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

IDENTIFICATION

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

CITY/TOWNSHIP/GROUP ___

VILLAGE CLUSTER ___
NEIGHBORHOOD/PLACE STRUCTURE ___

NAME OF HEAD OF HOUSEHOLD ___
HOUSEHOLD ___

MAN'S NAME ___
MAN'S LINE NUMBER ___

INTERVIEWER VISITS:

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

RESULTS___

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

FINAL VISIT
DAY__
MONTH__
YEAR 20__
INTERVIEWER__
RESULT__

TOTAL NUMBER OF VISITS____

LANGUAGE OF QUESTIONNAIRE:

LANGUAGE OF THE INTERVIEW:

INTERPRETER:

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: ___

101) RECORD TIME.

102) What year and what month were you born in?

103) How old were you at your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 AS NECESSARY.

104) Have you ever attended school?

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

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

107) CHECK 105:

108) Now I would like you to read this sentence aloud; read as much as you can.

SHOW CARD TO RESPONDENT.

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

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

110) CHECK 108:

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

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

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

114) Do you work at this time?

115) Have you done any type of work in the last 12 months?

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

PROBE TO GET THE SPECIFIC TYPE OF WORK.

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

118) How long have you continuously lived in (NAME OF CURRENT CITY/TOWN OF RESIDENCE)?

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

119) What is your religion?

120) 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 children you have had during your life. Have you had children?

202) Do you have children who are now living with you?

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

IF NONE, RECORD '00'.

204) Do you have any children who are alive but do not live with you?

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

IF NONE, RECORD '00'.

206) Have you ever had any children who were born alive but later died?

IF NO, PROBE: Any baby who cried or showed signs of life at birth but did not survive?

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

IF NONE, RECORD '00'.

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

IF NONE, RECORD '00'.

209) Just to makes sure that I have this right: You have had in total ____children during your life. Is that correct?

209A) Some men are circumcised, are you circumcised?

209B) Did you receive any type of injection over the last three months?

209C) How many times did you receive an injection over the last three months?

209D) Did you have a blood transfusion at any time in your life?

209E) How many times did you get a blood transfusion in the last five years?

SECTION 3. MARRIAGE AND SEXUAL ACTIVITY

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

302) Are you currently married or living with a woman as husband and wife?

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

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

305) RECORD THE NAME(S) OF THE SPOUSE(S)/WIFE(WIVES) AND THEIR LINE NUMBER ON THE HOUSEHOLD SHEET. IF SHE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

IF ONE SPOUSE/WIFE: Please tell me the name of your spouse/wife who you are currently living with.

IF MORE THAN ONE SPOUSE/WIFE: Please tell me the name of each of your spouses/wives who you are currently living with.

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

307A) In what month and year did you start living with your spouse/wife?
307B) Now we are going to talk about your first wife. In what month and year did you start living with her?

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

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

310) CHECK 103:

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

312) 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.

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

314) What is your relationship to the person with whom you last had sex?

IF 'GIRLFRIEND' OR 'FIANCÉE', ASK: Did your girlfriend/fiancée live with you when you last had sex with her?

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

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

IF YES: Who drank?

319) Have you had sex with any other person in the last 12 months?

320) The last time you had sexual intercourse with this other person, was a condom used?

321) What is your relationship with this person?

IF 'GIRLFRIEND' OR ' FIANCÉE', ASK: Did your girlfriend / fiancée live with you when you last had sex with her?

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

325) The last time you had sex with this person, did either you or your partner drink alcohol?

IF YES: Who drank?

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

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

328) What is your relationship with this person?

IF 'GIRLFRIEND' OR ' FIANCÉE', ASK: Did your girlfriend / fiancée live with you when you last had sex with her?

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

332) The last time you had sex with this person, did either you or your partner drink alcohol?

IF YES: Who drank?

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

334) Have you paid someone to have sexual intercourse in the last 12 months?

335) Was a condom used the last time that you paid someone to have sexual intercourse?

336) In total, how many different people have you had sex with in your life?

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

SECTION 4. HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

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

401A) Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

401B) Can people get the AIDS virus from mosquito bites?

401C) Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?

401D) Can people get the AIDS virus by sharing food with a person who has AIDS?

401E) Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

401F) Can people get the AIDS virus because of witchcraft or other supernatural means?

401G) Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?

401H) What can a person do?

Anything else?

RECORD ALL WAYS MENTIONED.

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

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

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

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

During pregnancy?
During delivery?
During breastfeeding?

413) CHECK 302:

414) Have you ever talked about ways to prevent getting the virus that causes AIDS with your wife/the person you are living with?

IF MORE THAN ONE WIFE/SPOUSE, ASK ABOUT ANY OF THE WOMEN.

414A) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?

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

416) 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?

416A) 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?

416B) Should children age 12-14 be taught about using a condom to avoid getting AIDS?

416J) I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?

416K) When was the last time you were tested?

416L) 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?

416M) I don't want to know the results, but did you get the results of the test?

416N) Have you ever heard of the CPDV (Prevention and Voluntary Screening Center)?

416O) Have you ever gone to the CPDV?

416P) CHECK 416J:

416Q) Have you ever had an AIDS test in a CPDV?

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

418) In a man, what do you think are the signs or symptoms that he has a sexually transmitted infection?

Any other signs or symptoms?

RECORD ALL SYMPTOMS MENTIONED.

419) In a woman, what do you think are the signs or symptoms that she has a sexually transmitted infection?

Any other signs or symptoms?

RECORD ALL SYMPTOMS MENTIONED.

419A) CHECK 309:

419B) CHECK 417:

419C) 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?

419D) Sometimes men have abnormal discharge from their penis. Have you had any abnormal discharge from your penis in the last 12 months?

419E) Sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer near your penis?

419F) CHECK 419C, 419D AND 419E:

419G) The last time you had (INFECTION FROM 419C, 419D, AND/OR 419E), did you seek any kind of advice or treatment?

419H) Where did you go to receive medical treatment?
Any other place?

CIRCLE ALL MENTIONED.

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

419I) When you had (INFECTION FROM 419C, 419D, AND/OR 419E), did you inform the people were you having sexual intercourse with?

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

419K) What did you do to prevent infection in your partner(s)? Did you...

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

419L) 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?

419M) 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?

SECTION 5. FEMALE GENITAL CUTTING

501) Have you ever heard of female circumcision?

502) 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?

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

PROBE: Other benefits?

RECORD ALL MENTIONED.

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

PROBE: Anything else?

RECORD ALL MENTIONED.

505) CHECK 503:

506) 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?

507) CHECK 503 AND 504:

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

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

510) Do you think that women want this practice to be continued, or discontinued?

SECTION 6. MATERNAL MORTALITY

601A) 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?

601B) Other than yourself, how many boys did your mother have who are still living?

601C) How many girls did your mother have who are still living?

601D) How many boys did your mother have who died?

601E) How many girls did your mother have who died?

601F) Did your mother give birth to any other children, who you don't know if they are living or dead?

601G) How many other children did your mother give birth to that you don't know if they are living or dead?

601H) ADD THE ANSWERS FROM 601B, C, D, E, AND G, ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL.

601I) CHECK 601H:

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

602) CHECK 601:

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

RECORD THE NAMES OF ALL THE SISTERS AND BROTHERS (IN THE FOLLOWING TABLE).

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

605) Is (NAME) male or female?

606) Is (NAME) still alive?

607) How old is (NAME)?

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

609) How old was (NAME) when he/she died?

IF 'DON'T KNOW', PROBE: Did (NAME) die before the age of 12?

IF YES, RECORD '95'.

IF NO, ASK OTHER QUESTIONS TO GET AN ESTIMATE. FOR EXAMPLE:
Did (NAME) die before getting married?

610) Was (NAME) pregnant when she died?

611) Did (NAME) die during childbirth?

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

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

IF NO OTHER BROTHERS OR SISTERS, GO TO 614.

614) RECORD TIME.

INTERVIEWER'S OBSERVATIONS:

TO BE FILLED IN AFTER COMPLETING INTERVIEW.

COMMENTS ABOUT RESPONDENT ___
COMMENTS ON SPECIFIC QUESTIONS ___

ANY OTHER COMMENTS ___

SUPERVISOR'S OBSERVATIONS
NAME OF SUPERVISOR ___
DATE ___

EDITOR'S OBSERVATIONS
NAME OF EDITOR ___
DATE ___