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<br />REPUBLIC OF BURUNDI THIRD DEMOGRAPHIC AND HEALTH SURVEY 2016 WOMAN???S QUESTIONNAIRE<br />

IDENTIFICATION

PLACE NAME

NAME OF HEAD OF HOUSEHOLD

PROVINCE

CLUSTER NUMBER

HOUSEHOLD NUMBER

NAME AND LINE NUMBER OF WOMAN

WOMAN SELECTED FOR MODULE ON VIOLENCE?

1=YES
2=NO

INTERVIEWER VISITS
1 2 3
DATE

INTERVIEWER???S NAME
RESULT

RESULT CODES:

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

TOTAL NO. OF VISITS

LANGUAGE OF QUESTIONNAIRE

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED (YES=1, NO=2)

LANGUAGE OF QUESTIONNAIRE

LANGUAGE CODES:

01 FRENCH
96 OTHER (SPECIFY)
OLD KIRUNDI (FROM PAPER)

SUPERVISOR
NAME
NUMBER

SECTION 1. RESPONDENT???S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT:

Hello. My name is ___. I am working with the Institute of Statistics and Economic Study of Burundi (ISTEEBU). We are conducting a survey about health all over Burundi. The information we collect will help the government to improve 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___________

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

SECTION 1. RESPONDENT'S BACKGROUND

101) RECORD THE TIME:

HOUR___
MINUTES___

102) How long have you been living continuously in (MAIRIE DE BUJUMBURA, NAME OF URBAN CENTER OR RESIDENTIAL HILLSIDE)? IF LESS THAN ONE YEAR, RECORD '00' YEARS.

YEARS__
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)


103) Just before you moved here, did you live in Mairie de Bujumbura, in another city, or in a rural area?

MAIRIE DE BUJUMBURA 1
OTHER LARGE CITY 2
A SMALL TOWN 3
RURAL AREA 4

104) Before you moved here, which [province/region] did you live in?

BUBANZA 01
MAIRIE DE BUJUMBURA 02
RURAL BUJUMBURA 03
BURURI 04
CANKUZO 05
CIBITOKE 06
GITEGA 07
KARUZI 08
KAYANZA 09
KIRUNDO 10
MAKAMBA 11
MURAMVYA 12
MUYINGA 13
MWARO 14
NGOZI 15
RUMONGE 16
RUTANA 17
RUYIGI 18
OUTSIDE OF BURUNDI (SPECIFY COUNTRY) 96

105) In what month and year were you born?

MONTH
DON???T KNOW MONTH 98

YEAR
DON???T KNOW YEAR 9998

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

AGE IN COMPLETED YEARS___

107) Have you ever attended school?

YES 1
NO 2 (GO TO 111)

108) What is the highest level of school you attended: primary, secondary 1, secondary 2, or higher?

PRIMARY 1
SECONDARY 1ST CYCLE 2
SECONDARY 2ND CYCLE 3
HIGHER 4

109) What is the highest (grade/form/year) you completed at this level? IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

GRADE/FORM/YEAR___

110) CHECK 108:

PRIMARY, SECONDARY 1ST CYCLE, SECONDARY 2ND CYCLE (GO TO 111)
HIGHER (GO TO 113)

111) Now I would like you to read this sentence to me.

SHOW CARD TO RESPONDENT.

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

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

112) CHECK 111:

CODE 2, 3, OR 4 CIRCLED (GO TO 113)
CODE 1 OR 5 CIRCLED (GO TO 114)

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

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

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

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

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

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

116) Do you own a mobile telephone?

YES 1
NO 2 (GO TO 118)

117) Do you own a mobile telephone to conduct financial transactions?

YES 1
NO 2

118) Do you have an account in another financial institution that you can use?

YES 1
NO 2

119) Have you ever used the internet? IF NECESSARY, PROBE FOR USAGE FROM ANY LOCATION ON ANY DEVICE.

YES 1
NO 2 (GO TO 122)

120) In the last 12 months, have you used the internet? IF NECESSARY, PROBE FOR USAGE FROM ANY LOCATION ON ANY DEVICE.

YES 1
NO 2 (GO TO 122)

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

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

122) What is your religion?

CATHOLIC 01
PROTESTANT 02
MUSLIM 3
ADVENTIST 04
JEHOVAH???S WITNESS 05
TRADITIONAL/ANIMIST 06
WITHOUT RELIGION/NONE 07
CULT 08
OTHER_____96

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

NUMBER OF TIMES___
NONE 00 (GO TO 201)

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

YES 1
NO 2

SECTION 2. REPRODUCTION

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

YES 1
NO 2 (GO TO 206)

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

YES 1
NO 2 (GO TO 204)

203) How many sons live with you?

SONS AT HOME___

And how many daughters live with you?

DAUGHTERS AT HOME___

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?

YES 1
NO 2 (GO TO 206)


205) How many sons are alive but do not live with you?

SONS ELSEWHERE___

And how many daughters are alive but do not live with you?

DAUGHTERS ELSEWHERE___

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, who made any movement, sound, or effort to breathe, or who showed any other signs of life even if for a very short time?

YES 1
NO 2 (GO TO 208)

207) How many boys have died?

BOYS DEAD___

And how many girls have died?

GIRLS DEAD___

IF NONE, RECORD ???00???.

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

TOTAL BIRTHS___

209) CHECK 208:

Just to makes sure that i have this right: you have had in total ____births during your life. Is that correct?

YES
NO (PROBE AND CORRECT 201-208 AS NECESSARY)

210) CHECK 208:

ONE OR MORE BIRTHS (GO TO 211)
NO BIRTHS (GO TO 226)

211) Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS. IF THERE ARE MORE THAN 10 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.

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

NAME______________

213) Is (name) a boy or a girl?

BOY 1
GIRL 2

214) Were any of these births twins?

SING 1
MULT 2

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

MONTH___
YEAR_____

216) Is (name) still alive?

YES 1
NO 2 (GO TO 220)

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

AGE IN YEARS___

218) Is (name) living with you?

YES 1
NO 2

219) RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD ???00??? IF CHILD NOT LISTED IN HOUSEHOLD)

HOUSEHOLD LINE NUMBER___

GO TO NEXT BIRTH, OR IF NO MORE BIRTHS, GO TO 221.

220) IF DEAD: How old was (NAME) when he/she died?

IF ???12 MONTHS??? OR ???1 YR???, ASK: Did (NAME) have (his/her) first birthday? THEN ASK: exactly how many months old was (name) when (he/she) died? RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS, OR YEARS.

DAYS 1___
MONTHS 2___
YEARS 3___

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

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

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

YES 1 (RECORD BIRTHS IN TABLE)
NO 2

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

NUMBERS ARE THE SAME (GO TO 224)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

224) CHECK 215: ENTER THE NUMBER OF BIRTHS IN 2011-2016.

NUMBER OF BIRTHS___
NONE 0 (GO TO 226)

225) FOR EACH BIRTH SINCE JANUARY 2010, ENTER B IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE CODE B FOR EACH BIRTH. FOR EACH BIRTH, ASK THE NUMBER OF COMPLETED MONTHS PREGNANCY LASTED AND RECORD P IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF THE PREGNANCY. (NOTE: THE NUMBER OF PS MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226) Are you pregnant now?

YES 1
NO 2 (GO TO 230)
UNSURE 8 (GO TO 230)

227) How many months pregnant are you?

RECORD NUMBER OF COMPLETED MONTHS. ENTER PS IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

MONTHS___

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

YES 1 (GO TO 230)
NO 2


229) CHECK 208: TOTAL NUMBER OF BIRTHS

ONE OR MORE: Did you want to have a baby later on or did you not want any more children?
NONE: Did you want to have a baby later on or did you not want any children?

LATER 1
NO MORE/NONE 2

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

YES 1
NO 2 (GO TO 239)

231) When did the last such pregnancy end?

MONTH___
YEAR_____

232) CHECK 231:

LAST PREGNANCY ENDED IN JAN 2011-2016 (GO TO 234)
LAST PREGNANCY ENDED BEFORE JAN. 2011 (GO TO 238)

233) In what month and year did the preceding such pregnancy end?

MONTH___
YEAR_____

234) How many months pregnant were you when that pregnancy ended?

NUMBER OF MONTHS___

235) Since January 2010, have you had any other pregnancies that did not result in a live birth?

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

236) FOR EACH PREGNANCY THAT DID NOT END IN A LIVE BIRTH IN 2010-2015 OR LATER, ENTER ???T??? IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND ???P??? FOR THE REMAINING NUMBER OF COMPLETED MONTHS OF PREGNANCY. IF THERE ARE MORE THAN FOUR PREGNANCIES THAT DID NOT END IN A LIVE BIRTH, USE AN ADDITIONAL QUESTIONNAIRE STARTING ON THE SECOND LINE.

237) Did you have any miscarriages, abortions or stillbirths that ended before 2011?

YES 1
NO 2 (GO TO 239)

237) When did the last such pregnancy that terminated before 2011 end?

MONTH___
YEAR_____

239) When did you last menstrual period start?

(DATE, IF GIVEN)__________

DAYS AGO 1
WEEKS AGO 3
MONTHS AGO 2
YEARS AGO 4
IN MENOPAUSE/HAS HAD HYSTERECTOMY 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

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

YES 1
NO 2 (GO TO 242)
DON???T KNOW 8 (GO TO 242)

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

JUST BEFORE HER PERIOD BEGINS 1
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAD ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) 6
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

SECTION 3. CONTRACEPTION

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

Have you ever heard of (method)?

01) FEMALE STERILIZATION: Women can have an operation to avoid having any more children.

YES 1
NO 2

02) MALE STERILIZATION: Men can have an operation to avoid having any more children

YES 1
NO 2

03) IUD: Women can have a loop or coil placed inside them by a doctor or a nurse which can prevent pregnancy for one or more years.

YES 1
NO 2

04) INJECTABLES: Women can have an injection by a heath provider that stops them from becoming pregnant for one or more months.

YES 1
NO 2

05) IMPLANTS: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.

YES 1
NO 2

06) PILL: Women can take a pill every day to avoid becoming pregnant

YES 1
NO 2

07) CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.

YES 1
NO 2

08) FEMALE CONDOM: Women can place a sheath in their vagina before sexual intercourse.

YES 1
NO 2

09) EMERGENCY CONTRACEPTION: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.

YES 1
NO 2

10) STANDARD DAYS METHOD: A woman uses a string of colored beads to know the days she can get pregnant. On the days she can get pregnant, she uses a condom or does not have intercourse.

YES 1
NO 2

11) LACTATIONAL AMENORRHEA METHOD (LAM): Up to six months after child birth, before the menstrual period has returned, women use a method requiring frequent breastfeeding day and night.

YES 1
NO 2

12) RHYTHM METHOD: To avoid pregnancy, women do not have sexual intercourse on the days of the month they think they can get pregnant.

YES 1
NO 2

13) WITHDRAWAL: Men can be careful and pull out before climax.

YES 1
NO 2

14) Have you heard of any other ways or methods that women or men can use to avoid pregnancy?

YES 1 (SPECIFY)
NO 2

302) CHECK 226:

NOT PREGNANT OR UNSURE
PREGNANT (GO TO 312)

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

YES 1
NO 2 (GO TO 312)

304) Which method are you using?

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

FEMALE STERILIZATION A (GO TO 307)
MALE STERILIZATION B (GO TO 307)
IUD C (GO TO 309)
INJECTABLES D (GO TO 309)
IMPLANTS E (GO TO 309)
PILL F
CONDOM G (GO TO 306)
FEMALE CONDOM H
EMERGENCY CONTRACEPTIVE I
STANDARD DAY METHOD J
LACTATIONAL AMEN. METHOD K
RHYTHM METHOD L
WITHDRAWAL M
OTHER MODERN METHOD X
OTHER TRADITIONAL METHOD Y

H-Y (GO TO 309)

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

IF DON???T KNOW BRAND, ASK TO SEE THE PACKAGE.

NORDETTE (COMBINATION ORAL CONTRACEPTIVE: 21 WHITE PILLS AND 7 RED PILLS) 01
OVRETTTE (PROGESTINE ORAL CONTRACEPTIVE: 35 WHITE PILLS) 02
OTHER________96
DON???T KNOW 98

GO TO 309.

306) What is the brand name of the condoms you are using?

IF DON???T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

PRUDENCE 01
PRUDENCE CLASS 02
OTHER_______96
DON???T KNOW 98

GO TO 309.

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.

(NAME OF PLACE)_______________
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 11
REGIONAL GOVERNMENT HOSPITAL 12
DISTRICT HOSPITAL 13
GOVERNMENT HEALTH CENTER 14
OTHER________15
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 21
CERTIFIED HEALTH CENTER 22
OTHER PRIVATE MEDICAL (SPECIFY) 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
PRIVATE HEALTH CARE CENTER 32
PRIVATE DOCTOR???S OFFICE 33
OTHER PRIVATE MEDICAL (SPECIFY) 36
OTHER______96
DON'T KNOW 98

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

MONTH___
YEAR______

GO TO 310.

309) 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?

MONTH___
YEAR_____

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

YES (GO BACK TO 308 OR 309, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION).)

NO (GO TO 311)

311) CHECK 309:

YEAR IS 2010-2016: ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND IN EACH MONTH BACK TO THE DATE STARTED USING. THEN GO TO 312.

YEAR IS 2009 OR EARLIER: ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK TO JANUARY 2010. THEN GO TO 324

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

USE THE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2011. USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

312A) Month and year of start of interval of use or non-use.

MONTH___
YEAR_____

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

YES 1
NO 2 (GO TO 312I)

312C) Which method was that?

METHOD CODE___

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

RECORD 95 IF RESPONDENT GIVES THE DATE OF STARTING TO USE THE METHOD.

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

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

MONTH___
YEAR_____

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

RECORD 95 IF RESPONDENT GIVES YOU DATE OF TERMINATION OF USE.

MONTHS___(GO TO 321H)
DATE GIVEN 95

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

MONTH___
YEAR_____

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

REASON STOPPED______________

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

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

NO METHOD USED (GO TO 314)
ANY METHOD USED (GO TO 315)

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

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

315) CHECK 304:

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

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

316) You first started using (CURRENT METHOD) in (DATE FROM 309). Where did you get it at that time?

315a) Where did you learn how to use the cycle beads/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.

(NAME OF PLACE)_____________
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 11
REGIONAL GOVERNMENT HOSPITAL 12
DISTRICT HOSPITAL 13
GOVERNMENT HEALTH CENTER 14
COMMUNITY FIELDWORKER 15
OTHER________16
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 21
CERTIFIED HEALTH CENTER 22
OTHER PRIVATE MEDICAL________26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
PRIVATE HEALTH CARE CENTER 32
PHARMACY 33
PRIVATE DOCTOR???S OFFICE 34
OTHER PRIVATE MEDICAL__________36
OTHER SOURCE
SHOP 41
FRIENDS/RELATIVES 42
OTHER____________96

317) CHECK 304:

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

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

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

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

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

YES 1 (GO TO 321)
NO 2

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

YES 1
NO 2 (GO TO 322)

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

YES 1
NO 2

322) CHECK 318 AND 319:

ANY YES: At that time, were you told about other methods of family planning that you could use?

OTHER: When you obtained (CURRENT METHOD FROM 315) from (SOURCE OF METHOD FROM 307 OR 316), were you told about other methods of family planning that you could use?

YES 1 (GO TO 324)
NO 2

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

YES 1
NO 2

324) CHECK 304:

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

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

325) 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.

(NAME OF PLACE)_________________________
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 11
REGIONAL GOVERNMENT HOSPITAL 12
DISTRICT HOSPITAL 13
GOVERNMENT HEALTH CENTER 14
OTHER________15
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 21
CERTIFIED HEALTH CENTER 22
OTHER PRIVATE MEDICAL_______ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
PRIVATE HEALTH CARE CENTER 32
PHARMACY 33
PRIVATE DOCTOR???S OFFICE 34
OTHER PRIVATE MEDICAL_______36
OTHER SOURCE
SHOP 41
FRIENDS/RELATIVES 42
OTHER________96

GO TO 327.

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

YES 1
NO 2

327) In the last 12 months, were you visited by a fieldworker?

YES 1
NO 2 (GO TO 329)

328) Did the fieldworker talk to you about family planning?

YES 1
NO 2

329) CHECK 202: LIVING CHILDREN

YES: In the last 12 months, have you visited a health facility for care for yourself or your children?
NO: In the last 12 months, have you visited a health facility for care for yourself?

YES 1
NO 2 (GO TO 401)

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

YES 1
NO 2

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

ONE OR MORE BIRTHS IN 2010-2016 (GO TO 402)
NO BIRTHS IN 2010-2016 (GO TO 648)

402) CHECK 215: ENTER THE BIRTH HISTORY NUMBER IN 403 AND THE NAME AND SURVIVAL STATE IN 404 FOR EACH BIRTH FROM 2011-2016. ASK THE QUESTIONS ABOUT ALL THESE BIRTHS. BEGIN WITH THE LAST BIRTH. IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES).

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

403) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

BIRTH HISTORY NUMBER____

404) FROM 212 AND 216:

NAME____________

LIVING
DEAD

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

YES 1 (GO TO 408)
NO 2

406) CHECK 208:

ONLY ONE BIRTH: Did you want to have a baby later on, or did you not want any children?

MORE THAN ONE BIRTH: Did you want to have a baby later on, or did you not want any more children?

LATER 1
NO MORE/NONE 2 (GO TO 408)

407) How much longer did you want to wait?

MONTHS 1
YEARS 2
DON???T KNOW 998

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

YES 1
NO 2 (GO TO 414)

409) Whom did you see? Anyone else?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEATH PROFESSIONAL
DOCTOR A
MIDWIFE B
NURSE C
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT D
COMMUNITY HEALTH WORKER E
OTHER______X

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.

(NAME OF PLACE(S))____________
HOME
HER HOME A
OTHER HOME B
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL C
REGIONAL GOVERNMENT HOSPITAL D
DISTRICT HOSPITAL E
GOVERNMENT HEALTH CENTER F
OTHER__________ G
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL H
CERTIFIED HEALTH CENTER I
OTHER PRIVATE MEDICAL____________ J
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC K
PRIVATE HEALTH CARE CENTER L
OTHER PRIVATE MEDICAL____________ M
OTHER___________ X

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

MONTHS____________
DON???T KNOW 98

412) How many times did you receive antenatal care during this pregnancy?

NUMBER OF TIMES____
DON???T KNOW 98

412A) Did you receive a Mother-Infant Card during any of the antenatal visits for this pregnancy?

YES 1
NO 2

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

Was your blood pressure measured?
YES 1
NO 2
Did you give a urine sample?
YES 1
NO 2
Did you give a blood sample?

YES 1
NO 2

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

YES 1
NO 2 (GO TO 417)
DON???T KNOW 8 (GO TO 417)

415) During this pregnancy, how many times did you get a tetanus injection?

TIMES___
DON???T KNOW 8

416) CHECK 415: TETANUS INJECTIONS

2 OR MORE TIMES (GO TO 420)
OTHER____________

417) At any time before this pregnancy, did you receive any tetanus injections?

YES 1
NO 2 (GO TO 420)
DON???T KNOW 8 (GO TO 420)

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

IF 7 OR MORE TIMES, RECORD 7.

TIMES___
DON???T KNOW 8

419) CHECK 418:

ONLY ONCE: How many years ago did you receive this tetanus injection before this pregnancy?
MORE THAN ONCE: How many years ago did you receive the last tetanus injection before this pregnancy?

YEARS AGO___

420) During this pregnancy, were you given or did you buy iron tablets or iron syrup?

SHOW TABLES/SYRUP.

YES 1
NO 2 (GO TO 422)
DON???T KNOW 8 (GO TO 422)

421) 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.

DAYS___
DON???T KNOW 998

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (GO TO 426)
DON???T KNOW 8 (GO TO 426)

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

TIMES___

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

IF MORE THAN ONE SOURCE, RECORD THE HIGHEST SOURCE ON THE LIST.

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6

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

VERY LARGE 1
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON???T KNOW 8

427) Was (Name) weighed at birth?

YES 1
NO 2 (GO TO 429)
DON???T KNOW 8 (GO TO 429)

428) How much did (NAME) weigh?

RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE.

KG FROM MOTHER-INFANT CARD 1
KG FROM ANOTHER HEALTH CARD 2
KG FROM RECALL 3
DON???T KNOW 99998

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

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

HEATH PROFESSIONAL
DOCTOR A
MIDWIFE B
NURSE C
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT D
RELATIVE/FRIEND E
OTHER__________X
NO ONE Y

430) 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.

(NAME OF PLACE(S))_______________
HOME
HER HOME 11 (GO TO 434)
OTHER HOME 12 (GO TO 434)
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 21
REGIONAL GOVERNMENT HOSPITAL 22
DISTRICT HOSPITAL 23
GOVERNMENT HEALTH CENTER 24
OTHER____________26
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 31
CERTIFIED HEALTH CENTER 32
OTHER PRIVATE MEDICAL__________ J
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 41
PRIVATE HEALTH CARE CENTER 42
OTHER PRIVATE MEDICAL__________ 46
OTHER____________96 (GO TO 434)

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

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

HOURS 1
DAYS 2
WEEKS 3
DON???T KNOW 998

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

YES 1
NO 2 (GO TO 434)

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

BEFORE 1
AFTER 2

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

YES 1
NO 2 (GO TO 434B)
DON???T KNOW 8 (GO TO 434B)

434A) Was (NAME)???s skin in contact with your skin?

YES 1
NO 2
DON???T KNOW 8

434B) CHECK 430: DELIVERY LOCATION

CODE 11, 12, OR 96 CIRCLED (GO TO 449)
OTHER (GO TO 435)

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

YES 1
NO 2 (GO TO 438)

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

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

HOURS__ 1
DAYS__ 2
WEEKS__ 3
DON???T KNOW 998

437) Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

HEATH PROFESSIONAL
DOCTOR 11
MIDWIFE 12
NURSE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
COMMUNITY FIELDWORKER 22
OTHER____________96

438) Now I would like to talk to you about checks on (NAME)???s health after delivery???for example, someone examining (NAME), checking the cord, or seeing if (NAME) is OK. Did anyone check on (NAME)???s health while you were still in the facility?

YES 1
NO 2 (GO TO 441)
DON???T KNOW 8 (GO TO 441)

439) How long after delivery was (NAME)???s health first checked?

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

HOURS__ 1
DAYS__ 2
WEEKS__ 3
DON???T KNOW 998

440) Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

HEATH PROFESSIONAL
DOCTOR 11
MIDWIFE 12
NURSE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
COMMUNITY FIELDWORKER 22
OTHER_________96

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

YES 1
NO 2 (GO TO 445)

442) 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.

HOURS__ 1
DAYS__ 2
WEEKS__ 3
DON???T KNOW 998

443) Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

HEATH PROFESSIONAL
DOCTOR 11
MIDWIFE 12
NURSE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
COMMUNITY FIELDWORKER 22
OTHER________96

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

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

(NAME OF PLACE(S))_________________________
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 21
REGIONAL GOVERNMENT HOSPITAL 22
DISTRICT HOSPITAL 23
GOVERNMENT HEALTH CENTER 24
OTHER______________26
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 31
CERTIFIED HEALTH CENTER 32
OTHER PRIVATE MEDICAL___________J
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 41
PRIVATE HEALTH CARE CENTER 42
OTHER PRIVATE MEDICAL___________46
OTHER__________96

445) I would like to talk to you about checks on (NAME)???s health after you left (FACILITY IN 430). Did any health care provider or a traditional birth attendant check on (NAME)???s health in the two months after you left (FACILITY IN 430)?

YES 1
NO 2 (GO TO 457)
DON???T KNOW 8 (GO TO 457)

446) Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

HEATH PROFESSIONAL
DOCTOR 11
MIDWIFE 12
NURSE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
COMMUNITY FIELDWORKER 22
OTHER_____________96

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

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

(NAME OF PLACE(S))_______________
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 21
REGIONAL GOVERNMENT HOSPITAL 22
DISTRICT HOSPITAL 23
GOVERNMENT HEALTH CENTER 24
OTHER___________26
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 31
CERTIFIED HEALTH CENTER 32
OTHER PRIVATE MEDICAL__________ J
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 41
PRIVATE HEALTH CARE CENTER 42
OTHER PRIVATE MEDICAL___________ 46
OTHER________96

GO TO 457.

449) I would like to talk to you about checks on your health after delivery, for example someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)?

YES 1
NO 2 (GO TO 453)

450) 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.

HOURS__ 1
DAYS__ 2
WEEKS__ 3
DON???T KNOW 998

451) Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

HEATH PROFESSIONAL
DOCTOR 11
MIDWIFE 12
NURSE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
COMMUNITY FIELDWORKER 22
OTHER__________96

452) Where did this first check of take place?

Probe to identity the type of source and circle the appropriate code. If unable to determine if public or private sector, write the name of the place.

(NAME OF PLACE(S))_________________
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 21
REGIONAL GOVERNMENT HOSPITAL 22
DISTRICT HOSPITAL 23
GOVERNMENT HEALTH CENTER 24
OTHER___________26
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 31
CERTIFIED HEALTH CENTER 32
OTHER PRIVATE MEDICAL____________J
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 41
PRIVATE HEALTH CARE CENTER 42
OTHER PRIVATE MEDICAL____________ 46
OTHER___________96

453) I would like to talk to you about checks on (NAME)???s health after delivery???for example, someone examining (NAME), checking the cord, or seeing if (NAME) is OK. In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on (NAME)???s health?

YES 1
NO 2 (GO TO 457)
DON???T KNOW 8 (GO TO 457)

454) 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.

HRS AFTER BIRTH__ 1
DAYS AFTER BIRTH__ 2
WKS AFTER BIRTH__ 3
DON???T KNOW 998

455) Who checked on (NAME)???s health at that time?

PROBE FOR THE MOST QUALIFIED PERSON.

HEATH PROFESSIONAL
DOCTOR 11
MIDWIFE 12
NURSE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
COMMUNITY FIELDWORKER 22
OTHER___________96

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

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

(NAME OF PLACE(S))_____________
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 21
REGIONAL GOVERNMENT HOSPITAL 22
DISTRICT HOSPITAL 23
GOVERNMENT HEALTH CENTER 24
OTHER___________26
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 31
CERTIFIED HEALTH CENTER 32
OTHER PRIVATE MEDICAL_________ J
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 41
PRIVATE HEALTH CARE CENTER 42
OTHER PRIVATE MEDICAL____________46
OTHER___________96

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

a) Examine the cord?
YES 1
NO 2
DON'T KNOW 8
b) Measure (name)???s temperature?
YES 1
NO 2
DON'T KNOW 8
c) Counsel you on danger signs for newborns?
YES 1
NO 2
DON'T KNOW 8
d) Counsel you on breastfeeding?
YES 1
NO 2
DON'T KNOW 8
e) Observe (name) breastfeeding?
YES 1
NO 2
DON'T KNOW 8

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

YES 1 (GO TO 460)
NO 2 (GO TO 461)

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

YES 1
NO 2 (GO TO 463)

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

MONTHS___
DON???T KNOW 98

461) CHECK 226: IS RESPONDENT PREGNANT?

NOT PREGNANT (GO TO 462)
PREGNANT OR NOT SURE (GO TO 463)

462) Have you had sexual intercourse since the birth of (NAME)?

YES 1
NO 2 (GO TO 464)

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

MONTHS___
DON???T KNOW 98

464) Did you ever breastfeed (NAME)?

YES 1 (GO TO 466)
NO 2

465) CHECK 404: CHILD IS LIVING?

LIVING (GO TO 470)
DEAD (GO TO 471)

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

IF LESS THAN 1 HOUR, RECORD 00 HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS.

IMMEDIATELY 000
HOURS__ 1
DAYS__ 2

467) In the first three days after delivery, was (NAME) given anything to drink other than breast milk?

YES 1
NO 2

468) CHECK 404: CHILD IS LIVING?

LIVING (GO TO 469)
DEAD (GO TO 471)

469) Are you still breastfeeding (NAME)?

YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

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

SECTION 5A. CHILD IMMUNIZATION (LAST BIRTH)

501A) CHECK 215 IN THE BIRTH HISTORY: ANY BIRTH IN 2013-2016?

ONE OR MORE BIRTHS IN 2013-2016 (GO TO 502A)
NO BIRTHS IN 2013-2016 (GO TO 601)

502A) RECORD THE NAME AND BIRTH HISTORY NUMBER FROM 212 OF THE LAST CHILD BORN IN 2013-2016.

NAME OF LAST BIRTH__________
BIRTH HISTORY NUMBER___

503A) CHECK 216 FOR CHILD:

LIVING (GO TO 504A)
DEAD (GO TO 501B)

504A) Do you have a mother-infant health card, a vaccination card, or another document where (NAME)???s vaccinations are written down?

YES, ONLY A MOTHER-INFANT CARD 1 (GO TO 507A)
YES, ONLY A VACCINATION CARD 2 (GO TO 507A)
YES, ONLY ANOTHER DOCUMENT 3
YES, A MOTHER-INFANT CARD AND ANOTHER DOCUMENT 4 (GO TO 507A)
YES, A VACCINATION CARD AND ANOTHER DOCUMENT 5 (GO TO 507A)
NO, DOES HAVE EITHER A MOTHER-INFANT CARD, NOR A VACCINATION CARD, NOR ANOTHER DOCUMENT 6

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

YES 1
NO 2

506A) CHECK 504A:

CODE 3 CIRCLED (GO TO 507A)
CODE 6 CIRCLED (GO TO 511A)

507A) May I see the card or other document where you have (NAME)???s vaccinations written down?

YES, ONLY A MOTHER-INFANT CARD SEEN 1
YES, ONLY A VACCINATION CARD SEEN 2
YES, ONLY ANOTHER DOCUMENT SEEN 3
YES, A MOTHER-INFANT CARD AND ANOTHER DOCUMENT SEEN 4
YES, A VACCINATION CARD AND ANOTHER DOCUMENT SEEN 5
NO, NEITHER MOTHER-INFANT CARD, NOR A VACCINATION CARD, NOR ANOTHER DOCUMENT SEEN 6 (GO TO 511A)

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

BCG
DAY___
MONTH___
YEAR_____
HEPATITIS B GIVEN AT BIRTH
DAY___
MONTH___
YEAR_____
ORAL POLIO VACCINE (OPV) 0 (POLIO GIVEN AT BIRTH)
DAY___
MONTH___
YEAR_____
ORAL POLIO VACCINE (OPV) 1
DAY___
MONTH___
YEAR_____
ORAL POLIO VACCINE (OPV) 2
DAY___
MONTH___
YEAR_____
ORAL POLIO VACCINE (OPV) 3
DAY___
MONTH___
YEAR_____
DPT-HEP.B-HIB (PENTAVALENT) 1
DAY___
MONTH___
YEAR_____
DPT-HEP.B-HIB (PENTAVALENT) 2
DAY___
MONTH___
YEAR_____
DPT-HEP.B-HIB (PENTAVALENT) 3
DAY___
MONTH___
YEAR_____
PNEUMOCOCCAL 1
DAY___
MONTH___
YEAR_____
PNEUMOCOCCAL 2
DAY___
MONTH___
YEAR_____
PNEUMOCOCCAL 3
DAY___
MONTH___
YEAR_____
ROTAVIRUS 1
DAY___
MONTH___
YEAR_____
ROTAVIRUS 2
DAY___
MONTH___
YEAR_____
MEASLES 1
DAY___
MONTH___
YEAR_____
MEASLES 2
DAY___
MONTH___
YEAR_____
VITAMIN A (MOST RECENT)
DAY___
MONTH___
YEAR_____

509A) CHECK 508A: BCG TO MEASLES 2 ALL RECORDED?

YES (GO TO 510A)
NO (GO TO 525A)

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

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

YES 1: PROBE FOR VACCINATIONS AND WRITE 66 IN THE CORRESPONDING DAY COLUMN IN 508A. RECORD 00 IN THE DAY COLUMN CORRESPONDING TO ALL THE VACCINATIONS NOT GIVEN. THEN GO TO 525A

NO 2: RECORD 00 IN THE DAY COLUMN CORRESPONDING TO ALL THE VACCINATIONS NOT GIVEN. THEN GO TO 525A

DON'T KNOW 8: RECORD 00 IN THE DAY COLUMN CORRESPONDING TO ALL THE VACCINATIONS NOT GIVEN. THEN GO TO 525A

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

YES 1
NO 2 (GO TO 525A)
DON???T KNOW 8 (GO TO 525A)

512A) Did (NAME) ever receive a BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (GO TO 517A)
DON???T KNOW 8 (GO TO 517A)

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

FIRST TWO WEEKS 1
LATER 2

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

NUMBER OF TIMES___

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

YES 1
NO 2 (GO TO 519A)
DON???T KNOW 8 (GO TO 519A)

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

NUMBER OF TIMES___

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

YES 1
NO 2 (GO TO 521A)
DON???T KNOW 8 (GO TO 521A)

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

NUMBER OF TIMES___

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

YES 1
NO 2 (GO TO 523A)
DON???T KNOW 8 (GO TO 523A)

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

NUMBER OF TIMES___

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

YES 1
NO 2 (GO TO 525A)
DON???T KNOW 8 (GO TO 525A)

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

NUMBER OF TIMES___

525A) In the last 7 days was (NAME) given:

a) A powdered mix of micronutrients?
YES 1
NO 2
DON'T KNOW 8
b) Read to use therapeutic foods like Plumpt???nuts?
YES 1
NO 2
DON'T KNOW 8
c) Additional ready to use foods like Plumpy???doz?
YES 1
NO 2
DON'T KNOW 8

526A) CONTINUE WITH 501B

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

501B) CHECK 215 IN THE BIRTH HISTORY: ANY BIRTH IN 2013-2016?

ONE OR MORE BIRTHS IN 2013-2016 (GO TO 502B)
NO BIRTHS IN 2013-2016 (GO TO 601)

502B) RECORD THE NAME AND BIRTH HISTORY NUMBER FROM 212 OF THE LAST CHILD BORN IN 2013-2016.

NAME OF LAST BIRTH__________
BIRTH HISTORY NUMBER___

503B) CHECK 216 FOR CHILD:

LIVING (GO TO 504B)
DEAD (GO TO 526B)

504B) Do you have a mother-infant health card, a vaccination card, or another document where (NAME)???s vaccinations are written down?

YES, ONLY A MOTHER-INFANT CARD 1 (GO TO 507B)
YES, ONLY A VACCINATION CARD 2 (GO TO 507B)
YES, ONLY ANOTHER DOCUMENT 3
YES, A MOTHER-INFANT CARD AND ANOTHER DOCUMENT 4 (GO TO 507B)
YES, A VACCINATION CARD AND ANOTHER DOCUMENT 5 (GO TO 507B)
NO, DOES HAVE EITHER A MOTHER-INFANT CARD, NOR A VACCINATION CARD, NOR ANOTHER DOCUMENT 6

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

YES 1
NO 2

506B) CHECK 504B:

CODE 3 CIRCLED (GO TO 507B)
CODE 6 CIRCLED (GO TO 511B)

507B) May I see the card or other document where you have (NAME)???s vaccinations written down?

YES, ONLY A MOTHER-INFANT CARD SEEN 1
YES, ONLY A VACCINATION CARD SEEN 2
YES, ONLY ANOTHER DOCUMENT SEEN 3
YES, A MOTHER-INFANT CARD AND ANOTHER DOCUMENT SEEN 4
YES, A VACCINATION CARD AND ANOTHER DOCUMENT SEEN 5
NO, NEITHER MOTHER-INFANT CARD, NOR A VACCINATION CARD, NOR ANOTHER DOCUMENT SEEN 6 (GO TO 511B)

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

BCG
DAY___
MONTH___
YEAR_____
HEPATITIS B GIVEN AT BIRTH
DAY___
MONTH___
YEAR_____
ORAL POLIO VACCINE (OPV) 0 (POLIO GIVEN AT BIRTH)
DAY___
MONTH___
YEAR_____
ORAL POLIO VACCINE (OPV) 1
DAY___
MONTH___
YEAR_____
ORAL POLIO VACCINE (OPV) 2
DAY___
MONTH___
YEAR_____
ORAL POLIO VACCINE (OPV) 3
DAY___
MONTH___
YEAR_____
DPT-HEP.B-HIB (PENTAVALENT) 1
DAY___
MONTH___
YEAR_____
DPT-HEP.B-HIB (PENTAVALENT) 2
DAY___
MONTH___
YEAR_____
DPT-HEP.B-HIB (PENTAVALENT) 3
DAY___
MONTH___
YEAR_____
PNEUMOCOCCAL 1
DAY___
MONTH___
YEAR_____
PNEUMOCOCCAL 2
DAY___
MONTH___
YEAR_____
PNEUMOCOCCAL 3
DAY___
MONTH___
YEAR_____
ROTAVIRUS 1
DAY___
MONTH___
YEAR_____
ROTAVIRUS 2
DAY___
MONTH___
YEAR_____
MEASLES 1
DAY___
MONTH___
YEAR_____
MEASLES 2
DAY___
MONTH___
YEAR_____
VITAMIN A (MOST RECENT)
DAY___
MONTH___
YEAR_____

509B) CHECK 508B: BCG TO MEASLES 2 ALL RECORDED?

YES (GO TO 510B)
NO (GO TO 525B)

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

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

YES 1: PROBE FOR VACCINATIONS AND WRITE 66 IN THE CORRESPONDING DAY COLUMN IN 508B. RECORD 00 IN THE DAY COLUMN CORRESPONDING TO ALL THE VACCINATIONS NOT GIVEN. THEN GO TO 525B

NO 2: RECORD 00 IN THE DAY COLUMN CORRESPONDING TO ALL THE VACCINATIONS NOT GIVEN. THEN GO TO 525B

DON'T KNOW 8: RECORD 00 IN THE DAY COLUMN CORRESPONDING TO ALL THE VACCINATIONS NOT GIVEN. THEN GO TO 525B

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

YES 1
NO 2 (GO TO 525B)
DON???T KNOW 8 (GO TO 525B)

512B) Did (NAME) ever receive a BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (GO TO 517B)
DON???T KNOW 8 (GO TO 517B)

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

FIRST TWO WEEKS 1
LATER 2

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

NUMBER OF TIMES___

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

YES 1
NO 2 (GO TO 519B)
DON???T KNOW 8 (GO TO 519B)

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

NUMBER OF TIMES___

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

YES 1
NO 2 (GO TO 521B)
DON???T KNOW 8 (GO TO 521B)

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

NUMBER OF TIMES___

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

YES 1
NO 2 (GO TO 523B)
DON???T KNOW 8 (GO TO 523B)

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

NUMBER OF TIMES___

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

YES 1
NO 2 (GO TO 525B)
DON???T KNOW 8 (GO TO 525B)

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

NUMBER OF TIMES___

525B) In the last 7 days was (NAME) given:

a) A powdered mix of micronutrients?
YES 1
NO 2
DON'T KNOW 8
b) Read to use therapeutic foods like Plumpt???nuts?
YES 1
NO 2
DON'T KNOW 8
c) Additional ready to use foods like Plumpy???doz?
YES 1
NO 2
DON'T KNOW 8

526B) CHECK 215 IN BIRTH HISTORY: ANY MORE BIRTHS IN 2013-2016?

MORE BIRTHS IN 2013-2016 (GO TO 502B IN AN ADDITIONAL QUESTIONNAIRE)
NO MORE BIRTHS IN 2013-2016 (GO TO 601)

SECTION 6. CHILD HEALTH AND NUTRITION

601) CHECK 224:

ONE OR MORE BIRTHS IN 2011-2016 (GO TO 602)
NO BIRTHS IN 2011-2016 (GO TO 648)

602) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME AND SURVIVAL STATE OF EACH BIRTH IN 2011-2016. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRE(S).

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

603) BIRTH HISTORY NUMBER FROM 212:

LAST BIRTH:
BIRTH HISTORY NUMBER___

NEXT-TO-LAST BIRTH:
BIRTH HISTORY NUMBER___

604) FROM 212 AND 216:

NAME_____________________
LIVING (GO TO 604A)
DEAD (GO TO 646)

604A) In the last six months, who many times has (NAME) been to the hospital or the head center for treatment? IF NONE, RECORD 00.

NUMBER OF TIMES_______________

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

YES 1
NO 2
DON'T KNOW 8

606) 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.

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 618)
DON'T KNOW 8 (GO TO 618)

609) CHECK 464: EVER BREASTFED?

YES: 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?

NO: Now I would like to know how much (NAME) was given to drink during the diarrhea. 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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON???T KNOW 8

610) 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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON???T KNOW 8

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

YES 1
NO 2 (GO TO 615)

612) 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.

(NAME OF PLACE(S))______________
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL A
REGIONAL GOVERNMENT HOSPITAL B
DISTRICT HOSPITAL C
GOVERNMENT HEALTH CENTER D
FIELDWORKER E
OTHER PUBLIC SECTOR_________F
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL G
CERTIFIED HEALTH CENTER H
OTHER PRIVATE MEDICAL___________I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC J
PRIVATE HEALTH CARE CENTER K
PHARMACY L
PRIVATE DOCTOR???S OFFICE M
OTHER PRIVATE MEDICAL____________N
OTHER SOURCE
SHOP O
TRADITIONAL PRACTITIONER P
MARKET Q
PEDDLER S
OTHER_____________X

613) CHECK 612:

TWO OR MORE CODES CIRCLED (GO TO 614)
ONLY ONE CODE CIRCLED (GO TO 615)

614) Where did you first seek advice or treatment? USE LETTER CODE FROM 612.

FIRST PLACE___

615) Was he/she given any of the following to drink at any time since (name) started having the diarrhea?

a) A fluid made from a special packet called SRO or Oracel?
YES 1
NO 2
DON'T KNOW 8
b) A pre-packaged ORS liquid?
YES 1
NO 2
DON'T KNOW 8
c) A government-recommended homemade fluid?
YES 1
NO 2
DON'T KNOW 8
d) Zinc tablets or syrup?
YES 1
NO 2
DON'T KNOW 8

616) CHECK 615:

ANY YES: Was anything else given to treat the diarrhea?

ALL NO OR DK: Was anything given to treat the diarrhea?

YES 1
NO 2 (GO TO 618)
DON'T KNOW 8 (GO TO 618)

617) CHECK 615:

ANY YES: What else was given to treat the diarrhea?

ALL NO OR DK: What was given to treat the diarrhea? Anything else?

RECORD ALL TREATMENTS GIVEN.

PILL OR SYRUP
ANTIBIOTIC A
ANTIMOTILITY B
OTHER (NOT ANTIBIOTIC, ANTIMOTILITY) C
UNKNOWN PILL OR SYRUP D
INJECTION
ANTIBIOTIC E
NON-ANTIBIOTIC F
UNKNOWN INJECTION G
(IV) INTRAVENOUS J
HOME REMEDY/HERBAL MEDICINE I
OTHER___________ X

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

YES 1
NO 2 (GO TO 620)
DON'T KNOW 8 (GO TO 620)

619) At any time during the illness, did (NAME) have blood taken from (NAME)???s finger or heal for testing?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

621) Has (NAME) had fast, short, rapid breaths or difficulty breathing at any time in the last 2 weeks?

YES 1
NO 2 (GO TO 623)
DON???T KNOW 8 (GO TO 623)

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

CHEST ONLY 1
NOSE ONLY 2
BOTH 3
OTHER________6
DON'T KNOW 8

ALL GO TO 624.

623) CHECK 618: HAD FEVER?

YES (GO TO 624)
NO OR DK (GO TO 646)

624) 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.

(NAME OF PLACE(S))__________________
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL A
REGIONAL GOVERNMENT HOSPITAL B
DISTRICT HOSPITAL C
GOVERNMENT HEALTH CENTER D
FIELDWORKER E
OTHER PUBLIC SECTOR____________ F
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL G
CERTIFIED HEALTH CENTER H
OTHER PRIVATE MEDICAL__________I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC J
PRIVATE HEALTH CARE CENTER K
PHARMACY L
PRIVATE DOCTOR???S OFFICE M
OTHER PRIVATE MEDICAL__________N
OTHER SOURCE
SHOP O
TRADITIONAL PRACTITIONER P
MARKET Q
PEDDLER R
OTHER_____________X

626) CHECK 625:

TWO OR MORE CODES CIRCLED (GO TO 627)
ONLY ONE CODE CIRCLED (GO TO 628)

627) Where did you first seek advice or treatment? USE LETTER CODE FROM 625.

FIRST PLACE___

628) How many days after the illness began did you first seek advice or treatment for (NAME)?

IF THE SAME DAY, RECORD 00.

DAYS___

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

YES 1
NO 2 (GO TO 646)
DON???T KNOW 8 (GO TO 646)

630) What drugs did (NAME) take? Any other drugs?

RECORD ALL MENTIONED.

ANTIMALARIAL DRUGS
ARTEMISININ COMBINATION THERAPY (ACT) A
SP/FANSIDAR B
QUININE BCHLOROQUINE C
AMODIAQUINE D
QUININE PILLS E
INJECTION F
ARTESUNATE RECTAL G
INJECTION/IV H
OTHER ANTIMALARIAL_________I
ANTIBIOTIC
PILL/SYRUP J
INJECTION/IV K
OTHER DRUGS
ASPIRIN L
ACETAMINOPHEN M
IBUPROFEN N
OTHER____________ X
DON???T KNOW Z

631) CHECK 630: ANY CODE A-F CIRCLED?

YES (GO TO 632)
NO (GO TO 646)

632) CHECK 630: ARTEMISININ COMBINATION THERAPY (A) GIVEN?

CODE A CIRCLED (GO TO 633)
CODE A NOT CIRCLED (GO TO 634)

633) How long after the fever started did (NAME) first take Artemisinin Combination Therapy?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON???T KNOW 8

634) CHECK 630: SP/FANSIDAR (B) GIVEN:

CODE B CIRCLED (GO TO 635)
CODE B NOT CIRCLED (GO TO 636)

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

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON???T KNOW 8

636) CHECK 630: CHLOROQUINE (C) GIVEN:

CODE C CIRCLED (GO TO 637)
CODE C NOT CIRCLED (GO TO 638)

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

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON???T KNOW 8

638) CHECK 630: AMODIAQUINE (D) GIVEN

CODE D CIRCLED (GO TO 640)
CODE D NOT CIRCLED (GO TO 640)

639) How long after the fever started did (NAME) first take Amodiaquine?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON???T KNOW 8

640) CHECK 630: QUININE (E OR F) GIVEN:

CODE E OR F CIRCLED (GO TO 641)
CODE E OR F NOT CIRCLED (GO TO 642)

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

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON???T KNOW 8

642) CHECK 630: ARTESUNATE (G OR H) GIVEN:

CODE G OR H CIRCLED (GO TO 643)
CODE G OR H NOT CIRCLED (GO TO 644)

643) How long after the fever started did (NAME) first take Artesunate?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON???T KNOW 8

644) CHECK 630: OTHER ANTIMALARIAL (I) GIVEN:

CODE I CIRCLED (GO TO 645)
CODE I NOT CIRCLED (GO TO 646)

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

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON???T KNOW 8

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

647) CHECK 615(a) AND 615(a), ALL COLUMNS:

NO CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID (GO TO 648)
ANY CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID (GO TO 649)

648) Have you ever heard of a special product called ORS you can get for the treatment of diarrhea?

YES 1
NO 2

649) CHECK 215 AND 218, ALL ROWS: NUMBER OF CHILDREN BORN IN 2014-2016 OR LATER LIVING
WITH RESPONDENT:

ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER)
NONE (GO TO 701)

650) Now I would like to ask you about liquids or foods that (NAME FROM 649) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods.

Did (NAME FROM 649) (drink/eat):

a) plain water?
YES 1
NO 2
DK 8
b) juice or juice drinks?
YES 1
NO 2
DK 8
c) clear broth?
YES 1
NO 2
DK 8
d) milk such as tinned, powdered, or fresh animal milk?
YES 1
NO 2
DK 8
IF YES: How many times did (NAME) drink milk? IF 7 OF MORE TIMES, RECORD 7.
NUMBER OF TIMES DRANK MILK__
e) Infant formula?
YES 1
NO 2
DK 8
IF YES: How many times did (NAME) drink infant formula? IF 7 OR MORE TIMES, RECORD 7
NUMBER OF TIMES DRANK FORMULA___
f) Any other liquids?
YES 1
NO 2
DK 8
g) Yogurt?
YES 1
NO 2
DK 8
IF YES: How many times did (NAME) eat yogurt? IF 7 OR MORE TIMES, RECORD 7.
NUMBER OF TIMES ATE YOGURT___
h) Any commercially fortified baby food like Cerelac, CSB?
YES 1
NO 2
DK 8
i) bread, rice, noodles, porridge, sorghum, rice, or any other foods made from grains?
YES 1
NO 2
DK 8
j) pumpkin, carrots, squash or sweet potatoes that are yellow or orange inside?
YES 1
NO 2
DK 8
k) white potatoes, white yams, manioc, cassava, or any other foods made from roots?
YES 1
NO 2
DK 8
l) any dark green, leafy vegetables?
YES 1
NO 2
DK 8
m) ripe mangoes, papayas, Japanese prunes, passion fruit, pineapple, oranges, ripe bananas, avocados, red currant, strawberries?
YES 1
NO 2
DK 8
n) any other fruits or vegetables)?
YES 1
NO 2
DK 8
o) liver, kidney, heart or any other organ meats?
YES 1
NO 2
DK 8
p) any meat, such as beef, pork, lamb, goat, chicken or duck?
YES 1
NO 2
DK 8
q) eggs?
YES 1
NO 2
DK 8
r) fresh or dried fish or shellfish?
YES 1
NO 2
DK 8
s) Other foods based in beans, peas, lentils, or nuts?
YES 1
NO 2
DK 8
t) cheese or other food made from milk?
YES 1
NO 2
DK 8
u) any type of food prepared with red palm oil?
YES 1
NO 2
DK 8
v) any type of food prepared with refined oil, meaning refrigerated yellow or white oil like corn oil or sunflower oil?
YES 1
NO 2
DK 8
w) Sugar, honey, cane sugar?
YES 1
NO 2
DK 8
x) Cookies or cakes?
YES 1
NO 2
DK 8
y) any other solid, semi-solid, or soft food?
YES 1
NO 2
DK 8

651) CHECK 650: (CATEGORIES G THROUGH Y)

NOT A SINGLE YES (GO TO 652)
AT LEAST ONE YES (GO TO 653)

652) Did (NAME FROM 649) eat any solid, semi-solid or soft foods yesterday during the day or at night?
IF YES, PROBE: What kind of solid, semi-solid, or soft foods did (NAME FROM 649) eat?

YES 1 (GO BACK TO 650 TO RECORD FOOD EATEN YESTERDAY)
NO 2

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

NUMBER OF TIMES___
DON???T KNOW 8

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

CHILD USED TOILET OR LATRINE 01
PUT/RINSED INTO TOILET OR LATRINE 02
PUT/RINSED INTO DRAIN OR DITCH 03
THROWN IN GARBAGE 04
BURIED 05
LEFT IN THE OPEN 06
OTHER_________96

SECTION 7: MARRIAGE AND SEXUAL ACTIVITY

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

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

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

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

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

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

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

LIVES WITH HER 1
STAYING ELSEWHERE 2

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

NAME_________
LINE NUMBER___

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

YES 1
NO 2 (GO TO 709)
DK 8 (GO TO 709)

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

TOTAL NUMBER OF WIVES AND LIVE-IN PARTNERS____
DON???T KNOW 98

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

RANK___

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

ONCE 1
MORE THAN ONCE 2

710) CHECK 709:

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: Now I would like to talk about your first (husband/partner). In what month and year did you start living with him?

MONTH ___
DON???T KNOW MONTH 98
YEAR ___ (GO TO 712)
DON???T KNOW YEAR 9998

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

AGE___

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

713) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don???t want to answer, just let me know and we will go to the next question. How old were you when you had sexual intercourse for the very first time?

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

714) I would like to ask you some questions about your recent sexual activity. 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.

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

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

DAYS AGO 1
WEEKS AGO 2
MONTHS AGO 3

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

YES 1
NO 2 (GO TO 718)

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

YES 1
NO 2

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

IF BOYFRIEND: Were you living together as if married?

HUSBAND 1
LIVE-IN PARTNER 2
BOYFRIEND NOT LIVING WITH RESPONDENT 3
CASUAL ACQUAINTANCE 4
CLIENT/SEX WORKER 5
OTHER___________6

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

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

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

NUMBER OF TIMES___

721) How old is this person?

AGE OF PARTNER___
DON???T KNOW 98

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

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

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

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

NUMBER OF PARTNERS LAST 12 MONTHS___
DON???T KNOW 98

724) CHECK 106:

AGE 15-24 (GO TO 725)
AGE 25-49 (GO TO 727)

725) CHECK 701:

NOT IN A UNION (GO TO 726)
CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 727)

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

YES 1
NO 2

727) In total, 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.

NUMBER OF PARTNERS IN LIFETIME___
DON???T KNOW 98

728) Check 716, most recent partner (FIRST COLUMN):

YES, CONDOM USED (GO TO 729)
NO, CONDOM NOT USED (GO TO 731)
QUESTION NOT ASKED (GO TO 731)

729) You told me that a condom was used the last time you had sex. What is the brand name of the condom used at that time? IF BRAND NOT KNOW, ASK TO SEE THE PACKAGE.

PRUDENCE 01
PRUDENCE CLASS 02
OTHER________96
DON???T KNOW 98

730) From where did you obtain the condom 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.

(NAME OF PLACE)_______________
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 11
REGIONAL GOVERNMENT HOSPITAL 12
DISTRICT HOSPITAL 13
GOVERNMENT HEALTH CENTER 14
COMMUNITY FIELDWORKER 15
OTHER___________16
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 21
CERTIFIED HEALTH CENTER 22
OTHER PRIVATE MEDICAL___________26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
PRIVATE HEALTH CARE CENTER 32
PHARMACY 33
PRIVATE DOCTOR???S OFFICE 34
OTHER PRIVATE MEDICAL________36
OTHER SOURCE
SHOP 41
FRIENDS/RELATIVES 42
OTHER_________96

731) PRESENCE OF OTHERS DURING THIS SECTION:

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

SECTION 8. FERTILITY PREFERENCES

801) CHECK 304:

NEITHER STERILIZED (GO TO 802)
HE OR SHE STERILIZED (GO TO 813)

802) CHECK 226:

PREGNANT (GO TO 803)
NOT PREGNANT OR UNSURE (GO TO 804)

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

HAVE ANOTHER CHILD 1 (GO TO 805)
NO MORE 2 (GO TO 811)
UNDECIDED/DON???T KNOW 8 (GO TO 811)

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

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 807)
SAYS SHE CAN???T GET PREGNANT 3 (GO TO 813)
UNDECIDED/DON???T KNOW (GO TO 810)

805) 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?

MONTHS 1
YEARS 2
SOON/NOW 993-SKIP TO 811
SAYS SHE CAN???T GET PREGNANT 994-SKIP TO 813
AFTER MARRIAGE 995 (GO TO 811)
OTHER (SPECIFY) 996 (GO TO 811)
DON???T KNOW 998 (GO TO 811)

806) CHECK 226:

NO PREGNANT OR UNSURE (GO TO 807)
PREGNANT (GO TO 812)

807) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT CURRENTLY USING (GO TO 808)
CURRENTLY USING (GO TO 813)

808) CHECK 805:

24 OR MORE MONTHS OR 02 OR MORE YEARS (GO TO 809)
NOT ASKED (GO TO 809)
00-23 MONTHS OR 00-01 YEARS (GO TO 812)

809) CHECK 714:

DAYS, WEEKS OR MONTHS AGO (GO TO 810)
YEARS AGO (GO TO 811)
NOT ASKED (GO TO 811)

810) CHECK 804:

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.

NOT MARRIED A
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
CAN???T GET PREGNANT E
NOT MENSTRUATED SINCE LAST BIRTH F
BREASTFEEDING G
UP TO GOD/FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND/PARTNER OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
SIDE EFFECTS/HEALTH CONCERNS O
LACK OF ACCESS/TOO FAR P
COSTS TOO MUCH Q
PREFERRED METHOD NOT AVAILABLE R
NO METHOD AVAILABLE S
INCONVENIENT TO USE T
INTERFERES WITH BODY???S NORMAL PROCESSES U
OTHER____________X
DON???T KNOW Z

811) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 812)
NO, NOT CURRENTLY USING (GO TO 812)
YES, CURRENTLY USING (GO TO 813)

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

YES 1
NO 2
DON???T KNOW 8

813) CHECK 216:

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

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

PROBE FOR A NUMERIC RESPONSE.

NONE 00 (GO TO 815)
NUMBER___
OTHER_________96 (GO TO 815)

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

NUMBER OF BOYS___
NUMBER OF GIRLS___
NUMBER OF EITHER___
OTHER__________96

815) In the last few months have you:

a) Heard about family planning on the radio?
YES 1
NO 2
b) Seen anything about family planning on the television?
YES 1
NO 2
c) Read about family planning in a newspaper or magazine?
YES 1
NO 2
d) Received a voice or text message about family planning on a mobile phone?
YES 1
NO 2

817) CHECK 701:

YES, CURRENTLY MARRIED (GO TO 818)
YES, CURRENTLY LIVING WITH A MAN (GO TO 818)
NO, NOT IN UNION (GO TO 901)

818) CHECK 303: USING A CONTRACEPTIVE METHOD?

CURRENTLY USING (GO TO 819)
NOT ASKED (GO TO 822)
NOT CURRENTLY USING OR NOT ASKED (GO TO 820)

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

MAINLY RESPONDENT 1
MAINLY HUSBAND/PARTNER 2
JOINT DECISION 3
OTHER__________6

820) Would you say that no using contraception is mainly your decision, mainly your (husband???s/partner???s) decision, or did you both decide together?

MAINLY RESPONDENT 1
MAINLY HUSBAND/PARTNER 2
JOINT DECISION 3
OTHER_________6

821) CHECK 304:

NEITHER STERILIZED (GO TO 822)
HE OR SHE STERILIZED (GO TO 901)

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

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DON???T KNOW 8

SECTION 9. HUSBAND???S BACKGROUND AND WOMAN???S WORK

901) CHECK 701:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 902)
NOT IN UNION (GO TO 909)

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

AGE___

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

YES 1
NO 2 (GO TO 906)

904) What is the highest level of school he attended: Primary, Secondary, or higher?

PRIMARY 1
SECONDARY 1ST CYCLE 2
SECONDARY 2ND CYCLE 3
HIGHER 4
DON???T KNOW 8 (GO TO 906)

905) What is the highest (grade/form/year) he completed at this level?

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 0.

GRADE/FORM/YEAR___
DON???T KNOW 98

906) Has your (husband/partner) done any work in the last 7 days?

YES 1 (GO TO 908)
NO 2
DON???T KNOW 8

907) Has your (husband/partner) done any work in the last 12 months?

YES 1
NO 2 (GO TO 909)
DON???T KNOW 8 (GO TO 909)

908) What is your (husband???s/partner???s) occupation? That is, what kind of work does he mainly do?

RECORD IN DETAIL_______________

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

YES 1 (GO TO 913)
NO 2

910) 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?

YES 1 (GO TO 913)
NO 2

911) 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?

YES 1 (GO TO 913)
NO 2

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

YES 1
NO 2 (GO TO 917)

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

RECORD IN DETAIL___________

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

FOR FAMILY MEMBER 1
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3

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

THROUGHOUT THE YEAR 1
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3

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

CASH ONLY 1
CASH AND KIND 2
IN KIND ONLY 3
NOT PAID 4

917) CHECK 701:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 918)
NOT IN UNION (GO TO 925)

918) Check 916:

CODE 1 OR 2 CIRCLED (GO TO 919)
OTHER (GO TO 921)

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
OTHER___________6

920) 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?

MORE THAN HIM 1
LESS THAN HIM 2
ABOUT THE SAME 3
HUSBAND/PARTNER HAS NO EARNINGS 4 (GO TO 922)
DON???T KNOW 8

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
HUSBAND HAS NO EARNINGS 4
OTHER__________6

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER______________6

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER___________6

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER____________6

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

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

926) Do you have a title deed for any house you own?

YES 1
NO 2 (GO TO 928)
DON???T KNOW 8 (GO TO 928)

927) Is your name on the title deed?

YES 1
NO 2
DON???T KNOW 8

928) Do you own any agricultural or non-agricultural land either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4 (GO TO 931)

929) Do you have a title deed for any land you own?

YES 1
NO 2 (GO TO 931)
DON???T KNOW (GO TO 931)

930) Is your name on the title deed?

YES 1
NO 2
DON???T KNOW 8

931) PRESENCE OF OTHERS AT THIS POINT:

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

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

If she goes out without telling him?
YES 1
NO 2
DON'T KNOW 8
If she neglects the children?
YES 1
NO 2
DON'T KNOW 8
If she argues with him?
YES 1
NO 2
DON'T KNOW 8
If she refuses to have sex with him?
YES 1
NO 2
DON'T KNOW 8
If she burns the food?
YES 1
NO 2
DON'T KNOW 8

SECTION 10. HIV/AIDS

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

YES 1
NO 2 (GO TO 1042)

1002) HIV is the virus that can lead to AIDS. Can people reduce their chance of getting HIV by having just one uninfected sex partner who has no other sex partners?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

1004) Can people reduce their chance of getting HIV by using a condom every time they have sex?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

1006) Can people get the HIV virus because of witchcraft or other supernatural means?

YES 1
NO 2
DON???T KNOW 8

1007) Is it possible for a healthy-looking person to have the HIV virus?

YES 1
NO 2
DON???T KNOW 8

1008) Can HIV be transmitted from a mother to a baby:

During pregnancy?
YES 1
NO 2
DON'T KNOW 8
During delivery?
YES 1
NO 2
DON'T KNOW 8
By breastfeeding?
YES 1
NO 2
DON'T KNOW 8

1009) CHECK 1008:

AT LEAST ONE YES (GO TO 1010)
OTHER (GO TO 1011)

1010) Are there any special drugs that a doctor or a nurse can give to a woman infected with HIV to reduce the risk of transmission to the baby?

YES 1
NO 2
DON'T KNOW 8

1011) CHECK 208 AND 215:

LAST BIRTH IN 2014-2016 (GO TO 1012)
NO BIRTHS (GO TO 1027)
LAST BIRTH IN 2013 OR EARLIER (GO TO 1027)

1012) CHECK 408 FOR LAST BIRTH:

HAD ANTENATAL CARE (GO TO 1013)
NO ANTENATAL CARE (GO TO 1020)

1013) CHECK FOR PRESENCE OF OTHERS, BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

1014) During any of the antenatal visits for your last birth were you given any information about:

Babies getting HIV from their mother?
YES 1
NO 2
DON'T KNOW 8
Things that you can do to prevent getting HIV?
YES 1
NO 2
DON'T KNOW 8
Getting tested for HIV?
YES 1
NO 2
DON'T KNOW 8

1015) Were you offered a test for HIV as part of your antenatal care?

YES 1
NO 2

1016) I don???t want to know the results, but were you tested for HIV as part of your antenatal care?

YES 1
NO 2 (GO TO 1020)

1017) 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.

(NAME OF PLACE)______________________
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 11
REGIONAL GOVERNMENT HOSPITAL 12
DISTRICT HOSPITAL 13
GOVERNMENT HEALTH CENTER 14
INDEPENDENT TESTING CENTER 15
SCHOOL CLINIC 16
MOBILE TESTING SERVICE 17
OTHER__________18
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 21
CERTIFIED HEALTH CENTER 22
OTHER PRIVATE MEDICAL____________26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR 31
PRIVATE HEALTH CARE CENTER 32
SCHOOL CLINIC 33
INDEPENDENT TESTING CENTER 34
PHARMACY 35
MOBILE TESTING SERVICE 36
OTHER PRIVATE MEDICAL___________37
OTHER SOURCE
HOME 41
WORKPLACE 42
CORRECTIONAL FACILITY 43
OTHER____________96

1018) I don???t want to know the results, but did you get the results of the test?

YES 1
NO 2 (GO TO 1020)

1019) All women are supposed to receive counseling after being tested. After you were tested, did you receive counseling?

YES 1
NO 2
DON???T KNOW 8

1020) CHECK 430 FOR LAST BIRTH:

ANY CODE 21-36 CIRCLED (GO TO 1021)
OTHER (GO TO 1024)

1021) Between the time you went for delivery but before the baby was born, were you offered an HIV test?

YES 1
NO 2

1022) I don???t want to know the results, but were you tested for HIV at that time?

YES 1
NO 2 (GO TO 1024)

1023) I don???t want to know the results, but did you get the results of the test?

YES 1
NO 2

1024) CHECK 1016:

YES (GO TO 1025)
NO OR NOT ASKED (GO TO 1027)

1025) Have you been tested for HIV since that time you were tested during your pregnancy?

YES 1 (GO TO 1028)
NO 2

1026) How many months ago was your most recent HIV test?

MONTHS AGO____
TWO OR MORE YEARS AGO 95

GO TO 1033.

1027) I don???t want to know the results, but have you ever been tested to see if you have the AIDS virus?

YES 1
NO 2 (GO TO 1031)

1028) How many months ago was your most recent HIV test?

MONTHS AGO___
TWO OR MORE YEARS AGO 95

1029) I don???t want to know the results, but did you get the results of the test?

YES 1
NO 2

1030) 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.

(NAME OF PLACE)______________
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL 11
REGIONAL GOVERNMENT HOSPITAL 12
DISTRICT HOSPITAL 13
GOVERNMENT HEALTH CENTER 14
INDEPENDENT TESTING CENTER 15
MOBILE TESTING SERVICE 16
SCHOOL CLINIC 17
OTHER___________18
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL 21
CERTIFIED HEALTH CENTER 22
OTHER PRIVATE MEDICAL____________26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR 31
PRIVATE HEALTH CARE CENTER 32
SCHOOL CLINIC 33
INDEPENDENT TESTING CENTER 34
PHARMACY 35
MOBILE TESTING SERVICE 36
OTHER PRIVATE MEDICAL___________37
OTHER SOURCE
HOME 41
WORKPLACE 42
CORRECTIONAL FACILITY 43
OTHER____________96

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

YES 1
NO 2 (GO TO 1033)

1032) 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.

(NAME OF PLACE)_____________
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL A
REGIONAL GOVERNMENT HOSPITAL B
DISTRICT HOSPITAL C
GOVERNMENT HEALTH CENTER D
INDEPENDENT TESTING CENTER E
MOBILE TESTING SERVICE F
SCHOOL CLINIC G
OTHER_____________H
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL I
CERTIFIED HEALTH CENTER J
OTHER PRIVATE MEDICAL___________K
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR L
PRIVATE HEALTH CARE CENTER M
SCHOOL CLINIC N
INDEPENDENT TESTING CENTER O
PHARMACY P
MOBILE TESTING SERVICE Q
OTHER PRIVATE MEDICAL__________ R
OTHER___________X

1033) Have you heard of test kits people can use to test themselves for HIV?

YES 1
NO 2 (GO TO 1035)

1034) Have you ever tested yourself for HIV using a self-test kits?

YES 1
NO 2

1035) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?

YES 1
NO 2
DON???T KNOW 8

1036) Do you think children living with HIV should be allowed to attend school with children who do not have HIV?

YES 1
NO 2
DK/NOT SURE/DEPENDS 8

1037) Do you think people hesitate to take an HIV test because they are afraid of how other people will react if the test results I positive for HIV?

YES 1
NO 2
DK/NOT SURE/DEPENDS 8

1038) Do people talk badly about people living with HIV, or who are thought to be living with HIV?

YES 1
NO 2
DK/NOT SURE/DEPENDS 8

1039) Do people living with HIV, or thought to be living with HIV, lose the respect of other people?

YES 1
NO 2
DK/NOT SURE/DEPENDS 8

1040) Do you agree or disagree with the following statement: I would be ashamed if someone in my family had HIV.

AGREE 1
DISAGREE 2
DK/NOT SURE/DEPENDS 8

1041) Do you fear that you could get HIV if you come into contact with the saliva of a person living with HIV?

YES 1
NO 2
SAYS SHE HAS HIV 3
DK/NOT SURE/DEPENDS 8

1042) CHECK 1001:

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

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

YES 1
NO 2

1043) CHECK 713:

HAS HAD SEXUAL INTERCOURSE (GO TO 1044)
NEVER HAD SEXUAL INTERCOURSE (GO TO 1051)

1044) CHECK 1042: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

YES (GO TO 1045)
NO (GO TO 1046)

1045) Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact?

YES 1
NO 2
DON???T KNOW 8

1046) Sometimes women experience a bad-smelling abnormal genital discharge. During the last 12 months, have you had a bad-smelling abnormal genital discharge?

YES 1
NO 2
DON???T KNOW 8

1047) Sometimes women have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?

YES 1
NO 2
DON???T KNOW 8

1048) Check 1045, 1046, or 1047:

HAS HAD AN INFECTION (ANY ???YES???) (GO TO 1049)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 1051)

1049) The last time you had (INFECTION FROM 1045/1046/1047), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 1051)

1050) 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.

(NAME OF PLACE)_________________
PUBLIC SECTOR
NATIONAL GOVERNMENT HOSPITAL A
REGIONAL GOVERNMENT HOSPITAL B
DISTRICT HOSPITAL C
GOVERNMENT HEALTH CENTER D
INDEPENDENT TESTING CENTER E
MOBILE TESTING SERVICE F
OTHER____________G
CERTIFIED MEDICAL SECTOR
CERTIFIED HOSPITAL H
CERTIFIED HEALTH CENTER I
OTHER PRIVATE MEDICAL__________J
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR K
PRIVATE HEALTH CARE CENTER L
INDEPENDENT TESTING CENTER M
PHARMACY N
MOBILE TESTING SERVICE O
OTHER PRIVATE MEDICAL__________P
OTHER SOURCE
SHOP Q
OTHER_____________X

1051) If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

YES 1
NO 2
DON???T KNOW 8

1052) Is a wife justified in refusing to have sex with her husband when she knows he has sex with other women?

YES 1
NO 2
DON???T KNOW 8

1053) CHECK 701:

CURRENTLY MARRIED/LIVING WITH A HUSBAND (GO TO 1054)
NOT IN UNION (GO TO 1101)

1054) Can you say no to your (husband/partner) if you do not want to have sexual intercourse?

YES 1
NO 2
DEPENDS/NOT SURE 8

1055) Can you ask your (husband/partner) to use a condom if you wanted him to?

YES 1
NO 2
DEPENDS/NOT SURE 8

SECTION 11. OTHER HEALTH ISSUES

1101) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months? IF YES: How many injections have you had?

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

NUMBER OF INJECTIONS____
NONE 00 (GO TO 1104)

1102) 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.

NUMBER OF INJECTIONS___
NONE 00 (GO TO 1104)

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

YES 1
NO 2
DON???T KNOW 8

1104) Do you currently smoke cigarettes every day, some days, or not at all?

EVERY DAY 1
SOME DAYS 2
NOT AT ALL 3 (GO TO 1106)

1105) On average, how many cigarettes do you currently smoke each day?

NUMBER OF CIGARETTES___

1106) Do you currently smoke or use any other type of tobacco every day, some days, or not at all?

EVERY DAY 1
SOME DAYS 2 (GO TO 1107A)
NOT AT ALL 3 (GO TO 1107A)

1107) What (other) type of tobacco do you currently smoke or use?

RECORD ALL MENTIONED.

KRETEKS A
PIPES FULL OF TOBACCO B
CIGARS, CHEROOTS, OR CIGARILLOS C
WATER PIPE D
SNUFF BY MOUTH E
SNUFF BY NOSE F
CHEWING TOBACCO G
BETEL QUID WITH TOBACCO H
OTHER____________X

1107A) Do you drink alcoholic beverages every day, almost every day, about once a week, about once a month, less often, or never?

EVERY DAY 1
ALMOST EVERY DAY 2
ABOUT ONCE A WEEK 3
ABOUT ONCE A MONTH 4
LESS OFTEN 5
NEVER 6

1107B) Since yesterday, have you had any alcoholic beverages?

YES 1
NO 2

1107C) How often do you get drunk: often, sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

1108) Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not?

a) Getting permission to go to the doctor?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
b) Getting money needed for advice or treatment?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
c) The distance to the health facility?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
d) Not wanting to go alone?
BIG PROBLEM 1
NOT A BIG PROBLEM 2

1109) Are you covered by any health insurance?

YES 1
NO 2 (GO TO 1111)

1110) What type of health insurance are you covered by? RECORD ALL MENTIONED.

MUTUAL HEALTH ORGANIZATION/COMMUNITY-BASED HEALTH INSURANCE A
NATIONAL HEALTH INSURANCE B
RELIGIOUS INSURANCE C
PRIVATE INSURANCE D
OTHER______________X

1111) A. Do you have any of the following illnesses? B. IF YES: Did you get a diagnosis from a medical professional?

a) Diabetes?
A.
YES 1
NO 2
B.
YES 1
NO 2
DON'T KNOW 8
b) High blood pressure?
A.
YES 1
NO 2
B.
YES 1
NO 2
DON'T KNOW 8
c) Heart problems?
A.
YES 1
NO 2
B.
YES 1
NO 2
DON'T KNOW 8
d) Kidney failure?
A.
YES 1
NO 2
B.
YES 1
NO 2
DON'T KNOW 8
e) Cancer?
A.
YES 1
NO 2
B.
YES 1
NO 2
DON'T KNOW 8
f) Paralysis?
A.
YES 1
NO 2
B.
YES 1
NO 2
DON'T KNOW 8
g) Asthma/chronic bronchitis?
A.
YES 1
NO 2
B.
YES 1
NO 2
DON'T KNOW 8
h) Leprosy?
A.
YES 1
NO 2
B.
YES 1
NO 2
DON'T KNOW 8

1112) In the last 12 months, have you gotten chigoe fleas on your feet or elsewhere?

YES 1
NO 2 (GO TO 1114)

1113) Since last (DAY OF THE WEEK), did you get chigoe fleas?

YES 1
NO 2

1114) 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?

YES 1 (GO TO 1201)
NO 2

1115) Have you ever heard of this problem, that is to say when a woman has constant leakage of urine or stool form her vagina during the day and night?

YES 1
NO 2 (GO TO 1201)

1116) Do you personally know a woman who has or had this problem?

YES 1
NO 2

SECTION 12. MATERNAL MORTALITY

1201) 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 who live with you, those who live elsewhere, and those who are dead. We have learned in previous surveys that it can be hard to create a complete list of all children born to your natural mother. We will work together to create a complete list and to help you remember all your brothers and sisters. Can you now give me the names of all your brothers and sisters born to your natural mother?

NAME_____________
ORDER NUMBER____

1202) CHECK 1201:

AT LEAST ONE BROTHER OR SISTER LISTED (GO TO 1203)
NOT A SINGLE BROTHER OR SISTER LISTED (GO TO 1204)

1203) READ THEIR NAMES TO THE RESPONDENT, AND AFTER THE LAST ONE, ASK: Are there any other brothers or sisters from the same mother that you didn???t list?

YES (RECORD THE OTHER BROTHERS AND SISTERS IN 1201)
NO (GO TO 1204)

1204) Sometimes people forget to list children of their natural mother because they do not live with them or because they don???t see each other very often. Are there brothers or sisters that do not live with you that you didn???t list?

YES (RECORD THE OTHER BROTHERS AND SISTERS IN 1201)
NO (GO TO 1205)

1205) Sometimes people forget to list children of their biological mother because they are dead. Do you have any brothers and sisters who are dead who you did not list?

YES (RECORD THE OTHER BROTHERS AND SISTERS IN 1201)
NO (GO TO 1206)

1206) Sometimes people have brothers or sisters from the same mother but from a different father. Are there any brothers or sisters born of your natural mother but who have a different natural father who you did not list?

YES (RECORD THE OTHER BROTHERS AND SISTERS IN 1201)
NO (GO TO 1207)

1207) COUNT THE NUMBER OF BROTHERS OR SISTERS RECORDED IN 1201.

TOTAL NUMBER OF BROTHERS AND SISTERS____

1208) CHECK 1207: Just to make sure that I???ve understood, not including yourself, your mother gave birth to _____ children total. Is that correct?

YES (GO TO 1209)
NO (PROBE AND CORRECT 1201 AND OR 1207)

1209) CHECK 1207:

AT LEAST ONE BROTHER OR SISTER LISTED (GO TO 1210)
NOT A SINGLE BROTHER OR SISTER LIST (GO TO 1300)

1210) Please tell me which brother or sister was born first? And who was the next?

RECORD '01' FOR THE ORDER NUMBER IN 1201 FOR THE FIRST BROTHER OR SISTER, '02' FOR THE SECOND, AND SO ON UNTIL YOU HAVE RECORDED ORDER NUMBERS FOR ALL BROTHERS AND SISTERS.

1211) How many births did your mother have before your own birth?

NUMBER OF PREVIOUS BIRTHS___

1212) RECORD THE BROTHER AND SISTERS ACCORDING TO THE ORDER NUMBER FROM 1201. ASK 1213 THROUGH 1224 FOR ONE BROTHER OR SISTER BEFORE MOVING TO THE NEXT BROTHER OR SISTER. IF THERE ARE MORE THAN 12 BROTHERS AND SISTERS, USE A SUPPLEMENTARY QUESTIONNAIRE.

1213) NAME OF BROTHER OR SISTER:

NAME__________________

1214) Is (NAME) male or female?

MALE 1
FEMALE 2

1215) Is (NAME) still alive?

YES 1
NO 2 (GO TO 1217)
DK 8 (GO TO [2,3,4,ETC])

1216) How old is (NAME)?

AGE____

GO TO [2,3,4,ETC].

1217) How many years ago did (NAME) die?

YEARS AGO___

1218) How old was (NAME) when he/she died?

IF DON???T KNOW, PROBE AND ASK OTHER QUESTIONS TO GET AN ESTIMATE.

AGE___

IF MAN, OR WOMAN DECEASED BEFORE AGED 12, GO TO 1223.

1219) Was (NAME) pregnant when she died?

YES 1 (GO TO 1223)
NO 2

1220) Did (NAME) die during childbirth?

YES 1 (GO TO [2,3,4,ETC])
NO 2

1221) Did (NAME) die within two months after the end of a pregnancy or childbirth?

YES 1
NO 2

1222) How many days after the end of (NAME)???s pregnancy did she die?

DAYS___

1223) Was (NAME)???s death the result of a violent act?

YES 1 (GO TO [2,3,4,ETC])
NO 2

1224) Was (NAME)???s death the result of an accident?

YES 1
NO 2

GO TO [2,3,4,ETC]

IF NO OTHER BROTHERS OF SISTERS, GO TO NEXT SECTION.

SECTION 13: DEVELOPMENT OF YOUNG CHILD

1300) CHECK 217 AND 218: ALL CHILDREN AGE 0-4 LIVING WITH HIS OR HER MOTHER?

YES (GO TO 1301)
NO (GO TO 1501)

1301) CHECK 217 AND 218: SELECT THE YOUNGEST CHILD AGE 0-4 LIVING WITH HIS OR HER MOTHER AND RECORD HIS OR HER NAME AND LINE NUMBER.

NAME OF THE YOUNGEST CHILD (FROM Q 212)_________
LINE NUMBER OF THE YOUNGEST CHILD (FROM Q 219)___

1302) READ TO THE RESPONDENT:

Now, I would like to ask you some questions about (NAME OF CHILD IN 1301), your youngest child from 0-4 living with you.

1303) How many children???s books and picture books do you have for (NAME)?

NONE 00
NUMBER OF CHILDREN???S BOOKS___
TEN OR MORE BOOKS 10

1304) I would like to ask you what objects (NAME) uses to play with while at home.

Does he/she play with:

a) homemade toys (like dolls, cars, or other homemade toys)?
YES 1
NO 2
DON'T KNOW 8
b) Toys from a store or a manufacture?
YES 1
NO 2
DON'T KNOW 8
c) Household objects (like bowls or pots), or objects found outside (like sticks, stones, animals, shells, or leaves)?
YES 1
NO 2
DON'T KNOW 8

IF THE RESPONDENT SAYS ???YES??? TO ONE OF THE ABOVE CATEGORIES, PROBE TO DETERMINE PRECISELY WHAT THE CHILD PLAYS WITH TO BE CERTAIN OF THE RESPONSE.

1305) Sometimes the adults who take care of the children have to leave the house to go shopping, do the laundry, or for other reasons and have to leave the young children.

During the last week, how many days was (NAME):

a) Left alone for more than one hour?
NUMBER OF DAYS___
b) Left in the care of another child (meaning someone under 10 years old) for more than one hour?
NUMBER OF DAYS___

IF 'NEVER' RECORD '0'. IF 'DON???T KNOW', RECORD '8'.

1306) CHECK 217: AGE OF THE CHILD

0, 1, OR 2 YEAR OLD CHILD (GO TO 1307)
3 OR 4 YEAR OLD CHILD (GO TO 1309)

1307) CHECK 217 AND 218: ALL CHILDREN AGE 3-4 LIVING WITH HIS OR HER MOTHER?

YES (GO TO 1308)
NO (GO TO 1401)

1308) CHECK 217 AND 218: SELECT THE YOUNGEST CHILD OF 3 OR 4 YEARS LIVING WITH HIS OR HER MONTH AND WRITE THE CHILD???S NAME AND LINE NUMBER.

NAME OF YOUNGEST 3-4 YEAR OLD CHILD (FROM Q 212)__________
LINE NUMBER OF YOUNGEST 304 YEAR OLD CHILD (FROM Q 219)___

1309) Is (NAME) in a preschool education program or an early learning class, in a public or private establishment, including nursery school or a community child-care center?

YES 1
NO 2
DON???T KNOW 8

1310) During the last three days did you or a member of your family age 15 or old participate with (NAME) in one of the following activities:

IF YES, ASK: Who participated in this activity with (NAME)?

CIRCLE ALL MENTIONED.

a) Read books or looked at illustrated books with (NAME)?
YES 1
NO 2

MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
b) Told stories to (NAME)?
YES 1
NO 2

MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
c) Sang songs to (NAME), or with (NAME), including lullabies?
YES 1
NO 2

MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
d) Took (NAME) for a walk outside of the house, the residence, the courtyard or the enclosure wall?
YES 1
NO 2

MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
e) Played with (NAME)?
YES 1
NO 2

MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
f) Spent time with (NAME), naming, counting, and/or drawing?
YES 1
NO 2

MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y

1311) Now I would like to ask you some questions about the health and development of your child. Children do not all develop in the same manner and at the same speed. Some, for example, walk earlier than others. These questions relate to several aspects of your child???s development.

Does (NAME) know or can he/she recite at least ten letters from the alphabet?

YES 1
NO 2
DK 8

1312) Can (NAME) read at least four simple, common words?

YES 1
NO 2
DK 8

1313) Can (NAME) list and recognize all digits from 1 to 10?

YES 1
NO 2
DK 8

1314) Can (NAME) grasp with two fingers a small object from the ground, like a stick or a pebble?

YES 1
NO 2
DK 8

1315) Is (NAME) ever too sick to play?

YES 1
NO 2
DK 8

1316) Is (NAME) able to follow simple instructions to do something correctly?

YES 1
NO 2
DK 8

1317) When you give (NAME) something to do, is he/she able to do it independently?

YES 1
NO 2
DK 8

1318) Does (NAME) get along well with other children?

YES 1
NO 2
DK 8

1319) Does (NAME) kick, bit, or hit other children or adults?

YES 1
NO 2
DK 8

1320) Is (NAME) easily distracted?

YES 1
NO 2
DK 8

SECTION 15. DOMESTIC VIOLENCE

1500) CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE: WOMAN SELECTED FOR MODULE ON DOMESTIC VIOLENCE?

WOMAN SELECTED FOR THIS SECTION (GO TO 1501)
WOMAN NOT SELECTED (GO TO 1533)

1501) CHECK FOR PRESENCE OF OTHERS: DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

PRIVACY OBTAINED 1
PRIVACY NOT POSSIBLE 2 (GO TO 1532)

1502) READ TO THE RESPONDENT:

Now I would like to ask you questions about some other important aspects of a woman???s life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in Burundi. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions. If I ask you a question you do not want to answer, let me know and I will skip to the next question.

1503) CHECK 701 AND 702:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 1504)

FORMERLY MARRIED/LIVED WITH A MAN (READ IN PAST TENSE AND USE ???LAST??? WITH HUSBAND/PARTNER)

NEVER MARRIED/NEVER LIVED WITH A MAN (GO TO 1516)

1504) First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband/partner?

a) He (is/was) jealous or angry if you (talk/talked) to other men?
YES 1
NO 2
DON'T KNOW 8
b) He frequently (accuses/accused) you of being unfaithful?
YES 1
NO 2
DON'T KNOW 8
c) He (does/did) not permit you to meet your female friends?
YES 1
NO 2
DON'T KNOW 8
d) He (tries/tried) to limit your contact with your family?
YES 1
NO 2
DON'T KNOW 8
e) He (insists/insisted) on knowing where you (are/where) at all times?
YES 1
NO 2
DON'T KNOW 8

1505) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner.

A. (Does/did) your last husband/partner ever:
B. How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) say or do something to humiliate you in front of others?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) Threaten to hurt or harm you or someone you care about?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) insult you or make you feel bad about yourself?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

1505)

A. Did your (last) (husband/partner) ever do any of the following things to you:
B. How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) push you, shake you, or throw something at you?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) slap you?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) twist your arm or pull your hair?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

d) punch you with his fist or with something that could hurt you?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
e) kick you, drag you, or beat you up?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
f) try to chock you or burn you?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
g) threaten you with a knife, gun, or other type of weapon?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
h) physically force you to have sexual intercourse with him even when you did not want to?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
i) physically force you to perform other sexual acts you did not want to?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
j) Force you with threats or in any other way to perform sexual acts you did not want to?
A.
YES 1
NO 2
B.
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

1506) Check 1505A (a-j):

AT LEAST ONE YES (GO TO 1507)
NOT A SINGLE YES (GO TO 1509)

1507) How long after you (first got married to/started living with) your (last) husband/partner did this or any of these things first happen? IF LESS THAN ONE YEAR, RECORD 00.

NUMBER OF YEARS___
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95

1508) Did the following ever happen as a result of what your (last) husband/partner did to you:

a) You had cuts, bruises, or aches?
YES 1
NO 2
b) you had eye injuries, sprains, dislocations, or burns?
YES 1
NO 2
c) you had deep wounds, broken bones, broken teeth, or any other serious injury?
YES 1
NO 2

1509) 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?

YES 1
NO 2 (GO TO 1511)

1510) In the last 12 months, how often have you done this to your (last) husband/partner: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1511) Does (did) your husband/partner drink (alcohol)?

YES 1
NO 2 (GO TO 1513)

1512) How often does (did) he get drunk: often, only sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

1513) Are (were) you afraid of your (last) (husband/partner): many times, sometimes, or never?

MANY TIMES AFRAID 1
SOMETIMES AFRAID 2
NEVER AFRAID 3

1514) CHECK 709:

MARRIED MORE THAN ONCE (GO TO 1515)
MARRIED ONLY ONCE (GO TO 1516)

1515)

A. So far we have been talking about the behavior of your (current/last) (husband/partner). Now I want to ask you about the behavior of any previous (husband/partner).

B. How long ago did this last happen?

a) Did any previous (husband/partner) ever hit, slap, kick or do anything else to hurt you physically?
A.
YES 1
NO 2
B.
0-11 MONTHS AGO 1
12 OR MORE MONTHS AGO 2
DON???T REMEMBER 3
b) Did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?
A.
YES 1
NO 2
B.
0-11 MONTHS AGO 1
12 OR MORE MONTHS AGO 2
DON???T REMEMBER 3

1516) CHECK 701 AND 702:

EVER MARRIED/EVER LIVED WITH A MAN: From the time you were 15 years old has anyone other than (your/any) (husband/partner) hit you, slapped you, kicked you, 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 hit you, slapped you, kicked you, or done anything else to hurt you physically?

YES 1
NO 2 (GO TO 1519)
REFUSED TO ANSWER/NO ANSWER 6 (GO TO 1519)

1517) Who has physically hurt you in this way? Anyone else?

RECORD ALL MENTIONED.

MOTHER/FATHER???S WIFE A
FATHER/MOTHER???S HUSBAND B
SISTER/BROTHER C
DAUGHTER/SON D
OTHER RELATIVE E
CURRENT BOYFRIEND F
EX-BOYFRIEND G
MOTHER-IN-LAW H
FATHER-IN-LAW I
OTHER IN-LAWS J
TEACHER K
EMPLOYER/SOMEONE AT WORK L
POLICE/SOLDIER M

OTHER____________X

1518) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1519) CHECK 201, 226, AND 230:

EVER BEEN PREGNANT (YES TO 201 OR 226 OR 230) (GO TO 1520)
NEVER BEEN PREGNANT (GO TO 1522)

1520) Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

YES 1
NO 2 (GO TO 1522)

1521) Who has done any of these things to physically hurt you while you were pregnant? Anyone else?

RECORD ALL MENTIONED.

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

OTHER_______________X

1522) CHECK 701 AND 702:

EVER MARRIED/EVER LIVED WITH A MAN (GO TO 1522A)
NEVER MARRIED/NEVER LIVED WITH A MAN (GO TO 1522B)

1522A) Now I want to ask you about things that may have been done to you by someone other than (your/any) (husband/partner).

At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?

YES 1 (GO TO 1523)
NO 2 (GO TO 1524A)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1524A)

1522B) At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?

YES 1
NO 2-SKIP TO 1326
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1526)

1523) Who was the person who was forcing you the first time?

CURRENT HUSBAND/PARTNER 01
FORMER HUSBAND/ PARTNER 02
CURRENT/FORMER BOYFRIEND 03
FATHER/STEP-FATHER 04
BROTHER/STEP-BROTHER 05
OTHER RELATIVE 06
IN-LAW 07
OWN FRIEND/ACQUAINTANCE 08
FAMILY FRIEND 09
TEACHER 10
EMPLOYER/SOMEONE AT WORK 11
POLICE/SOLDIER 12
PRIEST/RELIGIOUS LEADER 13
STRANGER 14

OTHER_______________96

1524) CHECK 701 AND 702:

EVER MARRIED/EVER LIVED WITH A MAN: In the last 12 months, has anyone other than (your/any) (husband/partner) physically forced you to have sexual intercourse when you did not want to?

NEVER MARRIED/NEVER LIVED WITH A MAN: In the last 12 months, has anyone physically forced you to have sexual intercourse when you did not want to?

YES 1 (GO TO 1525)
NO 2 (GO TO 1525)

1524A) Check 1505A (h-j) and 1515A (b):

AT LEAST ONE YES (GO TO 1525)
NOT A SINGLE YES (GO TO 1526)

1525) CHECK 701 AND 702:

EVER MARRIED/EVER LIVED WITH A MAN: How old were you the first time someone including (your/any) (husband/partner) forced you to have sexual intercourse or perform any other sexual?

NEVER MARRIED/NEVER LIVED WITH A MAN: How old were you the first time someone forced you to have sexual intercourse or perform any other sexual acts?

AGE IN COMPLETED YEARS___
DON???T KNOW 98

1526) CHECK 13150505 (a-j), 1516 (a,b), 1516, 1520, 1522A, AND 1522B:

AT LEAST ONE YES (GO TO 1527)
NOT A SINGLE YES (GO TO 1530)

1527) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?

YES 1
NO 2 (GO TO 1529)

1528) From whom have you sought help? Anyone else?

RECORD ALL MENTIONED.

OWN FAMILY A
HUSBAND???S/PARTNER???S FAMILY B
CURRENT/FORMER HUSBAND/PARTNER C
CURRENT/FORMER BOYFRIEND D
FRIEND E
NEIGHBOR F
RELIGIOUS LEADER G
DOCTOR/MEDICAL PERSONNEL H
POLICE I
LAWYER J
SOCIAL SERVICE ORGANIZATION K

OTHER________________X

ALL GO TO 1530.

1529) Have you ever told anyone about this?

YES 1
NO 2

1530) As far as you know, did your father ever beat your mother?

YES 1
NO 2
DON???T KNOW 8

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

1531) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

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

1532) INTERVIEWER???S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE:

______________________________________________________

1533) RECORD THE TIME.

HOUR___
MINUTE___

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

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

INFORMATION TO BE CODED FOR EACH COLUMN.

2017
03 MAR 10
02 FEB 11
01 JAN 12

2016*
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
01 JAN 12

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE

B BIRTH
P PREGNANCIES
T TERMINATIONS

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

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE

0 INFREQUENT SEX/HUSBAND AWAY
1 BECAME PREGNANT WHILE USING
2 WANTED TO BECOME PREGNANT
3 HUSBAND/PARTNER DISAPPROVED
4 WANTED MORE EFFECTIVE METHOD
5 SIDE EFFECTS/HEALTH CONCERNS
6 LACK OF ACCESS/TOO FAR
7 COSTS TOO MUCH
8 INCONVENIENT TO USE
F UP TO GOD/FATALIST
A DIFFICULT TO GET PREGNANT/MENOPAUSAL
D MARITAL DISSOLUTION/SEPARATION
X OTHER (SPECIFY)
Z DON???T KNOW