MINISTRY OF PLANNING
CONGO DEMOCRATIC REPUBLIC

IDENTIFICATION

RESPONDENT POOL _________

NAME OF LOCATION (NEIGHBORHOOD/VILLAGE) _________

NAME OF HOUSEHOLD HEAD ___________

CLUSTER NUMBER _____

HOUSEHOLD NUMBER ______

PROVINCE _____

URBAN/RURAL

RESIDENCE

INTERVIEWER VISITS

FIRST VISIT: (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
INTERVIEWER'S NAME _______________

RESULT* _____

NEXT VISIT: (FOR INTERVIEWS 1 AND 2)
DATE _____
TIME _____

FINAL VISIT:
DAY _____
MONTH _____
YEAR 2007
INT. NUMBER ____
RESULT ___

TOTAL NUMBER OF VISITS ____

LANGUAGE OF QUESTIONNAIRE:

LANGUAGE OF INTERVIEW: _________

INTERPRETER

SUPERVISOR
NAME _________
DATE _____

FIELD EDITOR
NAME ________
DATE _____

OFFICE EDITOR ____

KEYED BY ____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is ______ and I am working with the Ministry of Planning. We are conducting a national survey about men's, women's, and children's health. We would very much appreciate your participation in this survey. I would like to ask you some questions about your health (and your children's health). The information will help the government to plan health services. The questions usually take about 20 to 45 minutes. Whatever information you provide will be kept strictly confidential and will not be shared with anyone.

Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

SIGNATURE OF INTERVIEWER: _____________
DATE: __________

101) RECORD THE TIME.

102) First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in a large city, a city, or a rural location?

103) How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS.

104) Just before you moved here, did you live in a large city, a city, or a rural location?

105) In the last 12 months, how many times have you traveled out of your home location and slept somewhere other than your home?

106) Have you been outside of your home location for more than one continuous month in the last 12 months?

107) In what month and what year were you born?

108) How old were you at your last birthday?
COMPARE AND CORRECT 107 AND/OR 108 IF INCONSISTENT.

109) Have you ever attended school?

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

111) What is the highest (grade/form/year) you completed at this level?

112) CHECK 110:

113) 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?

114) Have you ever participated in a literacy program or any other program that involved learning to read or write (not including primary school)?

115) CHECK 113:

116) Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?

117) Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?

118) Do you watch television almost every day, at least once a week, less than once a week, or not at all?

119) Do you currently have a job of any kind, for which you earn money?

120) Have you had any kind of job in the last 12 months for which you earned money?

121) What have you done most of the time in the last 12 months?

122) What is (was) your occupation, that is, what kind of work do (did) you mainly do?

123) CHECK 122:

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

125) How many months have you worked in the last 12 months?

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

127) Who mainly decides how the money you earn will be used?

128) On average, how much of your household's expenditures do your earnings pay for: almost none, less than half, about half, more than half, or all?

129) What is your religion?

130) What is your tribe?

130A) I would like to ask you a question about the tribe of your biological parents. Do (did) they belong to the same tribe?

130B) Have you been ill in the last 2 weeks?

130C) Did you receive medical treatment?

130D) How much did you pay for the medical care (consultations, drugs, etc)?

103E) Why did you not received medical care?
Any other reason?
RECORD ALL MENTIONED.

SECTION 2. REPRODUCTION

201) Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours. Have you fathered any children?

202) Do you have any sons or daughters that you have fathered 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 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, RECORD '00'.

206) Have you ever had any sons or daughters who were born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life at birth but did not survive?

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

208) (Other than the children you just listed), did you have any:

a) other boys or girls who are still alive, who you are the biological father, but who you didn't recognize and who don't have your name?

b) other boys or girls who were born alive but later died, who you are the biological father, but who you wouldn't have recognized and who don't have your name?

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

210) CHECK 209:

211) Do all of the children you have fathered have the same biological mother?

212) In all, how many women have you fathered children with?

213) How old were you when your (first) child was born?

SECTION 3. CONTRACEPTION

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

CIRCLE CODE 1 IN 2013 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 301, ASK 302.

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.

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

301) Which ways or methods have you heard about? FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you heard of (METHOD)?

302) Have you ever used (METHOD)?

303) Now I would like to ask you about a woman's risk of pregnancy.

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

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

305) Do you think that a woman who is breastfeeding her baby can become pregnant?

306) Now I would like to read you some statements about contraception. Please tell me if you agree or disagree with each one.

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401) Are you currently married or living with a woman?

402) How many spouses/wives live with you total?
IF ONLY ONE SPOUSE, RECORD '01'.

403) Are there other women with whom you live with as if you were married?

404) Altogether, how many wives do you have or other partners do you live with as if married?
IF ONLY ONE SPOUSE/PARTNER, RECORD '01'.

405) Other than the wives/partners that you just mentioned, are there currently any other women with whom you have regular or occasional sexual intercourse?

406) Do you currently have a regular or occasional sexual partner, or no sexual partner at all?

407) Have you ever been married or lived with a woman?

408) What is your marital status now: are you widowed, divorced, or separated?

409) BASED ON THE HOUSEHOLD QUESTIONNAIRE, RECORD THE NAME AND LINE NUMBER OF EACH WIFE/PARTNER PROVIDED IN QUESTIONS 402 AND 404 ONLY. IF A WIFE/PARTNER DOESN'T LIVE IN THE HOUSEHOLD, RECORD '00' IN THE SPACE CORRESPONDING TO THAT WIFE/PARTNER. THE NUMBER OF SPACES FILLED OUT SHOULD BE EQUAL TO THE NUMBER OF WIVES AND PARTNERS.

410) CHECK: 402 AND 404

SUM OF 402 AND 404 EQUALS 1: Please tell me the name of your wife/partner.

SUM OF 402 AND 404 EQUALS 2 OR MORE: Please tell me the name of each of your current wives and of each women you are living with). Start with the one who is the first you lived with.

410A) How old was your wife/partner on her last birthday?

410B) CHECK 410:

411) Have you been married or lived with a woman only once, or more than once?

414) CHECK 410 AND 411:

MARRIED/LIVED WITH 1 WOMAN ONLY ONCE AND 411=1: In what month and year did you start living with your wife/partner?

OTHER: Now I would like to ask a question about the first time you were married or lived with a woman as if married. In what month and year did you start living with your first wife/partner?

415) How old were you when you started living with her?

416) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family life issues.
How old were you when you first had sexual intercourse (if ever)?

416A) Do you intend to wait until you get married to have sexual intercourse for the first time?

416B) CHECK 108:

416C) Was a condom used the first time you had sexual intercourse?

416D) How old was the person you first had sexual intercourse with?

417) When was the last time you had sexual intercourse?
IF 12 MONTHS OR MORE, ANSWER MUST BE RECORDED IN YEARS.

417A) 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.

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

419) What is the main reason you used the condom this time?

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

421) CHECK: 302 (02)

422) CHECK: 419

CONDOM USED TO AVOID PREGNANCY ('2' OR '3' CIRCLED): The last time you had sexual intercourse with this woman, did you or your partner do something or use a method other than the condom to avoid pregnancy?

OTHER ('1', '4', '5', '6', OR '8' CIRCLED, OR QUESTION NOT ASKED): The last time you had sexual intercourse with this woman, did you or your partner do something or use a method to avoid pregnancy?

423) What method was used?
IF MORE THAN ONE METHOD USED, CIRCLE THE METHOD CODE THAT COMES FIRST IN THE SCHEDULE.

423A) GO TO 426.

424) CHECK 419:

425) What is the main reason you did not use a contraceptive method to avoid pregnancy?

426) The last time you had sexual intercourse with this (second, third) person, did either you or your partner drink alcohol?

427) Were you or your partner drunk at that time?
IF YES: who was drunk?

428) What was your relationship to this person with whom you had sexual intercourse?
IF GIRLFRIEND: Were you living together as if married?
IF YES, CIRCLE '02'
IF NO, CIRCLE '03'

429) For how long (have you had/did you have) a sexual relationship with this person?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.

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

435) In total, with 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'.

436) CHECK 428 ALL COLUMNS:

436A) In the last 12 months, did you pay anyone in exchange for having sexual intercourse?

436B) The last time you paid someone in exchange for having sexual intercourse, was a condom used?

436C) Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse in the last 12 months?

438) In total, with how many different people have you had sex in your life?
IF NON-NUMERIC NUMBER, PROBE TO GET AN ESTIMATE.
IF THE NUMBER IS MORE THAN 95, WRITE '95'.

438A) CHECK 108:

438B) CHECK FOR PRESENCE OF OTHER PEOPLE.
DO NOT CONTINUE UNTIL YOU ARE COMPLETELY ALONE WITH RESPONDENT.

438C) Have you even been forced to have sexual intercourse against your will?

438D) The first time you had sexual intercourse, did you want to have sexual intercourse, or were you forced against your will?

438E) Did anyone make you have sexual intercourse against your will in the last 12 months?

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

440) Where is that?
Any other place?
RECORD ALL PLACES MENTIONED.

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

442) CHECK 418 ALL COLUMNS:

443) Where did you get the condom last time?
IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

SECTION 5. FERTILITY PREFERENCES

501) CHECK 410:

502) (Is your wife (partner)/Are any of your wives (partners)) currently pregnant?

503) CHECK 502:
NO WIFE/PARTNER OR DON'T KNOW: 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?

YES, WIFE/PARTNER PREGNANT: Now I have some questions about the future. After the child your wife/partner is expecting now, would you like to have another child, or would you prefer not to have any more children?

504) How long would you like to wait from now before the birth of (a/another) child?

505) CHECK 203 AND 205:

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.

506) How many of these children would you like to be boys, how many would you like to be girls, and for how many would the sex not matter?

507) Would you say that you approve or disapprove of couples using a contraceptive method to avoid getting pregnant?

508) In the last few months have you heard about family planning:

On the radio?
On the television?
In a newspaper or magazine?

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

511) With whom?
Anyone else?
RECORD ALL PERSONS MENTIONED.

512) In the last few months, have you discussed the practice of family planning with a health worker or health care professional?

SECTION 6. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

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

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

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

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

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

606) Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

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

608) Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?

609) What can a person do?
Anything else?
RECORD ALL WAYS MENTIONED.

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

611) Can the virus that causes AIDS be transmitted from a mother to a child:

During pregnancy?
During delivery?
By breastfeeding?

612) CHECK 611:

613) 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?

614) Are there any special drugs that people infected with the AIDS virus can get from a doctor or a nurse?

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

616) When was the last time you were tested?

617) the last time you had the test, did you yourself ask for the test, was if offered to you and you accepted, or was it required?

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

619) Where was the test done?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

621) Where is that?
Any other place?
RECORD ALL PLACES MENTIONED.

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME FO THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

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

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

625) 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?

626) Do you personally know someone who has been denied health services in the last 12 months because he or she has or is suspected to have the AIDS virus?

627) Do you personally know someone who has been denied involvement in social events, religious services, or community events in the last 12 months because he or she has or is suspected to have the AIDS virus?

628) Do you personally know someone who has been verbally abused or teased in the last 12 months because he or she has or is suspected to have the AIDS virus?

629) CHECK 626, 627, 628:

630) Do you personally know someone who has or is suspected to have the AIDS virus?

631) Do you agree or disagree with the following statement:
People with the AIDS virus should be ashamed of themselves.

632) Do you agree or disagree with the following statement:
People with the AIDS virus should be blamed for bringing the disease into the community.

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

634) Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid getting AIDS?

641) CHECK 601:

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?

642) If a man has a sexually transmitted disease, what symptoms might he have?
Any other sign or symptom? RECORD ALL SYMPTOMS MENTIONED.

643) If a woman has a sexually transmitted disease, what symptoms might she have?
Any other sign or symptom? RECORD ALL SYMPTOMS MENTIONED.

644) CHECK 416:

645) CHECK 641:

646) 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?

647) Sometimes men have abnormal discharge from their penis. Have you had any abnormal discharge from your penis in the last 12 months?

648) Sometimes men have a sore or ulcer near their penis.
During the last 12 months, have you had a sore or ulcer near your penis?

649) CHECK 646, 647, AND 648:

650) The last time you had (PROBLEM FROM 646/647/648), did you seek any kind of advice or treatment?

651) Where did you go?
Any other place?
RECORD ALL MENTIONED.

652) The last time you had (PROBLEM FROM 646/647/648), did your partner seek any kind of advice or treatment?

653) Where did she go?
Any other place?
RECORD ALL MENTIONED.

654) Some men are circumcised. Are you circumcised?

756) 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: __________________________________
NAME OF SUPERVISOR: __________
DATE: __________

EDITOR'S OBSERVATIONS: _____________________________
NAME OF EDITOR: __________
DATE: _________