partner having) an operation in order to have no more children?

320. Why do you regret the operation?

321. In what month and year was the sterilization performed?

322A. Why do you use the rhythm method over another method?

323. How do you determine which days in your menstrual cycle you should not have sexual intercourse?

325A. Why do you use the (METHOD IN 314) over another method?

326. For how many months have you been continuously using (METHOD)?
IF LESS THAN 1 MONTH, NOTE '00'.

326A. If a contraceptive method was made available to you for free, would you accept it?
IF NO, PROBE FOR REASON AND CIRCLE THE CORRESPONDING RESPONSE.

327. CHECK 314:
CIRCLE THE CODE OF THE METHOD USED.

328. Where did you last obtain (METHOD)?

IF IT IS A HOSPITAL, MEDICAL CENTER OR CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

329. Do you know of another place you could have gone last time to procure (METHOD)?
329A. At the time of your sterilization, did you know of another place where you could have had the same operation?

329B. People choose where they go for family planning services for different reasons. What is the main reason why you went to (NAME OF PLACE IN 328 OR 318) rather than the other place you know of? Other reasons?

RECORD ALL MENTIONED. IF THE RESPONSE IS "DOESN'T KNOW", YOU SHOULD ONLY CIRCLE THAT CORRESPONDING CODE.

330. Amongst the reasons you've given me, what is the primary reason?

INTERVIEWER: IF YOU ONLY CIRCLED ONE CODE IN 329B, CIRCLE THE CODE CORRESPONDING TO THE SAME RESPONSE HERE AND CONTINUE TO 334. IF YOU CIRCLED SEVERAL CODES IN 329B, ASK THE FOLLOWING QUESTION AND CIRCLE THE CODE CORRESPONDING TO THE RESPONSE.

331. CHECK 227:

331A. What is the main reason that you are not currently using a contraceptive method?

332. Do you know of a place where you can get contraception?

333. Where is it?

IF IT IS A HOSPITAL, MEDICAL CENTER OR CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

334. In the last 12 months, have you had a visit from an agent that talked with you about family planning?

335. In the last 12 months, have you visited a health facility for any reason?

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

337. Do you think that breastfeeding can influence a woman's ability to become pregnant?

338. Do you think that breastfeeding increases or decreases a woman's chance of becoming pregnant?

339. CHECK 210:

340. Have you previously relied on breastfeeding as a way to avoid becoming pregnant?

341. CHECK 227 AND 311:

342. Are you currently relying on breastfeeding in order to avoid getting pregnant?

SECTION 4: FAMILY HEALTH AND BREASTFEEDING

SECTION 4A: PREGNANCY AND BREASTFEEDING

401. CHECK 225:

402. ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS FOR EACH BIRTH SINCE JANUARY 1993 IN THE REPRODUCTION TABLE. ASK THE QUESTIONS FOR ALL BIRTHS BEGINNING WITH THE LAST BIRTH. IF THERE ARE MORE THAN 3 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES.

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

402A. LINE NUMBER FROM 212:

402B. FROM 212 AND 216:

403. At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later, or did you not want to have any more children at all?

404. How much longer would you have liked to wait?

405. When you were pregnant with (NAME), did you see anyone for antenatal care?
IF YES: Whom did you see? PROBE: Anyone else?
CIRCLE ALL CODES CORRESPONDING TO PERSONS SEEN.

406. Were you given a health card for this pregnancy?

407. How many months pregnant were you when you first received antenatal care for this pregnancy?

408. How many prenatal visits did you have during this pregnancy?

409. During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?

410. How many times did you get this injection?

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

412. Who assisted you with the delivery of (NAME)? Anyone else?
PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED.

413. Was (NAME) born full-term or premature?

414. Was (NAME) delivered by caesarean section?

415. When (NAME) was born, was he/she very large, larger than average, average, smaller than average, or very small?

416. Was (NAME) weighed at birth?

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

418. Has your period come back since the birth of (NAME)?
[ONLY ASK OF MOST RECENT BIRTH]

419. Did your period come back between the birth of (NAME) and your next birth?
[ASK FOR ALL BUT MOST RECENT BIRTH]

420. For how many months after the birth of (NAME) did you not have your period?

421. CHECK 227:
IS RESPONDENT PREGNANT?
[ONLY ASK FOR MOST RECENT BIRTH]

422. Have you begun to have sexual intercourse again since the birth of (NAME)?
[ONLY ASK FOR MOST RECENT BIRTH]

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

424. Did you breastfeed (NAME)?

425. Why didn't you breastfeed (NAME)?

426. 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.
[ASK ONLY FOR MOST RECENT BIRTH]

427. CHECK 216:
CHILD LIVING?
[ASK ONLY FOR MOST RECENT BIRTH]

428. Are you still breastfeeding (NAME)?
[ASK ONLY FOR MOST RECENT BIRTH]

429. How many times did you breastfeed last night between sunset and sunrise?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE ANSWER.
[ASK ONLY FOR MOST RECENT BIRTH]

430. How many times did you breastfeed yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE ANSWER.
[ASK ONLY FOR MOST RECENT BIRTH]

431. Did (NAME) receive, at any moment yesterday or last night, any of the following:

Water?
Sugar Water?
Juice?
Herbal tea?
Baby formula?
Powdered or boxed milk?
Fresh (animal) milk?
Any other liquid?
Gruel?
Other food especially prepared for child?
Family dish?

[ASK ONLY FOR MOST RECENT BIRTH]

432. CHECK 431:
FOOD OR LIQUID GIVEN YESTERDAY?
[ASK ONLY FOR MOST RECENT BIRTH]

433. For how many months did you breastfeed (NAME)?
IF LESS THAN 1 MONTH, RECORD '00'.

434. Why did you stop breastfeeding (NAME)?

435. CHECK 216:
CHILD LIVING?

436. Have you ever given (NAME) water, or something else to eat or drink that wasn't breast milk?

437. How many months old was (NAME) when you began to regularly give them the following foods and drinks:

Boxed milk or milk other than breast milk?
Water?
Herbal tea?
Other liquids?
Gruel?
Solid foods?

IF LESS THAN ONE MONTH, RECORD '00'.

438. CHECK 216:
CHILD LIVING?
[ASK ONLY FOR MOST RECENT BIRTH]

439. Did (NAME) drink anything from a bottle yesterday or last night?
[ASK ONLY FOR MOST RECENT BIRTH]

440. RETURN TO 403 FOR THE NEXT BIRTH; OR (IF NO MORE BIRTHS, GO TO THE FIRST COLUMN OF 441.)

SECTION 4B: VACCINATION AND HEALTH

441. COMPLETE THE HEADING OF THE TABLE BY FOLLOWING THE SAME PROCEDURE AS FOR SECTION 4A. THERE IS AN IMPORTANT DIFFERENCE BETWEEN SECTIONS 4A AND 4B. SECTION 4A GATHERS INFORMATION ABOUT CHILDREN BOTH ALIVE AND DECEASED, WHEREAS SECTION 4B CONCERNS ONLY LIVING CHILDREN (442-477).

HOWEVER, YOU SHOULD COMPLETE THE HEADING OF THE TABLE IN SECTION 4B FOR ALL CHILDREN, LIVING OR DECEASED, BECAUSE THE QUESTIONS ABOUT THE TREATMENT OF CHILDREN'S DIARRHEA THAT ARE AT THE END OF THE SECTION (478-488) WILL BE ASKED OF ALL WOMEN.

441A. LINE NUMBER FROM 212:

441B. FROM 212 AND 216:

442. Do you have a vaccination card for (NAME)?
IF YES: May I see it please?

443. Did you ever have a vaccination card for (NAME)?

444. (1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD.
(2) WRITE '44' IN DAY COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED.

445. Has (NAME) received any vaccinations that are not recorded on this card?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS: BCG, POLIO 0-3, DPT 1-3, IMOVAX 1-2, MEASLES AND/OR YELLOW FEVER VACCINES.

446. Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases?

447. Please tell me if (NAME) received any of the following vaccinations:

A BCG vaccination against tuberculosis, that is, an injection in the left arm or shoulder that causes a scar?

Polio vaccine, that is, drops in the mouth?

A measles injection?

An injection from a gun or syringe?

450. Has (NAME) had a fever at any time in the last 2 weeks?

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

452. Has (NAME) suffered from a cough within the last 24 hours?

453. How many days did/has the cough last/lasted?
IF LESS THAN ONE DAY, RECORD '00'.

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

455. CHECK 450 AND 451:
FEVER OR COUGH?

456. Did you seek advice or treatment for the fever or cough?

457. Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED.

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

460. Has (NAME) had diarrhea within the last 24 hours?

461. How many days did/has the diarrhea last/lasted?
IF LESS THAN ONE DAY, RECORD '00'.

462. Was there blood in the stool?

463. CHECK 428:
LAST INFANT STILL BEING BREASTFED?
[DO NOT ASK FOR MOST RECENT BIRTH]

464. When (NAME) had diarrhea, did you change the number of feedings/nursings?
[DO NOT ASK FOR MOST RECENT BIRTH]

465. Did you increase or decrease the number of feedings, or did you stop them altogether?
[DO NOT ASK FOR MOST RECENT BIRTH]

466. (Besides breast milk), did you give the child the same amount to drink as before the diarrhea, more, or less?

467. Was anything given to treat the diarrhea?

468. What was given to treat the diarrhea? Anything else?
RECORD ALL TREATMENTS GIVEN.

469. Did you seek advice or treatment for the diarrhea?

470. Where did you seek advice or treatment? Anywhere else?
RECORD ALL MENTIONED.

471. CHECK 468:
LIQUID FROM ORS PACKET MENTIONED?

472. Did (NAME) receive a liquid prepared from a special packet of powder to treat diarrhea?

473. For how many days did (NAME) receive this liquid?
IF LESS THAN ONE DAY, RECORD '00'.

474. CHECK 468:
RECOMMENDED HOMEMADE LIQUID MENTIONED?

475. Did (NAME) receive a liquid recommended by a health personnel and prepared at home with a solution of salt and sugar water when he/she had diarrhea?

476. For how many days did (NAME) receive the liquid prepared with a solution of salt and sugar water? IF LESS THAN ONE DAY, RECORD '00'.

477. RETURN TO 441B FOR THE NEXT BIRTH. IF NO MORE BIRTHS, GO TO 478.

478. CHECK 468 AND 472, ALL COLUMNS:

479. Have you ever heard of a product called ORS you can get for the treatment of diarrhea?

480. Have you already used this product?

481. Where did you last obtain the ORS packet?

IF IT IS A HOSPITAL, MEDICAL CENTER OR CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

482. Do you currently have an ORS packet in your house?

483. May I see the ORS packet you have?
IF THE PACKET IS SHOWN, CIRCLE THE CORRESPONDING CODE.
NOTE THE BRAND NAME.

484. What is the brand name of the ORS packet that you have at this time?
NOTE THE BRAND NAME.

485. How much did the ORS packet you currently have cost you?

486. CHECK 468 AND 472, ALL COLUMNS:

487. Have you ever heard of a solution of salt, sugar and water that one prepares at home and gives to children to treat diarrhea?

488. Have you ever prepared this solution?

SECTION 5: MARRIAGE

501. PRESENCE OF OTHERS AT THIS POINT:

502. Are you currently married or living with a man as if married?

503. Do you currently have a regular sexual partner, an occasional sexual partner, or no sexual partner at all?

504. Have you ever been married or lived with a man as if married?

506. What is your marital status now: are you widowed, divorced, or separated?

507. Is your husband/partner living with you now or is he staying elsewhere?

507A. NOTE HER HUSBAND'S LINE NUMBER ACCORDING TO THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT PART OF THE HOUSEHOLD, RECORD '00'.

508. Does your husband/partner have any wives or partners other than you?

509. How many other wives or partners does your husband have?

510. Are you the first, second, ... wife?

511. INTERVIEWER: IF WOMAN IS CURRENTLY MARRIED/IN A UNION: Before your current marriage/union, were you married or did you live with a man, once or more than once?

511AA. INTERVIEWER: IF WOMAN IS WIDOWED/DIVORCED/SEPARATED: Were you married or did you live with a man, once or more than once?

511A. How much time passed between the end of your next-to-last union and the beginning of your last union (current union)? IF LESS THAN ONE YEAR, RECORD '00'.

512. CHECK 511 AND 511AA:

MARRIED/LIVED WITH A MAN ONLY ONCE: In what month and year did you start living with your husband/partner?

MARRIED/LIVED WITH A MAN MORE THAN ONCE: Now we are going to talk about your first husband/partner. In what month and year did you start living with him?

513. How old were you when you first started living with him?

514A. CHECK 502:

Now I would like to ask you some questions about your sexual activity in order to gain a better understanding of certain problems related to family planning.

515. How long has it been since the last time you had sexual intercourse with your husband/the man with whom you live?

IF NEVER HAD SEXUAL RELATIONS, RETURN TO 502, CIRCLE CODE '3' FOR MARRIAGE NOT CONSUMMATED AND FOLLOW THE NEW INSTRUCTIONS BEGINNING AT 502.

515A. CHECK 301 AND 302:

YES, SHE HAS HEARD OF CONDOMS: Did you use a condom during your last sexual encounter with your husband/the man with whom you live?

NO, SHE HAS NEVER HEARD OF CONDOMS: Certain men use a condom, that is, they put a rubber sheath on their penis before having sexual intercourse. Did you use a condom during your last sexual encounter with your husband/the man with whom you live?

515AA. During your last sexual encounter, who proposed using the condom?

515B. Have you had sexual intercourse with someone other than your husband/the man with whom you live in the last 12 months?

515C. When was the last time you had sexual intercourse with someone other than your husband/the man with whom you live?

515CA. The last time you had sexual intercourse with someone other than your husband/the man with whom you live, was it with a regular partner, an acquaintance, for money, or with someone else?

515D. Was a condom used on this occasion?

515DA. During this last sexual encounter, who proposed using the condom?

515E. With how many different people other than your husband/the man with whom you live have you had sexual intercourse in the last 12 months?

Now I would like to ask you some questions about your sexual activity in order to gain a better understanding of certain problems related to family planning.

515F. How long has it been since the last time you had sexual intercourse, if you have ever had sexual intercourse?

515FA. The last time you had sexual intercourse, was it with a regular partner, an acquaintance, for money, or with someone else?

515G. CHECK 301 AND 302:

YES, SHE HAS HEARD OF CONDOMS: Did you use a condom during your last sexual encounter?

NO, SHE HAS NEVER HEARD OF CONDOMS: Certain men use a condom, that is, they put a rubber sheath on their penis before having sexual intercourse. Did you use a condom during your last sexual encounter?

515GA. During this last sexual encounter, who proposed using the condom?

515H. CHECK 515F:

515I. In total, with how many people have you had sexual intercourse in the last 12 months?

517. Do you know of a place where a person can get condoms?

518. Where is that?
Any other place?

RECORD ALL RESPONSES MENTIONED. EACH TIME A HOSPITAL, HEALTH CENTER, A CSPS OR A CLINIC IS MENTIONED, PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

518A. CHECK 515A, 515D, AND 515G:

518B. Where did you obtain condoms the last time?

IF IT IS A HOSPITAL, HEALTH CENTER, A CSPS OR A CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

518C. What is the brand name of the condoms you used the last time?

518D. The last time you bought condoms, how many did you buy?
DETERMINE THE NUMBER OF CONDOMS AND RECORD THIS NUMBER.

518E. How much did you pay?

518F. If condoms had to be offered to you for free, would you accept them?
IF THE RESPONSE IS NO, PROBE TO DETERMINE THE REASON AND CIRCLE THE CORRESPONDING CODE.

519. What age were you when you had your first sexual encounter?

SECTION 6: FERTILITY PREFERENCES

601. CHECK 314:

602. CHECK 227:

NOT PREGNANT OR UNSURE: 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?

PREGNANT: 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?

603. CHECK 227:

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

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

604. CHECK 227:

605. If you were to become pregnant in the next several weeks, would you be happy, not happy, or indifferent?

606. CHECK 313:
USING A METHOD?

607. Do you think you will use a contraceptive method to delay or avoid pregnancy at any time in the next 12 months?

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

609. Which contraceptive method would you prefer to use?

610. What is the main reason that you think you will never use a contraceptive method?

611. Would you ever use a contraceptive method if you were married?

612. CHECK 216:

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

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

PROBE FOR A NUMERIC RESPONSE.

613. 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?

614. In general, do you approve or disapprove of couples that use a method to avoid becoming pregnant?

615. In your opinion, is it appropriate or inappropriate to speak of family planning:

On the radio?
On television?

616. Over the last few months, have you heard or read messages about family planning:

On the radio?
On the television?
In a newspaper or magazine?
On a poster?
In brochures?
On a billboard?
During a community meeting?
In a health center/by a health agent?
At the mosque, church or temple?
At school/by a teacher?
At the workplace?
By a relative/friend?
By a neighbor?
During a theatrical performance?

616A. What is your principal source of information on family planning?

616B. If you had to choose, from what source would you like to receive information on family planning?

IF MORE THAN ONE SOURCE CITED, ASK WHICH IS THE MOST PREFERRED AND CIRCLE THE CORRESPONDING CODE.

618. Over the last 12 months, have you discussed family planning with anyone?

619. With whom did you discuss it? Anyone else?
RECORD ALL PERSONS MENTIONED.

620. CHECK 502:

Spouses don't always agree on everything. Now I would like to ask you some questions about your husband's/partner's opinions on family planning.

621. Do you think that your husband/partner approves or disapproves of couples that use a method to avoid a pregnancy?

622. How many times over the last 12 months have you discussed family planning with your husband/partner?

622A. Generally, who begins the discussion about family planning, you, your husband/partner, or both?

622B. CHECK 313:
USING A CONTRACEPTIVE METHOD?

622C. Before starting to use (CURRENT METHOD), did you discuss which method to use with your husband/partner?

622D. After having started to use (CURRENT METHOD), did you discuss the method with your husband/partner?

622E. CHECK 314:
CIRCLE THE CODE OF THE METHOD:

622F. Did your husband/partner encourage you to use or discourage you from using (CURRENT METHOD)?

623. Do you think that your husband/partner wants the same number of children that you want, or does he want more or fewer than you want?

624. In your opinion, who should make the decision to use a method of family planning, the man or the woman?

625. In your opinion, who generally makes the decision to use a method of family planning, the man or the woman?

626. Do you think that your mother (or guardian) approves or disapproves of couples that use a method to avoid a pregnancy?

IF MOTHER OR GUARDIAN IS DECEASED, ASK THE QUESTION IN THIS MANNER: If your mother (guardian) were alive, do you think she would approve or disapprove of couples that use a method to avoid a pregnancy?

627. Do you think that your father (or guardian) approves or disapproves of couples that use a method to avoid a pregnancy?

IF FATHER OR GUARDIAN IS DECEASED, ASK THE QUESTION IN THIS MANNER: If your father (guardian) were alive, do you think he would approve or disapprove of couples that use a method to avoid a pregnancy?

628. Would you say that using contraception is contrary or not contrary to the precepts of your religion?

629. In your opinion, in order to raise a family's standard of living, is it preferable to have a small family or a large family?

630. Have you ever encouraged or tried to persuade a friend or relative to use family planning?

SECTION 7: HUSBAND'S BACKGROUND AND WOMAN'S WORK

701. CHECK 502 AND 504:

702. How old was your husband/partner on his last birthday?

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

704. What was the highest level of school he attended: primary, secondary (1st cycle), secondary (2nd cycle), or higher?

705. What was the highest grade he completed at that level?

706. What is (was) your husband's/partner's occupation? That is, what kind of work does (did) he mainly do?

707. CHECK 706:

708. Did/Does your husband/partner work mainly on his own land or on family land, or does/did he work on land that he rents/rented from someone else, or does/did he work on someone else's land?

709. Aside from your own housework, do you currently work?

710. As you know, some women take up jobs for which they are paid in cash or kind. Some have a small business or work on the family farm or in the family business. Do you currently do any of these things or any other work?

711. Have you done any work in the last 12 months?

712. What is your occupation, that is, what kind of work do you mainly do?

713. CHECK 710:

714. Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else's land?

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

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

SECTION 8: AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

801A. Have you ever heard about infections that can be transmitted through sexual contact?

801B. Which ones do you know of?
RECORD ALL MENTIONED.

801C. CHECK 515:

801D. In the last 12 months, have you had one of these infections?

801E. Which infections did you have?
RECORD ALL MENTIONED.

801F. The last time you had (INFECTION FROM 801E), did you seek advice or treatment?

801G. Where did you seek advice or treatment?
RECORD ALL MENTIONED.

801H. When you had (INFECTION(S) FROM 801E), did you inform your sexual partner(s)?

801I. When you had (INFECTION(S) FROM 801E), did you do anything to avoid infecting your sexual partner(s)?

801J. What did you do?
RECORD ALL MENTIONED.

801K. CHECK 801B:

801L. Have you ever heard of an illness called AIDS?

802. From which sources have you heard about AIDS?
INSIST: Any other sources? RECORD ALL MENTIONED.

802AA. INTERVIEWER: IF YOU HAVE ONLY CIRCLED ONE CODE IN 802, CIRCLE THE CODE CORRESPONDING TO THE SAME RESPONSE HERE AND CONTINUE TO 802AB.

IF YOU CIRCLED MULTIPLE CODES IN 802, ASK THE FOLLOWING QUESTION AND CIRCLE THE CODE THAT CORRESPONDS TO THE RESPONSE: Amongst the sources you cited, which is the primary source?

802AB. If you had to choose, from which source would you prefer to receive information on AIDS?

IF MULTIPLE SOURCES ARE CITED, ASK WHICH IS THE PREFERRED SOURCE AND CIRCLE THE CORRESPONDING CODE.

802B. In your opinion, how can someone get AIDS?
INSIST: Any other way? RECORD ALL MENTIONED.

803. Is there something people can do to avoid contracting AIDS or the virus that causes AIDS?

804. In your opinion, what can one do?
PROBE: Anything else? RECORD ALL MENTIONED.

807. Is it possible for a healthy-looking person to have AIDS?

808. Do you think that a person with AIDS almost never dies from it, sometimes dies from it, or almost always dies from it?

808A. Can AIDS can be cured?

808B. Can AIDS be passed from mother to child?

808C. Do you personally know anyone who has AIDS or has died of AIDS?

808D. In your opinion, what should be done with people sick with AIDS?

809. Do you think your risk of getting AIDS is small, moderate, significant, or do you think you run no risk at all in contracting AIDS?

809B. Why do you think your risk of getting AIDS is small/Why do you think you run no risk of getting AIDS? Are there other reasons? RECORD ALL MENTIONED.

809C. Why do you think your risk of getting AIDS is moderate/Why do you think your risk of getting AIDS is significant? Are there other reasons? RECORD ALL MENTIONED.

811A. Since you've heard about AIDS, have you changed your behavior in order to avoid getting the illness? IF YES, INSIST: What have you done? Anything else?
RECORD ALL MENTIONED.

811B. Has knowing about AIDS influenced or changed your decision to have sexual relations or your sexual behavior? IF YES: In what way? RECORD ALL MENTIONED.

811C. Some people use a condom during sexual intercourse to protect themselves from AIDS and other sexually transmitted infections. Have you already heard of this?

811D. CHECK 515 AND 515F:

811E. We might have already talked about this. Have you ever used a condom during sexual relations to avoid catching or transmitting illnesses such as AIDS?

811EA. Do you use a condom from time to time, often, or every time you have sexual relations?

811F. CHECK 515 AND 515F:

811G. During the last 12 months, have you given or received money, gifts or favors in exchange for sexual intercourse?

SECTION 9: FEMALE CIRCUMCISION

Now I would like to ask you questions about female circumcision, which consists of the total or partial removal of the external parts of a woman's genitalia. This practice exists within certain societies in Burkina and other countries.

901. Have you ever heard of female circumcision?

902. Have you been circumcised?

903. What type of circumcision did you receive?

904. How old were you at the time of your circumcision?

905. Who performed your circumcision?

906. During your circumcision, did they partially or completely close the vaginal opening by sewing a seam?

907. At the time of your first menstrual period or at the time of your marriage, did the vaginal zone have to be opened by making an incision?

908. CHECK 214 AND 216:

909. Has (NAME OF ELDEST DAUGHTER) undergone this practice?

910. What type of circumcision did (NAME OF ELDEST DAUGHTER) receive?

911. What age was she at the time of her circumcision?

912. Who performed her circumcision?

913. Did anyone object to (NAME OF ELDEST DAUGHTER)'s circumcision? Anyone else? RECORD ALL PERSONS MENTIONED.

914. Do you intend to have her circumcised?

915. Do you think that someone around you (family, friends) could, without your permission, have your daughter circumcised?

915A. Who makes the decision to circumcise a girl?

916. Do you think that the practice of female circumcision should continue to be practiced, or on the contrary, that it should not continue to be practiced?

917. Why do you think that the practice of female circumcision should continue to be practiced? Any other reason? RECORD ALL MENTIONED.

918. What do you mean by GOOD TRADITION/CUSTOM AND TRADITION?
RECORD ALL RESPONSES MENTIONED.

919. Why do you think that the practice of female circumcision should be stopped?
Any other reason? RECORD ALL MENTIONED.

920. What do you mean by BAD TRADITION?
RECORD ALL MENTIONED.

920A. In the last six months, have you heard or seen something about female circumcision:

On the radio?
On the television?
In a newspaper or magazine?
On a poster?
In brochures?
On a billboard?
During a community meeting?
In a health center/by a health agent?
At the mosque, church or temple?
At school/by a teacher?
At the workplace?
By a relative/friend?
By a neighbor?
During a theatrical performance?

920B. What is your principal source of information on female circumcision?

920C. If you had to choose, from what source would you prefer to receive information on female circumcision?

920D. Do you know that a law exists in Burkina that prohibits female circumcision?

SECTION 10: MATERNAL MORTALITY

Now, I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your natural mother including those that live with you, those that live elsewhere, and those that are deceased.

1001. To how many children did your mother give birth in total, including yourself?

1002. CHECK 1001:

1003. How many of your brothers and sisters were born alive before you?

1004. What was the name given to your oldest (next oldest) brother or sister?

1005. Is (NAME) male or female?

1006. Is (NAME) still alive?

1007. How old is (NAME)?

1008. In what year did (NAME) die?

1009. How many years ago did (NAME) die?

1010. How old was (NAME) when he/she died?

1011. Was (NAME) pregnant when she died?

1012. Did (NAME) die during childbirth?

1013. Did (NAME) die within two months after the end of a pregnancy or childbirth?

1014. Did (NAME) die due to complications from pregnancy or childbirth?

1015. How many children did (NAME) give birth to?

[IF NO MORE SIBLINGS, GO TO 916.]

1016. RECORD THE TIME:

SECTION 11: HEIGHT AND WEIGHT

1101. CHECK 215, 216:

INTERVIEWER: IN 1102 (COLUMNS 2-4) RECORD THE LINE NUMBER OF EACH CHILD BORN SINCE JANUARY 1993 WHO IS STILL ALIVE.

IN 1103 AND 1104, RECORD THE NAME AND DATE OF BIRTH OF THE RESPONDENT AND EACH LIVING CHILD BORN SINCE JANUARY 1993.

IN 1106 AND 1108, RECORD THE WEIGHT AND HEIGHT OF THE RESPONDENT AND HER LIVING CHILDREN.

NOTE: ALL RESPONDENTS HAVING A BIRTH SINCE JANUARY 1993 MUST BE WEIGHED AND MEASURED, EVEN IF THE CHILDREN ARE DECEASED. IF THERE ARE MORE THAN 3 LIVING CHILDREN BORN AFTER JANUARY 1993, USE AN ADDITIONAL QUESTIONNAIRE.

1102. LINE NUMBER ACCORDING TO 212:
[ASK FOR RESPONDENT'S CHILDREN ONLY]

1103. NAME (ACCORDING TO 212 FOR CHILDREN)

1104. BIRTH DATE (ACCORDING TO 215 AND ASK FOR DAY OF BIRTH)
[ASK FOR RESPONDENT'S CHILDREN ONLY]

1105. TB VACCINE SCAR ON THE TOP OF LEFT SHOULDER?
[ASK FOR RESPONDENT'S CHILDREN ONLY]

1106. HEIGHT IN CENTIMETERS:

1107. WAS THE CHILD MEASURED LYING DOWN OR STANDING UP?
[ASK FOR RESPONDENT'S CHILDREN ONLY]

1108. WEIGHT (IN KILOGRAMS):

1109. DATE OF HEIGHT AND WEIGHT MEASUREMENT:

1110. RESULT:

1111. NAME OF OPERATOR _____
OPERATOR CODE _____

NAME OF ASSISTANT _____
ASSISTANT CODE:

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW.

COMMENTS ABOUT RESPONDENT _____

COMMENTS ON SPECIFIC QUESTIONS _____

ANY OTHER COMMENTS _____

SUPERVISOR'S OBSERVATIONS _____
NAME OF SUPERVISOR _____
DATE _____

EDITOR'S OBSERVATIONS _____
NAME OF EDITOR _____
DATE _____