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MADAGASCAR DEMOGRAPHIC AND HEALTH SURVEY - MEN'S QUESTIONNAIRE 2008-2009

IDENTIFICATION

PLACE NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
SEQUENTIAL NUMBER OF THE HOUSEHOLD WITHIN THE CLUSTER_____
BUILDING NUMBER _____
HOUSEHOLD UNIT NUMBER _____
REGION _____
VILLAGE _____

ANTANANARIVO/OTHER CITY/RURAL AREA?

ANTANANARIVO 1
OTHER CITY 2
RURAL 3

NAME AND LINE NUMBER OF RESPONDENT:

NAME _____
LINE NUMBER _____

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
RESULT _____

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT TIME OF VISIT
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) _____

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INTERVIEWER CODE _____
RESULT _____

TOTAL NUMBER OF VISITS _____

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____
KEYED BY _____

SECTION 1: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENT

INTRODUCTION AND CONSENT

CONSENT AFTER INFORMATION:
Hello. My name is ______ and I am working with (NAME OF ORGANIZATION). We are in the process of conducting a national survey in which we ask women (and men) questions about health-related problems. We would very much appreciate your participation in this survey. This information will be very useful to the government in order to put health services in place. The survey usually takes between 30 and 60 minutes to complete. The information you will give us is strictly confidential and will not be shared with anyone other than the survey team.

Participation in this survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important to us.

Do you have any questions to ask me about the survey?
May I begin the interview now?

SIGNATURE OF INTERVIEWER______
DATE ______

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

101. RECORD THE TIME:

HOUR _____
MINUTES_____

102. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS.

YEARS___

ALWAYS ___ 95 (GO TO 106)
VISITOR ___ 96 (GO TO 106)

103. Just before you moved here, did you live in a city, in a town, or in the countryside?

CITY 1
TOWN 2
COUNTRYSIDE 3

106. In what month and year were you born?

MONTH _____
DOESN'T KNOW MONTH 98
YEAR _____
DOESN'T KNOW YEAR 9998

107. How old were you at your last birthday?
COMPARE AND CORRECT 106 AND/OR 107 IF INCONSISTENT.

AGE IN COMPLETED YEARS ___

108. Have you ever attended school?

YES 1
NO 2 (GO TO 112)

109. What is the highest level of school you attended: primary, middle school, high school, or higher?

PRIMARY 1
MIDDLE SCHOOL 2
HIGH SCHOOL 3
HIGHER 4

110. What is the highest grade you completed at that level?

GRADE _____
0 LESS THAN ONE YEAR COMPLETED (FOR ALL LEVELS)
PRIMARY
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
8 DOESN'T KNOW
MIDDLE SCHOOL
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
8 DOESN'T KNOW
HIGH SCHOOL
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
8 DOESN'T KNOW
POST-SECONDARY
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
8 DOESN'T KNOW

111. CHECK 109:

PRIMARY (GO TO 112)
SECONDARY OR HIGHER (GO TO 115)

112. Now I would like you to read this sentence to me; read as much as you can.

SHOW CARD TO RESPONDENT.

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

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

113. Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?

YES 1
NO 2

114. CHECK 112:

CODE '2', '3', OR '4' CIRCLED (GO TO 115)
CODE '1' OR '5' CIRCLED (GO TO 116)

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

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

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

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

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

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

118. What is your religion?

CATHOLIC 1
PROTESTANT/MALAGASY LUTHERAN CHURCH (FLM) 2
MUSLIM 3
TRADITIONAL/ANIMIST 4
NOT RELIGIOUS/NONE 5
SECT 6
OTHER (SPECIFY) ______ 96

SECTION 2. REPRODUCTION

Now I would like to ask about all the children you have had during your life. I want to know about all of your biological children, even if they are not legally yours or do not have your last name.

201. Do you have/have you had any children?

YES 1
NO 2 (GO TO 206)
DOESN'T KNOW 8 (GO TO 206)

202. Do you have any sons or daughters of whom you are the father who are now living with you?

YES 1
NO 2 (GO TO 204)

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

SONS AT HOME ___
DAUGHTERS AT HOME ___

204. Do you have any sons or daughters of whom you are the father and are alive but do not live with you?

YES 1
NO 2 (GO TO 206)

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

SONS ELSEWHERE ___
DAUGHTERS ELSEWHERE ___

206. Have you ever fathered a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life at birth but did not survive?

YES 1
NO 2 (GO TO 208)
DOESN'T KNOW 8 (GO TO 208)

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

BOYS DEAD ___
GIRLS DEAD ___

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

TOTAL _____

209. CHECK 208:

HAS HAD MORE THAN ONE CHILD (GO TO 210)
HAS HAD ONLY ONE CHILD (GO TO 212)
HAS HAD NO CHILDREN (GO TO 301)

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

YES 1 (GO TO 212)
NO 2

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

NUMBER OF WOMEN _____

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

AGE IN YEARS _____

213. CHECK 203 AND 205:

AT LEAST ONE LIVING CHILD (GO TO 214)
NO LIVING CHILDREN (GO TO 301)

214. How old is your youngest child?

AGE IN YEARS ___

215. CHECK 214:

(YOUNGEST) CHILD IS AGE 0-3 YEARS (GO TO 215)
OTHER (GO TO 301)

216. What is the name of your (youngest) child?
WRITE NAME OF (YOUNGEST) CHILD.

NAME ______

217. When (NAME)'s mother was pregnant with (NAME) did she have any antenatal checkups?

YES 1
NO 2 (GO TO 219)
DOESN'T KNOW 8 (GO TO 219)

218. Were you ever present during any of those antenatal checkups?

PRESENT 1
NOT PRESENT 2

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

HOSPITAL/HEALTH FACILITY 1 (GO TO 221)
OTHER 2

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

COSTS TOO MUCH 01
FACILITY CLOSED 02
TOO FAR/NO TRANSPORTATION 03
DOESN'T TRUST FACILITY/POOR QUALITY SERVICE 04
NO FEMALE PROVIDER 05
NOT THE FIRST CHILD 06
CHILD'S MOTHER DID NOT THINK IT WAS NECESSARY 07
HE DID NOT THINK IT WAS NECESSARY 08
FAMILY DID NOT THINK IT WAS NECESSARY 09
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98

221. When a child has diarrhea, how much should he or she be given to drink: more than usual, about the same amount as usual, less than usual, or should he or she not be given anything to drink at all?

MORE THAN USUAL 1
ABOUT THE SAME 2
LESS THAN USUAL 3
NOTHING TO DRINK 4
DOESN'T KNOW 8

SECTION 3: CONTRACEPTION

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.

301. Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?

CIRCLE CODE '1' IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE '1' IF METHOD IS RECOGNIZED AND CODE '2' IF NOT RECOGNIZED. THEN, FOR METHODS 02, 07, 10, AND 11 WITH CODE '1' CIRCLED IN 301, ASK 302.

01. FEMALE STERILIZATION: Women can have an operation to avoid having any more children.
YES 1
NO 2
02. MALE STERILIZATION: Men can have an operation to avoid having any more children.
YES 1
NO 2 (GO TO NEXT METHOD)
03. PILL: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
04. IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
05. INJECTABLES: Women can have an injection by a health provider that stops them from becoming pregnant for three months.
YES 1
NO 2
06. IMPLANTS: Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2
07. CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2 (GO TO NEXT METHOD)
08. FEMALE CONDOM: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2
09. LACTATIONAL AMENORRHEA METHOD (LAM): For up to six months after giving birth, a woman can use this method which requires breastfeeding often, day and night, so that her menstrual cycle does not return.
YES 1
NO 2
10. RHYTHM METHOD: Every month that a woman is sexually active, she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2 (GO TO NEXT METHOD)
11. WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2 (GO TO NEXT METHOD)
12. MORNING AFTER PILL: As an emergency measure after unprotected sexual intercourse, women can take special pills at any time within three days to prevent pregnancy.
YES 1
NO 2
13. NECKLACE METHOD: A method involving moving a ring on a necklace each day from one pearl to the next, counting from the first day of her period. Using this necklace, the woman can know the days of the month where she is more likely to become pregnant.
YES 1
NO 2
14. Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
(SPECIFY) __________
YES 1
NO 2

302. Have you ever used (METHOD)?
THIS QUESTION IS ASKED ABOUT METHODS 02, 07, 10, AND 11 IN 301 WITH '1' CIRCLED.

02. MALE STERILIZATION: Men can have an operation to avoid having any more children. Have you ever had an operation to avoid having any (more) children?
YES 1
NO 2
07. CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
10. RHYTHM METHOD: Every month that a woman is sexually active, she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
11. WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2

303. In the last few months have you:

Heard about family planning on the radio?
Heard about family planning on the television?
Read about family planning in a newspaper or magazine?

ON THE RADIO
YES 1
NO 2
ON THE TELEVISION
YES 1
NO 2
NEWSPAPER OR MAGAZINE
YES 1
NO 2

304. In the last few months, have you discussed the practice of family planning with a health worker or health professional?

YES 1
NO 2

Now I would like to ask you about a woman's risk of pregnancy.

305. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations?

YES 1
NO 2 (GO TO 307)
DOESN'T KNOW 8 (GO TO 307)

306. 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
DOESN'T KNOW 8

307. Do you think that a woman who is breastfeeding her baby can become pregnant?

YES 1
NO 2
DEPENDS 3
DOESN'T KNOW 8

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

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

CONTRACEPTION IS A WOMAN'S BUSINESS
AGREE 1
DISAGREE 2
DOESN'T KNOW 8
WOMEN MAY BECOME PROMISCUOUS
AGREE 1
DISAGREE 2
DOESN'T KNOW 8

309. CHECK 301 (07):
KNOWS MALE CONDOM?

YES (GO TO 310)
NO (GO TO 401)

310. Do you know of a place where a person can get condoms?

YES 1
NO 2 (GO TO 401)

311. Where is that?
Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE INSTITUTION, WRITE THE NAME OF THE PLACE.

NAME OF PLACE(S) __________
PUBLIC SECTOR
DISTRICT HOSPITAL II (facility equipped for surgeries) A
DISTRICT HOSPITAL I (non-surgical medical capabilities) B
BASIC HEALTH CENTER II (basic health care, physician-run) C
BASIC HEALTH CENTER I (basic health care, run by para-medical officer) D
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC E
PRIVATE HEALTH CENTER F
PHARMACY/MEDICINE DISPERSAL CENTER G
PRIVATE DOCTOR H
PIF/FISA CENTER I
OTHER LOCATION
VBC AGENT J
STORE K
KIOSK L
CHURCH M
FRIENDS/RELATIVES N
MOTEL/HOTEL O
PEER EDUCATOR P
FIMAILO Q (Note: linked to a campaign to increase condom use in Madagascar)
OTHER (SPECIFY) ______ X

312. If you wanted to, could you get yourself a condom?

YES 1
NO 2

SECTION 4: MARRIAGE AND SEXUAL ACTIVITY

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

YES, CURRENTLY MARRIED 1 (GO TO 404)
YES, LIVING WITH A WOMAN 2 (GO TO 404)
NO, NOT IN UNION 3

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

YES, FORMERLY MARRIED 1
YES, LIVED WITH A WOMAN 2
NO 3 (GO TO 413)

403. What is your marital status now: are you widowed, divorced, or separated?

WIDOWED 1 (GO TO 410)
DIVORCED 2 (GO TO 410)
SEPARATED 3 (GO TO 410)

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

LIVING WITH HIM 1
STAYING ELSEWHERE 2

405. Do you have more than one wife or woman you live with as if married?

YES 1
NO 2 (GO TO 407)

406. In total, how many wives do you have or partners do you live with now as if married?

TOTAL NUMBER OF WIVES AND LIVE-IN PARTNERS_____

407. CHECK 405:

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

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

RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER. IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'. ASK 408 FOR EACH PERSON.

NAME(S) _____
LINE NUMBER_____

408. How old was (NAME) on her last birthday?
ASK FOR SPOUSE(S)/PARTNER(S) OF RESPONDENT.

AGE _____

409. CHECK 407:

ONE WIFE/PARTNER (GO TO 410)
MORE THAN ONE WIFE/PARTNER (GO TO 411A)

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

ONLY ONCE 1
MORE THAN ONCE 2 (GO TO 411A)

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

MONTH _____
DOESN'T KNOW MONTH 98
YEAR _____ (GO TO 413)
DOESN'T KNOW YEAR 9998

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

MONTH _____
DOESN'T KNOW MONTH 98
YEAR _____ (GO TO 413)
DOESN'T KNOW YEAR 9998

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

AGE _____

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

Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues.

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

NEVER HAD SEXUAL INTERCOURSE 00

AGE IN YEARS ___ (GO TO 417)

FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE/PARTNER 95 (GO TO 417)

415. CHECK 107:

AGE 15-24 YEARS (GO TO 416)
AGE 25-59 YEARS (GO TO 501)

416. Do you intend to wait until you get married to have sexual intercourse for the first time?

YES 1 (GO TO 501)
NO 2 (GO TO 501)
DOESN'T KNOW/UNSURE 8 (GO TO 501)

417. CHECK 107:

AGE 15-24 YEARS (GO TO 418)
AGE 25-59 YEARS (GO TO 419)

418. The first time you had sexual intercourse, was a condom used?

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

419. 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 ___
WEEKS AGO 2 ___
MONTHS AGO 3 ___
YEARS AGO 4 ___ (GO TO 435)

420. 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. (GO TO 422)

421. When was the last time you had sexual intercourse with this person?
ASK FOR PAST SEXUAL PARTNERS ONLY.

DAYS 1 ___
WEEKS 2 ___
MONTHS 3 ___

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

YES 1
NO 2 (GO TO 424)

423. Was condom used every time you had sexual intercourse with this person in the last 12 months?

YES 1
NO 2

424. What was your relationship to this person with whom you had sexual intercourse?
IF GIRLFRIEND: Were you living together as if married?
IF YES, CIRCLE '2'. IF NO, CIRCLE '3'.

WIFE 1 (GO TO 426)
LIVE-IN PARTNER 2 (GO TO 426)
GIRLFRIEND NOT LIVING WITH RESPONDENT 3
CASUAL ACQUAINTANCE 4
PROSTITUTE 5
OTHER (SPECIFY) ______ 6

425. For how long (have you had/did you have) a sexual relationship with this person?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.

DAYS 1 ___
MONTH 2 ___
YEARS 3 ___

426. The last time you had sexual intercourse with this person, did you or this person drink alcohol?

YES 1
NO 2 (GO TO 428)

427. Were you or your partner drunk at that time?
IF YES: Who was drunk?

RESPONDENT ONLY 1
PARTNER ONLY 2
RESPONDENT AND PARTNER BOTH 3
NEITHER 4

428. 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 LAST PARTNER.

YES 1 (GO BACK TO 421 IN NEXT COLUMN)
NO 2 (GO TO 430)

429. In total, with how many people have you had sexual intercourse in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.
[DO NOT ASK FOR MOST RECENT OR SECOND-MOST-RECENT PARTNER]

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

429A. In total, with how many people have you had sexual intercourse in the last month?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.
[DO NOT ASK FOR MOST RECENT PARTNER]

NUMBER OF PARTNERS IN LAST MONTH ____
DOESN'T KNOW 98

430. CHECK 424 (ALL PARTNERS):

AT LEAST ONE PARTNER IS A PROSTITUTE (GO TO 431)
NO PARTNERS ARE PROSTITUTES (GO TO 432)

431. CHECK 424 AND 422 (ALL PARTNERS):

CONDOM USED WITH EVERY PROSTITUTE (GO TO 434)
OTHER (GO TO 435)

432. In the past 12 months, did you pay anyone in exchange for having sexual intercourse?

YES 1
NO 2 (GO TO 435)

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

YES 1
NO 2 (GO TO 435)

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

YES 1
NO 2
DOESN'T KNOW 8

435. In total, with how many different people have you had sexual intercourse in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.

NUMBER OF PARTNERS IN LIFETIME ____
DOESN'T KNOW 98

436. CHECK 422:
MOST RECENT PARTNER (FIRST COLUMN):

CONDOM USED (GO TO 437)
NOT ASKED (GO TO 442)
NO CONDOM USED (GO TO 442)

437. You told me that a condom was used the last time you had sex. May I see the package of condoms you were using at that time?
RECORD NAME OF BRAND IF PACKAGE SEEN.

PACKAGE SEEN 1
BRAND NAME (SPECIFY) _______ (GO TO 439)
DOES NOT HAVE/NOT SEEN 2

438. Do you know the brand name of the condom used at that time?
RECORD NAME OF BRAND.

BRAND NAME (SPECIFY) ______
DOESN'T KNOW 98

439. How many condoms did you get the last time?

NUMBER OF CONDOMS _____
DOESN'T KNOW 998

440. The last time you obtained the condoms, how much did you pay in total, including the cost of the condom(s) and any consultation you may have had?

COST ____
FREE 9995
DOESN'T KNOW 9998

441. From where did you obtain the condom the last time?

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

NAME OF PLACE ______
PUBLIC SECTOR
DISTRICT HOSPITAL II (facility equipped for surgeries) 11
DISTRICT HOSPITAL I (non-surgical medical capabilities) 12
BASIC HEALTH CENTER II (basic health care, physician-run) 13
BASIC HEALTH CENTER I (basic health care, run by para-medical officer) 14
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE HEALTH CENTER 22
PHARMACY/MEDICINE DISPERSAL CENTER 23
PRIVATE DOCTOR 24
PIF/FISA CENTER 25
OTHER LOCATION
VBC AGENT 31
STORE 32
KIOSK 33
CHURCH 34
FRIENDS/RELATIVES 35
MOTEL/HOTEL 36
PEER EDUCATOR 37
FIMAILO 38 (Note: linked to a campaign to increase condom use in Madagascar)
OTHER (SPECIFY) _____ 96

442. CHECK 302 (02):
RESPONDENT IS STERILIZED?

NO (GO TO 443)
YES (GO TO 501)

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

YES 1
NO 2 (GO TO 501)
DOESN'T KNOW 8 (GO TO 501)

444. What method did you or your partner use?
PROBE: Did you or your partner use another method to prevent pregnancy?

FEMALE STERILIZATION A
PILL B
IUD C
INJECTABLES D
IMPLANTS E
CONDOM F
FEMALE CONDOM G
DIAPHRAGM H
FOAM/JELLY I
LACTATIONAL AMENNORHEA METHOD J
WITHDRAWAL K
NECKLACE METHOD L
OTHER (SPECIFY) ______ X

SECTION 5: FERTILITY PREFERENCES

501. CHECK 407:

HAS ONE WIFE/PARTNER OR MORE (GO TO 502)
QUESTION NOT ASKED (GO TO 508)

502. CHECK 302:

MAN NOT STERILIZED (GO TO 503)
MAN STERILIZED (GO TO 508)

503. Is (your wife(partner)/one of your wives(partners) currently pregnant?

YES 1
NO 2
DOESN'T KNOW 8

504. CHECK 503:

NO WIFE/PARTNER PREGNANT OR DOESN'T KNOW: 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?

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

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 508)
COUPLE INFECUND 3 (GO TO 508)
WIFE(WIVES)/PARTNER(S) STERILIZED 4 (GO TO 508)
UNDECIDED/DOESN'T KNOW 8 (GO TO 508)

505. CHECK 407:

ONE WIFE/PARTNER (GO TO 506)
MORE THAN ONE WIFE/PARTNER (GO TO 507)

506. CHECK 503:

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

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

MONTHS 1 ___ (GO TO 508)
YEARS 2 ___ (GO TO 508)

SOON/NOW 993 (GO TO 508)
COUPLE INFECUND 994 (GO TO 508)
OTHER (SPECIFY) _____ 996 (GO TO 508)
DOESN'T KNOW 998 (GO TO 508)

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

MONTHS 1 ___ (GO TO 508)
YEARS 2 ___ (GO TO 508)

SOON/NOW 993 (GO TO 508)
COUPLE INFECUND 994 (GO TO 508)
OTHER (SPECIFY) _____ 996 (GO TO 508)
DOESN'T KNOW 998 (GO TO 508)

508. CHECK 203 AND 205:

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

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

PROBE FOR A NUMERIC RESPONSE.

NONE 00 (GO TO 601)

NUMBER ____

OTHER (SPECIFY) _____ 96 (GO TO 601)

509. How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter?

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

SECTION 6: EMPLOYMENT AND GENDER ROLES

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

YES 1 (GO TO 604)
NO 2

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

YES 1 (GO TO 604)
NO 2

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

YES 1
NO 2 (GO TO 613)

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

WORK ____

605. CHECK 604:

WORKS IN AGRICULTURE (GO TO 606)
DOES NOT WORK IN AGRICULTURE (GO TO 607)

606. Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else's land?

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

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

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

608. 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

609. 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

610. CHECK 407:

ONE OR MORE WIVES/PARTNERS (GO TO 611)
QUESTION NOT ASKED (GO TO 613)

611. CHECK 609:

CODE '1' OR '2' CIRCLED (GO TO 612)
OTHER (GO TO 613)

612. Who usually decides how the money you earn will be used: mainly you, mainly your (wife(wives)/partner(s)), or you and your (wife(wives)/partner(s)) jointly?

RESPONDENT 1
WIFE (WIVES)/PARTNER(S) 2
RESPONDENT AND WIFE (WIVES)/PARTNER(S) JOINTLY 3
OTHER (SPECIFY) _____ 6

613. In a couple, who do you think should have the greater say in each of the following decisions: the husband, the wife or both equally:

A. Making major household purchases?
B. Making purchases for daily household needs?
C. Deciding about visits to the wife's family or relatives?
D. Deciding what to do with the money she earns for her work?
E. Deciding how many children to have?

MAJOR HOUSEHOLD PURCHASES
HUSBAND 1
WIFE 2
BOTH EQUALLY 3
DOESN'T KNOW/DEPENDS 8
DAILY HOUSEHOLD NEEDS
HUSBAND 1
WIFE 2
BOTH EQUALLY 3
DOESN'T KNOW/DEPENDS 8
VISITS TO WIFE'S FAMILY/RELATIVES
HUSBAND 1
WIFE 2
BOTH EQUALLY 3
DOESN'T KNOW/DEPENDS 8
HOW TO SPEND WIFE'S MONEY
HUSBAND 1
WIFE 2
BOTH EQUALLY 3
DOESN'T KNOW/DEPENDS 8
HOW MANY CHILDREN
HUSBAND 1
WIFE 2
BOTH EQUALLY 3
DOESN'T KNOW/DEPENDS 8

614. I will now read you some statements about pregnancy. Please tell me if you agree or disagree with them:

A. Childbearing is a woman's concern and there is no need for the father to get involved.
B. It is crucial for the mother's and child's health that a woman has assistance from a doctor or nurse at delivery.

CHILD BEARING IS A WOMAN'S CONCERN
AGREE 1
DISAGREE 2
DOESN'T KNOW 8
ASSISTANCE AT DELIVERY IS CRUCIAL
AGREE 1
DISAGREE 2
DOESN'T KNOW 8

615. Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

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

GOES OUT WITHOUT TELLING
YES 1
NO 2
DOESN'T KNOW 8
NEGLECTS CHILDREN
YES 1
NO 2
DOESN'T KNOW 8
ARGUES WITH HUSBAND
YES 1
NO 2
DOESN'T KNOW 8
REFUSES TO HAVE SEX
YES 1
NO 2
DOESN'T KNOW 8
BURNS THE FOOD
YES 1
NO 2
DOESN'T KNOW 8

616. Do you think that if a woman refuses to have sex with her husband when he wants her to, he has the right to:

A. Get angry and reprimand her?
B. Refuse to give her money or other means of support?
C. Use force to have sex with her even if she doesn't want to?
D. Go ahead and have sex with another woman?

GET ANGRY/REPRIMAND WOMAN
YES 1
NO 2
DOESN'T KNOW/DEPENDS 8
REFUSE TO GIVE MONEY
YES 1
NO 2
DOESN'T KNOW/DEPENDS 8
USE FORCE TO HAVE SEX
YES 1
NO 2
DOESN'T KNOW/DEPENDS 8
SEX WITH OTHER WOMEN
YES 1
NO 2
DOESN'T KNOW/DEPENDS 8

SECTION 7: HIV/AIDS

Now I would like to talk about something else.

701. Have you ever heard of an illness called AIDS?

YES 1
NO 2 (GO TO 733)

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

YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2
DOESN'T KNOW 8

706. Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

YES 1
NO 2
DOESN'T KNOW 8

707. Can people get the AIDS virus because of witchcraft or other supernatural means?

YES 1
NO 2
DOESN'T KNOW 8

708. Is it possible for a healthy-looking person to have the AIDS virus?

YES 1
NO 2
DOESN'T KNOW 8

709. Can the virus that causes AIDS be transmitted from a mother to her baby:

During pregnancy?
During delivery?
By breastfeeding?

DURING PREGNANCY
YES 1
NO 2
DOESN'T KNOW 8
DURING DELIVERY
YES1
NO 2
DOESN'T KNOW 8
BY BREASTFEEDING
YES 1
NO 2
DOESN'T KNOW 8

710. CHECK 709:

AT LEAST ONE 'YES' (GO TO 711)
OTHER (GO TO 712)

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

YES 1
NO 2
DOESN'T KNOW 8

712. Have you heard about special antiretroviral drugs that people infected with the AIDS virus can get from a doctor or a nurse to help them live longer?

YES 1
NO 2
DOESN'T KNOW 8

712A. CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

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

YES 1
NO 2 (GO TO 718)

714. When was the last time you were tested?

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

715. The last time you had the test, did you yourself ask for the test, was it offered to you and you accepted, or was it required?

ASKED FOR THE TEST 1
OFFERED AND ACCEPTED 2
REQUIRED 3

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

YES 1
NO 2

717 Where was the test done?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE INSTITUTION, WRITE THE NAME OF THE PLACE.

NAME OF PLACE(S) _____
PUBLIC SECTOR
DISTRICT HOSPITAL II (facility equipped for surgeries) 11 (GO TO 720)
DISTRICT HOSPITAL I (non-surgical medical capabilities) 12 (GO TO 720)
BASIC HEALTH CENTER II (basic health care, physician-run) 13 (GO TO 720)
BASIC HEALTH CENTER I (basic health care, run by para-medical officer) 14 (GO TO 720)
OTHER PUBLIC PLACE (SPECIFY) ______ 15 (GO TO 720)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21 (GO TO 720)
PRIVATE HEALTH CENTER 22 (GO TO 720)
PHARMACY/MEDICINE DISPERSAL CENTER 23 (GO TO 720)
PRIVATE DOCTOR 24 (GO TO 720)
PIF/FISA CENTER 25 (GO TO 720)
OTHER PRIVATE MEDICAL (SPECIFY) ______ 26 (GO TO 720)
OTHER (SPECIFY) ______ 96 (GO TO 720)

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

YES 1
NO 2 (GO TO 720)

719. Where is that?
Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE INSTITUTION, WRITE THE NAME OF THE PLACE.

NAME OF PLACE(S) ______
PUBLIC SECTOR
DISTRICT HOSPITAL II (facility equipped for surgeries) A
DISTRICT HOSPITAL I (non-surgical medical capabilities) B
BASIC HEALTH CENTER II (basic health care, physician-run) C
BASIC HEALTH CENTER I (basic health care, run by para-medical officer) D
OTHER PUBLIC PLACE (SPECIFY) ______ E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL CLINIC F
PRIVATE HEALTH CENTER G
PHARMACY/MEDICINE DISPERSAL CENTER H
PRIVATE DOCTOR I
PIF/FISA CENTER J
OTHER PRIVATE MEDICAL (SPECIFY) ______ K
OTHER (SPECIFY) ______ X

720. Would you buy fresh vegetables from a shopkeeper of vendor if you knew that this person had the AIDS virus?

YES 1
NO 2
DOESN'T KNOW 8

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

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

722. 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
DOESN'T KNOW/NOT SURE/DEPENDS 8

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

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

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

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

732. Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid getting AIDS?

YES 1
NO 2
DOESN'T KNOW/NOT SURE/DEPENDS 3

733. CHECK 701:

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

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

YES 1
NO 2 (GO TO 733C)

733A. What are the signs or symptoms in a man that make you think he may have a sexually transmitted infection?
INSIST: Anything else?
RECORD ALL MENTIONED.

ABDOMINAL PAIN A
GENITAL DISCHARGE B
FOUL-SMELLING DISCHARGE C
BURNING DURING URINATION D
RASH/INFLAMMATION IN THE GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
WEIGHT LOSS K
IMPOTENCE L
OTHER (SPECIFY) ______ W
OTHER (SPECIFY) ______ X
NO SYMPTOMS Y
DOESN'T KNOW Z

733B. What are the signs or symptoms in a woman that make you think she may have a sexually transmitted infection?
INSIST: Anything else?
RECORD ALL MENTIONED.

ABDOMINAL PAIN A
VAGINAL DISCHARGE B
FOUL-SMELLING DISCHARGE C
BURNING DURING URINATION D
RASH/INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
WEIGHT LOSS K
DIFFICULTY GETTING PREGNANT/HAVING CHILDREN L
OTHER (SPECIFY) ______ W
OTHER (SPECIFY) ______ X
NO SYMPTOMS Y
DOESN'T' T KNOW Z

733C. Have you obtained any free condoms within the last 12 months?

YES 1
NO 2
DOESN'T KNOW OF CONDOMS 3

734. CHECK 414:

HAS HAD SEXUAL INTERCOURSE (GO TO 735)
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 742)

735. CHECK 733:
HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

YES 1 (GO TO 736)
NO 2 (GO TO 737)

Now I would like to ask you some questions about your health in the last 12 months.

736. During the last 12 months, have you had a disease that you got through sexual contact?

YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2
DOESN'T KNOW 8

739. CHECK 736, 737, AND 738:

HAS HAD AN INFECTION (ANY 'YES') (GO TO 740)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 742)

740. The last time you had (PROBLEM FROM 736/737/738) did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 742)

741. Where did you go?
Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE INSTITUTION, WRITE THE NAME OF THE PLACE.

NAME OF PLACE _____
PUBLIC SECTOR
DISTRICT HOSPITAL II (facility equipped for surgeries) A
DISTRICT HOSPITAL I (non-surgical medical capabilities) B
BASIC HEALTH CENTER II (basic health care, physician-run) C
BASIC HEALTH CENTER I (basic health care, run by para-medical officer) D
OTHER PUBLIC PLACE (SPECIFY) ______ E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC F
PRIVATE HEALTH CENTER G
PHARMACY/MEDICINE DISPERSAL CENTER H
PRIVATE DOCTOR I
PIF/FISA CENTER J
TOP NETWORK K
OTHER PRIVATE MEDICAL (SPECIFY) _____ L
OTHER SOURCE
VBC AGENT M
STORE N
KIOSK O
CHURCH P
TRADITIONAL HEALER Q
RELATIVES/FRIENDS R
OTHER (SPECIFY) _____ X

742. Husbands and wives do not always agree on everything. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?

YES 1
NO 2
DOESN'T KNOW 8

743. 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
DOESN'T KNOW 8

744. Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?

YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2
DOESN'T KNOW 8

SECTION 8: OTHER HEALTH ISSUES

801. Have you ever heard of an illness called tuberculosis or TB?

YES 1
NO 2 (GO TO 805)

802. 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 FOOD D
THROUGH SEXUAL CONTACT E
THROUGH MOSQUITO BITES F
OTHER (SPECIFY) _____ X
DOESN'T KNOW Z

803. Can tuberculosis be cured?

YES 1
NO 2
DOESN'T KNOW 8

804. 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
DOESN'T KNOW/NOT SURE/DEPENDS 3

805. Some men are circumcised.
Are you circumcised?

YES 1
NO 2
DOESN'T KNOW 8

Now I would like to ask you some other questions relating to health matters.

806. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?

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

NUMBER OF INJECTIONS ____
NONE 00 (GO TO 810)

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

IF NUMBER OF INJECTIONS IS GREATER THAN '90', OR DAILY FOR THREE MONTHS OR MORE, RECORD '09'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS ___
NONE 00 (GO TO 810)

808. The last time you had an injection given to you by a health worker, where did you go to get the injection?

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

NAME OF PLACE _____
PUBLIC SECTOR
DISTRICT HOSPITAL II (facility equipped for surgeries) 11
DISTRICT HOSPITAL I (non-surgical medical capabilities) 12
BASIC HEALTH CENTER II (basic health care, physician-run) 13
BASIC HEALTH CENTER I (basic health care, run by para-medical officer) 14
OTHER PUBLIC PLACE (SPECIFY) _____ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE HEALTH CENTER 22
PHARMACY/MEDICINE DISPERSAL CENTER 23
PRIVATE DOCTOR 24
DENTAL OFFICE 25
OTHER PRIVATE MEDICAL (SPECIFY) _____ 26
OTHER SOURCE
AT HOME 31
OTHER (SPECIFY) _____ 96

809. Did the person who gave you that injection take the needle and syringe from a new, unopened package?

YES 1
NO 2
DOESN'T KNOW 8

810. Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 812)

811. In the last 24 hours, how many cigarettes did you smoke?

CIGARETTES ___

812. Do you currently smoke or use any other type of tobacco?

YES 1
NO 2 (GO TO 814)

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

PIPE A
CHEWING TOBACCO B
SNUFF C
OTHER (SPECIFY) _____ X

814. Are you covered by health insurance?

YES 1
NO 2 (GO TO 816)

815. What type of health insurance?
RECORD ALL MENTIONED.

MUTUAL HEALTH ORGANIZATION/COMMUNITY-BASED HEALTH INSURANCE A
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
OTHER (SPECIFY) ______ X

816. RECORD THE TIME:

HOURS ___
MINUTES ___

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW.

COMMENTS ABOUT RESPONDENT _____
COMMENTS ON SPECIFIC QUESTIONS _____
ANY OTHER COMMENTS _____

SUPERVISOR'S OBSERVATIONS _____
NAME _____
DATE _____

EDITOR'S OBSERVATIONS _____
NAME _____
DATE _____