Final Version

Identification

Department
Commune

Urban/rural (urban=1, rural=2)

Name of head of household
Cluster number
Household number
Name and line number of woman

Household selected for men's survey? (1=Yes, 2=No)

Household selected for domestic violence module? (1=Yes, 2=No)

Interviewer visits
1 2 3
Date

Interviewer's name
Result*

Final visit
Day
Month
Year 201
Int. number
Result

Next visit
Date
Time

Total no. of visits

* Result codes

Language of questionnaire 01

Language of interview

Native language of respondent

Translator used (yes=1, no=2)

Language of questionnaire: French

Language codes:

Supervisor
Name
Date

Editor
Name
Number

Introduction and consent

Hello. My name is ___. I am working with the National Institute 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 60 to 90 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?

Signature of interviewer Date

Section 1. Respondent's background

No.
Questions and filters
Coding categories
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101) Record the time

102) How long have you been living continuously in (Name of current city, town or village of residence)?
If less than one year, record 00 years

103) Just before you moved here, did you live in a city, in a town, or in a rural area?

104) Before you moved here, which (province/region/state) did you live in?

105) In what month and year were you born?

106) How old were you at your last birthday?
Compare and correct 105 and/or 106 if inconsistent

106a) Check cover of questionnaire

106b) Check 106:

106c) During this interview I would like to measure your blood pressure. I will do this three times during the interview. There is no danger to the procedure. We do it to know if a person has high blood pressure. If it isn't treated, high blood pressure can seriously hurt the heart.

I will give you the results of the blood pressure measurement after the interview and explain to you the meaning of the results. If you have high blood pressure, we recommend that you consult a health care facility or see a doctor because we cannot offer any treatment as part of the survey.

Do you have any questions to ask me about blood pressure measurement?

You can say yes or no, and you can also decide at any point in the interview to not participate in taking blood pressure measurements.

Respondent signature
Date

106d) Before measuring your blood pressure, I would like to ask you some questions on things that could affect the measurements. Did you do any of the following things in the last 30 minutes:

106e) Look at the respondent's arm and take the appropriate armband to take [##translator note: text is cut off here]

106f) Take the blood pressure
Record the systolic and diastolic pressure

If you can't measure the respondent's blood pressure, record the reason.

107) Have you ever attended school?

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

109) What is the highest (grade/form/year) you completed at this level?
If completed less than one year at that level, record 00

110) Check 108

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

Show card to respondent

If respondent cannot read whole sentence, probe:
Can you read any part of the sentence to me?

112) Check 111:

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

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

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

116) Do you own a mobile telephone?

117) Do you use your mobile phone for any financial transactions?

118) Do you have an account in a bank or other financial institution that you yourself use?

119) Have you ever used the internet?

120) In the last 12 months, have you used the internet?
If necessary, probe for use from any location, with any device.

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

122) What is your religion?

123) What is your ethnicity?

123a) Check cover of questionnaire

123b) Check 106:

123c) Can I measure your blood pressure now?
Respondent signature
Date

123d) Take blood pressure
Record systolic and diastolic pressure
If you cannot measure the respondent's blood pressure, record the reason

124) How many kilometers away is the nearest health care facility?

125) How much time does it take to reach the nearest health care facility?

Codes for Q 108 and 109: Education
Level attainted
Class successfully achieved

Section 2. Reproduction

No.
Questions and filters
Coding categories
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201) Now I would like to ask you about all the births you have had during your life. Have you ever given birth?

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

203) How many sons live with you?
And how many daughters live with you?
If none, record '00'

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

205) How many sons are alive but do not live with you?
And how many daughters are alive but do not live with you?
If none, recode '00'

206) Have you ever given birth to a boy or girl who was born alive but later died?
If no, probe: Any baby who cried, who made any movement, sound, or effort to breathe, or who showed any other signs of life even for a very short time?

207) How many boys have died?
And how many girls have died?
If none, record '00'

208) Sum answers to 203, 205, and 207 and enter total.
If none, record 00

209) Check 208:
Just to makes sure that I have this right: you have had in total ____births during your life. Is that correct?

210) Check 208:

211) Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had. Record names of all the births in 212. Record twins and triplets on separate rows.
If there are more than 10 births, use an additional questionnaire, starting with the second row.

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

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

214) Were any of these births twins?

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

216) Is (name) still alive?

217) If alive:
How old was (name) at his/her last birthday? Record age in completed years.

218) If alive:
Is (name) living with you?

219) If alive:
Record household line number of child (record '00' if child not listed in household)

220) If dead:
How old was (name) when he/she died?

If 12 months or 1 year, ask: Did (name) have his/her first birthday?
Then ask: Exactly how many months old was (name) when he/she died?
Record days if less than 1 month, months if less than two years, or years.

221) Were there any other live births between (name of previous birth) and (name), including any children who died after birth?

[##translator note: 212-221 were repeated for births 6-10]

222) Have you had any live births since the birth of (name of last birth)?

223) Compare 208 with number of births in history above and mark.

224) Check 215:
Enter the number of births in 2012-2017.

225) C
For each birth since in 2012-2017, enter B in the month of birth in the calendar. Write the name of the child to the left of the code B for each birth. Ask the number of months the pregnancy lasted and record P in each of the preceding months according to the duration of the pregnancy. (Note: The number of Ps must be one less than the number of months that the pregnancy lasted.)

226) Are you pregnant now?

227) How many months pregnant are you?
Record number of completed months.
Enter Ps in the calendar, beginning with the month of interview and for the total number of completed months.

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

229) Check 208: Total number of births
One or more-
a) Did you want to have a baby later on or did you not want any more children?
None-
b) Did you want to have a baby later on or did you not want any children?

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

231) When did the last such pregnancy end?

232) Check 231:

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

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

235) Since January 2012, have you had any other pregnancies that did not result in a live birth?

236) For each pregnancy that did not end in a live birth in 2012-2017 or later, enter T in the calendar in the month that the pregnancy terminated and P for the remaining number of completed months of pregnancy.
If there are more than four pregnancies that did not end in a live birth, use an additional questionnaire starting on the second line.

237) Did you have any miscarriages, abortions or stillbirths that ended before 2012?

238) When did the last such pregnancy that terminated before 2012 end?

239) When did you last menstrual period start?

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

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

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

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)?

302) Check 226:

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

304) Which method are you using?
Circle all mentioned.
If more than one method mentioned, follow skip instruction for highest method in list.

305) What is the brand name of the pills you are using?
If don't know brand, ask to see the package.

306) What is the brand name of the condoms you are using?
If don't know the brand, ask to see the package.

307) In what facility did the sterilization take place?
Probe to identify the type of source.
If unable to determine if public or private sector, write the name of the place
(Name of place)

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

309) Since what month and year did you start using (Current method) without stopping?
Probe: For how long have you been using (Current method first mentioned) now without stopping?

310) Check 308 and 309, 215, and 231:
Any birth or pregnancy termination after month and year of start of use of contraception in 308 or 309.

311) Check 308 and 309: Year is 2012-2017- C Enter code for method used in month of interview in the calendar and in each month back to the date started using.
Then continue.

312) I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.
Use calendar to probe for earlier periods of use and nonuse, starting with most recent use, back to January 2012. Use names of children, dates of birth, and periods of pregnancy as reference points.

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

312b) Between (event) in (Month/year) and (event) in (month/year), did you or your partner use any method of contraception?

312c) Which method was that?

312d) How many months after (event) in (month/year) did you start to use (method)?
Record 95 if respondent gives the date of starting to use the method. [##translator note: end of sentence cut off, I used what matched the standard English version]

312e) Record the month and year respondent started using method

312f) For how many months did you use (method)?
Record 95 if respondent gives the date of termination of use

312g) Record month and year respondent stopped using method

312h) Why did you stop using (method)?

312i) Go back to 312a in next column; or, if no more gaps, go to 313.

313) Check the calendar for use of any contraceptive method in any month.

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

315) Check 304:
Circle method code.
If more than one method code circled in 304, circle code for highest method in list.

316) You first started using (current method) in (date from 309). Where did you get it at that 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)

317) Check 304:
Circle method code:
If more than one method code circled in 304, circle code for highest method in list.

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

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

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

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

322) Check 318 and 319:

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

324) Check 304:
Circle method code.
If more than one method code circled in 304, circle code for highest method in list.

325) Where did you obtain (current method) the last time?
Probe to identity the type of source.
If unable to determine if public or private sector, write the name of the place.
(Name of place)

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

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

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

329) Check 202: Living children

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

Section 4. Pregnancy and postnatal care

401) Check 224:

402) Check 215: Record the birth history number in 403 and the name and the survival state from 404 for each birth in 2012-2017. Ask the questions about all these births. Begin with the last birth. (If there are more than 2 births, use last column of additional questionnaire(s)).

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

403) Birth history number from 212 in birth history

404) From 212 and 216

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

406) Check 208:
Only one birth- a) Did you want to have a baby later on, or did you not want any children?
More than one birth- b) Did you want to have a baby later on, or did you not want any more children?

407) How much longer did you want to wait?

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

409) Whom did you see?
Anyone else?
Probe to identify each type of person and record all mentioned.

410) Where did you receive this antenatal care for this pregnancy?
Anywhere else?
Probe to identity the type of source.
If unable to determine if public or private sector, write the name of the place.
(Name of place(s))

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

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

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

a) Was your blood pressure measured?
b) Did you give a urine sample?
c) Did you give a blood sample?
d) Did they weigh you?
e) Did they measure you?
f) Did they feel your abdomen?
g) Did they do an ultrasound?
h) Did they give you nutritional advice?

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

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

416) Check 416: Tetanus injections

416) Check 416: Tetanus injections

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

418) Before this pregnancy, how many times did you receive a tetanus injection?
If 7 or more times, record 7

419) Check 418;
Only once:
a) How many years ago did you receive the last tetanus injection?
More than once:
b) How many years ago did you receive the last tetanus injection before this pregnancy?

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

421) During the whole pregnancy, for how many days did you take the tables or syrup?
If answer not numeric, probe for approximate number of days.

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

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

423a) What drugs did you take?
Record all mentioned. If the type of drug isn't determined, show current malaria drugs to the respondent.

423b) Check 324a:
SP/Fansidar take as a preventative against malaria.

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

424b) How many times did you take SP/Fansidar while under observation from a health care worker?

425) Did you get the SP/Fansidar during any antenatal visit, during another visit to a health facility or from another source?
If more than one source, record the highest source on the list.

425a) Check 425:
Antenatal visit

425b) Did you have an antenatal card during the time you were pregnant with (name)?

425c) Check the antenatal card and record the number of times SP/Fansidar was given

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

427) Was (Name) weighed at birth?

428) How much did (Name) weigh?
Record weight in kilograms from health card, if available

429) Who assisted with the delivery of (Name)?
Anyone else?
Probe for the type of person and record all persons assisting.
If respondent says no one assisted, probe to determine whether any adults were present at the delivery

430) Where did you give birth to (name)?
Probe to identity the type of source.
If unable to determine if public or private sector, write the name of the place.
(Name of place(s))

431) How long after (Name) was delivered did you stay there?
If less than one day, record hours. If less than one week, record days. If a week or more, record weeks.

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

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

433a) Did you pay to delivery by caesarean?

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

434a) Did (name)'s skin have contact with your skin?

434b) Check 430: Place of delivery

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

436) 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.
If one week or more, record in weeks.

437) Who checked on your health at that time?
Probe for most qualified person.

437a) Does a woman pay to have a caesarean in Benin?

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

439) How long after delivery was (name)'s health first checked?
If less than one day, record hours. If less than one week, record days. If one week or more, record in weeks.

440) Who checked on (name)'s health at that time?
Probe for the most qualified person.

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

442) How long after delivery did that check take place?
If less than one day, record hours; if less than one week, record days. If one week or more, record in weeks.

443) Who checked on (name)'s health at that time?
Probe for the most qualified person.

444) Where did this first check of (name) take place?
Probe to identity the type of source and circle the appropriate code.
If unable to determine if public or private sector, write the name of the place.
(Name of place(s))

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

446) How many hours, days or weeks after the birth of (name) did that check take place?
If less than one day, record hours; if less than one week, record days. If one week or more, record in weeks.

447) Who check on (name)'s health at that time?
Probe for most qualified person.

448) Where did this 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))

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

450) How long after delivery did the first check take place?
If less than one day, record in hours. If less than one week, record days. If one week or more, record in weeks.

451) Who checked on your health at that time?
Probe for most qualified person.

452) Where did this first check 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))

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

454) How many hours, days, or weeks after the birth of (name) did the first check take place?
If less than one day, record in hours. If less than one week, record days. If one week or more, record in weeks.

455) Who checked on (name)'s health at that time?
Probe for the most qualified person.

456) Where did this first check of (name) take place?
Probe to identity the type of source and circle the appropriate code.
If unable to determine if public or private sector, write the name of the place.
(Name of place(s))

457) In the first two days after (name)'s birth, did any health care provider do the following:
a) Examine the cord?
b) Measure (name)'s temperature?
c) Counsel you on danger signs for newborns?
d) Counsel you on breastfeeding?
e) Observe (name) breastfeeding?

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

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

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

461) Check 226:
Is respondent pregnant?

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

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

464) Did you ever breastfeed (Name)?

465) Check 404: Child is living?

466) How long after birth did you first put (name) to the breast?
If less than 1 hour, record 00 hours.
If less than 24 hours, record hours.
Otherwise, record days

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

468) Check 404: Is child living?

469) Are you still breastfeeding (Name)?

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

471) (Go back to 405 in next column, or, if no more births, go to 501a)

Section 5a. Child immunization (last birth)
No.
Questions and filters
Coding category
Skip

501a) Check 215 in the birth history: Any births in 2014-2017?

502a) Record the name and birth history number from 212 of the last child born in 2014-2017.

503a) Check 216 for child:

504a) Do you have a card or other document where (name)'s vaccinations are written down?

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

506a) Check 504a

507a) May I see the card or other document where (name)'s vaccinations are written down?

508a) Copy dates from the card.
Write 44 in day column if card shows that a dose was given, but no date is recorded.

509a) Check 508a:
BCG to Yellow fever all recorded

510a) In addition to what is recorded on (this document/these documents), did (name) receive any other vaccinations, including vaccinations received in campaigns or immunization days or child health days?
Record Yes only if the respondent mentions at least one of the vaccinations in 508a that are not recorded as having been given.

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

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

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

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

516a) How many times did (name) receive the oral polio vaccine?

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

518a) How many times did (name) receive the pentavalent vaccine?

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

520a) How many times did (name) receive the pneumococcal vaccine?

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

524a) Has (name) ever received a vaccine against yellow fever, that is, an injection in the right thigh to prevent yellow fever?

524Aa) Did (name) receive certain vaccines over the past 12 months during a national vaccination campaign (day)?

524Ab) During which national vaccination campaign did (name) receive the vaccines?

525a) In the last 7 days was (name) given:
a) a micronutrient powder mix (MNP)?
b) Ready-made dietary supplements like Plumpy Buts?
c) Ready-made dietary supplements like Plumpy Doz?

526a) Continue with 501b

Section 5B: Child immunization (next-to-last birth)

No.
Questions and filters
Coding categories
Skip

501b) Check 215 in the birth history: Any more births in 2014-2017?

502b) Record the name and birth history number from 212 of the next-to-last child born in 2014-2017.

503b) Check 216 for child

504b) Do you have a card or other document where (name)'s vaccinations are written down?

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

506b) Check 504b

507b) May I see the card or other document where (name)'s vaccinations are written down?

508b) Copy dates from the card.
Write 44 in day column if card shows that a dose was given, but no date is recorded.

509a) Check 508a:
BCG to Yellow fever all recorded

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

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

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

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

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

516b) How many times did (name) receive the oral polio vaccine?

517b) Has (name) ever received a pentavalent vaccination, that is, an injection given in the right arm sometimes at the same time as polio drops?

518b) How many times did (name) receive the pentavalent vaccine?

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

520b) How many times did (name) receive the pneumococcal vaccine?

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

524b) Has (name) ever received a vaccine against yellow fever, that is, an injection in the right thigh to prevent yellow fever?

524Ba) Did (name) receive certain vaccines over the past 12 months during a national vaccination campaign (day)?

524Bb) During which national vaccination campaign did (name) receive the vaccines?

525b) In the last 7 days was (name) given:
a) a micronutrient powder mix (MNP)?
b) Ready-made dietary supplements like Plumpy Buts?
c) Ready-made dietary supplements like Plumpy Doz?

526b) Check 215 in birth history: any more births in 2014-2017?

Section 6. Child health and nutrition

601) Check 224:

602) Check 215: Enter in the table the birth history number in 603 and the name and survival state in 604 for each birth between 2012-2017. Ask the questions about all of these births. Begin with the last birth. If there are more births, use last column of additional questionnaires.

Now I would like to ask some questions about your children born in the last five years. (We will talk about each separately.)
603) Birth history number from 212 in birth history

604) From 212 and 216

605) In the last six months, was (name) given a vitamin A dose like (this/any of these)?
Show common types of ampoules/capsules/syrups.

606) In the last seven days, was (name) given iron pills, sprinkles with iron, or iron syrup like (this/any of these)?
Show common types of pills/sprinkles/syrups.

607) Was (name) given any drug for intestinal worms in the last six months? [#translator note: Text cuts off, and I filled in based on the standard English. However, there is a reference to a type of worm--"albendazole," that was part of what was cut off]

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

609) Check 464: Currently breastfeeding

610) When (Name) had diarrhea, was (name) given less than usual to eat, about the same amount, more than usual, or nothing to eat?
If less, probe: Was (name) given much less than usual to eat or somewhat less?

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

612) Where did you seek advice or treatment?

Anywhere else?
Probe to identify the type of source.
If unable to determine if public or private sector, write the name of the place(s).

(Name of place(s))

613) Check 612:

614) Where did you first seek advice or treatment?
Use letter code from 612

615) Was (name) given any of the following to drink at any time since (name) started having the diarrhea?
a) A fluid made from a special packet called ORASEL?
b) A government-recommended homemade fluid?
c) Zinc tablets or syrup?

616) check 615:
Any "Yes"
a) Was anything else given to treat the diarrhea?
All "No" or "DK"
b) Was anything given to treat the diarrhea?

617) Check 615:
Any "Yes" a) What else was given to treat the diarrhea?
Anything else?

All "No" or "DK" b) What was given to treat the diarrhea?
Anything else?
Record all treatments given.

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

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

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

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

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

623) Check 618: Had fever?

624) Did you seek advice or treatment for the illness from any source?

625) 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))

626) Check 625:

627) Where did you first seek advice or treatment?
Use letter code from 625

628) How many days after the illness began did you first seek advice or treatment for (name)?
If the same day record 00

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

630) What drugs did (name) take?
Any other drugs?
Record all mentioned

631) Check 630:
Any code A-J circled?

631a) How much did you pay for the drugs and the consultation to treat (name)'s fever?
Record the price is CFA Francs. If more than 99,000 CFA Francs, record 99,000 CFA Francs

632) Check 630:
Artemisinin Combination Therapy (A) given

633) How long after the fever started did (name) first take an artemisinin combination therapy?

634) Check 630:
SP/Fansidar (B) given

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

636) Check 630:
Chloroquine (C) given

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

638) Check 630:
Amodiaquine (D) given

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

640) Check 630:
Quinine (E or F) given

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

642) Check 630:
Artesunate (G or H) given

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

644) Check 630:
Other antimalarial (J) given

645) How long after the fever started did (name) first take (other antimalarial)?

645a) Is there are charge for the caring of children with malaria in Benin?

646) Go back to 604 in the next column; or if no more births, go to 647.

647) Check 615(a) and 615(b), all columns:

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

649) Check 215 and 218, all rows:
Number of children born in 2015-2017 living with respondent

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

651) Check 650 (categories g through w)

652) Did (name from 649) eat any solid, semi-solid or soft foods yesterday during the day or at night?
If yes, probe: What kind of solid, semi-solid, or soft foods did (name) eat?

653) How many times did (name from 649) eat solid, semi-solid, or soft foods yesterday during the day or at night?
If 7 or more times, record 7

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

Section 7. Marriage and sexual activity

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

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

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

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

705) Record the husband's/partner's name and line number from the household questionnaire. If he is not a listed in the household, record '00'.

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

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

708) Are you the first, second?wife?

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

710) Check 709:
Married/lived with man only once --a) in what month and year did you start living with your (husband/partner)?

Married/lived with man more than once --b) Now I would like to talk about your first (husband/partner) In what month and year did you start living with him?

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

712) Check for the presence of others. Before continuing, make every effort to ensure privacy.

713) I would like to ask you 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. How old were you when you had sexual intercourse for the very first time?

714) I would like to ask you about your recent sexual activity. When was the last time you had sexual intercourse?
If less than 12 months, answer must be recorded in days, weeks, or months.
If 12 months (one year) or more, answer must be recorded in years.

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

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

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

718) What was your relationship to this person with whom you had sexual intercourse?
If boyfriend: Were you living together as if married?
If yes, circle 2
If no, circle 3

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

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

If non-numeric answer, probe to get an estimate. If number of times if 95 or more, record 95.

721) How old is this person?

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

723) In total, how many different people have you had sexual intercourse with in the last 12 months?
If non-numeric answer, probe to get an estimate.
If number of partners is greater than 95, write 95

724) Check 106:

725) Check 701:

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

727) In total, how many different people have you had sexual intercourse with in your lifetime?
If non-numeric answer, probe to get an estimate.
If number of partners is greater than 95, write 95

728) Check 716, most recent partner (first column):

729) You told me that a condom was used the last time you had sex. What is the brand name of condom you used at that time?
If brand not known, ask to see the package.

730) From where did you obtain the condom the last time?
Probe to identify the type of source.
If unable to determine if public or private sector, write the name of the place
(Name of place)

731) Presence of others during this section.

Section 8. Fertility preferences

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801) Check 304:

802) Check 226:

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

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

805) Check 226:
Not pregnant or not sure- a) How long would you like to wait from now before the birth of (a/another) child?

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

806) Check 226:

807) Check 303:
Using a contraceptive method?

808) Check 805:

809) Check 714:
Days, weeks or months ago

810) Check 804:
Wants to have a/another child--a) 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--b) 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.

811) Check 303: Using a contraceptive method?

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

813) Check 216:
Has living children- a) 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- b) 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.

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

815) In the last few months have you:

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

817) Check 701:

818) Check 303: Using a contraceptive method?

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

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

821) Check 304:

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

Section 9. Husband's background and woman's work

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901) Check 701:

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

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

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

905) What is the highest (grade/year) you completed at this level?
If completed less than one year at that level, record 00

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

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

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

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

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

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

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

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

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

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

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

917) Check 701:

918) Check 916:

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

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

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

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

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

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

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

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

927) Is your name on the title deed?

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

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

930) Is your name on the title deed?

931) Presence of others at this point (present and listening, present but not listening, or not present)

932) In your opinion, is a husband justified in hitting or beating his wife in the following situations:
If she goes out without telling him?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

Section 10. HIV/AIDS

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1000) Check the cover page: Household selected for men's questionnaire?

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

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

1003) Can people get HIV from mosquito bites?

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

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

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

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

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

1009) Check 1008:

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

1011) Check 208 and 215:

1012) Check 408 for last birth

1013) Check for presence of others, before continuing, make every effort to ensure privacy.

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

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

1016) I don't want to know the results, but were you tested for HIV as part of your antenatal care?

1017) Where was the test done?

Probe to identify the type of source and circle the appropriate code.

If unable to determine if public or private sector, write the name of the place
(Name of place)

1018) I don't want to know the results, but did you get the results of the test?

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

1020) Check 430 for last birth

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

1022) I don't want to know the results, but were you tested for HIV at that time?

1023) I don't want to know the results, but did you get the results of the test?

1024) Check 1016:

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

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

1027) I don't want to know the results, but have you ever been tested for HIV?

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

1029) I don't want to know the results, but did you get the results of the test?

1030) Where was the test done?
Probe to identify the type of source and circle the appropriate code.
If unable to determine if public or private sector, write the name of the place
(Name of place)

[##translator note: The language was a bit confused in the French version for option 14-16 and 26, so I used what was in the standard English version and in the previous question with a similar response set.]

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

1032) Where is that?
Any other place?
Probe to identify the type of source and circle the appropriate code.
If unable to determine if public or private sector, write the name of the place
(Name of place)

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

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

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

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

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

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

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

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

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

1042) Check 1001:
Heard about HIV or AIDS- a) Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

Not heard about HIV or AIDS- b) Have you heard about infections that can be transmitted through sexual contact?

1043) Check 713:

1044) Check 1042: Heard about other sexually transmitted infections?

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

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

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

1048) Check 1045, 1046, and 1047:

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

1050) Where did you go?
Any other place?
Probe to identify the type of source.
If unable to determine if public or private sector, write the name of the place
(Name of place)

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

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

1053) Check 701:

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

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

Section 11. Other health issues

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1101) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?
If yes: How many injections have you had?
If number of injections is 90 or more, or daily for 3 months or more, record 90.
If non-numeric answer, probe to get an estimate.

1102) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or another healthcare worker?
If the number of injections is over 90 or if there were daily injections in the last 3 months or longer, record 90.
If the response is not numeric, probe to obtain an estimate.

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

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

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

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

1107) What (other) type of tobacco do you currently smoke or use?
Record all mentioned.

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

1109) Are you covered by health insurance?

1110) What type of health insurance are you covered by? Record all mentioned.

1112) Check cover of questionnaire

1113) Check 106:

1114) Can I measure your blood pressure?
Respondent signature
Date

1115) Read the blood pressure measurement.
Record the systolic and diastolic measurements.
If you cannot measure the respondent's blood pressure, record the reason.

Section 12. Development of young child

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1201) Check 217 and 218: All children age 0-4 living with his or her mother?

1202) Check 217 and 218: Select the youngest child age 0-4 living with his or her mother and record his or her name and line number.

1203) Read to the respondent:
Now, I would like to ask you some questions about (name of child in 1202), your youngest child from 0-4 living with you.

1204) How many children's books and picture books do you have for (name)?

1205) I would like to ask you what objects (name) uses to play with while at home.

Does he/she play with:

If the respondent says "yes" to one of the above categories, probe to determine precisely what the child plays with to be certain of the response.

1206) Sometimes the adults who take care of the children have to leave the house to go shopping, do the laundry, or for other reasons and have to leave the young children.

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

1207) Check 217: Age of the child

1208) Check 217 and 218: If other children age 3-4 living with their mother?

1208a) Check 217 and 218: Select the youngest child of 3 or 4 years living with his or her month and write the child's name and line number.

1209) Is (name) in a preschool education program or an early learning class, in a public or private establishment, including nursery school or a community child-care center?

1210) During the last three days did you or a member of your family age 15 or older participate with (name) in one of the following activities:
If yes, ask: Who participated in this activity with (name)?

Circle all mentioned.

1211) Now I would like to ask you some questions about the health and development of your child. Children do not all develop in the same manner and at the same speed. Some, for example, walk earlier than others. These questions relate to several aspects of your child's development.

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

1212) Can (name) read at least four simple, common words?

1213) Can (name) list and recognize all digits from 1 to 10?

1214) Can (name) grasp with two fingers a small object from the ground, like a stick or a pebble?

1215) Is (name) ever too sick to play?

1216) Is (name) able to follow simple instructions to do something correctly?

1217) When you give (name) something to do, is he/she able to do it independently?

1218) Does (name) get along well with other children?

1219) Does (name) kick, bit, or hit other children or adults?

1220) Is (name) easily distracted?

Section 13. Adult and maternal mortality

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1301) Now I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your natural mother, including those who live with you, those who live elsewhere, and those who are dead. We have learned in previous surveys that it can be hard to create a complete list of all children born to your natural mother. We will work together to create a complete list and to help you remember all your brothers and sisters. Can you now give me the names of all your brothers and sisters born to your natural mother?

1302) Check 1301:

1303) Read their names to the respondent, and after the last one, ask: Are there any other brothers or sisters from the same mother that you didn't list?

1304) Sometimes people forget to list children of their natural mother because they do not live with them or because they don't see each other very often. Are there brothers or sisters that do not live with you that you didn't list?

1305) Sometimes people forget to list children of their biological mother because they are dead. Do you have any brothers and sisters who are dead who you did not list?

1306) Sometimes people have brothers or sisters from the same mother but from a different father. Are there any brothers or sisters born of your natural mother but who have a different natural father who you did not list?

1307) Count the number of brothers or sisters recorded in 1301

1308) Check 1307:
Just to make sure that I've understood, not including yourself, your mother gave birth to _____ children total. Is that correct?

1309) Check 1307:

1410) Please tell me which brother or sister was born first? At who was the next?
Record 01 for the order number in 1301 for the first brother or sister, 02 for the second, and so on until you have recorded order numbers for all brothers and sisters.

1311) How many births did your mother have before your own birth?

1312) Record the brother and sisters according to the order number from 1301. Ask 1313 through 1324 for one brother or sister before moving to the next brother or sister. If there are more than 12 brothers and sisters, use a supplementary questionnaire.

1313) Name of brother or sister

1314) Is (NAME) male or female?

1315) Is (NAME) still alive?

1316) How old is (NAME)?

1317) How many years ago did (NAME) die?

1318) How old was (NAME) when he/she died?
If don't know, probe and ask questions to obtain an estimate.
If man, or if woman died before age 12, go to 1323.

1319) Was (NAME) pregnant when she died?

1320) Did (NAME) die during childbirth?

1321) Did (Name) die within two months after the end of a pregnancy or childbirth?

1322) How many days after the end of (name)'s pregnancy did she die?

1323) Was (name)'s death the result of a violent act?

1324) Was (name)'s death the result of an accident?

If no other brothers of sister, go to next section.
[##translator note: questions repeated for child 7-12 to accommodate larger families]

Section 14. Non-communicable diseases for women's questionnaire

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1401) Has a doctor or other health care professional taken your blood pressure?

1402) Has a doctor or other health care professional told you that you have elevated or high blood pressures?

1403) In the last 12 months, has a doctor or other health care professional that you have elevated or high blood pressure?

1404) Has a doctor or other health care professional prescribed drugs to control your blood pressure?

1405) Are you currently taking drugs to control your blood pressure?

1406) Has a doctor or other health care professional measured the level of sugar in your blood?

1407) Has a doctor or other health care professional told you that you have high levels of sugar in your blood, or that you have diabetes?

1408) In the last 12 months, has a doctor or other health care professional told you that you have high levels of sugar in your blood, or that you have diabetes?

1409) Has a doctor or other health care professional prescribed drugs to control the levels of sugar in your blood or to control diabetes?

1410) Are you currently taking drugs to control the level of sugar in your blood or to control diabetes?

1411) Has a doctor or other health care professional told you that you have heart disease or a chronic heart problem?

1412) Are you currently in treatment for heart disease or a chronic heart problem?

1413) Has a doctor or other health care professional told you that you have a pulmonary illness or a chronic pulmonary problem like asthma?

1414) Are you currently undergoing treatment for a pulmonary illness or a chronic pulmonary problem?

1415) Has a doctor or other health care professional told you that you have cancer or a tumor?

1416) Are you currently undergoing treatment for cancer or a tumor?

1417) Has a doctor or other health care professional told you have depression?

1418) Are you currently undergoing treatment for depression?

1419) Has a doctor or other health care professional told you that have arthritis?

1420) Are you currently undergoing treatment for arthritis?

1421) Has a doctor or other health care professional told you that you have another chronic illness, meaning an illness that lasts a long time?

1422) Are you currently undergoing treatment for (chronic illness from 1421)?

1423) Have you ever heard of cervical cancer?

1424) Have you heard of tests to detect cervical cancer?

1425) Now I will ask you questions about the tests that a health care professional can do to detect cervical cancer. The cervix is what connects the uterus to the vagina. To test for cervical cancer, we ask that a woman lie down on her back while spreading her legs apart. Next, using a small brush or a cotton swab, the health care professional takes a sample from the inside of the uterus. The sample is sent to a lab for testing. This test is called a Pap smear or an HPV test. There is another method called VIA or Visual Inspection with ascetic acid. During this test, the health care professional applies diluted vinegar to the cervix to see if a reaction occurs.

1426) Has a doctor or other health care professional ever tested you for cervical cancer?

1427) When was your last cervical cancer test?
If less than a year, record 00.

1428) What was the result of your last cervical cancer test?

1429) Did you undergo treatment for the cervix or did you have follow-up visits as a result of the test results?

1430) Check Q123D and Q1115:

1431) Record and calculate the average systolic and diastolic blood pressure from q123d and q1115.

1432) Blood pressure measurement from Q123d

1433) Blood pressure measurement form Q1115

1434) Total of Q1432 + Q1433

1435) Divide 1434 by 2

1436) Check 123d

1437) Check 1115

1438) Check 106f

1439) Record the systolic and diastolic blood pressure

1440) Use the table below to determine the correct code to record the report on blood pressure and the reference form.
Circle the line where you find the value of the systolic pressure from Q1435 or Q1439.
Next, circle the column with the value of the diastolic pressure from Q1435 or Q1439.
The value found at the intersection of the line and the column circled in the table should be used to compete Q1441.

1441) In the table below, record the number that you circled in Q1440. Next use the instructions to the right of this number to complete the report on blood pressure and the reference form for the respondent. Give the respondent the formula and answer any questions.

Category of blood pressure for respondent/Consult a health care professional to check blood pressure in:

Section 15. Domestic violence

No.
Questions and filters
Coding categories
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1500) Check cover page: household and woman selected for domestic violence?

1501) Check for presence of others:
Do not continue until privacy is ensured.

1501a) Read to the respondent:
Now I would like to ask you questions about some other important aspects of a woman's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in Benin. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions. If I ask you a question you do not want to answer, let me know and I will skip to the next question.

1502) Check 701 and 702:

1503) First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) (husband/partner).

1504) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner.
a) (Does/did) your (last) (husband/partner) ever:
b) How often did this happen during the last 12 months: often, only sometimes, or not in the last 12 months?

1505) a) Did your (last) (husband/partner) ever do any of the following things to you:
b) How often did this happen during the last 12 months: often, only sometimes, or not in the last 12 months?

1506) Check 1505A (a-j):

1507) How long after you (first got married to/started living with) your (last) (husband/partner) did this or any of these things first happen?
If less than one year, record 00.

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

1509) Have you ever hit, slapped, kicked or done anything else to physically hurt your (last) (husband/partner) at times when he was not already beating or physically hurting you?

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

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

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

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

1514) Check 709:

1515) a) So far we have been talking about the behavior of your (current/last) (husband/partner). Now I want to ask you about the behavior of any previous (husband/partner).

b) How long ago did this last happen?

a) Did any previous (husband/partner) ever hit, slap, kick or do anything else to hurt you physically?

b) Did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?

c) Did any previous (husband/partner) humiliate you in front of others, threaten to hurt or harm you or someone you care about, insult you or make you feel bad about yourself?

1516) Check 701 and 702:
Ever married/ever lived with a man:
From the time you were 15 years old has anyone other than (your/any) (husband/partner) hit you, slapped you, kicked you, or done anything else to hurt you physically?

Never married/never lived with a man:
From the time you were 15 years old has anyone hit you, slapped you, kicked you, or done anything else to hurt you physically?

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

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

1519) Check 201, 226, and 230:

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

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

1522) Check 701 and 702:

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

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

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

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

1524) Check 701 and 702:
Ever married/ever lived with a man: In the last 12 months, has anyone other than (your/any) (husband/partner) physically forced you to have sexual intercourse when you did not want to?

Never married/never lived with a man: In the last 12 months, has anyone physically forced you to have sexual intercourse when you did not want to?

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

1525) Check 701 and 702:
Ever married/ever lived with a man: How old were you the first time someone including (your/any) (husband/partner) forced you to have sexual intercourse or perform any other sexual?

Never married/never lived with a man: How old were you the first time someone forced you to have sexual intercourse or perform any other sexual acts?

1526) Check 1505 (a-j), 1515 (a,b), 1516, 1520, 1522a, and 1522b:

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

1528) From whom have you sought help?
Anyone else?
Record all mentioned.

1529) Have you ever told anyone about this?

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

Thank the respondent for her cooperation and reassure her about the confidentiality of her answers. Fill out the questions below with reference to the domestic violence module only.

1531) Did you have to interrupt the interview because some adult was trying to listen, or came into the room, or interfered in any other way?

1532) Interviewer's comments/explanation for not completing the domestic violence module

1533) Record the time

Interviewer's observations
To be filled in after completing interview

Comments about respondent:

Comments on specific questions:

Any other comments:

Supervisor's observations

Editor's observations

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 Emergency contraception
J Standard Days Method
K Lactational Amenorrhea Method
L Rhythm method

M Withdrawal
X Other modern method
Y Other traditional method

Column 2: Discontinuation of contraceptive use
0 Infrequent sex/husband away
1 Became pregnant while using
2 Wanted to become pregnant
3 Husband/partner disapproved
4 Wanted more effective method
5 Side effects/health concerns

6 Lack of access/too far
7 Costs too much
8 Inconvenient to use
F Up to God/Fatalist
A Difficult to get pregnant/menopausal
D Marital dissolution/separation
X Other (specify)
Z Don't know

Column 1 Column 2

2017 (1)
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

2016
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

2015
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

2014
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

2013
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

2012
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