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 _______

NEXT VISIT
DATE _____
TIME ______

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

RESULT:

TOTAL NUMBER OF VISITS ____

LANGUAGE OF INTERVIEW

INTERPRETER?

SUPERVISOR
NAME _________
DATE _________

FIELD EDITOR
NAME _________
DATE _________

OFFICER 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) In what month and year were you born?

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

104) HAVE YOU EVER ATTENDED SCHOOL?

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

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

107) CHECK 105:

108) 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?

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

110) CHECK 108:

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

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

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

114) Do you currently have a job of any kind?

115) Have you had any kind of job in the last 12 months?

116) What is your occupation, that is, what kind of work do you mainly do?
PROBE TO OBTAIN DETAILS OF THE TYPE OF WORK.

117) CHECK 116:

118) 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?

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

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

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

122) 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?

123) What have you mainly been doing for the last 12 months?

124) What is your religion?

125) 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 about any children you have had during your life. Have you had any children?

202) Do you have any sons or daughters 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, RECODE '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 who only survived a few days or hours?

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

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

209) Just to make sure that I have this right: you have had in total ____ children during your life. Is that correct?

210) CHECK AND 202 AND 204:

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.

211) 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?

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

213) Now I would like to talk about circumcision. Some men are circumcised. Are you, yourself, circumcised?

214) Now we will talk about injections. Over the last 6 months, have you recieved an injection for any reason? IF YES: how many injections did you receive?

IF THE 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.

215) 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 THE 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.

216) Where did you go to get the last injection?

217) 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 3. MARRIAGE AND SEXUAL ACTIVITY

301) Are you currently married or living with a woman as if married?

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

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

304) Is your wife/partner living with you now or is she staying elsewhere?

305) Do you currently have more than one spouse/wife that you live with as husband and wife?

306) How many spouses/wives live with you total?

307) CHECK 305 (1):

ONE WIFE/PARTNER: Please tell me the name of your wife (woman with whom you are currently living as if married).

MORE THAN ONE SPOUSE/WIFE: Please tell me the name of each of your current wives (and/or each woman with whom you are currently living as if married).

RECORD THE NAME(S) AND LINE NUMBERS FROM THE HOUSEHOLD QUESTIONNAIRE FOR THE SPOUSES/PARTNERS LIVING TOGETHER. IF THE PERSON ISN'T LISTED IN THE HOUSEHOLD, RECORD '00'.

308) How old was your wife/partner at her last birthday? ASK FOR EACH PERSON.

309) CHECK 307:

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

311) CHECK 307 AND 310:

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

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

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

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

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

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

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

321) CHECK 103:

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

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

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

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

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

ASK QUESTIONS 327 - 337 OF LAST THREE SEXUAL PARTNERS:

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

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

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

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

331) 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.

332) 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.

337) 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]

338) In total, how many different people have you had sexual intercourse with in the last 12 months?

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

339) 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'.

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

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

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

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

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

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

SECTION 4. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

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

402) 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?

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

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

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

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

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

408) Is there anything (else) a person can do to avoid or reduce their chances of getting the virus that causes AIDS?

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

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

411) Can the virus that causes AIDS be transmitted from a mother to a child...

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

412) CHECK 411:

413) 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?

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

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

425) When was the last time you were tested?

426) 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?

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

428) Where was the test done?

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

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

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

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

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

434) 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?

434A) Do you think that someone with the AIDS virus should reveal his or her status to:

...his wife/his or her partner?
...his/her close relatives?
...his/her friends/acquaintances?

435) 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?

436) 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?

437) 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?

438) CHECK 435, 436, AND 437:

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

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

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

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

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

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

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

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

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

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

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

450) CHECK 401:

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?

451) If a man has sexually transmitted disease, what symptoms might he have? Any other sign or symptom?

RECORD ALL SYMPTOMS MENTIONED.

452) If a woman has a sexually transmitted disease, what symptoms might she have? Any other sign or symptom?

RECORD ALL SYMPTOMS MENTIONED.

453) CHECK 319:

454) CHECK 450:

455) 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?

456) Sometimes men experience an abnormal discharge from their penis. During the last 12 months, have you had an abnormal discharge from your penis?

457) 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?

458) CHECK 455, 456, 457:

459) The last time you had (infection from 455/456/457), did you seek any kind of advice or treatment?

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

SECTION 5. MATERNAL MORTALITY

501A) 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.

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

501B) Other than yourself, how many boys did your mother have who are still living?

501C) How many girls did your mother have who are still living?

501D) How many boys did your mother have who died?

501E) How many girls did your mother have who died?

501F) Did your mother give birth to any other children, who you don't know if they are living or dead?

501G) How many other children did your mother give birth to, who you don't know if they are living or dead?

501H) ADD THE ANSWERS FROM 501B, C, D, E, AND G. ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL.

501I) CHECK 501H:
Just to make sure that I've understood, including yourself, your mother gave birth to ____ children total. Is that correct?

502) CHECK 501H:

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

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

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

504) What was the name given to the first (next) child your mother had?

505) Is (NAME) male or female?

506) Is (NAME) still alive?

507) How old is (NAME)?

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

509) 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?

510) Was (NAME) pregnant when she died?

511) Did (NAME) die during childbirth?

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

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

IF NO MORE BROTHERS OR SISTERS, GO TO 514.

514) 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: _________