IDENTIFICATION

PLACE NAME ______
CLUSTER NUMBER _____
PLOT NUMBER _____
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD _____
HOUSEHOLD NUMBER _____
REGION _____

URBAN/RURAL:

MILIEU:

NAME OF WOMAN _____

LINE NUMBER OF WOMAN _____

WOMAN SELECTED FOR HOUSEHOLD RELATIONSHIPS SECTION?

CHECK COVER OF HOUSEHOLD QUESTIONNAIRE:
IS THE ANEMIA/HIV TEST PLANNED FOR THIS HOUSEHOLD?

INTERVIEWER VISITS

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

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR 2010
INT. NAME _____
RESULT _____

TOTAL NUMBER OF VISITS _____

LANGUAGE OF QUESTIONNAIRE: FRENCH 01

LANGUAGE OF INTERVIEW:

INTERPRETER:

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____

KEYED BY _____

SECTION 1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENT

INTRODUCTION AND CONSENT:

INFORMED CONSENT:

Hello. My name is ___. I am working with the National Institute of Statistics and Demography (INSD). We are conducting a survey about health all over Burkina Faso. The information we collect will help the government to plan health services.

Your household was selected for the survey. The questions usually take about 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.

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

SIGNATURE OF INTERVIEWER_____
DATE_____

101. RECORD THE TIME:

102. In what month and year were you born?

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

104. Have you ever attended school?

105. What is the highest level of school you attended: primary, secondary 1 (1st cycle), secondary 2 (2nd cycle), or higher?

106. What is the highest (grade/form/year) you completed at this level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '0'.

107. CHECK 105:

108. 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?

109. CHECK 108:

110. Do you read a newspaper or magazine at least once a week, less than once a week or not at all?

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

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

113. What is your religion?

114. What is your ethnicity (for Burkinabés)/nationality (for foreigners)?

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

116. In the last 12 months, have you been away from home for more than one month at a time?

SECTION 2. REPRODUCTION

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

201. Have you ever given birth?

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

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

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

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

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

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

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

209. CHECK 208:
Just to makes 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 ROWS. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.)

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

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

214. Were any of these births twins?

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

216. Is (NAME) still alive?

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

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

219. IF ALIVE: RECORD HOUSEHOLD LINE NUMBER OF CHILD.
RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD.

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

221. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth?
[DO NOT ASK FOR FIRST BIRTH]

222. Have you had any live births since the birth of (NAME OF LAST BIRTH)?
IF YES, RECORD BIRTHS IN TABLE.

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

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

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

226. Are you pregnant now?

227. How many months pregnant are you?

C:
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'G's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

228. When you got pregnant, did you want to get pregnant at that time?

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

230. Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?

231. When did the last such pregnancy end?

232. CHECK 231:

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

C:
RECORD THE NUMBER OF COMPLETED MONTHS. ENTER 'F' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'G' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

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

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

C:
ENTER 'F' IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'G' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236. Did you have any miscarriages, abortions or stillbirths that ended before 2005?

237. When did the last such pregnancy that terminated before 2005 end?

238. When did your last menstrual period start?
RECORD THE DATE, IF GIVEN.

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

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

SECTION 3. CONTRACEPTION

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

301. Have you ever heard of (METHOD)?

302. CHECK 226:

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

304. Which method are you using?

CIRCLE ALL MENTIONED. IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.

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

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

307. In what facility did the sterilization take place?

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

308. In what month and year was the sterilization performed?
308A. Since what month and year did you start using (CURRENT METHOD) without stopping?
PROBE: For how long have you been using (CURRENT METHOD FIRST MENTIONED) now without stopping?

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

310. CHECK 308/308A

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

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

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

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

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

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

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

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

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

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

315. You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time?
315A. Where did you learn how to use the rhythm/lactational amenorrhea method?

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

316. CHECK 304:
CIRCLE METHOD CODE. IF THERE IS MORE THAN ONE CODE CIRCLED IN 304, CIRCLE THE FIRST/HIGHEST CODE ON THE LIST.

317. At that time, where you told about side effects or problems you might have with the method?
317A. When you got sterilized, were you told about side effects or problems you might have with the method?

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

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

320. CHECK 317:

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

CODE '1' NOT CIRCLED: When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?

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

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

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

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

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

325. Where is that?
Any other place?

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

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

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

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

SECTION 4. PREGNANCY AND POSTNATAL CARE

401. CHECK 224:

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

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

403. BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY:

404. FROM 212 AND 216:

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

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

407. How much longer did you want to wait?

408. Did you see anyone for antenatal care for this pregnancy?
[ASK ONLY FOR MOST RECENT BIRTH]

409. Whom did you see?
Anyone else?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
[ASK ONLY FOR MOST RECENT BIRTH]

410. Where did you receive this antenatal care for this pregnancy?
Anywhere else?

PROBE TO IDENTITY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
[ASK ONLY FOR MOST RECENT BIRTH]

411. How many months pregnant were you the last time you received antenatal care?
[ASK ONLY FOR MOST RECENT BIRTH]

412. How many times did you receive antenatal care during this pregnancy?
[ASK ONLY FOR MOST RECENT BIRTH]

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

Was your blood pressure measured?
Did you give a urine sample?
Did you give a blood sample?

[ASK ONLY FOR MOST RECENT BIRTH]

414. During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy?
[ASK ONLY FOR MOST RECENT BIRTH]

415. During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?
[ASK ONLY FOR MOST RECENT BIRTH]

416. During this pregnancy, how many times did you get this injection?
[ASK ONLY FOR MOST RECENT BIRTH]

417. CHECK 416:
[ASK ONLY FOR MOST RECENT BIRTH]

418. At any time before this pregnancy, did you receive any tetanus injections?
[ASK ONLY FOR MOST RECENT BIRTH]

419. Before this pregnancy, how many times did you receive a tetanus injection?
IF 7 OR MORE TIMES, RECORD '7'.
[ASK ONLY FOR MOST RECENT BIRTH]

420. How many years ago did you receive the last tetanus injection before this pregnancy?
[ASK ONLY FOR MOST RECENT BIRTH]

421. During this pregnancy, were you given or did you buy iron tablets or iron syrup?
SHOW TABLES/SYRUP.
[ASK ONLY FOR MOST RECENT BIRTH]

422. During the whole pregnancy, for how many days did you take the tables or syrup?
IF ANSWER NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.
[ASK ONLY FOR MOST RECENT BIRTH]

423. During this pregnancy, did you take any drug for intestinal worms?
[ASK ONLY FOR MOST RECENT BIRTH]

424. During this pregnancy, did you take any drugs to keep you from getting malaria?
[ASK ONLY FOR MOST RECENT BIRTH]

425. What drugs did you take?
RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.
[ASK ONLY FOR MOST RECENT BIRTH]

426. Check 425:
SP/FANSIDAR TAKEN FOR MALARIA PREVENTION?
[ASK ONLY FOR MOST RECENT BIRTH]

427. How many times did you take (SP/Fansidar) during this pregnancy?
[ASK ONLY FOR MOST RECENT BIRTH]

428. CHECK 409:
ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY?
[ASK ONLY FOR MOST RECENT BIRTH]

429. Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility, or from another source?
[ASK ONLY FOR MOST RECENT BIRTH]

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

431. Was (NAME) weighed at birth?

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

433. Who assisted with the delivery of (NAME)?
Anyone else?

PROBE FOR THE TYPE OF PERSON AND RECORD ALL PEOPLE ASSISTING. IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE IF ANY ADULTS WERE PRESENT AT THE DELIVERY.

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

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

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

436. After (NAME) was born, did someone check on your health while you were still in the facility? [ASK ONLY FOR MOST RECENT BIRTH]

437. Did anyone check on your health after you left the facility?
[ASK ONLY FOR MOST RECENT BIRTH]

438. After (NAME) was born, did someone check on your health?
[ASK ONLY FOR MOST RECENT BIRTH]

439. Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.
[ASK ONLY FOR MOST RECENT BIRTH]

440. How long after delivery did the first check take place?
IF LESS THAN ONE DAY, RECORD IN HOURS. IF LESS THAN ONE WEEK, RECORD DAYS. [ASK ONLY FOR MOST RECENT BIRTH]

441. CHECK 437:
[ASK ONLY FOR MOST RECENT BIRTH]

442. In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health? [ASK ONLY FOR MOST RECENT BIRTH]

443. How many hours, days, or weeks after the birth of (NAME) did the first check take place?
IF LESS THAN ONE DAY, RECORD IN HOURS. IF LESS THAN ONE WEEK, RECORD DAYS. [ASK ONLY FOR MOST RECENT BIRTH]

444. Who checked on (NAME)'s health at that time?
PROBE FOR THE MOST QUALIFIED PERSON.
[ASK ONLY FOR MOST RECENT BIRTH]

445. Where did this first check of (NAME) take place?
[ASK ONLY FOR MOST RECENT BIRTH]

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

446. In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)? SHOW COMMON TYPES OF AMPOULES/CAPSULES/SYRUPS.
[ASK ONLY FOR MOST RECENT BIRTH]

447. Has your menstrual period returned since the birth of (NAME)?
[ASK ONLY FOR MOST RECENT BIRTH]

448. Did your period return between the birth of (NAME) and your next pregnancy?
[DO NOT ASK FOR MOST RECENT BIRTH]

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

450. CHECK 226:
IS RESPONDENT PREGNANT?
[ASK ONLY FOR MOST RECENT BIRTH]

451. Have you had sexual intercourse since the birth of (NAME)?
[ASK ONLY FOR MOST RECENT BIRTH]

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

453. Did you ever breastfeed (NAME)?

454. CHECK 404:
CHILD IS LIVING?
[ASK ONLY FOR MOST RECENT BIRTH]

455. How long after birth did you first put (NAME) to the breast?
IF LESS THAN 1 HOUR, RECORD '00' HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS.
[ASK ONLY FOR MOST RECENT BIRTH]

456. In the first three days after delivery, was (NAME) given anything to drink other than breast milk? [ASK ONLY FOR MOST RECENT BIRTH]

457. What was (NAME) given to drink? Anything else?
RECORD ALL LIQUIDS MENTIONED.
[ASK ONLY FOR MOST RECENT BIRTH]

458. CHECK 404:
IS CHILD LIVING?

459. Are you still breastfeeding (NAME)?

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

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

SECTION 5. CHILD IMMUNIZATION, HEALTH AND NUTRITION

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

502. BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY:

503. FROM 212 AND 216:

504. Do you have a card where (NAME)'s vaccinations are written down?
IF YES: May I see it please?

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

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

507. CHECK 506:

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

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

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

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

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

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

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

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

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

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

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

511. Within the last six months, was (NAME) given a vitamin A dose like (this/any of these)?
SHOW COMMON TYPES OF AMPOULES/CAPSULES/SYRUPS.

512. In the last seven days, was (NAME) given iron pills, sprinkles with iron, or iron syrup like (this/any of these)? SHOW COMMON TYPES OF PILLS/SPRINKLES/SYRUPS.

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

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

515. Was there any blood in the stools?

516. Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk). Was he/she given less than usual to drink, about the same amount, or more than usual to drink?

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

517. When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?

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

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

519. Where did you seek advice or treatment? Anywhere else?

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

520. CHECK 519:

521. Where did you first seek advice or treatment?

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

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

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

524. What (else) was given to treat the diarrhea? Anything else?
RECORD ALL TREATMENTS GIVEN.

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

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

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

528. When (NAME) had an illness with a cough, did he/she breath faster than usual with short, rapid breaths?

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

530. CHECK 525:
HAD FEVER?

531. Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). Was he/she given less than usual to drink, about the same amount, or more than usual to drink?

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

532. When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?

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

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

534. Where did you seek advice or treatment? Anywhere else?

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

535. CHECK 534:

536. Where did you first seek advice or treatment?

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

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

539. CHECK 538:
ANY CODE A-F CIRCLED?

540. CHECK 538:
SP/FANSIDAR (A) GIVEN?

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

542. CHECK 538:
CHLOROQUINE (B) GIVEN?

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

544. CHECK 538:
AMODIAQUINE (C) GIVEN?

545. How long after the fever started did (name) first take (Amodiaquine)?

546. CHECK 538:
QUININE (D) GIVEN?

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

548. CHECK 538:
COMBINATION WITH ARTEMISININ (E) GIVEN?

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

550. CHECK 538:
OTHER ANTIMALARIAL (F) GIVEN

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

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

553. CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2005 OR LATER LIVING WITH THE RESPONDENT.
IF ONE OR MORE, RECORD NAME OF YOUNGEST CHILD LIVING WITH HER.

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

555. CHECK 522A AND 522B, ALL COLUMNS:

556. Have you ever heard of a special product called (NAME OF ORS PACKET OR PRE-PACKAGED ORS LIQUID) that you can get for the treatment of diarrhea?

557. CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2008 OR LATER LIVING WITH RESPONDENT?
IF ONE OF MORE, RECORD NAME OF YOUNGEST CHILD LIVING WITH HER

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

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

a) Plain water?
b) Juice or juice drinks?
c) Clear broth?
d) Milk such as tinned, powdered, or fresh animal milk?
e) Infant formula?
f) Any other liquids?
g) Yogurt?
h) Any (Brand name of commercially fortified baby food, e.g. Cerelac)?
i) Bread, rice, noodles, porridge, or any other foods made from grains?
j) Pumpkin, carrots, squash or sweet potatoes that are yellow or orange inside?
k) White potatoes, white yams, manioc, cassava, or any other foods made from roots?
l) Any dark green, leafy vegetables?
m) Ripe mangoes, papayas or (INSERT ANY OTHER LOCALLY AVAILABLE VITAMIN A-RICH FRUITS)?
n) Any other fruits or vegetables?
o) Liver, kidney, heart or any other organ meats?
p) Any meat, such as beef, pork, lamb, goat, chicken or duck?
q) Eggs?
r) Fresh or dried fish or shellfish?
s) Any foods made from beans, peas, lentils, or nuts?
t) Cheese or other foods made from milk?
u) Any other solid, semi-solid, or soft food?

559. CHECK 558 (CATEGORIES 'G' THROUGH 'U'):

560. Did name eat any solid, semi-solid or soft foods yesterday during the day or at night?
IF YES, PROBE: What kind of solid, semi-solid, or soft foods yesterday during the day or at night?

561. How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD '7'.

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

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

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

603. What is your current marital status: are you a widow, divorced, or separated?

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

605. RECORD THE LINE NUMBER OF HER HUSBAND/PARTNER ACCORDING TO THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

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

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

608. Are you the first, second?wife?

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

610. CHECK 609:

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

MARRIED/LIVED WITH MAN MORE THAN ONCE: I would like to talk about the first time you were married or started living with a man as if married. In what month and year was that?

611. How old were you when you started living with him?

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

Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues.

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

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

615. When was the last time you had sexual intercourse?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS. IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

[ASK QUESTIONS 616-626 FOR LAST (THREE) SEXUAL PARTNER(S)]

616. When was the last time you had sexual intercourse with this person?
[DO NOT ASK THIS FOR LAST SEXUAL PARTNER]

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

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

619. What was your relationship to this person with whom you had sexual intercourse?
IF BOYFRIEND: Were you living together as if married? IF YES, CIRCLE '2'. IF NO, CIRCLE '3'.

620. CHECK 609:

621. CHECK 613:

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

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

624. How old is this person?

625. Apart from (this person/these two people), have you had sexual intercourse with any other persons in the last 12 months?
[DO NOT ASK FOR THIRD-TO-LAST PARTNER]

626. In total, how many different people have you had sexual intercourse with in the last 12 months? [ASK ONLY FOR THIRD-TO-LAST SEXUAL PARTNER]

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

627. In total, how many different people have you had sexual intercourse with in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.

628. PRESENCE OF OTHERS DURING THIS SECTION:

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

630. Where is that?
Any other place?

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

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

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

633. Where is that?
Any other place?

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

634. If you wanted to, could you yourself get a female condom?

SECTION 7. FERTILITY PREFERENCES

701. CHECK 304:

702. CHECK 226:

Now I have some questions about the future.

703. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?

704. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

705. CHECK 226:

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

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

706. CHECK 226:

707. CHECK 303:
USING A CONTRACEPTIVE METHOD?

708. CHECK 705:

709. CHECK 703 AND 704:

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

WANTS NO MORE/NONE: You have said that you do not want any (more) children Can you tell me why you are not using a method to prevent pregnancy? Any other reason?

RECORD ALL REASONS MENTIONED.

710. CHECK 303:
USING A CONTRACEPTIVE METHOD?

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

712. CHECK 216:

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

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

PROBE FOR A NUMERIC RESPONSE.

713. How many of these children would you like to be boys, how many would you like to be girls, and for how many would it not matter?

714. In the last few months have you:

Heard about family planning on the radio?
Heard about family planning on the television?
Heard about family planning in cultural/educational cartoons?
Heard about family planning at school?
Read something on family planning in a newspaper or magazine?
Read something about family planning on posters or leaflets?

715. Do you think it's acceptable or unacceptable to talk about family planning:

On the radio?
On television?
In cultural/educational cartoons?
At school?
In newspapers or magazines?
In posters or leaflets?

715A. In the last few months, have you discussed the practice of family planning with your friends, your neighbors, your relatives or anyone else?

715B. With whom? Anyone else?
RECORD ALL PERSONS MENTIONED.

Now I want to ask you about your husband's/partner's views on family planning.

715C. Do you think your husband/partner approves or disapproves of couples using a contraceptive method to avoid pregnancy?

715D. How often have you talked to your husband/partner about family planning in the last twelve months?

716. CHECK 601:

717. CHECK 303:
USING A CONTRACEPTIVE METHOD?

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

719. CHECK 304:

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

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

801. CHECK 601 AND 602:

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

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

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

805. What was the highest (grade/form/year) he completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '0'.

806. CHECK 801:

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

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

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

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

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

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

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

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

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

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

815. CHECK 601:

816. CHECK 814:

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

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

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

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

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

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

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

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

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

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

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

SECTION 9. HIV/AIDS

Now I would like to talk about something else.

901. Have you ever heard of an illness called AIDS?

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

903. Can people get the AIDS virus from mosquito bites?

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

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

906. Can people get the AIDS virus because of witchcraft or other supernatural means?

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

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

During pregnancy?
During delivery?
By breastfeeding?

909. CHECK 908:

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

911. CHECK 208 AND 215:

912. CHECK 408 FOR LAST BIRTH:

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

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

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

915. Were you offered a test for that AIDS virus as part of your antenatal care?

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

917. Where was the test done?

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

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

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

920. CHECK 434 FOR LAST BIRTH:

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

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

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

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

925. How many months ago was your most recent HIV test?

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

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

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

929. Where was the test done?

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

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

931. Where is that?
Any other place?

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

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

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

934. If a relative of yours became sick with the virus that causes AIDS, would you be willing to care for her or him in your own household?

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

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

937. CHECK 901:

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

NOT HEARD ABOUT AIDS: Have you heard about infections that can be transmitted through sexual contact?

938. CHECK 613:

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

Now I would like to ask you some questions about your health in the last 12 months.

940. During the last 12 months, have you had a disease which you got through sexual contact?

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

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

943. CHECK 940, 941, AND 942:

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

945. Where did you go?
Any other place?

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

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

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

948. CHECK 601:

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

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

SECTION 10. OTHER HEALTH ISSUES

Now I would like to ask you some other questions relating to health matters.

1001. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?

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

1002. Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or another healthcare worker?

IF THE NUMBER OF INJECTIONS IS OVER 90 OR IF THERE WERE DAILY INJECTIONS IN THE LAST 3 MONTHS OR LONGER, RECORD '90'. IF THE RESPONSE IS NOT NUMERIC, PROBE TO OBTAIN AN ESTIMATE.

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

1004. Do you currently smoke cigarettes?

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

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

1007. What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.

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

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

1009. Are you covered by any health insurance?

1010. What type of health insurance are you covered by?
RECORD ALL MENTIONED.

1011. CHECK 217:

Now I would like to talk about your own children under 18 years old.

1012. Have you made any arrangements for someone to take care of these children if you were to get sick or if you were no longer able to take care of them?

1013. (Other than your own child/children) are you in charge of any children under 18 years old?

1014. Have you made any arrangements for someone to take care of these children if you were to get sick or if you were no longer able to take care of them?

1015. Have you ever heard of breast cancer or cervical cancer?

1016. Have you ever had a breast cancer or cervical cancer screening?

SECTION 11. FEMALE GENITAL CUTTING

1101. Have you ever heard of female circumcision?

1102. In some countries, there is a practice in which a girl may have part of her genitals cut. Have you ever heard about this practice?

1103. Have you yourself ever been circumcised?

1104. Now I would like to ask you what was done to you at that time.
Was any flesh removed from the genital area?

1105. Was the genital area just nicked without removing any flesh?

1106. Was your genital area sown closed?

1107. How old were you when you were circumcised?
IF THE RESPONDENT DOES NOT KNOW THE EXACT AGE, PROBE TO GET AN ESTIMATE.

1108. Who performed the circumcision?

1109. CHECK 213, 215, AND 216:

CHECK 213, 215, AND 216: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER AND NAME OF EACH LIVING DAUGHTER BORN IN 1995 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE DAUGHTERS. BEGIN WITH THE YOUNGEST DAUGHTER. (IF THERE ARE MORE THAN 6 DAUGHTERS, USE ADDITIONAL QUESTIONNAIRES).

Now I would like to ask you some questions about your (daughter/daughters).

1110. BIRTH HISTORY NUMBER AND NAME OF EACH LIVING DAUGHTER BORN IN 1995 OR LATER:

1111. Is (NAME OF DAUGHTER) circumcised?

1112. How old was (NAME OF DAUGHTER) when she was circumcised?
IF THE RESPONDENT DOES NOT KNOW THE AGE, PROBE TO GET AN ESTIMATE.

1113. Was her genital area sown closed?
PROBE: Was the genital area closed?

1114. Who performed the circumcision?

1115. GO BACK TO 1111 OR IF NO MORE DAUGHTERS, GO TO 1116.

1116. Do you believe that female circumcision is required by your religion?

1117. Do you think that female circumcision should be continued, or should it be stopped?

SECTION 12. FISTULA

1201. Sometimes a woman can have a problem of constant leakage of urine or stool from her vagina during the day and night. This problem usually occurs after a difficult childbirth, but may also occur after a sexual assault or after pelvic surgery. Have you ever experienced a constant leakage of urine or stool from your vagina during the day and night?

1202. Have you ever heard of this problem?

1203. Did this problem start after you delivered a baby?

1204. What do you think caused this problem?

1205. Did this problem start after a normal labor and delivery, or after a very difficult labor and delivery?

1206. Was this baby born alive?

1207. How many days after (CAUSE OF PROBLEM FROM 1203 OR 1204) did the leakage start? ENTER '90' IF 90 DAYS OR MORE.

1208. Have you sought treatment for this condition?

1209. Why have you not sought treatment?
PROBE AND RECORD ALL MENTIONED.

1210. From whom did you last seek treatment?

1211. Did the treatment stop the leakage completely?
IF NO: did the treatment reduce the leakage?

SECTION 13. HOUSEHOLD RELATIONSHIPS

1301. CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE:
RESPONDENT SELECTED FOR HOUSEHOLD RELATIONSHIPS?

1301A. CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED. CIRCLE CODE CORRESPONDING TO THE SITUATION AND FOLLOW INSTRUCTIONS FOR CONTINUATION.

READ TO THE RESPONDENT:

Now I would like to ask you some questions about certain aspects of your relationship as a couple. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in Burkina Faso. Let me assure you that your answers are completely confidential and will not be told to anyone. Additionally, you are the only person in your household that is being asked these questions and no one will know that you were asked these questions. If someone arrives while we are talking, we will talk about something else.

1302. CHECK 601, 602, AND 603:

1303. When two people marry or live together, they share both good and bad moments. In your relationship with your (last) husband/partner do (did) the following happened frequently, only sometimes, or never?

a) He usually (spends/spent) his free time with you?
b) He (consults/consulted) you on different household matters?
c) He (is/was) affectionate with you?
d) He (respects/respected) you and your wishes?

1304. Now 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 permit you to meet your girlfriends?
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 with any money?
g) He (prevents/prevented) you from working or he (isn't/wasn't) ok with you working?

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

1305A. (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 you care about?

1305B. How many times did this happen during the last 12 months?

a) Say or do something to humiliate you in front of others?

b) Threaten to hurt or harm you or someone you care about?

1306. Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner:

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

a) Push you, shake you, or throw something at you?

b) Slap you or twist your arm?

c) Punch you with his fist or with something that could hurt you?

d) Kick you or drag you?

e) Try to strangle you or burn you?

f) Threaten you with a knife, gun, or other type of weapon?

g) Attack you with a knife, gun, or other type of weapon?

h) Physically force you to have sexual intercourse with him even when you did not want to?

i) Force you to perform other sexual acts you did not want to?

1306B. How many times did this happen during the last 12 months?
IF WIDOW, DIVORCED, OR SEPARATED, RECORD '95'.

a) Push you, shake you, or throw something at you?

b) Slap you or twist your arm?

c) Punch you with his fist or with something that could hurt you?

d) Kick you or drag you?

e) Try to strangle you or burn you?

f) Threaten you with a knife, gun, or other type of weapon?

g) Attack you with a knife, gun, or other type of weapon?

h) Physically force you to have sexual intercourse with him even when you did not want to?

i) Force you to perform other sexual acts you did not want to?

1307. CHECK 1306:

1308. How long after you first got married to/started living with your (last) husband/partner did (this/any of these things) first happen?

1309A. Did the following ever happen because of something your (last) husband/partner did to you?

a) You had bruises and aches?

b) You had an injury, a broken bone, or a sprain?

c) You went to the doctor or health center as a result of something your husband/partner did to you?

1309B. How many times did this happened during the last 12 months?

a) You had bruises and aches?

b) You had an injury, a broken bone, or a sprain?

c) You went to the doctor or health center as a result of something your husband/partner did to you?

1310A. Did you ever do or say something to humiliate or threaten your (last) husband/partner in front of others?

1310B. How long after you first got married to/started living with your (last) husband/partner did (this/any of these things) first happen?

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

1311. In the last 12 months, how many times have you hit, slapped, kicked or done something to physically hurt your (last) husband/partner at a time when he was not already beating or physically hurting you?

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

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

1314. CHECK 1302:

MARRIED/LIVED WITH A MAN/SEPARATED/DIVORCED: 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?

NEVER MARRIED/NEVER LIVED WITH A MAN: From the time you were 15 years old has anyone ever hit, slapped, kicked, or done anything else to hurt you physically?

1315. Who has hurt you in this way? Anyone else?
RECORD ALL MENTIONED.

1316. Check 1315:

1317. Who has hit, slapped, kicked or done something to physically hurt you most often?

1318. In the last 12 months, how many times has this person hit, slapped, kicked, or done anything else to physically hurt you?

1319. CHECK 201, 226, AND 230:
LIVE BIRTHS, PREGNANCIES, STILLBIRTHS

1320. Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

1321. Who has done any of these things to physically hurt you while you were pregnant?
Anyone else?
RECORD ALL MENTIONED.

1322. CHECK 1306, 1309, 1314, AND 1320:

1323. Did you try to get help?

1324. From whom have you sought help?
Anyone else?
RECORD ALL MENTIONED.

1325. What is the main reason you have never sought help?

1326. As far as you know, did your father ever beat your mother?

1326A. Do you know of any services or support for women in trouble?

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

1327. 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?

1328. INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING SECTION 13. _____

SECTION 14. 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.

1401A. Did your mother give birth to any children other than yourself?

1401B. How many boys did your mother have who are still living?

1401C. Other than yourself, how many girls did your mother have who are still living?

1401D. How many boys did your mother have who died?

1401E. How many girls did your mother have who died?

1401F. Did your mother give birth to any other children, who you don't know if they are living or dead?

1401G. How many other children did your mother give birth to, who you don't know if they are living or dead?

1401H. ADD THE ANSWERS FROM 1401B, C, D, E, AND G, ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL.

1401I. CHECK 1401H:
Just to make sure that I've understood: Including yourself, your mother gave birth to _____ children total. Is that correct?

1402. CHECK 1401H:

1403. How many of these births did your mother have before you were born?

Now I would like to make a list of all your brothers and sisters, whether they are still alive or not, starting with the oldest. RECORD THE NAME OF ALL BROTHERS AND SISTERS.

1404. What was the name given to your oldest (next oldest) brother or sister?

1405. Is (NAME) male or female?

1406. Is (NAME) still alive?

1407. How old is (NAME)?

1408. How many years ago did (NAME) die?

1409. How old was (NAME) when he/she died?
IF DOESN'T KNOW, PROBE: Did (NAME) die before the age of 12?

IF YES, RECORD '95'. IF NO, ASK OTHER QUESTIONS TO GET AN ESTIMATE, FOR EXAMPLE: Did (NAME) die before getting married?

1410. Was (NAME) pregnant when she died?

1411. Did (NAME) die during childbirth?

1412. Did (NAME) die within two months after the end of a pregnancy or childbirth?

1413. How many live born children did (NAME) give birth to during her lifetime (before this pregnancy)?

[IF NO MORE BROTHERS OR SISTERS, GO TO 1414]

1414. RECORD TIME:

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW.

COMMENTS ABOUT RESPONDENT _____

COMMENTS ON SPECIFIC QUESTIONS _____

ANY OTHER COMMENTS_____

SUPERVISOR'S OBSERVATIONS _____
NAME _____
DATE _____

EDITOR'S OBSERVATIONS _____
NAME _____
DATE _____

CALENDAR INSTRUCTIONS

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

[YEAR OF FIELDWORK IS ASSUMED TO BE 2010. FOR FIELDWORK BEGINNING IN 2011 OR 2012, THE YEARS SHOULD BE ADJUSTED]

INFORMATION TO BE CODED FOR EACH COLUMN:

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE:
RESPONSE CATEGORIES MAY BE ADDED FOR OTHER METHODS, INCLUDING FERTILITY AWARENESS METHODS.

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE:

2010:
12 DEC 01 _____ _____
11 NOV 02 _____ _____
10 OCT 03 _____ _____
09 SEPT 04 _____ _____
08 AUG 05 _____ _____
07 JUL 06 _____ _____
06 JUN 07 _____ _____
05 MAY 08 _____ _____
04 APR 09 _____ _____
03 MAR 10 _____ _____
02 FEB 11 _____ _____
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2009:
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08 AUG 17 _____ _____
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2008:
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2007:
12 DEC 37_____ _____
11 NOV 38 _____ _____
10 OCT 39 _____ _____
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2006:
12 DEC 49 _____ _____
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10 OCT 51 _____ _____
09 SEPT 52 _____ _____
08 AUG 53 _____ _____
07 JUL 54 _____ _____
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2005:
12 DEC 61 _____ _____
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10 OCT 63 _____ _____
09 SEPT 64 _____ _____
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04 APR 69 _____ _____
03 MAR 70 _____ _____
02 FEB 71 _____ _____
01 JAN 72 _____ _____