IDENTIFICATION

PLACE NAME _________________________

NAME OF HOUSEHOLD HEAD __________________

DISTRICT _____________________

CLUSTER NUMBER __

HOUSEHOLD NUMBER ___

NAME AND LINE NUMBER OF MAN ______________

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER'S NAME ___________
RESULT* _____________

NEXT VISIT:
DATE __________
TIME ___________

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
INTERVIEWER NUMBER ____
RESULT* _____

TOTAL NUMBER OF VISITS __

LANGUAGE OF QUESTIONNAIRE**:

LANGUAGE OF INTERVIEW**: ___

NATIVE LANGUAGE OF RESPONDENT**: ___

TRANSLATOR USED

SUPERVISOR
NAME ________ ___
DATE ________

FIELD EDITOR
NAME ________ ___
DATE ________

OFFICE EDITOR____

KEYED BY_____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is ____________and I am working with the National Statistical Office.
We are conducting a national survey that asks men and women about various health issues.
We would very much appreciate your participation in this survey.
This information will help the government to plan health services.
The survey usually takes about 20 minutes to complete.
Whatever information you provide will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Participation in this survey is voluntary, and 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 that you will participate in this survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

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.

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

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

104. In the last 12 months, on how many separate occasions have you traveled away from your home community and slept away?
IF NUMBER OF TRIPS IS GREATER THAN 95, WRITE 95.

105. In the last 12 months, have you been away from your home community for more than one month at a time?

106. In what month and year were you born?

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

108. Have you ever attended school?

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

110. What is the highest (class/form/year) you completed at that level?

111. CHECK 109:

112. 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?

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

113A. CHECK 107:
AGE

113B. Have you ever participated in a vocational training program such as carpentry, tinsmithing, tailoring, photoprocessing, or any other vocational training program?

114. CHECK 112:

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

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

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

118. What is your religion?

119. What is your tribe or ethnic group?

SECTION 2A. REPRODUCTION

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

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

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

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

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

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

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

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

209. CHECK 208:

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

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

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

SECTION 2B. PARTICIPATION IN HEALTH CARE

213. CHECK 203 AND 205:

214. How many years old is your (youngest) child?

215. CHECK 214:

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

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

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

218A. At any time while (NAME)'s mother was pregnant with (NAME), did you yourself talk with a doctor or any other health care provider about the health of the mother or of the pregnancy?

218B. In your opinion, what are some serious health problems that can occur during labour and childbirth that could endanger the life of a pregnant woman or the baby?
PROBE: Any others?
RECORD ALL MENTIONED

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

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

220A. Were there any costs for the medical care received for the birth of (NAME), including fees for delivery care, supplies, medicines, transport or any other costs?

220B. Who paid MOST of the costs for the medical care for the birth of (NAME)?

220C. Does (NAME) live with you in your household?

220D. In your household who usually decides what to do if (NAME) is ill?
RECORD ALL PERSONS MENTIONED.

220E. Have you yourself ever taken (NAME) to a health facility for care?

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

221A. Have you ever heard of a special product called THANZI or ORS that can be used to treat diarrhea?

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.

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, 08, 09 AND 10, ASK 302 IF 301 HAS CODE 1 CIRCLED.

302. Have you ever used (METHOD)?

303A. In the last few months have you heard about family planning:

303B. In the last few months, have you listened to any of the following program series about family planning or health on the radio?

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

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

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

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

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

310. Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

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

313. Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

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

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

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

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

406. Altogether, how many wives do you have or other partners do you live with as if married?

407. CHECK 405:

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

MORE THAN ONE WIFE/PARTNER: Please tell me the name of each of your 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.

408. How old was (NAME) on her last birthday?

409. CHECK 407:

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

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

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

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

414. Now I would like to ask you 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?

414A. The first time you had sexual intercourse, was it to participate in a cultural practice or ritual such as chinamwali or kuchosa fumbi?

417. CHECK 107:

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

419. Now I would like to ask you some questions about your recent sexual activity in the last 12 months. 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.

420. 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.

421. When was the last time you had sexual intercourse with this person?
[FOR LAST THREE SEXUAL PARTNERS EXCEPT FOR THE LAST PARTNER]

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

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

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

424A. CHECK 410:

424B. CHECK 414:

425A. How long ago did you first have sexual intercourse with this (second/third) person?

425B. CHECK 424:

425C. How many times during the last 12 months did you have sexual intercourse with this person: once, twice, or more?

428. Apart from [this person/these two people], have you had sexual intercourse with any other person in the last 12 months?
[FOR LAST AND SECOND-TO-LAST SEXUAL PARTNER]

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

430. CHECK 424 (ALL COLUMNS):

431. CHECK 424 AND 422 (ALL COLUMNS):

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

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

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

434A. Have you ever paid for sex?

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'

435A. CHECK 414A:

435B. Have you ever had sexual intercourse as part of a cultural practice or ritual?

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

438. Do you know the brand name of the condom used at that time?
IF BRAND IS LISTED, CIRCLE THE MATCHING CODE. IF BRAND IS NOT LISTED, RECORD NAME OF BRAND. IF RESPONDENT DOES NOT KNOW WHAT BRAND OF CONDOMS SHE IS USING, CIRCLE 'DON'T KNOW'.

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 HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

442. CHECK 302 (02): RESPONDENT EVER STERILIZED

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

444. What method did you or your partner use?
PROBE: Did you or your partner use any other method to prevent pregnancy?
RECORD ALL MENTIONED.

SECTION 5. FERTILITY PREFERENCES

501. CHECK 407:

502. CHECK 302:

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

504. CHECK 503:

NO WIFE/PARTNER PREGNANT OR DON'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?

505. CHECK 407:

506. CHECK 503:

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

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

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

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.

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?

SECTION 6. EMPLOYMENT AND GENDER ROLES

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

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

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

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

605. CHECK 604:

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?

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

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

609. Are you paid in cash or kind for this work or are you not paid at all?

610. CHECK 407:

611. CHECK 609:

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?

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:

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

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:

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?

617. As far as you know, did your father ever beat your mother?

SECTION 7. HIV/AIDS

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

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

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

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

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

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

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

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

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

710. CHECK 709:

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?

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

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

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

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?

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?

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

733. CHECK 701:

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

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

734. CHECK 414:

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

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

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

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?

739. CHECK 736, 737, AND 738:

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

741. Where did you go? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE
CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

742. Husband and wives do not always agree in 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?

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?

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

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

SECTION 8. OTHER HEALTH ISSUES

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

802. How does tuberculosis spread from one person to another?
PROBE: Any other ways?
CIRCLE ALL MENTIONED.

802A. Has a doctor or other health care professional ever told you that you had tuberculosis?

802B. How long ago did a doctor or other healthcare professional tell you that you had tuberculosis: in the past year, more than one year ago, but less than five years ago, or more than five years ago?

803. Can tuberculosis be cured?

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

805. Some men are circumcised. Are you circumcised?

805A. How old were you when circumcision occurred?

805B. Who circumcised you?

805C. Where did you go to be circumcised?

806. Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

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

810. Do you currently smoke cigarettes?

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

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

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

SECTION 9. HIV TESTING AND AIDS TREATMENT

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

902. Have you ever been tested to see if you have the AIDS virus?

903. When was the last time you were tested?

904. 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?

905. Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

906. Did you get the results of the test?

906A. CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.

907. Let me remind you that all of your answers are confidential, and that the information you provide is very important for the survey. Could you please tell me what was the result of your last test for the AIDS virus?

908. Are you taking ARVs, that is, antiretroviral medicines, daily?

909. Have you ever taken ARV medicines daily?

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

911. Where is that? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE
CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

912. INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT FINISHING THE HIV TESTING AND AIDS TREATMENT MODULE:__________________________________

913. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:____________________________________________

COMMENTS ON SPECIFIC QUESTIONS:____________________________________

ANY OTHER COMMENTS:____________________________________________

SUPERVISOR'S OBSERVATIONS:____________________________________________

NAME OF SUPERVISOR: ____________________
DATE: _____________________

EDITOR'S OBSERVATIONS:_____________________________________________

NAME OF EDITOR: ______________________
DATE: _______________________