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29 May 2013
MINISTRY OF HEALTH AND SOCIAL SERVICES
2013 NAMIBIA DEMOGRAPHIC AND HEALTH SURVEY
WOMAN'S QUESTIONNAIRE

IDENTIFICATION

NAME AND THE CODE OR REGION __________

PLACE (LOCALITY) NAME __________

CLUSTER NAME _____

HOUSEHOLD NUMBER _____

NAME AND LINE NUMBER OF WOMAN __________

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS

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

RESULT* __________

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

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)

DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER _____
RESULT _____

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

TOTAL NUMBER OF VISITS ___

LANGUAGE OF QUESTIONNAIRE _____

1 AFRIKAANS
2 DAMARA/NAMA
3 ENGLISH
4 OTJIHERERO
5 RUKWANGALI
6 SILOZI
7 OSHIWAMBO
8 OTHER

LANGUAGE OF INTERVIEW _____

1 AFRIKAANS
2 DAMARA/NAMA
3 ENGLISH
4 OTJIHERERO
5 RUKWANGALI
6 SILOZI
7 OSHIWAMBO
8 OTHER

LANGUAGE OF RESPONDENT _____

1 AFRIKAANS
2 DAMARA/NAMA
3 ENGLISH
4 OTJIHERERO
5 RUKWANGALI
6 SILOZI
7 OSHIWAMBO
8 OTHER

TRANSLATOR USED (YES = 1, NO = 2)

YES 1
NO 2

SUPERVISOR
NAME __________
DATE __________

FIELD EDITOR
NAME __________
DATE __________

OFFICE EDITOR _____
KEYED BY _____

SECTION 1. RESPONDENT'S BACKGROUND

INFORMED CONSENT

Hello. My name is _______________________________________. I am working with the Ministry of Health and Social Services. We are conducting a survey about health all over Namibia. 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
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (GO TO END)

101A) COLLECT ANY RELEVANT DOCUMENTS THAT MAY HAVE INFORMATION ON THE RESPONDENT AND HER CHILDREN'S AGE AND IMMUNIZATIONS.

101) RECORD THE TIME.

HOUR ___
MINUTES ___

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

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

PRIMARY 1
SECONDARY 2
HIGHER 3

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

GRADE/YEAR ___

107) CHECK 105:

PRIMARY ___
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

108A) 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

109) CHECK 108:

CODE '2', '3', OR '4' CIRCLED
CODE '1' OR '5' CIRCLED (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 is your religion?

ROMAN CATHOLIC 1
PROTESTANT/ANGLICAN 2
ELCIN 3
SEVENTH-DAY ADVENTIST 4
NO RELIGION 5
OTHER (SPECIFY) _____ 6

114) What is the main language spoken in your home?

AFRIKAANS 01
DAMARA/NAMA 02
ENGLISH 03
HERERO 04
KWANGALI 05
LOZI 06
OSHIWAMBO 07
SAN 08
OTHER (SPECIFY) ________ 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 201A)

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

YES 1
NO 2

SECTION 2. REPRODUCTION

201A) CHECK COVER PAGE:

HOUSEHOLD SELECTED FOR MAN'S SURVEY (CONTINUE)
HOUSEHOLD NOT SELECTED FOR MAN'S SURVEY (GO TO 201)

201B) CHECK 103:

WOMAN AGE 15-49 (GO TO 201)
WOMAN AGE 50-64 (GO TO 601)

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 not 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'.

SONS AT HOME _____
DAUGHTERS AT HOME _____

204) Do you have any sons or daughters to whom you have given birth who are alive 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'.

SONS ELSEWHERE _____
DAUGHTERS ELSEWHERE _____

206) Have you ever given birth to a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of live 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'.

BOYS DEAD ___
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 a 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/ TRIPLETS/ MULTIPLES ON SEPARATE ROWS.

IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.

212) What name was given to your (first/next) baby?
RECORD NAME, BIRTH HISTORY NUMBER

NAME __________

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

BOY 1
GIRL 2

214) Were any of these births multiples?

SINGLE 1
MULTIPLE 2

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

MONTH _____
YEAR _____

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 _____

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 THAT 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

DAYS 1 _____
MONTH 2 _____
YEARS 3 _____

221) Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME) including any children who died after birth?

YES 1 (ADD BIRTH)
NO 2 (NEXT BIRTH)
TICK HERE IF CONTINUATION SHEET USED _____

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 (CONTINUE)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

224) CHECK 215:
ENTER THE NAME OF BIRTHS IN 2008 OR LATER

NUMBER OF BIRTHS _____
NONE 0 (GO TO 226)

225) FOR EACH BIRTH SINCE JANUARY 2008, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P'S MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226) Are you pregnant now?

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

227) How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.
ENTER 'P'S IN THE 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 JAN 2008 OR LATER (CONTINUE)
LAST PREGNANCY ENDED BEFORE JAN 2008 (GO TO 238)

233) How many months pregnant were you when the last such pregnancy ended?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'T' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

MONTHS _____

234) Since January 2008, have you had any other pregnancies that did not result in a live birth?

YES 1
NO 2 (GO TO 236)

235) ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2008.

ENTER 'T' IN THE CALDENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236) Did you have any miscarriages, abortions or stillbirths that ended before 2008?

YES 1
NO 2 (238)

237) When did the last such pregnancy that terminated before 2008 end?

MONTH _____
YES _____

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 BEGIN 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)?

01) FEMALE STERLIZATION: Women can have an operation to avoid having any more children.
YES 1
NO 2
02) MALE STERLIZATION: Men can have an operation to avoid having any more children.
YES 1
NO 2
03) IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
04) INJECTABLES: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2
05) IMPLANTS: 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
06) PILL: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
07) CONTRACEPTIVE PATCH (EVRA): Women can have a transdermal patch applied to their skin that releases synthetic estrogen and progestin hormones to prevent pregnancy.
YES 1
NO 2
08) CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
09) FEMALE CONDOM: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2
10) LACTATIONAL AMENORRHEA METHOD (LAM):
YES 1
NO 2
11) RHYTHM METHOD: 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
12) WITHDRAWL: Men can be careful and pull out before climax or ejaculation.
YES 1
NO 2
13) EMERGENCY CONTRACEPTION: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent.
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) CHECK 226:

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

303) Are you 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?
CIRCLE 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)
IUD C (GO TO 308A)
INJECTABLES (GO TO 308A)
IMPLANTS (GO TO 308A)
PILL F
CONTRACEPTIVE PATCH G (GO TO 308A)
CONDOM (GO TO 306)
FEMALE CONDOM I (GO TO 306)
DIAPHRAGM J (GO TO 308A)
FOAM/JELLY K (GO TO 308A)
LACTATIONAL AMEN. METHOD L (GO TO 308A)
RHYTHM METHOD M (GO TO 308A)
WITHDRAWL N (GO TO 308A)
OTHER MODERN METHOD X (GO TO 308A)
OTHER TRADITIONAL METHOD Y (GO TO 308A)

305) What is the brand name of the pills you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

OVRAL 01 (GO TO 308A)
MICRONOVUM 02 (GO TO 308A)
TRIPHASIL 03 (GO TO 308A)
NORDETTE 04 (GO TO 308A)
OTHER (SPECIFY __________) 96 (GO TO 308A)
DON'T KNOW 98 (GO TO 308A)

306) What is the brand name of the condoms you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

SMILE 01 (GO TO 308A)
COOL RIDER 02 (GO TO 308A)
SENSE 03 (GO TO 308A)
FEMIDOM 04 (GO TO 308A)
OTHER (SPECIFY __________) 96 (GO TO 308A)
DON'T KNOW 98 (GO TO 308A)

307) In what facility did the sterilization take place?
PROVE 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
GOVT. HOSPITAL 11
GOVT. HEALTH CENTER 12
OTHER PUBLIC SECTOR (SPECIFY __________) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
PRIVATE CLINIC 22
PRIVATE DOCTOR'S OFFICE 23
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) 26
OTHER (SPECIFY __________) 96
DON'T KNOW 98

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

MONTH _____
YEAR _____

308A) Since what month and year have you been using (CURRENT METHOD) without stopping? PROBE: For how long have you been using (CURRENT METHOD) not without stopping?

MONTH _____
YES _____

309) CHECK 308/308A, AND 215, 231:
ANY BIRTH OR PREGNANCY TERMINATIONED 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 2008 OR LATER:
ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND IN EACH MOTH BACK TO THE DATE STARTED USING.

YEAR IS 2007 OR EARLIER:
ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK TO JANUARY 2008. THEN 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.
USE CALENDAR TO PROBE FOR EARLIER PERIODS OR USE AND NONUSE, STARTING WITH MOIST RECENT USE, BACK TO JANUARY 2008.
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

IN COLUMN 1, ENTER METHOD USE CODE OR '0' FOR NONUSE IN EACH BLANK MONTH.

ILLUSTRATIVE QUESTIONS:
When was the last time you used a method? Which method was that?
When did you start using that method? How long after the birth of (NAME)?
How long did you use the method then?

METHOD __________

IN COLUMN 2, ENTER CODES FOR DISCONTINUATION NEXT TO THE LAST MONTH OF USE. NUMBER OF CODES IN COLUMN 2 MUST BE SAME AS NUMBER OF INTERRUPTIONS OR METHOD USE IN COLUMN 1.

ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT.

ILLUSTRATIVE QUESTIONS:
Why did you stop using the (METHOD)? Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason?

REASON __________

IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK: How many months did it take you to get pregnant after you stopped using (METHOD)? AND ENTER '0' IN EACH SUCH MONTH IN COLUMN 1.

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

NO METHOD USED (CONTINUE)
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:
CIRCLE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

NO CODE CIRCLED 00 (GO TO 324)
FEMALE STERILIZATION 01 (GO TO 317A)
MALE STERILIZATION 02 (GO TO 326)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONTRACEPTIVE PATCH 07
CONDOM 08
FEMALE CONDOM 09
DIAPHRAGM 10
FOAM/JELLY 11
LACTATIONAL AMEN. METHOD 12 (GO TO 315A)
RHYTHM METHOD 13 (GO TO 315A)
WITHDRAWAL 14 (GO TO 326)
OTHER MODERN METHOD 95 (GO TO 326)
OTHER TRADITIONAL METHOD 96 (GO TO 326)

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

PUBLIC SECTOR
GOVT HOSPITAL 11
GOVT HEALTH CENTER 12
GVT PRIMARY HEALTH CARE CLINIC 13
OUTREACH POINT 14
FIELDWORKER/COMMUNITY HEALTH CARE PROVIDER 15
OTHER PUBLIC SECTOR (SPECIFY __________) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
PRIVATE CLINIC 22
PHARMACY 23
PRIVATE DOCTOR 24
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) 26
OTHER SOURCE
SHOP 31
CHURCH 32
FRIEND/RELATIVE 33
SCHOOL 34
OTHER (SPECIFY __________) 96

315A) Where did you learn how to use the rhythm/lactational amenorrhea 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
GOVT HOSPITAL 11
GOVT HEALTH CENTER 12
GVT PRIMARY HEALTH CARE CLINIC 13
OUTREACH POINT 14
FIELDWORKER/COMMUNITY HEALTH CARE PROVIDER 15
OTHER PUBLIC SECTOR (SPECIFY __________) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
PRIVATE CLINIC 22
PHARMACY 23
PRIVATE DOCTOR 24
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) 26
OTHER SOURCE
SHOP 31
CHURCH 32
FRIEND/RELATIVE 33
SCHOOL 34
OTHER (SPECIFY __________) 96

316) CHECK 304:
CIRCLE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONTRACEPTIVE PATCH 07
CONDOM 08(GO TO 323)
FEMALE CONDOM 09 (GO TO 320)
DIAPHRAGM 10 (GO TO 320)
FOAM/JELLY 11 (GO TO 320)
LACTATIONAL AMEN. METHOD 12 (GO TO 326)
RHYTHM METHOD 13 (GO TO 326)

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

YES 1 (GO TO 319)
NO 2

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

YES 1 (GO TO 322)
NO 2

CODE '1' NOT CIRLCED:
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:
CIRCLE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION 01 (GO TO 326)
MALE STERILZATION 02 (GO TO 326)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONTRACEPTIVE PATCH 07
CONDOM 08
FEMALE CONDOM 09
DIAPHRAGM 10
FOAM/JELLY 11
LACTATIONAL AMEN. METHOD 12 (GO TO 326)
RHYTHM METHOD 13 (GO TO 326)
WITHDRAWL 14 (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
GOVT HOSPITAL 11 (GO TO 326)
GOVT HEALTH CENTER 12 (GO TO 326)
GVT PRIMARY HEALTH CARE CLINIC 13 (GO TO 326)
OUTREACH POINT 14 (GO TO 326)
FIELDWORKER/COMMUNITY HEALTH CARE PROVIDER 15 (GO TO 326)
OTHER PUBLIC SECTOR (SPECIFY __________) 16 (GO TO 326)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21 (GO TO 326)
PRIVATE CLINIC 22 (GO TO 326)
PHARMACY 23 (GO TO 326)
PRIVATE DOCTOR 24 (GO TO 326)
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) 26 (GO TO 326)
OTHER SOURCE
SHOP 31 (GO TO 326)
CHURCH 32 (GO TO 326)
FRIEND/RELATIVE 33 (GO TO 326)
SCHOOL 34 (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 OF PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) __________
PUBLIC SECTOR
GOVT HOSPITAL A
GOVT HEALTH CENTER B
GVT PRIMARY HEALTH CARE CLINIC C
OUTREACH POINT D
MOBILE CLINIC E
FIELDWORKER/COMMUNITY HEALTH CARE PROVIDER F
OTHER PUBLIC SECTOR (SPECIFY __________) G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL H
PRIVATE CLINIC I
PHARMACY J
PRIVATE DOCTOR K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) L
OTHER SOURCE
SHOP M
CHURCH N
FRIEND/RELATIVE O
SCHOOL P
OTHER (SPECIFY __________) X

326) In the last 12 months, were you visited by a fieldworker/community health worker/health promoter who talked to you about family planner?

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

SECTOR 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

ONE OR MORE BIRTHS IN 2008 OR LATER (CONTINUE)
NO BIRTHS IN 2008 OR LATER (GO TO 556)

402) CHECK 215:
ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2008 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

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

403) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

LAST BIRTH (REPEAT FOR ALL BIRTHS)
BIRTH HISTORY NUMBER _____

404) FROM 212 AND 216:

NAME __________
LIVING (CONTINUE)
DEAD (CONTINUE)

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

YES 1 (GO TO 408)
NO 2

406) Did you want to have a baby later on, or did you want any (more) children?

LATER 1
NO MORE 2 (GO TO 408)

407) How much longer did you want to wait?

MONTHS 1 _____
YEARS 2 _____
DON'T KNOW 998

408) Did you see anyone for antenatal care for this pregnancy?

YES 1
NO 2 (GO TO 415)

409) Whom did you see? Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PERSONNEL
DOCTOR A
NURSE/MIDWIFE B
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT C
COMMUNITY HLTH CARE PROVIDER D
OTHER (SPECIFY __________) X

410) Where did you recieve antenatal care for this pregnancy? 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)) __________
HOME
YOUR HOME A
OTHER HOME B
PUBLIC SECTOR
GOVT HOSPITAL C
GOVT HEALTH CENTER D
GOVT HEALTH CARE CLINIC E
OUTREACH POINT F
OTHER PUBLIC SECTOR (SPECIFY __________) G
PRIVATE MED. SECTOR
PVT HOSPITAL H
PVT CLINIC I
OTHER PRIVATE MED SECTOR (SPECIFY __________) J
OTHER (SPECIFY __________) X

410A) Did your husband/partner attend (any of) your antenatal care visit(s) for this pregnancy?

YES 1
NO 2

411) How many months pregnant were you when you first recieved antenatal care for this pregnancy?

MONTHS
DON'T KNOW 98

412) How many times did you recieve antenatal care during this pregnancy?

NUMBER OF TIMES _____
DON'T KNOW 98

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

Was your blood pressure measured?
YES 1
NO 2
Did you give a urine sample?
YES 1
NO 2
Did you give a blood sample?
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?

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?

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?

TIMES _____
DON'T KNOW 8

417) CHECK 416:

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

418) At any time before this pregnancy, did you receive any tetanus injections?

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

419) Before this pregnancy, how many times did you recieve a tetanus injection?
IF 7 OR MORE TIMES, RECORD '7'.

TIMES _____
DON'T KNOW 8

420) How many years ago did you recieve the last tetanus injection before this pregnancy?

YEARS AGO _____

421) During this pregnancy, were you given or did you buy any iron tables? SHOW TABLETS.

YES 1
NO 2 (GO TO 423)
DON'T KNOW 8 (GO TO 423)

422) During the whole pregnancy, for how many days did you take the tablets?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

DAYS _____
DON'T KNOW 998

423) During this pregnancy, did you take any drugs intestional worms?

YES 1
NO 2
DON'T KNOW 8

424) During this pregnancy, did you take any drugs to keep you from getting malaria?

YES 1
NO 2 (GO TO 430)
DON'T KNOW 8 (GO TO 430)

425) What drugs did you take?
RECORD ALL MENTIONED. IF TYPE OF DRUGS IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIA DRUGS TO RESPONDENT.

SP/FANSIDAR A
OTHER (SPECIFY __________) X
DON'T KNOW Z

426) CHECK 425:
SP/FANSIDAR TAKEN FOR MALARIA PREVENTION/

CODE 'A' CIRCLED (GO TO 427)
CODE 'A' NOT CIRCLED (GO TO 430)

427) How many times did you take (SP/Fansidar) during this pregnancy?

TIMES _____

428) CHECK 409:
ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

CODE 'A' 'B' OR 'C' CIRCLED (GO TO 429)
OTHER (GO TO 430)

429) Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to health facility or from another source?

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6

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 (GO TO 433)

432) How much did (NAME) weigh?
RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE.

1 KG. FROM CARD _____._____
2 KG FROM RECALL _____._____
DON'T KNOW 99998

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
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT C
RELATIVE/FRIEND D
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
GOVT HOSPITAL 21
GOVT HEALTH CENTER 22
GOVT HEALTH CARE CLINIC 23
OUTREACH POINT 24
OTHER PUBLIC SECTOR (SPECIFY __________) 26
PRIVATE MED. SECTOR
PVT HOSPITAL 31
PVT CLINIC 32
OTHER PRIVATE MED SECTOR (SPECIFY __________) 36
OTHER (SPECIFY __________) 96 (GO TO 438)

434A) How long after (NAME) was delivered did you stay there?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1 _____
DAYS 2 _____
WEEKS 3 _____
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?

YES 1 (GO TO 439)
NO 2

437) Did anyone check on your health after you left the facility?

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

437A) Why didn't you deliver in a health facility?
PROBE: Any other reasons?
RECORD ALL MENTIONED.

COST TOO MUCH A
FACILITY NOT OPEN B
TOO FAR/ NO TRANSPORTATION C
DON'T TRUST FACILITY/ POO QUALITY SERVICE D
NO FEMALE PROVIDER AT FACILITY E
HUSBAND/ FAMILY DID NOT ALLOW F
NOT NECESSARY G
NOT CUSTOMARY H
OTHER (SPECIFY __________) X

438) I would like to talk to you about checks on your health after deliver, for example, someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)?

YES 1
NO 2 (GO TO 442)

439) Who checked on your health at that time?
PROVE FOR MOST QUALIFED PERSON.

HEALTH PERSONNAL
DOCTOR 11
NURSE/MIDWIFE 12
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
COMMUNITY HEALTH CARE PROVIDER 22
OTHER (SPECIFY __________) 96

440) How long after delivery did the first check take place?
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 or a traditional birth attendant check on his/her health?

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

443) How many hours, days, or weeks after the birth of (NAME) did the first check take place?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

HRS AFTER BIRTH 1 _____
DAYS AFTER BIRTH 2 _____
WKS AFTER BIRTH 3 _____
DON'T KNOW 998

444) Who checked on (NAME)'s health at that time?
PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL
DOCTOR 11
NURSE/MIDWIFE 12
OTHER PERSON
TRADITIONAL BIRTH ATTENDENT 21
COMMUNITY HEALTH CARE PROVIDER 22
OTHER (SPECIFY __________) 96

445) Where did this frist check of (NAME) take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRLCE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVEATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) __________
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
GOVT HOSPITAL 21
GOVT HEALTH CENTER 22
GVT HEALTH CARE CLINIC 23
OUTREACH POINT 24
OTHER PUBLIC (SPECIFY __________) 26
PRIVATE MED. SECTOR
PVT HOSPITAL 31
PVT CLINIC 32
OTHER PRIVATE MED. (SPECIFY __________) 36
OTHER (SPECIFY __________) 96

446) In the first two months after delivery, did you recieve a vitamin A dose like this? SHOW CAPSULE.

YES 1
NO 2
DON'T KNOW 8

447) Has your menstrual period returned since the birth of (NAME)?

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

448) Did your period return between the birth of (NAME) and your next pregnancy?

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?

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

451) Have you had sexual intercourse since the birth of (NAME)?

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 LIVING?

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 the breast?
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?

YES 1
NO 2 (GO TO 458)

457) What was (NAME) given to drink? Anything else?
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/INFUSION H
COFFEE I
HONEY J
OTHER (SPECIFY __________) X

458) CHECK 404: IS CHILD LIVING?

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

459) Are you still breastfeeding (NAME)?

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 2008 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 QUESTIONNAIRES).

502) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

LAST BIRTH (REPEAT FOR ALL BIRTHS)
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 506)
YES, NOT SEEN 2 (GO TO 509)
NO CARD 3

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

YES 1 (GO TO 509)
NO 2

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

BCG
DAY _____
MONTH _____
YEAR _____
POLIO 0 (POLIO GIVEN AT BIRTH)
DAY _____
MONTH _____
YEAR _____
POLIO 1
DAY _____
MONTH _____
YEAR _____
POLIO 2
DAY _____
MONTH _____
YEAR _____
POLIO 3
DAY _____
MONTH _____
YEAR _____
RENTAVALENT 1
DAY _____
MONTH _____
YEAR _____
PENTAVALENT 2
DAY _____
MONTH _____
YEAR _____
PENTAVALENT 3
DAY _____
MONTH _____
YEAR _____
MEASLES
DAY _____
MONTH _____
YEAR _____
VITAMINE A (MOST RECENT)
DAY _____
MONTH _____
YEAR _____

507) CHECK 506:

BCG TO MEASLES ALL RECORD (GO TO 511)
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 WRITE '66' IN TEH CORRESPONDING DAY COLUMN IN 506, GO TO 511)
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)

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

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 arm or shoulder 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 DPT/Pentavalent vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops?

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

510F) How many times was the DPT/Pentavalent vaccination given?

NUMBER OF TIMES _____

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

YES 1
NO 2
DON'T KNOW 8

511) Within the last six months, was (NAME) given a vitam A does like this?
SHOW CAPSULE.

YES 1
NO 2
DON'T KNOW 8

513) Was (NAME) given any medication 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
DON'T KNOW 8

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
GOVT HOSPITAL A
GOVT HEALTH CENTER B
GOVT HEALTH CARE CLINIC C
OUTREACH POINT D
OTHER PUBLIC SECTOR (SPECIFY __________) E
PRIVATE MEDICAL SECTOR
PVT. HOSPITAL F
PVT. CLINIC G
PHARMACY H
PVT DOCTOR I
OTHER PRIVATE MED. SECTOR (SPECIFY __________) J
OTHER SOURCE
SHOP K
TRADITIONAL PRACTITIONER L
MARKET M
OTHER (SPECIFY __________) X

520) CHECK 519:

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

521) Where did you first seek advice or treatment?
USE LETTER CODE FROM 519

FIRST PLACE _____

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 ORS?
YES 1
NO 2
DK 8
b) Salt-sugar homemade solution?
YES 1
NO 2
DK 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 ANTIBIOTIC, ANTIMOTILITY, 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 (GO TO 527)
DON'T KNOW 8 (GO TO 527)

526) At any time during the illness, did (NAME) have blood taken from his/her finger or heel for testing for malaria?

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 (GO TO 531)

529) Was the fast or difficult breathing due to 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 (CONTINUE)
NO OR DON'T KNOW (GO BACK TO 503 IN 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 somehwat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 6

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
GOVT HOSPITAL A
GOVT HEALTH CENTER B
GOVT HEALTH CARE CLINIC C
OUTREACH POINT D
OTHER PUBLIC SECTOR (SPECIFY __________) E
PRIVATE MEDICAL SECTOR
PVT. HOSPITAL F
PVT. CLINIC G
PHARMACY H
PVT DOCTOR I
OTHER PRIVATE MED. SECTOR (SPECIFY __________) J
OTHER SOURCE
SHOP K
TRADITIONAL PRACTITIONER L
MARKET M
OTHER (SPECIFY __________) X

535) CHECK 534:

TWO OR MORE CODED 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 _____

537) At any time during the illness, did (NAME) take any medication 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 3 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

538) What medications did (NAME) take? Any other medications?
RECORD ALL MENTIONED.

ANTIMALARIALS
QUINNE A
ARTEMETHER LUMEFANTRINE B
OTHER ANTIMALARIAL (SPECIFY __________) C
ANTIBIOTIC
PILL/SYRUP D
INJECTION E
OTHER MEDICATIONS
ASPIRIN F
ACETAMINOPHEN G
IBUPROFEN I
OTHER (SPECIFY __________) X
DON'T KNOW Z

539) CHECK 538:
ANY CODE A-C CIRLCED?

YES (GO TO 546)
NO (GO BACK TO 503 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 553)

546) CHECK 538:
QUINNE ('A') GIVEN

CODE 'A' CIRCLED (GO TO 557)
CODE 'A' NOT CIRCLED (GO TO 548)

557) How long after the fever started did (NAME) first take quinine?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

548) CHECK 538:
ARTEMETHER LUMFANTRINE ('B') GIVEN

CODE 'B' CIRCLED (GO TO 549)
CODE 'B' NOT CIRCLED (GO TO 550)

549) How long after the fever started did (NAME) first take Artemether Lumefantrine (AL)?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

550) CHECK 538:
OTHER ANTIMALARIAL ('C') GIVEN

CODE 'C' CIRCLED (CONTINUE)
CODE 'C' NOT CIRCLED (GO BACK TO 503 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 553)

551) How long after the fever started did (NAME) first take (OTHER ANTIMALARIAL)?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

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 2008 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 522a, ALL COLUMNS:

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

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

YES 1
NO 2

557) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2011 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?
YES 1
NO 2
DON'T KNOW 8
b) Juice or juice drinks?
YES 1
NO 2
DON'T KNOW 8
c) Clear broth?
YES 1
NO 2
DON'T KNOW 8
d) Milk such as tinned, powdered, or fresh animal 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 FORMULA _____
f) Any other liquids
YES 1
NO 2
DON'T KNOW 8
g) Yogurt?
IF YES: How many times did (NAME) eat yogurt? IF 7 OR MORE TIMES, RECORD '7'
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES ATE YOGURT _____
h) Any commercially fortified baby food e.g. Cerelac, Nestum, Purity
YES 1
NO 2
DON'T KNOW 8
i) Bread, rice, noodles, porridge, or other foods made from grains?
YES 1
NO 2
DON'T KNOW 8
j) Pumpkin, carrots, squash or sweet potatoes that are yellow or orange inside?
YES 1
NO 2
DON'T KNOW 8
k) White potatoes, white yams, manioc, cassava, or any other foods made from roots?
YES 1
NO 2
DON'T KNOW 8
l) Any dark green, leafy vegetables?
YES 1
NO 2
DON'T KNOW 8
m) Ripe mangoes, papayas, or any other vitamin-A rich fruits?
YES 1
NO 2
DON'T KNOW 8
n) Any other fruits or vegetables?
YES 1
NO 2
DON'T KNOW 8
o) Liver, kidney, heart or organ meats?
YES 1
NO 2
DON'T KNOW 8
p) Any meat, such as beef, pork, lamb, goat, chicken, or duck?
YES 1
NO 2
DON'T KNOW 8
q) Eggs?
YES 1
NO 2
DON'T KNOW 8
r) Fresh or dried fish or shellfish?
YES 1
NO 2
DON'T KNOW 8
s) Any foods made from beans, peas, lentils, or nuts?
YES 1
NO 2
DON'T KNOW 8
t) Cheese or other food made from milk?
YES 1
NO 2
DON'T KNOW 8
u) Any 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 560)
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

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, FORMALLY 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 somewhere else?

LIVING WITH HER 1
STAYING ELSEWHERE 2

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 NO. _____

606) Does you (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 8 (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)?

MONTH _____
DON'T KNOW MONTH 98

YEAR _____ (GO TO 612)
DON'T KNOW YEAR 9998

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?

AGE IN YEARS _____
NEVER HAD SEXUAL INTERCOURSE 00 (GO TO 628)
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 questions 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 _____
WEEKS AGO 2 _____
MONTHS AGO 3 _____
YEARS AGO 4 _____ (GO TO 627)

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

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

HUSBAND 1
LIVE IN PARTNER 2
BOYFRIEND NOT LIVING WITH RESPONDENT 3 (GO TO 622)
CASUAL AQUAINTANCE 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, WRITE '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?

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?
IF NON-NUMBERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95'.

NUMBER OF PARTNERS LAST 12 MONTHS _____
DON'T KNOW 98

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

NUMBER OF PARTNERS IN LIFETIME _____
DON'T KNOW 98

628) PRESENCE OF OTHERS DURING THIS SECTION:

CHILDREN LESS 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 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
GOVT HOSPITAL A
GOVT HEALTH CENTER B
GVT PRIMARY HEALTH CARE CLINIC C
OUTREACH POINT D
MOBILE CLINIC E
FIELDWORKER/COMMUNITY HEALTH CARE PROVIDER F
OTHER PUBLIC SECTOR (SPECIFY __________) G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL H
PRIVATE CLINIC I
PHARMACY J
PRIVATE DOCTOR K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) L
OTHER SOURCE
SHOP M
FRIEND/RELATIVE N
SCHOOL O
OTHER (SPECIFY __________) X

631) If you wanted to, could you yourself get a 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 701A)

633) Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE HTE NAME OF THE PLACE.

(NAME OF PLACE(S)) __________
PUBLIC SECTOR
GOVT HOSPITAL A
GOVT HEALTH CENTER B
GVT PRIMARY HEALTH CARE CLINIC C
OUTREACH POINT D
MOBILE CLINIC E
FIELDWORKER/COMMUNITY HEALTH CARE PROVIDER F
OTHER PUBLIC SECTOR (SPECIFY __________) G
PRIVATE MEDICAL CENTER
PRIVATE HOSPITAL H
PRIVATE CLINIC I
PHARMACY J
PRIVATE DOCTOR K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) L
OTHER SOURCE
SHOP M
FRIEND/RELATIVE N
SCHOOL O
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

701A) CHECK COVER PAGE:

HOUSEHOLD SELECTED FOR MAN'S SURVEY (GO TO 701B)
HOUSEHOLD NOT SELECTED FOR MAN'S SURVEY (GO TO 701)

701B) CHECK 103:

WOMAN AGE 15-49 (GO TO 701)
WOMAN AGE 50-64 (GO TO 801)

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?

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)

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:
RECORD ALL REASONS MENTIONED.

WANTS TO HAVE A/ANOTHER CHILD:
You have 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?

NOT MARRIED A
FERTILITY-RELATED REASONS
NO 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
OTHERS 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
REFERRED 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

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 reasons?

NOT MARRIED A
FERTILITY-RELATED REASONS
NO 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
OTHERS 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
REFERRED 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:
PROBE FOR A NUMERIC RESPONSE.

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?

NONE 00 (GO TO 714)
NUMBER _____
OTHER (SPECIFY __________) 96 (GO TO 714)

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

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 matter if it's a boy or girl?

BOYS (NUMBER) _____
GIRLS (NUMBER) _____
EITHER (NUMBER) _____
OTHER (SPECIFY __________) 96

714) In the last few months have you:

Heard about family planning on the radio
YES 1
NO 2
Seen anything about family planning on the television?
YES 1
NO 2
Read about family planning in a newspaper or magazine?
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 contraception is mainly your decision, mainly your (husband's/partner's) decision, or did you both decide together?

MAINLY RESPONDENT 1
MAINLY HUSBAND/PARNTER 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 CHIDLREN 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
SECONDARY 2
HIGHER 3
DON'T KNOW 8 (GO TO 806)

805) What was the highest (grade/year) he completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

GRADE/YEAR _____

DON'T KNOW 98

806) CHECK 801:

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

OCCUPATION __________

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 form 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 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

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 in at all?

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

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 CIRCLED (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)
OTHER (SPECIFY __________) 6

819) Who usually decides how your (husband's/ partner's) earnings 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 visit 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 LESS THAN 10
PRESENT AND LISTENING 1
PRESENT NOT LISTENING 2
NOT PRESENT 3
HUSBAND
PRESENT AND LISTENING 1
PRESENT NOT LISTENING 2
NOT PRESENT 3
OTHER MALES
PRESENT AND LISTENING 1
PRESENT NOT LISTENING 2
NOT PRESENT 3
OTHER FEMALES
PRESENT AND LISTENING 1
PRESENT NOT LISTENING 2
NOT PRESENT 3

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

If she goes out without telling him?
YES 1
NO 2
DON'T KNOW 8
If she neglects the children
YES 1
NO 2
DON'T KNOW 8
If she argues with him?
YES 1
NO 2
DON'T KNOW 8
If she refuses to have sex with him?
YES 1
NO 2
DON'T KNOW 8
If she burns the food?
YES 1
NO 2
DON'T KNOW 8
If she is friendly with other men?
YES 1
NO 2
DK 8

SECTION 9. HIV/AIDS

901) Now I would like to talk about something else. Have you ever heard of HIV/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

908) Can HIV be transmitted from a mother to her baby:

During pregnancy?
YES 1
NO 2
DK 8
During delivery?
YES 1
NO 2
DK 8
By breastfeeding?
YES 1
NO 2
DK 8

909) CHECK 908:

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

910) Are there any special medications that a doctor or a 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 925:

LAST BIRTH SINCE JANUARY 2011 (GO TO 912)
NO BIRTHS (GO TO 926)
LAST BIRTH BEFORE JANUARY 2011 (GO TO 926)

912) CHECK 408 FOR LAST BIRTH:

RECORD NAME OF LAST BORN CHILD __________
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:

Babies getting HIV from their mothers
YES 1
NO 2
DK 8
Things that you can do to prevent getting HIV?
YES 1
NO 2
DK 8
Getting tested for HIV?
YES 1
NO 2
DK 8

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

YES 1
NO 2

916) Were you tested for HIV as part of your antenatal care?

YES 1
NO 2 (GO TO 919A)

917) Were was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) __________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVT. HEALTH CENTER 12
STAND-ALONE VCT CENTER 13
GVT. PRIMARY HEALTH CARE CLINIC 14
OUTREACH POINT 15
MOBILE CLINIC 16
SCHOOL BASED CLINIC 17
OTHER PUBLIC SECTOR (SPECIFY __________) 18
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR 21
STAND-ALONE VCT CENTER 22
PHARMACY 23
MOBILE CLINIC 24
FIELDWORKER 25
SCHOOL BASKED CLINIC 26
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) 27
OTHER SOURCE
HOME 31
CORRECTIONAL FACILITY 32
OTHER (SPECIFY __________) 96

918) Did you get the results of the test?

YES 1
NO 2 (GO TO 919A)

918A) Will you be willing to share the results with me?

YES 1
NO 2 (GO TO 918C)

918B) What was your HIV rest result?

POSITIVE 1
NEGATIVE 2

918C) All women are supposed to receive counselling before and after being tested. Before and after you were tested, did you receive counselling?

YES 1
NO 2

918D) Have you disclosed your result to your partner?

YES 1
NO 2
NO PARTNER 3 (GO TO 919C)

919A) Was your partner tested for HIV during any of the ANC visits for your last birth?

YES 1
NO 2
DON'T KNOW 8

919B) CHECK 916 TESTED DURING ANC:

YES (GO TO 919C)
NO (GO TO 920)

919C) CHECK 918, 918A, AND 918B FOR HIV TEST RESULTS:

NEGATIVE/NO RESULT (GO TO 920)
POSITIVE (GO TO 923D)

920) CHECK 434 FOR LAST BIRTH:

ANY CODE 21-36 CIRCLED (GO TO 921)
OTHER (GO TO 923D)

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

YES 1
NO 2

922) Were you tested for HIV at the time?

YES 1
NO 2 (GO TO 923D)

923) Did you get the results of the test?

YES 1
NO 2 (GO TO 923D)

923A) Will you be willing to share the results with me?

YES 1
NO 2 (GO TO 923C)

923B) What was your HIV test result?

POSITIVE 1
NEGATIVE 2

923C) Have you disclosed your result to your partner?

YES 1
NO 2
NO PARTNER 3

923D) Was (NAME) tested for HIV during the first 18 weeks of his/her life?

YES 1
NO 2 (GO TO 923F)

923E) Was (NAME) tested for HIV during the first 18 months of his/her life?

YES 1
NO 2 (GO TO 923M)

923F) Was (NAME) tested for HIV more than once during the first 18 months of his/her life?

YES 1
NO 2

923G) Did you get the results of the (last) HIV test for (NAME)?

YES 1
NO 2

923H) Will you be willing to share the results with me?

YES 1
NO 2 (GO TO 923M)

923I) What was (NAME)'s HIV test result?

POSITIVE 1
NEGATIVE 2 (GO TO 923M)

923J) CHECK 216 LAST ROW:
IS CHILD LIVING?

LIVING (GO TO 923L)
DEAD (GO TO 923M)

923L) Is (NAME) currently taking ARV's daily?

YES 1
NO 2

923M) CHECK 926 AND 922:
WOMAN TESTED FOR HIV

916 = YES OR 922 = YES (GO TO 924)
OTHER (GO TO 926)

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 928E)
TWO OR MORE YEARS 95 (GO TO 928E)

926) Have you ever been tested to see if your 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

927A) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) __________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVT. HEALTH CENTER 12
STAND-ALONE VCT CENTER 13
GVT. PRIMARY HEALTH CARE CLINIC 14
OUTREACH POINT 15
MOBILE CLINIC 16
SCHOOL BASED CLINIC 17
OTHER PUBLIC SECTOR (SPECIFY __________) 18
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLNIC/PRIVATE DOCTOR 21
STAND-ALONE VCT CENTER 22
PHARMACY 23
MOBILE CLNIC 24
FIELDWORKER 25
SCHOOL BASED CLINIC 26
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) 27
OTHER SOURCE
HOME 31
CORRECTIONAL FACILITY 32
OTHER (SPECIFY __________) 96

928) Did you get the results of the test?

YES 1
NO 2 (GO TO 928E)

928A) Will you be willing to share the results with me?

YES 1
NO 2 (GO TO 928C)

928B) What was your HIV test result?

POSITIVE 1
NEGATIVE 2

928C) All women are supposed to receive counseling before and after being tested. Before and after you were tested, did you receive counseling?

YES 1
NO 2

928D) Have you disclosed your result to your partner?

YES 1
NO 2
NO PARTNER 3

928E) Did you receive HIV counseling and testing individually or as a couple?

INDIVIDUAL 1
COUPLE 2 (GO TO 928H)

928F) Would you consider HIV counseling and testing as a couple in the future?

YES 1 (GO TO 928H)
NO 2

928G) What is the main reason you would not consider HIV counseling and testing as a couple in the future?

PARTNER REFUSES 1
DISTANCE TO SERVICE DELIVERY 2
NO TIME 2
SERVICE DELIVERY HOURS 4
OTHER (SPECIFY __________) 6

928H) CHECK 918B, 923B, AND 928B:
HIV TEST RESULT

ANY "POSITIVE" TEST RESULTS (GO TO 928I)
ALL ARE "NEGATIVE" OR BLANK (GO TO 932)

928I) Are you currently taking ARV'S daily?

YES 1 (GO TO 932)
NO 2

928J) What is the main reason for not taking ARV's daily?

TRANSPORTAION COST 1 (GO TO 932)
RELIGIOUS REASONS 2 (GO TO 932)
FOOD/NUTRITIONAL ISSUES 3 (GO TO 932)
SIDE EFFECTS 4 (GO TO 932)
FEAR OF BEING SEEN AT ARV CLINIC 5 (GO TO 932)
OTHER (SPECIFY __________) 6 (GO TO 932)

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

YES 1
NO 2 (GO TO 932)

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
GOVT. HEALTH CENTER B
STAND-ALONE VCT CENTER C
GVT. PRIMARY HEALTH CARE CLINIC D
OUTREACH POINT E
MOBILE CLINIC F
SCHOOL BASED CLINIC G
OTHER PUBLIC SECTOR (SPECIFY __________) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLNIC/PRIVATE DOCTOR I
STAND-ALONE VCT CENTER J
PHARMACY K
MOBILE CLNIC L
FIELDWORKER M
SCHOOL BASED CLINIC N
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) O
OTHER SOURCE
HOME P
CORRECTIONAL FACILITY Q
OTHER (SPECIFY __________) X

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 to remain a secret or not?

YES, REMAIN A SECRET 1
NO 2
DK/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
DK/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
DK/NOT SURE/DEPENDS 8

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

YES 1
NO 2
DK/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?

YES 1
NO 2

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 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?

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 months, 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
GOVT. HEALTH CENTER B
STAND-ALONE VCT CENTER C
GVT. PRIMARY HEALTH CARE CLINIC D
OUTREACH POINT E
MOBILE CLINIC F
SCHOOL BASED CLINIC G
OTHER PUBLIC SECTOR (SPECIFY __________) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLNIC/PRIVATE DOCTOR I
STAND-ALONE VCT CENTER J
PHARMACY K
MOBILE CLNIC L
FIELDWORKER M
SCHOOL BASED CLINIC N
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) O
OTHER SOURCE
SHOP P
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 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 1000A)

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

1000A) Have you ever heard of an illness called tuberculosis or TB?

YES 1
NO 2 (GO TO 1001)

1000B) How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORDE 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
DON'T KNOW Z

1000C) What symptoms will a person with tuberculosis or TB have? Anything else?
RECORD ALL MENTIONED.

PERSISTENT COUGH (GREATER THAN TWO WEEKS) A
WEIGHT LOSS B
POOR APPETITE C
NIGHT SWEATING D
CHEST PAIN E
FEVER F
OTHER (SPECIFY __________) X
DON'T KNOW Z

1000D) Can tuberculosis be cured?

YES 1
NO 2
DON'T KNOW 8

1000E) 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

1001) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months? IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS _____
NONE 00 (GO TO 1004)

1002) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS _____
NONE 00 (GO TO 1004)

1003) The last time you got an injection from a health worker, did he/she take the syringe and needle from a view unopened package?

YES 1
NO 2
DON'T KNOW 8

1004) Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 1006)

1005) In the last 24 hours, how many cigarettes did you smoke?

NUMBER OF CIGARETTES _____

1006) Do you currently smoke or use any (other) type of tobacco?

YES 1
NO 2 (GO TO 1007C)

1007) What (other) type of tobacco do you currently smoke or use? RECORD ALL MENTIONED.

PIPE A
CHEWING TOBACCO B
BETEL C
SNUFF D
HUBBLY BUBBLY E
MARIJUANA F
OTHER (SPECIFY __________) X

1007A) Do you use or smoke tobacco products daily?

YES 1
NO 2 (GO TO 1007C)

1007B) How old were you when you first started using any tobacco products daily?

AGE IN YEARS _____

1007C) Have you ever consumed an alcoholic drink, such a beer, wine, spirits, or other home-brewed liquor?

YES 1
NO 2 (GO TO 1008)

1007F) Have you consumed an alcoholic drink during the past two weeks?

YES 1
NO 2 (GO TO 1008)

1007G) During the past two weeks, on how many days did you have at least one alcoholic drink?

NUMBER OF DAY _____
DON'T KNOW/NOT SURE 98 (GO TO 1008)

1007H) During the past two weeks, when you consumed alcohol, on average, how many bottles/glasses/tots of alcohol did you have per day?

NUMBER OF DRINKS _____
DON'T KNOW/NOT SURE 98

1008) 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?

Getting permission to go to the doctor?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Getting money needed for advice or treatment?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
The distance to the health facility?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Not wanting to go alone?
BIG PROBLEM 1
NOT A BIG PROBLEM 2

1009) Are you covered by any health insurance?

YES 1
NO 2 (GO TO 1010A)

1010) What type of health insurance are you covered by? RECORD ALL MENTIONED.

HEALTH INSURANCE THROUGH EMPLOYER A
SOCIAL SECURITY B
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE C
OTHER (SPECIFY __________) X

1010A) Now I am going to ask you some questions about physical activity. Are you involved in exercise that causes an increase in your heart rate for at least 10 minutes continuously?

IF YES, ASK: At work?
During other physical activities?

NO 1 (GO TO 1010E)
YES AT WORK 2 (GO TO 1010E)
YES OTHER PHYSICAL ACTIVITY 3

1010B) In the last 7 days, on how many days did you do exercise that lasted for at least 10 minutes each time?
IF 'NONE' RECORD '0'

NUMBER OF DAY S_____
DON'T KNOW/NOT SURE 8

1010E) Now I would like to ask you about liquids and foods that you consume.
How many glasses of water do you drink in one day on average?
IF 'NONE' RECORD '00'

NUMBER OF GLASSES _____

1010F) In a typical week, on how many days do you eat fruits, such as apples, pears, oranges, bananas, mangoes, etc.?
IF 'NONE' RECORD '0'

NUMBER OF DAYS _____
DON'T KNOW/NOT SURE 98 (GO TO 1010H)

1010G) On a day when you eat fruits, how many times do you eat on average?
IF 'NONE' RECORD '00'

NUMBER OF TIMES _____
DON'T KNOW/NOT SURE 98

1010H) In a typical week, on how many days do you eat vegetables, such as tomatoes, carrots, cabbage, dark green leafy vegetables (e.g. spinach) pumpkin, squash, etc?

NUMBER OF DAYS _____
DON'T KNOW/NOT SURE 8 (GO TO 1010M)

1010I) On a day when you eat vegetables, how many times do you eat on average? IF 'NONE' RECORD '00'

NUMBER OF TIMES _____
DON'T KNOW/NOT SURE 8

1010M) In the past 30 days, when you were seated in a vehicle either as a driver or passenger, have you used a seatbelt always, sometimes or never?

ALWAYS 1
SOMETIME 2
NEVER 3
HAVE NOT BEEN IN VEHICLE IN PAST 30 DAYS 4
NO SEATBELT IN CAR 5
DON'T KNOW/NOT SURE 8

1010N) Now I would like to ask about women's health. Have you ever heard of cervical cancer?

YES 1
NO 2 (GO TO 1010Q)

1010O) Have you ever had a test or exam to see if you have cervical cancer?

YES 1
NO 2 (GO TO 1010Q)
DON'T KNOW 8 (GO TO 1010Q)

1010P) What type of exam did you have to see if you have cervical cancer?

PAP SMEAR A
VISUAL INSPECTION WITH ACETIC ACID B
DON'T KNOW/NOT SURE X

1010Q) Have you ever exampled your breasts to detect or check for breast cancer?

YES 1
NO 2

1010R) Has a doctor or other health professional examined your breasts to detect or check for breast cancer?

YES 1
NO 2
DON'T KNOW 8

1010S) Now I would like to ask some questions about mental health. Are there times when you see or hear things that are actually not there?

YES 1
NO 2

1010T) In the past 12 months, have you ever felt seriously worthless, hopeless, or wished you were dead?

YES 1
NO 2

1010U) In the past two weeks, have you felt that you had little interest or pleasure in doing things?
IF YES, ASK: How many days did you feel this way?

NUMBER OF DAYS 1 _____
NO 2
DON'T KNOW/NOT SURE 8

1010V) In the past two weeks, have you felt very low in energy, been in a bad mood, or been sad all the time? IF YES, ASK: How many days did you feel this way?

NUMBER OF DAYS 1 _____
NO 2
DON'T KNOW/NOT SURE 8

1010W) CHECK 1010S, 1010T, 1010U, AND 1010V:

YES TO ANY (CONTINUE)
NO/DK/NOT SURE TO ALL (GO TO 1101A)

1010X) Did you seek any medical care?

YES 1
NO 2

SECTION 11. MATERNAL MORTALITY

1101A) CHECK COVER PAGE:

HOUSEHOLD SELECTED FOR MAN'S SURVEY (GO TO 1101B)
HOUSEHOLD NOT SELECTED FOR MAN'S SURVEY (GO TO 1101)

1101B) CHECK 103:

WOMAN AGE 15-49 (GO TO 1101)
WOMAN AGE 50-64 (GO TO 1233)

1101) Now I would like to ask you some questions about your brothers and sister, 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 BIRTH TO NATURAL MOTHER _____

1102) CHECK 1101:

TWO OR MORE BIRTHS (GO TO 1103)
ONLY ONE BIRTH (RESPONDENT ONLY) (GO TO 1201A)

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 __________ (REPEAT FOR NEXT OLDEST, ETC)

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 OLDEST, ETC)

1107) How old is (NAME)?

AGE __________ (GO TO NEXT OLDEST, ETC)

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 OLDEST

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?

NUMBER OF CHILDREN __________

IF NO MORE BROTHERS OR SISTER, GO TO 1201A

SECTION 12. DOMESTIC VIOLENCE

1201A) CHECK COVER PAGE:

WOMAN 15-49 SELECTED FOR THIS SECTION (CONTINUE)
WOMAN NOT SELECTED (GO TO 1233)

1201B) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

PRIVACY OBTAINED 1 (GO TO READ TO RESPONDENT)
PRIVACY NOT POSSIBLE 2 (GO TO 1232)

READ TO RESPONDENT:
Now I would like to ask you questions about some other important aspects of a woman's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in Namibia. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions.

1202) CHECK 601 AND 602:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 1203)
FORMERLY MARRIED/ LIVED WITH A MAN (READ IN PAST TENSE AND USE 'LAST' WITH HUSBAND/PARTNER) (GO TO 1203)
NEVER MARRIED/NEVER LIVED WITH A MAN (GO TO 1216)

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) (husband/partner)?

a) He (is/was) jealous or angry if you (talk/talked) to other men?
YES 1
NO 2
DK 8
b) He frequently (accuses/accused) you of being unfaithful?
YES 1
NO 2
DK 8
c) He (does/did) not permit you to meet your female friends?
YES 1
NO 2
DK 8
d) He (tries/tried) to limit your contact with your family?
YES 1
NO 2
DK 8
e) He (insisted/insisted) on knowing where you (are/were) at all times?
YES 1
NO 2
DK 8
f) He (doesn't/didn't) trust you with money/finances?
YES 1
NO 2
DK 8

1204) Now I need to ask you some questions about your relationship with your (last) (husband/partner) ever:

A) Did your (last) (husband/partner) ever:

a) say or do something to humiliate you in front of others?
YES 1
NO 2
b) threaten to hurt or harm you or someone you care about?
YES 1
NO 2
c) insult you or make you feel bad about yourself?
YES 1
NO 2

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

a) say or do something to humiliate you in front of others?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) threaten to hurt or harm you or someone you care about?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) insult you or make you feel bad about yourself?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

1205) A) Did your (last) (husband/partner) ever do any of the following things to you:

a) Push you, shake you, or throw something at you?
YES 1
NO 2
b) Slap you?
YES 1
NO 2
c) twist your arm or pull your hair?
YES 1
NO 2
d) punch you with his fist or with something that could hurt you?
YES 1
NO 2
e) kick you, drag you, or beat you up?
YES 1
NO 2
f) try to choke you or burn you on purpose?
YES 1
NO 2
g) threaten or attack you with a knife, gun, or other weapon?
YES 1
NO 2
h) physically force you to have sexual intercourse with him when you did not want to?
YES 1
NO 2
i) physically force you to perform any other sexual acts you did not want to?
YES 1
NO 2
j) force you with threats or in any other way to perform sexual acts you did not want to?
YES 1
NO 2

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

a) push you, shake you, or throw something at you?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) slap you?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) twist your arm or pull your hair?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
d) punch you with his first or with something that could hurt you?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
e) kick you, drag you, or beat you up?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
f) try to choke you or burn you on purpose?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
g) threaten or attack you with a knife, gun, or other weapon?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
h) physically force you to have sexual intercourse with him when you did not want to?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
i) physically force you to perform any other sexual acts you did not want to?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
j) force you with threats or in any other way to perform sexual acts you did not want to?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

1206) CHECK 1205A (a-j):

AT LEAST ONE 'YES' (GO TO 1207)
NOT A SINGLE 'YES' (GO TO 1209)

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

NUMBER OF YEARS _____
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95

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

a) you had cut, bruises, or aches?
YES 1
NO 2
b) You had eye injuries, sprains, dislocations, or burns?
YES 1
NO 2
c) You had deep wounds, broken bones, broken teeth, or any other serious injury?
YES 1
NO 2

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

YES 1
NO 2 (1211)

1210) In the last 12 months, how often have you done this to your (last) (husband/partner): often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1211) Does (did) your (last) (husband/partner) drink alcohol?

YES 1
NO 2 (GO TO 1213)

1212) How often does (did) he get drunk: often, only sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

1213) Are (Were) you afraid of your (last) (husband/partner): most of the time, sometimes, or never?

MOST OF THE TIME AFRAID 1
SOMETIMES AFRAID 2
NEVER AFRAID 3

1214) CHECK 609:

MARRIED MORE THAN ONCE (GO TO 1215)
MARRIED ONLY ONCE (GO TO 1216)

1215) A) So far we have been talking about the behavior of your (current/last)(husband/partner). Now I want to ask you about the behavior of any previous (husband/partner).

a) Did any previous (husband/partner) ever hit, slap, kick, or do anything else to hurt you physically?
YES 1
NO 2
b) Did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?
YES 1
NO 2

B) How long ago did this last happen?

a) Did any previous (husband/partner) ever hit, slap, kick, or do anything else to hurt you physically?
0-11 MONTHS AGO 1
12+ MONTHS AGO 2
DON'T REMEMBER 3
b) Did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?
0-11 MONTHS AGO 1
12+ MONTHS AGO 2
DON'T REMEMBER 3

1216) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN:
From the time you were 15 years old has anyone other than (your/any) (husband/partner) hit you, slapped you, kicked you, or done anything else to hurt you?

YES 1
NO 2 (GO TO 1219)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1219)

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

YES 1
NO 2 (GO TO 1219)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1219)

1217) Who has hurt you in this way? Anyone else? RECORD ALL MENTIONED.

MOTHER/STEP-MOTHER A
FATHER/STEP-FATHER B
SISTER/BROTHER C
DAUGHTER/SON D
OTHER RELATIVE E
CURRENT BOYFRIEND F
FORMER BOYFRIEND G
MOTHER-IN-LAW H
FATHER-IN-LAW I
OTHER IN-LAW J
TEACHER K
EMPLOYER/SOMEONE AT WORK L
POLICE/SOLDIER M
OTHER (SPECIFY __________) X

1218) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1219) CHECK 201, 226, AND 230:

EVER BEEN PREGNANT (YES ON 201 OR 226 OR 230) (GO TO 1220)
NEVER BEEN PREGNANT (GO TO 1222)

1220) Has anyone ever hit, slapped, or kicked, or done anything else to hurt you physically while you were pregnant?

YES 1
NO 2 (GO TO 1222)

1221) Who has done any of these things to physically hurt you while you were pregnant? Anyone else? RECORD ALL MENTIONED

CURRENT HUSBAND/PARTNER A
MOTHER/STEP-MOTHER B
FATHER/STEP-FATHER C
SISTER/BROTHER D
DAUGHTER/SON E
OTHER RELATIVE F
FORMER HUSBAND/PARTNER G
CURRENT BOYFRIEND H
FORMER BOYFRIEND I
MOTHER-IN-LAW J
FATHER-IN-LAW K
OTHER IN-LAW L
TEACHER M
EMPLOYER/SOMEONE AT WORK N
POLICE/SOLDIER O
OTHER (SEPCIFY __________) X

1222) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN (GO TO 1222A)
NEVER MARRIED/NEVER LIVED WITH A MAN (GO TO 1222B)

1222A) Now I want to ask you about things that may have been done to you by someone other than (your/any) (husband/partner).

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 when you did not want to?

YES 1 (GO TO 1223)
NO 2 (GO TO 1224A)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1224A)

1222B) 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 when you did not want to?

YES 1 (GO TO 1223)
NO 2 (GO TO 1224A)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1224A)

1223) Who was the person who was forcing you the first time this happened?

CURRENT HUSBAND/PARTNER 01
FORMER HUSBAND/PARTNER 02
CURRENT/FORMER BOYFRIEND 03
FATHER/STEP-FATHER 04
BROTHER/STEP-BROTHER 05
OTHER RELATIVE 06
IN-LAW 07
OWN FRIEND/ACQUAINTANCE 08
FAMILY FRIEND 09
TEACHER 10
EMPLOYER/SOMEONE AT WORK 11
POLICE/SOLDIER 12
PRIEST/RELIGIOUS LEADER 13
STRANGER 14
OTHER (SPECIFY __________) 96

1224) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN:
In the last 12 months, has anyone other than (your/any) (husband/partner) physically forced you to have sexual intercourse when you did not want to?

YES 1 (GO TO 1225)
NO 2 (GO TO 1225)

NEVER MARRIED/NEVER LIVED WITH A MAN:
In the last 12 months has anyone physically forced you to have sexual intercourse when you did not want to?

YES 1 (GO TO 1225)
NO 2 (GO TO 1225)

1224A) CHECK 1205A (h-j) and 1215A (b)

AT LEAST ONE 'YES' (GO TO 1225)
NOT A SINGLE 'YES' (GO TO 1226)

1225) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN:
How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts by anyone, including (your/any) husband/partner.

AGE IN COMPLETED YEARS _____
DON'T KNOW 98

NEVER MARRIED/EVER LIVED WITH A MAN:
How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?

AGE IN COMPLETED YEARS _____
DON'T KNOW 98

1226) CHECK 1205A (a-j), 1215A (a,b), 1216, 1220, 1222A, AND 1222B:

AT LEAST ONE 'YES' (GO TO 1227)
NOT A SINGLE 'YES' (GO TO 1230)

1227) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?

YES 1
NO 2 (GO TO 1229)

1228) From whom have you sought help? Anyone else? RECORD ALL MENTIONED.

OWN FAMILY A (GO TO 1230)
HUSBAND'S/PARTNER'S FAMILY B (GO TO 1230)
CURRENTY/FORMER HUSBAND/PARTER C (GO TO 1230)
CURRENT/FORMER BOYFRIEND D (GO TO 1230)
FRIEND D (GO TO 1230)
NEIGHBOR F (GO TO 1230)
RELIGIOUS LEADER G (GO TO 1230)
DOCTOR/MEDICAL PERSONNEL H (GO TO 1230)
POLICE I (GO TO 1230)
LAWYER J (GO TO 1230)
SOCIAL SERVICE ORGANIZATION K (GO TO 1230)
OTHER (SPECIFY __________) X (GO TO 1230)

1229) Have you ever told anyone about this?

YES 1
NO 2

1230) As far as you know, did your father ever beat your mother?

YES 1
NO 2
DON'T KNOW 8

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

PROVIDE LIST OF REFERRAL PLACES TO RESPONDENT.

1231) 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?

HUSBAND
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3
OTHER MALE ADULT
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3
FEMALE ADULT
YEE, ONCE 1
YES, MORE THAN ONCE 2
NO 3

1232) INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE

COMMENT __________

1233) RECORD THE TIME

HOURS _____
MINUTES _____

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 STERLIZATION 1
MALE STERILIZATION 2
IUD 3
INJECTABLES 4
IMPLANTS 5
PILLS 6
CONTRACEPTIVE PATCH 7
CONDOM 8
FEMALE CONDOM 9
DIAPHRAGM 10
FOAM OR JELLY J
LACTATIONAL AMENORRHEA METHOD K
RHYTHEM METHOD L
WITHDRAWL M
OTHER MODERN METHOD X
OTHER TRADITIONAL METHOD Y

COLUMN 2: DISCONTUINATION 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

2013

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2012

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2011

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2010

12 DEC 37 __ __
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04 APR 45 __ __
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2009

12 DEC 49 __ __
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04 APR 57 __ __
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2008

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

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT: __________

COMMENTS ON SPECIFIC QUESTIONS: __________

ANY OTHER COMMENTS: __________

SUPERVISOR OBSERVATIONS: __________

NAME OF SUPERVISOR: __________
DATE: __________

EDITOR OBSERVATIONS: __________

NAME OF EDITOR: __________
DATE: __________