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Republic of Ivory Coast Demographic and Health Survey
EDSCI-III, Woman's questionnaire

MINISTRY OF HEALTH AND OF THE FIGHT AGAINST AIDS, NATIONAL OFFICE OF STATISTICS

IDENTIFICATION

PLACE NAME_________
NAME OF HEAD OF HOUSEHOLD__________
CLUSTER NUMBER_____
STRUCTURE NUMBER________
HOUSEHOLD NUMBER________
REGION_______

RESIDENTIAL TYPE/ MILIEU______

URBAN 1
RURAL 2

LARGE CITY/CITY/SMALL CITY/RURAL/ CITY_______

LARGE CITY 1
CITY 2
SMALL CITY 3
RURAL 4

NAME AND LINE NUMBER OF MAN

NAME__________
LINE NUMBER____________

INTERVIEWER VISITS

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE____ /201__
INTERVIEWER'S NAME
RESULT*____

NEXT VISIT
(REPEAT FOR INTERVIEWER 2)
DATE____ /201__
TIME______

FINAL VISIT
DAY_______
MONTH_______
YEAR 201___
INTERVIEWER CODE________
RESULT______

TOTAL NO. OF VISITS___________

RESULT CODES:

1COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY)________________

COUNTRY SPECIFIC INFORMATION
LANGUAGE OF QUESTIONNAIRE, LANGUAGE OF INTERVIEW
MATERNAL LANGUAGE OF RESPONDENT AND USE OF AN INTERPRETER

SUPERVISOR
NAME_______
DATE_______

FIELD EDITOR
NAME______
DATE______

OFFICE EDITOR_______

KEYED BY_______

PHRASES TO READ
DAD GOES TO THE FIELDS.
THE KIDS DANCE WITH THEIR FATHER.
YOU MUST GO GET WATER FROM THE MARIGOT.
MOM IS PILING

Section 1. Respondent's background

INTRODUCTION AND CONSENT
INFORMED CONSENT

Hello. My name is ___. I am working with the National Office of Statistics (INS) and the Ministry of Health and the Fight Against AIDS (MSLS). We are conducting a national survey about health in Cote d'Ivoire. The information we collect will help the government to plan health services. Your household was selected for this survey. The questions usually take about 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You are not required to participate in this survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question; you can also stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.

Do you have any questions?
May I begin the interview?

SIGNATURE OF INTERVIEWER_______
DATE_______

RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2-END

101) RECORD THE TIME

HOUR________
MINUTES_______

102) In what month and year were you born?

MONTH_________
DON'T KNOW MONTH 98
YEAR_________
DON'T KNOW YEAR 9998

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

AGE IN COMPLETED YEARS______

104) Have you ever attended school?

YES 1
NO 2- (SKIP TO 108)

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

PRIMARY 1
SECONDARY 2
HIGHER 3

106) What is the highest (grade/form/year) you completed at this level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 00

GRADE/FORM/YEAR________

107) CHECK 105

PRIMARY
SECONDARY OR HIGHER -- (SKIP TO 110)

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

SHOW CARD TO RESPONDENT

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

CANNOT READ AT ALL 1
ABLE TO READ ONLY PART OF SENTENCE 2
ABEL TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE _________(SPECIFY LANGUAGE) 4
BLIND/VISUALLY IMPAIRED 5

109) CHECK 108:

CODE 2, 3, OR 4 CIRCLED
CODE 1 OR 5 CIRCLED- (SKIP TO 111)

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

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

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

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

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

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

113) What is your religion?

MUSLIM 1
CHRISTIAN 2
METHODIST 3
EVANGELICAL 4
OTHER CHRISTIAN RELIGION 5
ANIMIST 6
OTHER RELIGIONS 7
NO RELIGION 8

114) What is your ethnicity?
RECORD THE ETHNICITY. LEAVE THE CODIFICATION SPACES EMPTY.
FOR FOREIGNERS, RECORD NATIONALITY.

ETHNICITY____________

115) In the last 12 months, how many times have you been away from for one or more nights?

NUMBER OF TIMES______
NONE 00- (SKIP TO 201)

116) In the last 12 months, have you been away from home for more than one month at a time?

YES 1
NO 2

Section 2. Reproduction

201) Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours, even if they are not legally yours or do not have your last name.

Have you ever fathered any children with any woman?

YES 1
NO 2- (SKIP TO 206)
DON'T KNOW 8- (SKIP TO 206)

202) Do you have any sons or daughters that you have fathered who are currently living with you?

YES 1
NO 2- (SKIP TO 204)

203) How many sons live with you?
And how many daughters live with you?
IF NONE, RECORD '00'

SONS AT HOME_______
DAUGHTERS AT HOME_______

204) Do you have any sons or daughters that you have fathered who are alive but do not live with you?

YES 1
NO 2- (SKIP TO 206)

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'

SONS ELSEWHERE_______
DAUGHTERS ELSEWHERE______

206) Have you ever fathered a son or a daughter who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

YES 1
NO 2- (SKIP TO 208)
DON'T KNOW 8- (SKIP TO 208)

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

BOYS DEAD_____
GIRLS DEAD________

208) SUM ANSWERS TO 203, 205, AND 207 AND ENTER TOTAL.

IF NONE, RECORD 00
TOTAL______

209) CHECK 208:

HAS HAD MORE THAN ONE CHILD
HAS ONLY HAD ONE CHILD- (SKIP TO 212)
HAS NOT HAD ANY CHILDREN- (SKIP TO 301)

210) Did all of the children you have fathered have the same biological mother?

YES 1- (SKIP TO 212)
NO 2

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

NUMBER OF WOMEN________

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

AGE IN YEARS______

213) CHECK 203 AND 205:

AT LEAST ONE LIVING CHILD
NO LIVING CHILDREN- (SKIP TO 301)

214) How old is your (youngest) child?

AGE IN YEARS_____

215) CHECK 214:

(YOUNGEST) CHILD IS AGE 0-2 YEARS
OTHER- (SKIP TO 301)

216) What is the name of your (youngest) child?
WRITE NAME OF (YOUNGEST) CHILD

(NAME OF (YOUNGEST) CHILD)________

217) When (name)'s mother was pregnant with (name), did she have any antenatal check-ups?

YES 1
NO 2- (SKIP TO 219)
DON'T KNOW 8- (SKIP TO 219)

218) Were you ever present during any of those antenatal check-ups?

PRESENT 1
NOT PRESENT 2

219) Was (name) born in a hospital or a health facility?

HOSPITAL/HEALTH FACILITY 1
OTHER 2

220) When a child has diarrhea, how much should he or she be given to drink: more than usual, about the same as usual, less than usual or nothing to drink at all?

MORE THAN USUAL 1
ABOUT THE SAME 2
LESS THAN USUAL 3
NOTHING TO DRINK 4
DON'T KNOW 8

SECTION 3. CONTRACEPTION

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

Which methods have you heard of? (Have you ever heard of (method)?)

01) FEMALE STERILIZATION
PROBE: Women can have an operation to avoid having any more children
YES 1
NO 2
02) MALE STERILIZATION
PROBE: Men can have an operation to avoid having any more children
YES 1
NO 2
03) IUD
PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
04) INJECTABLES
PROBE: Women can have an injection by a heath provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2
05) IMPLANTS
PROBE: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2
06) PILL
PROBE: Women can take a pill every day to avoid becoming pregnant
YES 1
NO 2
07) CONDOM
PROBE: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
08) FEMALE CONDOM
PROBE: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2
09) LACTATIONAL AMENORRHEA METHOD (LAM)
YES 1
NO 2
10) RHYTHM METHOD
PROBE: To avoid pregnancy, women do not have sexual intercourse on the days of the month they think they can get pregnant.
YES 1
NO 2
11) WITHDRAWAL
PROBE: Men can be careful and pull out before climax.
YES 1
NO 2
12) EMERGENCY CONTRACEPTION
PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
YES 1
NO 2
12A) DIAPHRAGM/CERVICAL CAP
PROBE: Women can place a latex disk on their cervix before intercourse.
YES 1
NO 2
12B) FOAM/JELLY/SPERMICIDE
PROBE: Women can place a suppository, jelly, or cream in their vagina before intercourse to kill men's sperm. This cream can also be used on the diaphragm.
YES 1
NO 2
13) Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES 1
(SPECIFY) ______
(SPECIFY) ______
NO 2

302) In the last few months have you:

Heard about family planning on the radio?
Seen anything about family planning on the television?
Read on family planning in a newspaper or magazine?
Read about family planning on posters or leaflets?

RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NEWSPAPER OR MAGAZINE
YES 1
NO 2
POSTERS OR LEAFLETS
YES 1
NO 2

302A) CHECK 302:

HEARD ABOUT FAMILY PLANNING ON THE RADIO, YES, CIRCLE
OTHER --(SKIP TO 302D)

302B) You told me that you heard about family planning on the radio. Did you hear about family planning on:

Radio Cote d'Ivoire or Frequence 2?
Radio ONUCI-FM?
Commercial radio?
Religious radio?

RADIO CI OR FREQUENCE 1
YES 1
NO 2
RADIO ONUCI-FM
YES 1
NO 2
COMMERCIAL RADIO
YES 1
NO 2
RELIGIOUS RADIO
YES 1
NO 2

302C) Did you hear about family planning during the show Health Space on community radio?

YES 1
NO 2
DON'T KNOW 8

302D) CHECK 302:

HEARD ABOUT FAMILY PLANNING ON THE TELEVISION, YES, CIRCLE
OTHER -- (SKIP TO 302F)

302E) You told me that you heard about family planning on the television. Did you hear about family planning on:

Ivorian Radio television (RTI)?
European channels?
African channels?
Other television channels?

RTI
YES 1
NO 2
EUROPEAN CHANNELS
YES 1
NO 2
AFRICAN CHANNELS
YES 1
NO 2
OTHER CHANNELS
YES 1
NO 2

302F) CHECK 302:

HEARD AT LEAST ONE MESSAGE, AT LEAST ONE YES CIRCLED
NOT A SINGLE YES CIRCLED- (SKIP TO 303)

302G) Have you received the message on:

The existence of family planning services?
A place to obtain contraceptive methods?
Types of methods?
Advantages of family planning on health, the economy, etc?

EXISTENCE OF FAMILY PLANNING
YES 1
NO 2
PLACE TO OBTAIN
YES 1
NO 2
TYPE OF METHODS
YES 1
NO 2
ADVANTAGES OF FAMILY PLANNING
YES 1
NO 2

303) In the last few months, have you discussed family planning with a health worker or health professional?

YES 1
NO 2

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

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

YES 1
NO 2- (SKIP TO 306)
DON'T KNOW 8- (SKIP TO 306)

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

JUST BEFORE HER PERIOD BEGINS 1
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER_________ (SPECIFY) 6
DON'T KNOW 8

306) I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.

a) Contraception is a woman's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous.

CONTRACEPTION WOMAN'S BUSINESS
AGREE 1
DISAGREE 2
DON'T KNOW 8
WOMAN CAN BECOME PROMISCUOUS
AGREE 1
DISAGREE 2
DON'T KNOW 8

307) CHECK 301 (07): KNOW MALE CONDOM

YES
NO -- (SKIP TO 311)

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

YES 1
NO 2- (SKIP TO 311)

309) Where is that?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE
(NAME OF PLACE(S))_____________

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
MOBILE CLINIC D
FIELDWORKER E
OTHER PUBLIC SECTOR_____________ (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
FIELDWORKER K
OTHER PRIVATE MEDICAL_____________ (SPECIFY) L
OTHER SOURCE
SHOP M
RELIGIOUS INSTITUTIONS N
FRIEND/RELATIVES O
OTHER___________ (SPECIFY) X

310) If you wanted, could you yourself get a condom?

YES 1
NO 2

311) CHECK 301 (08): KNOWS FEMALE CONDOM

YES
NO- (SKIP TO 401)

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

YES 1
NO 2- (SKIP TO 401)

313) Where is that?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE
(NAME OF PLACE(S))______________

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
MOBILE CLINIC D
FIELDWORKER E
OTHER PUBLIC SECTOR____________(SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
FIELDWORKER K
OTHER PRIVATE MEDICAL (SPECIFY) L
OTHER SOURCE
SHOP M
RELIGIOUS INSTITUTIONS N
FRIEND/RELATIVES O
OTHER____________ (SPECIFY) X

314) If you wanted, could you yourself get a female condom?

YES 1
NO 2

Section 4. Marriage and sexual activity

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

YES, CURRENTLY MARRIED 1- (SKIP TO 404A)
YES, LIVING WITH A WOMAN 2- (SKIP TO 404A)
NO, NOT IN UNION 3

402) Have you ever been married or lived together with a woman as if married?

YES, FORMERLY MARRIED 1
YES, LIVED WITH A WOMAN 2
NO 3- (SKIP TO 413)

402a) Did you consent to this marriage?

YES 1
NO 2

402b) CHECK 401:

NO, NOT IN UNION
YES, CURRENTLY MARRIED/LIVING WITH A MAN- (SKIP TO 404)

403) What is your current marital status: are you widowed, divorced, or separated?

WIDOWED 1- (SKIP TO 410)
DIVORCED 2- (SKIP TO 410)
SEPARATED 3- (SKIP TO 410)

404) Is your (wife/partner) currently living with you or is she staying elsewhere?

LIVING WITH HIM 1
STAYING ELSEWHERE 2

405) Do you have other wives or do you live with other women as if married?

YES (MORE THAN ONE) 1
NO (ONLY ONE) 2- (SKIP TO 407)

406) Altogether, how many wives or live-in partners do you have?

TOTAL NUMBER OF WIVES AND LIVE-IN PARTNERS________

407) CHECK 405:
ONE WIFE/PARTNER: Please tell me the name of (your wife/the woman you are living with as if married).

MORE THAN ONE WIFE/PARTNER: Please tell me the name of each of your wives or each woman you are living with as if married.

RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIFE-IN PARTNER.

IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD 00.

ASK 408 FOR EACH PERSON (IN THE LAST COLUMN OF 407)

NAME___________
LINE NUMBER___________

408) How old was (name) on her last birthday?

AGE_____

409) CHECK 407:

ONE WIFE/PARTNER
MORE THAN ONE WIFE/PARTNER-SKIP TO 411A

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

ONLY ONCE 1
MORE THAN ONCE 2- (SKIP TO 411A)

411) In what month and year did you start living with your (wife/partner)?

411a) Now we are going to talk about your first (wife/partner). In what month and year did you start living with her?

MONTH________
DON'T KNOW MONTH 98
YEAR_________ - (SKIP TO 413)
DON'T KNOW YEAR 9998

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

AGE_______

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

414) Now I would like to ask 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?

NEVER HAD SEXUAL INTERCOURSE 00- (SKIP TO 501)
AGE IN YEARS_______
FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE/PARTNER 95

415) Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question.

416) When was the last time you had sexual intercourse?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

DAYS AGO___________ 1
WEEKS AGO__________ 2
MONTHS AGO_________ 3
YEARS AGO_________ 4- (SKIP TO 430)

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

DAYS AGO________ 1
WEEKS AGO_______ 2
MONTHS AGO______ 3

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

YES 1
NO 2- (SKIP TO 420)

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

YES 1
NO 2

420) What was your relationship to this person with whom you had sexual intercourse?

IF GIRLFRIEND: Were you living together as if married?
IF YES, CIRCLE 2
IF NO, CIRCLE 3

WIFE 1
LIVE-IN PARTNER 2
GIRLFRIEND NOT LIVING WITH RESPONDENT 3- (SKIP TO 423)
CASUAL ACQUAINTANCE 4- (SKIP TO 423)
CLIENT/PROSTITUTE 5- (SKIP TO 423)
OTHER (SPECIFY) 6- (SKIP TO 423)

421) CHECK 410:

MARRIED ONLY ONCE
MARRIED MORE THAN ONCE OR BLANK-(SKIP TO 423)

422) CHECK 414:

FIRST TIME WHEN STARTED LIVING WITH FIRST WIFE (SKIP TO 424)
OTHER

423) How long ago did you first have sexual intercourse with this (second/third) person?

DAYS AGO______ 1
WEEKS AGO_____ 2
MONTHS AGO___ 3
YEARS AGO_____ 4

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

NUMBER OF TIMES________
IF 95 OR MORE, RECORD 95

425) How old is this person?

AGE OF PARTNER________
DON'T KNOW 98

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

YES 1-(GO BACK TO 417 IN NEXT COLUMN)
NO 2-(SKIP TO 428)

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

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE 95

NUMBER OF PARTNERS IN LAST 12 MONTHS________
DON'T KNOW 98

428) CHECK 420 (ALL COLUMNS):

AT LEAST ONE PARTNER IS PROSTITUTE
NO PARTNERS ARE PROSTITUTES- (SKIP TO 430)

429) CHECK 420 AND 418 (ALL COLUMNS)

OTHER- (SKIP TO 434)
CONDOM USED WITH EVERY PROSTITUTE- (SKIP TO 433)

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

YES 1- (SKIP TO 432)
NO 2

431) Have you ever paid anyone in exchange for having sexual intercourse?

YES 1- (SKIP TO 434)
NO 2- (SKIP TO 434)

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

YES 1
NO 2- (SKIP TO 434)

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

YES 1
NO 2
DON'T KNOW 8

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

NUMBER OF PARTNERS IN LIFETIME_______
DON'T KNOW 98

435) CHECK 418, MOST RECENT PARTNER (FIRST COLUMN):

CONDOM USED
NOT ASKED- (SKIP TO 438)
NO CONDOM USED- (SKIP TO 438)

436) You told me that a condom was used the last time you had sex. What is the brand name of the condom used at that time?
IF BRAND NOT KNOWN, ASK TO SEE THE PACKAGE.

PRUDENCE 01
IPPF 02
KAMASSOUTRA 03
OTHER_______ (SPECIFY) 96
DON'T KNOW 98

437) From where did you obtain the condom the last time?

PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE
(NAME OF PLACE)__________

PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
FIELDWORKER 15
OTHER PUBLIC SECTOR_________(SPECIFY) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
FIELDWORKER 25
OTHER PRIVATE MEDICAL (SPECIFY) 26
OTHER SOURCE
SHOP 31
RELIGIOUS INSTITUTION 32
FRIEND/RELATIVES 33
OTHER________ (SPECIFY) 96

438) The last time you had sex did you or your partner use any method (other than a condom) to avoid or prevent a pregnancy?

YES 1
NO 2- (SKIP TO 501)
DON'T KNOW 8- (SKIP TO 501)

439) What method did you or your partner use?
PROBE: Did you or your partner use any other method to prevent pregnancy?
RECORD ALL MENTIONED

FEMALE STERILIZATION A
MALE STERILIZATION B
IUD C
INJECTABLES D
IMPLANTS E
PILL F
FEMALE CONDOM G
DIAPHRAGM H
FOAM/JELLY I
LAM J
RHYTHM METHOD K
WITHDRAWAL L
OTHER MODERN METHOD X
OTHER TRADITIONAL METHOD Y

Section 5. Fertility preferences

501) CHECK 401:

CURRENTLY MARRIED OR LIVING WITH A PARTNER
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER- (SKIP TO 509)

502) CHECK 439:

MAN NOT STERILIZED
MAN STERILIZED- (SKIP TO 509)

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

YES 1
NO 2- (SKIP TO 505)
DON'T KNOW 8- (SKIP TO 505)

504) Now I have some questions about the future. After the (child/children) you and your (wife(wives)/partner(s)) are expecting now, would you like to have another child, or would you prefer not have any more children?

HAVE ANOTHER CHILD 1-(SKIP TO 506)
NO MORE 2- (SKIP TO 509)
UNDECIDED/DON'T KNOW 8- (SKIP TO 509)

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

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2- (SKIP TO 509)
SAYS COUPLE CAN'T GET PREGNANT 3- (SKIP TO 509)
WIFE (WIVES)/PARTNER(S) STERILIZED 4- (SKIP TO 509)
UNDECIDED/DON'T KNOW 8- (SKIP TO 509)

506) CHECK 407:

ONE WIFE/PARTNER
MORE THAN ONE WIFE/PARTNER -- (SKIP TO 508)

507) CHECK 503:
WIFE/PARTNER NOT PREGNANT OR DON'T KNOW: How long would you like to wait from now before the birth of (a/another) child?

WIFE/PARTNER PREGNANT: After the birth of the child you are expecting now, how long would you wait before the birth of another child?

MONTHS________ 1- (SKIP TO 509)
YEARS_________ 2- (SKIP TO 509)
SOON/NOW 993- (SKIP TO 509)
COUPLE INFECUND 994- (SKIP TO 509)
OTHER________ (SPECIFY) 996- (SKIP TO 509)
DON'T KNOW 998- (SKIP TO 509)

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

MONTHS_______ 1
YEARS_________ 2
SOON/NOW 993
HE/ALL HIS WIVES/PARTNERS ARE INFECUND 994
OTHER________ (SPECIFY) 996
DON'T KNOW 998

509) CHECK 203 AND 205:
HAS LIVING CHILDREN-If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?

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

PROBE FOR A NUMERIC RESPONSE.

NONE 00- (SKIP TO 601)
NUMBER_______
OTHER________ (SPECIFY) 96- (SKIP TO 601)

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

NUMBER BOYS _________
NUMBER GIRLS_______
NUMBER OF EITHER_______
OTHER_______ (SPECIFY) 96

Section 6. Employment and gender roles

601) Have you done any work in the last seven days?

YES 1- (SKIP TO 604)
NO 2

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

YES 1- (SKIP TO 604)
NO 2

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

YES 1
NO 2- (SKIP TO 607)

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

OCCUPATION_______

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

THROUGHOUT THE YEAR 1
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3

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

CASH ONLY 1
CASH AND KIND 2
IN KIND ONLY 3
NOT PAID 4

607) CHECK 401:

CURRENTLY MARRIED OR LIVING WITH A PARTNER
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER- (SKIP TO 612)

608) CHECK 606:

CODE 1 OR 2 CIRCLED
OTHER -- (SKIP TO 610)

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

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
OTHER________ (SPECIFY) 6

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

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER________ (SPECIFY) 6

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

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER_______ (SPECIFY) 6

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

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

613) Do you own any land either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

614) In your opinion, is a husband justified in hitting or beating his wife in the following situations:
If she goes out without telling him? Yes 1 No 2 DK 8
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

LEAVES WITHOUT TELLING HIM
YES 1
NO 2
DON'T KNOW 8
NEGLECT CHILDREN
YES 1
NO 2
DON'T KNOW 8
ARGUES
YES 1
NO 2
DON'T KNOW 8
REFUSES SEX
YES 1
NO 2
DON'T KNOW 8
BURN FOOD
YES 1
NO 2
DON'T KNOW 8

Section 7. HIV/AIDS

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

YES 1
NO 2- (SKIP TO 723)

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

707a) Can the virus that causes AIDS be transmitted by:

Sharp-edged objects?
Injections?
Blood transfusions?
Toothbrushes?

SHARP OBJECT
YES 1
NO 2
DON'T KNOW 8
INJECTIONS
YES 1
NO 2
DON'T KNOW 8
TRANSFUSION
YES 1
NO 2
DON'T KNOW 8
TOOTH BRUSH
YES 1
NO 2
DON'T KNOW 8

708) Can the virus that causes AIDS be transmitted from a mother to a child?

During pregnancy?
During delivery?
By breastfeeding?

PREGNANCY
YES 1
NO 2
DON'T KNOW 8
DELIVERY
YES 1
NO 2
DON'T KNOW 8
BREASTFEEDING
YES 1
NO 2
DON'T KNOW 8

709) CHECK 708:

AT LEAST ONE YES
OTHER- (SKIP TO 711)

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

YES 1
NO 2
DON'T KNOW 8

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

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

YES 1
NO 2- (SKIP TO 716)

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

MONTHS AGO_______
TWO OR MORE YEARS 96

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

YES 1
NO 2

715) Where was the test done?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE
(NAME OF PLACE)

PUBLIC SECTOR
GOVERNMENT HOSPITAL 11- (SKIP TO 718)
GOVERNMENT HEALTH CENTER 12- (SKIP TO 718)
INDEPENDENT VCT CENTER 13- (SKIP TO 718)
FAMILY PLANNING CLINIC 14- (SKIP TO 718)
MOBILE CLINIC 15- (SKIP TO 718)
SCHOOL BASED CLINIC 16- (SKIP TO 718)
OTHER PUBLIC SECTOR________ (SPECIFY) 17- (SKIP TO 718)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR 21- (SKIP TO 718)
INDEPENDENT VCT CENTER 22- (SKIP TO 718)
PHARMACY 23- (SKIP TO 718)
MOBILE CLINIC 24- (SKIP TO 718)
HEALTH AGENT 26- (SKIP TO 718)
SCHOOL BASED CLINIC 26- (SKIP TO 718)
OTHER PRIVATE MEDICAL___________ (SPECIFY) 27- (SKIP TO 718)
OTHER SOURCE
HOME 31- (SKIP TO 718)
CORRECTIONAL FACILITY 32- (SKIP TO 718)
OTHER______ (SPECIFY) 96- (SKIP TO 718)

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

YES 1
NO 2- (SKIP TO 718)

717) Where is that?
ANY OTHER PLACE?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE
(NAME OF PLACE)__________

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
INDEPENDENT VCT CENTER C
FAMILY PLANNING CLINIC D
MOBILE CLINIC E
FIELDWORKER F
OTHER PUBLIC SECTOR_________ (SPECIFY) G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR H
INDEPENDNET VCT CENTER I
PHARMACY J
MOBILE CLINIC K
FIELDWORKER L
OTHER PRIVATE MEDICAL SECTOR_________ (SPECIFY) M
OTHER__________ (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW 8

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

YES, REMAIN A SECRET 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

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

YES 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

721) 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?

SHOULD BE ALLOWED 1
SHOULD BE ALLOWED 2
DON'T KNOW/NOT SURE/DEPENDS 8

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

YES 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

723) CHECK 701:
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?

YES 1
NO 2

724) CHECK 414:

HAS HAD SEXUAL INTERCOURSE
HAS NOT HAD SEXUAL INTERCOURSE- (SKIP TO 732)

725) CHECK 723: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

YES
NO- (SKIP TO 727)

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

728) 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?

YES 1
NO 2
DON'T KNOW 8

729) CHECK 726, 727, AND 728:

HAS HAD AN INFECTION (ANY YES)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW -- (SKIP TO 732)

730) The last time you had (INFECTION FROM 726/727/728), did you seek any kind of advice or treatment?

YES 1
NO 2- (SKIP TO 732)

731) Where did you go?
Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE
(NAME OF PLACE(S))________________

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
INDEPENDENT VCT CENTER C
FAMILY PLANNING CLINIC D
MOBILE CLINIC E
FIELDWORKER F
OTHER PUBLIC SECTOR_______ (SPECIFY) G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR H
INDEPENDENT VCT CENTER I
PHARMACY J
MOBILE CLINIC K
FIELDWORKER L
OTHER PRIVATE MEDICAL_________ (SPECIFY) M
OTHER SOURCE
SHOP N
OTHER_______ (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

Section 8. Other health issues

801) Some men are circumcised, that is, the foreskin is completely removed from the penis. Are you circumcised?

YES 1
NO 2- (SKIP TO 805)
DON'T KNOW 8- (SKIP TO 805)

802) How old were you when you got circumcised?

AGE IN COMPLETED YEARS_________
DURING CHILDHOOD (LESS THAN 5 YEARS) 96
DON'T KNOW 98

803) Who did the circumcision?

TRADITIONAL PRACTITIONER/FAMILY/FRIEND 1
HEALTH WORKER/PROFESSIONAL 2
OTHER 3
DON'T KNOW 8

804) Where was the circumcision performed?

HEALTH FACILITY 1
HOME OF A HEALTH WORKER/PROFESSIONAL 2
CIRCUMCISION DONE AT HOME 3
RITUAL SITE 4
OTHER HOME/PLACE 5
DON'T KNOW 8

805) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD 90
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS_______
NONE 00- (SKIP TO 808)

806) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or another healthcare worker?

IF THE NUMBER OF INJECTIONS IS OVER 90 OR IF THERE WERE DAILY INJECTIONS FOR 3 MONTHS OR LONGER, RECORD 90.
IF THE RESPONSE IS NOT NUMERIC, PROBE TO OBTAIN AN ESTIMATE.

NUMBER OF INJECTIONS_______
NONE-00- (SKIP TO 808)

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

YES 1
NO 2
DON'T KNOW 8

808) Do you currently smoke cigarettes?

YES 1
NO 2- (SKIP TO 810)

809) In the last 24 hours, how many cigarettes did you smoke?

NUMBER OF CIGARETTES_________

810) Do you currently smoke or use any (other) type of tobacco?

YES 1
NO 2- (SKIP TO 812)

811) What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.

PIPE A
CHEWING TOBACCO B
SNUFF C
OTHER________ (SPECIFY) X

812) Are you covered by any health insurance?

YES 1
NO 2- (SKIP TO 814)

813) What type of health insurance are you covered by?
RECORD ALL MENTIONED

MUTUAL HEALTH ORGANIZATION/COMMUNITY-BASED HEALTH INSURANCE A
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
OTHER__________ (SPECIFY) X

814) Have you ever heard of female circumcision?

YES 1- (SKIP TO 816)
NO 2

815) In some countries, there is a practice in which a girl may have part of her genitals cut. Have you ever heard about this practice?

YES 1
NO 2- (SKIP TO 818)

816) Do you believe that female circumcision is required by your religion?

YES 1
NO 2
DON'T KNOW 8

817) Do you think that female circumcision should be continued, or should it be stopped?

CONTINUED 1
STOPPED 2
DEPENDS 3
DON'T KNOW 8

818) RECORD THE TIME

HOUR_________
MINUTES_________

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________________