IDENTIFICATION

NAME AND CODE OF DISTRICT

NAME AND CODE OF VILLAGE/MUNICIPALTY

WARD NUMBER

CLUSTER NUMBER

CITY/TOWN/RURAL

NAME AND LINE NUMBER OF MAN

NAME OF HOUSEHOLD HEAD

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER NAME
RESULT

NEXT VISIT:
DATE
TIME

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT

NEXT VISIT:
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

TOTAL NUMBER OF VISITS

LANGUAGE OF QUESTIONNAIRE: ENGLISH 5

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

SUPERVISOR

NAME ____
DATE ____

FIELD EDITOR

NAME ____
DATE ____

OFFICE EDITOR

___

KEYED BY

___

INTRODUCTION AND CONSENT

Hello. My name is _______________________________________ and I am working with the MINISTRY OF HEALTH AND POPULATION. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey.
The survey usually takes between 20 and 30 minutes to complete.
As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope you will participate in the survey since your views are important.
At this time, do you want to ask me anything about the survey? May I begin the interview now?

SIGNATURE OF INTERVIEWER:____________________________ DATE:______________

101. RECORD THE TIME.

102. HOW LONG HAVE YOU BEEN LIVING CONTINOUSLY IN (NAME OF CURRENT PLACE OF RESIDENCE)? IF LESS THAN ONE YEAR, RECORD '00' YEARS.

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

104. Have you travelled away from your home community at any time in the last 12 months?

105. How many months in total have you been in the last 12 months? IF LESS THAN 1 MONTH RECORD '00'.

106. Where have you travelled in the last 12 months?
PROBE: Anywhere else? RECORD ALL PLACES MENTIONED

107. In what month and year were you born?

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

109. Have you ever attended school?

110. What is the highest grade you completed?

111. CHECK 110:

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

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

114. CHECK 112:

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

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

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

118. What is your religion?

119. What is your caste/ethnicity? WRITE CASTE/ETHNICITY ON LINE PROVIDED. LEAVE BOX BLANK. CODE WILL BE FILLED BY FIELD EDITOR.

SECTION 2. REPRODUCTION

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

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

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

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

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

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

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

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

209. CHECK 208:

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

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

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

212A. CHECK 203 AND 205:

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

214. CHECK 213:

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

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

217. Were you present during any antenatal check-up?

217A. Were you ever told what to do if (NAME)'s mother had any pregnancy complication?

217B. At any time during the pregnancy did any health provider or health worker speak to you about:
a. The importance of delivering the baby in a hospital or health facility?
b. The importance of proper nutrition for the mother during pregnancy?
c. Family planning or delaying your next child?

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

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

219A. What kind of preparation did you make beforehand for the delivery of (NAME)? Anything else? CIRCLE ALL MENTIONED.

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

SECTION 3. CONTRACEPTION

Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy
Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?
CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY
THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.

302. Have you ever used (METHOD)?

01. FEMALE STERILIZATION Women can have an operation to avoid having any more children

02. MALE STERILIZATION Men can have an operation to avoid having any more children.

Have you ever had an operation to avoid having any more children?

03. PILL Women can take a pill every day to avoid becoming pregnant.

04. IUD Women can have a loop or coil placed inside them by a doctor or a nurse.

05. INJECTABLES Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.

06. IMPLANTS Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.

07. CONDOM Men can put a rubber sheath on their penis before sexual intercourse.

Have you ever had an operation to avoid having any more children?

08. RHYTHM METHOD. Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.

Have you ever had an operation to avoid having any more children?

09. WITHDRAWAL Men can be careful and pull out before climax.

Have you ever had an operation to avoid having any more children?

10. EMERGENCY CONTRACEPTION Women can take pills up to three days after sexual intercourse to avoid becoming pregnant.

11. Have you heard of any other ways or methods that women or men can use to avoid pregnancy?

303. CHECK 302 (02) RESPONDENT IS STERILIZED

304. Now I would like to talk about when you were sterilized.
In what facility did the sterilization take place? PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE
THE NAME OF THE PLACE.

305. In what month and year was the sterilization performed?

306. How much did you pay in total for the sterilization, including any consultation you may have had?

307. Before your sterilization operation, were you told that you would not be able to have any (more) children because of the operation?

308. Do you regret that you had the operation?

309. Why do you regret that you had the operation?

310. In the last few months have you heard or seen any message about family planning:
a. On the radio?
b. On the television?
c. In a newspaper, magazine or brochure?
d. On a poster or billboard?
e. Street drama?

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

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

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

314. Do you think that a woman who is breast feeding her baby can become pregnant?

315. I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.
a) Contraception is women's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous.
c) Being sterilized for a man is the same as castration.

316. CHECK 301 (07) KNOWS MALE CONDOM

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

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

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

SECTION 4. MARRIAGE AND SEXUAL LIFE

401. What is your current marital status?

402. Do you currently have one wife or more than one wife?
IF ONLY ONE WIFE, RECORD '01'. IF MORE THAN ONE, ASK: How many wives do you currently have?

403. WRITE THE LINE NUMBERS FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE. IF A WIFE IS NOT LISTED IN THE HOUSEHOLD SCHEDULE, RECORD '00' IN THE LINE NUMBER BOXES.
THE NUMBER OF LINES FILLED IN MUST BE EQUAL TO THE NUMBER OF WIVES.
(IF RESPONDENT HAS MORE THAN FOUR WIVES, USE ADDITIONAL QUESTIONNAIRE(S).)

CHECK 402:

404. Are you living with your wife/wives now, or is she/are they staying elsewhere?

LIVING WITH WIFE/AT LEAST ONE WIFE 1 (GO TO 406)
NOT LIVING WITH WIFE/ANY WIVES 2

405. For how long have you not been living with your wife/any of your wives? IF LESS THAN 1 YEAR, RECORD MONTHS; OTHERWISE RECORD COMPLETED YEARS

406. CHECK 402.

ONLY ONE WIFE: Have you ever been married to any woman other than your current wife?
MORE THAN ONE WIFE: Have you ever been married to any other woman in addition to those you have told me about?

407. Have you been married once or more than once?

408. CHECK 402 AND 406:

409. In what month and year did you get married?

409A. Now I would like to ask about when you married your first wife. In what month and year was that?

410. How old were you when you first got married?

411. CHECK 401:

412. CHECK 402 AND 406 AND, IF 402 AND 406 NOT ASKED,

IF MARRIED ONLY ONCE (402=01 AND 406='2') OR (407='1')
In what month and year did you start living with your wife?

IF MARRIED MORE THAN ONCE (402>01 OR 406='1') OR (407 = '2')
Now I would like to ask about when you started living with your first wife. In what month and year was that?

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

414. CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY. Now I need to ask you some questions about sexual
life in order to gain a better understanding of some important life issues. Let me assure you again that your answers are completely confidential and will not be told to anyone. If you do not want to answer, just let me know and I will skip to the next question. Have you ever had sexual intercourse?

415. CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY. (Now I need to ask you some questions about sexual life in order to gain a better understanding of some important life issues. Let me assure you again that your answers are completely confidential and will not be told to anyone. If you do not want to answer, just let me know and I will skip to the next question.) How old were you when you had sexual intercourse for the very first time?

416. CHECK 401

417. Do you intend to wait until you get married/after gauna to have sexual intercourse for the first time?

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

418A. What was this person's relationship to you?
IF GIRLFRIEND: Were you living together as if married? IF YES, CIRCLE '02'. IF NO, CIRCLE '03'.

419. When was the last time you had sexual intercourse? IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS. IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

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

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

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

424. What was this (second/third) person's relationship to you? IF GIRLFRIEND: Were you living together as if married? IF YES, CIRCLE '02'. IF NO, CIRCLE '03'.

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

426. The last time you had sexual intercourse with this (second/third) person, did you or this person drink alcohol?

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

428. Apart from [this person/these two people], have you had sexual intercourse with any other person in the last 12 months? IF FILLING FOR THIRD-TO-LAST SKIP THIS QUESTION.

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

430. CHECK 424 (ALL COLUMNS):

431. CHECK 422 AND 424 (ALL COLUMNS:

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

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

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

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

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

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

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

438A. Which condom brand do you use regularly?

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

439A. How many of the condoms you got last time did you use?

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

441. From where did you obtain the condom the last time? PROBE TO IDENTIFY TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE

442. CHECK 302 (02): RESPONDENT EVER STERILIZED

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

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

SECTION 5: FEMALE PREFERENCES

501. CHECK 401:

502. CHECK 302(02): EVER STERILIZED?

503. CHECK 402:

HAS ONE WIFE: Is your wife currently pregnant?

HAS MORE THAN ONE WIFE:
Are any of your wives currently pregnant?

504. CHECK 503:

NO WIFE PREGNANT OR UNSURE QUESTION NOT ASKED: Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children

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

505. CHECK 503:

NO WIFE PREGNANT OR UNSURE: How long would you like to wait from now before the birth of (a/another) child?

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

506. CHECK 203 AND 205:

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

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

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

SECTION 6. EMPLOYMENT AND GENDER ROLES

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

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

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

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

605. CHECK 604

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

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

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

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

610. CHECK 402:

611. CHECK 609:

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

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

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

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

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

SECTION 7. HIV/AIDS

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

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

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

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

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

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

707. Can people get the AIDS virus by touching someone who has AIDS?

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

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

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

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

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

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

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

715. CHECK 701:

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

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

716. CHECK 414 AND 415:

717. CHECK 715: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INECTIONS

718. 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?

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

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

721. CHECK 718, 719, AND 720:

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

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

724. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?

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

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

SECTION 8. OTHER HEALTH ISSUES

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

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

803. Can tuberculosis be cured?

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

805. Do you currently smoke cigarettes?

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

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

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

809. In the last few months have you heard or seen the following programs on the radio and/or television:

810. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT ___________

COMMENTS ON SPECIFIC QUESTIONS: __________

ANY OTHER COMMENTS: _________

SUPERVISOR'S OBSERVATION _____________

NAME OF SUPERVISOR: ________

DATE: ____________

EDITOR'S OBSERVATIONS ___________

NAME OF EDITOR: __________

DATE: _________