MINISTRY OF HEALTH, GHANA
GHANA STATISTICAL SERVICE

IDENTIFICATION

LOCALITY NAME _____

NAME OF HOUSEHOLD HEAD _____

CLUSTER NUMBER _____

STRUCTURE NUMBER _____

HOUSEHOLD NUMBER _____

REGION _____

DISTRICT _____

URBAN/RURAL:

NAME AND LINE NUMBER OF MAN _____

INTERVIEW VISITS

FIRST VISIT: (REPEAT FOR SECOND AND THIRD VISITS)

DATE _____
INTERVIEWER'S NAME _____
RESULT* ______

NEXT VISIT:
DATE _____
TIME _____

FINAL VISIT:
DAY ___
MONTH ___
YEAR 2014
INT. NUMBER ___
RESULT ___

RESULT CODES:

TOTAL NUMBER OF VISITS _____

LANGUAGE OF QUESTIONNAIRE: 1

LANGUAGE OF INTERVIEW:

LANGUAGE OF RESPONDENT:

TRANSLATOR USED:

LANGUAGE OF QUESTIONNAIRE:

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR ___

KEYED BY ___

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is _______________. I am working with Ghana Statistical Service and the Ministry of Health. We are conducting a survey about health all over Ghana. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.
In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.
Do you have any questions? May I begin the interview now?

SIGNATURE OF INTERVIEWER: __________
DATE: _____

101) RECORD THE TIME.

101A) During the interview I would like to measure your blood pressure. This will be done three times during the interview. This is a harmless procedure. It is used to find out if a person has high blood pressure. If it is not treated, high blood pressure may eventually cause serious damage to the heart.

The results of this blood pressure measurement will be given to you after the interview together with an explanation of the meaning of cannot provide any further testing or treatment during the survey. Do you have any questions about the blood pressure measurement so far? If you have any questions about the procedure at any time, please ask me. You can say yes or no to having the blood pressure measurement now. You can also decide at any time not to participate in the blood pressure measures.

Would you allow me to take your blood pressure measurement at this time?

Signature of interviewer: _________________
Date: _____

101B) Before taking your blood pressure, I would like to ask a few questions about things that may affect these measurements.

Have you done any of the following within the past 30 minutes:

a) Eaten anything?
b) Had coffee, tea, cola or other drink that has caffeine?
c) Smoked any tobacco product?
d) Conducted any vigorous physical activity or exercises?

101C) May I begin the process of measuring your blood pressure?

BEFORE TAKING THE FIRST BLOOD PRESSURE READING, MEASURE THE CIRCUMFERENCE OF THE RESPONDENT'S ARM MIDWAY BETWEEN THE ELBOW AND THE SHOULDER.

RECORD THE MEASUREMENT IN CENTIMETERS.

101D) USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR MODEL AND CUFF SIZE. CIRCLE THE CODE FOR THE MODEL AND CUFF SIZE.

MODEL 767

MODEL 789

101E) TAKE THE FIRST BLOOD PRESSURE READING.
RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE. THEN PROCEED TO Q102.
IF YOU ARE UNABLE TO MEASURE THE RESPONDENT'S BLOOD PRESSURE, RECORD THE REASON.

102) In what month and year were you born?

103) How old were you at your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

104) Have you ever attended school?

105) What is the highest level of school you attended: primary, middle/JSS/JHS, secondary/SSS/SHS, or higher?

106) What is the highest (grade) you completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

106A) CHECK 103:

106B) At what age did you enroll in primary school?

106C) Are you currently attending school at any level?

106D) Why did you stop attending school?

107) CHECK 105:

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

SHOW CARD TO RESPONDENT.
IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE:

Can you read any part of the sentence to me?

109) CHECK 108:

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

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

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

113) What is your religion?

114) To which ethnic group do you belong?

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

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

SECTION 2. REPRODUCTION

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

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

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

IF NONE, RECORD '00'.

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

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

IF NONE, RECORD '00'.

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

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

IF NONE, RECORD '00'.

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

IF NONE, RECORD '00'.

209) CHECK 208:

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

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

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

213) CHECK 203 AND 205:

214) How old is your (youngest) child?

215) CHECK 214:

216) What is he name of your (youngest) child?

WRITE NAME OF (YOUNGEST) CHILD:

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

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

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

219A) What was the main reason why (NAME)'s mother did not deliver in a hospital or health facility?

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

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)?

302) In the last few months have you:

a) Heard about family planning on the radio?
b) Seen anything about family planning on the television?
c) Read about family planning in a newspaper or magazine?

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

304) Now I would like to ask you about a woman's risk of pregnancy. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant when she has sexual relations?

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

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

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

307) CHECK 301 (07):
KNOWS MALE CONDOM

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

309) Where is that?
Any other place?

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

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

311) CHECK 301 (08):
KNOWS FEMALE CONDOM

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

313) Where is that?
Any other place?

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

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

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

401A) Was bridewealth negotiated in your current union?

401B) Why was the bridewealth not negotiated?

401C) What is the status of the bridewealth in your current union?

401D) Why was the bridewealth not completely paid?

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

403) What is your marital status now; are you widowed, divorced, or separated?

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

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

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

407) CHECK 405:

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

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

RECORD THE NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER. IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

408) ASK 408 FOR EACH PERSON.
How old was (NAME) on her last birthday?

409) CHECK 407:

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

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

411A) Now I would like to ask about your first (wife/partner). In what month and year did you start living with her?

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

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

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

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

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

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

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

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

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

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

420) What was your relationship to this person with whom you had sexual intercourse?
IF GIRLFRIEND: Were you living together as if married?

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

421) CHECK 410:

422) CHECK 414:

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

424) How many times during the last 12 months did you have sexual intercourse with this person?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, WRITE '95'.

425) How old is this person?

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

427) In total, with how many different people have you had sexual intercourse with in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95'.

428) CHECK 420 (ALL COLUMNS):

429) CHECK 420 AND 418 (ALL COLUMNS):

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

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

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

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

434) 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'.

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

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

437) From where did you obtain the condom the last time?
PROBE TO IDENTIFY TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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

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

RECORD ALL MENTIONED.

SECTION 5. FERTILITY PREFERENCES

500) CHECK 101A:

500A) RECORD THE TIME.

500B) May I measure your blood pressure at this time?

500C) TAKE THE BLOOD PRESSURE READING.
RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE. THEN PROCEED TO Q501.
IF YOU ARE UNABLE TO MEASURE THE RESPONDENT'S BLOOD PRESSURE, RECORD THE REASON.

501) CHECK 401:

502) CHECK 439:

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

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

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

506) CHECK 407:

507) CHECK 503:

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

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

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

509) CHECK 203 AND 205:

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

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

PROBE FOR A NUMERIC RESPONSE.

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

SECTION 6. EMPLOYMENT AND GENDER ROLES

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

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

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

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

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

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

607) CHECK 401:

608) CHECK 606:

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

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

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

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

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

614) In your opinion, is a husband justified in hitting or beating his wife in the following situations:

a) If she goes out without telling him?
b) If she neglects the children?
c) If she argues with him?
d) If she refuses to have sex with him?
e) If she burns the food?

SECTION 7. HIV/AIDS

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

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

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

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

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

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

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

708) Can the virus that causes AIDS be transmitted from a mother to her baby:

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

709) CHECK 708:

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

710A) Have you heard about special antiretroviral drugs (e.g. ARV, Nevirapine, zidovudine, lamivudine) that people infected with the AIDS virus can get from a doctor or a nurse to help them live longer?

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

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

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

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

715) Where was the test done?

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

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

717) Where is that?
Any other place?

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

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

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

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

721) In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?

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

723) CHECK 701:

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

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

724) CHECK 414:

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

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

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

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

729) CHECK 726, 727, AND 728:

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

731) Where did you go?
Any other place?

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

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

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

SECTION 8. OTHER HEALTH ISSUES

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

802) How old were you when you got circumcised?

803) Who did the circumcision?

804) Where was it done?

805) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?

IF YES: How many injections have you had?

IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

806) 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 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

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

808) Do you currently smoke cigarettes?

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

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

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

812) Are you covered by any health insurance?

812A) Are you registered with the National Health Insurance Scheme (NHIS)?

813) What type of health insurance are you (covered/registered) by?
RECORD ALL MENTIONED.

814) Does you insurance cover any of the following maternity benefits:

a) Antenatal health care?
b) Childbirth health care in health facility?
c) Postnatal health care for the mother?
d) Postnatal health care for the child?
e) Cash benefits during maternity leave?
f) Other?

815) CHECK 813:

816) Why have not registered with the National Health Insurance Scheme (NHIS)?
RECORD ALL MENTIONED.

817) Did you pay your NHIS membership yourself?

818) Do you hold a valid National Health Insurance Scheme (NHIS) card?
IF ANSWER IS 'YES', REQUEST TO SEE THE CARD.

819) Why do you not have a valid NHIS card?

820) How many weeks did it take you to obtain your NHIS card?

821) Do you plan to renew the NHIS card?

822) Why do you not want to renew the NHIS card?
Anything else?
RECORD ALL MENTIONED.

823) Do you have to pay out of pocket for drugs and services?

824) Are there any services that you need from a health provider that are not covered by NHIS?

825) What are these services?
Anything else?
RECORD ALL MENTIONED.

826) In your opinion, do NHIS card holders get better, the same, or worse service than others?

827) In your opinion, did you receive good service last time you were treated at a clinic or hospital? IF NO, PROBE: "What was the main problem?"

828) Are you aware of any programs that help pregnant women accessing health services?

829) Which ones?
RECORD ALL MENTIONED.

830) Are you aware of any programs that help children under age 18 accessing health services?

831) Which ones?
RECORD ALL MENTIONED.

832) These next questions are about common health problems in Ghana.
Have you ever heard of an illness called tuberculosis or TB?

833) How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORD ALL MENTIONED.

834) Can tuberculosis be cured?

835) If a member of your family got tuberculosis, would you want it to remain a secret or not?

836) These next questions are about blood pressure.
Have you ever been told by a doctor or other health professional that you had hypertension or high blood pressure?

837) Were you told on two or more different occasions by a doctor or other health professional that you had hypertension or high blood pressure?

838) To lower your hypertension or high blood pressure, are you now:

a) Taking prescribed medicine?
b) Controlling your weight or losing weight?
c) Cutting down on salt in your diet?
d) Exercising?
e) Cutting down on alcohol?
f) Stopping smoking?

839) Have you ever heard about iodized salt?

840) Can you mention benefits for consuming iodized salt?
PROBE: Any other benefits?
RECORD ALL MENTIONED.

841) How can you tell iodized salt from non-iodized salt?
RECORD ALL MENTIONED.

842) During the last 7 days, on how many days did you eat fruits, for example, mangoes, pawpaw, banana, orange, avocados, tomatoes, passion fruit, etc?

844) During the last 7 days, on how many days did you eat vegetables, for example carrots, cabbage, dark green, leafy vegetables (e.g. kontomire), pumpkin, squash, etc?

846) In the last 6 months, did you visit a health facility?

847) What type of facility did you visit during your most recent visit?

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

848) What type of service did you receive during this most recent visit?

849) How did you pay for the service during this most recent visit?

850) Now I want to ask you about the ease of getting care. In your opinion, was it very easy, easy, fairly easy, difficult, or very difficult to see the health provider?

851) Is the location of the health facility very convenient, convenient, fairly convenient, not convenient, or very inconvenient for you?

852) Are the hours the health facility open during the day very good, good, fair, poor, or very poor for you?

853) Now I want to talk about waiting time at the health facility.

Were you very satisfied, satisfied, fairly satisfied, not satisfied, or very dissatisfied about:

854) Were you very satisfied, satisfied, fairly satisfied, not satisfied, or very dissatisfied with the staff at the health facility when they:

855) In your opinion, did the health provider spend enough time with you?

856) Did the health provider seek your consent before providing treatment?

857) Was the health provider friendly to you?

858) Now I want to ask you about the condition of the health facility.

Were you very satisfied, satisfied, fairly satisfied, not satisfied, or very dissatisfied with:

859) CHECK 101A:

860) RECORD THE TIME.

861) May I measure your blood pressure at this time?

862) TAKE THE BLOOD PRESSURE READING.
RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE. THEN PROCEED TO Q901.
IF YOU ARE UNABLE TO MEASURE THE RESPONDENT'S BLOOD PRESSURE, RECORD THE REASON.

SECTION 9. AVERAGING BLOOD PRESSURE MEASURES

901) CHECK Q500C AND Q862:

902) RECORD AND CALCULATE THE AVERAGE OF THE SYSTOLIC AND DIASTOLIC BLOOD PRESSURE FROM Q500C AND Q862.

903) BLOOD PRESSURE MEASUREMENTS FROM Q500C:

904) BLOOD PRESSURE MEASUREMENTS FROM Q862:

905) RECORD THE SUM OF THE SYSTOLIC AND DIASTOLIC MEASURES.

906) CALCULATE THE AVERAGE SYSTOLIC AND DIASTOLIC PRESSURES BY DIVIDING THE SUM IN Q905 BY 2.

907) CHECK Q862:

908) CHECK Q500C:

909) CHECK Q101E:

910) RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

911) USE THE TABLE BELOW TO DETERMINE THE CORRECT CODE TO RECORD ON THE BLOOD PRESSURE REPORT AND REFERRAL FORM.
CIRCLE THE ROW IN WHICH THE VALUE FOR THE SYSTOLIC BLOOD PRESSURE FROM Q906 OR Q910 IS FOUND.
THEN CIRCLE THE COLUMN IN WHICH THE VALUE FOR THE DIASTOLIC BLOOD FROM Q906 OR Q910 IS FOUND.
THE VALUE WHERE THE ROW AND COLUMN YOU HAVE CIRCLED INTERSECT IN THE TABLE WILL BE USED IN COMPLETING Q912.

912) RECORD THE NUMBER YOU CIRCLED IN Q911 IN THE CHART BELOW. THEN USE THE INSTRUCTIONS TO THE RIGHT OF THAT NUMBER TO COMPLETE A BLOOD PRESSURE REPORT AND REFERRAL FORM FOR THE RESPONDENT. GIVE THE FORM TO THE RESPONDENT AND ANSWER ANY QUESTIONS HE MAY HAVE.

913) Thank you for taking the time to answer these questions.
RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

SUPERVISOR'S OBSERVATIONS _______________________________________________

EDITOR'S OBSERVATIONS ________________________________________