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NEPAL DEMOGRAPHIC AND HEALTH SURVEY 2016 BIOMARKER QUESTIONNAIRE

IDENTIFICATION

NAME AND CODE OF DISTRICT

NAME AND CODE OF VILLAGE/MUNICIPALITY

WARD NUMBER

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

YES 1
NO 2

ALTITUDE (METERS)

FIELD WORKER VISITS

FIRST VISIT

DATE __
FIELD WORKER'S NAME___

NEXT VISIT:

DATE__
TIME__

SECOND VISIT

DATE__
FIELD WORKER'S NAME

NEXT VISIT:

DATE__
TIME__

THIRD VISIT

DATE__
FIELD WORKER'S NAME

FINAL VISIT

DAY __
MONTH__
YEAR__

TOTAL NUMBER OF VISITS

___

NOTES

TOTAL ELGIBLE WOMEN

__

TOTAL ELGIBLE MEN

___

TOTAL ELIGIBLE CHILDREN

___

LANGUAGE OF QUESTIONNAIRE

01 ENGLISH

LANGUAGE OF INTERVIEW

ENGLISH 01
NEPALI 02
MAITHILI 03
BHOJPURI 04
OTHER 05

NATIVE LANGUAGE OF RESPONDENT

ENGLISH 01
NEPALI 02
MAITHILI 03
BHOJPURI 04
OTHER 05

TRANSLATOR

YES 1
NO 2

SUPERVISOR

NAME__
NUMBER__

OFFICE EDITOR

NUMBER__

KEYED BY

NUMBER__

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

101. CHECK COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 102; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

102. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 11.

LINE NUMBER__
NAME___

103. IF MOTHER INTERVIEWED: COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM PREGNANCY HISTORY. IF MOTHER NOT INTERVIEWED ASK: What is (NAME)'s date of birth?

DAY__
MONTH__
YEAR___

104. CHECK 103: CHILD BORN IN 2068-2073?

YES 1
NO 2 (SKIP TO 114)

105. WEIGHT IN KILOGRAMS.

KG __. __
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

106. HEIGHT IN CENTIMETERS.

CM __. __
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

107. MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2

108. MEASURER: ENTER YOUR FIELDWORKER NUMBER.

FIELDWORKER NUMBER ___

109. CHECK 103: CHILD AGE 0-5 MONTHS, I.E, WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?

0-5 MONTHS 1 (SKIP TO 114)
OLDER 2

110. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR CHILD FROM COLUMN 1 OF HOUSEHOLD SCHEDULE.

LINE NUMBER__

(RECORD '00' IF NOT LISTED)

111. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia 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 2068 or later take part in anemia 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. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team. Do you have any questions? You can say yes or no. It is up to you to decide. Will you allow (NAME OF CHILD) to participate in the anemia test?

112. CIRCLE THE CODE AND SIGN YOUR NAME

GRANTED 1 SIGN _____
REFUSED 2 SIGN ___
NOT PRESENT/OTHER 3 (SKIP TO 114)

113. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA.

G/DL __. __
REFUSED 995
OTHER 996

114. GO BACK TO 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201.

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR WOMEN AGE 15 AND ABOVE

201. CHECK COLUMN 9 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE WOMEN IN 202, 203, AND 204. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

202. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 9. NAME FROM FORM.

LINE NUMBER___
NAME___

203. CHECK HOUSEHOLD QUESTIONNAIRE

15-17 YEARS 1
18-49 YEARS 2
50 YEARS AND ABOVE 3

204. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2

205. WEIGHT IN KILOGRAMS.

KG ___. ___
NOT PRESENT 99994 (GO TO 203 FOR NEXT WOMAN OR, IF NO MORE WOMEN GO TO 303)
REFUSED 99995
OTHER 99996

206. HEIGHT IN CENTIMETERS.

CM ___. ___
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207. MEASURER: ENTER YOUR FIELDWORKER NUMBER

FIELDWORKER NUMBER ___

208. CHECK 203: AGE

15-17 YEARS 1
18-49 YEARS 2 (SKIP TO 213)
50 AND ABOVE 3 (SKIP TO 213)

209. CHECK 204: MARITAL STATUS

CODE 4 (NEVER IN UNION) 1
OTHER 2 (SKIP TO 213)

210. PARENTAL/RESPONSIBLE ADULT CONSENT FOR BLOOD PRESSURE MEASUREMENT
210. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ___

(RECORD '00' IF NOT LISTED)

211. ASK CONSENT FOR BLOOD PRESSURE FROM PARENT/OTHER ADULT IDENTIFIED IN 210 AS RESPONSIBLE FOR NEVER MARRIED WOMEN AGE 15-17.

I would like to measure (NAME OF ADOLESCENT)'s blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you and (NAME OF ADOLESCENT) after the measurement process is completed. The results of blood pressure measurement will be explained to you. If (NAME OF ADOLESCENT)'s blood pressure is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT) or you can say no. It is up to you to decide.
Will you allow me to measure (NAME OF ADOLESCENT)'s blood pressure?

212. CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGN ___
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 SIGN___ (SKIP TO 249)

ADULT RESPONDENT CONSENT FOR BLOOD PRESSURE MEASUREMENT

213. ASK CONSENT FOR BLOOD PRESSURE FROM RESPONDENT.

I would like to measure your blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart.
The results of this blood pressure measurement will be given to you after the measurement process is completed. The results of blood pressure measurement will be explained to you. 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. You can also decide at any time not to participate in the blood pressure measurement. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test or you can say no. It is up to you to decide.
Will you allow me to measure your blood pressure?

214. CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGN ___
RESPONDENT REFUSED 2 ___ (SKIP TO 243)

215. 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 minutes:
Eaten anything?
A) Had coffee, tea, cola or other drink that has caffeine?
B) Smoked or used any tobacco
C) product?
D) Took alcohol?

A) EATEN
YES 1
NO 2
B) HAD CAFFEINATED DRINK
YES 1
NO 2
C) SMOKED
YES 1
NO 2
D) TOOK ALCOHOL
YES 1
NO 2

216. 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.
MEASURE THE CIRCUMFERENCE OF THE RESPONDENT'S ARM MIDWAY BETWEEN THE ELBOW AND THE SHOULDER. RECORD THE MEASUREMENT IN CENTIMETRES.

ARM CIRCUMFERENCE (IN CENTIMETERS) ___

217. USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE. CIRCLE THE CODE FOR THE CUFF SIZE.

SMALL: 16 CM -24 CM 1
UNIVERSAL: 22 CM -42 CM 2
LARGE: 36 CM -45 CM 3

218. RECORD TIME OF FIRST BP READING

HOURS___
MINUTES___

219. TAKE THE FIRST BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SYSTOLIC___
DIASTOLIC ___
REFUSED 994 (IF NOT MEASURED, GO TO 243)
TECHNICAL PROBLEM 995 (IF NOT MEASURED, GO TO 243)
OTHER 996 (IF NOT MEASURED, GO TO 243)

220. Before this survey, has your blood pressure ever been checked?

YES 1
NO 2

221. Were you told on two or more different occasions by a doctor or other health professional that you had hypertension or high blood pressure?

YES 1
NO 2

222. To lower your blood pressure, are you now taking a prescribed medicine?

YES 1
NO 2

223. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT.

224. May I take your blood pressure at this time?

YES 1
NO 2 (GO TO 236)

225. RECORD TIME OF SECOND BP READING

HOURS__
MINUTES__

226. TAKE THE SECOND BLOOD PRESSURE READING, RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SYSTOLIC___
DIASTOLIC ___
REFUSED 994 (IF NOT MEASURED, GO TO 236)
TECHNICAL PROBLEM 995 (IF NOT MEASURED, GO TO 236)
OTHER 996 (IF NOT MEASURED, GO TO 236)

227. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT.

228. May I take your blood pressure at this time?

YES 1
NO 2 (GO TO 239)

229. RECORD THE TIME OF THIRD BP READING

HOURS__
MINUTES__

230. TAKE THE THIRD BLOOD PRESSURE READING, RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SYSTOLIC___
DIASTOLIC ___
REFUSED 994 (IF NOT MEASURED, GO TO 239)
TECHNICAL PROBLEM 995 (IF NOT MEASURED, GO TO 239)
OTHER 996 (IF NOT MEASURED, GO TO 239)

231. RECORD THE SUM OF SYSTOLIC MEASURES FROM 225 AND 230

SUM SYSTOLIC ___

232. CALCULATE THE AVERAGE SYSTOLIC PRESSURES BY DIVIDNG THE SUM IN 231 BY 2

AVERAGE SYSTOLIC ____ CIRCLE IN 241

233. RECORD THE SUM OF DIASTOLIC MEASURES FROM 226 AND 230.

SUM DIASTOLIC ___

234. CALCULATE THE AVERAGE DIASTOLIC PRESSURES BY DIVDING THE SUM IN 233 BY 2.

AVERAGE DIASTOLIC___ CIRCLE IN 241 AND SKIP TO 241

235. IF ONLY ONE MEASUREMENT WAS TAKEN, RECORD THE FIRST SYSTOLIC AND DIASTOLIC NUMBERS HERE. (236 AND 237)

236. RECORD THE SYSTOLIC MEASURE FROM 219.

SYSTOLIC ____ CIRCLE IN 241

237. RECORD THE DIASTOLIC MEASURE FROM 219.

DIASTOLIC ____ CIRCLE IN 241(SKIP TO 241)

238. IF ONLY TWO MEASUREMENTS WERE TAKEN, RECORD THE SECON DSYSTOLIC AND DIASTOLIC NUMBERS HERE. (239 AND 240)

239. RECORD THE SYSTOLIC MEASURE FROM 226.

SYSTOLIC ___ CIRCLE IN 241

240. RECORD THE DIASTOLIC MEASURE FROM 226.

DIASTOLIC _____ CIRCLE IN 241

241. CIRCLE THE SINGLE NUMBER WHERE THE AVERAGE DIASTOLIC AND SYSTOLIC MEASURES MEET.

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

242. RECORD THE NUMBER YOU CIRCLED IN 241 IN THE CHART BELOW. THEN USE THE INSTRUCTIONS TO THE RIGHT OF THAT NUMBER TO COMPLETE A BLOOD PRESSURE REPORT AND REFERRAL FORM FOR THE RESPONDENT. GIVE THE FORM TO THE RESPONDENT AND ANSWER ANY QUESTIONS.

NUMBER CIRCLED IN 241 IS 1 (NORMAL/OPTIMAL BLOOD PRESSURE)
CONSULT HEALTH PROVIDER TO CHECK BLOOD PRESSURE 1 YEAR
NUMBER CIRCLED IN 241 IS 2 (NORMAL/MILDLY HIGH PRESSURE)
CONSULT HEALTH PROVIDER TO CHECK BLOOD PRESSURE 1 YEAR
NUMBER CIRCLED IN 241 IS 3 (NORMAL/MODERATELY HIGH BLOOD PRESSURE)
CONSULT HEALTH PROVIDER TO CHECK BLOOD PRESSURE 2 MONTHS
NUMBER CIRCLED IN 241 IS 4 (ABNORMAL/MILDLY ELEVATED BLOOD PRESSURE)
CONSULT HEALTH PROVIDER TO CHECK BLOOD PRESSURE 1 MONTH
NUMBER CIRCLED IN 241 IS 5 (ABNORMAL/MODERATELY ELEVATED BLOOD PRESSURE)
CONSULT HEALTH PROVIDER TO CHECK BLOOD PRESSURE 1 WEEK
NUMBER CIRCLED IN 241 IS 6 (ABNORMAL/SEVERELY ELEVATED BLOOD PRESSURE)
CONSULT HEALTH PROVIDER TO CHECK BLOOD PRESSURE IMMEDIATELY

243. CHECK 203: AGE

15-17 YEARS 1
18-49 YEARS (SKIP TO 245)
50 YEARS AND ABOVE 3 (GO TO 203 FOR WOMAN OR, IF NO MORE WOMEN, GO TO 303)

244. CHECK 204: MARITAL STATUS

CODE 4 (NEVER IN UNION) 1 (SKIP TO 248)
OTHER 2

ADULT RESPONDENT CONSENT FOR ANEMIA TEST

245. ASK CONSENT FOR ANEMIA TEST.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia 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.
For the anemia 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 we take your blood. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you take the anemia test?

246. CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)_______
RESPONDENT REFUSED 2 (SIGN)_______ (SKIP TO 256)
NOT PRESENT/OTHER 3 (SKIP TO 256)

247. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1 (SKIP TO 254)
NO 2 (SKIP TO 254)
DON'T KNOW 8 (SKIP TO 254)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ______

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST
249. ASK CONSENT FOR ANEMIA TEST FROM PARENT/ADULT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia 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. For the anemia 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 anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anemia test?

250. CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)____ (SKIP TO 256)
NOT PRESENT/OTHER 3 (SKIP TO 256)

MINOR RESPONDENT CONSENT FOR ANEMIA TEST
251. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia 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.
For the anemia 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 we take your blood. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF PARENT/RESPONSIBLE ADULT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you take the anemia test?

252. CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)____
MINOR RESPONDENT REFUSED 2 (SIGN)___ (SKIP TO 256)
NOT PRESENT/OTHER 3 (SKIP TO 256)

253. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

254. PREPARE EQUPMENT AND SUPPLIES FOR ANEMIA TEST AND PROCEED WITH THE TEST.

255. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

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

256. GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 301.

WEIGHT, HEIGH, AND BLOOD PRESSURE MEASUREMENT FOR MEN AGE 15 AND ABOVE

301. CHECK COLUMN 10 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE MEN IN 302, 303 AND 304. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

302. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 10 AND NAME FROM COLUMN 2.

LINE NUMBER___
NAME___

303. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):

15-17 YEARS 1
18 YEARS AND ABOVE 2

304. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2

305. WEIGHT IN KILOGRAMS.

KG ____. ___
NOT PRESENT 99994 (GO TO 303 FOR NEXT MAN OR, IF NO MORE MEN, END INTERVIEW)
REFUSED 99995
OTHER 99996

306. HEIGHT IN CENTIMETERS

CM ___. __
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

307. MEASURER: ENTER YOUR FIELDWORKER NUMBER.

FIELDWORKER NUMBER ___

308. CHECK 303: AGE

15-17 YEARS 1
18 YEARS AND ABOVE 2 (SKIP TO 313)

309. CHECK 304: MARITAL STATUS

CODE 4 (NEVER IN UNION) 1
OTHER 2 (SKIP TO 313)

PARENTAL/RESPONSIBLE ADULT CONSENT FOR BLOOD PRESSURE MEASUREMENT

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ___

311. ASK CONSENT FOR BLOOD PRESSURE FROM PARENT/OTHER ADULT IDENTIFIED IN 410 AS RESPONSIBLE FOR NEVER MARRIED WOMEN AGE 15-17.
I would like to measure (NAME OF ADOLESCENT)'s blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you and (NAME OF ADOLESCENT) after the measurement process is completed. The results of blood pressure measurement will be explained to you. If (NAME OF ADOLESCENT)'s blood pressure is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT) or you can say no. It is up to you to decide.
Will you allow me to measure (NAME OF ADOLESCENT)'s blood pressure?

312. CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)___
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)___ (GO TO 343)

ADULT RESPONDENT CONSENT FOR BLOOD PRESSURE MEASUREMENT

313. ASK CONSENT FOR BLOOD PRESSURE FROM RESPONDENT.
I would like to measure your blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart.
The results of this blood pressure measurement will be given to you after the measurement process is completed. The results of blood pressure measurement will be explained to you. 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. You can also decide at any time not to participate in the blood pressure measurement. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test or you can say no. It is up to you to decide.
Will you allow me to measure your blood pressure?

314. CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)___
RESPONDENT REFUSED 2 (SIGN)___ (SKIP TO 343)

315. 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 minutes:
a) Eaten anything?
b) Had coffee, tea, cola or other drink that has caffeine?
c) Smoked or used any tobacco products?
d) Took alcohol?

A) EATEN
YES 1
NO 2
B) HAD CAFFEINATED DRINK
YES 1
NO 2
C) SMOKED
YES 1
NO 2
D) TOOK ALCOHOL
YES 1
NO 2

316. 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. MEASURE THE CIRCUMFERENCE OF THE RESPONDENT'S ARM MIDWAY BETWEEN THE ELBOW AND THE SHOULDER. RECORD THE MEASUREMENT IN CENTIMETERS.

ARM CIRCUMFERENCE ___ (IN CENTIMETERS).

317. USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE. CIRCLE THE CODE FOR THE CUFF SIZE.

SMALL: 16 CM TO 24 CM 1
UNIVERSAL: 22 CM TO 42 CM 2
LARGE; 36 CM TO 45 CM 3

318. RECORD TIME OF FIRST BP READING.

TIME
HOURS___
MINUTES ___

319. TAKE THE FIRST BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

FIRST BP MEASURE
SYSTOLIC ___
DIASTOLIC ___
REFUSED 994 (GO TO 343)
TECHNICAL PROBLEM 994 (GO TO 343)
OTHER 996 (GO TO 343)

320. Before this survey, has your blood pressure ever been checked?

YES 1
NO 2

321. Were you told on two or more different occasions by a doctor or other health professional that you had hypertension or high blood pressure?

YES 1
NO 2

322. To lower your blood pressure, are you now taking a prescribed medicine?

YES 1
NO 2

323. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT.

324. May I take your blood pressure at this time?

YES 1
NO 2 (GO TO 336)

325. RECORD TIME OF SECOND BP READING.

TIME
HOURS__
MINUTES__

326. TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SECOND BP MEASURE
SYSTOLIC ___
DIASTOLIC ___
REFUSED 994 (GO TO 336)
TECHNICAL PROBLEM 994 (GO TO 336)
OTHER 996 (GO TO 336)

327. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT.

328. May I take your blood pressure at this time?

YES 1
NO 2 (GO TO 339)

329. RECORD TIME OF THIRD BP READING

TIME
HOURS__
MINUTES___

330. TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

THIRD BP MEASURE
SYSTOLIC ___
DIASTOLIC ___
REFUSED 994 (GO TO 339)
TECHNICAL PROBLEM 995 (GO TO 339)
OTHER 996 (GO TO 339)

331. RECORD THE SUM OF THE SYSTOLIC MEASURES FROM 326 AND 330.

SUM SYSTOLIC ___

332. CALCULATE THE AVERAGE SYSTOLIC PRESSURES BY DIVIDING THE SUM IN 331 BY 2.

AVERAGE SYSTOLIC ____ (CIRCLE IN 341)

333. RECORD THE SUM OF THE DIASTOLIC MEASURES FROM 326 AND 330.

SUM DIASTOLIC____

334. CALCULATE THE AVERAGE DIASTOLIC PRESSURES BY DIVIDNG THE SUM IN 333 BY 2.

AVERAGE DIASTOLIC ___ (CIRCLE IN 341 AND SKIP TO 341)

335. IF ONLY ONE MEASUREMENT WAS TAKEN, RECORD THE FIRST SYSTOLIC AND DIASTOLIC NUMBERS HERE.

336. RECORD THE SYSTOLIC MEASURE FROM 319.

SYSTOLIC ____ (CIRCLE IN 341)

337. RECORD THE DIASTOLIC MEASURE FROM 319.

DIASTOLIC ___ (CIRCLE IN 341 AND SKIP TO 341)

338. IF ONLY TWO MEASUREMENTS WERE TAKEN, RECORD THE SECOND SYSTOLIC AND DIASTOLIC NUMBERS HERE.

339. RECORD THE SYSTOLIC MEASURE FROM 326.

SYSTOLIC ___ (CIRCLE IN 341)

340. RECORD THE DIASTOLIC MEASURE FROM 326.

DIASTOLIC ___ (CIRCLE IN 341)

341. CIRCLE THE SINGLE NUMBER WHERE THE AVERAGE DIASTOLIC AND SYSTOLIC MEASURES MEET.

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

343. GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.

FIELDWORKER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
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SUPERVISOR'S OBSERVATIONS
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