IDENTIFICATION

NAME AND CODE OF DISTRICT

NAME AND CODE OF VILLAGE/MUNICIPALITY

WARD NUMBER

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD NUMBER

NAME AND LINE NUMBER OF MAN

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 01

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

SUPERVISOR

OFFICE EDITOR

KEYED BY

INTRODUCTION AND CONSENT

Hello. My name is _______________________________________. I am working with Ministry of Health. We are conducting a survey about health and other topics all over Nepal. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. No part of this interview is being recorded in tape or video. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.
Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER_______________________________DATE_____________

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD TIME

102. How long have you been living continuously in (NAME OF CURRENT CITY, TOWN OR VILLAGE OF RESIDENCE)? IF LESS THAN ONE YEAR, RECORD '00' YEARS.

103. Just before you moved here, did you live in a city or in a rural area?

104. Before you moved here, which district did you live in?

105. In what month and year were you born?

106. How old were you at your last birthday? COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

107. Have you ever attended school?

109. What is the highest grade you have completed? IF COMPLETED LESS THAN ONE GRADE, RECORD '00'.

110. CHECK 109:

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

112. CHECK 111:

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

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

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

116. Do you own a mobile telephone?

117. Do you use your mobile phone for any financial transactions?

118. Do you have an account in a bank or other financial institution that you yourself use?

119. Have you ever used the internet?

120. In the last 12 months, have you used the internet? IF NECESSARY, PROBE FOR USE FROM ANY LOCATION, WITH ANY DEVICE.

121. During the last one month, how often did you use the internet: almost every day, at least once a week, less than once a week, or not at all?

122. What is your religion?

123. What is your caste/ethnicity?

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

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

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

206. Have you ever fathered a son or daughter who was born alive but later died?
IF NO, PROBE: Any baby who cried, who made any movement, sound, or effort to breathe, or who showed any other signs of life even if for a very short time?

207. a) How many boys have died?
b) 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. CHECK 208:
HAS MORE THAN ONE CHILD:
How old were you when your first child was born?

HAS ONLY ONE CHILD:
How old were you when your child was born?

212. CHECK 203 AND 205:

213. CHECK 203 AND 205:
MORE THAN ONE LIVING CHILD:
How old is your youngest child?

ONLY ONE LIVING CHILD:
How old is your child?

214. CHECK 213:

215. CHECK 203 AND 205:
MORE THAN ONE LIVING CHILD:
What is the name of your youngest child?

ONLY ONE LIVING CHILD:
What is the name of your child?

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

217. Were you ever present during any of those antenatal check-ups?

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

219. When a child has diarrhea, how much should he or she be given to drink: more than usual, about the same as usual, less than usual, or nothing to drink at all?

SECTION 3. CONTRACEPTION

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

302. In the last few months have you:
a) Heard about family planning on the radio?
b) Seen anything about family planning on the television?
c) Read about family planning in a newspaper or magazine?
d) Received a voice or text message about family planning on a mobile phone?
e) Read about family planning in brochure or flipchart?
f) Seen message on family planning in a poster, hoarding board or billboard?
g) Read/seen message in the internet?
h) Seen street dramas on family planning?
i) Heard from mother's group/teachers?
j) Heard from FCHVs?

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

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

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

306. After the birth of a child, can a woman become pregnant before her menstrual period has returned?

307. I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.
a) Contraception is a woman's concern and a man should not have to worry about it.
b) Women who use contraception may become promiscuous.

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401. Are you currently married or living together with a woman as if married?

402. Have you ever been married or lived together with a woman as if married?

403. What is your marital status now; are you widowed, divorced, or separated?

404. Is your (wife/partner) living with you now or is she staying elsewhere?

405. Do you have other wives or do you live with other women as if married?

406. Altogether, how many wives or live-in partners do you have?

407. CHECK 405:
ONE WIFE/PARTNER
a) Please tell me the name of (your wife/the woman you are living with as if married)

MORE THAN ONE WIFE/PARTNER
b) Please tell me the name of each of your wives or each woman you are living with as if married.

RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER. IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'. ASK 408 FOR EACH PERSON.

408. How old was (NAME) on her last birthday?

409. CHECK 407:

410. Have you been married or lived with a woman only once or more than once?

411. CHECK 405 AND 410:
BOTH ARE CODE '2':
a) In what month and year did you start living with your (wife/partner)?

OTHER:
b) Now I would like to ask about your first (wife/partner). In what month and year did you start living with her?

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

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

414. I would like to ask some questions about sexual activity 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 we should come to any question that you don't want to answer, just let me know and we will go to the next question. How old were you when you had sexual intercourse for the very first time?

415. Now I would like to ask you about your recent sexual activity. 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.

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

417. The last time you had sexual intercourse with this person, was a condom used?

418. Was a condom used every time you had sexual intercourse with this person in the last 12 months?

419. What was your relationship to this person with whom you had sexual intercourse?
IF GIRLFRIEND: Were you living together as if married?
IF YES, RECORD '2'. IF NO, RECORD '3'.

420. How long ago did you first have sexual intercourse with this person?

421. How many times during the last 12 months did you have sexual intercourse with this person?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, RECORD '95'.

422. How old is this person?

423. Apart from this person, have you had sexual intercourse with any other person in the last 12 months?

424. 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 95 OR MORE, RECORD '95'.

425. CHECK 419 (ALL COLUMNS):

426. CHECK 419 AND 417 (ALL COLUMNS):

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

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

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

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

431. In the past 12 months have you given any gifts or other goods in order to have sex or to become sexually involved with anyone?

432. Have you ever given any gifts or other goods in order to have sex or to become sexually involved with anyone?

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

434. CHECK 417: MOST RECENT PARTNER (FIRST COLUMN)

435. You told me that a condom was used the last time you had sex. What is the brand name of the condom used at that time?
IF BRAND NOT KNOWN, ASK TO SEE THE PACKAGE.

436. From where did you obtain the condom the last time?
PROBE TO IDENTIFY TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

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

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

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

440. Do you know of a place where you can obtain a method of family planning?

SECTION 5. FERTILITY PREFERENCES

510. Now I have some questions about the future. After the (child/children) you and your (wives/partners) are expecting now, would you like to have another child, or would you prefer to not have any more children?

511. After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?

512. CHECK 208:
HAS FATHERED CHILDREN
a) Now I have some questions about the future. Would you like to have another child, or would you prefer not to have any more children?

HAS NOT FATHERED CHILDREN
b) Now I have some questions about the future. Would you like to have a child, or would you prefer not to have any children?

513. CHECK 208:
HAS FATHERED CHILDREN
a) How long would you like to wait from now before the birth of another child?

HAS NOT FATHERED CHILDREN
b) How long would you like to wait from now before the birth of a child?

514. CHECK 203 AND 205:
HAS LIVING CHILDREN
a) If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?

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

515. How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter if it's a boy or a girl?

SECTION 6. EMPLOYMENT AND GENDER ROLES

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

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

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

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

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

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

606A. Would you say women are paid less, equal, or more than men for the same job in your locality?

607. CHECK 401:

608. CHECK 606:

609. Who usually decides how the money you earn will be used; you, your (wife/partner) or you and your (wife/partner) jointly?

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

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

611A. Who usually makes decisions about your children's education?

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

613. Do you have a title deed for any house you own?

615. Do you own any agricultural or non-agricultural land either alone or jointly with someone else?

616. Do you have a title deed for any land you own?

618. In your opinion, is a husband justified in hitting or beating his wife in the following situations:
a) If she goes out without telling him?
b) If she neglects the children?
c) If she argues with him?
d) If she refuses to have sex with him?
e) If she burns the food?
f) If she brings less or brings no dowry?

SECTION 7. HIV/AIDS

701. Now I would like to talk about something else. Have you ever heard of HIV or AIDS?

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

703. Can people get HIV from mosquito bites?

704. Can people reduce their chance of getting HIV by using a condom every time they have sex?

705. Can people get HIV by sharing food with a person who has HIV?

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

707. Is it possible for a healthy-looking person to have HIV?

708. Can HIV be transmitted from a mother to her baby:
a) During pregnancy?
b) During delivery?
c) By breast feeding?

709. CHECK 708:

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

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

712. I don't want to know the results, but have you ever been tested for HIV?

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

714. I don't want to know the results, but did you get the results of the test?

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

716. Do you know of a place where people can go to get an HIV test?

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

717A. Do you think there is a treatment for HIV?

717B. Do you know from where HIV treatment (Anti-Retroviral Treatment) can be received?

720. Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?

721. Do you think children living with HIV should be allowed to attend school with children who do not have HIV?

722. Do you think people hesitate to take an HIV test because they are afraid of how other people react if the test result is positive for HIV?

723. Do people talk badly about people living with HIV, or who are thought to be living with HIV?

724. Do people living with HIV, or thought to be living with HIV, lose the respect of other people?

725. Do you agree or disagree with the following statement: I would be ashamed if someone in my family had HIV.

726. Do you fear that you could get HIV if you come into contact with the saliva of a person living with HIV?

727. CHECK 701:
HEARD ABOUT HIV OR AIDS
a) Apart from HIV, have you heard about other infections that can be transmitted through sexual contact?

NOT HEARD ABOUT HIV OR AIDS
b) Have you heard about infections that can be transmitted through sexual contact?

728. CHECK 414:

729. CHECK 727: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

730. 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?

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

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

733. CHECK 730, 731 AND 732:

734. The last time you had (PROBLEM FROM 730/731/732) did you seek any kind of advice or treatment?

735. Where did you go?
Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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

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

SECTION 8. OTHER HEALTH ISSUES

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

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

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

808. Do you currently smoke tobacco every day, some days, or not at all?

809. In the past, have you smoked tobacco every day?

810. In the past, have you ever smoked tobacco every day, some days, or not at all?

811. On average, how many of the following products do you currently smoke each day? Also, let me know if you use the product, but not every day.
IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY DAY, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.
a) Manufactured cigarettes?
b) Hand-rolled cigarettes?
d) Pipes full of tobacco?
e) Cigars, cheroots, or cigarillos?
f) Number of water pipe sessions?
g) Any others? (SPECIFY) ___

812. On average, how many of the following products do you currently smoke each week? Also, let me know if you use the product, but not every week.
IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY WEEK, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.
a) Manufactured cigarettes?
b) Hand-rolled cigarettes?
d) Pipes full of tobacco?
e) Cigars, cheroots, or cigarillos?
f) Number of water pipe sessions?
g) Any others? (SPECIFY) ___

813. Do you currently use smokeless tobacco every day, some days, or not at all?

814. On average, how many times a day do you use the following products? Also, let me know if you use the product, but not every day.
IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY DAY, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.
a) Snuff, by mouth?
b) Snuff, by nose?
c) Chewing tobacco?
d) Betel quid with tobacco?
e) Any others? (SPECIFY) ___

815. On average, how many times a week do you use the following products? Also, let me know if you use the product, but not every week.
IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY WEEK, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.
a) Snuff, by mouth?
b) Snuff, by nose?
c) Chewing tobacco?
d) Betel quid with tobacco?
e) Any others? (SPECIFY) ___

815F. Have you ever heard of an illness called tuberculosis or TB?

815G. What are the common symptoms of TB? RECORD ALL MENTIONED

815H. How does tuberculosis spread from one person to another? RECORD ALL MENTIONED

815I. If you were sick with TB, where would you prefer to seek care? RECORD ALL MENTIONED.

815J. If a member of your family got tuberculosis, would you want it to remain a secret or not?

815K. In the last three months have you heard or seen the following programs on the radio and/or television:
a) Jana Swastha Radio Karyakram?
b) Janasankhya Chetana ka Sworeharu Radio Karyakram?
c) Jeevan Chakra TV Karyakram?
d) Thorai bhaye pugi sari TV Karyakram?
e) Sathi Sanga Manka Kura Radio Karyakram?
f) Bhanchin Aama Radio Karyakram?
g) Bhandai Sundai Radio Karyakram?
h) Pariwar Niyojan, SMART Bancha Jeevan TV/Radio Karyakram?
i) Navimalam TV/Radio Karyakram?

818 RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW:

_____

COMMENTS ON SPECIFIC QUESTIONS:

____

ANY OTHER COMMENTS:

___

SUPERVISOR'S OBSERVATIONS

____