REPUBLIC OF CAMEROON
PEACE WORK FATHERLAND
NATIONAL INSTITUTE OF STATISTICS

IDENTIFICATION

LOCALITY NAME: ___
NAME OF HEAD OF HOUSEHOLD: ___
REGION: ___
CLUSTER NUMBER: ___
STRUCTURE NUMBER: ___
HOUSEHOLD NUMBER: ___
NAME OF HEAD OF HOUSEHOLD AND HOUSEHOLD NUMBER: ___
NAME AND LINE NUMBER OF WOMAN: ___

CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE:
HOUSEHOLD SELECTED FOR MEN'S QUESTIONNAIRE AND HIV TEST?

CHECK THE HOUSEHOLD SURVEY:

IF THE HOUSEHOLD HAS NOT BEEN SELECTED FOR THE MEN'S SURVEY, CHECK 514 OF THE HOUSEHOLD QUESTIONNAIRE: HAS THIS WOMAN BEEN SELECTED FOR THE HOUSEHOLD RELATIONS SECTION?

INTERVIEWER VISITS:

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

RESULTS___

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__

TOTAL NUMBER OF VISITS____

QUESTIONNAIRE LANGUAGE:

INTERVIEW LANGUAGE:

INTERPRETER:

FIELD EDITED BY:
NAME ___
DATE ___

SUPERVISOR:
NAME ___
DATE ___

OFFICE EDITED BY:
NAME ___
KEYED BY ___

SECTION 1. RESPONDENT BACKGROUND

INTRODUCTION AND CONSENT
INFORMED CONSENT

Hello. My name is ___ and I am working with the National Institute of Statistics. We are conducting a national survey during which we are asking women and men questions about problems related to health. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes between 30 and 60 minutes to complete. Whatever information you provide will be kept strictly confidential, will not be shown to other persons, and will only be used for research purposes.
Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important.

At this time, do you want to ask me anything about the survey?

May I begin the interview now?

Interviewer signature: ___
Date: ___

101) RECORD TIME

102) In what month and year were you born?

103) How old were you on your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

NOTE: IF LESS THAN 15 YEARS OLD OR MORE THAN 49 YEARS OLD, END THE INTERVIEW.

104) Have you gone to school?

105) What is the highest level of study you have attained: primary, secondary 1st cycle/2nd cycle, or higher?

106) What is the last class/year that you finished successfully at this level?

107) CHECK 105:

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

SHOW CARD TO RESPONDENT.

IF RESPONDENT CAN NOT READ THE PHRASE, PROBE:

Can you read any part of the sentence?

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

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

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

112) What is your religion?

113) What is your ethnicity?

RECORD THE NAME OF THE ETHNICITY. LEAVE THE CODE BOX EMPTY.

FOR FOREIGNERS, RECORD 'FOREIGNER'.

114) In the past 12 months, how many times have you traveled outside of your community and slept somewhere other than your household?

115) In the past 12 months, have you been gone for a month or more?

SECTION 2. REPRODUCTION

201) Now I'd like to ask you some questions about all the children you've given birth to in your life.
Have you ever given birth to children?

202) Have you given birth to sons or daughters that are currently living with you?

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

IF NONE, ENTER '00'.

204) Have you given birth to any sons or daughters who are alive but who do not currently live with you?

205) How many sons are alive but not living with you?
And how many daughters?

IF NONE, ENTER '00'.

206) Have you given birth to a son or daughter who later died?

IF NO, PROBE:
Any child that cried at birth or gave another sign of life but who only lived a few hours or days?

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

IF NONE, RECORD '00'.

208) ADD THE RESPONSES FROM 203, 205, AND 207 AND RECORD THE TOTAL.

IF NONE, RECORD '00'.

209) CHECK 208:

I want to make sure I understood: you have had (TOTAL) ___ births in your life. Is that correct?

210) CHECK 208:

211) Now I would like to talk to you about your children, whether they are still alive or not, beginning with the first birth that you had.

IN 212 WRITE THE NAME OF EACH CHILD, WRITING THE NAMES OF TWINS OR TRIPLETS ON SEPARATE LINES. IF THERE ARE MORE THAN 12 BIRTHS, USE ADDITIONAL QUESTIONNAIRES AND START ON THE SECOND LINE.

NOTE: 212 THROUGH 221 IN TABLE FORMAT ON ORIGINAL QUESTIONNAIRE.

212) What was the name of your (first, next) child?

213) Was (NAME) a single birth or part of a multiple birth?

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

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

PROBE: What is his or her birthday?

216) Is (NAME) still alive?

217) IF ALIVE:

How old was (NAME) at his/her last birthday?

RECORD AGE IN COMPLETED YEARS.

218) IF ALIVE:

Is (NAME) living with you?

219) IF ALIVE:

NOTE THE LINE NUMBER OF THE CHILD IN THE HOUSEHOLD SURVEY. RECORD '00' IF THE CHILD IS NOT LISTED IN THE HOUSEHOLD.

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 ONE MONTH, MONTHS IF LESS THAN TWO YEARS, OR IN YEARS.

221) (SKIP FOR FIRST BIRTH): Were there other live births between (NAME OF LAST BIRTH) and (NAME)?

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

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

224) CHECK 215 AND RECORD THE NUMBER OF BIRTHS IN 2005 OR LATER. IF NONE, RECORD '00'.

226) Are you pregnant now?

227) How many months pregnant are you?

RECORD NUMBER IN COMPLETED MONTHS.

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

229) Have you ever had a pregnancy that ended with a miscarriage, an abortion, or stillbirth?

229A) How many pregnancies of this kind did you have?

229B) Among these pregnancies, how many ended with:

An induced abortion?
A miscarriage?
A stillbirth?

230) When did the last pregnancy of this kind end?

231) CHECK 230:

232) How many months along was the pregnancy when it ended?

RECORD THE NUMBER IN COMPLETED MONTHS.

233) Since January 2005, have you had any other pregnancies that did not end with a live birth?

235) Did you have a pregnancy that ended before January 2005 ending in a miscarriage, abortion, or stillbirth?

236) When did the last pregnancy of this kind end before 2005?

237) When did your last period start?

RECORD THE RESPONSE IN THE UNIT OF TIME USED BY THE RESPONDENT.

RECORD THE DATE, IF GIVEN:

238) From one menstrual period to the next, is there a time when a woman is more likely to become pregnant than others if she has sexual relations?

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

SECTION 3. CONTRACEPTION

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

Have you ever heard of (METHOD)?

304) Have you ever used any method or tried something to avoid pregnancy?

309) CHECK 226:

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

311) What method are you using?

CIRCLE ALL THAT ARE MENTIONED.

IF MORE THAN ONE METHOD IS MENTIONED, FOLLOW THE INSTRUCTIONS FOR THE HIGHEST METHOD ON THE LIST.

316) In what facility did the sterilization take place?

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

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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

319A) How long have you been using (METHOD FIRST CITED IN 311) without stopping?

PROBE: How long have you been using (METHOD FIRST CITED IN 311) continuously?

320) CHECK 319/319A, 215 AND 230:

WAS THERE ANY BIRTH OR PREGNANCY IN 215 OR 230 ENDING IN MISCARRIAGE, ABORTION, OR STILLBIRTH AFTER THE MONTH AND YEAR OF THE START OF USE OF CONTRACEPTION IN 319/319A?

321) CHECK 319/319A:

323) CHECK 311:

CIRCLE THE METHOD CODE.

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

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

324A) Where did you learn to use the LAM/Periodic Abstinence/Rhythm Method?

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

325) CHECK 311:

CIRCLE THE CODE OF THE METHOD.

IF THERE IS MORE THAN ONE CODE CIRCLED IN 311, CIRCLE THE HIGHEST CODE ON THE LIST.

326) You obtained your (METHOD FROM 323) at (SOURCE OF METHOD IN 316 OR 324) on (DATE IN 319/319A). At this time, were you spoken to about any possible side effects or problems with the use of this method?

327) Have you ever been informed by health personnel or by a family planning agent of side effects or problems that may arise because of the use of the method?

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

329) CHECK 326:

CODE '1' CIRCLED:
At this time, were you spoken to about other family planning methods you could use?

CODE '1' NOT CIRCLED:
When you obtained (METHOD FROM 323) at (SOURCE OF METHOD IN 316 OR 324), were you spoken to about other family planning methods you could use?

330) Was it a health care professional or a family planning agent that spoke to you about other family planning methods that you could use?

331) CHECK 331:

CIRCLE THE CODE OF THE METHOD.

IF MORE THAN ONE METHOD IS MENTIONED IN 311, CIRCLE THE HIGHEST METHOD ON THE LIST.

332) Where did you obtain (METHOD FROM 323) the last time?

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

IF YOU CANNOT DETERMINE IF THE HOSPITAL, HEALTH CENTER OR CLINIC IS PRIVATE OR PUBLIC, WRITE THE NAME OF THE PLACE.

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

334) What is this place?

Anywhere else?

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

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

335) During the past 12 months, have you had a visit from an agent who spoke to you about family planning?

336) In the past 12 months, have you gone to a health center to receive care for yourself (or your children)?

337) Did someone at the health center speak to you about family planning methods?

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

402) CHECK 215: RECORD IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2005 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.

(IF THERE ARE MORE THAN 3 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 5 years. (We will talk about each separately).

403) LINE NUMBER FROM 212:

404) FROM 212 AND 216:

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

406) How much longer would you like to have waited?

NOTE: 407 - 430 ASKED FOR LAST BIRTH ONLY.

407) Did you see anyone for prenatal care for this pregnancy?

IF YES: Whom did you see?

Anyone else?

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

408) Where did you receive prenatal care for this pregnancy?

Anywhere else?

PROBE FOR THE TYPE OF PLACE AND CIRCLE THE APPROPRIATE CODE(S).

IF YOU CAN NOT DETERMINE IF THE HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE, WRITE THE NAME OF THE PLACE.

409) How many months pregnant were you when you first received prenatal care for this pregnancy?

410) How many times did you receive prenatal care during this pregnancy?

411) During this pregnancy, were any of the following done at least once?

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

412) During these consultations, were you told about the signs of pregnancy complications?

414) During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?

415) During this pregnancy, how many times did you get this injection?

416) CHECK 415:

417) At any time before this pregnancy, did you receive a tetanus injection, either to protect yourself or to protect another baby?

418) Before this pregnancy, how many times did you receive a tetanus injection?

IF 7 OR MORE, RECORD '7'.

420) In what month of what year did you receive this (last) tetanus injection?

420A) How many years ago did you receive this (last) tetanus injection?

421) During this pregnancy, were you given or did you buy iron tablets or syrup/capsules containing iron?

SHOW TABLETS/SYRUP.

422) During the whole pregnancy, for how many days did you take these tablets or syrup?

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

423) During this pregnancy, did you take medication for intestinal worms?

426) During this pregnancy, did you take any drugs to prevent you from getting malaria?

427) What drugs did you take?

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

428) CHECK 427:

TYPE OF ANTIMALARIAL TAKEN FOR MALARIA PREVENTION DURING PREGNANCY.

429) How many times did you take SP/Fansidar/Maloxine during this pregnancy?

430) CHECK 407:

PRENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

431) Were you given SP/Fansidar/ Maloxine during a prenatal visit, during another visit to a health facility, or in another place?

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

433) Was (NAME) weighed at birth?

434) How much did (NAME) weigh?

RECORD WEIGHT FROM HEALTH CARD, IF AVAILABLE.

435) 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.

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

PROBE TO DETERMINE THE TYPE OF PLACE AND CIRCLE THE APPROPRIATE CODE.

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE, WRITE THE NAME OF THE PLACE.

438) Was (NAME) delivered by caesarian section?

NOTE: 439 - 454 ASKED FOR MOST RECENT BIRTH ONLY.

439) Before leaving the facility, did a health professional examine you?

440) How long after the delivery did the first post-natal check take place?

IF LESS THAN A DAY, RECORD IN HOURS.
IF LESS THAN A WEEK, RECORD IN DAYS.

441) Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

442) After leaving the health facility, did a health professional or traditional birth attendant examine you?

444) After the birth of (NAME), did a health professional or traditional birth attendant examine you?

445) How long after delivery did the first check take place?

IF LESS THAN A DAY, RECORD IN HOURS.
IF LESS THAN A WEEK, RECORD IN DAYS.

446) Who checked your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

447) Where did this first visit take place?

448) CHECK 442:

449) In the two months following the birth of (NAME), did a health care provider or traditional birth attendant examine his/her health?

450) How many hours, days, weeks long after delivery did the first check take place?

IF LESS THAN A DAY, RECORD IN HOURS.
IF LESS THAN A WEEK, RECORD IN DAYS.

451) Who checked his/her health at that time?

PROBE FOR MOST QUALIFIED PERSON.

452) Where did this first examination of (NAME) take place?

453) In the first two months after delivery, did you receive a vitamin A dose like this?

SHOW AMPULE/CAPSULE/SYRUP.

454) Has your period returned since the birth of (NAME)?

455) SKIP FOR MOST RECENT BIRTH: Did your period return between the birth of (NAME OF NEXT-TO-LAST BIRTH) and your next pregnancy?

456) For how many months after the birth of (NAME) did you not have a period?

457) CHECK 226:

IS RESPONDENT PREGNANT?

458) Have you resumed sexual relations since the birth of (NAME)?

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

460) Did you breastfeed (NAME)?

461) 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 IN DAYS.

462) In the first three days after delivery, was (NAME) given anything to drink other than breast milk?

463) What was given to (NAME) to drink?

Anything else?

CIRCLE ALL LIQUIDS MENTIONED.

464) CHECK 404:
IS CHILD LIVING?

465) Are you still breastfeeding (NAME)?

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

467) CHECK 404:
IS CHILD LIVING?

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

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

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

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

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

470A) Was sugar added to any food or liquid given to (NAME) yesterday?

470B) Yesterday, during the day or night, how many times was (NAME) fed purees or solid/semi-solid food?

IF 7 OR MORE TIMES, RECORD '7'.

471) GO BACK TO 405 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 501.

SECTION 5A. CHILD VACCINATIONS, HEALTH AND NUTRITION OF WOMEN AND CHILDREN

501) ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH THAT OCCURRED IN 2005 AND LATER. ASK QUESTIONS ABOUT ALL OF THESE BIRTHS, BEGINNING WITH THE LAST BIRTH (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

502) LINE NUMBER FROM 212:

503) FROM 212 AND 216:

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

IF YES: May I see it please?

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

506)
(1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD.
(2) WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED.
(3) IF MORE THAN 2 DOSES OF VITAMIN 'A,' RECORD THE DATES FOR THE LAST AND NEXT-TO-LAST DOSES.

506A) CHECK 506:

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

RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3, MEASLES, YELLOW FEVER, AND/OR HEP B VACCINE(S).

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

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

509A) A BCG vaccination against tuberculosis, that is, an injection in the forearm or shoulder that usually causes a scar.

509B) Polio vaccine, that is, drops in the mouth?

509C) When was the first polio vaccine received, just after birth or later?

509D) How many times was the polio vaccine received?

509E) A DPT vaccination, that is, an injection given in the thigh, buttocks, or shoulder generally given at the same time as polio drops?

509F) How many times was the DPT vaccine given?

509G) An injection to prevent measles or a MMR injection, that is, an injection in the arm at the age of 9 months or older to prevent him/her from getting measles?

509H) An injection in the shoulder against yellow fever?

509I) An injection against hepatitis, generally given in the arm?

509J) How many times was the hepatitis shot given?

512) CHECK 506: DATE RECORDED FOR THE VITAMIN A DOSE

513) According to his/her vaccination card, (NAME) received a dose of vitamin A (like this/these here) in (MONTH AND YEAR OF THE MOST RECENT DOSE ACCORDING TO THE CARD). Has (NAME) receive another dose of vitamin A since?

SHOW COMMON MODELS OF PILLS/TABLETS/SYRUP.

514) Was (NAME) ever given a dose of vitamin A (like this/any of these)?

SHOW TYPICAL AMPULES/PILLS/SYRUP.

515) Was (NAME) given a dose of vitamin A in the last 6 months?

516) In the last 7 days, was (NAME) given iron pills, sprinkles with iron, or iron syrup like this/any of these?

SHOW TYPICAL PILLS/SPRINKLES/SYRUP.

517) Was (NAME) given any drug for intestinal worms in the last 6 months?

518) Has (NAME) had diarrhea in the past two weeks?

519) Was there blood in the stool?

520) Now, I want to know how much liquid (NAME) received during his/her diarrhea. Did you give less than usual, about the same amount, or more than usual?

IF LESS, PROBE:
Did you give much less than usual or a little less than usual?

521) When (NAME) had diarrhea, did you give less to eat than usual, about the same amount, more than usual or nothing to eat at all?

IF LESS, PROBE:
Did you give much less than usual or a little less than usual?

522) Did you seek advice or treatment for diarrhea?

523) Where did you ask for advice or seek treatment?

Anywhere else?

PROBE TO IDENTIFY THE TYPE OF EACH SOURCE AND CIRCLE THE APPROPRIATE CODE(S).

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

524) CHECK 523:

525) Where did you go first to seek advice or treatment?

USE CODES FROM 523.

528) Did you give him/her one of the following things to drink since he/she had diarrhea?

a. A liquid prepared from a special packet called ORS?
b. A thin gruel made from rice (or corn, millet, yam, manioc, plantain)?
c. Soup, for example, carrot soup?
d. Tea, infusion, guava leaves?
e. Homemade sugar-salt-water solution (SSS)?
f. Milk or baby formula?
g. Yogurt-based drink?
h. Water?
i. Any other liquid?

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

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

Anything else?

RECORD ALL TREATMENTS GIVEN.

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

533A) Has (NAME) had any convulsions at any time in the last 2 weeks?

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

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

536) Was the fast or difficult breathing due to a problem in the chest or to a blocked or runny nose?

537) CHECK 533, 533A, AND 534:

DID HE/SHE HAVE FEVER OR A COUGH OR CONVULSIONS?

538) Now, I want to know how much liquid (NAME) received when he/she had a cough/fever/convulsions.

Did you give less than usual, about the same amount, or more than usual?

IF LESS, PROBE:
Did you give to drink much less than usual or a little less than usual?

539) When (NAME) had a cough/fever/convulsions, did you give less to eat than usual, about the same amount, more than usual or nothing to eat at all?

IF LESS, PROBE:
Did you give much less than usual or a little less than usual?

540) Did you seek treatment when (NAME) had a fever/cough?

541) Where did you ask for advice or seek treatment?

Anywhere else?

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

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

542) CHECK 541:

543) Where did you go first to seek advice or treatment?

USE CODES FROM 541.

546) At any time during the illness, did (NAME) take any drugs for the illness?

547) What drugs did (NAME) take?

Any other drugs?

RECORD ALL MENTIONED.

547A) Was (NAME) given an injection or suppository to treat fever/convulsions?

550) CHECK 547: ANY CODE A-G CIRCLED?

551) CHECK 547:

FANSIDAR ('A') GIVEN?

552) How long after the fever started did (NAME) first take Fansidar?

553) For how many days did (NAME) take Fansidar?

IF 7 OR MORE DAYS, RECORD '7'.

554) CHECK 547:

CHLOROQUINE ('B') GIVEN ?

555) How long after the fever started did (NAME) first take Chloroquine?

556) For how many days did (NAME) take chloroquine?

IF 7 OR MORE DAYS, RECORD '7'.

557) CHECK 547:

AMODIAQUINE ('C') GIVEN ?

558) How long after the fever started did (NAME) first take Amodiaquine?

559) For how many days did (NAME) take Amodiaquine?

IF 7 OR MORE DAYS, RECORD '7'.

560) CHECK 547:

QUININE ('D') GIVEN?

561) How long after the fever started did (NAME) first take quinine?

562) For how many days did (NAME) take quinine?

IF 7 OR MORE DAYS, RECORD '7'.

563) CHECK 547:

COMBINATION WITH ARTEMISININE ('E') GIVEN ?

564) How long after the fever started did (NAME) first take the combination with artemisinine?

565) For how many days did (NAME) take the combination with artemisinine?

566) CHECK 547:

CDB ANTIMALARIAL ('F') GIVEN?

567) How long after the fever started did (NAME) first take a CDB antimalarial?

568) For how many days did (NAME) take a CDB antimalarial?

IF 7 DAYS OR MORE, RECORD '7'.

569) CHECK 547:

ANOTHER ANTIMALARIAL ('G') GIVEN?

570) How long after the fever started did (NAME) first take (OTHER ANTIMALARIAL)?

571) For how many days did (NAME) take (OTHER ANTIMALARIAL)?

IF 7 OR MORE DAYS, RECORD '7'.

572) GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 573.

573) CHECK 215 AND 218, ALL ROWS:

NUMBER OF CHILDREN BORN IN 2005 OR LATER LIVING WITH THE RESPONDENT?

574) The last time that (NAME FROM 573) passed stools, what was done to dispose of the stools?

575) CHECK 528(a) AND 528(b), ALL COLUMNS:

576) Have you ever heard of a special product called ORS that you can get to treat diarrhea?

SHOW ORS PACKET.

577) CHECK 215 AND 218, ALL ROWS:

NUMBER OF CHILDREN BORN IN 2007 OR LATER LIVING WITH RESPONDENT?

578) Now I would like to ask you about liquids or foods that (NAME FROM 577) drank and ate yesterday during the day or at night?

Did (NAME FROM 577) drink/eat:

Plain water?
Store-bought infant formula?
Any type of grains, such as CERELAC?
Other gruel or porridge?

579) Now I would like to ask you about liquids or foods that (NAME FROM 577) drank and ate yesterday during the day or at night, even if your child consumed it with other foods?

Did (NAME FROM 577) drink/eat:

a) Any other kind of milk, such as canned milk, powdered milk, or fresh animal milk?
b) Natural fruit juice?
c) Sugar water, tea or coffee, or carbonated beverages?
d) Other liquids?
e) Grain-based foods such as millet, sorghum, corn, rice, wheat in the form of gruel, paste, dumpling, or bread?
f) Pumpkin, carrots, or squash that are yellow or orange inside?
g) Potatoes, white yams, manioc, cassava, taro, arrow leaf elephant ear root, or other food made from roots?
h) Green leafy vegetables such as spinach?
i) Mango, papaya (or other local fruit rich in vitamin A)?
j) Any other fruit or vegetable, (for ex: banana, plantain, apple, applesauce, green beans, avocado, tomato)?
k) Liver, kidneys, or other organ meats?
l) Meat such as beef, pork, lamb, goat, chicken, duck, or game?
m) Eggs?
n) Fresh or dried fish or shellfish?
o) Vegetable-based foods (for ex: beans, peas, soybeans, peanuts, lentils, or nuts)?
p) Cheese, yogurts or other food made from milk?
q) Oil, fat, or butter or any food prepared from these ingredients?
r) Sugary foods such as chocolate, candies, cakes, pastries, or biscuits?
s) Any other solid or semisolid food?

580) CHECK 578: (TWO LAST CATEGORIES: GRAIN-BASED BABY FOOD OR OTHER GRUEL/PORRIDGE)

581) How many times did (NAME FROM 577) eat solid or semi-solid food or gruel yesterday, during the day or night?

IF 7 TIMES OR MORE, RECORD '7'.

SECTION 5B. OBSTETRICAL FISTULAS

582) Women can sometimes have continual leakage of urine or excrement from their vaginas.
This problem generally occurs after a difficult delivery, rape, or pelvic surgery.

Have you ever had a continual leakage of urine or excrement from your vagina?

583) Have you ever heard of this kind of problem, I mean of a woman who had a continual leakage of urine or excrement from her vagina?

584) (When? How?) did this problem occur?

After a delivery?
After a rape?
After pelvic surgery?
After another event?

585) Did this problem occur after a normal labor or delivery or after a difficult labor or delivery?

586) Was this child born alive?

587) Did this problem occur after your first, second, third?. delivery?

588) How many days after (EVENT IN 584) did this leakage occur?

RECORD '95' IF 95 DAYS OR MORE.

589) Did you seek treatment?

590) Why did you not seek treatment?

Did not know that the problem could be treated?
Did not know where to go?
Too expensive?
Health facility too far?
Poor quality of care at facility?
Could not get permission to go?
Embarrassment?
Others?

591) Whom did you consult the last time?

592) Did this treatment resolve the problem?

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

601) Are you currently married or are you currently living with a man?

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

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

604) Does your husband/partner live with you now, or is he elsewhere?

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

606) Does your husband/partner have other spouses/wives other than yourself?

607) Including you, in total, how many wives does he have?

608) Are you the first, second ?wife?

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

615) CHECK 609:

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, let's talk about your first husband/partner what month and year did you start living with him?

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

616A) Who chose your first husband/partner?

617) CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, DO EVERYTHING YOU CAN TO ENSURE PRIVACY.

618) Now I would like to ask some questions about sexual activity in order to gain a better understanding of important life issues.

How old were you when you have sexual intercourse for the first time?

618A) Now I would like to ask you some questions about your recent sexual activity. Let me assure you that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go on to the next question.

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

IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS.

IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

(QUESTIONS 627-638 MUST BE FILLED OUT PARTNER AFTER PARTNER, COLUMN AFTER COLUMN).

627) (SKIP FOR MOST RECENT PARTNER) When did you last have sexual relations with this second (third) person?

628) The last time you had sex with this (second, third) person was a condom used?

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

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

IF BOYFRIEND:
Were you living together as if married?

IF YES, CIRCLE '2'.
IF NO, CIRCLE '3'.

630A) CHECK 609:

630B) CHECK 618:

631) When did you first have sexual relations with this person?

631A) In the last 12 months, how many times did you have sexual relations with this person?

IF THE NUMBER OF TIMES IS GREATER THAN 95, RECORD '95'.

633) How old is this person?

IF AGE IS GREATER THAN 95, RECORD '95'.

638) Apart from this person/these people have you had sexual intercourse with any other person in the past 12 months?

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

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95'.

640) In total, with how many different people have you had sexual intercourse in your lifetime?

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

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

642) Where is that?

Any other place?

PROBE TO DETERMINE EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE, RECORD THE NAME OF THE SOURCE.

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

SECTION 7. FERTILITY PREFERENCES

701) CHECK 311:

702) CHECK 226:

NOT PREGNANT OR DK:
Now I have some questions about the future. Would you like to have (a/nother) child or would you prefer not 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 to not have any more children?

703) CHECK 226:

NOT PREGNANT OR UNSURE:
How long would you like to wait starting from now before having a(nother) child?

PREGNANT:
After the child you are expecting now, how long would you like to wait starting from now before having another child?

704) CHECK 226:

705) CHECK 310: USING CONTRACEPTION?

706) CHECK 703:

707) CHECK 702:

WANTS TO HAVE A/ANOTHER CHILD:
You said that, right now, you did not want to have a/another child, but you are not currently using a method of contraception. Can you tell me why you are not using a method to prevent pregnancy?

Any other reason?

WANTS NO MORE/NONE:
You said that you did not want to have any (more) children, but you are not currently using a method of contraception. Can you tell me why you are not using a method to prevent pregnancy?

Any other reason?

RECORD ALL REASONS MENTIONED.

708) CHECK 310: USING A CONTRACEPTIVE METHOD?

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

713) CHECK 216:

HAS LIVING CHILDREN:
If you could go back to when you had no children and choose exactly the number of children to have in your life, how many would you have wanted?

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

PROBE FOR A NUMERICAL ANSWER.

714) Of these children, how many would you like to be boys, how many would you like to be girls, and for how many would the sex not matter?

715) In the past few months, have you:

Heard of family planning on the radio?
Heard of family planning on television?
Read something about family planning in:
- newspapers or magazines?
- posters/pamphlets?

717) CHECK 601:

718) CHECK 310:

USING A METHOD OF CONTRACEPTION?

720) Would you say that using contraception is mainly your decision, mainly your husband/partner's decision, or did you both decide together?

720A) Now I would like to ask you about your husband/partner's opinions about family planning.

Do you think that your husband/partner approves or disapproves of couples that use a method to avoid pregnancy?

720B) How many times, in the last twelve months, have you spoken about family planning with your husband/partner?

721) CHECK 311:

722) Does your husband/partner want the same number of children as you, or does he want more or fewer than you want?

SECTION 8. HUSBAND BACKGROUND AND WOMEN'S WORK

801) CHECK 601 AND 602:

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

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

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

805) What was the last (class/year) he completed at that level?

806) CHECK 801:

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

WAS MARRIED/LIVED WITH A MAN:
What was the occupation of your (last) husband/partner? That is to say, what kind of work was he doing mainly?

807) Aside from your own housework, have you done any work in the past seven days?

808) As you know, some women have jobs for which they are paid in cash or kind. Others have a small business, sell things, or work on the land or in the family business. Do you do something like this or any other kind work?

809) Although you did not work in the last seven days, did you have any job or business from which you were absent for leave, illness, vacation, or for another reason?

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

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

814) Do you work for a member of your family, someone else, or on your own?

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

817) For this work, are you paid in cash or kind, or are you not paid at all?

818) CHECK 601:

819) CHECK 817:

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

820A) On average, how much of your household expenses is paid by what you earn: almost nothing, less than half, nearly half or more than half?

820B) On average, how much of your earnings do you spend on household expenses: almost none, less than half, nearly half or more than half?

821) Would you say that the money you earn is more than what your husband/partner earns, less than what he earns, or about the same?

822) Who decides mainly how the money your husband/partner earns will be used?

823) Who usually has the last word in decisions about health care for yourself: you, your husband/partner, you and your husband/partner jointly, or someone else?

824) Who usually has the last word in decisions about making major household purchases?

825) Who usually has the last word in decisions about purchases for daily household needs?

826) Who usually has the last word in decisions about visits to your family or relatives?

826B) Who usually has the last word in decisions about what food will be prepared each day?

828) 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?

SECTION 9. MATERNAL MORTALITY

900) Now, I want to ask you questions about your brothers and sisters, that is to say, all children born to your natural mother.

Has your mother given birth to any children besides yourself?

901) How many boys did your mother have that are still alive?

902) Besides yourself, how many girls did your mother have that are still alive?

903) How many boys did your mother have that are now deceased?

904) How many girls did your mother have that are now deceased?

905) Did your mother give birth to other children who you do not know whether they are living or dead?

906) How many other children that you do not know whether they are living or dead did your mother give birth to?

907) ADD THE RESPONSES TO 901, 902, 903, 904, AND 906.

ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL.

908) CHECK 907:

Just to be sure I understood, including yourself, your mother gave birth to a total of ___ children. Is that correct?

909) CHECK 907:

910) How many births did your mother have before your birth?

Now I would like to make a list of your brothers and sisters, whether still living or not, beginning with the eldest.

RECORD THE NAME OF ALL BROTHERS AND SISTERS FROM THE SAME BIOLOGICAL MOTHER.

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

912) Is (NAME) male or female?

913) Is (NAME) still alive?

914) How old is (NAME)?

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

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

IF UNKNOWN, PROBE:
Did (NAME) die before the age of 12?

IF YES, RECORD '95'.
IF NOT, ASK OTHER QUESTIONS TO OBTAIN AN ESTIMATE.
FOR EXAMPLE: Did (NAME) die before getting married?

917) Was (NAME) pregnant when she died?

918) Did (NAME) die in childbirth?

919) Did (NAME) die in the two months following the end of pregnancy or of a birth?

920) How many live children did (NAME) give birth to in her lifetime?

IF NO MORE BROTHERS OR SISTERS, GO TO 1000.

SECTION 10. CHILDHOOD DEVELOPMENT AND EARLY LEARNING

1000) CHECK COVER PAGE:

1001) CHECK 217 AND 218:

A CHILD BETWEEN THE AGES OF 0 AND 4 LIVES IN THE HOUSEHOLD (217 = 0 AND 4 YEARS AND 218 = 1)?

1002) CHECK 217:

SELECT THE YOUNGEST CHILD BETWEEN 0 AND 4 YEARS. RECORD HIS/HER NAME AND LINE NUMBER.

1003) Now I would like to ask you some questions about (NAME OF YOUNGEST CHILD FROM QUESTION 219), your youngest child aged 0 - 4 years.

1004) How many children's books or picture books to you have for (NAME)?

1005) I would like to know which objects (NAME) uses to play when he/she is at home.

Does he/she play with:

a) Homemade toys (such as dolls, cars, or other homemade toys)?
b) Toys from a store or toymaker?
c) Household objects (such as bowls or pots) or object found outside (such as sticks, stones, animals, shells, or leaves)?

IF RESPONDENT ANSWERS 'YES' TO ANY OF THE ABOVE CATEGORIES, PROBE TO FIND OUT PRECISELY WITH WHAT THE CHILD PLAYS TO BE SURE OF THE RESPONSE.

1006) Sometimes, the adults who watch children have to leave the house to go shopping, do laundry, or for other reasons and have to leave young children.

In the last week, how often was (NAME):

a) left alone for more than an hour?
b) left under the care of another child (that is to say, someone under the age of 10) for more than an hour?

IF 'NEVER', RECORD '0'. IF 'DK', RECORD '8'

1007) CHECK 217: AGE OF CHILD:

1008) CHECK 217 AND 218:

A CHILD BETWEEN 3 AND 4 IS LIVING IN THIS HOUSEHOLD (217 = 3 OR 4 COMPLETED YEARS AND 218 = 1)?

1009) CHECK 217:

SELECT THE YOUNGEST CHILD BETWEEN 3 AND 4 YEARS AND RECORD HIS/HER NAME AND LINE NUMBER:

1010) Now I would like to ask you some questions about (NAME OF CHILD FROM 1009), your youngest child between 3 and 4 years old.

1011) Is (NAME OF CHILD FROM 1009) in an education program or preschool, as in a public or private school, including a nursery or community child care center?

1012) In the past 7 days, how many hours has (NAME) gone to this place?

1013) In the past three days, have you, or another member of your family over 15, participated in the following activities with (NAME)?

IF YES, ASK: Who participated in this activity with (NAME)?

CIRCLE ALL MENTIONED.

a) Read books or looked at picture books with (NAME)?
b) Told stories to (NAME)?
c) Sung songs to (NAME) or with (NAME), including lullabies?
d) Taken (NAME) for a walk outside the house, of the dwelling, yard, or property?
e) Played with (NAME)?
f) Spent time naming, counting, and/or drawing with (NAME)?

1014) Now I would like to ask some questions about the health and development of your child. Children do not develop in the same way and do not learn at the same speed. Some, for example, walk earlier than others. These questions concern several aspects of your child's development.

Does (NAME) know or can he/she recite at least ten letters of the alphabet?

1015) Can (NAME) read at least four simple, everyday words?

1016) Can (NAME) recite all the numbers from 1 to 10?

1017) Can (NAME) pick up something with two fingers, like a stick or pebble?

1018) Is (NAME) sometimes too sick to play?

1019) Can (NAME) follow simple instructions to do something correctly?

1020) When someone gives (NAME) something to do, can he/she do it independently?

1021) Does (NAME) get along with other children?

1022) Does (NAME) kick, bite or hit other children or adults?

1023) Is (NAME) easily distracted?

SECTION 11. HOUSEHOLD RELATIONS

1100) CHECK COVER PAGE (WOMAN SELECTED FOR THIS SECTION):

1101) CHECK FOR PRESENCE OF OTHERS.
DO NOT CONTINUE UNTIL IN PRIVATE.

READ TO RESPONDENT:

Now, I would like to ask you some questions about some aspects of relations in a couple. I know that some of these questions are very personal. However, your answers are very important in helping us understand the situation of women in Cameroon. I guarantee that your answers will stay totally confidential and will not be repeated to anyone. I would like to tell you that you are the only person in your household to whom these questions are asked and that no one will know that you were posed these questions. Finally, if anyone comes in during our discussion, we will change the subject.

1102) CHECK 601, 602, AND 303:

1103) Now I would like to ask you some questions about certain situations that some women experience. Please tell me if the following phrases apply to your relations with your (last) husband/partner?

a) He is/was jealous or angry if you speak/spoke to others?
b) He accuses/accused you frequently of being unfaithful?
c) He does not/did not allow you to see your female friends?
d) He tries/tried to limit your contact with your family?
e) He insist/insisted on knowing where you are/were at all times?
f) He does not/did not trust you with matters concerning money?
g) He threaten/threatened to kick you out, to leave you without a 'cent', or to reduce/restrict your access to money?

1104) Now, if you will allow me, I need to ask you some other questions about your (last) husband/partner.

A. Has he ever:

a) Said or done something to humiliate you in front of other people?

b) Threatened to harm you or someone close to you?

c) Insulted or belittled you?

CHECK 403: DO NOT ASK IF THE RESPONDENT IS A WIDOW.

B: In the last 12 months, has this happened often, sometimes, or never?

FOR DIVORCED/SEPARATED, ASK? In the last 12 months, has this happened often, sometimes, or never?

a) Said or done something to humiliate you in front of other people?

b) Threatened to harm you or someone close to you?

c) Insulted or belittled you?

1105)
A. Has your husband/partner ever done any of the following to you?

a) Shoved or shook you or thrown something at you?

b) Slapped you?

c) Twisted your arm or pulled your hair?

d) Hit you with his fist or anything else that might hurt you?

e) Have he ever kicked you, dragged you, or beaten you?

f) Tried to strangle you or burn you?

g) Threatened you with a knife, a pistol, or other type of weapon?

h) Physically forced you to have sexual relations when you did not want to?

i) Forced you to perform sexual acts that you did not want to perform?

CHECK 603: ONLY ASK IF THE RESPONDENT IS NOT A WIDOW.

B: In the last 12 months, has this happened often, sometimes, or never?

a) Shoved or shook you or thrown something at you?

b) Slapped you?

c) Twisted your arm or pulled your hair?

d) Hit you with his fist or anything else that might hurt you?

e) Has he ever kicked you, dragged you, or beaten you?

f) Tried to strangle you or burn you?

g) Threatened you with a knife, a pistol, or other type of weapon?

h) Physically forced you to have sexual relations when you did not want to?

i) Forced you to perform sexual acts that you did not want to perform?

1106) CHECK 1105 (a-i):

1107) How long after your (marriage/union/you began living together) with your (last) husband/partner did the following act(s) occur for the first time?

IF LESS THAN A YEAR, RECORD '00'.

1108) After any action on the part of your (last) husband/partner did you have one or more of the following problems?

a) Have cuts, hematoma, or bruises?

b) Have hematomas of the eye, sprains, dislocations or burns?

c) Have deep wounds, broken bones, broken teeth, or other serious injuries?

1109) Did you ever hit, slap, kick or do anything else to hurt physically your (last) husband/partner when he neither hit nor physically harmed you?

1110) CHECK 603:

1111) In the past 12 months, did you do this to your husband/partner often, sometimes, or never?

1112) Did your (last) husband/partner drink alcohol?

1113) Does/did he get drunk often, sometimes, or never?

1114) CHECK 601 AND 602:

HAS BEEN/IS MARRIED/IN UNION:
From age 15, has anyone else besides your (last) husband/partner/boyfriend beaten, slapped, kicked or did anything else to hurt you physically when you neither hit nor physically harmed them?

NEVER MARRIED/IN UNION:
From age 15, has anyone else beaten, slapped, kicked or did anything else to hurt you physically when you neither his nor physically harmed them?

1115) Who physically harmed you in this way?

Anyone else?

RECORD ALL MENTIONED.

1116) In the past 12 months, were you often, sometimes, or never beaten, slapped, kicked or harmed by this/these person(s)?

1117) CHECK 201, 226 AND 229:

1118) Have you ever been hit, slapped, kicked, or has anything else done to you to harm you while you were pregnant?

1119) Who physically harmed you while you were pregnant?

Anyone else?

RECORD ALL MENTIONED.

1120) CHECK 618: EVER HAD SEXUAL INTERCOURSE?

1121) The first time you had sexual relations, would you say that you wanted to have them, or were you forced against your will?

1122) CHECK 601 AND 602:

WAS/IS MARRIED/IN UNION:
In the past 12 months, has anyone else besides your husband/partner/boyfriend forced you to have sexual intercourse against your will?

NEVER MARRIED/IN UNION:
In the past 12 months, has anyone forced you to have sexual intercourse against your will?

1123) CHECK 1121 AND 1122:

1124) CHECK 1105(h) AND 1105(i):

1125) At any point in your life, whether as a child or as an adult, has anyone ever forced you by whatever means to perform sexual acts that you did not want to perform?

1126) How old were you when, for the first time, you were forced to have sex or perform sexual acts?

1127) Who forced you then?

1128) CHECK 1105A (a-i), 1114, 1118, 1121, 1122 and 1125:

1129) For everything that we just spoke about and that you went through, did you try to get help to get this/these person(s) to stop doing this to you?

1130) From whom did you seek assistance?

Anyone else?

RECORD ALL MENTIONED.

1131) Have you ever spoken to anyone about this?

1132) As far as you know, has your father ever beaten your mother?

THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER THAT HER ANSWERS WILL REMAIN CONFIDENTIAL. ANSWER THE BELOW QUESTIONS ONLY AS THEY RELATE TO THE HOUSEHOLD RELATIONS QUESTIONNAIRE.

1133) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULTS TRIED TO LISTEN OR CAME IN TO THE ROOM OR TRIED TO INTERFERE AT ANY TIME?

1134) INTERVIEWER COMMENTS: IF THE SURVEY COULD NOT BE ADMINISTERED, EXPLAIN REASONS

1135) RECORD THE TIME:

THIS HOUSEHOLD IS NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST: ___ (GO TO END)

SECTION 12. HIV/AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES

(ONLY IN HOUSEHOLDS SELECTED FOR THE MEN'S SURVEY AND HIV TEST)

1200) Now I would like to talk to you about something else. Have you ever heard of an illness called AIDS?

1201) Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

1202) Can people get the AIDS virus from mosquito bites?

1203) Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?

1204) Can people get the AIDS virus by sharing food with a person who has AIDS?

1205) Can people get the AIDS virus by witchcraft or other supernatural means?

1206) Is there something (else) a person can do to avoid catching the AIDS virus?

1207) What can be done?

Anything else?

RECORD ALL WAYS MENTIONED.

1208) Is it possible for a healthy-looking person to, in fact, have the AIDS virus?

1209) Do you know someone personally who has the AIDS virus or who died of AIDS?

1210) Can the virus that causes AIDS can be transmitted from mother to child:

During pregnancy?
During childbirth?
During breastfeeding?

1211) CHECK 1210:

1212) Are there any special drugs that a doctor or nurse can give to a woman infected with the AIDS virus to reduce the risk of transmission to her baby?

1213) Have you heard about specially antiretroviral drugs (USE LOCAL NAME) that people infected by the AIDS virus can get from a doctor or nurse to allow them to live for longer?

1214) CHECK 215:

1215) CHECK 407 FOR LAST BIRTH:

1216) CHECK FOR PRESENCE OF OTHERS BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

1217) During one of these prenatal visits for your last birth, did someone speak to you about one of the following subjects?

Babies getting the AIDS virus from their mothers?
Things you can do to prevent getting the AIDS virus?
Getting tested for the AIDS virus?

1218) Were you offered a test for the AIDS virus as part of this antenatal care?

1219) I don't want to know the results, but were you tested for the AIDS virus as part of your prenatal care?

1220) Where was the test done?

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

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, CTV CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

1221) I don't want to know the results, but have you gotten the test results?

1222) All women are supposed to receive counseling after being tested. After you were tested, did you receive counseling?

1223) CHECK 435 FOR THE LAST BIRTH:

1224) Between the time you went for delivery but before the baby was born, were you offered a test for the AIDS virus?

1225) I don't want to know the results, but were you tested for the AIDS virus at that time?

1226) I don't want to know the results, but did you get the results of the test?

1227) Have you been tested for the AIDS virus since that time you were tested during your pregnancy?

1228) When did you last take a test for the AIDS virus?

1229) I don't want to know the results, but have you ever been tested for the AIDS virus?

1230) When did you last take a test for the AIDS virus?

1231) The last time you had a test, did you ask to take it yourself, was it offered and you accepted, or was it obligatory?

1232) I don't want to know the results, but have you gotten the test results?

1233) Where was the test done?

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

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, CTV CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

1234) Do you know of a place where you could go to take a test for the AIDS virus?

1235) Where is that?

Anywhere else?

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

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

1236) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?

1237) If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?

1238) If someone in your family contracted the virus that causes AIDS, would you be willing to take care of him or her in your own household?

1239) If a female teacher has the AIDS virus, but is not sick, should she be allowed to continue teaching at the school?

1240) Should children age 12-14 be taught about using a condom to avoid getting AIDS?

1241) CHECK 1200:

HAS HEARD ABOUT AIDS:
Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

HAS NOT HEARD ABOUT AIDS:
Have you heard about infections that can be transmitted through sexual contact?

1242) CHECK 618:

1243) CHECK 1241: HAS HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

1244) Now I would like to ask you some questions about your health. In the last 12 months, have you had a disease which you got through sexual contact?

1245) Sometimes women experience an abnormal, bad-smelling discharge from their vaginas. In the past 12 months, have you had an abnormal discharge from your vagina?

1246) Sometimes women have a genital sore or ulcer. In the past 12 months, have you had a genital sore or ulcer?

1247) CHECK 1244, 1245, AND 1246:

1248) The last time you had (PROBLEM FROM 1244/1245/1246), did you seek any kind of advice or treatment?

1249) Where did you go?

Anywhere else?

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

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, CTV CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

1250) When you had (PROBLEM MENTIONED IN 1244/1245/1246), did you inform the person(s) with whom you have sexual intercourse?

1251) When you had (PROBLEM MENTIONED IN 1244/1245/1246), did you do something to avoid infecting your sexual partner(s)?

1252) What did you do to avoid infecting your partner(s)?

Did you?
Stop having sexual intercourse?
Use a condom during sexual intercourse?
Take medication?

1253) If a wife knows her husband has a disease that she can get during sexual intercourse, do you think she is justified in asking that they use a condom when they have sex?

1254) Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women?

1255) CHECK 601:

1256) Can you say no to your husband/partner if you do not want to have sexual intercourse?

1257) Could you ask your husband/partner to use a condom if you wanted him to?

SECTION 13. OTHER HEALTH ISSUES

(ONLY IN HOUSEHOLDS SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

1300) Now I want to ask you some other questions about relating to health matters. In the last 12 months, have you had an injection for any reason?

IF YES: How many injections have you had?

IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR IF DAILY FOR 3 MONTHS OR MORE, RECORD '90'.

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1301) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?

IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR IF DAILY FOR 3 MONTHS OR MORE, RECORD '90'.

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1302) Did the person who gave you the injection take the syringe and needle from a new, unopened package?

1303) Do you currently smoke cigarettes?

1304) In the last 24 hours, how many cigarettes did you smoke?

1305) Do you currently smoke or use any (other) type of tobacco?

1306) What (other) type of tobacco do you currently smoke or use?

RECORD ALL MENTIONED.

1307) 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?

Getting permission to go?
Getting money needed for advice or treatment?
The distance to the health facility?
Not wanting to go alone?

1308) Do you have medical insurance?

1309) What type of medical insurance?

RECORD ALL MENTIONED.

SECTION 14. DEVELOPMENT PARTICIPATION

(ONLY FOR HOUSEHOLDS SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

1401) Do you have any responsibility in your neighborhood/village/city?

IF YES: What?

1402) Do you own your own house?

IF YES: Do you have a title?

1403) Are you the owner of any empty land?

IF YES: Do you have a title?

1404) Are you a member:

a) of a cultural association?
b) of a religious association?
c) of a political association?
d) of a tontine?
e) of a development committee?
f) of a sports club?
g) of a club or association?
h) of a professional association?
i) of another type of organization?

1405) CHECK 1404 (a-i): MEMBER OF AT LEAST ONE ASSOCIATION

1406) CHECK 1404 (h): MEMBER OF A PROFESSIONAL ASSOCIATION

1407) What professional association do you belong to?

IF MORE THAN ONE ASSOCIATION MENTIONED, DETERMINE THE LARGEST AND RECORD IT.

1408) Do you have responsibilities within at least one of these associations/organizations?

1409) Over the past 24 months have you obtained any credit?

1410) What was the primary reason you obtained credit the last time?

1411) Where did you receive credit from the last time you got it?

1412) RECORD THE TIME:

INTERVIEWER OBSERVATIONS

TO BE FILLED OUT AFTER COMPLETING THE INTERVIEW.

COMMENTS ON THE RESPONDENT ___

COMMENTS ON SPECIFIC ISSUES ___

OTHER COMMENTS ___

SUPERVISOR OBSERVATIONS:

NAME OF SUPERVISOR ___
DATE ___

EDITOR'S OBSERVATIONS

EDITOR NAME ___
DATE ___