IDENTIFICATION

NAME OF HOUSEHOLD HEAD_______

PLACE NAME ________

PROVINCE_______

URBAN/RURAL

NAME AND NUMBER OF ENUMERATION AREA (DHS I.D.)_____

HOUSEHOLD NUMBER_______

NAME AND LINE NUMBER OF MAN_______

HOUSEHOLD SELECTED TO INTERVIEW MEN____

MAN SELECTED FOR DOMESTIC VIOLENCE MODULE___

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_________
INTERVIEWER'S NAME_________
RESULT___

RESULT*_________

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE_________
TIME_________

FINAL VISIT
DAY_________
MONTH_________
YEAR 2011
CODE_________
RESULT_________

TOTAL NUMBER OF VISITS_________

SUPERVISOR
NAME_________
DATE_________

SECTION 1: RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

Good morning/afternoon. My name is _________(SAY YOUR NAME) and I am working with the INE and here is my identification (SHOW YOUR ID BADGE). 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 45 minutes to complete. All of the answers you give will be kept strictly confidential and will not be shared with anyone other than members of our survey team. We hope that you will participate in this survey since your views are important. If I ask you a 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 that you need more information about the survey, you may contact the province delegate of Statistics.

Do you have any questions? May I begin the interview now?

SIGNATURE OF INTERVIEWER:____________
DATE:________________

101. RECORD THE TIME

102. In what month and year were you born?

103. How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 03 IF INCONSISTENT

104. Have you ever attended school?

105. What is the highest level of school you attended?

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

107. CHECK 105:

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

109. CHECK 108:

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

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

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

113. What is your religion?

113B. How often do you go to the church/mosque?

114. What language did you grow up speaking?

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

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

SECTION 2. REPRODUCTION

201. Now I would like to ask about all the children you have had/fathered during your life (and if the children are still alive). Do you have any children (male or female)?

202. Do you have any sons or daughters 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 do not live with you?

205. How many sons are living somewhere else? And how many daughters are living somewhere else?
IF NONE RECORD '00'

206. Have you ever had a boy or a girl who was born alive but later died? IF NO, PROBE: Any baby who cried or showed signs of life but survived only a few hours or days?

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 RECORD THE TOTAL. IF NONE, RECORD '00'

209. CHECK 208 IF ONE OR MORE BORN ALIVE:

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

211. In total, with how many women/partners do you have children?

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

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?

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

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

SECTION 3. CONTRACEPTION

301. Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid pregnancy. Have you heard of (METHOD)?

'

302. In the last few months have you:

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

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

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

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

307. CHECK 301 (07):
KNOWS MALE CONDOM

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

309. Where is that? Any other place?

PROBE TO IDENTIFY THE 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.

310. If you wanted to, could you yourself get a 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/partner (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/partners (and/or 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 WIFE/PARTNER.

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?

415. 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 you don't want to answer, just let me know and we will go to the next question.

416. When was the last time you had sexual intercourse?
IF ANSWER IS IN LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS OR MONTHS. IF IS 12 OR MORE MONTHS ANSWER MUST BE RECORDED IN YEARS. IF ANSWER IS SAME DAY, RECORD '00'.

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

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

419. Did you use a condom every time you had sexual intercourse with this person in the last 12 months?

420. 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'

421. CHECK 410:

422. CHECK 414:

423. How long ago (have you had/did you have) a sexual relationship with this (second/third) person?
IF ONLY MORE THAN 95 TIMES, RECORD '95'.

424. How many times during the last 12 months did you have sexual intercourse with this person?

425. How old was this person?

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

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

428. CHECK 420 (ALL COLUMNS):

429. CHECK 420 AND 418 (ALL COLUMNS):

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

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

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

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

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

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

436. You told me that a condom was used the last time you had sex. Do you know the brand name of the condom used at that time?
IF BRAND IS NOT KNOWN, ASK TO SEE PACKAGE.
RECORD ALL MENTIONED.

437. From where did you obtain the condoms the last time? Any other place?
PROBE TO IDENTIFY THE 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.

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

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

SECTION 5 FERTILITY PREFERENCES

501. CHECK 401:

502. CHECK 439:

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

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

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

506. CHECK 407:

507. CHECK 503:

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

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

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

509. CHECK 203 AND 205:

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

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

PROBE FOR A NUMERIC RESPONSE

510. How many of these children would you like to be boys, how many would you like to be girls and for how would it 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. Do you usually work throughout the year, or do you work seasonally, or only once in a while?

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

607. CHECK 401:

608. CHECK 606:

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

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

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

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

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

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

SECTION 7. HIV/AIDS

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

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

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

704. Can people reduce their chances 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 avoid the AIDS virus because of witchcraft or other supernatural means?

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

708. Can the virus that causes AIDS be transmitted from mother to a child:

709. CHECK 708:

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

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

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

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

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

715. Where was the test done?

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

717. Where is that?

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

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

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

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

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

723. CHECK 701:

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

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

724. CHECK 414:

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

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

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

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

729. CHECK 726, 727 AND 728:

730. The last time you had those problems (PROBLEMS MENTIONED IN 726/727/278), did you seek advice or treatment?

731. Where did you seek advice or treatment? Anywhere else?
PROBE TO IDENTIFY THE 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.

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

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

SECTION 8. OTHER HEALTH ISSUES

801. Some people are circumcised. Are you circumcised?

802. How old were you when you were circumcised?

803. Who did the circumcision?

804. Where was it done?

805. Now I would like to ask you some 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.

806. Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

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

808. Do you currently smoke cigarettes?

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

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

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

814. Are you covered by any medical assistance or health insurance?

SECTION 12. DOMESTIC VIOLENCE MODULE

1200. CHECK COVER PAGE:

1201. CHECK FOR PRESENCE OF OTHERS:

DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED. RECORD THE CORRECT CODE AND FOLLOW THE INSTRUCTIONS

1202. CHECK 401 AND 402:

1203. First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) wife/partner?

1204. Now if you will permit me, I need to ask some more questions about your relationship with your (last) wife/partner.

A. (Does/did) your (last) wife/partner ever:

B. How often did this happen during the last 12 months: often, only sometimes, rarely, or not at all?

1205. A. (Does/did) your (last) wife/partner ever:

B. How often did this happen during the last 12 months: often, only sometimes, rarely, or not at all?

1206. CHECK 1205A:

1207. How long after you first got married to/started living with your (last) wife/partner did (this/any of these things) first happen?
IF LESS THAN 1 YEAR, RECORD '00'.

1208. Did the following ever happen as a result of what your (last) wife/partner did to you:

1209. Have you ever hit, slapped, kicked or done anything else to physically hurt your (last) wife/partner at times when she was not already beating or physically hurting you?

1210. In the last 12 months, how many times have you done this to your wife/partner: many times, sometimes, rarely, never?

1211. Does (did) your wife/partner drink beer, wine, or any other alcoholic beverage?

1212. During the last month how often does (did) she get drunk: often, only sometimes, rarely or not at all?

1212A. Some woman can be violent when they drink alcohol or are drunk. Has your wife/partner, during the last 12 months, become violent after drinking alcoholic beverages?

1212B. In the last 12 months how many times did your wife/partner became violent after drinking alcoholic beverages: often, only sometimes, rarely or not at all?

1213. CHECK 401 AND 202:

EVER MARRIED/LIVED WITH A WOMAN/SEPARATED/DIVORCED/WIDOW: From the time you were 15 years old has anyone other than your (current/last) wife/partner hit, slapped, kicked or done anything else to hurt you physically?

NEVER MARRIED/NEVER LIVED WITH A WOMAN: From the time you were 15 years old has anyone hit, slapped, kicked or done anything else to hurt you physically?

1214. Who has hurt you in this way?
Anyone else?
RECORD ALL MENTIONED.

1215. In the past 12 months, how often were you hit, slapped, kicked or hurt physically: often, only sometimes, rarely or not at all?

1219. CHECK 414:

1220. The first time you had sexual intercourse, would you say that you had it because you wanted to, or because you were forced to have it against your will?

1221. CHECK 401 AND 402:

EVER MARRIED/LIVED WITH A WOMAN: In the last 12 months, has anyone other than your (current/last) wife/partner forced you to have sexual intercourse against your will?

NEVER MARRIED/NEVER LIVED WITH A WOMAN: In the last 12 months, has anyone forced you to have sexual intercourse against your will?

1222. CHECK 1220 AND 1221:

1223. CHECK 1025(h) AND 1205(i):

1224. At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts?

1225. How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?

1226. Who was the person who was forcing you at that time?

1226A.Were you forced to have sexual intercourse or perform any other sexual acts: often, only sometimes, rarely or not at all?

1226B. Did you seek for medical help after (the last time) you were forced to have sexual intercourse or perform any other sexual acts?

1226C. How long after you were forced to have sexual intercourse did you seek for medical help?

1227. CHECK 1205A, 1213, 1217, 1221 AND 1224:

1228. Thinking about what you yourself have experienced among different things we have been talking about, have you ever tried to seek help to stop (the/these) person(s) from doing this to you again?

1229. From whom have you sought help? Anyone else?
RECORD ALL MENTIONED.

1229A. What was the reason you did not seek any help?
RECORD ALL MENTIONED.

1230. Have you ever told anyone else about this?

1231. As far as you know, did your father ever beat your mother?

THANK THE RESPONDENT FOR HIS COOPERATION AND REASSURE HIM ABOUT THE CONFIDENTIALITY OF HIS ANSWERS. FILL OUT THE QUESTIONS BELOW REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

1232. DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

1233. INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE__________________________________________

1234. RECORD TIME

INTERVIEWER'S OBSERVATIONS

To be filled in after completing interview

Comments about the interview:__________________

Comments on Specific Questions:_________________
Any other comments:___________

SUPERVISOR'S OBSERVATIONS_______________________________________

Name of Supervisor:__________________
Date:________

EDITOR'S OBSERVATIONS________________________________________

Name of Editor:__________________
Date:________