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2014 LESOTHO DEMOGRAPHIC AND HEALTH SURVEY
WOMAN'S QUESTIONNAIRE

IDENTIFICATION:

PLACE NAME ____

NAME OF HOUSEHOLD HEAD ____

EA NUMBER ____

HOUSEHOLD NUMBER ____

LESOTHO ECOLOGICAL ZONE

LOWLANDS 1
FOOTHILLS 2
MOUNTAINS 3
SENQU RIVER VALLEY 4

DISTRICT CODE* ____

*DISTRICT CODES:

01 BUTHA-BUTHE
02 LERIBE
03 BEREA
04 MASERU
05 MAFETENG
06 MOHALE'S HOEK
07 QUTHING
08 QACHA'S NEK
09 MOKHOTLONG
10 THABA-TSEKA

URBAN/RURAL

URBAN 1
RURAL 2

HOUSEHOLD SELECTED FOR MALE SURVEY AND BIOMARKER COLLECTION?

YES 1
NO 2

INTERVIEWER VISITS:

FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT CODE**

NEXT VISIT:
DATE ____
TIME ____

SECOND VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT CODE**

NEXT VISIT:
DATE ____
TIME ____

THIRD VISIT
DATE ____
INTERVIEWER'S NAME____
RESULT CODE**

FINAL VISIT
DAY ____
MONTH ____
YEAR 2014
INT. NUMBER ____
RESULT CODE**

TOTAL NUMBER OF VISITS ____

**RESULT CODES:

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ____

TOTAL PERSONS IN HOUSEHOLD____

TOTAL ELIGIBLE WOMEN____

TOTAL ELIGIBLE MEN____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___

LANGUAGE OF QUESTIONNAIRE*** 2

LANGUAGE OF QUESTIONNAIRE*** ENGLISH

LANGUAGE OF INTERVIEW***

***LANGUAGE CODES:

1 SESOTHO
2 ENGLISH

TRANSLATOR USED

YES 1
NO 2

SUPERVISOR
NAME ____
DATE ____

SECTION 1. RESPONDENT'S BACKGROUND:

INFORMED CONSENT

Hello. My name is _______________. I am with the Ministry of Health. We are conducting a survey about health all over the country. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 to 60 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: ____

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

101) RECORD THE TIME

HOUR ____
MINUTES ____

101A) CHECK COVER PAGE OF WOMAN'S QUESTIONNAIRE: IS HOUSEHOLD SELECTED FOR MALE SURVEY AND BIOMARKERS?

YES (GO TO 101B)
NO (GO TO 102)

101B) 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 your blood pressure numbers. If your blood pressure is high, we will suggest that you consult a health facility or doctor since we 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 proceed to take your blood pressure measurement at this time?

SIGNATURE OF INTERVIEWER: ____
DATE: ____

RESPONDENT AGREES 1 (GO TO 101C)
RESPONDENT DOES NOT AGREE 2 (GO TO 102)

101C) 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?

A) EATEN
YES 1
NO 2
B) HAD CAFFEINATED DRINK
YES 1
NO 2
C) SMOKED
YES 1
NO 2

101D) 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.

ARM CIRCUMFERENCE (IN CENTIMETERS) ____

101E) USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE CUFF SIZE. RECORD THE CODE FOR CUFF SIZE

SMALL: 17 CM - 22 CM 1
MEDIUM: 23 CM -32 CM 2
LARGE: 33 CM - 42 CM 3

101F) TAKE THE FIRST BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SYSTOLIC ____
DIASTOLIC ____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

102) In what month and year were you born?

MONTH ____
DON'T KNOW MONTH 98
YEAR ____
DON'T KNOW YEAR 9998

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

AGE IN COMPLETED YEARS ____

104) Have you ever attended school?

YES 1
NO 2 (GO TO 108)

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

PRIMARY 1
VOCATIONAL/TECHNICAL TRAINING AFTER PRIMARY 2
SECONDARY/HIGH 3
VOCATIONAL/TECHNICAL TRAINING AFTER SECONDARY/HIGH 4
COLLEGE 5
GRADUATE/POST GRADUATE 6

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

STANDARD/FORM/YEAR ____

107) CHECK 105:

PRIMARY OR VOCATIONAL/TECH. AFTER PRIMARY (GO TO 108)
SECONDARY OR HIGHER (GO TO 110)

108) Now I would like you to read this sentence to me. SHOW CARD TO RESPONDENT. IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

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

109) CHECK 108:

CODE '2', '3' OR '4' RECORDED (GO TO 110)
CODE '1' OR '5' RECORDED (GO TO 111)

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

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

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

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

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

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

113) What religion do you belong to?

IF CHRISTIAN: What church do you belong to?

ROMAN CATHOLIC CHURCH 01
LESOTHO EVANGELICAL CHURCH 02
METHODIST 03
ANGLICAN CHURCH 04
SEVENTH DAY ADVENTIST 05
PENTECOSTAL 06
OTHER CHRISTIAN 07
ISLAM 08
HINDU 09
NONE 10
OTHER RELIGION 96

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

NUMBER OF TIMES ____
NONE 00 (GO TO 122)

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

YES 1
NO 1 (GO TO 122)

117) The last time you were away for more than a month, how many months were you away?

IF 12 MONTHS OR MORE, RECORD '95.'

NUMBER OF MONTHS ____
12 OR MORE MONTHS 95

118) Where did you go?

ELSEWHERE IN LESOTHO 1
RSA 2
OTHER 3

120) Why did you go there? PROBE: What was the main purpose of your trip?

WORK 1
SCHOOL/UNIVERSITY 2
FAMILY/MARRIAGE 3
ACCESS HEALTH OR OTHER SERVICES 4
OTHER 6

121) CHECK 117

'1' OR '2' MONTHS (GO TO 122)
'3' OR MORE MONTHS (GO TO 125)

122) In the last 5 years, how many times have you been away from home for three or more months at a time?

NUMBER OF TIMES _____
NONE 00 (GO TO 201)

123) The most recent time you were away from home for three or more months, where did you go?

ELSEWHERE IN LESOTHO 1
RSA 2
OTHER 6

124) Why did you go there? PROBE: What was the main purpose of your trip?

WORK 1 (GO TO 201)
SCHOOL/UNIVERSITY 2 (GO TO 201)
FAMILY/MARRIAGE 3 (GO TO 201)
ACCESS HEALTH OR OTHER SERVICES 4 (GO TO 201)
OTHER 6 (GO TO 201)

125) Including the time you already mentioned, in the last 5 years, how many times have you been away from home for three or more months at a time?

NUMBER OF TIMES____
ONE TIME 01

SECTION 2. REPRODUCTION:

201) Now I would like to ask about all the births you have had during your life. Have you ever given birth?

YES 1
NO 2 (GO TO 206)

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

YES 1
NO 2 (GO TO 204)

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

a) SONS AT HOME ____
b) DAUGHTERS AT HOME ____

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

YES 1
NO 2 (GO TO 206)

205) How many sons are alive but do not live with you?
And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'.

a) SONS ELSEWHERE ____
b) DAUGHTERS ELSEWHERE ____

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

YES 1
NO 2 (GO TO 208)

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

a) BOYS DEAD ____
b) GIRLS DEAD ____

208) SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'.

TOTAL BIRTHS ____

209) CHECK 208:

Just to make sure that I have this right: you have had in TOTAL ____ births during your life. Is that correct?

YES (GO TO 210)
NO (PROBE AND CORRECT 201-208 AS NECESSARY.)

210) CHECK 208:

ONE OR MORE BIRTHS (GO TO 211)
NO BIRTHS (GO TO 226)

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

RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS. (IF THERE ARE MORE THAN 6 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW).

212) What name was given to your (first/next) baby? RECORD NAME.

NAME ____
BIRTH HISTORY NUMBER ____

213) Were any of these births twins?

SINGULAR 1
MULTIPLE 2

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

BOY 1
GIRL 2

215) In what month and year was (NAME) born? PROBE: When is his/her birthday?

MONTH ____
YEAR ____

215A) IF BIRTH SINCE JANUARY 2009: ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE. ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD BELOW. IN THE CALENDAR, PLACE A 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF THE PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT [Transcriber note: survey text cuts off at this point]

MONTH ____

216) Is (NAME) still alive?

YES 1
NO 2 (GO TO 220)

217) IF ALIVE: How old was (NAME) at his/ her last birthday? RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS ____

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

YES 1
NO 2

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

HOUSEHOLD LINE NUMBER ____ (GO TO NEXT BIRTH)

220) IF DEAD: How old was (NAME) when he/she died? IF '1 YR', PROBE: How many months old was (NAME)?

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

DAYS 1 ____
MONTH 2 ____
YEARS 3 ____

221) Were any other live births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth? [DO NOT ASK FOR MOST RECENT BIRTH]

YES 1 (ADD BIRTH)
NO 2 (NEXT BIRTH)

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

IF YES, RECORD BIRTH(S) IN TABLE.

YES 1
NO 2

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

NUMBERS ARE SAME (GO TO 224)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

224) CHECK 215: ENTER THE NUMBER OF BIRTHS IN 2009 OR LATER.

NUMBER OF BIRTHS____
NONE 0

226) Are you pregnant now?

YES 1
NO 2 (GO TO 230)
UNSURE 8 (GO TO 230)

227) How many months pregnant are you? RECORD NUMBER OF COMPLETED MONTHS.

C: ENTER 'P'S IN CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

MONTHS ____

228) When you got pregnant, did you want to get pregnant at that time?

YES 1 (GO TO 230)
NO 2

229) Did you want to have a baby later on or did you not want any (more) children?

LATER 1
NO MORE 2

230) Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?

YES 1
NO 2 (GO TO 238)

231) When did the last such pregnancy end?

MONTH ____
YEAR ____

232) CHECK 231:

LAST PREGNANCY ENDED IN JANUARY 2009 OR LATER (GO TO 233)
LAST PREGNANCY ENDED BEFORE JANUARY 2009 (GO TO 238)

232A) C:
In what month and year did that pregnancy end?

MONTH ____
YEAR ____

233) C:
How many months pregnant were you when that pregnancy ended?

NUMBER OF MONTHS ____

234) C:
Since January 2009, have you had any other pregnancies that did not result in a live birth?

YES 1 (GO TO NEXT LINE)
NO 2 (GO TO 235)

235) C:
FOR EACH PREGNANCY THAT DID NOT RESULT IN A LIVE BIRTH IN JANUARY 2009 OR LATER, ENTER 'T' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS OF PREGNANCY.

IF THERE ARE MORE THAN FOUR PREGNANCIES THAT DID NOT END IN A LIVE BIRTH, USE AN ADDITIONAL QUESTIONNAIRE STARTING ON THE SECOND LINE.

236) Did you have any miscarriages, abortions or stillbirths that ended before 2009?

YES 1
NO 2 (GO TO 238)

237) When did the last such pregnancy that terminated before 2009 end?

MONTH ____
YEAR ____

238) When did your last menstrual period start?

(DATE, IF GIVEN) ____
DAYS AGO 1 ____
WEEKS AGO 2 ____
MONTHS AGO 3 ____
YEARS AGO 4 ____

IN MENOPAUSE/HAS HAD HYSTERECTOMY 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

239) From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant?

YES 1
NO 2 (GO TO 301)
DON'T KNOW 8 (GO TO 301)

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

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

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)?

METHOD 1 FEMALE STERILIZATION. PROBE: Women can have an operation to avoid having any more children.
YES 1
NO 2
METHOD 2 MALE STERILIZATION. PROBE: Men can have an operation to avoid having any more children.
YES 1
NO 2
METHOD 3 IUCD. PROBE: Women can have a loop or coil placed inside them by a doctor or nurse.
YES 1
NO 2
METHOD 4 INJECTABLES/DEPO. PROBE: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2
METHOD 5 IMPLANTS. PROBE: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2
METHOD 6 PILL. PROBE: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
METHOD 7 MALE CONDOM. PROBE: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
METHOD 8 FEMALE CONDOM. PROBE: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2
METHOD 9 RHYTHM METHOD. PROBE: To avoid pregnancy, women do not have sexual intercourse on the days of the month they think they can get pregnant.
YES 1
NO 2
METHOD 10 WITHDRAWAL. PROBE: Men can be careful and pull out before climax.
YES 1
NO 2
METHOD 11 EMERGENCY CONTRACEPTION/MORNING AFTER PILL. PROBE: As an emergency measure, within five days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
YES 1
NO 2
METHOD 12 Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES 1 (SPECIFY) ____
NO 2

302) CHECK 226:

NOT PREGNANT OR UNSURE (GO TO 303)
PREGNANT (GO TO 311)

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

YES 1
NO 2 (GO TO 311)

304) Which method are you using? RECORD ALL MENTIONED.

IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION A (GO TO 307)
MALE STERILIZATION B (GO TO 307)
IUCD C (GO TO 308A)
INJECTABLES D (GO TO 308A)
IMPLANTS E (GO TO 308A)
PILL F (GO TO 308A)
MALE CONDOM G (GO TO 308A)
FEMALE CONDOM H (GO TO 308A)
RHYTHM METHOD I (GO TO 308A)
WITHDRAWAL J (GO TO 308A)
OTHER MODERN METHOD X (GO TO 308A)
OTHER TRADITIONAL METHOD (GO TO 308A)

307) In what facility did the sterilization take place? PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

NAME OF PLACE ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
FAMILY PLANNING CLINIC 12
OTHER PUBLIC SECTOR (SPECIFY) ____ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ 26
CHAL
CHAL HOSPITAL 31
FACILITY OUTSIDE LESOTHO 41
OTHER (SPECIFY) ____ 96

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

308A) Since what month and year have you been using (CURRENT METHOD) without stopping?

PROBE: For how long have you been using (CURRENT METHOD) now without stopping?

MONTH ____
YEAR ____

309) CHECK 308/308A, 215 AND 231:

ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 308/308A

YES (GO BACK TO 308/308A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION).
NO (GO TO 310)

310) CHECK 308/308A:

YEAR IS 2009 OR LATER
C: ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND IN EACH MONTH BACK TO THE DATE STARTED USING.
YEAR IS 2008 OR EARLIER
C: ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK TO JANUARY 2009. (GO TO 322)

311) I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.

C: PROBE FOR EARLIER INTERVALS OF USE AND NONUSE, STARTING WITH MOST RECENT GAP BACK TO JANUARY 2009. USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS. ENTER METHOD AND DISCONTINUATION CODES FROM THE CALENDAR.

311A) INTERVAL OF USE OR NON-USE

311B) MONTH AND YEAR OF START OF INTERVAL OF USE OR NON-USE.

MONTH ____
YEAR ____

311C) Between (EVENT) in (MONTH/YEAR) and (EVENT) in (MONTH/YEAR), did you or your (husband/partner) use any method of contraception?

YES, USED A METHOD 1
NO, DID NOT USE A METHOD (GO TO 311B OF NEXT COLUMN)

311D) Which method was that? SEE CALENDAR FOR CODES.

METHOD ____

311E) How many months after (EVENT) in (MONTH/YEAR) did you start to use (METHOD)?

RECORD '95' IF RESPONDENT GIVES THE DATE OF STARTING TO USE THE METHOD.

IMMEDIATELY 00 (GO TO 311G)
MONTHS ____ (GO TO 311G)
DATE GIVEN 95

311F) RECORD MONTH AND YEAR RESPONDENT STARTED USING METHOD.

MONTH ____
YEAR ____

311G) For how many months did you use (METHOD)?

RECORD '95' IF RESPONDENT GIVES THE DATE OF TERMINATION OF USE.

MONTHS ____ (GO TO 311J)
DATE GIVEN 95

311H) RECORD THE MONTH AND YEAR RESPONDENT STOPPED USING METHOD.

MONTH ____
YEAR ____

311J) Why did you stop using (METHOD)?

SEE CALENDAR FOR CODES.

INFREQUENT SEX/HUSBAND AWAY 0
BECAME PREGNANT WHILE USING 1
WANTED TO BECOME PREGNANT 2
HUSBAND/PARTNER DISAPPROVED 3
WANTED MORE EFFECTIVE METHOD 4
SIDE EFFECTS/HEALTH CONCERNS 5
LACK OF ACCESS/TOO FAR 6
COSTS TOO MUCH 7
INCONVENIENT TO USE 8
UP TO GOD/FATALISTIC F
DIFFICULT TO GET PREGNANT/MENOPAUSAL A
MARITAL DISSOLUTION/SEPARATION D
OTHER (SPECIFY) ____ X
DON'T KNOW Z

311K) GO BACK TO 311B IN NEXT COLUMN; OR, IF NO MORE GAPS, GO TO 312.

312) CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH.

NO METHOD USED (GO TO 313)
ANY METHOD USED (GO TO 314)

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

YES 1 (GO TO 324)
NO 2 (GO TO 324)

314) CHECK 304:

RECORD METHOD CODE:

IF MORE THAN ONE METHOD CODE RECORDED IN 304, RECORD CODE FOR HIGHEST METHOD IN LIST.

NO CODE RECORDED 00 (GO TO 324)
FEMALE STERILIZATION 01 (317A)
MALE STERILIZATION 02 (GO TO 326)
IUCD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
MALE CONDOM 07
FEMALE CONDOM 08
RHYTHM METHOD 09 (GO TO 315A)
WITHDRAWAL 10 (GO TO 326)
OTHER MODERN METHOD (GO TO 326)
OTHER TRADITIONAL METHOD (GO TO 326)

315) You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time?

315A) Where did you learn how to use the rhythm method?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

NAME OF PLACE ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
GOVERNMENT HEALTH POST 13
FAMILY PLANNING CLINIC 14
OTHER PUBLIC SECTOR (SPECIFY) ____ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
LESOTHO PLANNED PARENTHOOD 24
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ 26
CHAL
CHAL HOSPITAL 31
CHAL HEALTH CENTER 32
CHAL HEALTH POST 33
RED CROSS HEALTH CENTER 41
CBD 51
VILLAGE HEALTH WORKER 52
SUPPORT GROUPS 53
FACILITY OUTSIDE LESOTHO 61
OTHER SOURCE
SHOP 71
CHURCH 72
PEER EDUCATORS 73
FRIEND/RELATIVE 74
OTHER (SPECIFY) ____ 96

316) CHECK 304:

RECORD METHOD CODE:

IF MORE THAN ONE METHOD CODE RECORDED IN 304, RECORD FOR HIGHEST METHOD IN LIST.

IUCD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
MALE CONDOM 07 (GO TO 323)
FEMALE CONDOM 08 (GO TO 320)
RHYTHM METHOD 09 (GO TO 326)

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

317A) When you got sterilized, were you told about side effects or problems you might have with the method?

YES 1 (GO TO 319)
NO 2

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

YES 1
NO 2 (GO TO 320)

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

YES 1
NO 2

320) CHECK 317:

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

CODE '1' NOT RECORDED: When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?

YES 1 (GO TO 322)
NO 2

321) Were you ever told by a health or family planning worker about other methods of family planning that you could use?

YES 1
NO 2

322) CHECK 304:

RECORD METHOD CODE:

IF MORE THAN ONE METHOD CODE RECORDED IN 304, RECORD CODE FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION 01 (GO TO 326)
MALE STERILIZATION 02 (GO TO 326)
IUCD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
MALE CONDOM 07
FEMALE CONDOM 08
RHYTHM METHOD 09 (GO TO 326)
OTHER MODERN METHOD 95 (GO TO 326)
OTHER TRADITIONAL METHOD 96 (GO TO 326)

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

PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

NAME OF PLACE ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11 (GO TO 326)
GOVERNMENT HEALTH CENTER 12 (GO TO 326)
GOVERNMENT HEALTH POST 13 (GO TO 326)
FAMILY PLANNING CLINIC 14 (GO TO 326)
OTHER PUBLIC SECTOR (SPECIFY) ____ 16 (GO TO 326)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21(GO TO 326)
PHARMACY 22 (GO TO 326)
PRIVATE DOCTOR 23 (GO TO 326)
LESOTHO PLANNED PARENTHOOD 24 (GO TO 326)
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ 26 (GO TO 326)
CHAL
CHAL HOSPITAL 31 (GO TO 326)
CHAL HEALTH CENTER 32 (GO TO 326)
CHAL HEALTH POST 33 (GO TO 326)
RED CROSS HEALTH CENTER 41 (GO TO 326)
CBD 51
VILLAGE HEALTH WORKER 52 (GO TO 326)
SUPPORT GROUPS 53 (GO TO 326)
FACILITY OUTSIDE LESOTHO 61 (GO TO 326)
OTHER SOURCE
SHOP 71 (GO TO 326)
CHURCH 72 (GO TO 326)
PEER EDUCATORS 73 (GO TO 326)
FRIEND/RELATIVE 74 (GO TO 326)
OTHER (SPECIFY) ____ 96 (GO TO 326)

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

YES 1
NO 2 (GO TO 326)

325) Where is that? Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

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

NAME OF PLACE(S) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
FAMILY PLANNING CLINIC D
OTHER PUBLIC SECTOR (SPECIFY) ____ E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC F
PHARMACY G
PRIVATE DOCTOR H
LESOTHO PLANNED PARENTHOOD I
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ J
CHAL
CHAL HOSPITAL K
CHAL HEALTH CENTER L
CHAL HEALTH POST M
RED CROSS HEALTH CENTER N
CBD O
VILLAGE HEALTH WORKER P
SUPPORT GROUPS Q
FACILITY OUTSIDE LESOTHO R
OTHER SOURCE
SHOP S
CHURCH T
PEER EDUCATORS U
FRIEND/RELATIVE V
OTHER (SPECIFY) ____ X

326) In the last 12 months, were you visited by a fieldworker or a community-based distributor (CBD) who talked to you about family planning?

YES 1
NO 2

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

YES 1
NO 2 (GO TO 401)

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

YES 1
NO 2

SECTION 4. PREGNANCY AND POSTNATAL CARE:

401) CHECK 224:

ONE OR MORE BIRTHS IN 2009 OR LATER (GO TO 402)
NO BIRTHS IN 2009 OR LATER (GO TO 556)

402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2009 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.

(IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRE(S)).

Now I would like to ask some questions about your children born in the last five years. (We will talk about each separately.)

403) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

BIRTH HISTORY NUMBER ____

404) FROM 212 AND 216

NAME ____
LIVING ____
DEAD ____

405) When you got pregnant with (NAME), did you want to get pregnant at that time?

YES 1 (GO TO 430)
NO 2

406) Did you want to have a baby later on, or did you not want any (more) children?

LATER 1
NO MORE 2 (GO TO 408)

407) How much longer did you want to wait?

MONTHS ____
YEARS ____
DON'T KNOW 998

408) Did you see anyone for antenatal care for this pregnancy?
[FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2 (GO TO 415)

409) Whom did you see? Anyone else?
[FOR MOST RECENT BIRTH ONLY]

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PERSONNEL
DOCTOR A
NURSE/MIDWIFE B
OTHER PERSON
COMMUNITY HEALTH WORKER C
OTHER (SPECIFY) ____ X

410) Where did you receive antenatal care for this pregnancy? Anywhere else?
[FOR MOST RECENT BIRTH ONLY]

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

NAME OF PLACE(S) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
OTHER PUBLIC SECTOR (SPECIFY) ____ D
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC E
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ F
CHAL
CHAL HOSPITAL G
CHAL HEALTH CENTER H
CHAL HEALTH POST I
REDCROSS HEALTH CENTER J
FACILITY OUTSIDE LESOTHO K
OTHER (SPECIFY) ____ X

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

MONTHS ____
DON'T KNOW 98

412) How many times did you receive antenatal care during this pregnancy?
[FOR MOST RECENT BIRTH ONLY]

NUMBER OF TIMES ____
DON'T KNOW 98

412A) How many months pregnant were you the last time you received antenatal care for this pregnancy? [FOR MOST RECENT BIRTH ONLY]

MONTHS ____
DON'T KNOW 98

413) As part of your antenatal care during this pregnancy, were any of the following done at least once:

a) Was your blood pressure measured?
b) Did you give a urine sample?
c) Did you give a blood sample?

[FOR MOST RECENT BIRTH ONLY]

A) BP
YES 1
NO 2
B) URINE
YES 1
NO 2
C) BLOOD
YES 1
NO 2

414) During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy? [FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 418)
DON'T KNOW 8 (GO TO 418)

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

TIMES ____
DON'T KNOW 8

417) CHECK 416:
[FOR MOST RECENT BIRTH ONLY]

2 OR MORE TIMES (GO TO 421)
OTHER (GO TO 418)

418) At any time before this pregnancy, did you receive any tetanus injections?
[FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2 (GO TO 421)
DON'T KNOW 8 (GO TO 421)

419) Before this pregnancy, how many times did you receive a tetanus injection?
[FOR MOST RECENT BIRTH ONLY]

IF 7 OR MORE TIMES, RECORD '7'.

TIMES ____
DON'T KNOW 8

420) How many years ago did you receive the last tetanus injection before this pregnancy?
[FOR MOST RECENT BIRTH ONLY]

YEARS AGO ____

421) During this pregnancy, were you given or did you buy any iron tablets?
[FOR MOST RECENT BIRTH ONLY]

SHOW TABLETS.

YES 1
NO 2 (GO TO 430)
DON'T KNOW (GO TO 430)

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

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

DAYS ____
DON'T KNOW 998

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

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

431) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 433)
DON'T KNOW 8

432) How much did (NAME) weigh?

RECORD WEIGHT IN KILOGRAMS FROM HEALTH BOOKLET, IF AVAILABLE.

KILOGRAMS FROM BOOKLET ____
KILOGRAMS FROM RECALL ____
DON'T KNOW 9998

433) Who assisted with the delivery of (NAME)? Anyone else?

PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED. IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

HEALTH PERSONNEL
DOCTOR A
NURSE/MIDWIFE B
COMMUNITY HEALTH WORKER C
OTHER PERSON
TRADITIONAL HEALER D
RELATIVE/FRIEND E
OTHER (SPECIFY) ____ X
NO ONE ASSISTED Y

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

PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

NAME OF PLACE ____
HOME
YOUR HOME 11 (GO TO 437A)
OTHER HOME 12 (GO TO 437A)
PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
GOVERNMENT HEALTH POST 23
OTHER PUBLIC SECTOR (SPECIFY) ____ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ 36
CHAL
CHAL HOSPITAL 41
CHAL HEALTH CENTRE 42
CHAL HEALTH POST 43
RED CROSS HEALTH CENTER 51
FACILITY OUTSIDE LESOTHO 61
OTHER (SPECIFY) ____ 96 (GO TO 437A)

434A) How long after (NAME) was delivered did you stay there?
[FOR MOST RECENT BIRTH ONLY]

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS ____
DAYS ____
WEEKS ____
DON'T KNOW 998

435) Was (NAME) delivered by caesarean, that is, did they cut your belly open to take the baby out?

YES 1
NO 2

436) I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health while you were still in the facility? [FOR MOST RECENT BIRTH ONLY]

YES 1 (GO TO 439)
NO 2

437) Did anyone check on your health after you left the facility?
[FOR MOST RECENT BIRTH ONLY]

YES 1 (GO TO 439)
NO 2 (GO TO 442)

437A) Why didn't you deliver in a health facility? PROBE: Any other reason?
[FOR MOST RECENT BIRTH ONLY]

RECORD ALL MENTIONED.

COST TOO MUCH A
FACILITY NOT OPEN B
TOO FAR/NO TRANSPORTATION C
DON'T TRUST FACILITY/POOR QUALITY SERVICE D
NEAREST FACILITY DOESN'T PROVIDE SERVICES E
HUSBAND/FAMILY DID NOT ALLOW F
NOT NECESSARY G
NOT CUSTOMARY H
WAS OUTSIDE OF LESOTHO I
OTHER X

438) I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)? [FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2 (GO TO 4742)

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

PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL
DOCTOR 11
NURSE/MIDWIFE 12
VILLAGE HEALTH WORKER 13
OTHER PERSON
TRADITIONAL HEALER 21
RELATIVE/FRIEND 22
OTHER (SPECIFY) ____ 96

440) How long after delivery did the first check take place?
[FOR MOST RECENT BIRTH ONLY]

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1 ____
DAYS 2 ____
WEEKS 3 ____
DON'T KNOW 998

442) In the two months after (NAME) was born, did any health care provider check on his/her health? [FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2 (GO TO 446)
DON'T KNOW 8 (GO TO 446)

443) How many hours, days, or weeks after birth of (NAME) did the first check take place?
[FOR MOST RECENT BIRTH ONLY]

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS AFTER BIRTH 1 ____
DAYS AFTER BIRTH 2 ____
WEEKS AFTER BIRTH 3 ____
DON'T KNOW 998

444) Who checked on (NAME)'s health at that time?
[FOR MOST RECENT BIRTH ONLY]

PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL
DOCTOR 11
NURSE/MIDWIFE 12
VILLAGE HEALTH WORKER 13
OTHER PERSON
TRADITIONAL HEALER 21
RELATIVE/FRIEND 22
OTHER (SPECIFY) ____ 96

445) Where did this first check of (NAME) take place?
[FOR MOST RECENT BIRTH ONLY]

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

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

NAME OF PLACE ____
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
GOVERNMENT HEALTH POST 23
OTHER PUBLIC (SPECIFY) ____ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL (SPECIFY) ____ 36
CHAL
CHAL HOSPITAL 41
CHAL HEALTH CENTRE 42
CHAL HEALTH POST 43
RED CROSS HEALTH CENTER 51
FACILITY OUTSIDE LESOTHO 61
OTHER (SPECIFY) ____ 96

446) In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)? [FOR MOST RECENT BIRTH ONLY]

SHOW COMMON TYPES OF CAPSULES.

YES 1
NO 2
DON'T KNOW 8

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

YES 1 (GO TO 449)
NO 2 (GO TO 450)

448) Did your period return between the birth of (NAME) and your next pregnancy?
[FOR ALL BIRTHS EXCEPT MOST RECENT BIRTH]

YES 1
NO 2 (GO TO 452)

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

MONTHS ____
DON'T KNOW 98

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

NOT PREGNANT (GO TO 451)
PREGNANT OR UNSURE (GO TO 452)

451) Have you had sexual intercourse since the birth of (NAME)?
[FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2 (GO TO 453)

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

MONTHS ____
DON'T KNOW 98

453) Did you ever breastfeed (NAME)?

YES 1 (GO TO 455)
NO 2

454) CHECK 404:
IS CHILD STILL LIVING?
[FOR MOST RECENT BIRTH ONLY]

LIVING (GO TO 460)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501)

455) How long after birth did you first put (NAME) to breast?
[FOR MOST RECENT BIRTH ONLY]

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

IMMEDIATELY 000
HOURS 1 ____
DAYS 2 ____

456) In the first three days after delivery, was (NAME) given anything to drink other than breast milk? [FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2 (GO TO 458)

457) What was (NAME) given to drink? Anything else?
[FOR MOST RECENT BIRTH ONLY]

RECORD ALL LIQUIDS MENTIONED.

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

458) CHECK 404:

IS CHILD LIVING?

LIVING (GO TO 458)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

459) Are you still breastfeeding (NAME)?
[FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

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

SECTION 5. CHILD IMMUNIZATION, HEALTH, AND NUTRITION

501) ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2009 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRE(S)).

502) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

BIRTH HISTORY NUMBER ____

503) FROM 212 AND 216

NAME ____

LIVING (GO TO 504)
DEAD (GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 553)

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

IF YES: May I see it please?

YES, SEEN 1 (GO TO 505A)
YES, NOT SEEN 2 (GO TO 509)
NO CARD 3

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

YES 1 (GO TO 509)
NO 2 (GO TO 509)

505A) RECORD WHETHER CARD IS FROM LESOTHO, SOUTH AFRICA, OR ANOTHER COUNTRY.

BAKUNA FROM LESOTHO 1
ROAD TO HEALTH CARD FROM SOUTH AFRICA 2 (GO TO 507B)
CARD FROM COUNTRY OTHER THAN LESOTHO OR SOUTH AFRICA 3

506) (1) COPY DATES FROM THE CARD. (2) RECORD '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

BCG
DAY ____
MONTH ____
YEAR ____
OPV-0 (POLIO GIVEN AT BIRTH)
DAY ____
MONTH ____
YEAR ____
DTP-HEP B-HIB 1/PENTAVALENT 1
DAY ____
MONTH ____
YEAR ____
OPB-1
DAY ____
MONTH ____
YEAR ____
DTP-HEP B-HIB 2/PENTAVALENT 2
DAY ____
MONTH ____
YEAR ____
OPV-2
DAY ____
MONTH ____
YEAR ____
DTP-HEP B-HIB 3/PENTAVALENT 3
DAY ____
MONTH ____
YEAR ____
OPV-3
DAY ____
MONTH ____
YEAR ____
MEASLES
DAY ____
MONTH ____
YEAR ____
VITAMIN A (MOST RECENT)
DAY ____
MONTH ____
YEAR ____

507) CHECK 506:

BCG TO MEASLES ALL RECORDED (GO TO 510H)
OTHER (GO TO 508)

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

RECORD 'YES' ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 506 THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

YES 1 (PROBE FOR VACCINATIONS AND RECORD '66' IN THE CORRESPONDING DAY COLUMN IN 506) (GO TO 510H)

NO 2 (GO TO 510H)

DON'T KNOW 8 (GO TO 510H)

507B) (1) COPY DATES FROM THE CARD. (2) RECORD '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

BCG
DAY ____
MONTH ____
YEAR ____
OPV-0 (POLIO GIVEN AT BIRTH)
DAY ____
MONTH ____
YEAR ____
OPV1
DAY ____
MONTH ____
YEAR ____
DTAP-IPV-HIB1 OR DTP1
DAY ____
MONTH ____
YEAR ____
DTAP-IPV-HIB2 OR DTP2
DAY ____
MONTH ____
YEAR ____
DTAP-IPV-HIB3 OR DTP3
DAY ____
MONTH ____
YEAR ____
MEASLES
DAY ____
MONTH ____
YEAR ____
VITAMIN A (MOST RECENT)
DAY ____
MONTH ____
YEAR ____

507C) CHECK 507B:

BCG TO MEASLES ALL RECORDED (GO TO 510H)
OTHER (GO TO 508)

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

RECORD 'YES' ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 506 THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

YES 1 (PROBE FOR VACCINATIONS AND RECORD '66' IN THE CORRESPONDING DAY COLUMN IN 507B) (GO TO 510H)

NO 2 (GO TO 510H)

DON'T KNOW 8 (GO TO 510H)

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

YES 1
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)

510) Please tell me if (NAME) had any of the following vaccinations:

510A) A BCG vaccination against tuberculosis, that is, an injection in the left forearm or upper arm that usually causes a scar?

YES 1
NO 2
DON'T KNOW 8

510B) Polio vaccine, that is, drops in the mouth?

YES 1
NO 2 (GO TO 510E)
DON'T KNOW 8 (GO TO 510E)

510C) Was the first polio vaccine given in the first two weeks after birth or later?

FIRST 2 WEEKS 1
LATER 2

510D) How many times was the polio vaccine given?

NUMBER OF TIMES ____

510E) A DTP-Hep B-Hib vaccination, also known as a penta vaccination, that is, an injection given in the thigh, sometimes at the same time as polio drops?

YES 1
NO 2 (GO TO 510G)
DON'T KNOW 8 (GO TO 510G)

510F) How many times was the DTP-Hep B-Hib vaccination given?

NUMBER OF TIMES ____

510G) A measles injection - that is, a shot in the right arm at the age of 9 months old or older - to prevent him/her from getting measles?

YES 1
NO 2
DON'T KNOW 8

510H) Were any of the vaccinations that (NAME) received given outside of Lesotho?

YES 1
NO 2
DON'T KNOW 8

511) Within the last six months, was (NAME) given a vitamin A dose like (this/any of these)?

SHOW COMMON TYPES OF CAPSULES.

YES 1
NO 2
DON'T KNOW 8

513) Was (NAME) given any drug for intestinal worms in the last six months?

YES 1
NO 2
DON'T KNOW 8

514) Has (NAME) had diarrhoea in the last 2 weeks?

YES 1
NO 2 (GO TO 525)
DON'T KNOW (GO TO 525)

515) Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

516) Now I would like to know how much (NAME) was given to drink during the diarrhoea (including breastmilk). Was he/she given less than usual to drink, about the same amount, or more than usual to drink?

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

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

517) When (NAME) had diarrhoea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?

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

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

518) Did you seek advice or treatment for the diarrhoea from any source?

YES 1
NO 2 (GO TO 522)

519) Where did you seek advice or treatment? Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

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

NAME OF PLACE(S) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
OTHER PUBLIC SECTOR (SPECIFY) ____ D
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC E
PHARMACY F
PRIVATE DOCTOR G
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ H
CHAL
CHAL HOSPITAL I
CHAL HEALTH CENTRE J
CHAL HEALTH POST K
RED CROSS HEALTH CENTER L
VILLAGE HEALTH WORKER M
FACILITY OUTSIDE LESOTHO N
OTHER SOURCE
SHOP O
TRADITION HEALER P
OTHER (SPECIFY) ____ X

520) CHECK 519:

TWO OR MORE CODES RECORDED (GO TO 521)
ONLY ONE CODE RECORDED (GO TO 522)

521) Where did you first seek advice or treatment?

USE LETTER CODE FROM 519.

FIRST PLACE ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
OTHER PUBLIC SECTOR (SPECIFY) ____ D
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC E
PHARMACY F
PRIVATE DOCTOR G
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ H
CHAL
CHAL HOSPITAL I
CHAL HEALTH CENTRE J
CHAL HEALTH POST K
RED CROSS HEALTH CENTER L
VILLAGE HEALTH WORKER M
FACILITY OUTSIDE LESOTHO N
OTHER SOURCE
SHOP O
TRADITION HEALER P
OTHER (SPECIFY) ____ X

522) Was he/she given any of the following to drink at any time since he/she started having the diarrhoea:

a) A fluid made from a special packet called Motsoako or ORS?
b) A health clinic-recommended homemade fluid?

A) FLUID FROM ORS PACKET
YES 1
NO 2
DON'T KNOW 8
B) HOMEMADE FLUID
YES 1
NO 2
DON'T KNOW 8

523) Was anything (else) given to treat the diarrhoea?

YES 1
NO 2 (GO TO 525)
DON'T KNOW 8 (GO TO 525)

524) What (else) was given to treat the diarrhoea? Anything else?

RECORD ALL TREATMENTS GIVEN.

PILL OR SYRUP
ANTIBIOTIC A
ANTIMOTILITY B
ZINC C
OTHER (NOT ANTI-BIOTIC, ANTI-MOTILITY OR ZINC) D
UNKNOWN PILL OR SYRUP E
INJECTION
ANTIBIOTIC F
NON-ANTIBIOTIC G
UNKNOWN INJECTION H
(IV) INTRAVENOUS I
HOME REMEDY/HERBAL MEDICINE J
OTHER (SPECIFY) ____ X

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 530)
DON'T KNOW (GO TO 530)

528) When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?

YES 1
NO 2 (GO TO 531)
DON'T KNOW 8 (GO TO 531)

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

CHEST ONLY 1 (GO TO 531)
NOSE ONLY 2 (GO TO 531)
BOTH 3 (GO TO 531)
OTHER (SPECIFY) ____ 6 (GO TO 531)
DON'T KNOW 8 (GO TO 531)

530) CHECK 525:

HAD FEVER?

YES (GO TO 531)
NO OR DON'T KNOW (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

531) Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). Was he/she given less than usual to drink, about the same amount, or more than usual to drink?

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

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

532) When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?

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

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

533) Did you seek advice or treatment for the illness from any source?

YES 1
NO 2 (GO TO 537)

534) Where did you seek advice or treatment? Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

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

NAME OF PLACE(S) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTRE B
GOVERNMENT HEALTH POST C
OTHER PUBLIC SECTOR (SPECIFY) ____ D
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC E
PHARMACY F
PRIVATE DOCTOR G
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ H
CHAL
CHAL HOSPITAL I
CHAL HEALTH CENTRE J
CHAL HEALTH POST K
RED CROSS HEALTH CENTER L
VILLAGE HEALTH WORKER M
FACILITY OUTSIDE LESOTHO N
OTHER SOURCE
SHOP O
TRADITION HEALER P
OTHER (SPECIFY) ____ X

535) CHECK 534:

TWO OR MORE CODES CIRCLED (GO TO 536)
ONLY ONE CODE CIRCLED (GO TO 537)

536) Where did you first seek advice or treatment?

USE LETTER CODE FROM 534.

FIRST PLACE ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTRE B
GOVERNMENT HEALTH POST C
OTHER PUBLIC SECTOR (SPECIFY) ____ D
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC E
PHARMACY F
PRIVATE DOCTOR G
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ H
CHAL
CHAL HOSPITAL I
CHAL HEALTH CENTRE J
CHAL HEALTH POST K
RED CROSS HEALTH CENTER L
VILLAGE HEALTH WORKER M
FACILITY OUTSIDE LESOTHO N
OTHER SOURCE
SHOP O
TRADITION HEALER P
OTHER (SPECIFY) ____ X

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

YES 1
NO 2 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)
DON'T KNOW 8 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

538) What drugs did (NAME) take? Any other drugs?

RECORD ALL MENTIONED.

ANTIBIOTIC PILLS A
ANTIBIOTIC INJECT B
PARACETEMOL C
IBUPROFEN D
ASPIRIN E
OTHER (SPECIFY) ____ X
DON'T KNOW Z

552) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553.

553) CHECK 215 AND 218, ALL ROWS:

NUMBER OF CHILDREN BORN IN 2009 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE WITH 554)
NAME ____
NONE (GO TO 556)

554) The last time (NAME FROM 553) passed stools, what was done to dispose of the stools?

CHILD USED TOILET OR LATRINE 01
PUT/RINSED INTO TOILET OR LATRINE 02
PUT/RINSED INTO DRAIN OR DITCH 03
THROWN INTO GARBAGE 04
BURIED 05
LEFT IN THE OPEN 06
OTHER (SPECIFY) ____ 96

555) CHECK 522(a) ALL COLUMNS:

NO CHILD RECEIVED FLUID FROM ORS PACKET (GO TO 556)
ANY CHILD RECEIVED FLUID FROM ORS PACKET (GO TO 557)

556) Have you ever heard of a special product called ORS or Motsoako you can get for the treatment of diarrhoea?

YES 1
NO 2

557) CHECK 215 AND 218, ALL ROWS:

NUMBER OF CHILDREN BORN IN 2012 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE WITH 558)
NAME ____
NONE (GO TO 601)

558) Now I would like to ask you about liquids or foods that (NAME FROM 557) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods.

Did (NAME FROM 557) (drink/eat):

a) Plain water?
b) Juice or juice drinks?
c) Clear broth?
d) Milk such as powdered, evaporated, condensed or fresh animal milk? IF YES: How many times did (NAME) drink milk?
e) Infant formula? IF YES: How many times did (NAME) drink infant formula?
f) Any other liquids?
g) Yogurt? IF YES: How many times did (NAME) eat yogurt?
h) Any Nestum, Cerelac, Purity or other commercially fortified baby food?
i) Bread, rice, noodles, soft or hard porridge, or other foods made from grains?
j) Pumpkin, carrots, red pepper, squash or sweet potatoes that are yellow or orange inside?
k) White potatoes, white yams, or any other foods made from roots?
l) Dark green leafy vegetables such as beet greens, mustard leaves, pumpkin leaves, turnip leaves, wild moroho, spinach, swiss chard or broccoli?
m) Ripe mangoes, apricots, dried peaches or papayas?
n) Any other fruits or vegetables such as bananas, apples, apple sauce, oranges, grapefruit, lemon, pears, fresh peaches, plums, grapes, watermelon, figs, gooseberry, cauliflower, cabbage, beet root, mushrooms, green bean, avocados, tomatoes and eggplant?
o) Liver, kidney, heart or other organ meats?
p) Any meat, such as beef, pork, lamb, goat, chicken, or duck?
q) Eggs?
r) Fresh, dried or tinned fish or shellfish?
s) Any foods made from beans, peas, lentils, or nuts?
t) Cheese or other food made from milk?
u) Any other solid, semi-solid, or soft food?

A) WATER
YES 1
NO 2
DON'T KNOW 8
B) JUICE
YES 1
NO 2
DON'T KNOW 8
C) BROTH
YES 1
NO 2
DON'T KNOW 8
D) MILK
IF YES: How many times did (NAME) drink milk?
IF 7 OR MORE TIMES, RECORD '7'.
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES DRANK MILK ____
E) INFANT FORMULA
IF YES: How many times did (NAME) drink infant formula?
IF 7 OR MORE TIMES, RECORD '7'.
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES DRANK FORMULA ____
F) OTHER LIQUIDS
YES 1
NO 2
DON'T KNOW 8
G) YOGURT?
IF YES: How many times did (NAME) ate yogurt?
IF 7 OR MORE TIMES, RECORD '7'.
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES ATE YOGURT ____
H) FORTIFIED BABY FOOD?
YES 1
NO 2
DON'T KNOW 8
I) GRAINS
YES 1
NO 2
DON'T KNOW 8
J) PUMPKIN, CARROTS, RED PEPPER, SQUASH OR SWEET POTATOES
YES 1
NO 2
DON'T KNOW 8
K) ROOTS
YES 1
NO 2
DON'T KNOW 8
L) DARK GREEN LEAFY VEGETABLES
YES 1
NO 2
DON'T KNOW 8
M) MANGOES, APRICOTS, DRIED PEACHES, OR PAPAYAS
YES 1
NO 2
DON'T KNOW 8
N) OTHER FRUITS OR VEGETABLES
YES 1
NO 2
DON'T KNOW 8
O) ORGAN MEATS
YES 1
NO 2
DON'T KNOW 8
P) MEAT
YES 1
NO 2
DON'T KNOW 8
Q) EGGS
YES 1
NO 2
DON'T KNOW 8
R) FISH OR SHELLFISH
YES 1
NO 2
DON'T KNOW 8
S) BEANS, PEAS, LENTILS, OR NUTS
YES 1
NO 2
DON'T KNOW 8
T) CHEESE/FOOD MADE FROM MILD
YES 1
NO 2
DON'T KNOW 8
U) OTHER SOLID, SEMI-SOLID, OR SOFT FOOD
YES 1
NO 2
DON'T KNOW 8

559) CHECK 558 (CATEGORIES "g" THROUGH "u"):

NOT A SINGLE "YES" (GO TO 559)
AT LEAST ONE "YES" (GO TO 561)

560) Did (NAME) eat any solid, semi-solid, or soft foods yesterday during the day or at night?

IF 'YES' PROBE: What kind of solid, semi-solid or soft foods did (NAME) eat?

YES 1 (GO BACK TO 558 TO RECORD FOOD EATEN YESTERDAY)
NO 2 (GO TO 601)

561) How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night?

IF 7 OR MORE TIMES, RECORD '7'.

NUMBER OF TIMES ____
DON'T KNOW 8

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

600A) CHECK 101B:

AGREED TO MEASUREMENT (GO TO 600B)
DID NOT AGREE TO MEASUREMENT OR WAS NOT ASKED 101B (GO TO 601)

600B) May I measure your blood pressure at this time?

INTERVIEWER SIGNATURE ____
DATE ____
RESPONDENT AGREES (RECORD OUTCOME OF BLOOD PRESSURE MEASUREMENT.)
RESPONDENT DOES NOT AGREE (RECORD 994)
SYSTOLIC ____
DIASTOLIC ____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

601) Are you currently married or living together with a man as if married?

YES, CURRENTLY MARRIED 1 (GO TO 604)
YES, LIVING WITH A MAN 2 (GO TO 604)
NO, NOT IN UNION 3

602) Have you ever been married or lived together with a man as if married?

YES, FORMERLY MARRIED 1
YES, LIVED WITH A MAN 2
NO 3 (GO TO 612)

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

WIDOWED 1 (GO TO 609)
DIVORCED 2 (GO TO 609)
SEPARATED 3 (GO TO 609)

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

PROBE: Elsewhere in Lesotho or outside of Lesotho?

LIVING WITH HER 1 (GO TO 605)
STAYING ELSEWHERE IN LESOTHO 2
STAYING ELSEWHERE OUTSIDE LESOTHO 3

604A) Does he stay there for work or another reason?

WORK 1
OTHER REASON 2
DON'T KNOW 8

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

NAME ____
LINE NUMBER ____

606) Does your (husband/partner) have other wives or does he live with other women as if married?

YES 1
NO 2 (GO TO 609)
DON'T KNOW (GO TO 609)

607) Including yourself, in total, how many wives or live-in partners does he have?

TOTAL NUMBER OF WIVES AND LIVE-IN PARTNERS ____
DON'T KNOW 98

608) Are you the first, second, ... wife?

RANK ____

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

ONLY ONCE 1
MORE THAN ONCE 2

610) 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 I would like to ask about your first (husband/partner). In what month and year did you start living with him?

MONTH ____
DON'T KNOW MONTH 98
YEAR ____ (GO TO 612)
DON'T KNOW YEAR 9998

611) How old were you when you first started living with him?

AGE ____

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

613) Now I would like to ask some questions about sexual activity in order to gain a better understanding of some important life issues. How old were you when you had sexual intercourse for the very first time?

NEVER HAD SEXUAL INTERCOURSE 00 (GO TO 628)
AGE IN YEARS ____
FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND/PARTNER 95

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

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

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

DAYS AGO 1 ____ (GO TO 617)
WEEKS AGO 2 ____ (GO TO 617)
MONTHS AGO 3 ____ (GO TO 617)
YEARS AGO 4 ____ (GO TO 627)

616) When was the last time you had sexual intercourse with this person?
[DO NOT ASK FOR MOST RECENT SEXUAL PARTNER]

DAYS AGO 1 ____
WEEKS AGO 2 ____
MONTHS AGO 3 ____

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

YES 1
NO 2 (GO TO 619)

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

YES 1
NO 2

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

IF BOYFRIEND: Were you living together as if married?
IF YES, RECORD '2'.
IF NO, RECORD '3'.

HUSBAND 1
LIVE-IN PARTNER 2
BOYFRIEND NOT LIVING WITH RESPONDENT 3 (GO TO 622)
CASUAL ACQUAINTANCE 4 (GO TO 622)
CLIENT/PROSTITUTE 5 (GO TO 622)
OTHER (SPECIFY) ____ 6 (GO TO 622)

620) CHECK 609:

MARRIED ONLY ONCE (GO TO 621)
MARRIED MORE THAN ONCE (GO TO 622)

621) CHECK 613:

FIRST TIME WHEN STARTED LIVING WITH FIRST HUSBAND (GO TO 623)
OTHER (GO TO 622)

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

DAYS AGO 1 ____
WEEKS AGO 2 ____
MONTHS AGO 3 ____
YEARS AGO 4 ____

623) 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, RECORD '95'.

NUMBER OF TIMES ____

624) How old is this person?

AGE OF PARTNER ____
DON'T KNOW 98

625) Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months? [DO NOT ASK FOR THIRD MOST RECENT SEXUAL PARTNER]

YES 1 (GO BACK TO 616 IN NEXT COLUMN)
NO 2 (GO TO 627)

626) In total, with how many different people have you had sexual intercourse in the last 12 months? [FOR THIRD MOST RECENT SEXUAL PARTNER ONLY]

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

NUMBER OF PARTNERS IN LAST 12 MONTHS ____
DON'T KNOW 98

627) In total, 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, RECORD '95'.

NUMBER OF PARTNERS IN LIFETIME ____
DON'T KNOW 98

628) PRESENCE OF OTHERS DURING THIS SECTION

CHILDREN YOUNGER THAN 10
YES 1
NO 2
MALE ADULTS
YES 1
NO 2
FEMALE ADULTS
YES 1
NO 2

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

YES 1
NO 2 (GO TO 632)

630) Where is that? Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

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

NAME OF PLACE (S) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
FAMILY PLANNING CLINIC D
OTHER PUBLIC SECTOR (SPECIFY) ____ E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC F
PRIVATE DOCTOR H
LESOTHO PLANNED PARENTHOOD I
PSI/NEW START CENTER J
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ K
CHAL
CHAL HOSPITAL L
CHAL HEALTH CENTER M
CHAL HEALTH POST N
RED CROSS HEALTH CENTER O
CBD P
VILLAGE HEALTH WORKER Q
SUPPORT GROUPS R
FACILITY OUTSIDE OF LESOTHO S
OTHER SOURCE
SHOP T
CHURCH U
PEER EDUCATORS V
FRIEND/RELATIVE W
OTHER (SPECIFY) ____ X

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

YES 1
NO 2
DON'T KNOW/UNSURE 8

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

YES 1
NO 2 (GO TO 701)

633) Where is that? Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

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

NAME OF PLACE (S) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
FAMILY PLANNING CLINIC D
OTHER PUBLIC SECTOR (SPECIFY) ____ E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC F
PRIVATE DOCTOR H
LESOTHO PLANNED PARENTHOOD I
PSI/NEW START CENTER J
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ K
CHAL
CHAL HOSPITAL L
CHAL HEALTH CENTER M
CHAL HEALTH POST N
RED CROSS HEALTH CENTER O
CBD P
VILLAGE HEALTH WORKER Q
SUPPORT GROUPS R
FACILITY OUTSIDE OF LESOTHO S
OTHER SOURCE
SHOP T
CHURCH U
PEER EDUCATORS V
FRIEND/RELATIVE W
OTHER (SPECIFY) ____ X

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

YES 1
NO 2
DON'T KNOW/UNSURE 8

SECTION 7. FERTILITY PREFERENCES

701) CHECK 304:

NEITHER STERILIZED (GO TO 702)
HE OR SHE STERILIZED (GO TO 712)

702) CHECK 226:

PREGNANT (GO TO 703)
NOT PREGNANT OR UNSURE (GO TO 704)

703) Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?

HAVE ANOTHER CHILD 1 (GO TO 705)
NO MORE 2 (GO TO 711)
UNDECIDED/DON'T KNOW 8 (GO TO 711)

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

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 707)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 712)
UNDECIDED/DON'T KNOW 8 (GO TO 710)

705) CHECK 226:

NOT PREGNANT OR UNSURE: How long would you like to wait from now before the birth of (a/another) child?

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

MONTHS 1 ____
YEARS 2 ____
SOON/NOW 993 (GO TO 710)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 712)
AFTER MARRIAGE 995 (GO TO 710)
OTHER (SPECIFY) ____ 996 (GO TO 710)
DON'T KNOW 998 (GO TO 710)

706) CHECK 226:

NOT PREGNANT OR UNSURE (GO TO 707)
PREGNANT (GO TO 711)

707) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT CURRENTLY USING (GO TO 708)
CURRENTLY USING (GO TO 712)

708) CHECK 705:

NOT ASKED (GO TO 709)
24 OR MORE MONTHS OR 02 OR MORE YEARS (GO TO 709)
00-23 MONTHS OR 00-01 YEARS (GO TO 711)

709) CHECK 704:

WANTS TO HAVE A/ANOTHER CHILD: You said that you do not want (a/another) child soon. Can you tell me why you are not using a method to prevent pregnancy? Any other reason?

WANTS NO MORE/NONE: You have said that you do not want any (more) children. Can you tell me why you are not using a method to prevent pregnancy? Any other reason?

NOT MARRIED A
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
CAN'T GET PREGNANT E
NOT MENSTRUATED SINCE LAST BIRTH F
BREASTFEEDING G
UP TO GOD/FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND/PARTNER OPPOSED J
OTHER OPPOSED K
RELIGIOUS PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
SIDE EFFECTS/HEALTH CONCERNS O
LACK OF ACCESS/TOO FAR P
COSTS TOO MUCH Q
PREFERRED METHOD NOT AVAILABLE R
NO METHOD AVAILABLE S
INCONVENIENT TO USE T
INTERFERES WITH BODY'S NORMAL PROCESSES U
OTHER (SPECIFY) ____ X
DON'T KNOW Z

710) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 711)
NO, NOT CURRENTLY USING (GO TO 711)
YES, CURRENTLY USING (GO TO 712)

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

YES 1
NO 2
DON'T KNOW 8

712) CHECK 216:

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

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

PROBE FOR A NUMERIC RESPONSE.

NONE 00 (GO TO 714)
NUMBER ____
OTHER (SPECIFY) ____ 96 (GO TO 714)

713) 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 girl?

BOYS ____
GIRLS ____
EITHER ____
OTHER (SPECIFY) ____ 96

714) In the last three 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?
d) Read about family planning on billboards, posters, or pamphlets?

A) RADIO
YES 1
NO 2
B) TELEVISION
YES 1
NO 2
C) NEWSPAPER OR MAGAZINE
YES 1
NO 2
D) BILLBOARDS/POSTERS/PAMPHLET
YES 1
NO 2

716) CHECK 601:

YES, CURRENTLY MARRIED (GO TO 717)
YES, LIVING WITH A MAN (GO TO 717)
NO, NOT IN UNION (GO TO 801)

717) CHECK 303: USING A CONTRACEPTIVE METHOD?

CURRENTLY USING (GO TO 718)
NOT CURRENTLY USING OR NOT ASKED (GO TO 720)

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

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

719) CHECK 304:

NEITHER STERILIZED (GO TO 720)
HE OR SHE STERILIZED (GO TO 801)

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

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

SECTION 8. HUSBAND'S BACKGROUND AND WOMAN'S WORK

801) CHECK 601 AND 602:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 802)
FORMERLY MARRIED/LIVED WITH A MAN (GO TO 803)
NEVER MARRIED AND NEVER LIVED WITH A MAN (GO TO 807)

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

AGE IN COMPLETED YEARS ____

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

YES 1
NO 2 (GO TO 806)

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

PRIMARY 1
VOCATIONAL/TECHNICAL TRAINING AFTER PRIMARY 2
SECONDARY/HIGH 3
VOCATIONAL/TECHNICAL TRAINING AFTER SECONDARY/HIGH 4
COLLEGE 5
GRADUATE/POST GRADUATE 6
DON'T KNOW (GO TO 806)

805) What was the highest (standard/form/year) he completed at that level?

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

STANDARD/FORM/YEAR ____
DON'T KNOW 98

806) CHECK 801:

CURRENTLY MARRIED/LIVING WITH A MAN: What is your (husband's/partner's) occupation? That is, what kind of work does he mainly do?

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

OCCUPATION ____

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

YES 1 (GO TO 811)
NO 2

808) As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work?

YES 1 (GO TO 811)
NO 2

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

YES 1 (GO TO 811)
NO 2

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

YES 1
NO 2 (GO TO 815)

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

OCCUPATION ____

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

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

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

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

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

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

814A) Where do you usually work? In your home community, elsewhere in Lesotho, or outside Lesotho?

HOME COMMUNITY 1 (GO TO 815)
ELSEWHERE IN LESOTHO 2
OUTSIDE LESOTHO 3

814B) The last time you worked away from your home community, how long were you away from home?

DAYS 1 ____
WEEKS 2 ____
MONTHS 3 ____
ONE YEAR GONE OR MORE 996

815) CHECK 601:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 816)
NOT IN UNION (GO TO 823)

816) CHECK 814:

CODE 1 OR 2 RECORDED (GO TO 817)
OTHER (GO TO 819)

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
OTHER (SPECIFY) ____ 6

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

MORE THAN HIM 1
LESS THAN HIM 2
ABOUT THE SAME 3
HUSBAND/PARTNER HAS NO EARNINGS 4 (GO TO 820)
DON'T KNOW 8

819) Who usually decides how your (husband's/partner's) earning will be used: you, your (husband/partner), or you and your (husband/partner) jointly?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
HUSBAND/PARTNER HAS NO EARNINGS 4
OTHER (SPECIFY) ____ 6

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER 6

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER 6

822) Who usually makes decisions about visits to your family or relatives?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER 6

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

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

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

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

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

CHILDREN YOUNGER THAT 10
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 3
HUSBAND
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 3
OTHER MALES
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 3
OTHER FEMALES
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 3

826) 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?

A) GOES OUT
YES 1
NO 2
DON'T KNOW 8
B) NEGLECTS CHILDREN
YES 1
NO 2
DON'T KNOW 8
C) ARGUES
YES 1
NO 2
DON'T KNOW 8
D) REFUSES SEX
YES 1
NO 2
DON'T KNOW 8
E) BURNS FOOD
YES 1
NO 2
DON'T KNOW 8

SECTION 9. HIV/AIDS

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

YES 1
NO 2 (GO TO 937)

902) Can people reduce their chance of getting HIV by having just one uninfected sex partner who has no other sex partners?

YES 1
NO 2
DON'T KNOW 8

903) Can people get HIV from mosquito bites?

YES 1
NO 2
DON'T KNOW 8

904) Can people reduce their chance of getting HIV by using a condom every time they have sex?

YES 1
NO 2
DON'T KNOW 8

905) Can people get HIV by sharing food with a person who has AIDS?

YES 1
NO 2
DON'T KNOW 8

906) Can people get HIV because of witchcraft or other supernatural means?

YES 1
NO 2
DON'T KNOW 8

907) Is it possible for a healthy-looking person to have HIV?

YES 1
NO 2
DON'T KNOW 8

907A) Can AIDS be cured?

YES 1
NO 2 (GO TO 908)
DON'T KNOW 8 (GO TO 908)

907B) What can cure AIDS? PROBE: Anything else?

MODERN DRUGS/ANTIRETROVIRALS A
HERBS B
PRAYER/GOD C
OTHER X
DON'T KNOW Z

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

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

A) DURING PREGNANCY
YES 1
NO 2
DON'T KNOW 8
B) DURING DELIVERY
YES 1
NO 2
DON'T KNOW 8
C) BREASTFEEDING
YES 1
NO 2
DON'T KNOW 8

909) CHECK 908:

AT LEAST ONE 'YES' (GO TO 910)
OTHER (GO TO 911)

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

YES 1
NO 2
DON'T KNOW 8

911) CHECK 208 AND 215:

LAST BIRTH SINCE JANUARY 2012 (GO TO 912)
NO BIRTHS (GO TO 926)
LAST BIRTH BEFORE JANUARY 2012 (GO TO 926)

912) CHECK 408 FOR LAST BIRTH:

HAD ANTENATAL CARE (GO TO 913)
NO ANTENATAL CARE (GO TO 920)

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

914) During any of the antenatal visits for your last birth were you given any information about:

a) Babies getting HIV from their mother?
b) Things that you can do to prevent getting HIV?
c) Getting tested for HIV?

A) AIDS FROM MOTHER
YES 1
NO 2
DON'T KNOW 8
B) THINGS TO DO
YES 1
NO 2
DON'T KNOW 8
C) TESTED FOR AIDS
YES 1
NO 2
DON'T KNOW 8

915) Were you offered a test for HIV as part of your antenatal care?

YES 1
NO 2

916) I don't want to know the results, but were you tested for HIV as part of your antenatal care?

YES 1 (GO TO 917)
NO 2

916A) CHECK 915 AND 916:

915 EQUALS 1 AND 916 EQUALS 2 (GO TO 916B)
915 EQUALS 2 AND 916 EQUALS 2 (GO TO 920)

916B) You told me you were offered a test for HIV as part of your antenatal care, but that you were not tested. Why were you not tested?

STOCKOUTS/TEST KITS NOT AVAILABLE A (GO TO 920)
ALREADY KNOWS STATUS B (GO TO 920)
FEELS SHE IS NOT AT RISK C (GO TO 920)
FEAR D (GO TO 920)
TOO EXPENSIVE E (GO TO 920)
OTHER REASON X (GO TO 920)
DON'T KNOW Z (GO TO 920)

917) Where was the test done?

PROBE TO IDENTIFY TYPE OF SOURCE.

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

NAME OF PLACE ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
GOVERNMENT HEALTH POST 13
FAMILY PLANNING CLINIC 14
OTHER PUBLIC SECTOR (SPECIFY) ____ 15
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
LESOTHO PLANNED PARENTHOOD 24
PSI/NEW START CENTER 25
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ 26
CHAL
CHAL HOSPITAL 31
CHAL HEALTH CENTER 32
CHAL HEALTH POST 33
RED CROSS HEALTH CENTER 41
VILLAGE HEALTH WORKER 51
SUPPORT GROUPS 52
FACILITY OUTSIDE LESOTHO 61
OTHER (SPECIFY) ____ 96

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

YES 1
NO 2 (GO TO 924)

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

YES 1 (GO TO 924)
NO 2 (GO TO 924)
DON'T KNOW 8 (GO TO 924)

920) CHECK 434 FOR LAST BIRTH:

ANY CODE 21-61 RECORDED (GO TO 921)
OTHER (GO TO 926)

921) Between the time you went for delivery but before the baby was born, were you offered a test for HIV?

YES 1
NO 2

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

YES 1
NO 2 (GO TO 926)

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

YES 1
NO 2

924) Have you been tested for HIV since that time you were tested during your pregnancy?

YES 1 (GO TO 927)
NO 2

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

MONTHS AGO ____ (GO TO 931A)
TWO OR MORE YEARS 95 (GO TO 931A)

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

YES 1
NO 2 (GO TO 930)

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

MONTHS AGO ____
TWO OR MORE YEARS 95

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

YES 1
NO 2

929) Where was the test done?

PROBE TO IDENTIFY TYPE OF SOURCE.

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

NAME OF PLACE ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11 (GO TO 931A)
GOVERNMENT HEALTH CENTER 12 (GO TO 931A)
GOVERNMENT HEALTH POST 13 (GO TO 931A)
FAMILY PLANNING CLINIC 14 (GO TO 931A)
OTHER PUBLIC SECTOR (SPECIFY) ____ 15 (GO TO 931A)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21 (GO TO 931A)
PHARMACY 22 (GO TO 931A)
PRIVATE DOCTOR 23 (GO TO 931A)
LESOTHO PLANNED PARENTHOOD 24 (GO TO 931A)
PSI/NEW START CENTER 25 (GO TO 931A)
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ 26 (GO TO 931A)
CHAL
CHAL HOSPITAL 31 (GO TO 931A)
CHAL HEALTH CENTER 32 (GO TO 931A)
CHAL HEALTH POST 33 (GO TO 931A)
RED CROSS HEALTH CENTER 41 (GO TO 931A)
VILLAGE HEALTH WORKER 51 (GO TO 931A)
SUPPORT GROUPS 52 (GO TO 931A)
FACILITY OUTSIDE LESOTHO 61 (GO TO 931A)
OTHER (SPECIFY) ____ 86 (GO TO 931A)

930) Do you know of a place where people can go to get tested for HIV?

YES 1
NO 2 (GO TO 931A)

931) Where is that? Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

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

NAME OF PLACE ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
FAMILY PLANNING CLINIC D
OTHER PUBLIC SECTOR (SPECIFY) ____ E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC F
PHARMACY G
PRIVATE DOCTOR H
LESOTHO PLANNED PARENTHOOD I
PSI/NEW START CENTER J
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ K
CHAL
CHAL HOSPITAL L
CHAL HEALTH CENTER M
CHAL HEALTH POST N
RED CROSS HEALTH CENTER O
VILLAGE HEALTH WORKER P
SUPPORT GROUPS Q
FACILITY OUTSIDE OF LESOTHO R
OTHER (SPECIFY) ____ X

931A) Some individuals choose not to go for HIV testing and counseling. In your opinion, why is this so? PROBE: Any other reason?

ALREADY KNOW STATUS A
FEEL THEY ARE NOT AT RISK B
FEAR OF RESULT C
FEAR OF STIGMA/DISCRIMINATION D
FEAR OF DEATH E
FEAR OF DEPRESSION F
DON'T KNOW WHERE TO GET HTC G
FEAR OF GETTING INFECTED DURING TEST H
FEAR OF PARTNERS' REACTION I
LACK OF KNOWLEDGE/IGNORANCE J
FATALISM/NO CURE K
TOO EXPENSIVE L
OTHER REASON X
DON'T KNOW Z

931B) CHECK 916, 922 AND 926:

HAS NOT BEEN TESTED FOR HIV (GO TO 931C)
HAS BEEN TESTED FOR HIV (GO TO 932)

931C) What is the main reason you have not been tested for HIV?

ALREADY KNOW STATUS 01
NOT AT RISK 02
FEAR OF RESULT 03
FEAR OF STIGMA/DISCRIMINATION 04
FEAR OF DEATH 05
FEAR OF DEPRESSION 06
DON'T KNOW WHERE TO GET HTC 07
FEAR OF GETTING INFECTED DURING TEST 08
FEAR OF PARTNERS' REACTION 09
LACK OF KNOWLEDGE/IGNORANCE 10
FATALISM/NO CURE 11
TOO EXPENSIVE 12
OTHER REASON 96
DON'T KNOW 98

932) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?

YES 1
NO 2
DON'T KNOW 8

933) If a member of your family got infected with HIV, would you want it to remain a secret or not?

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

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

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

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

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

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

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

937) CHECK 901:

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

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

YES 1
NO 2

938) CHECK 613:

HAS HAD SEXUAL INTERCOURSE (GO TO 939)
NEVER HAD SEXUAL INTERCOURSE (GO TO 946)

939) CHECK 937: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

YES (GO TO 940)
NO (GO TO 941)

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

YES 1
NO 2
DON'T KNOW 8

941) Sometimes women experience a bad-smelling abnormal genital discharge. During the last 12 months, have you had a bad-smelling abnormal genital discharge?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

943) CHECK 940, 941, AND 942:

HAS HAD AN INFECTION (ANY 'YES') (GO TO 944)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 946)

944) The last time you had (PROBLEM FROM 940/941/942), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 946)

945) 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.

NAME OF PLACE (S) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
FAMILY PLANNING CLINIC D
OTHER PUBLIC SECTOR (SPECIFY) ____ E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC F
PHARMACY G
PRIVATE DOCTOR H
LESOTHO PLANNED PARENTHOOD I
PSI/NEW START CENTER J
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ K
CHAL
CHAL HOSPITAL L
CHAL HEALTH CENTER M
CHAL HEALTH POST N
RED CROSS HEALTH CENTER O
VILLAGE HEALTH WORKER P
SUPPORT GROUPS Q
FACILITY OUTSIDE OF LESOTHO R
OTHER SOURCE
SHOP S
CHURCH T
FRIEND/RELATIVE U
TRADITIONAL HEALER V
OTHER (SPECIFY) ____ X

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

948) CHECK 601:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 949)
NOT IN UNION (GO TO 1001)

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

YES 1
NO 2
DEPENDS/NOT SURE 8

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

YES 1
NO 2
DEPENDS/NOT SURE 8

SECTION 10. OTHER HEALTH ISSUES

1001A) Now I would like to ask you about something else. Since age 15, have you ever had the following symptoms:

a) Cough for two weeks or more?
b) Fever for two weeks or more?
c) Sweating at night?
d) Weight loss?

A) COUGH 2 OR MORE WEEKS
YES 1
NO 2
B) FEVER 2 OR MORE WEEKS
YES 1
NO 2
C) NIGHT SWEATING
YES 1
NO 2
D) WEIGHT LOSS
YES 1
NO 2

1001B) CHECK 1001A:

AT LEAST ONE 'YES' (GO TO 1001C)
NOT A SINGLE 'YES' (GO TO 1001L)

1001C) Did you seek consultation or treatment for the symptoms?

YES 1 (GO TO 1001E)
NO 2

1001D) What is the main reason you did not seek treatment for the symptoms?

SYMPTOMS HARMLESS 1 (GO TO 1001L)
COST 2 (GO TO 1001L)
DISTANCE 3 (GO TO 1001L)
EMBARRASSED 4 (GO TO 1001L)
LONG QUEUE 5 (GO TO 1001L)
OTHER 6 (GO TO 1001L)

1001E) The last time you had such symptoms, where did you first go for advice or treatment?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

NAME OF PLACE(S) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
GOVERNMENT HEALTH POST 13
OTHER PUBLIC SECTOR (SPECIFY) ____ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ 26
CHAL
CHAL HOSPITAL 31
CHAL HEALTH CENTER 32
RED CROSS HEALTH CENTER 41
VILLAGE HEALTH WORKER 51
SUPPORT GROUPS 52
FACILITY OUTSIDE LESOTHO 61
OTHER SOURCE
SHOP 71
CHURCH 72
FRIEND/RELATIVE 73
TRADITIONAL HEALER 74
OTHER (SPECIFY) ____ 96

1001F) How soon after the symptom(s) appeared did you first seek consultation or treatment?

DAYS 1 ____
WEEKS 2 ____
MONTHS 3 ____
DON'T KNOW 998

1001G) Were you told by a doctor or a nurse that you had tuberculosis?

YES 1
NO 2 (GO TO 1001L)

1001H) Were you given any medicine to treat TB?

YES 1
NO 2 (GO TO 1001J)

1001I) How long were you told to take the medicine?

NUMBER OF MONTHS ____
DON'T KNOW/DON'T REMEMBER 98

1001J) Did you go anywhere else for advice or treatment after you were told that you had tuberculosis?

YES 1
NO 2 (GO TO 1002)

1001K) Where did you go?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

NAME OF PLACE(S) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11 (GO TO 1002)
GOVERNMENT HEALTH CENTER 12 (GO TO 1002)
GOVERNMENT HEALTH POST 13 (GO TO 1002)
OTHER PUBLIC SECTOR (SPECIFY) ____ 16 (GO TO 1002)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21 (GO TO 1002)
PHARMACY 22 (GO TO 1002)
PRIVATE DOCTOR 23 (GO TO 1002)
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____ 26 (GO TO 1002)
CHAL
CHAL HOSPITAL 31 (GO TO 1002)
CHAL HEALTH CENTER 32 (GO TO 1002)
RED CROSS HEALTH CENTER 41 (GO TO 1002)
VILLAGE HEALTH WORKER 51 (GO TO 1002)
SUPPORT GROUPS 52 (GO TO 1002)
FACILITY OUTSIDE LESOTHO 61 (GO TO 1002)
OTHER SOURCE
SHOP 71 (GO TO 1002)
CHURCH 72 (GO TO 1002)
FRIENDS/RELATIVES 73 (GO TO 1002)
TRADITIONAL HEALER 74 (GO TO 1002)
OTHER (SPECIFY) ____ 96 (GO TO 1002)

1001L) Have you ever heard of an illness called tuberculosis or TB?

YES 1
NO 2 (GO TO 1005)

1002) How does tuberculosis spread from one person to another? PROBE: Any other ways?

RECORD ALL MENTIONED.

THROUGH THE AIR WHEN COUGHING OR SNEEZING A
THROUGH SHARING UTENSILS B
THROUGH TOUCHING A PERSON WITH TB C
THROUGH SHARING FOOD D
THROUGH SEXUAL CONTACT E
THROUGH MOSQUITO BITES F
OTHER X
DON'T KNOW Z

1003) Can tuberculosis be cured?

YES 1
NO 2
DON'T KNOW 8

1004) If a member of your family got tuberculosis, would you want it to remain a secret or not?

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

1004A) Would you be willing to work with someone who has been previously treated for tuberculosis?

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

1004B) What signs or symptoms would lead you to think that a person has tuberculosis? PROBE: Any other signs or symptoms?

RECORD ALL MENTIONED.

COUGHING A
COUGHING WITH SPUTUM B
COUGHING FOR SEVERAL WEEKS C
FEVER D
BLOOD IN SPUTUM E
LOSS OF APPETITE F
NIGHT SWEATING G
PAIN IN CHEST OR BACK H
TIREDNESS/FATIGUE I
WEIGHT LOSS J
OTHER X
NO SYMPTOMS Y
DON'T KNOW Z

1004C) What do you think is the cause of tuberculosis? PROBE: Any other causes?

RECORD ALL MENTIONED.

MICROBES/GERMS/BACTERIA A
INHERITED B
LIFESTYLE C
SMOKING D
ALCOHOL DRINKING E
EXPOSURE TO COLD TEMPERATURE F
DUST/POLLUTION G
MINING H
OTHER X
DON'T KNOW Z

1005) Now I would like to ask you some other questions relating to health matters. Have you had any injections for any reason in the last 12 months?

IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS ____
NONE 00 (GO TO 1009)

1006) Among these injections, how many were administered by a doctor, a nurse, 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.

NUMBER OF INJECTIONS ____
NONE 00 (GO TO 1009)

1007) The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

YES 1
NO 2
DON'T KNOW 8

1009) Do you currently smoke cigarettes, either manufactured or hand-rolled?

YES 1
NO 2 (GO TO 1011)

1010) In the last 24 hours, how many cigarettes did you smoke?

CIGARETTES ____

1011) Do you currently smoke or use any (other) type of tobacco?

YES 1
NO 2 (GO TO 1012A)

1012) What (other) type of tobacco do you currently smoke or use?

RECORD ALL MENTIONED.

PIPE A
CHEWING TOBACCO B
SNUFF C
OTHER X

1012A) Now I want to talk about diabetes. Have you ever heard of an illness called diabetes?

YES 1
NO 2 (GO TO 1012E)

1012AA) What are symptoms of diabetes? PROBE: Any other symptoms?

RECORD ALL MENTIONED.

FREQUENT URINATION A
FEELING VERY THIRSTY B
FEELING VERY HUNGRY C
EXTREME FATIGUE D
BLURRY VISION E
CUTS/BRUISES SLOW TO HEAL F
WEIGHT LOSS G
PAIN/TINGLING/NUMBNESS IN HANDS AND FEET H
OTHER X
DON'T KNOW Z

1012B) Have you ever been told by a doctor or a nurse that you have diabetes?

YES 1
NO 2 (GO TO 1012E)

1012C) Are you taking medications for diabetes?

YES 1
NO 2 (GO TO 1012E)

1012D) How do you take the medicine?

INJECTED 1
ORALLY 2
BOTH INJECTED AND ORALLY 3

1012E) Now I want to talk about blood pressure. (Before this survey,) has your blood pressure ever been checked?

YES 1
NO 2 (GO TO 1012J)

1012F) When was the last time you had your blood pressure checked?

LESS THAN 6 MONTHS AGO 1
6 - 11 MONTHS AGO 2
1 - 5 YEARS AGO 3
MORE THAN 5 YEARS AGO 4
DON'T KNOW 8

1012G) Who took your blood pressure?

DOCTOR/NURSE 1
PHARMACIST 2
SELF 3
OTHER 6
DON'T KNOW 8

1012H) Have you ever been told by a doctor or a nurse that you have high blood pressure?

YES 1
NO 2 (GO TO 1012J)

1012I) To lower your blood pressure, are you now:

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

A) TAKE MEDICINE
YES 1
NO 2
N/A 3
B) CONTROL WEIGHT
YES 1
NO 2
N/A 3
C) CUT DOWN SALT
YES 1
NO 2
N/A 3
D) EXERCISE
YES 1
NO 2
N/A 3
E) CUT DOWN ALCOHOL
YES 1
NO 2
N/A 3
F) STOP SMOKING
YES 1
NO 2
N/A 3
G) TRADITIONAL MEDICINE/HERBS
YES 1
NO 2
N/A 3

1012J) Have you ever heard of a disease called breast cancer?

YES 1
NO 2 (GO TO 1012L)

1012K) Who can get breast cancer: women only, men only, or both men and women?

WOMEN ONLY 1
MEN ONLY 2
BOTH 3

1012L) Have you performed a breast exam to detect lumps within the last 12 months?

YES 1
NO 2

1012M) Have you had a breast cancer clinical exam to detect breast cancer in the last 12 months?

YES 1
NO 2
NOT SURE 8

1012N) Have you ever heard of a pap smear, that is an exam that consists of removing cells from the cervix to detect changes that can suggest the presence of cancer in a woman's womb?

YES 1
NO 2 (GO TO 1013)

1012O) Have you ever had such an exam in your life time?

YES 1
NO 2 (GO TO 1013)

1012P) How long ago was the last exam performed?

LESS THAN 12 MONTHS AGO 1
1-3 YEARS 2
4 OR MORE YEARS 3
DON'T KNOW/REMEMBER 8

1013) 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?

a) Getting permission to go?
b) Getting money needed for treatment?
c) The distance to the health facility?
d) Not wanting to go alone?

A) PERMISSION TO GO
BIG PROBLEM 1
NOT A BIG PROBLEM 2
B) GETTING MONEY
BIG PROBLEM 1
NOT A BIG PROBLEM 2
C) DISTANCE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
D) GO ALONE
BIG PROBLEM 1
NOT A BIG PROBLEM 2

1014) Are you covered by any health insurance?

YES 1
NO 2 (GO TO 1101)

1015) What type of health insurance are you covered by?

RECORD ALL MENTIONED.

MUTUAL HEALTH ORGANIZATION/COMMUNITY-BASED HEALTH INSURANCE A
HEALTH INSURANCE THROUGH EMPLOYER B
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE C
OTHER X

SECTION 11. MATERNAL MORTALITY

1101) Now I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your natural mother, including those who are living with you, those living elsewhere and those who have died. How many children did your mother give birth to, including you?

NUMBER OF BIRTHS TO NATURAL MOTHER ____

1102) CHECK 1101:

TWO OR MORE BIRTHS (GO TO 1103)
ONLY ONE BIRTH (RESPONDENT ONLY) (GO TO 1115)

1103) How many births did your mother have before you were born?

NUMBER OF PRECEDING BIRTHS ____

1104) What was the name given to your oldest (next oldest) brother or sister?

NAME ____

1105) Is (NAME) male or female?

MALE 1
FEMALE 2

1106) Is (NAME) still alive?

YES 1
NO 2 (GO TO 1108)
DON'T KNOW 8 (GO TO NEXT COLUMN IN 1104 FOR THE NEXT SIBLING)

1107) How old is (NAME)?

AGE ____ (GO TO NEXT COLUMN IN 1104 FOR THE NEXT SIBLING)

1108) How many years ago did (NAME) die?

YEARS ____

1109) How old was (NAME) when he/she died?

AGE ____ (IF MALE OR DIED BEFORE 12 YEARS OF AGE GO TO NEXT COLUMN IN 1104 FOR NEXT SIBLING)

1110) Was (NAME) pregnant when she died?

YES 1 (GO TO 1113)
NO 2

1111) Did (NAME) die during childbirth?

YES 1 (GO TO 1113)
NO 2

1112) Did (NAME) die within two months after the end of a pregnancy or childbirth?

YES 1
NO 2

1113) How many live born children did (NAME) give birth to during her lifetime?

IF NO MORE BROTHERS OR SISTERS, GO TO 1114.

NUMBER OF CHILDREN ____

1114) CHECK Qs. 1110, 1111 AND 1112 FOR ALL SISTERS

ANY YES: Just to make sure I have this right, you told me that your sister(s) ____ (NAME) died when she was (pregnant/delivering/had just delivered). Is that correct? IF CORRECT, CONTINUE. IF NOT, CORRECT QUESTIONNAIRE AND CONTINUE TO 1115.
ALL NO OR BLANK (GO TO 1115)

1115) CHECK 101B:

AGREED TO MEASUREMENT (GO TO 1116)
DID NOT AGREE TO MEASUREMENT OR WAS NOT ASKED 101B (GO TO 1117)

1116) May I measure your blood pressure at this time?

INTERVIEWER SIGNATURE ____
DATE ____
RESPONDENT AGREES (RECORD OUTCOME OF BLOOD PRESSURE MEASUREMENT.)
RESPONDENT DOES NOT AGREE (RECORD 994)
SYSTOLIC ____
DIASTOLIC ____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

1117) RECORD THE TIME.

HOURS ____
MINUTES ____

SECTION 12. AVERAGE BLOOD PRESSURE MEASURES

1201) CHECK Q600B AND Q1116:

SYSTOLIC AND DIASTOLIC BLOOD PRESSURE RECORDED IN BOTH Q600B AND Q1116 (GO TO 1202)
SYSTOLIC AND DIASTOLIC BLOOD PRESSURE MEASURES NOT RECORDED IN BOTH Q600B AND Q1116 (GO TO 1207)

1202) RECORD AND CALCULATE THE AVERAGE OF THE SYSTOLIC AND DIASTOLIC BLOOD PRESSURE FROM Q600B AND Q1116.

1203) BLOOD PRESSURE MEASUREMENTS FROM Q600B:

SYSTOLIC ____
DIASTOLIC ____

1204) BLOOD PRESSURE MEASUREMENTS FROM Q1116:

SYSTOLIC ____
DIASTOLIC ____

1205) RECORD THE SUM OF THE SYSTOLIC AND DIASTOLIC MEASURES.

SUM SYSTOLIC ____
SUM DIASTOLIC ____

1206) CALCULATE THE AVERAGE SYSTOLIC AND DIASTOLIC BY DIVIDING THE SUM IN Q1205 BY 2

AVERAGE SYSTOLIC ____
AVERAGE DIASTOLIC ____ (GO TO 1211)

1207) CHECK Q1116:

SYSTOLIC AND DIASTOLIC BLOOD PRESSURE NOT RECORDED IN Q1116 (GO TO 1208)
BOTH SYSTOLIC AND DIASTOLIC BLOOD PRESSURE RECORDED IN Q1116 (GO TO 1210)

1208) CHECK Q600B:

SYSTOLIC AND DIASTOLIC BLOOD PRESSURE NOT RECORDED IN Q600B (GO TO 1209)
BOTH SYSTOLIC AND DIASTOLIC BLOOD PRESSURE RECORDED IN Q600B (GO TO 1210)

1209) CHECK Q102F:

SYSTOLIC AND DIASTOLIC BLOOD PRESSURE RECORDED IN Q102F (GO TO 1210)
BOTH SYSTOLIC AND DIASTOLIC BLOOD PRESSURE NOT RECORDED IN Q102F (GO TO 1213)

1210) RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SYSTOLIC ____
DIASTOLIC ____

1211) 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 Q1206 OR Q1210 IS FOUND. CIRCLE THE COLUMN IN WHICH THE VALUE FOR THE DIASTOLIC BLOOD FROM Q1206 OR Q1210 IS FOUND. THE VALUE WHERE THE ROW AND COLUMN YOU HAVE CIRCLED INTERSECT IN THE TABLE WILL BE USED IN COMPLETING Q1212.

AVG. SYSTOLIC PRESSURE LESS THAN 120:
1 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
2 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
3 AVERAGE DIASTOLIC PRESSURE 85 - 89
4 AVERAGE DIASTOLIC PRESSURE 90 - 99
5 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE 110 OR MORE
AVG. SYSTOLIC PRESSURE LESS THAN 130:
2 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
2 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
3 AVERAGE DIASTOLIC PRESSURE 85 - 89
4 AVERAGE DIASTOLIC PRESSURE 90 - 99
5 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE 110 OR MORE
AVG. SYSTOLIC PRESSURE 130 - 139:
3 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
3 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
3 AVERAGE DIASTOLIC PRESSURE 85 - 89
4 AVERAGE DIASTOLIC PRESSURE 90 - 99
5 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE 110 OR MORE
AVG. SYSTOLIC PRESSURE 140 - 159:
4 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
4 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
4 AVERAGE DIASTOLIC PRESSURE 85 - 89
4 AVERAGE DIASTOLIC PRESSURE 90 - 99
5 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE 110 OR MORE
AVG. SYSTOLIC PRESSURE 160 - 179:
5 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
5 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
5 AVERAGE DIASTOLIC PRESSURE 85 - 89
5 AVERAGE DIASTOLIC PRESSURE 90 - 99
5 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE GREAT THAN 110
AVG. SYSTOLIC PRESSURE GREATER THAN 180:
6 AVERAGE DIASTOLIC PRESSURE LESS THAN 80
6 AVERAGE DIASTOLIC PRESSURE LESS THAN 85
6 AVERAGE DIASTOLIC PRESSURE 85 - 89
6 AVERAGE DIASTOLIC PRESSURE 90 - 99
6 AVERAGE DIASTOLIC PRESSURE 100 - 109
6 AVERAGE DIASTOLIC PRESSURE GREAT THAN 110

1212) RECORD THE NUMBER YOU RECORDED IN Q1211 IN THE CHART BELOW. THEN USE THE INSTRUCTIONS TO THE RIGHT OF THAT NUMBER TO COMPLETE A BLOOD PRESSURE FINDINGS REPORT FORM FOR THE RESPONDENT. GIVE THE FORM TO THE RESPONDENT AND ANSWER ANY QUESTIONS SHE MAY HAVE.

RESPONDENT'S BLOOD PRESSURE CATEGORY ____
NORMAL/OPTIMAL 1
NORMAL/MILDLY HIGH 2
NORMAL/MODERATELY HIGH 3
ABNORMAL/MILDLY ELEVATED 4
ABNORMAL/MODERATELY ELEVATED 5
ABNORMAL/SEVERELY ELEVATED 6
CONSULT HEALTH PROVIDE TO CHECK BLOOD PRESSURE WITHIN:
NORMAL/OPTIMAL: 1 YEAR
NORMAL/MILDLY HIGH: 1 YEAR
NORMAL/MODERATELY HIGH: 2 MONTHS
ABNORMAL/MILDLY ELEVATED: 1 MONTH
ABNORMAL/MODERATELY ELEVATED: 1 WEEK
ABNORMAL/SEVERELY ELEVATED: IMMEDIATELY

1213) THANK THE RESPONDENT AND ADVISE THAT THE RESPONDENT OR OTHER MEMBERS OF THE HOUSEHOLD MAY BE ASKED TO PARTICIPATE AGAIN IN INTERVIEWS OR OTHER SURVEY ACTIVITIES IN THE FUTURE.

Thank you for taking the time to answer these questions. We may return to interview you or other members of your household again or to ask you to participate in other survey activities in the future. We hope that you will agree at that 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: ____

CALENDAR

INSTRUCTIONS: ONLY ONE CODE SHOULD APPEAR IN ANY BOX. COLUMN 1 REQUIRES A CODE IN EVERY MONTH.

INFORMATION TO BE CODED FOR EACH COLUMN.

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE

BIRTHS B
PREGNANCIES P
TERMINATIONS T
NO METHOD 0
FEMALE STERILIZATION 1
MALE STERILIZATION 2
IUCD 3
INJECTABLES 4
IMPLANTS 5
PILL 6
MALE CONDOM 7
FEMALE CONDOM 8
RHYTHM METHOD 9
WITHDRAWAL M
OTHER MODERN METHOD X
OTHER TRADITIONAL METHOD Y

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE

INFREQUENT SEX/HUSBAND AWAY 0
BECAME PREGNANT WHILE USING 1
WANTED TO BECOME PREGNANT 2
HUSBAND/PARTNER DISAPPROVED 3
WANTED MORE EFFECTIVE METHOD 4
SIDE EFFECTS/HEALTH CONCERNS 5
LACK OF ACCESS/TOO FAR 6
COSTS TOO MUCH 7
INCONVENIENT TO USE 8
UP TO GOD/FATALISTIC F
DIFFICULT TO GET PREGNANT/MENOPAUSAL A
MARITAL DISSOLUTION/SEPARATION D
OTHER (SPECIFY) ____ X
DON'T KNOW Z

2014

12 DEC 01 _ _
11 NOV 02 _ _
10 OCT 03 _ _
09 SEP 04 _ _
08 AUG 05 _ _
07 JUL 06 _ _
06 JUN 07 _ _
05 MAY 08 _ _
04 APR 09 _ _
03 MAR 10 _ _
02 FEB 11 _ _
01 JAN 12 _ _

2013

12 DEC 13 _ _
11 NOV 14 _ _
10 OCT 15 _ _
09 SEP 16 _ _
08 AUG 17 _ _
07 JUL 18 _ _
06 JUN 19 _ _
05 MAY 20 _ _
04 APR 21 _ _
03 MAR 22 _ _
02 FEB 23 _ _
01 JAN 24 _ _

2012

12 DEC 25 _ _
11 NOV 26 _ _
10 OCT 27 _ _
09 SEP 28 _ _
08 AUG 29 _ _
07 JUL 30 _ _
06 JUN 31 _ _
05 MAY 32 _ _
04 APR 33 _ _
03 MAR 34 _ _
02 FEB 35 _ _
01 JAN 36 _ _

2011

12 DEC 37 _ _
11 NOV 38 _ _
10 OCT 39 _ _
09 SEP 40 _ _
08 AUG 41 _ _
07 JUL 42 _ _
06 JUN 43 _ _
05 MAY 44 _ _
04 APR 45 _ _
03 MAR 46 _ _
02 FEB 47 _ _
01 JAN 48 _ _

2010

12 DEC 49 _ _
11 NOV 50 _ _
10 OCT 51 _ _
09 SEP 52 _ _
08 AUG 53 _ _
07 JUL 54 _ _
06 JUN 55 _ _
05 MAY 56 _ _
04 APR 57 _ _
03 MAR 58 _ _
02 FEB 59 _ _
01 JAN 60 _ _

2009

12 DEC 61 _ _
11 NOV 62 _ _
10 OCT 63 _ _
09 SEP 64 _ _
08 AUG 65 _ _
07 JUL 66 _ _
06 JUN 67 _ _
05 MAY 68 _ _
04 APR 69 _ _
03 MAR 70 _ _
02 FEB 71 _ _
01 JAN 72 _ _