Data Cart

Your data extract

0 variables
0 samples
View Cart


MINISTRY OF HEALTH AND SOCIAL SERVICES
2013 NAMIBIA DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION
NAME AND CODE OF REGION __________

PLACE (LOCALITY) NAME __________

NAME OF HOUSEHOLD HEAD __________

CLUSTER NUMBER _____

HOUSEHOLD NUMBER _____

IS HOUSEHOLD SELECTED FOR MAN'S SURVEY

YES 1
NO 2

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

RESULT

1 COMPLETE
2 NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NO FOUND
9 OTHER (SPECIFY) _____

NEXT VISIT (REPEAT FOR INTERVIEWERS 1 AND 2)
DATE_____
TIME _____

TOTAL NUMBER OF VISITS __________
IS HOUSEHOLD SELECTED FOR MAN'S SURVEY?

YES 1
NO 2

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN (15-64) _____
TOTAL ELIGILBE WOMEN (15-64)
TOTAL ELIGIBLE MEN (15-64)

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

LANGUAGE OF QUESTIONAIRE _____

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

LANGUAGE OF RESPONDENT _____

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

LANGUAGE OF INTERVIEW _____

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

TRANSLATOR USED

YES 1
NO 2

SUPERVISOR
NAME __________

FIELD EDITOR __________
NAME___

OFFICER EDITOR __________
KEYED BY __________

INTRODUCTION AND 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. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential, are protected by the statistics law, and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, participation is voluntary, but we hope you will agree to answer the questions since your views are important. If I ask you any questions 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(s) listed on this card.
GIVE CARD WITH CONTACT INFORMATION
Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER: _______________________ DATE __________

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

HOUSEHOLD SCHEDULE

1) LINE NO

LINE NUMBER___

2) USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-24 FOR EACH PERSON.

2A) Just to make sure I have a complete listing: are there any other persons such as small children or infants that we have not listed?

YES (ADD TO TABLE)
NO

2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?

YES (ADD TO TABLE)
NO

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

YES (ADD TO TABLE)
NO

3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

01 HEAD
02 WIFE/HUSBAND/PARTNER
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED/FOSTER/STEPCHILD
11 NOT RELATED
98 DON'T KNOW

4) SEX: Is (NAME) male or female?

1 MALE
2 FEMALE

RESIDENCE
5) Does (NAME) usually live here?

1 YES
2 NO

6) Did (NAME) stay here last night?

1 YES
2 NO

7) AGE
How old is (NAME)?
IF 95 OR MORE, RECORD '95'.

AGE IN YEARS _____

8) MARITAL STATUS IF AGE 15 OR OLDER: What is (NAME)'s current marital status?

1 MARRIED OR LIVING TOGETHER
2 DIVORCED/SEPERATED
3 WIDOWED
4 NEVER-MARRIED AND NEVER LIVED TOGETHER

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS

9) Is (NAME)'s natural mother alive?

1 YES
2 NO (GO TO 11)
8 DON'T KNOW ( GO TO 11)

10) Does (NAME)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name? RECORD MOTHER'S LINE NUMBER.
IF NO, RECORD '00'

NAME __________
LINE NO. _____

11) Is (NAME)'s natural father alive?

YES 1
NO 2 (GO TO 13)
DON'T KNOW 8 (GO TO 13)

12) Does (NAME)'s natural father usually live in this household or was he a guest last night?IF YES: What is his name? RECORD FATHER'S LINE NUMBER
IF NO, RECORD '00'

NAME __________
LINE NO. _____

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER

13) Has (NAME) ever attended School?

1 YES
2 NO (GO TO 18)

14) What is the highest level of school (NAME) has attended? SEE CODES BELOW

LEVEL _____
1 PRIMARY
2 SECONDARY
3 HIGHER
6 PRE-PRIMARY
8 DON'T KNOW

What is the highest grade (NAME) complete at that level?

GRADE _____
PRIMARY 1
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON'T KNOW 8
LESS THAN 1 YEAR COMPLETED 00

CURRENT/RECENT SCHOOL ATTENDENCE IF AGE 5-24 YEARS

15) Did (NAME) attend school at any time during the 2013 school year?

1 YES
2 NO (GO TO 18)

16) During this school year, what level and grade is (NAME) attending?

LEVEL _____
PRIMARY 1
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON'T KNOW 98
GRADE
PRIMARY 1
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON'T KNOW 98

BIRTH REGISTRATION IF AGE 0-4 YEARS
17) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with civil authority?

HAS CERTIFICATION 1
REGISTERED 2
HAS ONLY HOSPITAL CARD 3
NEITHER CERTIFICATE NOR REGISTERED 4
DOESN'T KNOW 8

ELIGIBILITY
WOMEN

18) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

IF HOUSEHOLD SELECTED FOR MAN'S SURVEY

19) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-64

20) CIRCLE LINE NUMBER OF ALL WOMEN AGE 35-64

21) CIRCLE LINE NUMBER OF ALL MEN AGE 15-49

22) CIRCLE LINE NUMBER OF AL MEN AGE 15-64

23) CIRCLE LINE NUMBER OF ALL MEN AGE 35-64

24) CIRCLE LINE NUMBER OF ALL CHIDLREN AGE 0-5YEARS

HOUSEHOLD CHARACTERISTICS
101) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5

102) What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED INTO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 105)
TANKER TRUCK 61
CART WITH SMALL TRUCK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLE WATER 91
OTHER 96 (SPECIFY) _____

103) Where is that water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

104) How long does it take to go there, get water, and come back?

MINUTES _____
DON'T KNOW 998

105) Does you do anything to the water to make it safer to drink?

YES 1
NO 2 (GO TO 107)
DON'T KNOW 8 (GO TO 107)

106) What do you usually do to make the water safer to drink? Anything else? RECORD ALL MENTIONED

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC) D
LET IT STAND AND SETTLE E
OTHER (SPECIFY) _____ X
DON'T KNOW Z

107) What kind of toilet facility do members of your household usually use?

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVEDPIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/ OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 110)
OTHER 96 (SPECIFY) _____

108) Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 110)

109) How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10 _____

10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

110) Does your household have:

Electricity?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A cell phone?
YES 1
NO 2
A landline/telephone?
YES 1
NO 2
A refridgerator/freezer?
YES 1
NO 2
A computer/laptop?
YES 1
NO 2
A stove?
YES 1
NO 2
A microwave?
YES 1
NO 2
Home internet connectivity?
YES 1
NO 2
A wardrobe?
YES 1
NO 2
A sofa?
YES 1
NO 2
A bed?
YES 1
NO 2
A table and chairs?
YES 1
NO 2
Windows with glass?
YES 1
NO 2

111) What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE/PARAFFIN 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER 96 (SPECIFY) _____

112) Is the cooking usually done in the house, in a separate building, or outdoors?

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 114)
OUTDOORS 3 (GO TO 114)
OTHER 6 (SPECIFY) _____ (GO TO 114)

113) Do you have a separate room which is used as a kitchen?

YES 1
NO 2

114) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
MUD/CLAY 13
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER 96 (SPECIFY) _____

115) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF/GRASS 12
SOD 13
RUDIMENTARY ROOFING
21 RUSTIC MAT
22 PALM/BAMBOO
23 WOOD PLANKS
24 CARDBOARD
25 STICKS WITH MUD AND DUNG
26 PLASTIC/PVC
FINISHED ROOFING
CORRUGATED IRON SHEET 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC/BRICK TILES 34
CEMENT 35
ROOFING SHINGLES 36
TIN 37
ASBESTOS SHEET 38
SLATE 39
OTHER 96 (SPECIFY) _____

116) MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATIONS.

NATURAL WALLS
11 NO WALLS
12 CANE/PALM/TRUNKS
13 DIRT
RUDIMENTARY WALLS
BAMBOO WITH MUD/CLAY/DUNG 21
STICKS WITH MUD/CLAY/DUNG 22
STONE WITH MUD 23
UNCOVERED ADOBE 24
PLYWOOD 25
CARDBOARD 26
REUSED WOOD 27
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS/CEMENT STONES 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
CORRUGATED IRON/ZINC 37
TIN 38
OTHER 96 (SPECIFY) _____

117) How many rooms in this household are used for sleeping?

ROOMS _____

118) Does any member of this household own:

A watch?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
An animal-drawn cart?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A boat with a motor?
YES 1
NO 2

119) Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 121)

120) How many hectares of agricultural land do members of this household own? IF 95 OR MORE, CIRCLE "950"

HECTARES _____

95 OR MORE HECTARES 950
DON'T KNOW 998

121) Does this household own any livestock, herds, other farm animals, or poultry?

1 YES
2 NO (GO TO 123)

122) How many of the following animals does this household own?
IF NONE, ENTER '00.' IF 95 OR MORE, ENTER '95.' IF UNKNOWN, ENTER '98'

Cattle?
CATTLE _____
Milk cows or bulls?
COWS/BULLS _____
Horses, donkeys, or mules?
HORESES, DONKEYS, MULES _____
Goats?
GOAT _____
Sheep?
SHEEP _____
Chickens?
CHICKEN _____

123) Does any member of this household have an active bank account?

YES 1
NO 2

123A) Have you ever heard of an illness called malaria?

1 YES
2 NO (GO TO 124)

123B) What are the signs of malaria? PROBE: Any other signs? RECORD ALL MENTIONED.

HEADACHES A
CHILLS B
HIGH TEMPERATURES C
BODY PAIN D
LOSS OF ENERGY E
OTHER X (SPECIFY) _____
DON'T KNOW Z

123C) What causes malaria? PROBE: Any other signs? RECORD ALL MENTIONED.

MOSQUITO BITES A
RAIN B
UNHYGIENIC ENVIRONMENT C
SLEEPING WITH SOMEONE WITH MALARIA D
OTHER X (SPECIFY) _____
DON'T KNOW Z

123D) What would you do if you suspected that you have malaria?

NOTHING 1
GO TO A HEALTH FACILITY/ HEALTH PERSONNEL 2
GO TO A TRADITIONAL HEALER 3
OTHER 6 (SPECIFY) _____
DON'T KNOW 8

123E) What do you do to prevent getting malaria? Anything else? RECORD ALL MENTIONED.

HAVE THE HOUSE SPRAYED A
USE REPELLENTS B
USE MOSQUITO NETS C
USE MOSQUITO COILS D
BURN LEAVES E
OTHER X (SPECIFY) _____
DON'T KNOWZ

124) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

YES 1
NO 2 (GO TO 126)
DON'T KNOW 8 (GO TO 126)

125) Who sprayed the dwelling?

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NON GOVERNMENTAL ORGANIZATION (NGO) C
OTHER X (SPECIFY) _____
DONT KNOW Z

126) Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 137)

127) How many mosquito nets does your household have? IF 7 OR MORE NETS, RECORD '7'

NUMBER OF NETS _____

128) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF MORE THEN NETS, USE ADDITIONAL QUESTIONNARIE(S).

OBSERVED 1
NOT OBSERVED 2

129) How many months ago did your household get the mosquito net? IF LESS THAN ONE MONTH AGO, RECORD '00'

MONTHS AGO _____

MORE THAN 36 MONTHS AGO 95
NOT SURE 98

130) OBSERVE OR ASK THE BRAND/ TYPE OF MOSQUITO NET. IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

LONG-LASTING INSECTICIDE-TREATED NET
PERMANET 11 (GO TO 134)
DAWA 12 (GO TO 134)
OLYSET 13 (GO TO 134)
YORKOOL 14 (GO TO 134)
OTHER LLIN/ DK LLIN BRAND 16 (GO TO 134)
OTHER BRAND 96
DK BRAND 98

131) When you go the net, was it already treated with an insecticide to kill or repel?

YES 1
NO 2
NOT SURE 8

132) Since you got the net, was it ever soaked, dipped in a liquid to kill or repel mosquitos?

YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)

133) How many months ago was the net last soaked or dipped? IF LESS THAN ONE MONTH AGO, RECORD '00'

MONTHS AGO _____

MORE THAN 24 MONTHS AGO 95
NOT SURE 98

134) Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 136)
NOT SURE 8 (GO TO 136)

135) Who slept under this mosquito net last night? RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME __________
LINE NO. _____

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

137) Please show me where members of your household most often wash their hands.

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 141)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 141)
NOT OBSERVED, OTHER REASON 4 (GO TO 141)

138) OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE PLACE OF HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

139) OBSERVATION ONLY: OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

SOAP OR DETERGENT (BAR, LIQUID, POWDER, PASTE) A
ASH, MUD, SAND B
NONE C

HEALTH EXPENDITURES
141) In that last six months, was a member of this household admitted overnight to stay at a health facility?

YES 1
NO 2 (GO TO 147)

142) What is the name of the household member who was last admitted overnight to stay at a health facility overnight in the last six months?
RECORD NAME AND THE LINE NUMBER OF COLS 1 AND 2 IN THE HOUSEHOLD SCHEDULE

LINE NUMBER _____
NAME __________

143) Where did (NAME in 142) most recently stay overnight for health care?

PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
GOVERNMENT HEALTH CLINIC 23
OTHER PUBLIC SECTOR (SPECIFY) __________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 31
PRIVATE CLINIC 32
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) __________ 36
OTHER __________ 96

144) How much money was spend by your household on (NAME in 142)'s treatment and services received during the most recent overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

COST _____

NO COST/FREE 00000
IN KIND 99995
DON'T KNOW 99998

145) What was the main reason for (NAME in 142) to seek care this most recent time?

ANTENATAL CARE/DELIVERY/POSTNATAL CARE 01
MALARIA 02
FEVER 03
DIARRHOEA 04
HIV/AIDS/STD 05
OTHER ILLNESS 06
MALNUTRITION 07
TRAFFIC ACCIDENT/ INJURY 08
NON TRAFFIC ACCIDENT/INJURY 09
OTHER (SPECIFY) __________ 96
DON'T KNOW 98

146) In total, how many times did (NAME in 142) stay overnight in a health facility in the last six months?

NUMBER OF INPATIENT VISITS _____
DON'T KNOW 98

147) In the last four weeks, did someone in this household recieve care from a health provider, a pharmacy, or a traditional healer without staying overnight?

YES 1
NO 2 (GO TO 154)

148) What is the name of the household member who last received care from a health provider, a pharmacy, or a traditional healer without staying overnight? RECORD NAME AND LINE NUMBER FROM COLS 1 AND 2 IN THE HOUSEHOLD SCHEDULE

LINE NUMBER _____
NAME __________

149) Now I would like to ask some questions about (NAME in 148) who consulted a provider for healthcare in the last four weeks, without staying overnight. From what type of health provider did (NAME in 148) get care most recently without staying overnight?

PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
GOVERNMENT HEALTH CLINIC 23
OUTREACH POINT 24
FIELDWORKER/COMMUNITY HEALTH CARE PROVIDER 25
OTHER PUBLIC SECTOR (SPECIFY) __________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 31
PRIVATE CLINIC 32
PHARMACY 33
PRIVATE DOCTOR 34
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 36
OTHER SOURCE
SHOP 41
TRADITIONAL PRACTITIONER 42
OTHER (SPECIFY) __________ 46

150) How much money was spent by your household on (NAME in 148)'s treatment and services from (NAME OF PROVIDER IN 149)? Please include the consulting fee and any expenses for other items including drugs and tests.

COST _____

NO COST/FREE 00000
IN KIND 999995
DON'T KNOW 99998

151) What was the main reason for (NAME in 148) to seek care this most recent time?

FAMILY PLANNING 01
ANTENATAL CARE/DELIVERY/POSTNATAL CARE 02
MALARIA 03
FEVER 04
DIARRHOEA 05
HIV/AIDS/STD 06
OTHER ILLNESS 07
CHECK-UP/ PREVENTIVE CARE 08
ACCIDENT/INJURY 09
OTHER (SPECIFY) 96
DON'T KNOW 98

152) In total, how many times did (NAME in 148) get care from a health provider in the last four weeks, without staying overnight?

NUMBER OF OUTPATIENT VISITS _____
DON'T KNOW 98

153) How many times in the last four weeks was money spent by your household for care (NAME in 148) received (without staying overnight)?

NUMBER OF OUTPATIENT VISITS FOR WHICH MONEY WAS SPENT _____
DON'T KNOW 98

154) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. EXPLAIN THAT YOU WILL TEST SALT FOR IODINE, AN IMPORTANT MICRONUTRIENT. TEST SALT FOR IODINE.

IODINE PRESENT 1
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) __________ 6

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS
HOUSEHOLD SELECTED FOR MAN'S SURVEY?

NO (CONTINUE)
YES (GO TO NEXT SECTION)

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 18) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMAN IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE HOUSEHOLD QUESTIONAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 18 SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN TEH HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE HTE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEE ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HER NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE.

LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER

TOTAL NUMBER OF ELIGIBLE WOMEN AGE 15-49 IN HOUSEHOLD SCHEDULE COLUMN 18
NAME OF SELECTED WOMAN 15-49
HH LINE NUMBER OF SELECTED WOMAN 15-49

TABLE FOR SELECTION OF MEN FOR THE DOMESTIC VIOLENCE QUESTIONS

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

YES (CONTINUTE)
NO (GO TO NEXT SECTION)

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE MEN (COLUMN 21) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE MAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE MEN IN COLUMN 21 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SLECTED MAN IN THE SPACE BELOW THE TABLE.
EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 21 SHOWS THAT THERE ARE THREE ELIGIBLE MEN AGE 15-49 IN TEH HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE MEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND MAN WHO IS ELIGIBLE FOR THE MAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HIS NAME AND THE LINE NUMBER IN THE SPACE BELOW THE TABLE.

LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER
TOTAL NUMBER OF ELIGIBLE MEN AGE 15-49 IN HOUSEHOLD SCHEDULE COLUMN 18
NAME OF SELECTED MAN 15-49
HH LINE NUMBER OF SELECTED MAN 15-49

END HOUSEHOLD INTERVIEW

WEIGHT, HEIGHT AND HAEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5 YEARS

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

YES (GO TO 201)
NO (END SURVEY)

201) CHECK COLUMN 24 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 2

LINE NUMBER _____
NAME __________

203) IN MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK : What is (NAME)'s birthday?

DAY _____
MONTH _____
YEAR _____

204) CHECK 203:
CHILD BORN IN JANUARY 2008 OR LATER?

YES 1
NO 2 (GOT TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 300)

205) WEIGHT IN KILOGRAMS

KG _____._____

NO PRESENT 9994
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS

CM _____._____

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

208) CHECK 203:
IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INVERVIEW OR FIVE PREVIOUS MONTHS?

0-5 MONTHS 1 (GO TO NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 300)
OLDER 2

209) LINE NUMBER OF PARENT/ OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD '00' IF NOT LISTED.

LINE NUMBER _____

210) ASK CONSENT FOR ANAEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

As part of the survey, we are asking people all over the country to take an anaemia test. Anaemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
We ask that all children born in 2008 or later take part in anaemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
SHOW UNOPENED PACKAGE.
The blood will be tested for anaemia immediately, and the result will be told to you right away for further follow up, if necessary. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
You can say yes to the test, or you can say no. It is up to you to decide.
Do you have any questions? If you have questions about the procedure at any time, please ask me. For more information about the procedure, you may contact the person(s) listed on this card.
Will you allow (NAME OF CHILD) to participate in the anaemia test?

211) CIRCLE TO APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN __________)
REFUSED 2 (SIGN __________)

212) RECORD HAEMOGLOBIN LEVEL HERE AND IN THE ANAEMIA PAMPHLET.

G/DL _____._____

NOT PRESENT 994
RFUSED 995
OTHER 996

213) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 300.

BLOOD PRESSURE AND BLOOD GLUCOSE FOR WOMEN AGE 35-64
HOUSEHOLD SELECTED FOR MAN'S SURVEY?

YES 1 (GO TO 300)
NO 2 (END SURVEY)

300) CHECK COLUMN 20 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL ELIGILIBE WOMEN AGE 35-64 FOR BLOOD GLUCOSE AND BLOOD PRESSURE MEASUREMENTS.
IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S)

301) LINE NUMBER FROM COLUMN 20

LINE NUMBER _____
NAME _________

301A) PREGNANCY STATUS CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

302) Now I am going to ask you to participate in several physical measurements or tests. I will explain each measurement or test before starting the procedure. You will be free to say yes or no to each one. Before taking the measurements, I am going to ask a few questions about yourself.

303) AGE: How old were you at your last birthday?

YEARS _____

304) MARITAL STATUS: What is your current marital status?

CURRENTLY IN UNION 1
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER MARRIED/ NEVER IN UNION 4

EDUCATION
305) Have you ever attended school?

YES 1
NO 2 (GO TO 307)

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

PRIMARY 1
SECONDARY 2
HIGHER 3

WORK
307) Are you currently working?

YES 1
NO 2

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

OCCUPATION __________

309) ASK FOR CONSENT FOR BLOOD PRESSURE MEASUREMENT:
I would like to measure your blood pressure. This will be done three times during the interview and it will take about ten minutes for each measurement. This is a harmless procedure. It is used to find out if a person has high blood pressure. If it is not treated, high blood pressure may eventually cause serious damage to the heart and may lead to stroke and death.
The results of this blood pressure measurement will be given to you after the measurement process is complete for further follow up if necessary. I will explain the meaning of your blood pressure numbers. If your blood pressure is high, we will suggest that you consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
You can say yes or no to having the blood pressure measurement now. You can also decide at anytime not to participate in the blood pressure measures.
Do you have any questions about the blood pressure measurement so far? if you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.
Will you undergo the blood pressure measurements?

310) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. (IF 'NOT PRESENT' MAKE 2 MORE CALL BACKS TO FIND RESPONDENT)

GRANTED 1 (SIGN __________)
REFUSED 2 (SIGN __________)(GO TO 317)

RESP. NOT PRESENT (GO TO 365)

311) Before taking your blood pressure, I would like to ask a few questions about things that may affect these measurements.
Have you done any of the following within the past 30 min: Eaten anything? Had coffee, tea, cola, or other drink that has caffeine, smoked/used tobacco?

EATEN?
YES 1
NO 2
HAD CAFFEINETED DRINK?
YES 1
NO 2
SMOKED/USED TOBACCO?
YES 1
NO 2

312) May I begin the process of measuring your blood pressure? I will begin by measuring the circumference of your arm to make sure that I sue the right equipment.
BEFORE TAKING THE FIRST BP READING, MEASURE RESPONDENT'S ARM CIRCUMFERENCE MIDWAY BETWEEN THE ELBOW AND THE SHOULDER.
RECORD THE MEASUREMENT IN CENTIMETRES.

ARM CIRCUMFERENCE (IN CENTIMETRES) _____

313) USE THE ARM CIRCUM. MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE.

SMALL: 16CM-23CM 1
MEDIUM: 24CM-35CM 2
LARGE: 36CM-45CM 2

314) RECORD TIME

HOURS _____
MINUTES _____

314A) May I take your blood pressure at this time?

YES 1
NO 2 (GO TO 316)

315) TAKE THE FIRST BLOOD PRESURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE, THEN PROCEED TO 317.
IF YOU ARE UNABLE TO MEASURE RESPONDENT'S BLOOD PRESSURE, RECORD REASON IN 316.
BLOOD PRESSURE MEASURED

SYSTOLIC _____
DIASTOLIC _____

316) RECORD REASON BLOOD PRESSURE WAS NOT MEASURED
REASON BLOOD PRESURE NOT MEASURED

REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

317) Before this survey, has your blood pressure ever been measured?

YES 1
NO 2

318) Have you ever been told by a doctor or other health worker that you have high blood pressure or hypertension?

YES 1
NO 2 (GO TO 321)

319) Are you currently receiving any of the following treatment/advice by a doctor or other health worker to control your blood pressure?

PRESCRIBED MEDICATION
YES 1
NO 2
ADVICE TO REDUCE SALT INTAKE?
YES 1
NO 2
ADVICE/TREATMENT TO LOSE WEIGHT?
YES 1
NO 2
ADVICE/TREATMENT TO STOP SMOKING?
YES 1
NO 2
ADVICE TO START/DO MORE EXERCISE?
YES 1
NO 2

320) Are you currently taking any herbal or traditional remedies for your high blood pressure?

YES 1
NO 2

320A) CHECK 310:
CONSENT FOR BP MEASUREMENT

'GRANTED' 1 (GO TO 321)
'REFUSED' 2 (GO TO 326)

321) HEALTH TECHNICIAN: CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT.

322) RECORD TIME

HOURS _____
MINUTES _____

323) May I take your blood pressure this time?

YES 1
NO 2 (GO TO 325)

324) TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE, THEN PROCEED TO 326.

IF YOU ARE UNABLE TO MEASURE RESPONDENT'S BLOOD PRESSURE, RECORD REASON IN 325.

SYSTOLIC _____
DIASTOLIC _____

325) RECORD REASON BLOOD PRESSURE WAS NOT MEASURED

REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

326) Have you ever heard of an illness called diabetes?

YES 1
NO 2

327) Before this survey, has your blood glucose ever been measured?

YES 1
NO 2

328) Have you ever been told by a doctor or other health worker that you have high blood pressure or diabetes?

YES 1
NO 2 (GO TO 331)

329) Are you currently receiving any of the following treatment/advice by a doctor or other health worker for your high blood glucose of diabetes?

PRESCRIBED MEDICATION
YES 1
NO 2
ADVICE ON SPECIAL DIET?
YES 1
NO 2
ADVICE/TREATMENT TO LOSE WEIGHT?
YES 1
NO 2
ADVICE/TREATMENT TO STOP SMOKING?
YES 1
NO 2
ADVICE TO START/DO MORE EXERCISE?
YES 1
NO 2

330) Are you currently taking any herbal or traditional remedies for your high blood glucose or diabetes?

YES 1
NO 2

330A) CHECK 310:
CONSENT FOR BP MEASUREMENT

'GRANTED' 1
'REFUSED' 2 (GO TO 336A)

331) HEALTH TECHNICIAN: CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT.

332) RECORD TIME

HOURS _____
MINUTES _____

333) May I take your blood pressure this time?

YES 1
NO 2 (GO TO 335)

334) TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE, THEN PROCEED TO 336A.
IF YOU ARE UNABLE TO MEASURE RESPONDENT'S BLOOD PRESSURE, RECORD REASON IN 335.

BLOOD PRESSURE MEASURED
SYSTOLIC _____
DIASTOLIC _____

335) RECORD REASON BLOOD PRESSURE WAS NOT MEASURED

REFUSED 995
TECHNICAL PROBLEMS 995
OTHER 996

335A) CALCULATE THE AVERAGE OF THE SYSTOLIC AND DIASTOLIC BP READINGS FROM 324 AND 334.

(1) CALCULATE THE SUM OF THE SYSTOLIC AND DIASTOLIC MEASURED IN 324 AND 334
(2) DIVIDE EACH SUM BY 2 AND RECORD THE AVERAGE

PLEASE NOTE:
(1) IF THERE IS ONLY ONE BP TEADING, RECORD IT AS THE AVERAGE
(2) IF THERE IS MORE THAN ONE BP READING, ALWAYS EXCLUDE THE FIRST FROM THE AVERAGE
(3) IF THERE ARE ONLY TWO BP READINGS, THE 2ND IS THE AVERAGE
(4) IF ALL DIASTOLIC VALUES ARE '0', THE AVERAGE IS '0'

AVERAGE OF 2ND AND 3RD MEASURES
SYSTOLIC _____
DIASTOLIC _____

335B) USE THE TABLE BELOW TO TMAKE THE CORRECT REFERRAL BASED ON AVERAGE VALUES IN 335A

ADULT BLOOD PRESSURE VALUE BOX:

SYSTOLIC LESS THAN 120
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6
SYSTOLIC LESS THAN 130
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6
SYSTOLIC 130-139
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6
SYSTOLIC 140-159
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6
SYSTOLIC 160-179
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6
SYSTOLIC GREATER THAN 180
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6

CIRCLE AVERAGE VALUES FOR THE DIASTOLIC AND THE SYSTOLIC BLOOD PRESSURE IN THE TABLE ABOVE. DRAW A HORIZONTAL LINE IN THE SYSTOLIC PRESSURE ROW AND A VERTICAL LINE IN THE DIASTOLIC PRESSURE COLUMN. CIRCLE THE VALUE WHERE THE LINES MEET. CIRCLE THE SAME VALUE CODE IN THE BLOOD PRESSURE REPORTING FORM AND GIVE IT TO THE RESPONDENT.

336A) ASK CONSENT FOR FASTING BLOOD SUGAR TESTING

As part of this survey, we are asking people all over the country to take a blood glucose test. Your glucose level may is an indicator that can measure your risk associated with some non-communicable diseases such as diabetes. This survey will assist the government to develope programs to prevent and treat high and low glucose levels.

For the blood glucose testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for glucose immediately, and the result will be told to you right away for further follow up, if necessary. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team. The results will be given to you with an explanation of the meaning of your blood glucose numbers.
If your blood glucose is high, we will suggest that you consult a health facility or doctor since we cannot provide any counselling, further testing or treatment during the survey.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

To obtain correct blood glucose measurement, we would ask that you do not eat or drink anything except plain water for at least 8 hours prior to my blood glucose testing visit.
Would you allow me to return to take your blood glucose measurement before you break your fast?

336B) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(IF 'NOT PRESENT' IN THE 1ST APPOINTMENT, MAKE A 2ND APPOINTMENT, MAKE A 3RD APPOINTMENT)

1ST APP
GRANTED 1 (SIGN __________)
REFUSED 2 (SIGN AND GO TO 337)
RESP. NOT PRESENT 3 (GO TO 365)
2ND APP
GRANTED 1 (SIGN __________)
REFUSED 2 (SIGN AND GO TO 337)
RESP. NOT PRESENT 3 (GO TO 365)
3RD APP
GRANTED 1
REFUSED 2
RESP. NOT PRESENT 3 (GO TO 365)

336C) When can I come to test your blood glucose? RECORD APOINTMENT FOR BLOOD TESTING AND PROCEED TO NEXT SECTION.

1ST APP. DATE _________
HOUR _____
MINUTE ____
2ND APP. DATE __________
HOUR_____
MINUTE _____
3RD APP. DATE __________
HOUR _____
MINUTE _____
NAME FROM COLUMN 2 __________

336D) WHEN RETURNING FOR BLOOD GLUCOSE TESTING: ASK CONSENT FOR BLOOD GLUCOSE TESTING

As I mentioned yesterday, we are going to measure the level of sugar in blood. As part of this survey, we are asking people all over the country to take a blood glucose test. Your glucose level is an indicator that can measure your risk associated with some non-communicable disease such as diabetes. This survey will assist the government to develope programs to prevent and treat high and low glucose levels.

For the blood glucose testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

SHOW UNOPENED PACKAGE.

The blood will be tested for glucose immediately, and the result will be told to you right away for further follow up if necessary. The result will be kept other strictly confidential and will not be shared with anyone other than members of our survey team. The results will be given to you with an explanation of the meaning of your blood glucose numbers. If you blood glucose is high, we will suggest that you consult a health facility or doctor since we cannot provide any counselling, further testing or treatment during the survey.

You can say yes or no to having the blood glucose measurement now.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

Would you allow me to proceed to take your measurement?

336E) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. (IF 'NOT PRESENT' MAKE 2 MORE CALL BACKS TO FIND THE RESPONDENT)

GRANTED 1 (SIGN __________)
REFUSED 2 (SIGN____) (GO TO 336L)
RESP. NOT PRESENT 3 (GO TO 365)

336F) When was the last time you had something to eat?

1ST APP.
HOURS _____
MINUTES _____
2ND APP.
HOURS _____
MINUTES _____
3RD APP.
HOURS _____
MINUTES _____

336G) When was the last time you had something to drink other than plain water?

1ST APP.
HOURS _____
MINUTES _____
2ND APP.
HOURS _____
MINUTES _____
3RD APP.
HOURS _____
MINUTES _____

336H) CHECK 336F and 336G:
READ TO RESPONDENT: As mentioned before, in order to obtain correct blood glucose measurement, we need you to fast for at least 8 hours prior to testing. THEN REPEAT QUESTIONS 336A-336H.

8 HOURS OR MORE SINCE RESPONDENT LAST ATE OR DRANK (GO TO 336I)
LESS THAN 8 HOURS SINCE RESPONDENT LAST ATE OR DRANK:

336I) PREPARE EQUIPMENT AND SUPPLIED FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE BLOOD GLUCOSE TEST.

336J) RECORD TIME FOR BLOOD GLUCOSE TESTING.

DAY _____
MONTH _____
YEAR _____
HOURS _____
MINUTES _____

336K) RECORD FASTING BLOOD SUGAR IN MMOL/L. IF YOU ARE UNABLE TO MEASURE RESPONDENT'S BLOOD GLUCOSE RECORD THE REASON IN 336L.

MMOL/L (GO TO 337)

336L) RECORD REASON BLOOD GLUCOSE IS NOT MEASURED.

REASON BLOOD GLUCOSE NOT MEASURED
REFUSED 994 (GO TO 337)
TECHNICAL PROBLEMS 995 (GO TO 337)
OTHER 996 (GO TO 337)

WEIGHT, HEIGHT, HAEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 15-64
337) CHECK COLUM 19 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN AGE 15-64 IN 215. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE (S).

338) LINE NUMBER FROM COLUMN 19. NAME FROM COLUMN 2.

LINE NUMBER _____
NAME __________

339) WEIGHT IN KILOGRAMS

KG _____._____
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

340) HEIGHT IN CENTIMETERS

CM _____._____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

341) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-64 YEARS 2 (GO TO 346)

342) MARITAL STATUS: CHECK COLUMN 8.

CODE 4 (NEVER IN UNION)
OTHER 2 ( GO TO 346)

343) RECORD THE LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT _____

344) ASK CONSENT FOR ANAEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 343 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anaemia.

For the anaemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anaemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away for further follow up, if necessary. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

SHOW UNOPENED PACKAGE.

You can say yes to the test for (NAME OF ADOLESCENT) or you can say no. It is up to you to decide.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

Will you allow (NAME OF ADOLESCENT) to take the anaemia test?

345) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

GRANTED 1 (SIGN __________)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN __________)(GO TO 351)

346) ASK CONSENT FOR CONSENT FOR ANAEMIA TEST FROM RESPONDENT.

As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anaemia.

For the anaemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anaemia immediately, and the result will be told to you right away for further follow up, if necessary. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

SHOW UNOPENED PACKAGE.

You can say yes, or no to the test. It is up to you to decide.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

Will you take the anaemia test?

347) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN __________)
RESPONDENT REFUSED 2 (SIGN __________)(GO TO 349)

348) PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK : Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

349) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-64 YEARS 2 (GO TO 353)

350) MARITAL STATUS: CHECK COLUMN 8.

CODE 4 1 (NEVER IN UNION)
OTHER 2 (GO TO 353)

351) ASK CONSENT FOR DBS COLLECTION FROM PARENT/ OTHER ADULT IDENTIFIED IN 343 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to determine the HIV prevalence in Namibia.

For the HIV test, we need to collect a few (more) drops of blood from a finger to be tested later at a lab for HIV. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give her a voucher for free services that can be used to any of these facilities.

You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

Will you allow (NAME OF ADOLESCENT) to take the HIV test?

352) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN __________)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN __________, GO TO 362)

353) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to determine the HIV prevalence in Namibia.

For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know you test results either. If you want to know whether you have HIV, I can provide you with a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

You can say yes or no to the test. It is up to you to decide.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on teh card that was given out at the beginning.

Will you take the HIV test?

354) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.

GRANTED 1 (SIGN _________)
RESPONDENT REFUSED (SIGN _________)(GO TO 362)

355) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-64 YEARS 2

356) MARITAL STATUS: CHECK COLUMN 8

CODE 4 1(NEVER IN UNION)
OTHER 2 (GO TO 359)

357) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 343 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

We ask you to allow the Ministry of Health and Social Services to store part of the blood sample at the laboratory for additional tests or research.

You can say yes or no to storing the blood of (NAME OF ADOLESCENT) for additional testing. The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

358) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN __________)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN __________, GO TO 361)

359) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to allow the Ministry of Health and Social Services to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.

You can say yes or no to storing you blood for additional testing. The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do no want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

360) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANT 1 (SIGN __________)
RESPONDENT REFUSED (SIGN __________, GO TO 362)

361) ADDITIONAL TESTS
CHECK 358 AND 360.
IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

362) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

363) RECORD HAEMOGLOBIN LEVEL HERE AND IN ANAEMIA PAMPHLET.

G/DL _____._____
NOT PRESENT 994
REFUSED 995
OTHER 996

364) BAR CODE LABEL

PUT THE 1ST BAR CODE LABEL HERE.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

365) GO BACK TO 300 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 400.

BLOOD PRESSURE AND BLOOD GLUCOSE FOR MEN AGE 35-64.

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

YES 1 (GO TO 400)
NO 2 (END SURVEY)

400) CHECK COLUMN 23 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL ELIGILBE MEN AGE 35-64 FOR BLOOD GLUCOSE AND BLOOD PRESSURE MEASUREMENTS.

IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

401) LINE NUMBER FROM COLUMN 23. NAME FROM COLUMN 2.

LINE NUMBER _____
NAME __________

402) Now I am going to ask you to participate in several physical measurements or tests. I will explain each measurement or test before starting the procedure. You will be free to say yes or no to each one. Before taking the measurements, I am going to ask a few questions about yourself.

403) AGE: How old were you at your last birthday?

YEARS _____

404) MARITAL STATUS: What is your current marital status?

CURRENTLY IN UNION 1
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER MARRIED/ NEVER IN UNION 4

405) EDUCATION: Have you ever attended school?

YES 1
NO 2 (GO TO 407)

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

PRIMARY 1
SECONDARY 2
HIGHER 3

WORK
407) Are you currently working?

YES 1
NO 2

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

OCCUPATION __________

409) ASK CONSENT FOR BLOOD PRESSURE MEASUREMENT
I would like to measure your blood pressure. This will be done three times during the interview and it will take about ten minutes for each measurement. This is a harmless procedure. It is used to find out if a person has high blood pressure. If it is not treated, high blood pressure may eventually cause serious damage to the heart and may lead to stroke and death.

The results of this blood pressure measurement will be given to you after the measurement process is completed for further follow up if necessary. I will explain the meaning of your blood pressure numbers. If your blood pressure is high, we will suggest that you consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

You can say yes or no to having the blood pressure measurement now. You can also decide at anytime not to participate in the blood pressure measures.

Do you have any questions about the blood pressure measurement so far? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

Will you undergo the blood pressure measurements?

410) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. (IF 'NOT PRESENT' MAKE 2 MORE CALL BACKS TO FIND THE RESPONDENT)

GRANTED 1 (SIGN __________)
REFUSED 2 (SIGN __________, GO TO 417)
RESP. NO PRESENT 3 (GO TO 465)

411) Before taking your blood pressure, I would like to ask a few questions about things that may affect the measurements.

Have you done any of the following within the pass 40 minutes?

Eaten anything?
YES 1
NO 2
Had coffee, tea, cola, or other drink that has caffeine?
YES 1
NO 2
Smoked/used tobacco?
YES 1
NO 2

412) May I begin the process of measuring your blood pressure? I will begin by measuring the circumference of your arm to make sure that I use the right equipment.
BEFORE TAKING THE FIRST BP READING, MEASURE RESPONDENT'S ARM CIRCUMFERENCE MIDWAY BETWEEN THE ELBOW AND SHOULDER.

RECORD MEASUREMENT IN CENTIMETRES.

ARM CIRCUMFERENCE (IN CENTIMETRES) _____

413) USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE.

CIRCLE THE CODE FOR THE CUFF SIZE.

SMALL: 16-23CM 1
MEDIUM: 24-35CM 2
LARGE: 36CM-45CM 3

414) RECORD TIME

HOURS _____
MINUTES _____

414A) May I take your blood pressure at this time?

YES 1
NO 2 (GO TO 416)

415) TAKE THE FIRST BLOOD PRESSURE READING RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE, THEN PROCEED TO 417.

IF YOU ARE UNABLE TO MEASURE RESPONDENT'S BLOOD PRESSURE, RECORD REASON IN 416.

BLOOD PRESSURE MEASURED

SYSTOLIC _____
DIASTOLIC _____

416) RECORD REASON BLOOD PRESSURE WAS NOT MEASURED

REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

417) Before this survey, has your blood pressure been measured?

YES 1
NO 2

418) Have you ever been told by a doctor or other health worker that you have high blood pressure or hypertension?

YES 1
NO 2 (GO TO 421)

419) Are you currently receiving any of the following treatment/advice by a doctor or other health worker to control your blood pressure?

Prescribed medication?
YES 1
NO 2
Advice to reduce salt intake?
YES 1
NO 2
Advice/treatment to lose weight?
YES 1
NO 2
Advice/treatment to stop smoking?
YES 1
NO 2
Advice to start/do more exercise?
YES 1
NO 2

420) Are you currently taking any herbal or traditional remedies for your high blood pressure.

YES 1
NO 2

420A) CHECK 410:
CONSENT FOR BP MEASUREMENT

GRANTED 1 (GO TO 421)
REFUSED 2 (GO TO 426)

421) HEALTH TECHNICIAN: CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT.

422) RECORD TIME

HOUR _____
MINUTES _____

423) May I take your blood pressure this time?

YES 1
NO 2

424) TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE, THEN PROCEED TO 426. IF YOU ARE UNABLE TO MEASURE RESPONDENT'S BLOOD PRESSURE, RECORD REASON IN 425.

BLOOD PRESSURE MEASURED

SYSTOLIC _____
DIASTOIC _____

425) RECORD REASON BLOOD PRESSURE WAS NOT MEASURED

REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

426) Have you ever heard of an illness called diabetes?

YES 1
NO 2

427) Before this survey, has your blood glucose ever been measured?

YES 1
NO 2

428) Have you ever been told by a doctor or other health worker that you have high sugar or diabetes?

YES 1
NO 2 (GO TO 431)

429) Are you currently receiving any of the following treatment/advice by a doctor or other health worker for your high blood glucose or diabetes?

Prescribed medication such as insulin?
YES 1
NO 2
Advice on special diet?
YES 1
NO 2
Advice/treatment to lose weight?
YES 1
NO 2
Advice/treatment to stop smoking?
YES 1
NO 2
Advice to start/do more exercise?
YES 1
NO 2

430) Are you currently taking any herbal or traditional remedies for your high blood glucose or diabetes?

YES 1
NO 2

430A) CHECK 410:
CONSENT FOR BP MEASUREMENT

GRANT 1 (GO TO 431)
REFUSED 2 (GO TO 436A)

431) HEALTH TECHNICIAN: CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT.

432) RECORD TIME

HOURS _____
MINUTES _____

433) May I take your blood pressure this time?

YES 1
NO 2

434) TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE, THEN PROCEED TO 436A.

IF YOU ARE UNABLE TO MEASURE RESPONDENT'S BLOOD PRESSURE, RECORD REASON IN 435.

BLOOD PRESSURE MEASURED

SYSTOLIC _____
DIASTOLIC _____

435) RECORD REASON BLOOD PRESSURE WAS NO MEASURED

REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

435A) CALCULATE THE AVERAGE OF THE SYSTOLIC AND DIASTOLIC BP READINGS FROM 424 AND 434.

(1) CALCULATE THE SUM OF SYSOTLIC AND DIASTOLIC MEASURES IN 424 AND 434.
(2) DIVIDE EACH SUM BY 2 AND RECORD THE AVERAGE

PLEASE NOTE:

(1) IF THERE IS ONLY ONE BP READING, RECORD IT AS THE AVERAGE
(2) IF THERE IS MORE THAN ONE BP READING, ALWAYS EXCLUDING THE FIRST FROM THE AVERAGE
(3) IF THERE ARE ONLY TWO BP READINGS, THE 2ND IS THE AVERAGE
(4) IF ALL DIASTOLIC VALUES ARE '0' THE AVERAGE IS '0'.

435B) USE THE TABLE BELOW TO TMAKE THE CORRECT REFERRAL BASED ON AVERAGE VALUES IN 435A

ADULT BLOOD PRESSURE VALUE BOX:

SYSTOLIC LESS THAN 120
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6
SYSTOLIC LESS THAN 130
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6
SYSTOLIC 130-139
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6
SYSTOLIC 140-159
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6
SYSTOLIC 160-179
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6
SYSTOLIC GREATER THAN 180
DIASTOLIC LESS THAN 80 1
DIASTOLIC LESS THAN 85 2
DIASTOLIC 85-89 3
DIASTOLIC 90-99 4
DIASTOLIC 100-109 5
DIASTOLIC GREATER THAN OR EQUAL TO 110 6

436A) ASK CONSENT FOR FASTING BLOOD SUGAR TESTING

As part of this survey, we are asking people all over the country to take a blood glucose test. You glucose level may is an indicator that can measure your risk associated with some non-communicable disease such as diabetes. This survey will assist the government to develop programs to prevent and treat high and low glucose levels.

For the blood pressure testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for glucose immediately, and the result will be told to you right away for further follow up, if necessary. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team. The results will be given to you with an explanation of the meaning of your blood glucose numbers.

If your blood glucose is high, we will suggest that you consult a health facility or doctor since we cannot provide any counselling, further testing or treatment during the survey.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

To obtain correct blood glucose measurement, we would ask that you do not eat or drink anything except plain water for at least 8 hours prior to my blood glucose testing visit.

Would you allow me to return to take your blood glucose measurement before you break your fast?

436B) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. (IF 'NOT PRESENT' IN THE 1ST APPOINTMENT, MAKE A 2ND APPOINTMENT; MAKE A 3RD APPOINTMENT)

1ST APP.
GRANTED 1 (SIGN __________)
REFUSED 2 (SIGN __________, GO TO 437)
RESP. NOT PRESENT 3 (GO TO 465)
2ND APP.
GRANTED 1 (SIGN __________)
REFUSED 2 (SIGN __________, GO TO 437)
RESP. NOT PRESENT 3 (GO TO 465)
3RD APP.
GRANTED 1 (SIGN __________)
REFUSED 2 (SIGN __________, GO TO 437)
RESP. NOT PRESENT 3 (GO TO 465)

436C) When can I come to test your blood glucose?
RECORD APPOINTMENT FOR BLOOD GLUCOSE TESTING AND PROCEED TO NEXT SECTION

1ST APP.
DATE _________
HOUR _____
MINUTE _____
2ND APP.
DATE __________
HOUR _____
MINUTE _____
3RD APP.
DATE __________
HOUR _____
MINUTE _____

436D) WHEN RETURNING FOR BLOOD GLUCOSE TESTING: ASK CONSENT FOR BLOOD GLUCOSE TESTING

As I mentioned yesterday, we are going to measure the level of sugar in blood. As part of this survey, we are asking people all over the country to take a blood glucose test. Your glucose level is an indicator that can measure your risk associated with some non-communicable diseases such as diabetes. This survey will assist the government to develop programs to prevent and treat high and low glucose levels.

For the blood glucose testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

SHOW UNOPENED PACKAGE

The blood will be tested for glucose immediately, and teh result will be told to you right away for further follow up, if necessary. The result will be kept other strictly confidential and will not be shared with anyone other than members of our survey team. The results will be given to you with an explanation of the meaning of your blood glucose numbers. If you blood glucose is high, we will suggest that you consult a health facility or doctor since we cannot provide any counselling, further testing or treatment during the survey.

You can say yes or no to having the blood glucose measurement now.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

Would you allow me to proceed to take your measurement?

436E) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. (IF 'NOT PRESENT' MAKE 2 MORE CALL BACKS TO FIND THE RESPONDENT)

GRANTED 1 (SIGN _________)
REFUSED 2 (SIGN _________, GO TO 436L)
RESP. NO PRESENT 3 (GO TO 435)

436F) When was the last time you had something to eat?

1ST APP.
HOURS _____
MINUTES _____
2ND APP.
HOURS _____
MINUTES _____
3RD APP.
HOURS _____
MINUTES _____

436G) When was the last time you had something to drink other than plain water?

1ST APP.
HOURS _____
MINUTES _____
2ND APP.
HOURS _____
MINUTES _____
3RD APP.
HOURS _____
MINUTES _____

436H) CHECK 436F AND 436G:
READ TO RESPONDENT: As mentioned before, in order to obtain correct blood glucose measurement, we need you to fast for at least 8 hours prior to testing. THEN REPEAT QUESTIONS 436A-436H.

8 HOURS OR MORE SING RESPONDENT LAST ATE OR DRANK (GO TO 336I)
LESS THAN 8 HOURS SINCE RESPONDENT LAST ATE OR DRANK

436I) PREPARE EQUIPMENT AND SUPPLIES FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH BLOOD GLUCOSE TEST.

436J) RECORD BLOOD GLUCOSE TESTING

DAY __________
MONTH __________
YEAR _________
HOURS _____
MINUTES _____

436K) RECORD FASTING BLOOD SUGAR IN MMOL/L.

IF YOU ARE UNABLE TO MEASURE RESPONDENT'S BLOOD GLUCOSE RECORD THE REASON IN 436L.

MMOL/L _____ (GO TO 437)

436L) RECORD REASON BLOOD GLUCOSE IS NOT MEASURED
REASON BLOOD GLUCOSE NOT MEASURED

REFUSED 994 (GO TO 437)
TECHNICAL PROBLEMS 995 (GO TO 437)
OTHER 996 (GO TO 437)

WEIGHT, HEIGHT, HAEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-64

437) CHECK COLUMN 22 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN AGE 15-64 IN 215. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S). START THE MEASUREMENTS/TESTING WITH MEN 35-64 FROM THE PREVIOUS SECTION.

438) LINE NUMBER FROM COLUMN 22. NAME FROM COLUMN 2.

LINE NUMBER __________
NAME __________

439) WEIGHT IN KILOGRAMS

KG. _____._____

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

440) HEIGHT IN CENTIMETERS

CM. _____._____

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

441 AGE: CHECK COLUMN 7

15-17 YEARS 1
18-64 YEARS 2 (GO TO 446)

442) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 446)

443) RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONDSIBLE FOR ADOLESCENT RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT _____

444) ASK CONSENT FOR ANAEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 443 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anaemia.

For the anaemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anaemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away for further follow up, if necessary. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

SHOW UNOPENED PACKAGE

You can say yes to the test for (NAME OF ADOLESCENT) or you can say no. It is up to you to decide.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

Will you allow (NAME OF ADOLESCENT) to take the anaemia test?

445) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN __________)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN __________)(GO TO 451)

446) ASK CONSENT FOR ANAEMIA TEST FROM RESPONDENT

As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develope programs to prevent and treat anaemia.

For the anaemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anaemia immediately, and the result will be told to you right away for further follow up, if necessary. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

SHOW UNOPENED PACKAGE.

You can say yes or no to the test. It is up to you to decide.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

Will you take the anaemia test?

447) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN __________)
RESPONDENT REFUSED (SIGN _________)(GO TO 449)

449) AGE: CHECK COLUMN 7.

15-17 YEARS OLD 1
18-64 YEARS OLD 2 (GO TO 453)

450) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 453)

451) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 343 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to determine the HIV prevalence in Namibia.

For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give her a voucher for free services that can be used at any of these facilities.

You can say yes to the test for (NAME OF ADOLESCENT), of you can say no. It is up to you to decide.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on the card that was given out at the beginning.

Will you allow (NAME OF ADOLESCENT) to take the HIV test?

452) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN __________)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN __________)(GO TO 462)

453) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

As part of the survey we also are asking people all over the country to take a HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to determine the HIV prevalence in Namibia.

For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No mans will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know whether you have HIV, I can provide you with a list of [nearby] facilities offering counselling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can used at any of these facilities.

You can say yes or no to the test. It is up to you to decide.

Do you have any questions? If you have any questions about the procedure at any time, please ask me. For more information, you may also contact the person(s) on teh card that was given out at the beginning.

Will you take the HIV test?

454) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.

GRANTED 1 (SIGN __________)
RESPONDENT REFUSED 2 (SIGN __________)
INTERVIEWER NUMBER _____

455) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-64 YEARS 2 (GO TO 459)

456) MARITAL STATUS: CHECK COLUMN 8

CODE 4 1 (NEVER IN UNION)
OTHER 2 (GO TO 459)

457) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT INDENTIFIED IN 443 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

We ask you to allow the Ministry of Health and Social Sciences to store part of the blood sample at the laboratory for additional tests or research.

You can say yes or no to storing the blood of (NAME OF ADOLESCENT) for additional testing. The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

458) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN __________)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN __________)(GOT TO 461)

459) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to all the Ministry of Health and Social Services to store part of the blood sample at the laboratory for additional tests or research.

You can say yes or no to storing your blood for additional testing. The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

460) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

GRANTED 1 (SIGN __________)
RESPONDENT REFUSED 2 (SIGN __________)
INTERVIEWER NUMBER _____

461) ADDITIONAL TESTS:

CHECK 458 AND 460:
IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

462) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

463) RECORD HAEMOGLOBIN LEVEL HERE AND IN ANAEMIA PAMPHLET

G/DL _____._____
NOT PRESENT 994
REFUSED 995
OTHER 996

464) BAR CODE LABEL

PUT THE 1ST BAR CODE LABEL HERE.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

PUT THE 2ND BAR LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

465) GO BACK TO 400 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.