MINISTRY OF PLANNING, TERRITORY PLANNING, AND ECONOMIC INTEGRATION (MPATIE)

NATIONAL CENTER OF STATISTICS AND ECONOMIC STUDY (CNSEE)

IDENTIFICATION

NAME OF LOCALITY ___________________________

NAME OF HEAD OF HOUSEHOLD/HOUSEHOLD NUMBER _____ _____

STRUCTURE NUMBER ______

CLUSTER NUMBER (EDSC) _______

DEPARTMENT ________________

MUNICIPALITY/DISTRICT _____________________

NEIGHBORHOOD/COMMUNITY ________________________

URBAN/RURAL:

BRAZZAVILLE, POINTE NOIRE, DOLISIE, NKAYI, OTHER CITIES, RURAL:

RESPONDENT'S NAME AND LINE NUMBER:

CHECK HOUSEHOLD QUESTIONNAIRE: MEN'S SURVEY IN THIS HOUSEHOLD?

INTERVIEWER VISITS

FIRST VISIT
DATE __________
INTERVIEWER'S NAME ____________
RESULT* ______

SECOND VISIT
DATE __________
INTERVIEWER'S NAME ____________
RESULT* ______

THIRD VISIT
DATE __________
INTERVIEWER'S NAME ____________
RESULT* ______

NEXT VISIT
DATE ________
TIME ________

FINAL VISIT
DAY ____
MONTH _____
YEAR 200___
INTERVIEWER CODE _____
RESULT _____

RESULT:

TOTAL NUMBER OF VISITS ____

_

LANGUAGE OF INTERVIEW ____

INTERPRETER?

SUPERVISOR
NAME ________
DATE ________

FIELD EDITOR
NAME ________
DATE ________

OFFICE EDITOR ________

KEYED BY ________

TABLE FOR AGE-DATE OF BIRTH CONSISTENCY FOR SURVEY IN 2005

CURRENT AGE: 0

CURRENT AGE: 1

... CURRENT AGE: 59

SECTION 1. RESPONDENT'S BACKGROUND

INFORMED CONSENT:

Hello, my name is _________ and I work with the National Statistics office. We are conducting a national survey about the health of women and children. We would very much appreciate your participation in this survey. I would like to ask you about your health (and the health of your children). This information will help the government to plan health services. The survey usually takes between 20 and 45 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

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 Brazzaville, in Pointe Noire, in Dolisie, in Nkayi, in another city, in a rural location, or abroad?

IF ABROAD, SPECIFY LOCATION OF RESIDENCE.

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 Brazzaville, in Pointe Noire, in Dolisie, in Nkayi, in another city, in a rural location, or abroad?

IF ABROAD, SPECIFY LOCATION OF RESIDENCE.

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.

107) Have you ever attended school?

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

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

110) CHECK 108:

111) Now I would like you to read this sentence out loud to me; read as much as you can.

SHOW CARD TO RESPONDENT.

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

112) Have you ever participated in a literacy program that involved learning to read or write, like night classes?

113) CHECK 111:

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

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

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

117) What is your religion?

118) What is your ethnicity? RECORD THE NAME OF THE ETHNICITY. LEAVE THE CODE SPACE BLANK.
FOR FOREIGNERS, RECORD 'FOREIGNER'.

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 an 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, RECORD '00'.

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

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

207A) Have you had other children who were born alive but later died after a few minutes, hours, or days?

207B) CORRECT Q. 207, THEN CONTINUE TO QUESTION 208.

208) SUM ANSWERS TO 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 THE 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?

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 THE 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 ONE YEAR PROBE: How many months old was (NAME)?

RECORD DAYS IF LESS THAN ONE MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

221) Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)? [DO NOT ASK FOR FIRST BIRTH]

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 AND ENTER THE NUMBER OF BIRTHS SINCE 2000 OR LATER. IF NONE, RECORD '00'.

226) Are you pregnant now?

227) How many months pregnant are you? RECORD NUMBER OF COMPLETED MONTHS.

228) 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 at all?

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

229B) When did the last such pregnancy end?

229C) CHECK 229B:

229D) How many months pregnant were you when the last such pregnancy ended? RECORD THE NUMBER OF COMPLETED MONTHS.

229E) Was this pregnancy terminated by an elective abortion?

229F) Did you yourself decide to have this abortion, or were you pushed or forced by someone else to have this abortion?

229G) Who pushed or forced you to have this abortion?

229H) What is the main reason you decided to end this pregnancy? PROBE: Any other reason?

229I) Can you tell me what means or procedures were used to terminate this pregnancy?

229J) Where did the abortion take place?

229K) CHECK 229J:

CODES '11' TO '25' OR '35' CIRCLED: Who helped you at the time of the abortion? PROBE: Anyone else?

CODES '31,' '33,' OR '96' CIRCLED: Was anyone present to help you during the abortion? IF YES: Who helped you at the time of the abortion? PROBE: Anyone else?

PROBE TO DETERMINE THE TYPE OF PERSON. RECORD ALL PERSONS LISTED.

229L) After the abortion, did you have a consultation?

229M) Who consulted with you? PROBE: Anyone else? PROBE TO OBTAIN THE TYPE OF PERSON. RECORD ALL PERSONS LISTED.

229N) After the abortion, did you have any complications, like, for example, excessive bleeding (hemorrhage) or an infection?

229O) Have you had any other pregnancies that did not result in a live birth?

229P) All together, how many pregnancies have you had that were not terminated by an elective abortion? IF NONE, RECORD '00'.

229Q) All together, how many pregnancies have you had that have not ended in a live birth?

237) When did your last menstrual period start? RECORD THE ANSWER BASED ON THE UNIT GIVEN.

238) 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?

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

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 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 ever heard of (METHOD)?

302) Have you ever used (METHOD) or have you ever had a partner who had an operation to avoid having any more children?

303) CHECK 302:

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

306) What have you used or done? CORRECT 302 AND 303 (AND 301) IF NECESSARY.

307) 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? IF NONE, RECORD '00'.

308) CHECK 302 (01):

309) CHECK 302:

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

311) Which method are you using?
311A) CIRCLE 'A' FOR FEMALE STERILIZATION. IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD ON LIST.

313) In what facility did the sterilization take place?

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

316A) Since what month and year have you been using (FIRST METHOD FROM Q. 311) without stopping? PROBE: For how long have you been using (FIRST METHOD FROM Q. 311) now without stopping?

316B) CHECK 316/316A, 215, AND 229B:

IN 215 THERE WAS A BIRTH OR IN 229 A PREGNANCY ENDING IN A MISCARRIAGE, AN ELECTIVE ABORTION, OR A STILL-BIRTH AFTER THE MONTH AND THE YEAR OF THE BEGINNING OF CONTRACEPTION USAGE IN 316/316A.

327) CHECK 311/311A:

CIRCLE METHOD CODE. IF MORE THAN ONE CODE CIRCLED IN 311/311A, CIRCLE THE CODE FOR THE HIGHEST METHOD CIRCLED IN 311/311A.

328) Where did you obtain (CURRENT METHOD) last time?

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

330) Where is this?
RECORD ALL MENTIONED.

SECTION 4A. PREGNANCY, POSTNATAL CARE, AND BREASTFEEDING

401) CHECK 224:

402) ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN JANUARY 2000 OR AFTER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OR ADDITIONAL QUESTIONNAIRES).

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

403) LINE NUMBER FROM Q. 212

404) FROM 212 AND 216

405) At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all?

406) How much longer would you have liked to wait?

407) Did you see anyone for antenatal care for this pregnancy?
IF YES: Whom did you see? Anyone else?
[ASK FOR MOST RECENT BIRTH ONLY]

PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN.

408) How many months pregnant were you when you first received antenatal care for this pregnancy? [ASK FOR MOST RECENT BIRTH ONLY]

409) How many times did you receive antenatal care during this pregnancy?
[ASK FOR MOST RECENT BIRTH ONLY]

410) CHECK 409: NUMBER OF TIMES RECEIVED ANTENATAL CARE
[ASK FOR MOST RECENT BIRTH ONLY]

411) How many months pregnant were you the last time you received antenatal care?
[ASK FOR MOST RECENT BIRTH ONLY]

412) During this pregnancy, were any of the following done at least once?
[ASK FOR MOST RECENT BIRTH ONLY]

a) Were you weighted?
b) Was your height measured?
c) Was your blood pressure measured?
d) Did you give a urine sample?
e) Did you give a blood sample?
f) Did you get a vaginal exam?

413) Were you told about the signs of pregnancy complications?
[ASK FOR MOST RECENT BIRTH ONLY]

414) Were you told where to go if you had any of these complications?
[ASK FOR MOST RECENT BIRTH ONLY]

415) During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?
[ASK FOR MOST RECENT BIRTH ONLY]

416) During this pregnancy, how many times did you get this injection?
[ASK FOR MOST RECENT BIRTH ONLY]

416A) How much time before this pregnancy did you get this last tetanus injection?
[ASK FOR MOST RECENT BIRTH ONLY]

417) During this pregnancy, were you given or did you buy iron pills or capsules?
SHOW PILLS OR CAPSULES. [ASK FOR MOST RECENT BIRTH ONLY]

418) During the whole pregnancy, for how many days did you take the iron, as pills or as capsules? IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS. [ASK FOR MOST RECENT BIRTH ONLY]

419) During this pregnancy, did you have difficulty with your vision during the daylight?
[ASK FOR MOST RECENT BIRTH ONLY]

420) During this pregnancy, did you suffer from night blindness?
[ASK FOR MOST RECENT BIRTH ONLY]

421) During this pregnancy, did you take any drugs in order to keep you from getting malaria? [ASK FOR MOST RECENT BIRTH ONLY]

422) What drugs did you take? Other drugs?
[ASK FOR MOST RECENT BIRTH ONLY]

RECORD ALL MENTIONED. IF THE TYPE OF DRUG CANNOT BE DETERMINED, SHOW THE ANTIMALARIALS TO THE RESPONDENT.

422A) CHECK 422: TYPE OF DRUG TAKEN DURING PREGNANCY TO AVOID MALARIA [ASK FOR MOST RECENT BIRTH ONLY]

422B) How many times did you take Chloroquine/Nivaquine during this pregnancy?
[ASK FOR MOST RECENT BIRTH ONLY]

422C) CHECK 407: TYPE OF PERSONNEL WHO GAVE THE ANTENATAL CARE DURING THIS PREGNANCY. [ASK FOR MOST RECENT BIRTH ONLY]

422D) When you were pregnant with (NAME), did you get the Chloroquine/Nivaquine during an antenatal visit, during a different visit to a health facility, or from another source? [ASK FOR MOST RECENT BIRTH ONLY]

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

424) Was (NAME) weighed at birth?

425) How much did (NAME) weigh? RECORD WEIGHT FROM HEALTH CARD, IF AVAILABLE.

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

PROBE FOR THE TYPE OF PERSON. RECORD ALL PERSONS MENTIONED. IF RESPONDENT SAYS NO ONE ASSISTED HER, PROBE TO DETERMINE IF ANY ADULT WAS PRESENT AT BIRTH.

427) Where did you give birth to (NAME)?
RECORD NAME OF PLACE.

428) Was (NAME) delivered by cesarean section, meaning, did you have an operation?

429) After (NAME) was born, did a health professional or someone else give you an exam?

430) How many days or weeks after delivery did the first check take place?
RECORD '00' DAYS IF SAME DAY.
[ASK FOR MOST RECENT BIRTH ONLY]

431) Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.
[ASK FOR MOST RECENT BIRTH ONLY]

432) Where did this first check take place?
[ASK FOR MOST RECENT BIRTH ONLY]

433) In the first two months after delivery, did you receive a vitamin A does like this? SHOW CAPSULE. [ASK FOR MOST RECENT BIRTH ONLY]

434) Has your period returned since the birth of (NAME)?
[ASK FOR MOST RECENT BIRTH ONLY]

435) Did your period return between the birth of (NAME) and your next pregnancy?
[DO NOT ASK FOR MOST RECENT BIRTH]

436) How many months after the birth of (NAME) did you not have a period?

437) CHECK 226: IS RESPONDENT PREGNANT?
[ASK FOR MOST RECENT BIRTH ONLY]

438) Have you resumed sexual intercourse since the birth of (NAME)?
[ASK FOR MOST RECENT BIRTH ONLY]

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

440) Did you ever breastfeed (NAME)?

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

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

442) In the first three days after delivery, before your milk began flowing regularly, was (NAME) given anything to drink other than breast milk?

443) What was (NAME) given to drink before your milk began flowing regularly? Anything else? RECORD ALL LIQUIDS MENTIONED.

444) CHECK 404: IS CHILD LIVING?

445) Are you still breastfeeding (NAME)?

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

447) CHECK 404: CHILD ALIVE?

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

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

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

451) Was sugar added to any of the foods or liquids given to (NAME) yesterday?

452) How many times did (NAME) eat pureed, solid, or semisolid solid foods, other than liquids, yesterday during the day or at night? IF SEVEN OR MORE TIMES, RECORD '7'.

453) RETURN TO 405 IN THE NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 454.

SECTION 4B. VACCINATION, HEALTH, AND NUTRITION

454) ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH OCCURRING IN 2000 OR LATER. ASK THE QUESTIONS FOR ALL BIRTHS. START WITH THE LAST BIRTH. IF THERE ARE MORE THAN 2 BIRTHS, USE THE LAST COLUMN OF THE ADDITIONAL QUESTIONNAIRE.

455) LINE NUMBER FROM Q. 212:

456) FROM Q. 212 AND 216:

457) Did (NAME) get a dose of vitamin A like this one during the last 6 months? SHOW CAPSULE.

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

459) Have you ever had a vaccination care for (NAME)?

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

461) Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in a national-immunization-day campaign?

RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DTCOQ 1-3, MEASLES, AND/OR YELLOW FEVER.

462) Did (NAME) receive any vaccinations to prevent him/her from getting diseases, including vaccinations received in a national immunization day cmapign?

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

463A) A BCG vaccination against tuberculosis, that is, an injection in the arm or forearm that usually causes a scar?

463B) Polio vaccine, that is, drops in the mouth?

463C) When was the first polio vaccine received, just after birth or later?

463D) How many times was the polio vaccine received?

463E) A DTcoq vaccination, that is, an injection sometimes given at the same times as polio drops?

463F) How many times?

463G) An injection to prevent measles around the age of 9 months?

463H) An injection to prevent yellow fever done at the same time as the vaccine against measles?

466) Now I would like to talk to you about children's illnesses. Has (NAME) been ill with a fever at any time in the last two weeks?

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

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

469) CHECK 466 AND 467: FEVER OR COUGH?

470) Did you seek advice or treatment for the fever/cough?

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

472) CHECK 466: HAD A FEVER?

472A) Does (NAME) currently have a fever?

472B) Has (NAME) had convulsions at any time in the last two weeks?

472C) CHECK 466 AND 472B:
FEVER OR CONVULSIONS?

473) Did (NAME) take any drugs to treat the fever?

474) What drugs did (NAME) take?

RECORD ALL MENTIONED. ASK TO SEE THE DRUGS IF THE TYPE OF DRUG IS UNKNOWN. IF THE TYPE OF DRUG CANNOT BE DETERMINED, SHOW THE RESPONDENT TYPICAL ANTIMALARIALS.

474A) Did (NAME) get an injection or suppository to treat the (fever/convulsions)?

474B) CHECK 474: CHLOROQUINE/NIVAQUINE

474C) How long after the fever/convulsions started did (NAME) first take Chloroquine/Nivaquine?

474D) How many days in a row did (NAME) take Chloroquine/Nivaquine?
IF SEVEN DAYS OR MORE, RECORD '7'.

474E) Did you have the Chloroquine/Nivaquine in your home or did you get it from another source? IF MORE THAN ONE SOURCE, ASK: Where did you get the Chloroquine/Nivaquine the first time?

474F) CHECK 474: AMODIAQUINE/FLAVOQUINE/CAMOQUINE

474G) How long after the fever/convulsions started did (NAME) first take Amodiaquine/Flavoquine/Camoquine?

474H) How many days in a row did (NAME) take Amodiaquine/Flavoquine/Camoquine? IF SEVEN DAYS OR MORE, RECORD '7'.

474I) Did you have the Amodiaquine/Flavoquine/Camoquine in your home, or did you get it from another source? IF MORE THAN ONE SOURCE, ASK: Where did you get the Amodiaquine/Flavoquine/Camoquine the first time?

474J) CHECK 474: FANSIDAR/MALOXINE

474K) How long after the fever/convulsions started did (NAME) first take Fansidar/Maloxine?

474L) How many days in a row did (NAME) take Fansidar/Maloxine? IF SEVEN DAYS OR MORE, RECORD '7'.

474M) Did you have the Fansidar/Maloxine in your home or did you get it from another source? IF MORE THAN ONE SOURCE, ASK: Where did you get the Fansidar/Maloxine the first time?

474N) CHECK 474: QUININE/QUINIMAX

474O) How long after the fever/convulsions started did (NAME) first take Quinine/Quinimax?

474P) How many days in a row did (NAME) take Quinine/Quinimax?
IF SEVEN DAYS OR MORE, RECORD '7'.

474Q) Did you have the Quinine/Quinimax in your home, or did you get it from another source? IF MORE THAN ONE SOURCE, ASK: Where did you get the Quinine/Quinimax the first time?

474R) CHECK 474: ARSUMAX/ARSUNATE/ARTESIANE/COARTEM

474S) How long after the fever/convulsions started did (NAME) first take Arsumax/Arsunate/Arinate/Artesiane/Coartem?

474T) How many days in a row did (NAME) take Arsumax/Arsunate/Arinate/Artesiane/Coartem? IF SEVEN DAYS OR MORE, RECORD '7'.

474U) Did you have the Arsumax/Arsunate/Arinate/Artesiane/Coartem in your home or did you get it from another source? IF MORE THAN ONE SOURCE, ASK: Where did you get the Arsumax/Arsunate/Arinate/Artesiane/Coartem the first time?

474V) Was anything (else) done to treat (NAME)'s fever/convulsions?

474W) Other than medical treatment, do you have access to:

Traditional medicine?
Spiritual medicine?

474X) Now I would like to know how much (NAME) was given to drink during the fever/convulsions. Was he/she given less than usual to drink, about the same amount, or more than usual to drink?

IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

474Y) When (NAME) had the fever/convulsions, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?

IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

475) Has (NAME) had diarrhea in the last two weeks?

476) Now I would like to know how much (NAME) was given to drink during the diarrhea. Was he/she given less than usual to drink, about the same amount, or more than usual to drink?

IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

477) When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?

IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

477A) CHECK 445: Still breastfeeding?

477B) When (NAME) had diarrhea, was he/she given less breastmilk than usual, about the same amount, or more than usual?

IF LESS, INSIST: Was he/she given much less breastmilk than usual, or somewhat less?

478) Was he/she given any of the following to drink?

a) A fluid made from a special packet called ORS
b) Homemade sugar-salt water solution (SSS)?
c) Light gruel made from rice (or corn, yams, manioc, plantains)?
d) Soup (for example, carrot soup)?
e) Tea, herbal tea, or guava leaves?
f) Milk or baby formula?
g) Yogurt-based drink?
h) Water?
i) Any other liquid?

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

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

481) Did you seek advice or treatment for the diarrhea?

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

483) GO BACK TO 456 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 484.

486) CHECK 478A ALL COLUMNS:

487) Have you ever heard of a special product called ORS you can get for the treatment of diarrhea? (SHOW ORS PACKET)

487A) CHECK 478B ALL COLUMNS:

487B) Have you ever heard of a homemade sugar-salt-water solution you can use for the treatment of diarrhea?

491) CHECK 215 AND 218:

492) Now I would like to ask you about the liquids (NAME FROM Q. 491) drank over the last seven days, including yesterday. How many days in the last seven did (NAME FROM Q.) drink one or several of the following liquids?

FOR EACH LIQUID DRANK AT LEAST ONCE IN THE LAST SEVEN DAYS, ASK: How many times total did (NAME FROM Q. 491) drink during the day or night?

IF SEVEN TIMES OR MORE, RECORD '7'. IF DON'T KNOW, RECORD '8'.

a) Water?
b) Baby formula? For example, Cerelac or soy flour?
c) Any other type of milk such as tinned, powdered, or fresh bottled milk?
d) Natural fruit juice?
e) Other liquids such as sugar water, tea, coffee, carbonated beverages?
f) Bouillon or soup?
g) Any other liquid?

493) Now I would like to ask you about the foods (NAME FROM Q. 491) ate over the last seven days, including yesterday. How many days in the last seven did (NAME FROM Q. 491) eat one or several of the following foods?

FOR EACH FOOD EATEN AT LEAST ONCE IN THE LAST SEVEN DAYS, ASK: How many times total did (NAME) eat during the day or night?

IF SEVEN OR MORE TIMES, RECORD '7'. IF DON'T KNOW, RECORD '8'.

494) Did you sleep under a mosquito net last night?

499A) Over the last 6 months, have you received an injection for any reason?
IF YES: How many injections did you receive?

IF NUMBER OF INJECTIONS IS OVER 94 OR IF THERE WERE DAILY INJECTIONS IN THE LAST 3 MONTHS OR LONGER, RECORD '95'. IF THE RESPONSE IS NOT NUMERIC, PROBE TO OBTAIN AN ESTIMATE.

499B) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or another healthcare worker?
IF YES: How many injections did you receive?

IF NUMBER OF INJECTIONS IS OVER 94 OR IF THERE WERE DAILY INJECTIONS IN THE LAST 3 MONTHS OR LONGER, RECORD '95'.
IF THE RESPONSE IS NOT NUMERIC, PROBE TO OBTAIN AN ESTIMATE.

449C) Where did you go to get the last injection?

499D) Did the person who administered the injection the last time take the syringe and needle from a new package that wasn't already opened?

SECTION 5. MARRIAGE AND SEXUAL ACTIVITY

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

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

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

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

505) RECORD HUSBAND'S PARTNER'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

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

507) Other than yourself, does your husband/partner have other wives or does he live other women as if married?

508) Including yourself, in total, how many other wives or partners does your husband live with now?

509) Are you the first, second... wife?

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

511) CHECK 510:

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

MARRIED/LIVED WITH MAN MORE THAN ONCE: I would like to talk about the first time you were married or started living with a man as if married. In what month and year were you married or did you start living with a man as if married for the first time?

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

513) CHECK 503: Is respondent currently widowed?

514) CHECK 510:

515) How did your previous marriage/union end?

516) To whom did most of your late husband's property go to?

517) Did you receive any of your late husband's assets or valuables?

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

Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues.

519) How old were you when you had sexual intercourse for the very first time (if ever)?

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

521) CHECK 106:

522) The first time you sexual intercourse, was a condom used?

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

524) Was this person older than you, younger than you, or about the same age as you?

525) Would you say this person was ten or more years older than you or less than ten years older than you?

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

ASK QUESTIONS 527 -537 FOR LAST THREE SEXUAL PARTNERS.

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

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

529) The last time you had sexual intercourse with this (second/third) person, did you or this person drink alcohol?

530) Were you or your partner drunk at that time? IF YES: Who was drunk?

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

532) 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'.

533) CHECK 106:

534) How old is this person?

535) Was this person older than you, younger than you, or about the same age as you?

536) Would you say this person was ten or more years older than you or less than ten years older than you?

537) Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months? [DO NOT ASK FOR THIRD LAST SEXUAL PARTNER]

538) In total, how many different people have you had sexual intercourse within the last 12 months?

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

539) 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'.

540) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY?

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

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

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

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

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

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

SECTION 6. FERTILITY PREFERENCES

601) CHECK 311/311A:

602) CHECK 226:

NOT PREGNANT OR UNSURE ____ Now I have some question about the future. Would you like to have (a/another) child, or would you prefer to have any (more) children?

PREGNANT ___ 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?

603) CHECK 226:

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

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

604) CHECK 226:

605) CHECK 310: USING A CONTRACEPTIVE METHOD?

606) CHECK 603:

607) CHECK 602:

WANTS TO HAVE ANOTHER CHILD ___ You have said that you do not want (a/another) child soon, but you are not using any method to avoid pregnancy. Can you tell me why you are not using a method? Any other reason?

WANTS NO MORE/NONE ___ You have said that you do not want any (more) children, but you are not using any method to avoid pregnancy. Can you tell me why you are not using a method? Any other reason? RECORD ALL REASONS MENTIONED.

608) In the next few weeks, if you discovered that you were pregnant, would that be a big problem, a small problem, or no problem at all?

609) CHECK 310: USING A CONTRACEPTIVE METHOD?

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

611) Which method would you prefer to use?

612) What is the main reason that you think you will never use a contraceptive method at any time in the future?

613) Would you ever use a contraceptive method if you were married?

614) CHECK 216:

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

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

PROBE FOR A NUMERIC RESPONSE.

615) 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?

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

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

a) On the radio?
b) On the television?
c) In a newspaper or magazine?
d) On a poster/leaflet?

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

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

621) CHECK 501:

622) CHECK 311/311A:

624) 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?

624A) CHECK 310: Using a contraceptive method?

624B) If you decided to use a method to avoid or delay pregnancy, do you think that your husband/partner would approve of your decision?

624C) CHECK 311/311A:

624D) Do you think your husband/partner approves or disapproves of your use of a method to avoid or delay pregnancy?

625) How many times in the last 12 months have you talked to your husband/partner about family planning?

626) CHECK 311/311A:

627) 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?

SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK

701) CHECK 501 AND 502:

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

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

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

705) What was the highest (grade/form/year) he completed at that level?

706) CHECK 701:

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

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

707) Aside from your own housework, do you currently work?

708) 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. Do you do something like this now or do any other work?

709) Have you done any work in the past 12 months?

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

711) CHECK 710:

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

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

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

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

716) Are you paid in cash or in kind for this work, or are you not paid at all?

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

718) 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?

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

721) Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

a) If she is unfaithful?
b) If she goes out without telling him?
c) If she refuses to have sex with him?
d) If she does not respect her husband?
e) If she doesn't respect her husband's family?
f) If she neglects the children?
g) If she neglects household work?
h) If she spends household money without husband's authorization?

SECTION 8. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

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

802) Can people reduce their chance of getting the AIDS virus by having just one sex partner who is not infected and who has no other sex partners?

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

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

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

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

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

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

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

810) Is it possible for a health-looking person to have the AIDS virus?

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

a) During pregnancy?
b) During delivery?
c) By breastfeeding?

812) CHECK 811:

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

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

815) CHECK 515:

816) CHECK 407 FOR LAST BIRTH:

817) During any of the antenatal visits for this pregnancy, did anyone talk to you about:

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

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

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

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

821) Where was the test done?

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

823) When was the last time you were tested for the AIDS virus?

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

825) When was the last time you were tested?

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

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

828) Where was the test done?

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

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

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

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

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

834) 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?

834A) Do you believe someone who has learned that he/she is suffering from the AIDS virus should disclose their status to:

- Their spouse/partner?
- Close relatives?
- Friends?

835) 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?

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

837) 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?

838) CHECK 835, 836, AND 837:

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

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

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

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

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

844) Do you think that young men should wait until marriage to have sexual intercourse?

845) Do you think that women should wait until marriage to have sexual intercourse?

846) Do you think that married men should not have sexual intercourse with people other than their spouses?

847) Do most of the men you know only have sexual intercourse with their spouses?

848) Do you think that married women should not have sexual intercourse with people other than their spouses?

849) Do most of the women you know only have sexual intercourse with their spouses?

850) CHECK 801:

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?

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

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

853) CHECK 519:

854) CHECK 850:

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

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

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

858) CHECK 855, 856, 857:

859) The last time you had (INFECTION FROM 855/856/857), did you seek any kind of advice or treatment?

860) Where did you go? Any other place?
CIRCLE ALL MENTIONED.

SECTION 9. MATERNAL MORTALITY

901A) Now I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your biological mother. Did your mother give birth to any children other than yourself?

901B) How many boys did your mother have who are still living?

901C) Other than yourself, how many girls did your mother have who are still living?

901D) How many boys did your mother have who died?

901E) How many girls did your mother have who died?

901F) Did your mother give birth to any other children who you don't know if they are living or dead?

901G) How many other children did your mother give birth to who you don't know if they are living or dead?

901H) ADD THE ANSWERS FROM 901B, C, D, E, AND G. ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL.

901I) CHECK 901H: Just to make sure that I've understood, including yourself, your mother gave birth to ____ children total. Is that correct?

902) CHECK 901H:

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

Now I would like to make a list of all your sisters and brothers, whether they are still alive or not, starting with the oldest.

RECORD THE NAME OF ALL THE SISTERS AND BROTHERS. IF MORE THAN 15 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE.

904) What was the name given to the oldest (next oldest) child your mother had?

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 DON'T KNOW, PROBE: Did (NAME) die before he/she was 12 years old?

IF YES, RECORD '95'. IF NO, ASK OTHER QUESTIONS TO OBTAIN AN ESTIMATE. FOR EXAMPLE: Did (NAME) die before getting married?

IF MALE OR DIED BEFORE 12 YEARS OF AGE, GO TO 913.

910) Was (NAME) pregnant when she died?

911) Did (NAME) die during childbirth?

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

913) Did (NAME) die because of an accident or an act of violence?

IF NO MORE BROTHERS OR SISTERS, GO TO 914.

914) 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: _____