MINISTRY OF PLANNING FINANCE AND OF INTERNATIONAL COOPERATION
CENTRAL AFRICAN REPUBLIC
DEMOGRAPHIC AND HEALTH SURVEY

IDENTIFICATION____
CODES

NAME OF PREFECTURE____
SUB-PREFECTURE____
TOWN____
URBAN OR RURAL

CLUSTER NUMBER____
VILLAGE/NEIGHBORHOOD____
HOUSEHOLD NUMBER____
NAME OF HEAD OF HOUSEHOLD____

NAME AND LINE NUMBER OF WOMAN__

INTERVIEWER VISITS
DATE____

INTERVIEWER'S NAME____
RESULT

FINAL VISIT
DAY____
MONTH____
YEAR____
NAME____
RESULT

NEXT VISIT
DATE
TIME

FRENCH QUESTIONNAIRE
LANGUAGE OF INTERVIEW

INTERPRETER

SUPERVISOR
NAME____
DATE____

FIELD EDITOR
NAME____
DATE____

OFFICE EDITOR____

KEYED BY____

SECTION 1. RESPONDENT'S BACKGROUND

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 Bangui, in another large city, in a town, or in a village?

103) How long have you been continuously living in (NAME OF CURRENT PLACE OF RESIDENCE)

104) Just before you moved here, did you live in Bangui, in another large city, in a town, or in a village?

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

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

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?*

110) CHECK 106:

111) Are you currently attending school?

112) What is the main reason you stopped attending school?

113) CHECK 108: RESPONDENT'S LEVEL OF EDUCATION

114) Can you read and understand a letter or a newspaper easily, with difficulty, or not at all?

115) Do you usually read a newspaper or magazine at least once a week?

116) Do you usually listen to the radio every day?

117) Do you usually watch television at least once a week?

118) What is your religion?

119) What is your ethnicity?

120) CHECK QUESTION 4 ON HOUSEHOLD QUESTIONNAIRE

121) Now I would like to ask about the place in which you usually live.

Is it in Bangui, in another large city, in a town, or in a village?
IF TOWN: In what town do you live (NAME OF PLACE)

122) In which prefecture do you live?

123) Now I would like to ask you about the household in which you usually live.
What is the main source of drinking water for your household?

124) How long does it take to go there, get water, and come back?

125) What kind of toilet facility does your household have?

126) Does your household have:

127A) MAIN MATERIAL OF ROOF
RECORD OBSERVATION

127B) MAIN MATERIAL OF WALLS
RECORD OBSERVATION

127C) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

128) Does any member of your household own:

SECTION 2. REPRODUCTION

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

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?
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?
How many daughters are alive but do not live with you?
IF 'NONE', RECORD '00'

206) Have you ever given birth to a boy or a girl who was born alive but later died?
If no, probe: any child cried or showed signs of life but survived only a few hours or days?

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

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

209) CHECK 208:
Just to make 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 LINES.

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

213) Were any of these births twins?

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

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

216) Is (NAME) still alive?

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

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

219) IF DEAD: How old was (NAME) when he/she died?
IF "1 YEAR," PROBE: How many months old was (NAME)?

RECORD IN DAYS IF LESS THAN 1 MONTH;
MONTHS IF LESS THAN TWO YEARS;
OR YEARS

220) FROM YEAR OF BIRTH OF (NAME) SUBTRACT YEAR OF PREVIOUS BIRTH.
Is the difference 4 or more years?

221) Were there any other lives births between (NAME OF PREVIOUS BIRTH) and (NAME)?

[##translator note: questions 212-221 are repeated on the next page to account for larger families--line number 08-11]

222) FROM YEAR OF INTERVIEW SUBTRACT YEAR OF LAST BIRTH
Is the difference 4 years or more?

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

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

225) CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1991
IF NONE, NOTE '0'.

227) Are you pregnant now?

228) How many months pregnant are you?

229) At the time you became pregnant did you want to become pregnant then, did you want to wait until later, or did you not want to have any more children?

236) When did you last menstrual cycle start?
(DATE, IF GIVEN)

237) Between the first day of a woman's period and the first day of her next period, are there certain times when she has a greater chance of becoming pregnant than other times?

238) During which times of the monthly cycle does a woman have the greatest chance of becoming pregnant?

239) Did you ever have a pregnancy end from an abortion, a miscarriage, or stillbirth?

240) How many pregnancies have you had that did not end with a live birth?

241) Of these pregnancies, how many ended in: An abortion? A miscarriage? A still birth?

242) In your opinion, what are the main causes of your lost pregnancy or pregnancies?

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. Which ways or methods have you heard of?

Circle code 1 in 301 for each method mentioned spontaneously. Then proceed down column 302, reading the name and description of each method not mentioned spontaneously. Circle code 2 if method is recognized, and code 3 if not recognized. Then, for each method with code 1or 2 circled in 301 or 302, ask 303.

301/302. Which ways or methods have you heard about?

303) Have you ever used (method)?

304) CHECK 303:

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

307) What have you used or done?
CORRECT 303 AND 304 (AND 302 IF NECESSARY)

309) Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant.
How many living children did you have at that time, if any?

310) CHECK 303:

311) CHECK 227:

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

313) Which method are you using?
CHECK THAT THE METHOD LISTED IS KNOWN AND ALREADY USED
313A) CIRCLE 07 FOR FEMALE STERILIZATION

314) May I see the package of pills you are using right now?
(RECORD NAME OF BRAND IF PACKAGE IS SEEN)

315) You know the brand name of the pills you are now using?
RECORD NAME OF BRAND

316) How much does one packet (cycle) of pills cost you?

317) Where did the sterilization take place?
IF SOURCE IS HOSPITAL, HEATH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

318) Do you regret that (you/your husband) had the operation not to have any (more) children?

319) Why do you regret the operation?
(Why do you regret that your husband had the operation?)

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

321) How do you determine which days of your monthly cycle not to have sexual relations to avoid getting pregnant?

325) For how many months have you used (METHOD) continuously?
IF LESS THAN 1 MONTH, RECORD 00

326) CHECK 314:
CIRCLE THE CODE OF THE METHOD

327) Where did you obtain (CURRENT METHOD) 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.

328) Do you know of another place where you could have obtained (METHOD) last time?

328a) At the time of the sterilization operation, did you know of another place where you could have received the operation?

329) People select the place where they get family planning services for various reasons.
What is your main reason you went to (NAME OF PLACE FORM QUESTION 328 OR QUESTION 318) instead of some other place you know about?
RECORD ANSWER AND CIRCLE CODE

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

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

332) Where is this?
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.

333) Were you visited by a family planning program worker in the last 12 months?

334) Have you visited a health facility for any reason in the last 12 months?

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

336) Do you think that breastfeeding can affect a woman's chance of becoming pregnant?

337) Do you think a woman's chance of becoming pregnant is increased or decreased by breastfeeding?

338) CHECK 210:

339) Have you ever relied on breastfeeding as a method of avoiding pregnancy?

340) Are you currently relying on breastfeeding to avoid getting pregnant?

SECTION 4A: PREGNANCY AND BREASTFEEDING

401) CHECK 225:

402) RECORD THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1991 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS.
BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 2 BIRTHS, USE THE ADDITIONAL QUESTIONNAIRE.)

Now I would like to ask you some more questions about the health of all your children born in the last three years. We will talk about once child at a time.

403) LINE NUMBER FROM QUESTION 212

404) FROM QUESTION 212 AND QUESTION 216:

405) At the time you became pregnant with (NAME), did you want to get pregnant then, did you want to wait until later, or did you want no (more) children at all?

406) How much longer would you like to have waited?
(LESS THAN 1 YEAR, RECORD IN MONTHS, ONE YEAR OR MORE, RECORD IN YEARS)

407A) When you were pregnant with (NAME), did you see anyone for antenatal care for this pregnancy?
IF YES: Whom did you see?
Someone else?

PROBE TO OBTAIN THE TYPE OF PERSON AND RECORD ALL OF THE PERSONS SEEN.

407B) Where did this first consultation take place?

407C) Do you have a health card where these consultations are recorded?
IF YES: Can I see it, please?

408A) How many months pregnant were you when you first received antenatal care?
(CHECK QUESTION 407A FOR YES, SEEN. MAKE SURE THAT THE NUMBER OF MONTHS FROM THE FIRST CONSULTATION IS WHAT IS RECORDED IN THE HEALTH CARD. IF NOT, PROBE TO GET IT FOR EACH CHILD)

408B) Why did you go get antenatal care for the first time?

409) How many times did you receive antenatal care during this pregnancy?
(CHECK QUESTION 407A FOR YES, SEEN. MAKE SURE THAT ALL THE CONSULTATIONS ARE RECORDED IN THE CARD. IF NOT, PROBE TO OBTAIN THE ONES THAT WEREN'T RECORDED, FOR EACH CHILD)

410) When you were pregnant with (NAME), were you given an injection in the back to prevent the baby from getting tetanus, that is, convulsions after birth?

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

412) Where did you give birth to (NAME)?

413A) Who assisted you with the delivery of (NAME)?
Anyone else?
PROBE TO OBTAIN THE TYPE OF PERSON AND RECORD ALL PERSONS ASSISTING.

413B) How much were the medical fees cost for you to give birth to (NAME)?
PROBE TO DETERMINE THE COST

414) Are the time of the birth of (NAME), did you have any of the following problems? A long labor, that is, did your regular contractions last more than 12 hours? Excessive bleeding that was so much that you feared it was life threatening? A high fever with bad smelling vaginal discharge? Convulsions not caused by fever?

415) Was (NAME) delivered by cesarean?

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

417) Was (NAME) weighed at birth?

418) How much did (NAME) weigh?
Record the weight written in the health card, if available
(IF IN KILOGRAMS, CONVERT TO GRAMS)

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

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

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

422) CHECK 227:
RESPONDENT PREGNANT?

423) Have you resumed sexual relations since the birth of (NAME)?

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

425) Did you ever breastfeed (NAME)?

426) 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.

427) CHECK 404:
CHILD ALIVE?

428) Are you still breastfeeding (NAME)?

429) For how many months did you breastfeed (NAME)?

430) Why did you stop breastfeeding (NAME)?

431) CHECK 404:
CHILD ALIVE?

432) How many times did you breastfeed last night between sunset and sunrise?
(IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER)

433) How many times did you breastfeed yesterday during the daylight hours?
(IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER)

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

435) At any time yesterday or last night, was (NAME) given any of the following:

436) CHECK 435: FOOD OR LIQUID GIVEN YESTERDAY?

437) CHECK 428:
STILL BREASTFEEDING?

438) Did (NAME) have anything other than breastmilk to eat or drink yesterday during the day or at night?
IF YES: What did (NAME) eat or drink? CORRECT 435:

439) (Aside from breastfeeding), how many times did (NAME) eat yesterday, including both meals and liquids?
IF 7 OR MORE, RECORD 7

440) How many days during the last seven days was (NAME) given any of the following:
RECORD THE NUMBER OF DAYS, IF DON'T KNOW, RECORD 8

441) GO BACK TO 405 IN THE NEXT COLUMN OR IF NO MORE BIRTHS, GO TO 442.

SECTION 4B. IMMUNIZATION AND HEALTH

442) ENTER LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1991 IN THE TABLE.
ASK THE QUESTIONS FOR ALL THE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNAIRE)

443) LINE NUMBER FROM QUESTIONS 212
LAST BIRTH

444) ACCORDING TO QUESTIONS 212 AND 216

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

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

447)
(1) COPY VACCINATION DATES FOR EACH VACCINE FROM THE CARD.
(2) WRITE '44' IN 'DAY' COLUMN IF THE CARD SHOWS THAT A VACCINE WAS GIVEN, BUT NO DATE IS RECORDED.

448) Has (NAME) received any vaccinations that are not recorded on this card?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DTCOQ 1-3, MEASLES, AND/OR YELLOW FEVER.

449) Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases?

450) Please tell me if (NAME) received any of the following vaccinations:

450A) A BCG vaccination against tuberculosis, that is, an injection in the upper left arm that caused a scar.

450B) Polio vaccine, that is, drops in the mouth?

450C) How many times?

450D) When was the first polio vaccine given, just after birth or later?

450E) DPT vaccination, that is, an injection usually given in the back at the same time as polio drops?

450F) How many times?

450G) Any injection to prevent measles (in the upper arm or back)?

450H) An injection in the left arm to prevent yellow fever?

451) Has (NAME) ever been ill with a fever at any time during the last 2 weeks?

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

453) When (NAME) was ill with a cough, did he/she breathe more rapidly than usual with short, rapid breaths?

454) Did you seek advice or treatment for the cough?

455) Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED

455A) How much did you pay for this advice or treatment?

445B) Was medicine prescribed for this treatment?

455C) Did you get this medicine at the same place where it was prescribed, or elsewhere?

455D) How much did you pay for this medicine?

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

457) Was there blood in the stools?

458) the worst day of the diarrhea, how many bowel movements did (NAME) have?

459) Was he/she given the same amount to drink as before the diarrhea, or more, less or nothing?

460) Was he/she given the same amount of food to eat as before the diarrhea, or more, less or nothing?

461) Did (NAME) get a liquid made from a special packet of powder called (Oral Rehydration Salt-ORS)

462) Was anything else given to (NAME) to treat the diarrhea?

463) What was given to treat the diarrhea?
Anything else?
RECORD ALL MENTIONED

464) Did you seek advice or for a treatment for the diarrhea?

463) Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED

465A) How much did you pay for this advice or treatment?

465B) Was medicine prescribed for this treatment?

465C) Did you get this medicine at the same place where it was prescribed, or elsewhere?

465D) How much did you pay for this medicine?

466) GO BACK TO 444 IN THE NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 467.

467) When a child has diarrhea, should he/she be given less to drink than usual to drink, the same amount, or more than usual?

468) When a child has diarrhea, should he/she be given less to eat than usual, about the same amount, or more than usual?

469) When a child is sick diarrhea, what signs of illness would tell you that he or she should be taken to a health facility or health worker?
RECORD ALL MENTIONED

470) When a child is sick with a cough, what signs of illness would tell you that he or she should be taken to a health facility or health worker?
RECORD ALL MENTIONED

471) CHECK 461, ALL COLUMNS:

472) Have you ever heard of a special product called (rehydration salt) you can get for the treatment of diarrhea?

SECTION 4C: CAUSE OF DEATH

473) CHECK 225:

RECORD THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1991 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS.
BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 2 BIRTHS, USE THE ADDITIONAL QUESTIONNAIRE.)

474) LINE NUMBER FROM QUESTION 212

475) FROM QUESTION 212 AND QUESTION 216:

Now, I would like to ask you some questions about what happened and the symptoms that (NAME) had during the period before his or her death. I know that it is difficult to talk about children you had who died later, but this information is important to help put in place health programs and therefore to help avoid the deaths of other children.

476A) In your opinion, what was (NAME)'s cause of death?

476B) During the illness that lead to (NAME)'s death, did you seek advice or treatment somewhere?
IF YES, SPECIFY.
RECORD ALL MENTIONED.

476C) Where did (NAME)'s death occur?

477) CHECK QUESTION 219 AGE AT DEATH

478A) Was (NAME) born after a difficult delivery?

478B) Was (NAME) born with a malformation?

478C) During the first two days of his/her life, was (NAME) breastfeeding or drinking as you would expect?

478D) During the days just before his/her death, was (NAME) breastfeeding less, or with difficulty?

478E) During the illness that lead to death, did (NAME) have any convolutions or spasms?

479A) During the illness that lead to death, did name have a cough?

479B) How long did the cough last?
IF LESS THAN A DAY, RECORD 00

479C) When (NAME) had the cough, did he/she experience difficulty breathing or rapid breathing?

479D) How long did the difficult or rapid breathing last?
IF LESS THAN A DAY, RECORD 00.

480) GO BACK TO QUESTION 475 FOR THE NEXT DECEASED CHILD. IF NO MORE DECEASED CHILDREN, SKIP TO QUESTION 501.

481A) During the illness that lead to death, did (NAME) have loose or liquid stools, meaning did he or she have diarrhea?

481b) When (NAME) had diarrhea, did he/she have liquid stools very frequently, frequently, or from time to time?

481C) How long did the diarrhea last?
IF LESS THAN A WEEK, RECORD IN DAYS AND CIRCLE CODE 1.
IF ONE WEEK OR MORE AND LESS THAN A MONTH, RECORD IN WEEKS AND CIRCLE CODE 2.
IF ONE MONTH OR MORE, RECORD IN MONTHS AND CIRCLE CODE 3.

481D) Was there blood in the stools?

482A) During the illness that lead to death, did (NAME) have a cough?

482B) How long did the cough last?
IF LESS THAN A WEEK, RECORD IN DAYS AND CIRCLE CODE 1.
IF ONE WEEK OR MORE AND LESS THAN A MONTH, RECORD IN WEEKS AND CIRCLE CODE 2.
IF ONE MONTH OR MORE, RECORD IN MONTHS AND CIRCLE CODE 3.

482C) When (NAME) had a cough, did he/she have difficulty breathing or rapid breathing?

482D) How long did the difficult or rapid breathing last?
IF LESS THAN A WEEK, RECORD IN DAYS AND CIRCLE CODE 1.
IF ONE WEEK OR MORE AND LESS THAN A MONTH, RECORD IN WEEKS AND CIRCLE CODE 2.
IF ONE MONTH OR MORE, RECORD IN MONTHS AND CIRCLE CODE 3.

483A) Did (NAME) have a fever during the illness that lead to death?

483B) Was the fever moderate or severe?

483C) How long did the final fever last?
IF LESS THAN A WEEK, RECORD IN DAYS AND CIRCLE CODE 1.
IF ONE WEEK OR MORE AND LESS THAN A MONTH, RECORD IN WEEKS AND CIRCLE CODE 2.
IF ONE MONTH OR MORE, RECORD IN MONTHS AND CIRCLE CODE 3.

483D) During the illness that lead to death, was (NAME) unconscious?

483E) During the illness that lead to death, did (NAME) have convulsions?

484A) During the illness that lead to death, did (NAME) have an outbreak of spots on the body and face?

484B) How long did the final outbreak of spots last?
IF LESS THAN A WEEK, RECORD IN DAYS AND CIRCLE CODE 1.
IF ONE WEEK OR MORE AND LESS THAN A MONTH, RECORD IN WEEKS AND CIRCLE CODE 2.
IF ONE MONTH OR MORE, RECORD IN MONTHS AND CIRCLE CODE 3.

485A) During the illness that lead to death, was (NAME) very thin?

485B) For how long was (NAME) very thin?
IF LESS THAN A WEEK, RECORD IN DAYS AND CIRCLE CODE 1.
IF ONE WEEK OR MORE AND LESS THAN A MONTH, RECORD IN WEEKS AND CIRCLE CODE 2.
IF ONE MONTH OR MORE, RECORD IN MONTHS AND CIRCLE CODE 3.

485C) During the illness that lead to death, did (NAME) have swollen feet or legs?

485D) For how long?
IF LESS THAN A WEEK, RECORD IN DAYS AND CIRCLE CODE 1.
IF ONE WEEK OR MORE AND LESS THAN A MONTH, RECORD IN WEEKS AND CIRCLE CODE 2.
IF ONE MONTH OR MORE, RECORD IN MONTHS AND CIRCLE CODE 3.

486) GO BACK TO Q. 475 FOR THE NEXT DECEASED CHILD, IF NO MORE DECEASED CHILDREN, SKIP TO Q. 501.

SECTION 5. MARRIAGE AND SEXUAL ACTIVITY

501) PRESENCE OF OTHERS AT THIS POINT

502) Are you currently married or living with a man?

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

504) Have you ever been married or lived with a man?

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

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

507B) CHECK WITH RESPONDENT FOR THE PRECISE REGISTRATION OF HER HUSBAND IN THE HOUSEHOLD QUESTIONNAIRE AND RECORD HIS LINE NUMBER

508) Does your husband/partner have any other wives besides yourself?

509) How many other wives does he have?

510) Are you the first, second?wife?

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

512) CHECK 511:

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

514) What is the family relationship between you and your first husband?

515) Now I would like to ask you some questions about sexual activity in order to gain a better understanding of some family planning issues.

When was the last time you had sexual intercourse?

516) CHECK 301 AND 302:

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

518) Where can you get a condom?

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.

519) How old were you when you first had sexual intercourse?

520) CHECK 401:

521) Have you had sexual intercourse with your husband/the man you live with within the last four weeks.

522) How many times?

523) Was a condom used on one of these occasions?
IF YES: Was it used each time or some of the times?

524) With whom did you have sexual intercourse the last time? With your husband/the man you live with or with someone else?

525) Have you had sexual intercourse with someone other than your husband/the mane you live with within the last four weeks.

526) With how many people other than your husband/the man you live with did you have sexual intercourse in the last four weeks?

527) How many times did you have sexual intercourse with someone other than your husband/the man you live with, in the last four weeks?

528) Was a condom used on one of these occasions?
IF YES: Was it used each time or some of the times?

529) Have you had sexual intercourse with someone in the last four weeks?

530) With how many people did you have sexual intercourse during the last four weeks?

531) How many times did you have sexual intercourse in the last four weeks?

532) Was a condom used on one of these occasions?
IF YES: Was it used each time or some of the times?

533) Why was a condom used?
(CHECK QUESTION 523, QUESTION 528, QUESTION 532, AT LEAST ONE YES)

SECTION 6. FERTILITY PREFERENCES

601) CHECK 314:

602) CHECK 227:

603) CHECK 227:

604) CHECK 602:

605) If you became pregnant in the next few weeks, would you be happy, unhappy, or would it not matter very much?

606) CHECK 313: USING A METHOD?

607) Do you think you will use a method to delay or avoid pregnancy within the next 12 months?

608) Do you think you will use a method any time in the future?

609) Which method would you prefer to use?

610) What is the main reason that you think you will never use a method?

611) CHECK 610:

612) Would you use a method if you were married?

613) CHECK 216:

614) How many of these children would you like to be boys and how many would you like to be girls?

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

616) Is it acceptable or not acceptable to you for information on family planning to be provided:

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

618) Do you usually watch the following shows?

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

620) With whom?
Anyone else?
RECORD ALL PERSONS MENTIONED

621) CHECK 502:

622) Spouses/partner do not always agree on everything. Now I want to ask you about your husband's/partner's views on family planning.

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

623) How often have you talked to your husband/partner about family planning?

624) Do you think your husband/partner wants the same number of children that you want, or does he want more or fewer than you want?

625) CHECK 515:

626) Sometimes, a woman gets pregnant without wanting to. Have you ever gotten pregnant without wanting to?

627) When was the last time you were pregnant without wanting to be?

628) What did you do when that happened?

629) What was done for this?

630) How did you see for this treatment?
Anyone else?

631) Did you have health problems after this?

632) Did you need to be hospitalized?

633) How many nights did you spend at the hospital?
IF NO NIGHTS, RECORD 00.

634) Have you ever had an unwanted pregnancy that you (or someone else) terminated?

Section 7. Characteristics of Partner and Work of the Woman

701) CHECK 504:

701A) How old was your husband/partner on his last birthday?

701B) What is your husband's/partner's religion?

701C) What is your husband's/partner's ethnicity?

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

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

704) What was the highest (GRADE/FORM/YEAR) he completed at that level?
(CONVERT TO NUMBER OF YEARS COMPLETED)

705) What is/was your (last) husband's occupation? That is, what kind of work does/did he mainly do?

706) CHECK 705:

707) Does/did your husband/partner work mainly on his own land or on family land, or does/did he work on land that he rent from someone else, or does/did he work on someone else's land?

708) Aside from your own housework, are you currently working?

709) 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. Are you currently doing any of these things or any other work?

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

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

712) CHECK 711:

713) 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?

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

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

716) During the last 12 months, how many months did you work?

717) During the last 12 months, how many days a week did you usually work (in the months that you worked)?

718) During the last 12 months, approximately how many days did you work?

719) Do you earn cash for your work?
PROBE: Do you make money for working?

720) How much do you usually earn for this work?
PROBE: Is this by the day, by the week, by the month, or by the year?

721) CHECK 502:

722) Do you usually work at home or away from home?

723) CHECK 217 AND 218: Is a child living at home who is age 5 or less?

724) Who usually takes care of (NAME OF YOUNGEST CHILD AT HOME) while you are working?

SECTION 8. HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

801) Have you ever heard of an illnesses that you can get from having sex, which are also referred to as venereal diseases?

802) What illnesses have you heard of?
RECORD ALL RESPONSES

803) CHECK 515:

804) Over the last 12 months, have you had any of these illnesses?

805) Which illnesses did you have?
RECORD ALL RESPONSES

806) SEE QUESTION 805:

807) The last time that you had one of these illnesses, did you seek advice or treatment, did you try to heal yourself, or did you do nothing?

808) Where did you seek advice or treatment?
Any other place?

CIRCLE ALL MENTIONED

808A) For the last STD, did you pay for the consultation?

808B) For the last STD, did you pay for the treatment?

808C) Where did you pay for the treatment?

809) When you had the (ILLNESS(S) OF 805) did you tell your husband/partner(s)?

810) When you had the (ILLNESS(S) OF 805), did you do something to avoid infecting your husband/partner(s)?

811) What did you do?
CIRCLE ALL MENTIONED

812) SEE QUSTION 802:

813) Have you ever heard of an illness called AIDS?

814) From which sources of information have you learned most about AIDS?
Any other sources?
RECORD ALL MENTIONED

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

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

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

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

818A) Can this person transmit the virus?

819) Can AIDS be cured?

819A) How can AIDS be cured?

820) Can AIDS be transmitted from a mother to a child during pregnancy?

821A) Do you know someone personally who has AIDS?

821B) Do you know someone personally who has died of AIDS?

821C) Would you help someone with AIDS?

821D) In what way?

822) Do you think your chances of getting AIDS are small, moderate, great, or no risk at all?

823) Why do you think that you (have no risk/have small risk) for getting AIDS?
Any other reason?
RECORD ALL MENTIONED

824) Why do you think your have (moderate/great) risk of getting AIDS?
Any other reason?
RECORD ALL MENTIONED

825) Since you have heard of AIDS, have you changed your behavior to avoid getting AIDS?

826) What have you done?
Anything else?
RECORD ALL MENTIONED.

827) Some people use condoms during sex to avoid getting AIDS or other sexually transmitted illnesses. Have you ever heard of condoms?

828) Have you ever used a condom during sexual relations to avoid getting or transmitting illnesses, like AIDS?

829) CHECK 515:

830) Have you given or received money, gifts, or favors in exchange for sex in the last 4 weeks?

SECTION 9. MATERNAL MORTALITY

901) 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 are living with you, those living elsewhere and those who have died.

How many children did your mother give birth to, including you?

902) CHECK 901:

903) How many of these births did your mother have before you were born?

904) What was the name given to your oldest (next oldest) brother or sister (from oldest to youngest)?

905) Is (NAME) male or female?

906) Is (NAME) still alive?

907) How old is (NAME)?

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

909) How old was (NAME) when he/she died?
IF MALE OR DIED BEFORE 10 YEARS OF AGE TO GO NEXT BIRTH.

910) Did (NAME) die during childbirth?

911) Was (NAME) pregnant when she died?

912) Did (NAME) die within six weeks after the end of a pregnancy or childbirth?

913) Did (NAME) die due to complications of pregnancy or childbirth?

914) How many children did (NAME) give birth to before this pregnancy?

SECTION 10. TRADITIONAL PRACTICES

1001) Are you circumcised?

1002) How old were you when this occurred?

1003) Did you have any problems after the circumcision?

1004) What were these problems?

1005) Do you think that this practice should be continued, or should it be discontinued?

1006) Why do you think circumcision should be continued?

1007) Why do you think circumcision should be discontinued?

1008) RECORD THE TIME:

SECTION 11. HEIGHT AND WEIGHT

1101) CHECK 215:

IN 1102 (COLUMNS 2 THROUGH 4) RECORD THE LINE NUMBER FOR EACH CHILD BORN SINCE JANUARY 1991 AND STILL ALIVE. IN 1103 AND 1104, RECORD THE NAME AND BIRTH DATE FOR THE RESPONDENT AND FOR ALL LIVING CHILDREN BORN SINCE JANUARY 1991. IN 1106 AND 1108 RECORD HEIGHT AND WEIGHT OF THE RESPONDENT AND THE LIVING CHILDREN. (NOTE: ALL RESPONDENTS WITH ONE OR MORE BIRTHS SINCE JANUARY 1991 SHOULD BE WEIGHED AND MEASURED EVEN IF ALL THE CHILDREN HAVE DIED.) IF THERE ARE MORE THAN 3 LIVING CHILDREN BORN SINCE JANUARY 1991, USE ADDITIONAL QUESTIONNAIRES.

1102) LINE NUMBER FROM QUESTION 212

1103) NAME FROM QUESTION 212 FOR CHILDREN

1104) DATE OF BIRTH FROM QUESTION 215, AND ASK FOR DAY OF BIRTH

1105) BCG SCAR ON TOP OF LEFT SHOULDER

1106) HEIGHT (IN CENTIMETERS)

1107) WAS LENGTH/HEIGHT OF CHILD MEASURED LYING DOWN OR STANDING UP?

1108) WEIGHT (IN KILOGRAMS)

1109) DATE WEIGHED AND MEASURED

1110) RESULT

>1111) NAME OF MEASURER____

NAME OF ASSISTANT____

>INTERVIEWER'S OBSERVATIONS

TO BE FILLED OUT 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____