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DEMOGRAPHIC AND HEALTH SURVEY (EDSB-IV, 2011) WOMAN'S QUESTIONNAIRE - REPUBLIC OF BENIN NATIONAL OFFICE OF STATISTICS AND ECONOMIC ANALYSIS

MINISTRY OF DEVELOPMENT, ECONOMIC ANALYSIS, AND FORECASTING

IDENTIFICATION

DEPARTMENT ______
COMMUNE ______
DISTRICT ______

URBAN/RURAL

URBAN 1
RURAL 2

VILLAGE/NEIGHBORHOOD___________
CLUSTER NUMBER __________
STRUCTURE NUMBER _________
HOUSEHOLD NUMBER________

NAME OF HEAD OF HOUSEHOLD __________

NAME AND LINE NUMBER OF WOMAN _________

CHECK HOUSEHOLD QUESTIONNAIRE: IF HOUSEHOLD IS SELECTED FOR ARTERIAL BLOOD PRESSURE, QUESTIONS ON BLOOD PRESSURE MUST BE ASKED

TAKE BLOOD PRESSURE:

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE______
INTERVIEWER'S NAME_________
RESULT

NEXT VISIT
DATE________
TIME_________

FINAL VISIT
DAY_______
MONTH_______
YEAR 2011
INTERVIEWER CODE_______
RESULT _____

RESULT CODES:

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

TOTAL NO. OF VISITS_________

LANGUAGE OF QUESTIONNAIRE: FRENCH 1

LANGUAGE OF INTERVIEW

FRENCH 1
ADJA 2
BARIBA 3
FON 4
DENDI 5
DITAMARI 6
YORUBA 7
OTHERS 8

INTERPRETER

YES 1
NO 2

SUPERVISOR
NAME_______
DATE_______

FIELD EDITOR
NAME_______
DATE______

OFFICE EDITOR_______

KEYED BY_______

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

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

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

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

SIGNATURE OF INTERVIEWER________
DATE_______

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END INTERVIEW)

101) RECORD THE TIME

HOUR_____
MINUTES______

101AA) CHECK COVER PAGE:

IF HOUSEHOLD SELECTION = 1 (GO TO 101A)
IF HOUSEHOLD SELECTION = 2 (GO TO 102)

101A) During this interview, I would like to take your blood pressure. I will take your blood pressure three times during this interview.

There is no danger to the procedure. It is done to see if a person suffers from hypertension. Without treatment, hypertension can cause serious damage to the heart.

The results of the blood pressure test will be given at the end of the interview along with an explanation of your blood pressure results. If you have high blood pressure, given that we cannot perform further testing to give you proper treatment during the survey, we will advise you to consult a health care facility or a doctor.

Do you have any questions about the blood pressure test? If at any point you have questions, you may ask them to me.

You can say yes, or you can say no to the blood pressure test now. You can also decide to stop this blood pressure testing at any time.

Will you allow me to take your blood pressure now?

SIGNATURE OF INTERVIEWER:________

RESPONDENT ACCEPTS 1 (GO TO 101B)
RESPONDENT REFUSES 2 (GO TO 102)

101B) Before taking your blood pressure, I would like to ask you some questions about some things that can affect the measurement? Did you do any of the following in the last 30 minutes:

Eat something?
Drank coffee, tea, a Coca-cola or other drink that has caffeine?
Smoked any tobacco product?

EAT
YES 1
NO 2
DRINK THAT HAS CAFFEINE
YES 1
NO 2
SMOKE
YES 1
NO 2

101D) May I take your blood pressure?
BEFORE TAKING BLOOD PRESSURE FOR THE FIRST TIME, MEASURE THE INTERVIEWER'S ARM CIRCUMFERENCE, IN THE SPACE BETWEEN THE SHOULDER AND THE ELBOW.
RECORD THE MEASUREMENT IN CENTIMETERS

ARM CIRCUMFERENCE (IN CENTIMETERS)_______

101C) USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE TYPE OF BLOOD PRESSURE DEVICE MODEL AND THE APPROPRIATE DIMENSIONS. CIRCLE THE CODE FOR THE DEVICE MODEL AND DIMENSIONS.

MEDIUM: 24 CM-35CM (9.5-13 IN) 1
LARGE: 36 CM- 41 CM (12-16 IN) 2

101E) May I take your blood pressure now?

INTERVIEWER SIGNATURE________
DATE_______

RESPONDENT ACCEPTED MEASUREMENT (RECORD THE RESULT OF THE BLOOD PRESSURE TEST)
RESPONDENT REFUSED MEASUREMENT (RECORD 9994)

BLOOD PRESSURE

SYSTOLIC/MAX 1__________
DIASTOLIC/MIN 2_________

REASONS FOR WHICH THE BLOOD PRESSURE WASN'T MEASURED

REFUSED '9994
TECHNICAL PROBLEMS '9995
OTHERS________ (SPECIFY) '9996

102) In what month and year were you born?

MONTH______
DON'T KNOW MONTH 98
YEAR________
DON'T KNOW YEAR 9998

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

AGE IN COMPLETED YEARS_______

104) Have you ever attended school?

YES 1
NO 2 (GO TO 108)

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

PRIMARY 1
SECONDARY 2
SECONDARY 3
HIGHER 4

106) 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_______

107) CHECK 105:

PRIMARY (GO TO 108)
SECONDARY OR HIGHER (GO TO 110)

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

SHOW CARD TO RESPONDENT

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

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

109) CHECK 108:

CODE '2', '3', OR '4' CIRCLED (GO TO 110)
CODE '1' OR '5' CIRCLED (GO TO 111)

110) 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

111) 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

112) 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

113) What is your religion?

VOODOO 11
OTHER TRADITIONAL 12
ISLAM 21
CATHOLIC 31
PROTESTANT METHODIST 41
OTHER PROTESTANTS 42
CELESTIAL 51
OTHER CHRISTIAN 52
OTHER RELIGIONS 61
NONE 71

114) What is your ethnicity?

ADJA AND SIMILAR 11
BARIBA AND SIMILAR 21
DENDI AND SIMILAR 31
FON AND SIMILAR 41
YOA AND LOKPA AND SIMILAR 51
BETAMARIBE AND SIMILAR 61
PEULH AND SIMILAR 71
YORUBA AND SIMILAR 81
OTHER BENINESE__________ (SPECIFY) 96
OTHER NATIONALITY ________(SPECIFY) 97

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

NUMBER OF TIMES______
NONE 00 (GO TO 201)

116) 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 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? And how many daughters live with you?
IF NONE, RECORD '00'

SONS AT HOME______
DAUGHTERS AT HOME_______

204) Do you have any sons or daughters 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? And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'

SONS ELSEWHERE__________
DAUGHTERS ELSEWHERE______

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

YES 1
NO 2 (GO TO 208)

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

BOYS DEAD_______
GIRLS DEAD_______

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 (GO TO 210)
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 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.)

212) What name was given to you (first/next) baby?
RECORD NAME AND BIRTH HISTORY NUMBER

LINE NUMBER_______

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

BOY 1
GIRL 2

214) Were any of these births twins?

SINGLE 1
MULTIPLE 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) IF ALIVE: Is (NAME) living with you?

YES 1
NO 2

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

HOUSEHOLD LINE NUMBER_______ (GO TO NEXT BIRTH)

220) IF DEAD: How old was (NAME) when he/she died?
IF '1 YR', PROBE: How many months old was (NAME)? RECORD DAYS IF LESS THAN 1 MONTH; MONTHS 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)?
IF YES, RECORD BIRTH(S) IN TABLE.

YES 1
NO 2

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

NUMBERS ARE EQUAL (GO TO 224)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

224) CHECK 215:
ENTER THE NUMBER OF BIRTHS IN 2006 OR LATER.

NUMBER OF BIRTHS_________
NONE 0 (GO TO 226)

225) FOR EACH BIRTH SINCE JANUARY 2006, ENTER 'N' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE CODE 'N' FOR EACH BIRTH. ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'G' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF THE PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226) Are you pregnant now?

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

227) How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'G's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

MONTHS_______

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

YES 1 (GO TO 230)
NO 2

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

LATER 1
NONE/NO MORE 2

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

YES 1
NO 2 (GO TO 238)

231) When did the last such pregnancy end?

MONTH____
YEAR____

232) CHECK 231:

LAST PREGNANCY ENDED IN JAN 2006 OR LATER (GO TO 233)
LAST PREGNANCY ENDED BEFORE JAN. 2006 (GO TO 238)

233) How many months pregnant were you when the last such pregnancy ended?
RECORD THE NUMBER OF COMPLETED MONTHS. ENTER F IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'G' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

MONTHS_________

234) Since January 2006, have you had any other pregnancies that did not result in a live birth?

YES 1
NO 2 (GO TO 236)

235) ASK THE DATE AND DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2006. ENTER "F" IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND "G" FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236) Did you have any miscarriages, abortions or stillbirths that ended before 2006?

YES 1
NO 2 (GO TO 238)

237) When did the last such pregnancy that terminated before 2006 end?

MONTH_______
YEAR_______

238) 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

239) 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 301)
DON'T KNOW 8 (GO TO 301)

240) 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

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. PROBE: Women can have an operation to avoid having any more children.
YES 1
NO 2
02) MALE STERILIZATION. PROBE: Men can have an operation to avoid having any more children.
YES 1
NO 2
03) IUD. PROBE: Women can have a coil placed inside them by a doctor or a nurse.
YES 1
NO 2
04) INJECTABLES. PROBE: 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. PROBE: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2
06) PILL. PROBE: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
07) CONDOM. PROBE: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
08) FEMALE CONDOM. PROBE: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2
09) LACTATIONAL AMENORRHEA METHOD (LAM).
YES 1
NO 2
10) RHYTHM METHOD. PROBE: 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
11) WITHDRAWAL. PROBE: Men can be careful and pull out before climax.
YES 1
NO 2
12) EMERGENCY CONTRACEPTION. PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
YES 1
NO 2
13) Have you heard of any other ways or methods that women or men can use to avoid pregnancy? RECORD UP TO TWO METHODS
SPECIFY____
YES 1
NO 2

302) CHECK 226:

NOT PREGNANT OR UNSURE (GO TO 303)
PREGNANT (GO TO 311)

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

YES 1
NO 2 (GO TO 311)

304) Which method are you using?

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 308A)
INJECTABLES D (GO TO 308A)
IMPLANTS E (GO TO 308A)
PILL F
CONDOM G (GO TO 306)
FEMALE CONDOM H (GO TO 308A)
DIAPHRAGM I (GO TO 308A)
FOAM/JELLY J (GO TO 308A)
LACTATIONAL AMEN. METHOD K (GO TO 308A)
RHYTHM METHOD L (GO TO 308A)
WITHDRAWAL M (GO TO 308A)
OTHER MODERN METHOD_________(SPECIFY) X (GO TO 308A)
OTHER TRADITIONAL METHOD__________(SPECIFY) Y (GO TO 308A)

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

HARMONIE 01 (GO TO 308A)
DUOFEM 02 (GO TO 308A)
MICROGYNON 03 (GO TO 308A)
EUGYNON 04 (GO TO 308A)
LO-FEMENAL 05 (GO TO 308A)
CONFIANCE 06 (GO TO 308A)
MINIDIRL 07 (GO TO 308A)
STEDIRIL 08 (GO TO 308A)
OTHER (SPECIFY) 96 (GO TO 308A)
DON'T KNOW 98 (GO TO 308A)

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 (GO TO 308A)
COOL 02 (GO TO 308A)
OTHER ________(SPECIFY) 96 (GO TO 308A)
DON'T KNOW 98 (GO TO 308A)

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
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
OTHER PUBLIC SECTOR _________(SPECIFY) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE MEDICAL OFFICE 23
MOBILE CLINIC 24
OTHER PRIVATE MEDICAL_________ (SPECIFY) 26
OTHER_________ (SPECIFY) 96
DON'T KNOW 98

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

MONTH _______
YEAR_______

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

YES (GO BACK TO 308/308A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION))
NO (GO TO 310)

310) CHECK 308/308A:

YEAR IS 2006 OR LATER (ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN CALENDAR AND IN EACH MONTH BACK TO THE DATE STARTED USING) (GO TO 311)

YEAR IS 2005 OR EARLIER (ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK TO JANUARY 2006) (GO TO 332.)

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

USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2006
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

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

ILLUSTRATIVE QUESTIONS:

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

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

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

ILLUSTRATIVE QUESTIONS:

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

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

NO METHOD USED (GO TO 313)
ANY METHOD USED (GO TO 314)

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

YES 1 (GO TO 324)
NO 2 (GO TO 324)

314) 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 324)
FEMALE STERILIZATION 01 (GO TO 317A)
MALE STERILIZATION 02 (GO TO 326)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 315A)
RHYTHM METHOD 12 (GO TO 315A)
WITHDRAWAL 13 (GO TO 326)
OTHER MODERN METHOD_______ (SPECIFY) 95 (GO TO 326)
OTHER TRADITIONAL METHOD______(SPECIFY) 96 (GO TO 326)

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

315A) Where did you learn how to use the rhythm/lactational amenorrhea method?

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

(NAME OF PLACE)_______
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
FIELDWORKER 14
SOCIAL CENTER 15
STRAT AV HEALTH WORKER 16
HEALTH WORKER/COMMUNITY LIAISON 17
VENDING MACHINE 18
OTHER PUBLIC SECTOR_______(SPECIFY) 19
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
RELIGIOUS HOSPITAL 22
PRIVATE DOCTOR'S OFFICE 23
PHARMACY 24
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) 25
FIELDWORKER (NOG) 26
OTHER PRIVATE MEDICAL_______ (SPECIFY) 26
OTHER SOURCE
SHOP/MARKET 31
CHURCH/MOSQUE 32
FRIEND/RELATIVES 33
BAR/REFRESHMENT AREA 34
OTHER_______ (SPECIFY) 96

316) 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 320)
DIAPHRAGM 09 (GO TO 320)
FOAM/JELLY 10 (GO TO 320)
LACTATIONAL AMEN. METHOD 11 (GO TO 326)
RHYTHM METHOD 12 (GO TO 326)

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

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

YES 1 (GO TO 319)
NO 2

318) 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 320)

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

YES 1
NO 2

320) CHECK 317:

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

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

YES 1 (GO TO 322)
NO 2

321) 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

322) 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 326)
MALE STERILIZATION 02 (GO TO 326)
IUD 03 (GO TO 326)
INJECTABLES 04
IMPLANTS 05 (GO TO 326)
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 326)
RHYTHM METHOD 12 (GO TO 326)
WITHDRAWAL 13 (GO TO 326)
OTHER MODERN METHOD_________ (SPECIFY) 95 (GO TO 326)
OTHER TRADITIONAL METHOD________(SPECIFY) 96 (GO TO 326)

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

(NAME OF PLACE)___________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11 (GO TO 326)
GOVERNMENT HEALTH CENTER 12 (GO TO 326)
FAMILY PLANNING CLINIC 13 (GO TO 326)
FIELDWORKER 14 (GO TO 326)
SOCIAL CENTER 15 (GO TO 326)
STRAT AV HEALTH WORKER 16 (GO TO 326)
HEALTHWORKER/COMMUNITY LIAISON 17 (GO TO 326)
VENDING MACHINE 18 (GO TO 326)
OTHER PUBLIC SECTOR_______(SPECIFY) 19 (GO TO 326)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21 (GO TO 326)
RELIGIOUS HOSPITAL 22 (GO TO 326)
PRIVATE DOCTOR'S OFFICE 23 (GO TO 326)
PHARMACY 24 (GO TO 326)
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) 25 (GO TO 326)
FIELDWORKER (NOG) 26 (GO TO 326)
OTHER PRIVATE MEDICAL_______ (SPECIFY) 26 (GO TO 326)
OTHER SOURCE
SHOP/MARKET 31 (GO TO 326)
CHURCH/MOSQUE 32 (GO TO 326)
FRIEND/RELATIVES 33 (GO TO 326)
BAR/REFRESHMENT AREA 34 (GO TO 326)
OTHER______ (SPECIFY) 96 (GO TO 326)

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

YES 1
NO 2 (GO TO 326)

325) Where is that? Any other place?
PROBE TO IDENTITY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))___________
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
FIELDWORKER D
SOCIAL CENTER E
STRAT AV HEALTH WORKER F
HEALTH WORKER/COMMUNITY LIAISON G
VENDING MACHINE H
OTHER PUBLIC SECTOR______(SPECIFY) I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC J
RELIGIOUS HOSPITAL K
PRIVATE DOCTOR'S OFFICE L
PHARMACY M
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) N
FIELDWORKER (NGO) O
OTHER PRIVATE MEDICAL _______(SPECIFY) P
OTHER SOURCE
SHOP/MARKET Q
CHURCH/MOSQUE R
FRIEND/RELATIVES S
BAR/REFRESHMENT AREA T
OTHER______ (SPECIFY) X

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 401)

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

YES 1
NO 2

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

ONE OR MORE BIRTHS IN 2006 OR LATER (GO TO 402)
NO BIRTHS IN 2006 OR LATER (GO TO 556)

402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2006 OR LATER. ASK THE QUESTIONS ABOUT ALL THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

Now I would like to ask some questions about your children born in the last 5 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 (GO TO 405)
DEAD (GO TO 405)

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

YES 1 (GO TO 408)
NO 2

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

LATER 1
NO MORE 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 415)

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

HEATH PROFESSIONAL
DOCTOR A
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
OTHER PERSON
MATRON D
TRADITIONAL BIRTH ATTENDANT E
COMMUNITY/VILLAGE HEALTH WORKER F
OTHER______ (SPECIFY) X

410) Where did you receive 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
YOUR HOME A
OTHER HOME B
PUBLIC SECTOR
GOVERNMENT HOSPITAL C
GOVERNMENT HEALTH CENTER D
STAND-ALONE MATERNITY E
VILLAGE UNIT F
OTHER PUBLIC SECTOR________(SPECIFY) G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC H
RELIGIOUS HOSPITAL I
OTHER PRIVATE MEDICAL___________ (SPECIFY) J
OTHER________ (SPECIFY) 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

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

Were you weighed?
Was your height measured?
Was your blood pressure measured?
Did you give a urine sample?
Did you give a blood sample?
Did someone feel your stomach?
Did you have an ultrasound?
Did you undergo a de-worming?
Did someone give you nutritional advice?

WEIGHED
YES 1
NO 2
HEIGHT
YES 1
NO 2
BLOOD PRESSURE
YES 1
NO 2
URINE
YES 1
NO 2
BLOOD SAMPLE
YES 1
NO 2
STOMACH
YES 1
NO 2
ULTRASOUND
YES 1
NO 2
DE-WORMING
YES 1
NO 2
NUTRITIONAL ADVICE
YES 1
NO 2

414) During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy?

YES 1
NO 2
DON'T KNOW 8

414A) Did they prepare you for delivery?

YES 1
NO 2
DON'T KNOW 8

415) 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 418)
DON'T KNOW 8 (GO TO 418)

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

TIMES______
DON'T KNOW 8

417) CHECK 416:

2 OR MORE TIMES (GO TO 421)
OTHER (GO TO 418)

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

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

419) Before this pregnancy, how many times did you receive a tetanus injection?
IF 7 OR MORE TIMES, RECORD '7'

TIMES_______
DON'T KNOW 8

420) How many years ago did you receive the last tetanus injection before this pregnancy?

YEARS AGO ________

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

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

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

DAYS______
DON'T KNOW 998

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

YES 1
NO 2
DON'T KNOW 8

424) During this pregnancy, did you take any drugs to keep you from getting malaria?

YES 1
NO 2 (GO TO 430)
DON'T KNOW 8 (GO TO 430)

425) What drugs did you take?
RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

SP/FANSIDAR A
CHLOROQUINE B
OTHER ___________(SPECIFY) X
DON'T KNOW Z

426) CHECK 425:
SP/FANSIDAR TAKEN FOR MALARIA PREVENTION

CODE 'A' CIRCLED (GO TO 427)
CODE 'A' NOT CIRCLED (GO TO 430)

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

TIMES_______

427A) When in your pregnancy did you start taking SP/Fansidar (before the 4th month, at the 4th month, or after the 4th month) or (when the baby started moving)?

BEFORE 4TH MONTH 1
AT 4TH MONTH 2
AFTER 4TH MONTH 3
WHEN BABY STARTED MOVING 4

428) CHECK 409:
ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

CODE 'A', 'B', OR 'C' CIRCLED (GO TO 429)
OTHER (GO TO 430)

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

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6

430) 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

431) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 433)
DON'T KNOW 8 (GO TO 433)

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

KILOGRAMS FROM CARD_____________ 1
KILOGRAMS FROM RECALL___________ 2

DON'T KNOW 99998

433) Who assisted with the delivery of (NAME)? Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSON ASSISTING. IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE IF ANY ADULTS WERE PRESENT AT THE DELIVERY.

HEATH PROFESSIONAL
DOCTOR A
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
OTHER PERSON
MATRON D
TRADITIONAL BIRTH ATTENDANT E
COMMUNITY/VILLAGE HEALTH WORKER F
FRIENDS/RELATIVES G
OTHER______ (SPECIFY) X
NO ONE ASSISTED Y

434) Where did you give birth to (NAME)?
PROBE TO IDENTITY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))_________
HOME
YOUR HOME 11 (GO TO 438)
OTHER HOME 12 (GO TO 438)
PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
STAND-ALONE MATERNITY 23
VILLAGE UNIT 24
OTHER PUBLIC SECTOR________ (SPECIFY) 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
RELIGIOUS HOSPITAL 32
OTHER PRIVATE MEDICAL________ (SPECIFY) 36
OTHER_________ (SPECIFY) 96 (GO TO 438)

434A) How long after (NAME) was delivered did you stay there?
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS______ 1
DAYS_______ 2
WEEKS_____ 3

DON'T KNOW 998

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

YES 1
NO 2

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

YES 1 (GO TO 439)
NO 2

437) Did anyone check on your health after you left the facility?

YES 1 (GO TO 439)
NO 2 (GO TO 446)

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

YES 1
NO 2 (GO TO 442)

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

HEATH PROFESSIONAL
DOCTOR 11
NURSE/MIDWIFE 12
AUXILIARY MIDWIFE 13
OTHER PERSON
MATRON 21
TRADITIONAL BIRTH ATTENDANT 22
COMMUNITY/VILLAGE HEALTH WORKER 23
OTHER_________ (SPECIFY) 96

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

HOURS_______ 1
DAYS________ 2
WEEKS_______ 3

DON'T KNOW 998

442) In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health?

YES 1
NO 2 (GO TO 446)
DON'T KNOW 8 (GO TO 446)

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

HRS AFTER BIRTH_______ 1
DAYS AFTER BIRTH________ 2
WKS AFTER BIRTH_________ 3

DON'T KNOW 998

444) Who checked on (NAME)'s health at that time?
PROBE FOR THE MOST QUALIFIED PERSON.

HEATH PROFESSIONAL
DOCTOR 11
NURSE/MIDWIFE 12
AUXILIARY MIDWIFE 13
OTHER PERSON
MATRON 21
TRADITIONAL BIRTH ATTENDANT 22
COMMUNITY/VILLAGE HEALTH WORKER 23
OTHER________ (SPECIFY) 96

445) 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
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
STAND-ALONE MATERNITY 23
VILLAGE UNIT 24
OTHER PUBLIC_________(SPECIFY) 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
RELIGIOUS HOSPITAL 32
OTHER PRIVATE MEDICAL________ (SPECIFY) 36
OTHER________ (SPECIFY) 96

446) In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)?
SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS

YES 1
NO 2
DON'T KNOW 8

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

YES 1 (GO TO 449)
NO 2 (GO TO 450)

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

YES 1
NO 2 (GO TO 452)

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

MONTHS _________
DON'T KNOW 98

450) CHECK 226:
IS RESPONDENT PREGNANT?

NOT PREGNANT (GO TO 451)
PREGNANT OR UNSURE (GO TO 452)

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

YES 1
NO 2 (GO TO 453)

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

MONTHS__________
DON'T KNOW 98

453) Did you ever breastfeed (NAME)?

YES 1 (GO TO 455)
NO 2

454) CHECK 404:
IS CHILD LIVING?

LIVING (GO TO 460)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501)

455) How long after birth did you first put (NAME) to the breast?
IF LESS THAN 1 HOUR, RECORD '00' HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS

IMMEDIATELY 000

HOURS________ 1
DAYS__________ 2

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

YES 1
NO 2 (GO TO 458)

57) What was (NAME) given to drink?
Anything else?
RECORD ALL LIQUIDS MENTIONED.

MILK (OTHER THAN BREAST MILK) A
PLAIN WATER B
SUGAR OR GLUCOSE WATER C
GRIPE WATER D
SUGAR-SALT-WATER SOLUTION E
FRUIT JUICE F
INFANT FORMULA G
TEA/INFUSIONS H
COFFEE I
HONEY J
OTHER________ (SPECIFY) X

458) CHECK 404:
IS CHILD LIVING?

LIVING (GO TO 459)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

459) Are you still breastfeeding (NAME)?

YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

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

SECTION 5. CHILD IMMUNIZATION, HEALTH AND NUTRITION

501) ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2006 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES.)

502) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

BIRTH HISTORY NUMBER___________

503) FROM 212 AND 216

NAME______

LIVING (GO TO 504)
DEAD (GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 553)

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

YES, SEEN 1 (GO TO 506)
YES, NOT SEEN 2 (GO TO 509)
NO CARD 3

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

YES 1 (GO TO 509)
NO 2

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

BCG
DAY _______
MONTH ________
YEAR______
POLIO 0 (POLIO GIVEN AT BIRTH)
DAY _______
MONTH ________
YEAR______
POLIO 1
DAY _______
MONTH ________
YEAR______
POLIO 2
DAY _______
MONTH ________
YEAR______
POLIO 3
DAY _______
MONTH ________
YEAR______
DPT 1
DAY _______
MONTH ________
YEAR______
DPT 2
DAY _______
MONTH ________
YEAR______
DPT 3
DAY _______
MONTH ________
YEAR______
HepB + Hib 1
DAY _______
MONTH ________
YEAR______
HepB + Hib 2
DAY _______
MONTH ________
YEAR______
HepB + Hib 3
DAY _______
MONTH ________
YEAR______
PENTA 1
DAY _______
MONTH ________
YEAR______
PENTA 2
DAY _______
MONTH ________
YEAR______
PENTA 3
DAY _______
MONTH ________
YEAR______
VAA/MEASLES
DAY _______
MONTH ________
YEAR______
YELLOW FEVER
DAY _______
MONTH ________
YEAR______
VITAMIN A (MOST RECENT)
DAY _______
MONTH ________
YEAR______

507) CHECK 506:

BCG TO MEASLES ALL RECORDED (GO TO 511)
OTHER (GO TO 508)

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

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

YES 1 (PROBE FOR VACCINATIONS AND WRITE 66 IN THE CORRESPONDING DAY COLUMN IN 506 (GO TO 511)
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)

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

YES 1
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)

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

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 510E)
DON'T KNOW 8 (GO TO 510E)

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

FIRST 2 WEEKS 1
LATER 2

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

NUMBER OF TIMES_______

510E) A DPT vaccination, that is, an injection given in the left arm, sometimes at the same time as polio drops?

YES 1
NO 2 (GO TO 510G)
DON'T KNOW 3 (GO TO 510G)

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

NUMBER OF TIMES________

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

YES 1
NO 2
DON'T KNOW 8

511A) Was (NAME) given any of these vaccines in the last twelve month during a national immunization (day) campaign?

YES 1
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)

511B) During which national immunization campaign did (NAME) receive these vaccinations?
RECORD ALL MENTIONED

MARCH, 2010 A
APRIL, 2010 B
NOVEMBER, 2010 C
DECEMBER, 2010 D
MAY, 2011 E
OTHER________ (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 525)
DON'T KNOW (GO TO 525)

515) Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

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

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8

517) When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

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

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

YES 1
NO 2 (GO TO 522)

519) Where did you seek advice or treatment? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))__________
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
FIELDWORKER D
SOCIAL CENTER E
STRAT AV HEALTH WORKER F
HEALTH WORKER/COMMUNITY LIAISON G
OTHER PUBLIC SECTOR________(SPECIFY) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC I
RELIGIOUS HOSPITAL J
PRIVATE DOCTOR'S OFFICE K
PHARMACY L
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) M
FIELDWORKER (NGO) N
OTHER PRIVATE MEDICAL______ (SPECIFY) O
OTHER SOURCE
SHOP/MARKET P
TRADITIONAL PRACTITIONER Q
MARKET R
OTHER________ (SPECIFY) X

520) CHECK 519:

TWO OR MORE CODES CIRCLED (GO TO 521)
ONLY ONE CODE CIRCLED (GO TO 522)

521) Where did you first seek advice or treatment?
USE LETTER CODE FROM 519

FIRST PLACE_____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
FIELDWORKER D
SOCIAL CENTER E
STRAT AV HEALTH WORKER F
HEALTH WORKER/COMMUNITY LIAISON G
OTHER PUBLIC SECTOR________(SPECIFY) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC I
RELIGIOUS HOSPITAL J
PRIVATE DOCTOR'S OFFICE K
PHARMACY L
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) M
FIELDWORKER (NGO) N
OTHER PRIVATE MEDICAL______ (SPECIFY) O
OTHER SOURCE
SHOP/MARKET P
TRADITIONAL PRACTITIONER Q
MARKET R
OTHER________ (SPECIFY) X

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

a) A fluid made from a special packet called [local name for ORS packet]?
b) A pre-packaged ORS liquid?
c) A government-recommended homemade fluid?

ORS PACKET
YES 1
NO 2
DON'T KNOW 8
ORS LIQUID
YES 1
NO 2
DON'T KNOW 8
HOMEMADE FLUID
YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 525)
DON'T KNOW 8 (GO TO 525)

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

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

524A) CHECK 524:

CODE C CIRCLED
CODE C NOT CIRCLED- (GO TO 525)

524B) Was the treatment (NAME) received comprised of one-half tablet for days, or one tablet for 10 days, or other?

1/2 TABLET FOR 10 DAYS 1
1 TABLET FOR 10 DAYS 2
OTHER_______ (SPECIFY) 6
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 527)
DON'T KNOW 8 (GO TO 527)

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 530)
DON'T KNOW 8 (GO TO 530)

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

YES 1
NO 2 (GO TO 531)
DON'T KNOW 8 (GO TO 531)

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

CHEST ONLY 1 (GO TO 531)
NOSE ONLY 2 (GO TO 531)
BOTH 3 (GO TO 531)
OTHER_______ (SPECIFY) 6 (GO TO 531)
DON'T KNOW 8

530) CHECK 525:
HAD FEVER?

YES (GO TO 531)
NO OR DON'T KNOW (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

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

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8

532) When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

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

533) Did you seek advice or treatment for the disease?

YES 1
NO 2 (GO TO 537)

534) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
FIELDWORKER D
SOCIAL CENTER E
STRAT AV HEALTH WORKER F
HEALTHWORKER/COMMUNITY LIAISON G
OTHER PUBLIC SECTOR________ (SPECIFY) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC I
RELIGIOUS HOSPITAL J
PRIVATE DOCTOR'S OFFICE K
PHARMACY L
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) M
FIELDWORKER (NGO) N
OTHER PRIVATE MEDICAL______ (SPECIFY) O
OTHER SOURCE
SHOP/MARKET P
TRADITIONAL PRACTITIONER/HEALER Q
MARKET R
OTHER_______ (SPECIFY) X

535) CHECK 534:

TWO OR MORE CODES CIRCLED (GO TO 536)
ONLY ONE CODE CIRCLED (GO TO 537)

536) Where did you first seek advice or treatment?
USE LETTER CODE FROM 534

FIRST PLACE_____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
FIELDWORKER D
SOCIAL CENTER E
STRAT AV HEALTH WORKER F
HEALTHWORKER/COMMUNITY LIAISON G
OTHER PUBLIC SECTOR________ (SPECIFY) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC I
RELIGIOUS HOSPITAL J
PRIVATE DOCTOR'S OFFICE K
PHARMACY L
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) M
FIELDWORKER (NGO) N
OTHER PRIVATE MEDICAL______ (SPECIFY) O
OTHER SOURCE
SHOP/MARKET P
TRADITIONAL PRACTITIONER/HEALER Q
MARKET R
OTHER_______ (SPECIFY) X

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

YES 1
NO 2 (GO TO 552A)
DON'T KNOW 8 (GO TO 552A)

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

ANTIMALARIAL DRUGS
SP/FANSIDAR A
CHLOROQUINE B
AMODIAQUINE C
QUININE D
CTA/COMBINATION WITH ARTEMISININ (COARTEM/COARSUCAM) E
OTHER ANTIMALARIAL______ (SPECIFY) F
ANTIBIOTIC
PILL/SYRUP G
INJECTION H
OTHER DRUGS
ASPIRIN/PARACETAMOL I
ACETAMINOPHEN J
IBUPROFEN K
OTHER
GAVE MEDICAL PLANTS L
OTHER___________ (SPECIFY) X
DON'T KNOW Z

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

YES (GO TO 540)
NO (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

540) CHECK 538:
SP/FANSIDAR ('A') GIVEN

CODE 'A' CIRCLED (GO TO 541)
CODE 'A' NOT CIRCLED (GO TO 542)

541) 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

542) CHECK 538:
CHLOROQUINE ('B') GIVEN

CODE 'B' CIRCLED (GO TO 543)
CODE 'B' NOT CIRCLED (GO TO 544)

543) 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

544) CHECK 538:
AMODIAQUINE ('C') GIVEN

CODE 'C' CIRCLED (GO TO 545)
CODE 'C' NOT CIRCLED (GO TO 546)

545) 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

546) CHECK 538:
QUININE ('D') GIVEN

CODE 'D' CIRCLED (GO TO 547)
CODE 'D' NOT CIRCLED (GO TO 548)

547) 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

548) CHECK 538:
CTA/COMBINATION WITH ARTEMISININ (COARTEM/COARSUCAM) ('E') GIVEN

CODE 'E' CIRCLED (GO TO 549)
CODE 'E' NOT CIRCLED (GO TO 550)

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

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

550) CHECK 538:
OTHER ANTIMALARIAL ('F') GIVEN

CODE 'F' CIRCLED (GO TO 551)
CODE F NOT CIRCLED (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

551) 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

552A) What was done, then, for (NAME)'s fever/convulsions/fits?

LONG BATH (PACKING) 1
GAVE MEDICINAL PLANTS 2
OTHER______ (SPECIFY) 6
DON'T KNOW 8

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

553) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2006 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE TO 554) (NAME_______________)
NONE (GO TO 556)

554) The last time (NAME FROM 553) 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 INTO GARBAGE 04
BURIED 05
LEFT IN THE OPEN 06
OTHER_______ (SPECIFY) 07

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

NO CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID (GO TO 556)
ANY CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID (GO TO 557)

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

YES 1
NO 2

557) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2009 OR LATER LIVING WITH RESPONDENT

ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE TO 558) (NAME_________)
NONE (GO TO 562A)

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

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

a) Plain water?
YES 1
NO 2
DON'T KNOW 8
b) Juice or juice based drinks?
YES 1
NO 2
DON'T KNOW 8
c) Clear broth?
YES 1
NO 2
DON'T KNOW 8
d) Milk such as boxed, powdered, or fresh animal milk?
YES 1
NO 2
DON'T KNOW 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
DON'T KNOW 8
IF YES, how many times did (NAME) drink infant formula?
IF 7 OR MORE TIMES, RECORD '7'.
NUMBER OF TIMES DRANK FORMULA_______
f) Any other liquids?
YES 1
NO 2
DON'T KNOW 8
g) Yogurt?
YES 1
NO 2
DON'T KNOW 8
IF YES, how many times did (NAME) eat yogurt?
IF 7 OR MORE TIMES, RECORD '7'.
NUMBER OF TIMES ATE YOGURT_______
h) Any [BRAND NAME OF COMMERCIALLY FORTIFIED BABY FOOD, E.G. Cerelac]?
YES 1
NO 2
DON'T KNOW 8
i) Bread, rice, noodles, porridge, or any other foods made from grains?
YES 1
NO 2
DON'T KNOW 8
j) Pumpkin, carrots, squash or sweet potatoes, etc that are yellow or orange inside?
YES 1
NO 2
DON'T KNOW 8
k) White potatoes, white yams, manioc, cassava, or any other foods made from roots?
YES 1
NO 2
DON'T KNOW 8
l) Any dark green, leafy vegetables?
YES 1
NO 2
DON'T KNOW 8
m) Ripe mangoes, papayas or [INSERT ANY OTHER LOCALLY AVAILABLE VITAMIN A-RICH FRUITS]?
YES 1
NO 2
DON'T KNOW 8
n) Any other fruits or vegetables [for example, banana, apple, applesauce, green beans, avocado, tomato]?
YES 1
NO 2
DON'T KNOW 8
o) Other legume based food [example, beans, lentils, soy, legume, cashew nut, peanut, or other nut, etc]?
YES 1
NO 2
DON'T KNOW 8
p) Liver, kidney, heart or any other organ meats?
YES 1
NO 2
DON'T KNOW 8
q) Any meat, such as beef, pork, lamb, goat, chicken or duck?
YES 1
NO 2
DON'T KNOW 8
r) Eggs?
YES 1
NO 2
DON'T KNOW 8
s) Fresh or dried fish or shellfish?
YES 1
NO 2
DON'T KNOW 8
t) Any foods made from beans, peas, lentils, or nuts?
YES 1
NO 2
DON'T KNOW 8
u) Cheese or other food made from milk?
YES 1
NO 2
DON'T KNOW 8
v) any other solid, semi-solid, or soft food?
YES 1
NO 2
DON'T KNOW 8

559) CHECK 558 (CATEGORIES "g" THROUGH "v")

NOT A SINGLE 'YES' (GO TO 560)
AT LEAST ONE 'YES' (GO TO 561)

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

YES 1 (GO BACK TO 558 TO RECORD FOOD EATEN YESTERDAY, THEN CONTINUE TO 561)
NO 2 (GO TO 562)

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

NUMBER OF TIMES______
DON'T KNOW 8

562A) CHECK COVER PAGE:

IF HOUSEHOLD SELECTION = 1 (GO TO 562)
IF HOUSEHOLD SELECTION = 2 (GO TO 601)

562) RECORD THE TIME

HOUR______
MINUTE_______

563) CHECK 101E AND 101F:

ACCEPTED BLOOD PRESSURE MEASUREMENT (GO TO 564)
REFUSED BLOOD PRESSURE MEASUREMENT (GO TO 601)

564) May I take your blood pressure now?

INTERVIEWER SIGNATURE_______
DATE_________

RESPONDENT ACCEPTED MEASUREMENT-RECORD THE RESULT OF THE BLOOD PRESSURE TEST
RESPONDENT REFUSED MEASUREMENT-RECORD 9994

BLOOD PRESSURE

SYSTOLIC/MAX 1__________
DIASTOLIC/MIN 2_______

REASONS FOR WHICH THE BLOOD PRESSURE WASN'T MEASURED

REFUSED '9994
TECHNICAL PROBLEMS '9995
OTHERS__________ (SPECIFY) '9996

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

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

YES, CURRENTLY MARRIED 1 (GO TO 604)
YES, LIVING WITH A MAN 2 (GO TO 604)
NO, NOT IN UNION 3

602) 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 612)

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

WIDOW 1 (GO TO 609)
DIVORCED 2 (GO TO 609)
SEPARATED 3 (GO TO 609)

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

LIVES WITH HER 1
STAYING ELSEWHERE 2

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

NAME_______
LINE NUMBER_______

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

YES 1
NO 2 (GO TO 609)
DON'T KNOW 8 (GO TO 609)

607) 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

608) Are you the first, second…wife?

RANK _____

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

ONCE 1
MORE THAN ONCE 2

610) CHECK 609:

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

MARRIED/LIVED WITH MAN MORE THAN ONCE: 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 612)
DON'T KNOW YEAR 9998

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

AGE _____

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

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

NEVER HAD SEXUAL INTERCOURSE 00 (GO TO 628)
AGE IN YEARS _____
FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND/PARTNER 95

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

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

DAYS AGO 1________
WEEKS AGO 2________
MONTHS AGO 3_______
YEARS AGO 4_______ (GO TO 627)

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

DAYS AGO 1________
WEEKS AGO 2__________
MONTHS AGO 3__________

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

YES 1
NO 2 (GO TO 619)

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

YES 1
NO 2

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

HUSBAND 1
LIVE-IN PARTNER 2
BOYFRIEND NOT LIVING WITH RESPONDENT 3 (GO TO 622)
CASUAL ACQUAINTANCE 4 (GO TO 622)
CLIENT/PROSTITUTE 5 (GO TO 622)
OTHER________ (SPECIFY) 6 (GO TO 622)

620) CHECK 609:

MARRIED ONLY ONCE (GO TO 621)
MARRIED MORE THAN ONCE (GO TO 622)

621) CHECK 613:

FIRST TIME WHEN STARTED LIVING WITH FIRST HUSBAND (GO TO 623)
OTHER (GO TO 622)

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

DAYS AGO 1______
WEEKS AGO 2_______
MONTHS AGO 3________
YEARS AGO 4_________

623) How many times during the last 12 months did you have sexual intercourse with this person?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, WRITE '95'.

NUMBER OF TIMES__________

624) How old is this person?

AGE OF PARTNER________
DON'T KNOW 98

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

YES 1 (GO BACK TO 616 IN NEXT COLUMN)
NO 2 (GO TO 627)

626) In total, with how many different people have you had sexual intercourse in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE 95

NUMBER OF PARTNERS LAST 12 MONTHS______
DON'T KNOW 98

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

NUMBER OF PARTNERS IN LIFETIME_______
DON'T KNOW 98

628) PRESENCE OF OTHERS DURING THIS SECTION

CHILDREN LESS THAN 10
YES 1
NO 2
MALE ADULTS
YES 1
NO 2
FEMALE ADULTS
YES 1
NO 2

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

YES 1
NO 2 (GO TO 632)

630) Where is that?
Any other place?

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

(NAME OF PLACE(S))_____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
FIELDWORKER D
SOCIAL CENTER E
STRAT AV HEALTH WORKER F
HEALTH WORKER/COMMUNITY LIAISON G
VENDING MACHINE H
OTHER PUBLIC SECTOR______ (SPECIFY) I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC J
RELIGIOUS HOSPITAL K
PRIVATE DOCTOR'S OFFICE L
PHARMACY M
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) N
FIELDWORKER (NGO) O
OTHER PRIVATE MEDICAL_______ (SPECIFY) P
OTHER SOURCE
SHOP/MARKET Q
CHURCH/MOSQUE R
FRIEND/RELATIVES S
BAR/REFRESHMENT AREA T
OTHER________ (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW/UNSURE 8

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

YES 1
NO 2 (GO TO 701)

633) Where is that?
Any other place?

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

(NAME OF PLACE(S))_______
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
FIELDWORKER D
SOCIAL CENTER E
STRAT AV HEALTH WORKER F
HEALTH WORKER/COMMUNITY LIAISON G
VENDING MACHINE H
OTHER PUBLIC SECTOR________ (SPECIFY) I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC J
RELIGIOUS HOSPITAL K
PRIVATE DOCTOR'S OFFICE L
PHARMACY M
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) N
FIELDWORKER (NGO) O
OTHER PRIVATE MEDICAL ________(SPECIFY) P
OTHER SOURCE
SHOP/MARKET Q
CHURCH/MOSQUE R
FRIEND/RELATIVES S
BAR/REFRESHMENT AREA T
OTHER________ (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW/UNSURE 8

SECTION 7. FERTILITY PREFERENCES

701) CHECK 304:

NEITHER STERILIZED (GO TO 701)
HE OR SHE STERILIZED (GO TO 712)

702) CHECK 226:

PREGNANT (GO TO 703)
NOT PREGNANT OR UNSURE (GO TO 704)

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

HAVE ANOTHER CHILD 1 (GO TO 705)
NO MORE 2 (GO TO 711)
UNDECIDED/DON'T KNOW 8 (GO TO 711)

704) 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 707)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 712)
UNDECIDED/DON'T KNOW 8 (GO TO 710)

705) CHECK 226:

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

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

MONTHS 1_______
YEARS 2_______

SOON/NOW 993 (GO TO 710)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 712)
AFTER MARRIAGE 995 (GO TO 710)
OTHER______ (SPECIFY) 996 (GO TO 710)
DON'T KNOW 998 (GO TO 710)

706) CHECK 226:

NO PREGNANT OR UNSURE (GO TO 707)
PREGNANT (GO TO 711)

707) CHECK 303:
USING A CONTRACEPTIVE METHOD?

NOT CURRENTLY USING (GO TO 708)
CURRENTLY USING (GO TO 712)

708) CHECK 705:

NOT ASKED (GO TO 709)
24 OR MORE MONTHS OR 02 OR MORE YEARS (GO TO 709)
00-23 MONTHS OR 00-01 YEARS (GO TO 711)

709) CHECK 703 AND 705:

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______ (SPECIFY) X
DON'T KNOW Z

710) CHECK 303:
USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 711)
NO, NOT CURRENTLY USING (GO TO 711)
YES, CURRENTLY USING (GO TO 712)

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

YES 1
NO 2
DON'T KNOW 8

712) CHECK 216:

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

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

PROBE FOR A NUMERIC RESPONSE.

NONE 00 (GO TO 714)
NUMBER______
OTHER (SPECIFY) 96 (GO TO 714)

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

NUMBER BOYS ______
NUMBER GIRLS ________
NUMBER EITHER________
OTHER_______ (SPECIFY) 96

714) In the last few months have you:

Heard about family planning on the radio?
Seen anything about family planning on the television?
Read about family planning in a newspaper or magazine?
On a poster?
In a leaflet/brochure?
In a cultural/educational animated performance?
In a religious institution (church/mosque)?
At school?

RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NEWSPAPER OR MAGAZINE
YES 1
NO 2
POSTER
YES 1
NO 2
BROCHURE
YES 1
NO 2
CULTURAL ANIMATION
YES 1
NO 2
CHURCH/MOSQUE
YES 1
NO 2
AT SCHOOL
YES 1
NO 2

715) In your opinion, is it acceptable or not acceptable to talk about family planning:

On the radio?
On the television?
In a newspaper in magazine?
On a poster?
In a leaflet/brochure?
In a cultural/educational animated performance?
In a religious institution (church/mosque)?
At school?

RADIO
ACCEPTABLE 1
NOT ACCEPTABLE 2
TELEVISION
ACCEPTABLE 1
NOT ACCEPTABLE 2
NEWSPAPER IN MAGAZINE
ACCEPTABLE 1
NOT ACCEPTABLE 2
POSTER
ACCEPTABLE 1
NOT ACCEPTABLE 2
BROCHURE
ACCEPTABLE 1
NOT ACCEPTABLE 2
CULTURAL ANIMATION
ACCEPTABLE 1
NOT ACCEPTABLE 2
CHURCH/MOSQUE
ACCEPTABLE 1
NOT ACCEPTABLE 2
AT SCHOOL
ACCEPTABLE 1
NOT ACCEPTABLE 2

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

YES 1
NO 2 (GO TO 716)

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

HUSBAND/PARTNER A
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
COUSIN (S) F
DAUGHTERS(S) G
SON(S) H
MOTHER(S)-IN-LAW I
FATHER-IN-LAW G
FRIENDS/NEIGHBORS K
OTHER______ (SPECIFY) X

716) CHECK 601:

YES, CURRENTLY MARRIED (GO TO 717)
YES, LIVING WITH A MAN (GO TO 717)
NO, NOT IN UNION (GO TO 801)

717) CHECK 303:
USING A CONTRACEPTIVE METHOD?

CURRENTLY USING (GO TO 718)
NOT CURRENTLY USING OR NOT ASKED (GO TO 720)

718) 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________ (SPECIFY) 6

719) CHECK 304:

NEITHER STERILIZED (GO TO 720)
HE OR SHE STERILIZED (GO TO 801)

720) 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 8. HUSBAND'S BACKGROUND AND WOMAN'S WORK

801) CHECK 601 AND 602:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 802)
FORMERLY MARRIED/LIVED WITH A MAN (GO TO 803)
NEVER MARRIED AND NEVER LIVED WITH A MAN (GO TO 807)

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

AGE______

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

YES 1
NO 2 (GO TO 806)

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

PRIMARY 1
SECONDARY (1ST CYCLE 2
SECONDARY (2ND CYCLE) 3
HIGHER 4
DON'T KNOW (GO TO 806)

805) What was the highest (grade/form/year) he completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

GRADE________
DON'T KNOW 98

806) CHECK 801:

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

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

OCCUPATION________

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

YES 1 (GO TO 811)
NO 2

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

YES 1 (GO TO 811)
NO 2

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

YES 1 (GO TO 811)
NO 2

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

YES 1
NO 2 (GO TO 815)

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

OCCUPATION_______

812) 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

813) 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

814) Are you paid in cash or 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

815) CHECK 601:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 816)
NOT IN UNION (GO TO 823)

816) CHECK 814:

CODE 1 OR 2 CIRCLED (GO TO 817)
OTHER (GO TO 819)

817) 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________ (SPECIFY) 6

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

MORE THAN HIM 1
LESS THAN HIM 2
ABOUT THE SAME 3
HUSBAND/PARTNER HAS NO EARNINGS 4 (GO TO 820)
DON'T KNOW 8

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
HUSBAND/PARTNER HAS NO EARNINGS 4
OTHER_______ (SPECIFY) 6

820) 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_______ (SPECIFY) 6

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

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

822) 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_________ (SPECIFY) 6

823) 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

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

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

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

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

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

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

GOES OUT WITHOUT TELLING HIM
YES 1
NO 2
DON'T KNOW 8
NEGLECTS CHILDREN
YES 1
NO 2
DON'T KNOW 8
ARGUES
YES 1
NO 2
DON'T KNOW 8
REFUSES SEX
YES 1
NO 2
DON'T KNOW 8
BURNS FOOD
YES 1
NO 2
DON'T KNOW 8

826A) Husbands and wives do not always get along. Do you think it is okay for a woman to refuse to have sexual relations with her husband/partner when:

She know that her husband/partner has a sexually transmitted infection?
She knows that her husband/partner has sexual relations with women other than his spouses?
He refuses to wear a condom when she asks?
She recently gave birth?
She is tired or not in the mood?

HAS AN STI
YES 1
NO 2
DON'T KNOW 8
OTHER WOMEN
YES 1
NO 2
DON'T KNOW 8
CONDOM
YES 1
NO 2
DON'T KNOW 8
RECENT BIRTH
YES 1
NO 2
DON'T KNOW 8
TIRED/NOT IN THE MOOD
YES 1
NO 2
DON'T KNOW 8

826B) When a woman knows her husband has a sexually transmitted infection/illness, is she justified in asking him to use a condom when they have sexual relations?

YES 1
NO 2
DON'T KNOW 8

826C) Can you refuse to have sexual relations with your husband when you don't want to have sex?

YES 1
NO 2
DON'T KNOW 8

826D) Can you ask your husband to use a condom if you wanted him to use one?

YES 1
NO 2
DON'T KNOW 8

826E) Who makes decisions regarding your children's health in your household?

RESPONDENT ALONE 1
RESPONDENT AND PARTNER JOINTLY 2
RESPONDENT WITH SOMEONE ELSE 3

826F) Who decides to send your children to school in your household?

RESPONDENT ALONE 1
RESPONDENT AND PARTNER JOINTLY 2
RESPONDENT WITH SOMEONE ELSE 3

SECTION 9. HIV/AIDS

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

YES 1
NO 2 (GO TO 937)

901a) How can you get AIDS?
Any other way?
RECORD ALL MENTIONED

SEX A
SEX WITH SEVERAL PARTNERS B
SEX WITH PROSTITUTES C
NOT USING A CONDOM D
SEX WITH HOMOSEXUALS E
BLOOD TRANSFUSIONS F
INJECTIONS G
KISSING H
MOSQUITO BITES I
DIRTY OBJECTS J
OTHER_________ (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

During pregnancy?
During delivery?
By breastfeeding?

PREGNANCY
YES 1
NO 2
DON'T KNOW 8
DELIVERY
YES 1
NO 2
DON'T KNOW 8
BREASTFEEDING
YES 1
NO 2
DON'T KNOW 8

909) CHECK 908:

AT LEAST ONE YES (GO TO 910)
OTHER (GO TO 911)

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

YES 1
NO 2
DON'T KNOW 8

911) CHECK 208 AND 215:

LAST BIRTH SINCE JANUARY 2009 (GO TO 912)
NO BIRTHS (GO TO 926)
LAST BIRTH BEFORE JANUARY 2009 (GO TO 926)

912) CHECK 408 FOR LAST BIRTH:

HAD ANTENATAL CARE (GO TO 913)
NO ANTENATAL CARE (GO TO 920)

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

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

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

AIDS FROM MOTHER
YES 1
NO 2
DON'T KNOW 8
THINGS TO DO
YES 1
NO 2
DON'T KNOW 8
TEST
YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 920)

917) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE)____________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
STAND-ALONE VCT CENTER 13
FAMILY PLANNING CLINIC 14
FIELDWORKER 15
STRAT AV HEALTH WORKER 16
HEALTHWORKER/COMMUNITY LIAISON 17
SCHOOL CLINIC 18
OTHER PUBLIC SECTOR_______(SPECIFY) 19
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
RELIGIOUS HOSPITAL 22
INDEPENDENT VCT CENTER 23
PRIVATE DOCTOR'S OFFICE 24
PHARMACY 25
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) 26
FIELDWORKER (NOG) 27
SCHOOL CLINIC 28
OTHER PRIVATE MEDICAL_____________ (SPECIFY) 29
OTHER SOURCE
HOME 31
CORRECTIONAL FACILITY 32
OTHER ________(SPECIFY) 96

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

YES 1
NO 2 (GO TO 924)

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

YES 1 (GO TO 924)
NO 2 (GO TO 924)
DON'T KNOW 8 (GO TO 924)

920) CHECK 434 FOR LAST BIRTH:

ANY CODE 21-36 CIRCLED (GO TO 921)
OTHER (GO TO 926)

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 926)

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

YES 1
NO 2

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

YES 1 (GO TO 927)
NO 2

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

MONTHS AGO______ (GO TO 932)
TWO OR MORE YEARS AGO 96 (GO TO 932)

926) 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 930)

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

MONTHS AGO_____
TWO OR MORE YEARS AGO 96

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

YES 1
NO 2

929) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE)________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11 (GO TO 932)
GOVERNMENT HEALTH CENTER 12 (GO TO 932)
STAND-ALONE VCT CENTER 13 (GO TO 932)
FAMILY PLANNING CLINIC 14 (GO TO 932)
FIELDWORKER 15 (GO TO 932)
STRAT AV HEALTH WORKER 16 (GO TO 932)
HEALTH WORKER/COMMUNITY LIAISON 17 (GO TO 932)
SCHOOL CLINIC 18 (GO TO 932)
OTHER PUBLIC SECTOR_______ (SPECIFY) 19 (GO TO 932)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21 (GO TO 932)
RELIGIOUS HOSPITAL 22 (GO TO 932)
INDEPENDENT VCT CENTER 23 (GO TO 932)
PRIVATE DOCTOR'S OFFICE 24 (GO TO 932)
PHARMACY 25 (GO TO 932)
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) 26 (GO TO 932)
FIELDWORKER (NOG) 27 (GO TO 932)
SCHOOL CLINIC 28 (GO TO 932)
OTHER PRIVATE MEDICAL_______ (SPECIFY) 29 (GO TO 932)
OTHER SOURCE
HOME 31 (GO TO 932)
CORRECTIONAL FACILITY 32 (GO TO 932)
OTHER______ (SPECIFY) 96 (GO TO 932)

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

YES 1
NO 2 (GO TO 932)

931) Where is that?
Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE)_______
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
STAND-ALONE VCT CENTER C
FAMILY PLANNING CLINIC D
FIELDWORKER E
STRAT AV HEALTH WORKER F
HEALTH WORKER/COMMUNITY LIAISON G
SCHOOL CLINIC H
OTHER PUBLIC SECTOR______ (SPECIFY) I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR J
RELIGIOUS HOSPITAL K
INDEPENDENT VCT CENTER L
PRIVATE DOCTOR'S OFFICE M
PHARMACY N
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) O
FIELDWORKER (NOG) P
SCHOOL CLINIC Q
OTHER PRIVATE MEDICAL SECTOR_________ (SPECIFY) R
OTHER______ (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW 8

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

YES, REMAIN A SECRET 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

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

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

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

SHOULD BE ALLOWED 1
SHOULD BE ALLOWED 2
DON'T KNOW/NOT SURE/DEPENDS 8

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

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

936A) Should we teach students age 12-14 about HIV/AIDS in school?

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

936B) Do you agree or disagree with the following statement:
You should know your friend/partner's seropositivity before having sexual relations with him or her?

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

937) CHECK 901:

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

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

YES 1
NO 2

938) CHECK 613:

HAS HAD SEXUAL INTERCOURSE (GO TO 939)
NEVER HAD SEXUAL INTERCOURSE (GO TO 946)

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

YES (GO TO 940)
NO (GO TO 941)

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

YES 1
NO 2
DON'T KNOW 8

941) 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

942) 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

943) CHECK 940, 941, AND 942:

HAS HAD AN INFECTION (ANY 'YES') (GO TO 944)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 946)

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

YES 1
NO 2- (GO TO 946)

945) Where did you go?
Any other place?

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

(NAME OF PLACE)_______
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
STAND-ALONE VCT CENTER C
FAMILY PLANNING CLINIC D
FIELDWORKER E
STRAT AV HEALTH WORKER F
HEALTH WORKER/COMMUNITY LIAISON G
SCHOOL CLINIC H
OTHER ________(SPECIFY) I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR J
RELIGIOUS HOSPITAL K
INDEPENDENT VCT CENTER L
PRIVATE DOCTOR'S OFFICE M
PHARMACY N
BENINESE FAMILY PLANNING ASSOCIATION (ABPF) O
FIELDWORKER (NOG) P
SCHOOL CLINIC Q
OTHER PRIVATE MEDICAL SECTOR________(SPECIFY) R
OTHER SOURCE
SHOP S
OTHER_______ (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW 8

947) 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

948) CHECK 601:

CURRENTLY MARRIED/LIVING WITH A HUSBAND (GO TO 949)
NOT IN UNION (GO TO 1001)

949) 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

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

YES 1
NO 2
DEPENDS/NOT SURE 8

SECTION 10. OTHER HEALTH ISSUES

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

IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD 90. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS_______
NONE 00 (GO TO 1004)

1002) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other 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 1004)

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

YES 1
NO 2
DON'T KNOW 8

1004) Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 1006)

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

NUMBER OF CIGARETTES________

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

YES 1
NO 2 (GO TO 1008)

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

PIPE A
CHEWING TOBACCO B
SNUFF C
OTHER_______ (SPECIFY) X

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

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

PERMISSION TO GO
BIG PROBLEM 1
NOT A BIG PROBLEM 2
GETTING MONEY
BIG PROBLEM 1
NOT A BIG PROBLEM 2
DISTANCE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
GO ALONE
BIG PROBLEM 1
NOT A BIG PROBLEM 2

1009) Are you covered by any health insurance?

YES 1
NO 2 (GO TO 1010A)

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

MUTUAL HEALTH ORGANIZATION/COMMUNITY-BASED HEALTH INSURANCE A
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
OTHER_______ (SPECIFY) X

1010A) Sometimes children get serious illnesses and need to be taken to a health center immediately. What types of symptoms could a child have that would make you immediately take him or her to a health center?

RECORD ALL MENTIONED

CHILD ILL AND UNDER 2 YEARS OLD A
UNABLE TO DRINK OR BREASTFEED B
VOMITS EVERYTHING CONSUMED C
CONVULSIONS D
LETHARGIC OR UNCONSCIOUS E
HOT BODY AND URINE DARK/COCA-COLA COLORED F
BODY HOT AND YELLOW EYES G
BLOOD IN STOOLS OR ABNORMAL BLEEDING H
SEVERELY PALE PALMAR I
DIARRHEA/SKI FOLD SLOWLY REDUCING/SUNKEN IN EYES J
DIFFICULT BREATHING K
HOT BODY AND RIGID NECK L
GENERAL OUTBREAK/RUNNY NOSE OR RED EYES M

1010B) Sometimes children have coughs. How did you treat a cough the last time in your household?
RECORD ALL MENTIONED

SOOTHED COUGH WITH HONEY A
SOOTHED COUGH WITH EUCALYPTUS LEAF TEA B
KEEP WARM C
PUT FAR AWAY FROM SOURCES OF SMOKE D
OTHER______ (SPECIFY) X

1011A) CHECK COVER PAGE:

IF HOUSEHOLD SELECTION = 1 (GO TO 1011)
IF HOUSEHOLD SELECTION = 2 (GO TO 1101)

1011) These questions are about blood pressure. Have you ever been told by a doctor or any health care professional that you have hypertension or high blood pressure?

YES 1
NO 2 (GO TO 1014)
DON'T KNOW 8 (GO TO 1014)

1012) Have you been told at least twice by a doctor or other health care professional that you have hypertension or high blood pressures?

YES 1
NO 2
DON'T KNOW 8

1013) To lower your hypertension or high blood pressure, are you currently:

a. taking prescribed drugs?
b. Controlling your weight or losing weight?
c. Reducing the amount of salt in your food?
d. Eating plants?
e. Exercising?
f. Quitting smoking?

MEDICATION
YES 1
NO 2
N/A 3
CONTROLLING WEIGHT
YES 1
NO 2
N/A 3
REDUCING SALT
YES 1
NO 2
N/A 3
PLANTS
YES 1
NO 2
N/A 3
EXERCISING
YES 1
NO 2
N/A 3
QUITTING SMOKING
YES 1
NO 2
N/A 3

1014) Have you ever been told by a doctor or any other health care professional that you have diabetes?

YES 1
NO 2
DON'T KNOW 8

1015) Do you have a close relative (father, mother, brother, or sister) who has diabetes or hypertension?

YES, HAS A DIABETIC RELATIVE A
YES, HAS A RELATIVE WITH HYPERTENSION B
NO, NO SICK RELATIVE C
DON'T KNOW X

1016) RECORD THE TIME

HOUR______
MINUTE_______

1017) CHECK 101E AND 564:

ACCEPTED TWO BLOOD PRESSURE MEASUREMENTS IN Q 101E AND Q564 (GO TO 1018)
OTHER (GO TO 1101)

1018) May I take your blood pressure now?

INTERVIEWER SIGNATURE _________
DATE________

RESPONDENT ACCEPTED MEASUREMENT-RECORD THE RESULT OF THE BLOOD PRESSURE TEST
RESPONDENT REFUSED MEASUREMENT-RECORD 9994

BLOOD PRESSURE

SYSTOLIC/MAX 1_________
DIASTOLIC/MIN 2_________

REASONS FOR WHICH THE BLOOD PRESSURE WASN'T MEASURED

REFUSED '9994
TECHNICAL PROBLEMS '9995
OTHERS________ (SPECIFY) '9996

SECTION 11. FEMALE GENITAL CUTTING

1101) Have you ever heard of female circumcision?

YES 1 (GO TO 1103)
NO 2

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

YES 1
NO 2 (GO TO 1201)

1103) Have you yourself ever been circumcised?

YES 1
NO 2 (GO TO 1109)

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

YES 1 (GO TO 1106)
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

1106) Was your genital area sewn closed?

YES 1
NO 2
DON'T KNOW 8

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

AGE IN COMPLETED YEARS______

AS A BABY/DURING INFANCY 95
DON'T KNOW 98

1108) Who performed the circumcision?

TRADITIONAL
TRADITIONAL CIRCUMCISER 11
TRADITIONAL BIRTH ATTENDANT/MATRONE 12
OTHER TRADITIONAL______ (SPECIFY) 16
HEALTH PROFESSIONAL
DOCTOR 21
NURSE/MID-WIFE 22
OTHER HEALTH PROFESSIONAL________ (SPECIFY) 26
DON'T KNOW 98

1109) CHECK 213, 215, 216:

HAS ONE OR MORE LIVING DAUGHTERS BORN IN 1996 OR LATER (GO TO 1110)
HAS NO LIVING DAUGHTERS BORN IN 1996 OR LATER- (GO TO 1116)

CHECK 213, 215, AND 216: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER AND NAME OF EACH LIVING DAUGHTER BORN IN 1996 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE DAUGHTERS. BEGIN WITH THE YOUNGEST DAUGHTER. (IF THERE ARE MORE THAN 6 DAUGHTERS, USE ADDITIONAL QUESTIONNAIRES).

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

1110) BIRTH HISTORY NUMBER AND NAME OF EACH LIVING DAUGHTER BORN IN 1996 OR LATER

BIRTH HISTORY NUMBER______
NAME_______

1111) Is (NAME OF DAUGHTER) circumcised?

YES 1
NO 2 (GO TO 1111 IN NEXT COLUMN OR IF NO MORE DAUGHTERS, GO TO 1116)

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

AGE IN COMPLETED YEARS________
DON'T KNOW 98

1113) Was her genital area sewn closed?
PROBE: was the genital area closed?

YES 1
NO 2
DON'T KNOW 8

1114) Who performed the circumcision?

TRADITIONAL
TRADITIONAL CIRCUMCISER 11
TRADITIONAL BIRTH ATTENDANT 12
OTHER TRADITIONAL_______ (SPECIFY) 16
HEALTH PROFESSIONAL
DOCTOR 21
NURSE/MID-WIFE 22
OTHER HEALTH PROFESSIONAL_____ (SPECIFY) 26
DON'T KNOW 98

1115) GO BACK TO 1111 IN NEXT COLUMN; OR, IF NO MORE DAUGHTERS, GO TO 1116

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

YES 1
NO 2
DON'T KNOW 8

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

CONTINUED 1
STOPPED 2
DEPENDS 3
DON'T KNOW 8

SECTION 12. FISTULA

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

YES 1 (GO TO 1203)
NO 2

1202) Have you ever heard of this problem?

YES 1 (GO TO 1301)
NO 2 (GO TO 1301)

1203) Did this problem start after you delivered a baby or had a stillbirth?

YES 1 (GO TO 1205)
NO 2

1204) What do you think caused this problem?

SEXUAL ASSAULT 1 (GO TO 1207)
PELVIC SURGERY 2 (GO TO 1207)
OTHER (SPECIFY) 6 (GO TO 1207)
DON'T KNOW 8 (GO TO 1208)

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

NORMAL LABOR/DELIVERY 1
VERY DIFFICULT LABOR/DELIVERY 2

1206) Was this baby born alive?

YES, BABY WAS BORN ALIVE 1
NO, BABY WASN'T BORN ALIVE 2

1207) How many days after [CAUSE OF PROBLEM FROM 1203 OR 1205] did the leakage start?
ENTER 90 IF 90 DAYS OR MORE

NUMBER OF DAYS AFTER DELIVERY/OTHER EVENT________

1208) Have you sought treatment for this condition?

YES 1 (GO TO 1210)
NO 2

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

DO NOT KNOW CAN BE FIXED A (GO TO 1301)
DO NOT KNOW WHERE TO GO B (GO TO 1301)
TOO EXPENSIVE C (GO TO 1301)
TOO FAR D (GO TO 1301)
POOR QUALITY OF CARE E (GO TO 1301)
COULD NOT GET PERMISSION F (GO TO 1301)
EMBARRASSMENT G (GO TO 1301)
PROBLEM DISAPPEARED H (GO TO 1301)
OTHER (SPECIFY)________ X (GO TO 1301)

1210) From whom did you last seek treatment?

HEALTH PROFESSIONAL
DOCTOR 1
NURSE/MIDWIFE 2
OTHER PERSON
COMMUNITY/VILLAGE HEALTH WORKER 3
OTHER 6

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

YES, STOPPED COMPLETELY 1
NOT STOPPED BUT REDUCED 2
NOT STOPPED AT ALL 3

SECTION 13: 3rd BLOOD PRESSURE MEASUREMENT AND AVERAGE

1301A) CHECK COVER PAGE:

IF HOUSEHOLD SELECTION = 1 (GO TO 1301)
IF HOUSEHOLD SELECTION = 2 (GO TO 1314)

1301) CHECK Q564 AND Q1018:

SYSTOLIC AND DIASTOLIC BLOOD PRESSURE MEASURED IN Q 564 AND Q 1018 (GO TO 1302)
SYSTOLIC AND DIASTOLIC BLOOD PRESSURE NOT MEASURED IN Q 564 AND Q 1018 (GO TO 1307)

1302) RECORD AND CALCULATE THE AVERAGE SYSTOLIC AND DIASTOLIC BLOOD PRESSURE FROM Q 564 AND Q 1018

1303) BLOOD PRESSURE MEASURED IN Q 564

SYSTOLIC_______
DIASTOLIC_______

1304) BLOOD PRESSURE MEASURED IN Q 1018

SYSTOLIC_______
DIASTOLIC_______

1305) RECORD THE SUM OF THE SYSTOLIC AND DIASTOLIC BLOOD PRESSURE MEASURED IN Q 101 AND DIASTOLIC MEASURED IN Q.564 AND Q 1018

SUM SYSTOLIC_______
SUM DIASTOLIC_________

1306) CALCULATE THE AVERAGE OF SYSTOLIC AND DIASTOLIC BLOOD PRESSURE MEASURED BY DIVIDING THE SUM FROM 1305 BY 2.

AVERAGE SYSTOLIC_______
AVERAGE DIASTOLIC________

1307) CHECK Q1018:

SYSTOLIC AND DIASTOLIC BLOOD PRESSURE NOT RECORDED IN Q 1018 (GO TO 1308)
BOTH SYSTOLIC AND DIASTOLIC BLOOD PRESSURE RECORDED IN Q 1018 (GO TO 1310)

1308) CHECK Q 564:

SYSTOLIC AND DIASTOLIC BLOOD PRESSURE NOT RECORDED IN Q 564 (GO TO 1309)
BOTH SYSTOLIC AND DIASTOLIC BLOOD PRESSURE RECORDED IN Q 564 (GO TO 1310)

1309) CHECK 101E:

SYSTOLIC AND DIASTOLIC BLOOD PRESSURE NOT RECORDED IN Q 101E (GO TO 1313)
BOTH SYSTOLIC AND DIASTOLIC BLOOD PRESSURE RECORDED IN Q 101E (GO TO 1310)

1310) CHECK SYSTOLIC AND DIASTOLIC BLOOD PRESSURE

SYSTOLIC_________
DIASTOLIC _________

1311) USE THE TABLE BELOW TO DETERMINE THE APPROPRIATE CODE TO RECORD ON THE BLOOD PRESSURE RECORD SHEET AND THE REFERENCE SHEET.

CIRCLE THE LINE WITH THE VALUE OF THE SYSTOLIC BLOOD PRESSURE FROM Q 1306 AND Q 1310

THEN CIRCLE THE COLUMN WITH THE VALUE OF THE DIASTOLIC BLOOD PRESSURE FROM Q 1306 AND Q 1310

THE VALUE CORRESPONDING TO THE INTERSECTION OF THE LINE AND THE COLUMN THAT YOU HAVE CIRCLED IN THE TABLE WILL BE USED TO COMPLETE Q 1312.

AVERAGE SYSTOLIC BLOOD PRESSURE

LESS THAN 130
AVERAGE DIASTOLIC BLOOD PRESSURE
LESS THAN 84 1
85-89 2
90-99 3
100-109 4
110-119 5
GREATER THAN OR EQUAL TO 120 6
130-139
AVERAGE DIASTOLIC BLOOD PRESSURE
LESS THAN 84 2
85-89 2
90-99 3
100-109 4
110-119 5
GREATER THAN OR EQUAL TO 120 6
140-159
AVERAGE DIASTOLIC BLOOD PRESSURE
LESS THAN 84 3
85-89 3
90-99 3
100-109 4
110-119 5
GREATER THAN OR EQUAL TO 120 6
160-179
AVERAGE DIASTOLIC BLOOD PRESSURE
LESS THAN 84 4
85-89 4
90-99 4
100-109 4
110-119 5
GREATER THAN OR EQUAL TO 120 6
180-209
AVERAGE DIASTOLIC BLOOD PRESSURE
LESS 84 5
85-89 5
90-99 5
100-109 5
110-119 5
GREATER THAN OR EQUAL TO 120 6
GREATER THAN OR EQUAL TO 210
AVERAGE DIASTOLIC BLOOD PRESSURE
LESS 84 6
85-89 6
90-99 6
100-109 6
110-119 6
GREATER THAN OR EQUAL TO 120 6

1312) [##translator note: top line from this question is cut off, I will begin the translation mid-sentence][…] IN Q 1311, THEN USE THE INSTRUCTIONS ON THE RIGHT OF THIS DIGIT TO COMPLETE THE BLOOD PRESSURE RECORD SHEET AND THE REFERENCE SHEET FOR THE RESPONDENT.
GIVE THE REFERENCE SHEET TO THE RESPONDENT AND ANSWER ANY QUESTIONS HE/SHE MAY HAVE

RESPONDENT'S TYPE OF BLOOD PRESSURE: NORMAL
CONSULT THE HEALTH CARD TO CHECK BLOOD PRESSURE WITHIN THE BOUNDARY OF: 24 MONTHS
HIGHEST LEVEL OF NORMAL RANGE
CONSULT THE HEALTH CARD TO CHECK BLOOD PRESSURE WITHIN THE BOUNDARY OF: 12 MONTHS
ABOVE NORMAL RANGE
CONSULT THE HEALTH CARD TO CHECK BLOOD PRESSURE WITHIN THE BOUNDARY OF: 2 MONTHS
SLIGHTLY HIGH
CONSULT THE HEALTH CARD TO CHECK BLOOD PRESSURE WITHIN THE BOUNDARY OF: 1 MONTH
VERY HIGH
CONSULT THE HEALTH CARD TO CHECK BLOOD PRESSURE WITHIN THE BOUNDARY OF: 7 DAYS
EXTREMELY HIGH
CONSULT THE HEALTH CARD TO CHECK BLOOD PRESSURE WITHIN THE BOUNDARY OF: TODAY

1313) [##translator note: top line from this question is cut off, I will begin the translation mid-sentence] (VERIFY THAT HE HEAD OF THE HOUSEHOLD RECEIVED A BROCHURE ____THE BLOOD PRESSURE.)
THANK THE RESPONDENT AND WARN HIM OR HER THAT OTHER MEMBERS OF THE HOUSEHOLD OR HIM- OR HERSELF MIGHT BE SOLICITED AGAIN TO PARTICIPATE IN INTERVIEW OR OTHER SURVEYS IN THE FUTURE.

Thank you for taking the time to answer these questions.
We may return to survey other members of your household or yourself or to ask you to participate in other surveys in the future
We hope you accept that at the time.

1314) RECORD THE TIME OF THE END OF THE INTERVIEW

HOUR_______
MINUTE___________

DEMOGRAPHIC AND HEALTH SURVEY IN BENIN, 2011, BLOOD PRESSURE REFERENCE SHEET

NAME________
DATE_______
BLOOD PRESSURE___/_____
AVERAGE OF TWO MEASUREMENTS_____
SINGLE MEASUREMENT_______

READ THE DECLARATION BELOW, THEN CIRCLE:
1) Your blood pressure today is within the acceptable limit (systolic less than 130 and/or diastolic less than 85). We recommend that you see a doctor to redo the measurement of your blood pressure in the next two years. You need to show this sheet to the doctor.

2) Your blood pressure today is acceptable, but in the high range of the limit (systolic 130-139 and/or diastolic 85-89). We recommend that you see your doctor to redo the measurement of your blood pressure in the next year. You need to show this sheet to the doctor.

3) Your blood pressure today is above the acceptable range (systolic 140-159 and/or diastolic 90-99). We recommend that you consult your doctor to redo the measurement of your blood pressure in the next two months. You need to show this sheet to the doctor.

4) Your blood pressure today is moderately high (systolic 160-175 and/or diastolic 100-109). We recommend that you consult your doctor to redo the measurement of your blood pressure in the next 30 days. You need to show this sheet to the doctor.

5) Your blood pressure today is high (systolic 160-175 and/or diastolic 110-119). You must consult a doctor in the next week to retake your blood pressure. You need to show this sheet to the doctor.

6) Your blood pressure today is very high (systolic = 210 and/or diastolic = 120). You must consult a doctor or a health center immediately to retake your blood pressure. You need to show this sheet to the doctor.

Your blood pressure was measured by a trained individual. These measurements were conducted within a survey and thus does not represent a medical diagnosis. A proper interpretation of the measurements should be done by a doctor.

DATE_______
SIGNATURE________

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_____

CALENDAR

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

INFORMATION TO BE CODED FOR EACH COLUMN:

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE**

B 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 DIAPHRAGM
J FOAM OR JELLY
K LACTATIONAL AMENORRHEA METHOD
L RHYTHM METHOD
M WITHDRAWAL
X OTHER MODERN METHOD
Y OTHER TRADITIONAL METHOD

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE:

0 INFREQUENT SEX/HUSBAND AWAY
1 BECAME PREGNANT WHILE USING
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

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

**RESPONSE CATEGORIES MAY BE ADDED FOR OTHER METHODS, INCLUDING FERTILITY AWARENESS METHOD

2011*

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 ____ ____

2010

12 Dec 13 ____ ____
11 Nov 14 ____ ____
10 Oct 15 ____ ____
09 Sept 16 ____ ____
08 Aug 17 ____ ____
07 Jul 18 ____ ____
06 Jun 19 ____ ____
05 May 20 ____ ____
04 Apr 21 ____ ____
03 Mar 22 ____ ____
02 Feb 23 ____ ____
01 Jan 24 ____ ____

2009

12 Dec 25 ____ ____
11 Nov 26 ____ ____
10 Oct 27 ____ ____
09 Sept 28 ____ ____
08 Aug 29 ____ ____
07 Jul 30 ____ ____
06 Jun 31 ____ ____
05 May 32 ____ ____
04 Apr 33 ____ ____
03 Mar 34 ____ ____
02 Feb 35 ____ ____
01 Jan 36 ____ ____

2008

12 Dec 37 ____ ____
11 Nov 38 ____ ____
10 Oct 39 ____ ____
09 Sept 40 ____ ____
08 Aug 41 ____ ____
07 Jul 42 ____ ____
06 Jun 43 ____ ____
05 May 44 ____ ____
04 Apr 45 ____ ____
03 Mar 46 ____ ____
02 Feb 47 ____ ____
01 Jan 48 ____ ____

2007

12 Dec 49 ____ ____
11 Nov 50 ____ ____
10 Oct 51 ____ ____
09 Sept 52 ____ ____
08 Aug 53 ____ ____
07 Jul 54 ____ ____
06 Jun 55 ____ ____
05 May 56 ____ ____
04 Apr 57 ____ ____
03 Mar 58 ____ ____
02 Feb 59 ____ ____
01 Jan 60 ____ ____

2006

12 Dec 61 ____ ____
11 Nov 62 ____ ____
10 Oct 63 ____ ____
09 Sept 64 ____ ____
08 Aug 65 ____ ____
07 Jul 66 ____ ____
06 Jun 67 ____ ____
05 May 68 ____ ____
04 Apr 69 ____ ____
03 Mar 70 ____ ____
02 Feb 71 ____ ____
01 Jan 72 ____ ____