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DEMOGRAPHIC AND HEALTH SURVEY
EDSC-III 2004
WOMAN'S QUESTIONNAIRE

MINISTRY OF ECONOMIC AFFAIRS, PROGRAMMING, AND TERRITORIAL DEVELOPMENT
NATIONAL STATISTICS INSTITUTE
REPUBLIC OF CAMEROON
PEACE-WORK-COUNTRY

IDENTIFICATION

PROVINCE ___
PROVINCE ___
DEPARTMENT ___
LAYER ___
DISTRICT ___
DISTRICT ___

CITY/TOWNSHIP/GROUP ___

YAOUNDE/DOUALA 1
GAROUA/MAROUA/BAFOUSSAM/BAMENDA 2
OTHER CITIES 3
RURAL 4

VILLAGE CLUSTER ___
NEIGHBORHOOD/PLACE STRUCTURE ___

NAME OF HEAD OF HOUSEHOLD ___
HOUSEHOLD ___

WOMAN'S NAME ___
WOMAN'S LINE NUMBER ___

CHECK COVER OF HOUSEHOLD QUESTIONNAIRE: WAS THE HOUSEHOLD SELECTED FOR THE QUESTIONS ON FEMALE GENITAL CUTTING/HIV TEST AND ANEMIA/ANTHROPOMETRY?

YES 1
NO 2

CHECK COVER OF HOUSEHOLD QUESTIONNAIRE: WAS THE HOUSEHOLD SELECTED FOR QUESTIONS ON "HOUSEHOLD RELATIONSHIPS"?

IF YES, CHECK SCHEDULE 35A FOR THE SELECTION OF ELIGIBLE WOMEN FOR THE SECTION OF "HOUSEHOLD RELATIONSHIPS." WAS THE WOMAN WHO YOU ARE SURVEYING SELECTED?

YES 1
NO 2

INTERVIEWER VISITS

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
INTERVIEWER NAME___

RESULTS:

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY): ___

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__

TOTAL NUMBER OF VISITS____

FRENCH QUESTIONNAIRE 1

LANGUAGE OF THE INTERVIEW

1 FRENCH
2 ENGLISH
3 FUFULDE
4 EWONDO
5 PIDGIN
6 OTHER

INTERPRETER:

YES 1
NO 2

SUPERVISOR
NAME: ___
DATE: ___

FIELD EDITOR
NAME: ___
DATE: ___

OFFICE EDITOR ___
KEYED BY ___

SECTION 1. RESPONDENT'S BACKGROUND

INFORMED CONSENT

Hello. My name is ____ and I work with the National Institute of Statistics. In collaboration with the Ministry of Public Health, 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?

May I begin the interview now?

SIGNATURE OF INTERVIEWER ____
DATE ____

RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END SURVEY)

101) RECORD THE TIME.

HOUR: ___
MINUTES: ___

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 Yaounde/Douala, in Garoua/Maroua/Bafoussam/Bamenda, in another city, in a rural location, or abroad?

IF ABROAD, SPECIFY THE PLACE OF RESIDENCE.

YAOUNDE/DOUALA/OTHER CAPITAL 1
GAROUA/MAROUA/BAFOUSSAM/BAMENDA/LARGE CITY ABROAD 2
OTHER CITY/SMALL CITY ABROAD 3
RURAL/RURAL LOCATION ABROAD 4
UNSPECIFIED ABROAD 5

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

IF LESS THAN ONE YEAR, RECORD '00' YEARS.

YEARS: ___
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)

104) Just before you moved here, did you live in Yaounde/Douala, in Garoua/Maroua/Bafoussam/Bamenda, in another city, in a rural location, or abroad?

IF "ABROAD", SPECIFY THE PLACE OF RESIDENCE.

YAOUNDE/DOUALA/OTHER CAPITAL 1
GAROUA/MAROUA/BAFOUSSAM/BAMENDA/LARGE CITY ABROAD 2
OTHER CITY/SMALL CITY ABROAD 3
RURAL/RURAL LOCATION ABROAD 4
UNSPECIFIED ABROAD 5

105) In what month and year were you born?

MONTH: ___
DK MONTH 98
YEAR: ___
DK YEAR 9998

106) How old were you at your last birthday?

COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

AGE: ___

IF LESS THAN 15 OR GREATER THAN 49, END INTERVIEW.

107) Have you ever attended school?

YES 1
NO 2 (GO TO 111)

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

PRIMARY 1
SECONDARY 2
HIGHER 3

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

PRIMARY
LESS THAN ONE YEAR 0
INFANT/CLASS ONE/SIL 1
STANDARD ONE/CLASS TWO/CP 2
STANDARD TWO/CLASS THREE/CE1 3
STANDARD THREE/CLASS FOUR/CE2 4
STANDARD FOUR/CLASS FIVE/CM1 5
STANDARD FIVE/CLASS SIX/CM2 6
STANDARD SIX/CLASS SEVEN 7
DK 8
SECONDARY
LESS THAN ONE YEAR 0
FORM 1/SIXTH/1ST YEAR 1
FORM 2/FIFTH/2ND YEAR 2
FORM 3/FOURTH/3RD YEAR 3
FORM 4/THIRD/4TH YEAR 4
FORM 5/SECOND 5
LOWER SIXTH FORM/FIRST 6
UPPER SIXTH FORM/FINAL 7
DK 8
HIGHER
LESS THAN ONE YEAR 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH+ YEAR 4
DK 8

110) CHECK 109:

PRIMARY: __
SECONDARY OR HIGHER: __ (GO TO 114)

111) Now I would like you to read aloud this sentence 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?

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

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

YES 1
NO 2

113) CHECK 111:

CODE '2', '3', OR '4' CIRCLED: ___
CODE '1' OR '5' CIRCLED: ___ (GO TO 115)

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?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

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

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

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

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

117) What is your religion?

CATHOLIC 1
PROTESTANT 2
MUSLIM 3
ANIMIST 4
OTHER (SPECIFY): ___ 6
NONE 7

118) What is your ethnicity?

WRITE DOWN THE NAME OF THE ETHNICITY. LEAVE THE CODE SPACE EMPTY. FOR FOREIGNERS, MARK '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?

YES 1
NO 2 (GO TO 206)

202) Do you have any sons or daughters to whom you have given birth who are now living with you?

YES 1
NO 2 (GO TO 204)

203) How many sons live with you?
How many daughters live with you?

IF NONE, RECORD '00'.

SONS AT HOME: ___
DAUGHTERS AT HOME: ___

204) Do you have any sons or daughters to whom you have given birth who are alive but do not live with you?

YES 1
NO 2 (GO TO 206)

205) How many sons are alive but do not live with you?
How many daughters are alive but do not live with you?

IF NONE, RECORD '00'.

SONS ELSEWHERE: ___
DAUGHTERS ELSEWHERE: ___

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 of life but did not survive?

YES 1
NO 2 (GO TO 208)

207) How many boys have died?
How many girls have died?

IF NONE, RECORD '00'.

BOYS DECEASED: ___
GIRLS DECEASED: ___

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

YES 1
NO 2 (GO TO 208)

207B) CORRECT QUESTION 207 AND CONTINUE TO QUESTION 208.

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

IF NONE, RECORD '00'.

TOTAL: ___

209) CHECK 208:

Just to makes sure that I have this right: you have had in total ____births during your life. Is that correct?

YES: ___
NO: ___ (PROBE AND CORRECT 201-208 AS NECESSARY)

210) CHECK 208:

ONE OR MORE BIRTHS: ___
NO BIRTHS: ___ (GO TO 226)

211) Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.

RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.

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

NAME: ___

213) Were any of these births twins?

SINGLE 1
MULTIPLE 2

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

BOY 1
GIRL 2

215) In what month and year was (NAME) born?

PROBE: What is his/her birthday?

MONTH: ___
YEAR: ___

216) Is (NAME) still alive?

YES 1
NO 2 (GO TO 220)

217) IF ALIVE: How old was (NAME) at his/her last birthday?

RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS: ___

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

YES 1
NO 2

219) IF ALIVE: RECORD HOUSEHOLD LINE NUMBER OF CHILD. RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD.

LINE NUMBER: ___ (GO TO NEXT BIRTH FOR FIRST CHILD, GO TO 221 FOR ALL OTHERS)

220) IF DECEASED: How old was (NAME) when he/she died?

IF 1 YEAR, PROBE: How many months old was (NAME)?

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

DAYS: ___ 1
MONTHS: ___ 2
YEARS: ___ 3

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

YES 1
NO 2

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

YES 1 (ADD BIRTH TO 212)
NO 2

223) COMPARE WITH 208 NUMBER OF BIRTHS IN THE TABLE ABOVE AND
MARK:

NUMBERS ARE SAME: ___
CHECK:
FOR EACH BIRTH: THE YEAR OF BIRTH IS RECORDED.
FOR EACH LIVING CHILD: THE CURRENT AGE IS RECORDED.
FOR EACH DECEASED CHILD: THE AGE AT DEATH IS RECORDED.
FOR AGE AT DEATH 12 MONTHS OR 1 YEAR: PROBE TO DETERMINE EXACT NUMBER OF MONTHS.
NUMBERS ARE DIFFERENT: ___ (PROBE AND RECONCILE)

224) CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE 1999 OR LATER. IF NONE, RECORD '0'.

___

226) Are you pregnant now?

YES 1
NO 2 (GO TO 228A)
NOT SURE 8 (GO TO 228A)

227) How many months pregnant are you?

RECORD NUMBER OF COMPLETED MONTHS.

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?

THEN 1
LATER 2
NOT AT ALL 3

228A) Have you had a pregnancy that did not end in a live birth?

YES 1
NO 2 (GO TO 237)

228B) How many pregnancies have you had that did not end in a live birth?

NUMBER OF PREGNANCIES: ___

228C) Among these pregnancies, how many ended in:

An abortion?
A miscarriage?
A stillbirth?

ABORTION: ___
MISCARRIAGE: ___
STILLBIRTH: ___

230) When did the last such pregnancy end?

MONTH: ___
YEAR: ___

237) When did your last menstrual cycle start?

MARK THE RESPONSE IN THE UNITS OF TIME GIVEN BY THE WOMAN BEING INTERVIEWED.

DATE, IF GIVEN: ___
DAYS AGO: ___ 1
WEEKS AGO: ___ 2
MONTHS AGO: ___ 3
YEARS AGO: ___ 4
IN MENOPAUSE/HAS HAD HYSTERECTOMY 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

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

YES 1
NO 2 (GO TO 240)
DON'T KNOW 8 (GO TO 240)

239) 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 HAD ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY): ___ 6
DON'T KNOW 8

SECTION 3. FAMILY PLANNING

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 PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY.

CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.

301) Which ways or methods have you heard about?

FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you heard of (METHOD)?

01. Female Sterilization: Women can have an operation to avoid having any more children.
YES 1
NO 2
02. Male Sterilization: Men can have an operation to avoid having any more children.
YES 1
NO 2
03. Pill: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
04. IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
05. Injectables: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2
06. Implants: Women can have several 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
07. Condom: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
08. Female condom: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2
09. Diaphragm: Women can place a thin flexible disk in their vagina before intercourse.
YES 1
NO 2
10. Foam or jelly: Women can place a suppository, jelly, or cream in their vagina before intercourse.
YES 1
NO 2
11. Lactational amenorrhea method (LAM): Up to 6 months after childbirth, a woman can use a method that requires that she breastfeeds frequently, day and night, and that her menstrual period has not returned.
YES 1
NO 2
12. Rhythm or Periodic abstinence (cervical mucus): Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
13. Withdrawal: Men can be careful and pull out before climax.
YES 1
NO 2
14. Emergency contraception: Women can take pills up to three days after sexual intercourse to avoid becoming pregnant.
YES 1
NO 2
15. Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES (SPECIFY): ___ 1
NO 2

302) Have you ever used (METHOD)?

01. Have you ever had an operation to avoid having any more children?
YES 1
NO 2
02. Have you ever had a partner who had an operation to avoid having any more children?
YES 1
NO 2
03. Pill: Women can take a pill every day to avoid becoming pregnant
YES 1
NO 2
04. IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
05. Injectables: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2
06. Implants: Women can have several 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
07. Condom: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
08. Female condom: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2
09. Diaphragm: Women can place a thin flexible disk in their vagina before intercourse.
YES 1
NO 2
10. Foam or jelly: Women can place a suppository, jelly, or cream in their vagina before intercourse.
YES 1
NO 2
11. Lactational amenorrhea method (LAM): Up to 6 months after childbirth, a woman can use a method that requires that she breastfeeds frequently, day and night, and that her menstrual period has not returned.
YES 1
NO 2
12. Rhythm or Periodic abstinence (cervical mucus): Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
13. Withdrawal: Men can be careful and pull out before climax.
YES 1
NO 2
14. Emergency contraception: Women can take pills up to three days after sexual intercourse to avoid becoming pregnant.
YES 1
NO 2
15. Have you used any other ways or methods that women or men can use to avoid pregnancy?
YES 1
NO 2

303) CHECK 302:

NOT A SINGLE YES (NEVER USED): ___
AT LEAST ONE YES (EVER USED): ___ (GO TO 307)

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

YES 1
NO 2 (GO TO 329)

306) What have you used or done?

CORRECT 302, 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'.

NUMBER OF CHILDREN: ___

308) CHECK 302 (01):

WOMAN NOT STERILIZED: ___
WOMAN STERILIZED: ___ (GO TO 311A)

309) CHECK 226:

NOT PREGNANT OR UNSURE: ___
PREGNANT: ___ (GO TO 329)

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

YES 1
NO 2 (GO TO 329)

311) Which method are you using?

311A) CIRCLE 'A' FOR FEMALE STERILIZATION. IF MORE THAN ONE METHOD MENTIONED, FOLLOW (GO TO) INSTRUCTION FOR HIGHEST METHOD ON LIST.

FEMALE STERILIZATION A
MALE STERILIZATION B
PILL C (GO TO 316A)
IUD D (GO TO 316A)
INJECTABLES E (GO TO 316A)
IMPLANTS F (GO TO 316A)
CONDOM G (GO TO 316A)
FEMALE CONDOM H (GO TO 316A)
DIAPHRAGM I (GO TO 316A)
FOAM/JELLY J (GO TO 316A)
LACTATIONAL AMEN. METHOD K (GO TO 316A)
PERIODIC ABSTINENCE L (GO TO 316A)
WITHDRAWAL M (GO TO 316A)
OTHER (SPECIFY): ___ X (GO TO 316A)

313) In what facility did the sterilization take place?

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

NAME OF PLACE: ___
PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
OTHER PUBLIC (SPECIFY): ___ 16
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL 21
SECULAR HOSPITAL/CLINIC 22
HEALTH CENTER/RELIGIOUS CLINIC/MISSION 23
OTHER PRIVATE MEDICAL (SPECIFY): ___ 26
OTHER (SPECIFY): ___ 96
DON'T KNOW 98

314) CHECK 311:

CODE 'A' CIRCLED: Before your sterilization operation, were you told that you would not be able to have any (more) children because of the operation?

CODE 'B' CIRCLED: Before the sterilization operation, was your husband/partner told that he would not be able to have any (more) children because of the operation?

YES 1
NO 2
DON'T KNOW 8

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

316A) For how long have you been using, (CURRENT METHOD FIRST MENTIONED IN 311) now without stopping?

PROBE: In what month and year did you start using (CURRENT METHOD FIRST MENTIONED IN 311) continuously?

MONTH: ___
YEAR: ___

316B) CHECK 315A, 316, 215, AND 230:

WAS THERE WAS A BIRTH IN 215 OR A PREGNANCY IN 230 THAT ENDED IN A MISCARRIAGE, AN ABORTION, OR A STILLBIRTH BEFORE THE MONTH AND THE YEAR OF THE START OF THE USE OF CONTRACEPTION BASED ON 316/316A?

YES: ___ (GO TO 316/316A TO CORRECT, PROBE TO RECORD THE MONTH AND THE YEAR OF THE START OF THE CONTINUED USED OF THE CURRENT METHOD. DATE MUST BE AFTER THAT OF THE LAST BIRTH OR THE LAST PREGNANCY)

NO: ___

317) CHECK 316/316A:

YEAR IS 1999 OR LATER: ___
YEAR IS 1998 OR BEFORE: ___ (GO TO 327)

319) CHECK 311/311A:

CIRCLE THE METHOD CODE:

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

FEMALE STERILIZATION 01 (GO TO 322)
MALE STERILIZATION 02 (GO TO 331)
PILL 03
IUD/INTRAUTERINE DEVICE 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 320A)
PERIODIC ABSTINENCE 12 (GO TO 331)
WITHDRAWAL 13 (GO TO 331)
OTHER METHOD 96 (GO TO 331)

320) Where did you obtain (CURRENT METHOD) when you started using it?

320A) Where did you learn to use the lactational amenorrhea method?

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

NAME OF PLACE: ___
PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
OTHER PUBLIC (SPECIFY): ___ 16
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL 21
SECULAR HOSPITAL/CLINIC 22
HEALTH CENTER/RELIGIOUS CLINIC/MISSION 23
DOCTOR'S OFFICE (SPECIFY): ___ 24
PHARMACY 25
OTHER PRIVATE MEDICAL (SPECIFY): ___ 26
OTHER PRIVATE SECTOR
SHOP/MARKET 31
BAR/NIGHTCLUB 32
KIOSK 33
INFORMAL COMMERCIAL DISTRIBUTION 34
RELATIVES/FRIENDS 35
OTHER (SPECIFY): ___ 96

321) CHECK 311/311A:

CIRCLE METHOD CODE:

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

PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07 (GO TO 328)
FEMALE CONDOM 08 (GO TO 325)
DIAPHRAGM 09 (GO TO 325)
FOAM/JELLY 10 (GO TO 325)
LACTATIONAL AMEN. METHOD 11 (GO TO 325)

322) You obtained (CURRENT METHOD FROM 319) from (SOURCE OF METHOD FROM 313 OR 320).

At that time, where you told about side effects or problems you might have with the method?

YES 1 (GO TO 324)
NO 2

323) Has a health worker or family planning worker ever told you about side effects or problems you might have with the method?

YES 1
NO 2 (GO TO 325)

324) Were you told what to do if you experienced side effects or problems?

YES 1
NO 2

325) CHECK 322:

CODE 1 CIRCLED: At that time, were you told about other methods of family planning that you could use?

CODE 1 NOT CIRCLED: When you obtained (CURRENT METHOD) from (SOURCE OF METHOD FROM 313 OR 320), were you told about other methods of family planning that you could use?

YES 1 (GO TO 327)
NO 2

326) Did a health worker or family planning worker ever tell you about other methods of family planning that you could use?

YES 1
NO 2

327) CHECK 311/311A:

CIRCLE METHOD CODE.

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

FEMALE STERILIZATION 01 (GO TO 331)
MALE STERILIZATION 02 (GO TO 331)
PILL 03
IUD/INTRAUTERINE DEVICE 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 331)
PERIODIC ABSTINENCE 12 (GO TO 331)
WITHDRAWAL 13 (GO TO 331)
OTHER METHOD 96 (GO TO 331)

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

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

NAME OF PLACE: ___
PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL 11 (GO TO 331)
HEALTH CENTER 12 (GO TO 331)
OTHER PUBLIC (SPECIFY): ___ 16 (GO TO 331)
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL 21 (GO TO 331)
SECULAR HOSPITAL/CLINIC 22 (GO TO 331)
HEALTH CENTER/RELIGIOUS CLINIC/MISSION 23 (GO TO 331)
DOCTOR'S OFFICE (SPECIFY): ___ 24 (GO TO 331)
PHARMACY 25 (GO TO 331)
OTHER PRIVATE MEDICAL (SPECIFY): ___ 26 (GO TO 331)
OTHER PRIVATE SECTOR
SHOP/MARKET 31 (GO TO 331)
BAR/NIGHTCLUB 32 (GO TO 331)
KIOSK 33 (GO TO 331)
INFORMAL COMMERCIAL DISTRIBUTION 34 (GO TO 331)
RELATIVES/FRIENDS 35 (GO TO 331)
OTHER (SPECIFY): ___ 96 (GO TO 331)

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

YES 1
NO 2 (GO TO 331)

330) Where is this? Another place?

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

NAME OF PLACE: ___
PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
OTHER PUBLIC (SPECIFY): ___ C
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL D
SECULAR HOSPITAL/CLINIC E
HEALTH CENTER/RELIGIOUS CLINIC/MISSION F
DOCTOR'S OFFICE (SPECIFY): ___ G
PHARMACY H
OTHER PRIVATE MEDICAL (SPECIFY): ___ I
OTHER PRIVATE SECTOR
SHOP/MARKET J
BAR/NIGHTCLUB K
KIOSK L
INFORMAL COMMERCIAL DISTRIBUTION M
RELATIVES/FRIENDS N
OTHER (SPECIFY): ___ X

331) In the last 12 months, were you visited by a field worker who talked to you about family planning?

YES 1
NO 2

332) In the last 12 months, have you visited a health facility for care for yourself or your children?

YES 1
NO 2 (GO TO 401)

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

YES 1
NO 2

SECTION 4A. PREGNANCY, POSTNATAL CARE, AND BREASTFEEDING

401) CHECK 224:

ONE OR MORE BIRTHS IN 1999 OR LATER: ___
NO BIRTHS IN 1999 OR LATER: ___ (GO TO 487)

402) ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 1999 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF 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 212:

LAST BIRTH LINE NUMBER: ___
NEXT-TO-LAST-BIRTH LINE NUMBER: ___

404) FROM 212 AND 216:

NAME: ___
LIVING: __
DECEASED: __
NAME: ___
LIVING: __
DECEASED: __

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?

THEN 1 (GO TO 407 FOR LAST BIRTH, FOR 423 FOR OTHER BIRTHS)
LATER 2
NOT AT ALL 3 (GO TO 407 FOR LAST BIRTH, FOR 423 FOR OTHER BIRTHS)

406) How much longer would you have waited?

MONTHS: ___ 1
YEARS: ___ 2
DON'T KNOW 998

407) Did you see anyone for prenatal 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. IF NO ONE, CIRCLE CODE 'Y'.

HEALTH PROFESSIONAL
DOCTOR A
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT D
OTHER (SPECIFY): ___ X
NO ONE Y (GO TO 415)

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

MONTHS: ___
DON'T KNOW 98

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

NUMBER OF TIMES: ___
DON'T KNOW 98

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

ONCE: ___ (GO TO 412)
MORE THAN ONCE OR DON'T KNOW: ___

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

MONTHS: ___
DON'T KNOW 98

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

Were you weighed?
Was your height measured?
Was your blood pressure measured?
Did you give a urine sample?
Did you give a blood sample?
Did you have a vaginal exam?

WEIGHT
YES 1
NO 2
HEIGHT
YES 1
NO 2
BLOOD PRESSURE
YES 1
NO 2
URINE
YES 1
NO 2
BLOOD
YES 1
NO 2
VAGINAL EXAM
YES 1
NO 2

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

YES 1
NO 2 (GO TO 415)
DON'T KNOW 8 (GO TO 415)

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 417)
DON'T KNOW 8 (GO TO 417)

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

NUMBER OF TIMES: ___
DON'T KNOW 8

417) During this pregnancy, were you given or did you buy iron tablets or capsules?
SHOW TABLES OR CAPSULES.

[ASK FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2 (GO TO 419)
DON'T KNOW 8 (GO TO 419)

418) During the whole pregnancy, for how many days did you take the tablets or capsules?
[ASK FOR MOST RECENT BIRTH ONLY]

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

NUMBER OF DAYS: ___
DON'T KNOW 998

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

YES 1
NO 2
DON'T KNOW 8

420) During this pregnancy, did you have difficulty with your vision at nightfall, sunrise, or in poorly light spaces? [ASK FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 423)
DON'T KNOW 8 (GO TO 423)

422) What medication did you take? Other medication?

RECORD ALL MENTIONED. IF TYPE OF MEDICATION IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

(RESPONSE SET FOR MOST RECENT BIRTH)

AMODIAQUINE/FLAVOQUINE/CAMOQUIN A
FANSIDAR/MALOXINE B
CHLOROQUINE/NIVAQUINE C
QUININE/QUINIMAX D
UNKNOWN DRUG E
OTHER (SPECIFY): ___ X

(RESPONSE SET FOR OTHER BIRTHS)

SP/FANSIDAR A
CHLOROQUINE B
OTHER (SPECIFY): ___ X
DON'T KNOW Z

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

CODE 'A' CIRCLED: ___
CODE 'A' NOT CIRCLED: ___ (GO TO 423)

422B) How many times did you take the Amodiaquine/Flavoquine/Camoquin during this pregnancy? [ASK FOR MOST RECENT BIRTH ONLY]

NUMBER OF TIMES: ___

422C) CHECK 407: TYPE OF PERSON THAT GAVE PRENATAL CARE DURING THIS PREGNANCY? [ASK FOR MOST RECENT BIRTH ONLY]

CODE 'A' CIRCLED: ___
OTHER CODE CIRCLED: ___ (GO TO 423)

422D) When you were pregnant with (NAME), did you get Amodiaquine/Flavoquine/Camoquin during a prenatal visit, during a different visit in a health care facility, or from another source?
[ASK FOR MOST RECENT BIRTH ONLY]

PRENATAL VISIT 1
OTHER MEDICAL VISIT 2
OTHER SOURCE (SPECIFY): ___ 6

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

VERY LARGE 1
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON'T KNOW 8

424) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 425A)
DON'T KNOW 8 (GO TO 425A)

425) How much did (NAME) weigh?

RECORD WEIGHT FROM HEALTH CARD, IF AVAILABLE.

GRAMS FROM CARD: ___ 1
GRAMS FROM RECALL: ___ 2
DON'T KNOW 99998

425A) Was the birth of (NAME) declared to the civil state?

YES 1
NO 2
DON'T KNOW 8

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

Anyone else?

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

IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE IF ANY ADULTS WERE PRESENT AT THE DELIVERY.

HEALTH PROFESSIONAL
DOCTOR A
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT D
FRIEND/RELATIVE E
OTHER (SPECIFY): ___ X
NO ONE Y

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

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

NAME OF PLACE: ___
HOME
YOUR HOME 11 (GO TO 429)
OTHER HOME 12 (GO TO 429)
PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL 21
HEALTH CENTER 22
OTHER PUBLIC (SPECIFY): ___ 26
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL 31
SECULAR HOSPITAL/CLINIC 32
HEALTH CENTER/RELIGIOUS CLINIC/MISSION 33
OTHER PRIVATE MEDICAL (SPECIFY): ___ 36
OTHER (SPECIFY): ___ 96 (GO TO 429)

428) Was (NAME) delivered by cesarean section?

YES 1 (GO TO 433)
NO 2 (GO TO 433)

429) After (NAME) was born, did a health professional or a traditional birth attendant check on your health?

YES 1
NO 2 (GO TO 433)

430) How many days or weeks after delivery did the first check take place?
[ASK FOR MOST RECENT BIRTH ONLY]

RECORD '00' DAYS IF SAME DAY.

DAYS AFTER DELIVERY: ___ 1
WEEKS AFTER DELIVERY: ___ 2
DON'T KNOW 998

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

PROBE FOR MOST QUALIFIED PERSON.

HEALTH PROFESSIONAL
DOCTOR 11
NURSE/MIDWIFE 12
AUXILIARY MIDWIFE 13
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
OTHER (SPECIFY): ___ 96

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

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

NAME OF PLACE: ___
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL 21
HEALTH CENTER 22
OTHER PUBLIC (SPECIFY): ___ 26
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL 31
SECULAR HOSPITAL/CLINIC 32
HEALTH CENTER/RELIGIOUS CLINIC/MISSION 33
OTHER PRIVATE MEDICAL (SPECIFY): ___ 36
OTHER (SPECIFY): ___ 96

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

YES 1
NO 2

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

YES 1 (GO TO 436)
NO 2 (GO TO 437)

435) Did your period return between the birth of (NAME) and your next pregnancy?
[ASK FOR ALL BUT MOST RECENT BIRTH]

YES 1
NO 2 (GO TO 439)
MULTIPLE BIRTH (GO TO 440)

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

MONTHS: ___
DON'T KNOW 98

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

NOT PREGNANT: ___
PREGNANT OR UNSURE: ___ (GO TO 439)

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

YES 1
NO 2 (GO TO 440)

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

MONTHS: ___
DON'T KNOW 98 (GO TO 447)

440) Did you ever breastfeed (NAME)?

YES 1
NO 2 (GO TO 447)

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

IF LESS THAN 1 HOUR, RECORD '00' HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS.

IMMEDIATELY 000
HOURS: ___ 1
DAYS: ___ 2

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

YES 1
NO 2 (GO TO 444)

443) What was (NAME) given to drink before your milk began flowing regularly?

Anything else?

RECORD ALL LIQUIDS MENTIONED.

MILK (OTHER THAN BREAST MILK) A
PLAIN WATER B
SUGAR OR GLUCOSE WATER C
GRIPE WATER D
SUGAR-SALT-WATER SOLUTION E
FRUIT JUICE F
INFANT FORMULA G
TEA/INFUSIONS H
HONEY I
OTHER (SPECIFY): ___ X

444) CHECK 404: IS CHILD LIVING?

LIVING: ___
DEAD: ___ (GO TO 446)

445) Are you still breastfeeding (NAME)?

YES 1 (GO TO 448)
NO 2

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

MONTHS: ___
DON'T KNOW 98

447) CHECK 404: IS CHILD LIVING?

LIVING: ___ (GO TO 450)
DECEASED: ___ (GO TO 405 IN NEXT COLUMN. IF NO MORE BIRTHS: GO TO 454)

448) How many times did you breastfeed last night between sunset and sunrise?

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

NUMBER OF NIGHTTIME FEEDINGS: ___

449) How many times did you breastfeed yesterday during the daylight hours?

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

NUMBER OF DAYLIGHT FEEDINGS: ___

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

452) How many times did (NAME) eat solid, semisolid, or soft foods other than liquids yesterday during the day or at night?

IF 7 OR MORE TIMES, RECORD '7'.

NUMBER OF TIMES: ___
DON'T KNOW 8

453) GO BACK TO 405 IN NEXT COLUMN. IF NO MORE BIRTHS: GO TO 454.

SECTION 4B. IMMUNIZATION, HEALTH, AND NUTRITION

454) ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 1999 OR LATER. (IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES).

455) LINE NUMBER FROM 212:

LAST BIRTH NAME: ___
NEXT-TO-LAST BIRTH NAME: ___

456) FROM 212 AND 216:

NAME: ___
LIVING: ___
DECEASED: ___ (GO TO 456 IN NEXT COLUMN. IF NO MORE BIRTHS: GO TO 483)

457) Did (NAME) receive a vitamin A dose like this during the last 6 months?

SHOW CAPSULE.

YES 1
NO 2
DON'T KNOW 8

458) Do you have a card where (NAME'S) vaccinations are written down?

IF YES: May I see it please?

YES, SEEN 1 (GO TO 460)
YES, NOT SEEN 2 (GO TO 462)
NO CARD 3

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

YES 1 (GO TO 462)
NO 2 (GO TO 462)

460)

(1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARE AND THE DATE OF THE MOST RECENT VITAMIN A, ACCORDING TO THE CARD.

(2) WRITE '44' IN THE 'DAY' COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE WAS RECORDED.

BCG
DAY: ___
MONTH: ___
YEAR: ___
POLIO 0 (GIVEN AT BIRTH)
DAY: ___
MONTH: ___
YEAR: ___
POLIO 1
DAY: ___
MONTH: ___
YEAR: ___
POLIO 2
DAY: ___
MONTH: ___
YEAR: ___
POLIO 3
DAY: ___
MONTH: ___
YEAR: ___
DPT 1
DAY: ___
MONTH: ___
YEAR: ___
DPT 2
DAY: ___
MONTH: ___
YEAR: ___
DPT 3
DAY: ___
MONTH: ___
YEAR: ___
MEASLES
DAY: ___
MONTH: ___
YEAR: ___
YELLOW FEVER
DAY: ___
MONTH: ___
YEAR: ___
VITAMIN A (MOST RECENT)
DAY: ___
MONTH: ___
YEAR: ___

461) Has (NAME) received any vaccines 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, DPT 1-3, MEASLES, AND/OR YELLOW FEVER VACCINE(S).

YES 1 (PROBE FOR SPECIFIC VACCINES AND WRITE '66' IN CORRESPONDING 'DAY' COLUMN IN 460, THEN GO TO 466)
NO 2 (GO TO 466)
DON'T KNOW 8 (GO TO 466)

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

YES 1
NO 2 (GO TO 466)
DON'T KNOW 8 (GO TO 466)

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 shoulder that usually causes a scar?
YES 1
NO 2
DON'T KNOW 8
463B. Polio vaccine, that is, drops in the mouth?
YES 1
NO 2 (GO TO 463E)
DON'T KNOW 8 (GO TO 463E)
463C. When was the first polio vaccine received, just after birth or later?
JUST AFTER BIRTH 1
LATER 2
463D. How many times was the polio vaccine received?
NUMBER OF TIMES: ___
463E. A DPT vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops?
YES 1
NO 2 (GO TO 463G)
DON'T KNOW 3 (GO TO 463G)
463F. How many times?
NUMBER OF TIMES: ___
463G. An injection to prevent measles?
YES 1
NO 2
DON'T KNOW 8
463H. An injection to prevent yellow fever?
YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

467) Has (NAME) had an illness with a cough at any time in the last 2 weeks?

YES 1
NO 2 (GO TO 469)
DON'T KNOW 8 (GO TO 469)

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

YES 1
NO 2
DON'T KNOW 8

469) CHECK 466 AND 467: FEVER OR COUGH?

YES IN 466 OR 467: ___
OTHER: ___ (GO TO 475)

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

YES 1
NO 2 (GO TO 472)

471) Where did you seek advice or treatment?

Anywhere else?

RECORD ALL SOURCES MENTIONED.

PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
OTHER PUBLIC (SPECIFY): ___ C
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL D
SECULAR HOSPITAL/CLINIC E
HEALTH CENTER/RELIGIOUS CLINIC/MISSION F
DOCTOR'S OFFICE G
PHARMACY H
OTHER PRIVATE MEDICAL (SPECIFY): ___ I
OTHER PRIVATE SECTOR
SHOP/MARKET J
TRADITIONAL PRACTITIONER K
OTHER (SPECIFY): ___ X

472) CHECK 466: HAD FEVER?

YES IN 466: ___
'NO' OR 'DON'T KNOW' IN 466: ___ (GO TO 475)

472A) Does (NAME) have a fever right now?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES TO 466 OR 472B: ___
OTHER: ___ (GO TO 475)

473) Did (NAME) take any medication for the fever?

YES 1
NO 2 (GO 474A)
DON'T KNOW 8 (GO TO 474A)

474) What medications did (NAME) take?

RECORD ALL MENTIONED. ASK TO SEE DRUG(S) IF TYPE OF DRUG IS NOT KNOWN. IF TYPE OF DRUG IS STILL NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

ANTIMALARIAL DRUGS
AMODIAQUINE/FLAVOQUINE/CAMOQUIN A
FANSIDAR/MALOXINE B
CHLOROQUINE/NIVAQUINE C
QUININE/QUINIMAX D
UNKNOWN DRUG E
OTHER (SPECIFY): ___ F
OTHER DRUGS
ASPIRIN G
PARACETAMOL H
OTHER X
DON'T KNOW Z

474A) Did (NAME) receive any injection or a suppository to treat the fever/convulsions?

INJECTION A
SUPPOSITORY B
NONE Y
DON'T KNOW Z

474B) CHECK 474: AMODIAQUINE/FLAVOQUINE/CAMOQUIN?

CODE 'A' CIRCLED: ___
CODE 'A' NOT CIRCLED: ___ (GO TO 474F)

474C) How long after the fever/convulsions started did (NAME) start taking the Amodiaquine/Flavoquine/Camoquin?

IF MORE THAN 7 DAYS, RECORD '7'.

SAME DAY 1
NEXT DAY 2
2 DAYS AFTER THE FEVER 3
3 OR MORE DAYS AFTER THE FEVER 4
DON'T KNOW 8

474D) How many days in a row did (NAME) take the Amodiaquine/Flavoquine/Camoquin?

IF MORE THAN 7 DAYS, RECORD '7'.

DAYS: ___
DON'T KNOW 8

474E) Do you have Amodiaquine/Flavoquine/Camoquin at home or did you get it from somewhere else?

IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the Amodiaquine/Flavoquine/Camoquin first?

AT HOME 1
OTHER SOURCE 2
DON'T KNOW 8

474F) CHECK 474: FANSIDAR/MALOXINE?

CODE 'B' CIRCLED: ___
CODE 'B' NOT CIRCLED: ___ (GO TO 474J)

474G) How long after the fever/convulsions started did (NAME) start to take the Fansidar/Maloxine?

SAME DAY 1
NEXT DAY 2
2 DAYS AFTER THE FEVER 3
3 OR MORE DAYS AFTER THE FEVER 4
DON'T KNOW 8

474H) How many days did (NAME) take the Amodiaquine Fansidar/Maloxine?

IF MORE THAN 7 DAYS, RECORD '7'.

DAYS: ___
DON'T KNOW 8

474I) Do you have Fansidar/Maloxine at home or did you get it from somewhere else?

IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the Fansidar/Maloxine first?

AT HOME 1
OTHER SOURCE 2
DON'T KNOW 8

474J) CHECK 474: CHLOROQUINE/NIVAQUINE?

CODE 'C' CIRCLED: ___
CODE 'C' NOT CIRCLED: ___ (GO TO 474N)

474K) How long after the fever/convulsions started did (NAME) start to take the Chloroquine/Nivaquine?

SAME DAY 1
NEXT DAY 2
2 DAYS AFTER THE FEVER 3
3 OR MORE DAYS AFTER THE FEVER 4
DON'T KNOW 8

474L) How many days in a row did (NAME) take the Chloroquine/Nivaquine?

IF MORE THAN 7 DAYS, RECORD '7'.

DAYS: ___
DON'T KNOW 8

474M) Do you have Chloroquine/Nivaquine at home or did you get it from somewhere else?

IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the Chloroquine/Nivaquine first ?

AT HOME 1
OTHER SOURCE 2
DON'T KNOW 8

474N) CHECK 474: QUININE/QUINIMAX?

CODE 'D' CIRCLED: ___
CODE 'D' NOT CIRCLED: ___ (GO TO 474R)

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

SAME DAY 1
NEXT DAY 2
2 DAYS AFTER THE FEVER 3
3 OR MORE DAYS AFTER THE FEVER 4
DON'T KNOW 8

474P) How many days in a row did (NAME) take the Quinine/Quinimax?

IF MORE THAN 7 DAYS, RECORD '7'.

DAYS: ___
DON'T KNOW 8

474Q) Do you have Quinine/Quinimax at home or did you get it from somewhere else?

IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the Quinine/Quinimax first?

AT HOME 1
OTHER SOURCE 2
DON'T KNOW 8

474R) Was something else done to treat (NAME'S) fever/convulsions?

YES 1
NO 2 (GO TO 475)
DON'T KNOW 8 (GO TO 475)

474S) What was done for (NAME'S) fever/convulsions?

CONSULTED TRADITIONAL HEALER A
GAVE TEPID SPONGING B
GAVE HERBS C
OTHER (SPECIFY): ___ X

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

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

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8

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

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

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 483)
DON'T KNOW 8 (GO TO 483)

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

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

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8

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

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

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8

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

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

ORS PACKET
YES 1
NO 2
DON'T KNOW 8
LIGHT GRUEL
YES 1
NO 2
DON'T KNOW 8
SOUP
YES 1
NO 2
DON'T KNOW 8
TEA/HERBAL TEA
YES 1
NO 2
DON'T KNOW 8
SUGAR-SALT-WATER SOLUTION
YES 1
NO 2
DON'T KNOW 8
MILK/BABY FORMULA
YES 1
NO 2
DON'T KNOW 8
YOGURT BASED DRINK
YES 1
NO 2
DON'T KNOW 8
WATER
YES 1
NO 2
DON'T KNOW 8
OTHER
YES 1
NO 2
DON'T KNOW 8

479) Was anything else given to treat the diarrhea?

YES 1
NO 2 (GO TO 481)
DON'T KNOW 8 (GO TO 481)

480) What (else) was given to treat the diarrhea?

Anything else?

RECORD ALL TREATMENTS MENTIONED.

PILL OR SYRUP A
INJECTION B
(I.V.) INTRAVENOUS C
HOME REMEDIES/HERBAL MEDICINES D
OTHER (SPECIFY): ___ X

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

YES 1
NO 2 (GO TO 483)

482) Where did you seek advice or treatment?

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

NAME OF PLACE: ___

Anywhere else?

RECORD ALL PLACES MENTIONED.

PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
OTHER PUBLIC (SPECIFY): ___ C
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL D
SECULAR HOSPITAL/CLINIC E
HEALTH CENTER/RELIGIOUS CLINIC/MISSION F
DOCTOR'S OFFICE G
PHARMACY H
OTHER PRIVATE MEDICAL (SPECIFY): ___ I
OTHER PRIVATE SECTOR
SHOP/MARKET J
TRADITIONAL PRACTITIONER K
OTHER (SPECIFY): ___ X

483) GO BACK TO 465 IN NEXT COLUMN. IF NO MORE BIRTHS, GO TO 486.

486) CHECK 478A, ALL COLUMNS:

NO CHILD RECEIVED FLUID FROM ORS PACKET OR QUESTION NOT ASKED: ___
ANY CHILD RECEIVED FLUID FROM ORS PACKET: ___ (GO TO 488)

487) Have you ever heard of a special product called ORS, for example, Orasel, that you can get for the treatment of diarrhea?

YES 1
NO 2

488) CHECK 218:

HAS ONE OR MORE CHILDREN LIVING WITH HER: ___
HAS NO CHILDREN LIVING WITH HER: ___ (GO TO 490)

489) When (your child/one of your children) is seriously ill, can you decide by yourself whether or not the child should be taken for medical treatment?

IF SAYS NO CHILD EVER SERIOUSLY ILL, ASK: If (your child/one of your children) became seriously ill, could you decide by yourself whether the child should be taken for medical treatment?

YES 1
NO 2
DEPENDS 3
NO CHILD UNDER 18 YEARS OLD 4

490) Now I would like to ask you some questions about medical care for you yourself.

Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not?

Not knowing where to go?
Getting permission to go?
Getting money needed for treatment?
The distance to the health facility?
Having to take transport?
Not wanting to go alone?
Concern that there may not be a female health care provider?

WHERE TO GO
BIG PROBLEM 1
NOT A BIG PROBLEM 2
PERMISSION
BIG PROBLEM 1
NOT A BIG PROBLEM 2
MONEY
BIG PROBLEM 1
NOT A BIG PROBLEM 2
DISTANCE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
TRANSPORTATION
BIG PROBLEM 1
NOT A BIG PROBLEM 2
ALONE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
FEMALE HEALTH CARE PROVIDER
BIG PROBLEM 1
NOT A BIG PROBLEM 2

491) CHECK 215 AND 218:

HAS AT LEAST ONE CHILD BEFORE IN 2001 OR LATER AND LIVING WITH HER: ___ RECORD NAME OF YOUNGEST CHILD LIVING WITH HER:

NAME: ___ (GO TO 492)

DOES NOT HAVING ANY CHILDREN BORN IN 2001 OR LATER AND LIVING WITH HER: ___ (GO TO 494)

492) Now I would like to ask you about liquids (NAME IN QUESTION 491) drank over the last seven days, including yesterday.

How many days during the last seven days did (NAME IN QUESTION 491) drink each of the following?

FOR EACH ITEM GIVEN AT LEAST ONCE IN LAST SEVEN DAYS, BEFORE PROCEEDING TO THE NEXT ITEM, ASK:

In total, how many times yesterday during the day or at night did (NAME IN QUESTION 491) drink (ITEM)?

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

a. Plain water?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
b. Baby formula, for example, Cerelac, or soybean flour?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
c. Any other milk such as tinned, powdered, or fresh animal milk?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
d. Fruit juice?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
e. Any other liquids such a sugar water, tea, coffee, or carbonated drinks?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
f. Soup broth?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
g. Any other type of liquid?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___

493) Now I would like to ask you about the types of foods (NAME IN QUESTION 491) ate over the last seven days, including yesterday.

How many days during the last seven days did (NAME IN QUESTION 491) eat each of the following foods either separately or combined with other food?

FOR EACH ITEM GIVEN AT LEAST ONCE IN THE LAST SEVEN DAYS, BEFORE PROCEEDING TO THE NEXT ITEM, ASK:

In total, how many times yesterday during the day or at night did (NAME IN QUESTION 491) eat (ITEM)?

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

a. Any food made from grains (e.g. millet, sorghum, maize, rice, wheat, or other local grains), as a gruel, a paste, a ball, a bread, or yellow or red sweet potatoes?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
b. Red or yellow (melon) squash/gourd, carrots, or yams.
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
c. Any other food made from roots or tubers (e.g. white potatoes, white yams manioc, cocoyam, taro, or other local roots/tubers)?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
d. Any green leafy vegetable? (for example, spinach)?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
e. Mango, papaya, (or any local fruits rich in vitamin A)?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
f. Any other fruits and vegetables (e.g. bananas, plantains, apples, applesauce, green beans, avocado, tomatoes)?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
g. Meat, poultry, fish, shellfish, eggs, termites, or animals from the bush, like wild game?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
h. Grasshoppers, snails, eels, termites, or snakes?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
i. Pulses and legumes like soybeans, peanuts, sesame, peas, or beans?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
j. Cheese or yoghurt?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
k. Any food made with oil, fat, or butter (for example, palm/peanut/soybean/cotton/corn oil)?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___
l. Any other type of solid or semi-solid food?
NUMBER OF DAYS IN LAST 7 DAYS: ___
NUMBER OF TIMES YESTERDAY/LAST NIGHT: ___

494) Did you sleep under a bednet last night?

YES 1
NO 2

494A) When did you last wash your hands with soap/ash?

Any other time?

CIRCLE ALL RESPONSES MENTIONED SPONTANEOUSLY. DO NOT SUGGEST ANY RESPONSES TO THE RESPONDENT.

NEVER A
BEFORE PREPARING FOOD B
BEFORE FEEDING CHILDREN C
AFTER TOILET D
AFTER HELPING CHILDREN WITH TOILET E
OTHER X

496) Do you currently smoke cigarettes or use tobacco?

IF YES: What type of tobacco do you smoke or use? Anything else?

RECORD ALL TYPES MENTIONED.

YES, CIGARETTES A
YES, PIPE B
YES, OTHER TOBACCO C
NO Y

497) CHECK 496:

CODE 'A' CIRCLED: ___
CODE 'A' NOT CIRCLED: ___ (GO TO 498A)

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

CIGARETTES: ___

498A) Did you receive any type of injection over the last three months?

YES 1
NO 2 (GO TO 498C)

498B) How many times did you receive an injection over the last three months?

NUMBER OF INJECTIONS: ___

498C) Did you have a blood transfusion at any time in your life?

YES 1
NO 2 (GO TO 501)

498D) How many times did you get a blood transfusion in the last five years?

NUMBER OF TRANSFUSIONS: ___

SECTION 5. MARRIAGE AND SEXUAL ACTIVITY

501) Are you currently married or living with a man as husband and wife?

YES, CURRENTLY MARRIED 1 (GO TO 505)
YES, LIVING WITH A MAN 2 (GO TO 505)
NO, NOT IN UNION 3

502) Have you ever been married or lived with a man as husband and wife?

YES, FORMERLY MARRIED 1
YES, LIVED WITH A MAN 2 (GO TO 510)
NO 3 (GO TO 514)

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

WIDOWED 1 (GO TO 510)
DIVORCED 2 (GO TO 510)
SEPARATED 3 (GO TO 510)

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

LIVING WITH HER 1
STAYING ELSEWHERE 2

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

NAME: ___
LINE NUMBER: ___

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

YES 1
NO 2 (GO TO 510)

508) How many other wives does he have?

NUMBER: ___
DON'T KNOW 98 (GO TO 510)

509) Are you the first, second…wife?

RANK: ___

510) Have you been married or lived with a man as husband and wife only once, or more than once?

ONLY ONCE 1
MORE THAN ONCE 2

511) CHECK 510:

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

MARRIED/LIVED WITH A MAN MORE THAN ONCE: Now we will talk about your first husband/partner. In what month and year did you start living with him?

MONTH: ___
DON'T KNOW MONTH 98
YEAR: ___ (GO TO 514)
DON'T KNOW YEAR 9998

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

AGE: ___

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

NEVER 00 (GO TO 524)
AGE IN YEARS: ___
FIRST TIME WAS WHEN STARTED LIVING WITH FIRST HUSBAND/PARTNER 95

514A) CHECK 106:

AGE 15-24: ___
AGE 24-49: ___ (GO TO 515)

514B) Was a condom used the first time you had sexual intercourse?

YES 1
NO 2
DON'T KNOW/DON'T REMEMBER 8

515) When was the last time you had sexual intercourse?

RECORD 'YEARS AGO' ONLY IF LAST INTERCOURSE WAS ONE OR MORE YEARS AGO. IF 12 MONTHS OR MORE, ANSWER MUST BE RECORDED IN YEARS.

DAYS AGO: ___ 1
WEEKS AGO: ___ 2
MONTHS AGO: ___ 3
YEARS AGO: ___ 4 (GO TO 523A)

516) The last time you had sexual intercourse, was a condom used?

YES 1
NO 2

517) What is your relationship to the man with whom you last had sex?

IF MAN IS 'BOYFRIEND' OR 'FIANCÉ', ASK: Was your boyfriend/fiancé living with you when you last had sex?

IF YES, CIRCLE '01'.
IF NO, CIRCLE '02'.

SPOUSE/COHABITATING PARTNER 01 (GO TO 518D)
MAN IS BOYFRIEND/FIANCÉ 02
OTHER FRIEND 03
CASUAL ACQUAINTANCE 04
RELATIVE 05
CLIENT (COMMERCIAL SEX WORKER) 06
OTHER (SPECIFY): ___ 96

518) For how long have you been having sexual intercourse with this man?

IF SHE HAD SEXUAL INTERCOURSE WITH THIS MAN ONLY ONCE, RECORD '01' DAYS. IF 12 MONTHS OR MORE, THE ANSWER SHOULD BE RECORDED IN YEARS.

DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
YEARS: ___ 4

518A) CHECK 106:

AGE 15-24: ___
AGE 25-49: ___ (GO TO 518D)

518B) How old is this man?

COMPLETED YEARS: ___ (GO TO 518D)
DON'T KNOW 98

518C) Do you think he's more than 10 years older than you?

YES, 10 YEARS OR OLDER 1
NO, LESS THAN 10 YEARS OLDER 2
OLDER, BUT DON'T KNOW THE DIFFERENCE 3
YOUNGER THAN WOMAN 4
DON'T KNOW 8

518D) Did either you or your partner drink alcohol the last time you had sexual intercourse?

IF YES: Who drank?

RESPONDENT ONLY 1
PARTNER ONLY 2
RESPONDENT AND PARTNER 3
NO 4

519) Have you had sex with any other man in the last 12 months?

YES 1
NO 2 (GO TO 523A)

520) The last time you had sexual intercourse with another man, was a condom used?

YES 1
NO 2

521) What is your relationship to this man?

IF MAN IS 'BOYFRIEND' OR 'FIANCÉ', ASK: Was your boyfriend/fiancé living with you when you last had sex?

IF YES, CIRCLE '01'.
IF NO, CIRCLE '02'

SPOUSE/COHABITATING PARTNER 01 (GO TO 522D)
MAN IS BOYFRIEND/FIANCÉ 02
OTHER FRIEND 03
CASUAL ACQUAINTANCE 04
RELATIVE 05
COMMERCIAL SEX WORKER 06
OTHER (SPECIFY): ___ 96

522) How long have you or did you have sexual intercourse with this man?

IF SHE HAD SEXUAL INTERCOURSE WITH THIS MAN ONLY ONCE, RECORD '01' DAYS.
IF 12 MONTHS OR MORE, THE ANSWER SHOULD BE RECORDED IN YEARS.

DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
YEARS: ___ 4

522A) CHECK 106:

AGE 15-24: ___
AGE 25-49: ___ (GO TO 522D)

522B) How old is this man?

COMPLETED YEARS: ___ (GO TO 522D)
DON'T KNOW 98

522C) Do you think he's more than 10 years older than you?

YES, 10 YEARS OR OLDER 1
NO, LESS THAN 10 YEARS OLDER 2
OLDER, BUT DON'T KNOW THE DIFFERENCE 3
YOUNGER THAN WOMAN 4
DON'T KNOW 8

522D) Did either you or your partner drink alcohol the last time you had sexual intercourse?

IF YES: Who drank?

RESPONDENT ONLY 1
PARTNER ONLY 2
RESPONDENT AND PARTNER 3
NO 4

522E) Other than these two partners, have you had sex with any other man in the last 12 months?

YES 1
NO 2 (GO TO 523A)

522F) The last time you had sexual intercourse with another man, was a condom used?

YES 1
NO 2

522G) What is your relationship to this man?

IF MAN IS 'BOYFRIEND' OR 'FIANCÉ', ASK: Was your boyfriend/fiancé living with you when you last had sex?

IF YES, CIRCLE '01'.
IF NO, CIRCLE '02'.

SPOUSE/COHABITATING PARTNER 01 (GO TO 522L)
MAN IS BOYFRIEND/FIANCÉ 02
OTHER FRIEND 03
CASUAL ACQUAINTANCE 04
RELATIVE 05
CLIENT (COMMERCIAL SEX WORKER) 06
OTHER (SPECIFY): ___ 96

522H) For how long had you been having sexual intercourse with this man?

IF SHE HAD SEXUAL INTERCOURSE WITH THIS MAN ONLY ONCE, RECORD '01' DAYS.
IF 12 MONTHS OR MORE, THE ANSWER SHOULD BE RECORDED IN YEARS.

DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
YEARS: ___ 4

522I) CHECK 106:

AGE 15-24: ___
AGE 25-49: ___(GO TO 522L)

522J) How old is this man?

COMPLETED YEARS: ___ (GO TO 522L)
DON'T KNOW 98

522K) Do you think he's more than 10 years older than you?

YES, 10 YEARS OR OLDER 1
NO, LESS THAN 10 YEARS OLDER 2
OLDER, BUT DON'T KNOW THE DIFFERENCE 3
YOUNGER THAN WOMAN 4
DON'T KNOW 8

522L) Did either you or your partner drink alcohol the last time you had sexual intercourse?

IF YES: Who drank?

RESPONDENT ONLY 1
PARTNER ONLY 2
RESPONDENT AND PARTNER 3
NO 4

523) In total, with how many different men have you had sex in the last 12 months?

NUMBER OF PARTNERS: ___

523A) In total, with how many different men have you had sex in your life?

PROBE TO GET AN EXACT NUMBER.
IF THE NUMBER IF MORE THAN 95, RECORD '95'.

NUMBER OF PARTNERS: ___

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

YES 1
NO 2 (GO TO 601)

525) Where is that?

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

Any other place?

RECORD ALL PLACES MENTIONED.

NAME OF PLACE: ___
PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
OTHER PUBLIC (SPECIFY): ___ C
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL D
SECULAR HOSPITAL/CLINIC E
HEALTH CENTER/RELIGIOUS CLINIC/MISSION F
DOCTOR'S OFFICE G
PHARMACY H
OTHER PRIVATE MEDICAL (SPECIFY): ___ I
OTHER PRIVATE SECTOR
SHOP/MARKET J
BAR/NIGHTCLUB K
KIOSK L
INFORMAL COMMERCIAL DISTRIBUTION M
RELATIVES/FRIENDS N
PARTNER HAD CONDOM O
OTHER (SPECIFY): ___ X

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

YES 1
NO 2
DON'T KNOW 8

SECTION 6. FERTILITY PREFERENCES

601) CHECK 311/311A:

NEITHER STERILIZED: ___
HE OR SHE STERILIZED: ___ (GO TO 614)

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 not 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?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 604)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 614)
UNDECIDED/DON'T KNOW AND PREGNANT 4 (GO TO 610)
UNDECIDED/DON'T KNOW AND NOT PREGNANT OR UNSURE 5 (GO TO 608)

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?

MONTHS: ___ 1
YEARS: ___ 2
SOON/NOW 993 (GO TO 609)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 614)
AFTER MARRIAGE 995 (GO TO 609)
OTHER (SPECIFY): ___ 996 (GO TO 609)
DON'T KNOW 998 (GO TO 609)

604) CHECK 226:

NOT PREGNANT OR UNSURE: ___
PREGNANT: ___ (GO TO 610)

605) CHECK 310: USING A CONTRACEPTIVE METHOD?

NOT ASKED: ___
NOT CURRENTLY USING: ___
CURRENTLY USING: ___ (GO TO 608)

606) CHECK 603:

NOT ASKED: ___
24 OR MORE MONTHS OR 2 OR MORE YEARS: ___
00-23 MONTHS OR 00-01 YEARS: ___ (GO TO 610)

607) CHECK 602:

WANTS TO HAVE A/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?

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?

Any other reason?

RECORD ALL REASONS MENTIONED

NOT MARRIED A
FERTILITY RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
SUBFECUND/INFECUND E
POSTPARTUM AMENORRHEA F
BREASTFEEDING G
FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND/PARTNER OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
HEALTH CONCERNS O
FEAR OF SIDE EFFECTS P
LACK OF ACCESS/TOO FAR Q
COSTS TOO MUCH R
INCONVENIENT TO USE S
INTERFERES WITH BODY'S NORMAL PROCESSES T
OTHER (SPECIFY): ___ X
DON'T KNOW Z

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?

BIG PROBLEM 1
SMALL PROBLEM 2
NO PROBLEM 3
SAYS SHE CAN'T GET PREGNANT/NOT HAVING SEX 4

609) CHECK 310: USING A CONTRACEPTIVE METHOD?

NOT ASKED: ___
NO, NOT CURRENTLY USING: ___
YES, CURRENTLY USING: ___ (GO TO 614)

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

YES 1
NO 2 (GO TO 612)
DON'T KNOW 8 (GO TO 612)

611) Which contraceptive method would you prefer to use?

FEMALE STERILIZATION 01 (GO TO 614)
MALE STERILIZATION 02 (GO TO 614)
PILL 03 (GO TO 614)
IUD 04 (GO TO 614)
INJECTABLES 05 (GO TO 614)
IMPLANTS 06 (GO TO 614)
CONDOM 07 (GO TO 614)
FEMALE CONDOM 08 (GO TO 614)
DIAPHRAGM 09 (GO TO 614)
FOAM/JELLY 10 (GO TO 614)
LACTATIONAL AMEN. METHOD 11 (GO TO 614)
PERIODIC ABSTINENCE 12 (GO TO 614)
WITHDRAWAL 13 (GO TO 614)
OTHER (SPECIFY): ___ 96 (GO TO 614)
UNSURE 98 (GO TO 614)

612) What is the main reason that you think you will not use a contraceptive method at any time in the future?

NOT MARRIED 11
FERTILITY-RELATED REASONS
INFREQUENT SEX/NO SEX 22 (GO TO 614)
MENOPAUSAL/HYSTERECTOMY 23 (GO TO 614)
SUBFECUND/INFECUND 24 (GO TO 614)
WANTS AS MANY CHILDREN AS POSSIBLE 26 (GO TO 614)
OPPOSITION TO USE
RESPONDENT OPPOSED 31 (GO TO 614)
HUSBAND/PARTNER OPPOSED 32 (GO TO 614)
OTHERS OPPOSED 33 (GO TO 614)
RELIGIOUS PROHIBITION 34 (GO TO 614)
LACK OF KNOWLEDGE
KNOWS NO METHOD 41 (GO TO 614)
KNOWS NO SOURCE 42 (GO TO 614)
METHOD-RELATED REASONS
HEALTH CONCERNS 51 (GO TO 614)
FEAR OF SIDE EFFECTS 52 (GO TO 614)
LACK OF ACCESS/TOO FAR 53 (GO TO 614)
COSTS TOO MUCH 54 (GO TO 614)
INCONVENIENT TO USE 55 (GO TO 614)
INTERFERES WITH BODY'S NORMAL PROCESSES 56 (GO TO 614)
OTHER (SPECIFY): ___ 96 (GO TO 614)
DON'T KNOW 98 (GO TO 614)

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

YES 1
NO 2
DON'T KNOW 8

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.

NO CHILDREN 00 (GO TO 616)
NUMBER: ___
OTHER (SPECIFY) 96 (GO TO 616)

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 the sex not matter?

NUMBER OF BOYS: ___
NUMBER OF GIRLS: ___
EITHER: ___
OTHER (SPECIFY): ___ 96

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

APPROVE 1
DISAPPROVE 2
DON'T KNOW/UNSURE 3

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

On the radio?
On the television?
In a newspaper or magazine?
On a poster/pamphlet?

RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NEWSPAPER/MAGAZINE
YES 1
NO 2
POSTER/PAMPHLET
YES 1
NO 2

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

YES 1
NO 2 (GO TO 621)

620) With whom did you speak? Anyone else?

RECORD ALL PERSONS MENTIONED.

HUSBAND/PARTNER A
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTERS(S) F
SON(S) G
MOTHER(S)-IN-LAW H
FRIENDS/NEIGHBORS I
OTHER (SPECIFY): ___ X

621) CHECK 501:

YES, CURRENTLY MARRIED: ___
YES, LIVING WITH A MAN: ___
NO, NOT IN UNION: ___ (GO TO 701)

622) CHECK 311/311A:

ANY CODE CIRCLED: ___
NO CODE CIRCLED: ___ (GO TO 624)

623) You have told me that you are currently using contraception. Would you say that using contraception is mainly your decision, mainly your husband's/partner's decision or did you both decide together?

MAINLY RESPONDENT 1
MAINLY HUSBAND/PARTNER 2
JOINT DECISION 3
OTHER (SPECIFY): ___ 6

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?

APPROVES 1
DISAPPROVES 2
DON'T KNOW 8

625) How often have you talked to your husband/partner about family planning in the last twelve months?

NEVER 1
ONCE OR TWICE 2
MORE OFTEN 3

626) CHECK 311/311A:

NEITHER STERILIZED: ___
HE OR SHE IS STERILIZED: ___ (GO TO 701)

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

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8

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

701) CHECK 501 AND 502:

CURRENTLY MARRIED/LIVING WITH A MAN: ___
FORMERLY MARRIED/LIVING WITH A MAN: ___ (GO TO 703)
NEVER MARRIED AND NEVER LIVED WITH A MAN: ___ (GO TO 707)

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

AGE IN COMPLETED YEARS: ___

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

YES 1
NO 2 (GO TO 706)

704) What was the highest level of school he attended: primary, secondary, or higher?

PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8 (GO TO 706)

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

PRIMARY
LESS THAN ONE YEAR 0
INFANT/CLASS ONE/SIL 1
STANDARD ONE/CLASS TWO/CP 2
STANDARD TWO/CLASS THREE/CE1 3
STANDARD THREE/CLASS FOUR/CE2 4
STANDARD FOUR/CLASS FIVE/CM1 5
STANDARD FIVE/CLASS SIX/CM2 6
STANDARD SIX/CLASS SEVEN 7
DK 8
SECONDARY
LESS THAN ONE YEAR 0
FORM 1/SIXTH/1ST YEAR 1
FORM 2/FIFTH/2ND YEAR 2
FORM 3/FOURTH/3RD YEAR 3
FORM 4/THIRD/4TH YEAR 4
FORM 5/SECOND 5
LOWER SIXTH FORM/FIRST 6
UPPER SIXTH FORM/FINAL 7
DK 8
HIGHER
LESS THAN ONE YEAR 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH+ YEAR 4
DK 8
DON'T KNOW 8

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

______________

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

YES 1 (GO TO 710)
NO 2

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.

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

YES 1 (GO TO 701)
NO 2

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

YES 1
NO 2 (GO TO 719)

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

___________

711) CHECK 710:

WORKS IN AGRICULTURE: ___
DOES NOT WORK IN AGRICULTURE: ___ (GO TO 713)

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

OWN LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
PARTNER'S LAND 5

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

FOR FAMILY MEMBER 1
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3

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

HOME 1
AWAY 2

715) 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

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

CASH ONLY 1
CASH AND KIND 2
IN KIND ONLY 3 (GO TO 719)
NOT PAID 4 (GO TO 719)

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5

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?

ALMOST NONE 1
LESS THAN HALF 2
ABOUT HALF 3
MORE THAN HALF 4
ALL 5
NONE, HER INCOME IS ALL SAVED 6

718A) On average, how much of your income to you reserve for your household's expenditures: almost none, less than half, about half, more than half, or all?

ALMOST NONE 1
LESS THAN HALF 2
ABOUT HALF 3
MORE THAN HALF 4
ALL 5
NONE, HER INCOME IS ALL SAVED 6

719) Who in your household usually has the final say on the following decisions:

Your own health care?
Making large household purchases?
Making household purchases for daily needs?
Visits to family or relatives?
What food should be cooked every day?

CARE
RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
LARGE PURCHASES
RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
DAILY NEEDS
RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
VISITS
RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
COOKING
RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6

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

CHILDREN LESS THAN 10
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 8
HUSBAND
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 8
OTHER MALES
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 8
OTHER FEMALES
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 8

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:

If she goes out without telling him?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

GOES OUT
YES 1
NO 2
DON'T KNOW 8
NEGLECTS 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
BURNS FOOD
YES 1
NO 2
DON'T KNOW 8

SECTION 8. HIV/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?

YES 1
NO 2 (GO TO 817)

801A) 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

801B) Can people get the AIDS virus from mosquito bites?

YES 1
NO 2
DON'T KNOW 8

801C) 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

801D) Can people get the AIDS virus by sharing food with a person who has AIDS?

YES 1
NO 2
DON'T KNOW 8

801E) Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

YES 1
NO 2
DON'T KNOW 8

801F) Can people get the AIDS virus because of witchcraft or other supernatural means?

YES
NO 2
DON'T KNOW 8

801G) Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?

YES 1
NO 2 (GO TO 809)
DON'T KNOW 8 (GO TO 809)

801H) What can a person do?

Anything else?

RECORD ALL WAYS MENTIONED.

ABSTAIN FROM SEX A
USE CONDOMS B
LIMIT SEX TO ONE PARTNER/STAY FAITHFUL TO ONE PARTNER C
LIMIT NUMBER OF SEXUAL PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS F
AVOID SEX WITH HOMOSEXUALS G
AVOID SEX WITH PERSONS WHO INJECT DRUGS INTRAVENOUSLY H
AVOID BLOOD TRANSFUSIONS I
AVOID INJECTIONS J
AVOID SHARING RAZORS/BLADES K
AVOID KISSING L
AVOID MOSQUITO BITES M
SEEK PROTECTION FROM TRADITIONAL PRACTITIONER N
OTHER (SPECIFY): ___ W
OTHER (SPECIFY): ___ X
DON'T KNOW Z

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

YES 1
NO 2
DON'T KNOW 8

810) Do you know someone personally who has the virus that causes AIDS or someone who died of AIDS?

YES 1
NO 2

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

YES 1
NO 2 (GO TO 813)
DON'T KNOW 8 (GO TO 813)

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

During pregnancy?
During delivery?
During breastfeeding?

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

813) CHECK 501:

YES, CURRENTLY MARRIED/LIVING WITH A MAN: ___
NO, NOT IN UNION: ___ (GO TO 814A)

814) Have you ever talked about ways to prevent getting the virus that causes AIDS with (your husband/the man you are living with)?

YES 1
NO 2

814A) 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/NOT SURE 8

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

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

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

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

816A) 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 NOT BE ALLOWED 2
DON'T KNOW/NOT SURE/DEPENDS 8

816B) 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

816C) CHECK 407:

HAD PRENATAL CARE: ___

QUESTION 407 NOT ASKED OR NO BIRTHS SINCE JANUARY 1999 OR RECORDED CODE Y (NO PRENATAL CARE) FOR QUESTION 407: ___ (GO TO 816I)

816D) During the prenatal visits for (NAME OF LAST BIRTH ON QUESTION 404), did anyone:

Tell you that children can contract the virus that causes AIDS from their mother?
Speak to you about being tested for the virus that causes AIDS?

CHILD-MOTHER
YES 1
NO 2
AIDS TEST
YES 1
NO 2

816E) I don't want to know the results, but were you tested to see if you have the AIDS virus during any of these prenatal visits?

YES 1
NO 2 (GO TO 816I)

816F) Did you yourself ask for the test, was it offered to you and you accepted, or was it required?

ASKED FOR THE TEST 1
OFFERED AND ACCEPTED 2
REQUIRED 3

816G) I don't want to know the results, but did you get the results of the test?

YES 1
NO 2

816H) Have you had an AIDS test since you were tested during your pregnancy?

YES 1 (GO TO 816K)
NO 2 (GO TO 816N)

816I) 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 (GO TO 816N)

816J) When was the last time you were tested?

LESS THAN 12 MONTHS AGO 1
12-23 MONTHS AGO 2
2 OR MORE YEARS AGO 3

816K) Where was the test done?

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

NAME OF PLACE: ___
PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
OTHER PUBLIC (SPECIFY): ___ 13
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL 21
SECULAR HOSPITAL/CLINIC 22
HEALTH CENTER/RELIGIOUS CLINIC/MISSION 23
DOCTOR'S OFFICE 24
PHARMACY 25
OTHER PRIVATE MEDICAL (SPECIFY): ___ 26

816L) 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?

ASKED FOR THE TEST 1
OFFERED AND ACCEPTED 2
REQUIRED 3

816M) I don't want to know the results, but did you get the results of the test?

YES 1
NO 2

816N) Have you ever heard of the CPDV (Prevention and Voluntary Screening Center)?

YES 1
NO 2 (GO TO 817)

816O) Have you ever gone to the CPDV?

YES 1
NO 2

816P) CHECK 816E AND 816I:

ALREADY BEEN TESTED: ___
NEVER TESTED: ___ (GO TO 817)

816Q) Have you ever had an AIDS test in a CPDV?

YES 1
NO 2

817) Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

YES 1
NO 2 (GO TO 819A)

818) If a man has a sexually transmitted disease, what symptoms might he have?

Any other sign or symptom?

RECORD ALL SYMPTOMS MENTIONED.

ABDOMINAL PAIN A
GENITAL DISCHARGE B
FOUL SMELLING DISCHARGE C
BURNING PAIN ON URINATION D
REDNESS/INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
LOSS OF WEIGHT K
HARD TO GET PREGNANT/HAVE A CHILD L
OTHER (SPECIFY): ___ W
OTHER (SPECIFY): ___ X
NO SYMPTOMS Y
DON'T KNOW Z

819) If a woman has a sexually transmitted disease, what symptoms might she have?

Any other sign or symptom?

RECORD ALL SYMPTOMS MENTIONED.

ABDOMINAL PAIN A
GENITAL DISCHARGE B
FOUL SMELLING DISCHARGE C
BURNING PAIN ON URINATION D
REDNESS/INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
LOSS OF WEIGHT K
HARD TO GET PREGNANT/HAVE A CHILD L
OTHER (SPECIFY): ___ W
OTHER (SPECIFY): ___ X
NO SYMPTOMS Y
DON'T KNOW Z

819A) CHECK 514:

HAD HAD SEXUAL INTERCOURSE: ___
HAS NOT HAD SEXUAL INTERCOURSE (IF '00' CIRCLED): ___ (GO TO 901)

819B) CHECK 817:

HAS HEARD OF SEXUALLY TRANSMITTED INFECTIONS: ___
HAS NOT HEARD OF SEXUALLY TRANSMITTED INFECTIONS: ___ (GO TO 819D)

819C) 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

819D) Sometimes women experience a bad-smelling abnormal genital discharge. Have you had a bad-smelling abnormal genital discharge in the last 12 months?

YES 1
NO 2
DON'T KNOW 8

819E) Sometimes women have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?

YES 1
NO 2
DON'T KNOW 8

819F) CHECK 819C, 819D, 819E:

YES TO QUESTION (819C, D, OR E): HAS HAD AN INFECTION: ___

NO OR DON'T KNOW TO QUESTION (819C, D, E: HAS NOT HAD AN INFECTION: ___ (GO TO 819L)

819G) The last time you had (INFECTION FROM 819C, 819D, AND/OR 819E), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 819I)

819H) Where did you go for treatment?

Any other place?

CIRCLE ALL MENTIONED.

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

PUBLIC/SEMIPUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
OTHER PUBLIC (SPECIFY): ___ C
PRIVATE MEDICAL SECTOR
PRIVATE RELIGIOUS HOSPITAL D
SECULAR HOSPITAL/CLINIC E
HEALTH CENTER/RELIGIOUS CLINIC/MISSION F
DOCTOR'S OFFICE G
PHARMACY H
OTHER PRIVATE MEDICAL (SPECIFY): ___ I

819I) When you had (INFECTION FROM 819C, 819D, AND/OR 819E), did you inform the people were you having sexual intercourse with?

YES 1
NO 2
SOME PEOPLE/NOT ALL 3

819J) When you had (INFECTION FROM 419C, 419D, AND/OR 419E), did you do something to avoid infecting your sexual partners?

YES 1
NO 2 (GO TO 819L)
PARTNER(S) ALREADY INFECTED 3 (GO TO 819L)
DIDN'T HAVE PARTNER 4 (GO TO 819L)

819K) What did you do to prevent infection in your partner(s)? Did you...

Stop sexual intercourse?
Use a condom during sexual intercourse?
Taken medication?

STOP SEXUAL INTERCOURSE
YES 1
NO 2
USE CONDOM
YES 1
NO 2
TAKE MEDICATION
YES 1
NO 2

819L) Husband and wives do not always agree on everything. Please tell me if you think a woman is justified refusing to have sex with her husband when:

She knows her husband has a disease that she can get during sexual intercourse?
She knows her husband has sex with other women?
She recently gave birth?
She is tired or not in the mood?

HE HAS A STD
YES 1
NO 2
DON'T KNOW 8
OTHER WOMEN
YES 1
NO 2
DON'T KNOW 8
RECENT BIRTH
YES 1
NO 2
DON'T KNOW 8
TIRED/NOT IN MOOD
YES 1
NO 2
DON'T KNOW 8

819M) 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

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?

YES 1
NO 2 (GO TO 901H)

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

BOYS LIVING: ___

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

GIRLS LIVING: ___

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

BOYS DECEASED: ___

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

GIRLS DECEASED: ___

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

YES 1
NO 2 (GO TO 901H)

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

OTHER CHILDREN: ___

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

TOTAL: ___

901I) CHECK 901H:

Just to make sure that I've understood, including yourself, your mother gave birth to ___ children total. Is that correct?

YES: ___
NO: ___ (PROBE AND CORRECT 901A-901H AS NECESSARY)

902) CHECK 901H:

TWO OR MORE BIRTHS: ___
ONLY ONE BIRTH (RESPONDENT ONLY): ___ (GO TO 1000A)

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

NUMBER OF PRECEDING BIRTHS: ___

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.

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

___________

905) Is (NAME) male or female?

MALE 1
FEMALE 2

906) Is (NAME) still alive?

YES 1
NO 2 (GO TO 908)
DK 8 (GO TO NEXT SIBLING)

907) How old is (NAME)?

____ (GO TO NEXT SIBLING)

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 the age of twelve?

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

_____ (IF MALE OR DIED BEFORE 12 YEARS, GO TO NEXT SIBLING)

910) Was (NAME) pregnant when she died?

YES 1 (GO TO 913)
NO 2

911) Did (NAME) die during childbirth?

YES 1 (GO TO 913)
NO 2

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

YES 1
NO 2

913) How many live born children did (NAME) give birth to during her lifetime, before this pregnancy?

______ (GO TO NEXT SIBLING. IF NO MORE SIBLINGS, GO TO 1000A)

SECTION 10. FEMALE GENITAL CUTTING

1000A) CHECK THE FRONT PAGE: HOUSEHOLD SELECTED FOR FEMALE GENITAL CUTTING MODULE?

YES
NO (GO TO 1100A)

1001) Have you ever heard of female circumcision?

YES 1 (GO TO 1003)
NO 2

1002) In a number of countries, there is a practice in which a girl may have part of her genitals cut. Have you ever heard of this practice?

YES 1
NO 2 (GO TO 1129)

1003) Have you yourself ever had your genitals cut, meaning did someone cut a part of your external genital organs?

YES 1
NO 2 (GO TO 1009)

1004) Now I would like to ask you what was done to you at this time.
Was any flesh removed from the genital area?

YES 1 (GO TO 1006)
NO 2
DON'T KNOW 8

1005) Was the genital area just nicked without removing any flesh?

YES 1
NO 2
DON'T KNOW 8

1006) Was your genital area sewn closed?

YES 1
NO 2
DON'T KNOW 8

1007) How old were you when this occurred?

IF LESS THAN ONE YEAR, RECORD '00'.
IF THE RESPONDENT DOES NOT KNOW THE EXACT AGE, PROBE TO GET AN ESTIMATE.

AGE IN COMPLETED YEARS: ___
DURING INFANCY 95
DON'T KNOW 98

1008) Who cut (or nicked) your genitals?

TRADITIONAL
TRADITIONAL CIRCUMCISER 11
TRADITIONAL BIRTH ATTENDANT 12
OTHER TRADITIONAL (SPECIFY): ___ 16
HEALTH PROFESSIONAL
DOCTOR 21
TRAINED NURSE/MIDWIFE 22
OTHER HEALTH PROFESSIONAL (SPECIFY): ___ 26
DON'T KNOW 98

1009) CHECK 214 AND 216:

HAS AT LEAST ONE LIVING DAUGHTER: ___
HAS NO LIVING DAUGHTER: ___ (GO TO 1019)

1010) CHECK 214 AND 216:

HAS ONE LIVING DAUGHTER: Did your daughter have her genitals cut? IF YES, RECORD 01. IF NO, CIRCLE 95.

HAS TWO OR MORE LIVING DAUGHTERS: Have any of your daughters had her genitals cut?
IF YES: How many?
RECORD THE NUMBER; IF NONE, CIRCLE 95.

NUMBER CIRCUMCISED______
NO DAUGHTER CIRCUMCISED 95 (GO TO 1018)

1011) CHECK 1010:

HAD ONLY ONE DAUGHTER CIRCUMCISED: What is the name of your daughter who was circumcised?
CHECK 212 AND RECORD THE LINE NUMBER FOR THE DAUGHTER.

HAD TWO OR MORE DAUGHTERS CIRCUMCISED: To which of your daughters did this happen most recently?
CHECK 212 AND RECORD THE LINE NUMBER FOR THE DAUGHTER.

NAME OF DAUGHTER: ___
DAUGHTER'S LINE NUMBER FROM QUESTION 212: ___

1012) Now I would like to ask you what was done to (NAME OF THE DAUGHTER FROM QUESTION 1011) at this time. Was any flesh removed from her genital area?

YES 1 (GO TO 1014)
NO 2
DON'T KNOW 8

1013) Was her genital area just nicked without removing any flesh?

YES 1
NO 2
DON'T KNOW 8

1014) Was her genital area sewn closed?

YES 1
NO 2
DON'T KNOW 8

1015) How old was (NAME OF THE DAUGHTER FROM QUESTION 1011) when this occurred?

IF LESS THAN ONE YEAR RECORD '00'.

IF THE RESPONDENT DOES NOT KNOW THE AGE, PROBE TO GET AN ESTIMATE.

AGE IN COMPLETED YEARS: ___
DURING INFANCY 95
DON'T KNOW 98

1016) Who cut (or nicked) her genitals?

TRADITIONAL
TRADITIONAL CIRCUMCISER 11
TRADITIONAL BIRTH ATTENDANT 12
OTHER TRADITIONAL (SPECIFY): ___ 16
HEALTH PROFESSIONAL
DOCTOR 21
TRAINED NURSE/MIDWIFE 22
OTHER HEALTH PROFESSIONAL (SPECIFY): ___ 26
DON'T KNOW 98

1017) At the time that the genitals were cut or afterwards, did (NAME OF THE DAUGHTER FROM QUESTION 1011) have any of the following problems:

Excessive bleeding?
Difficulty in passing urine or urine retention?
Swelling in the genital area?
Infection in the genital area?
Wound that did not heal properly?

EXCESSIVE BLEEDING
YES 1 (GO TO 1019)
NO 2 (GO TO 1019)
DON'T KNOW 8 (GO TO 1019)
URINE RETENTION
YES 1 (GO TO 1019)
NO 2 (GO TO 1019)
DON'T KNOW 8 (GO TO 1019)
SWELLING
YES 1 (GO TO 1019)
NO 2 (GO TO 1019)
DON'T KNOW 8 (GO TO 1019)
INFECTION
YES 1 (GO TO 1019)
NO 2 (GO TO 1019)
DON'T KNOW 8 (GO TO 1019)
HEALING BADLY
YES 1 (GO TO 1019)
NO 2 (GO TO 1019)
DON'T KNOW 8 (GO TO 1019)

1018) CHECK 214 AND 216:

HAS ONE LIVING DAUGHTER: Do you intend to have this genital cutting done on your daughter in the future?

HAS TWO OR MORE LIVING DAUGHTERS: Do you intend to have this genital cutting done to any of your daughters in the future?

YES 1
NO 2
DON'T KNOW 8

1019) What benefits do girls get if they undergo this genital cutting?

PROBE: Other benefits?

RECORD ALL MENTIONED.

CLEANLINESS/HYGIENE A
SOCIAL ACCEPTANCE B
BETTER MARRIAGE PROSPECTS C
PRESERVE VIRGINITY/PREVENT PREMARITAL SEX D
MORE SEXUAL PLEASURE FOR THE MAN E
RELIGIOUS APPROVAL F
OTHER (SPECIFY): ___ X
NO BENEFITS Y
DON'T KNOW Z

1020) What benefits do girls get if they do not undergo this genital cutting?

PROBE: Anything else?

RECORD ALL MENTIONED.

FEWER MEDICAL PROBLEMS A
FEWER CHILDBIRTH PROBLEMS B
AVOIDING PAIN C
MORE SEXUAL PLEASURE FOR HER D
MORE SEXUAL PLEASURE FOR THE MAN E
FOLLOWS RELIGION F
OTHER (SPECIFY): ___ X
NO ADVANTAGES Y
DON'T KNOW Z

1020A) CHECK 1019:

CODE 'D' NOT CIRCLED: ___
CODE 'D' CIRCLED: ___ (GO TO 1021A)

1021) Would you say that this practice is a way to prevent a girl from having sex before marriage or does it have no effect on premarital sex?

PREVENT SEX 1
NO EFFECT 2
DON'T KNOW 8

1021A) CHECK 1019 AND 1020:

NEITHER 'F' (1019) NOR 'F' (1020) CIRCLED: ___
CODE 'F' (1019) OR 'F' (1020) CIRCLED: ___ (GO TO 1023)

1022) Do you believe that this practice is required by your religion?

YES 1
NO 2
DON'T KNOW 8

1023) Do you think that this practice should be continued, or should it be discontinued?

CONTINUED 1
DISCONTINUED 2
DEPENDS 3
DON'T KNOW 8

1024) Do you think that men want this practice to be continued, or discontinued?

CONTINUED 1 (GO TO 1129)
DISCONTINUED 2 (GO TO 1129)
DEPENDS 3 (GO TO 1129)
DON'T KNOW 8 (GO TO 1129)

SECTION 11. HOUSEHOLD RELATIONSHIPS

1100A) CHECK THE FRONT COVER PAGE: WAS THE WOMAN YOU ARE SURVEYING SELECTED FOR THE QUESTIONS ON "HOUSEHOLD RELATIONSHIPS"?

YES: ___
NO: ___ (CHECK THAT SECTION 10 WAS COMPLETED AND GO TO 1129)

1101) CHECK FOR THE PRESENCE OF OTHERS: DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.

PRIVACY OBTAINED 1
PRIVACY NOT POSSIBLE 2 (GO TO 1128)

READ TO ALL RESPONDENTS:

Now I would like to ask you some questions about other important aspects of a woman's life.

I know that some of these questions are very personal. However, your answers are crucial for helping to understand the condition of women in Cameroon. Let me assure you that your answer are completely confidential and will not be told to anyone.

Additionally, you are the only person in your household that is being asked these questions and no one will know that you were asked these questions. If someone arrives while we are talking, we will talk about something else.

1102) CHECK 501, 502, AND 504:

CURRENTLY MARRIED/LIVING WITH A MAN: ___
SEPARATED/DIVORCED: ___
WIDOWED/NEVER MARRIED/NEVER LIVED WITH A MAN: ___ (GO TO 1114)

1103) When two people marry or live together, they share both good and bad moments. In your relationship with your (last) husband/partner does/did the following happened frequently, only sometimes, or never?

a) He usually (spends/spent) his free time with you?
b) He (consults/consulted) you on different household matters?
c) He (is/was) affectionate with you?
d) He (respects/respected) you and your wishes?

FREE TIME
FREQUENTLY 1
SOMETIMES 2
NEVER 3
CONSULTS
FREQUENTLY 1
SOMETIMES 2
NEVER 3
AFFECTION
FREQUENTLY 1
SOMETIMES 2
NEVER 3
RESPECT
FREQUENTLY 1
SOMETIMES 2
NEVER 3

1104) Now I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband/partner?

a) He (is/was) jealous or angry if you (talk/talked) to other men?
b) He frequently (accuses/accused) you of being unfaithful?
c) He (does/did) not permit you to meet your girlfriends?
d) He (tries/tried) to limit your contact with your family?
e) He (insist/insisted) on knowing where you (are/were) at all time?
f) He (does/did) not trust you with any money?
g) He prevents you from working or he isn't alright with you working?

JEALOUS
YES 1
NO 2
DON'T KNOW 8
ACCUSES
YES 1
NO 2
DON'T KNOW 8
SEE FRIENDS
YES 1
NO 2
DON'T KNOW 8
VISIT FAMILY
YES 1
NO 2
DON'T KNOW 8
WHERE YOU ARE
YES 1
NO 2
DON'T KNOW 8
MONEY
YES 1
NO 2
DON'T KNOW 8
BUSINESS
YES 1
NO 2
DON'T KNOW 8

1105) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner.

5A. (Does/did) your (last) husband/partner ever:

a) Say or do something to humiliate you in front of others?
YES 1 (GO TO 5B)
NO 2
b) Threaten you or someone close to you with harm?
YES 1 (GO TO 5B)
NO 2

5B. How many times did this happen during the last 12 months?

a) TIMES IN THE LAST 12 MONTHS: ___
IF WIDOWED, DIVORCED OR SEPARATED 95

b) TIMES IN THE LAST 12 MONTHS: ___
IF WIDOWED, DIVORCED OR SEPARATED 95

1106)

6A. (Does/did) your (last) husband/partner ever:

a) Push you, shake you, or throw something at you?
YES 1 (GO TO 6B)
NO 2
b) Slap you or twist your arm?
YES 1 (GO TO 6B)
NO 2
c) Punch you with his fist or with something that could hurt you?
YES 1 (GO TO 6B)
NO 2
d) Kick you or drag you?
YES 1 (GO TO 6B)
NO 2
e) Try to strangle you or burn you?
YES 1 (GO TO 6B)
NO 2
f) Threaten you with a knife, gun, or other type of weapon?
YES 1 (GO TO 6B)
NO 2
g) Attack you with a knife, gun, or other type of weapon?
YES 1 (GO TO 6B)
NO 2
h) Physically force you to have sexual intercourse with him even when you did not want to?
YES 1 (GO TO 6B)
NO 2
i) Force you to perform other sexual acts you did not want to?
YES 1 (GO TO 6B)
NO 2

6B. How often did this occur in the past 12 months?

a) NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95
b) NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95
c) NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95
d) NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95
e) NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95
f) NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95
g) NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95
h) NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95
i) NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95

1107) CHECK 1106:

AT LEAST ONE 'YES': ___
NOT A SINGLE 'YES': ___ (GO TO 1109C)

1108) How long after you first got married to/started living with your (last) husband/partner did (this/any of these things) first happen?

IF LESS THAN ONE YEAR, RECORD '00'.

NUMBER OF YEARS: ___
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95
AFTER SEPARATION/DIVORCE 96

1109)
9A. Did the following ever happen because of something your (last) husband/partner did to you:

a) You had bruises and aches?
YES 1 (GO TO 9B)
NO 2
b) You had an injury, a broken bone, or a sprain?
YES 1 (GO TO 9B)
NO 2
c) You went to the doctor or health center as a result of something your husband/partner did to you?
YES 1 (GO TO 9B)
NO 2

9B. How many times did this happened during the last 12 months?

a) TIMES IN THE LAST 12 MONTHS: ___
IF WIDOWED, DIVORCED OR SEPARATED 95
b) TIMES IN THE LAST 12 MONTHS: ___
IF WIDOWED, DIVORCED OR SEPARATED 95
c) TIMES IN THE LAST 12 MONTHS: ___
IF WIDOWED, DIVORCED OR SEPARATED 95

1109C) Did you ever do or say something to humiliate or threaten your (last) husband/partner in front of others?

YES 1
NO 2 (GO TO 1110)

1109D) How many times in the last 12 months did you say or do something to threaten or humiliate him in front of other people?

NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95

1110) Have you ever hit, slapped, kicked or done anything else to physically hurt your (last) husband/partner at times when he was not already beating or physically hurting you?

YES 1
NO 2 (GO TO 1112)

1111) In the last 12 months, how many times have you hit, slapped, kicked or done something to physically hurt your (last) husband/partner at a time when he was not already beating or physically hurting you?

NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95

1112) Does (did) your husband/partner drink (alcohol)?

YES 1
NO 2 (GO TO 1114)

1113) How often does (did) he get drunk: very often, only sometimes, or never?

VERY OFTEN 1
SOMETIMES 2
NEVER 3

1114) CHECK 1102:

MARRIED/LIVING WITH A MAN/SEPARATED/DIVORCE:
From the time you were 15 years old has anyone other than your (current/last) husband/partner hit, slapped, kicked, or done anything else to hurt you physically?

WIDOWED/NEVER MARRIED/NEVER LIVED WITH A MAN:
From the time you were 15 years old has anyone ever hit, slapped, kicked, or done anything else to hurt you physically?

YES 1
NO 2 (GO TO 1119)
NO RESPONSE 6 (GO TO 1119)

1115) Who has physically hurt you in this way?

Anyone else?

RECORD ALL MENTIONED.

MOTHER A
FATHER B
STEP-MOTHER C
STEP-FATHER D
SISTER E
BROTHER F
DAUGHTER G
SON H
LATE/EX-HUSBAND/EX-PARTNER I
CURRENT BOYFRIEND J
FORMER BOYFRIEND K
MOTHER-IN-LAW L
FATHER-IN-LAW M
OTHER FEMALE RELATIVE/IN-LAW N
OTHER MALE RELATIVE/IN-LAW O
FEMALE FRIEND/ACQUAINTANCE P
MALE FRIEND/ACQUAINTANCE Q
TEACHER R
EMPLOYER S
STRANGER T
OTHER (SPECIFY): ___ X

1116) CHECK 1115:

MORE THAN ONE PERSON MENTIONED: ___
ONLY ONE PERSON MENTIONED: ___ (GO TO 1118)

1117) Who has hit, slapped, kicked or done something to physically hurt you most often?

MOTHER 01
FATHER 02
STEP-MOTHER 03
STEP-FATHER 04
SISTER 05
BROTHER 06
DAUGHTER 07
SON 08
LATE/EX-HUSBAND/EX-PARTNER 09
CURRENT BOYFRIEND 10
FORMER BOYFRIEND 11
MOTHER-IN-LAW 12
FATHER-IN-LAW 13
OTHER FEMALE RELATIVE/IN-LAW 14
OTHER MALE RELATIVE/IN-LAW 15
FEMALE FRIEND/ACQUAINTANCE 16
MALE FRIEND/ACQUAINTANCE 17
TEACHER 18
EMPLOYER 19
STRANGER 20
OTHER (SPECIFY): ___ 96

1118) In the last 12 months, how many times has this person hit, slapped, kicked, or done anything else to physically hurt you?

NUMBER OF TIMES: ___
IF WIDOWED, DIVORCED OR SEPARATED 95

1119) CHECK QUESTION 201, QUESTION 226 AND QUESTION 228A: LIVE BIRTHS, PREGNANCIES, STILLBIRTHS

HAD AT LEAST ONE PREGNANCY: ___
NEVER HAD A PREGNANCY: ___ (GO TO 1122)

1120) Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

YES 1
NO 2 (GO TO 1122)

1121) How has done any of these things to physically hurt you while you were pregnant?

Anyone else?

RECORD ALL MENTIONED.

CURRENT HUSBAND/PARTNER A
MOTHER B
FATHER C
STEP-MOTHER D
STEP-FATHER E
SISTER F
BROTHER G
DAUGHTER H
SON I
LAST/EX-HUSBAND/EX-PARTNER J
CURRENT BOYFRIEND K
FORMER BOYFRIEND L
MOTHER-IN-LAW M
FATHER-IN-LAW N
OTHER FEMALE RELATIVE/IN-LAW O
OTHER MALE RELATIVE/IN-LAW P
FEMALE FRIEND/ACQUAINTANCE Q
MALE FRIEND/ACQUAINTANCE R
TEACHER S
EMPLOYER T
STRANGER U
OTHER (SPECIFY): ___ X

1122) CHECK 1106, 1109, 1114, AND 1120:

AT LEAST ONE 'YES': ___
NOT AT SINGLE 'YES': ___ (GO TO 1126)

1123) Have you ever tried to get help to prevent or stop (this person/these persons) from physically hurting you?

YES 1
NO 2 (GO TO 1125)

1124) From whom have you sought help?

Anyone else?

RECORD ALL MENTIONED.

MOTHER A (GO TO 1126)
FATHER B (GO TO 1126)
SISTER C (GO TO 1126)
BROTHER D (GO TO 1126)
CURRENT/LAST/LATE HUSBAND/PARTNER E (GO TO 1126)
CURRENT/FORMER BOYFRIEND F (GO TO 1126)
MOTHER-IN-LAW G (GO TO 1126)
FATHER-IN-LAW H (GO TO 1126)
OTHER FEMALE RELATIVE/IN-LAW I (GO TO 1126)
OTHER MALE RELATIVE/IN-LAW J (GO TO 1126)
FRIEND K (GO TO 1126)
NEIGHBOR L (GO TO 1126)
TEACHER M (GO TO 1126)
EMPLOYER N (GO TO 1126)
RELIGIOUS LEADER O (GO TO 1126)
DOCTOR/MEDICAL PROFESSIONAL P (GO TO 1126)
POLICE Q (GO TO 1126)
LAWYER R (GO TO 1126)
TRADITIONAL AUTHORITY S
SOCIAL SERVICES T
WOMEN'S ASSOCIATION U
OTHER (SPECIFY): ___ X (GO TO 1126)

1125) What is the main reason you have never sought help?

DON'T KNOW WHO TO GO TO 01
NO USE 02
PART OF LIFE 03
AFRAID OF DIVORCE/DESERTION 04
AFRAID OF FURTHER BEATINGS 05
AFRAID OF GETTING PERSON BEATING HER INTO TROUBLE 06
EMBARRASSED 07
DON'T WANT TO DISGRACE FAMILY 08
OTHER (SPECIFY): ___ 96

1126) As far as you know, did your father ever beat your mother?

YES 1
NO 2
DON'T KNOW 8

1126A) Do you know of any services or support for women in trouble?

YES 1
NO 2
DON'T KNOW 8

THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER ABOUT THE CONFIDENTIALITY OF HER ANSWERS. FILL OUT THE QUESTIONS BELOW WITH REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

1127) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

HUSBAND
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3
OTHER MALE ADULT
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3
FEMALE ADULT
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3

1128) INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE

1129) RECORD THE TIME

HOUR: ___
MINUTE: ___

INTERVIEWER'S OBSERVATIONS___

COMMENTS ABOUT RESPONDENT ___

COMMENTS ON SPECIFIC QUESTIONS ___

ANY OTHER COMMENTS ___

SUPERVISOR'S OBSERVATIONS
NAME OF SUPERVISOR ___
DATE ___

EDITOR'S OBSERVATIONS
NAME OF EDITOR ___
DATE ___