IDENTIFICATION

NAME OF LOCALITY_____

NAME OF HEAD OF HOUSEHOLD_____

PREFECTURE (ADMINISTRATIVE CENTER)_______

TOWN OR MUNICIPALITY______

SECTOR_____

SUB-SECTOR_____

HOUSEHOLD NUMBER______

URBAN/RURAL

LARGE CITY, OTHER CITY, OR RURAL?

NAME AND LINE NUMBER OF WOMAN______

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER NAME____
RESULT*____

RESULT*

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE___
TIME___

FINAL VISIT
DAY____
MONTH____
YEAR____
NAME____
RESULT*_____

TOTAL NUMBER OF VISITS_____

LANGUAGE OF INTERVIEW:

INTERPRETER USED?

FIELD EDITOR
NAME___
DATE____

SUPERVISOR
NAME____
DATE____

OFFICE EDITOR_____
KEYED BY____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is ___and I am working with National Population Office (NPO). We are conducting a national survey about the health of women and children in Rwanda. We would very much appreciate your participation in this survey. I would like to ask you about your health (and the health of your children). This information will help the government to plan health services. The survey usually takes between 20 and 45 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this 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. To begin, I would like to ask you some questions about yourself and your household. Until the age of 12, did you mostly live in Kigali, in another city, or in a rural area?

103. For how long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?

104. Just before moving here, did you live in the city of Kigali, another city, or in a rural area?

105. In what month and year were you born?

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

107. Have you ever attended school?

108. What is the highest level of school you attended: primary, post-primary, secondary, or higher?

109. What was the highest (class/year) that you successfully completed at that level?

110. CHECK 108:

111. Now, I would like you to read this sentence aloud to me. Read as much as you can.
SHOW CARD TO RESPONDENT

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

113. CHECK 111:

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

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

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

119. Have you ever drunk alcoholic beverages?

120. Have you ever become drunk after drinking alcoholic beverages?

121. During the last three months, how many times did you drink alcoholic beverages?

122. CHECK 120:

123. During the last three months how many times did you become drunk?

124. During the last three months, have you had an injection?

125. During the last three months, how many times have you had an injection?

126. The last time you had an injection, who gave you the shot?

SECTION 2. REPRODUCTION

201. Now I would like to ask you questions about all the births you have had in your life. Have you ever given birth?

202. Do you have any sons or daughters that you gave birth to who are currently living with you?

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

204. Do you have any sons or daughters that you gave birth to who are still alive but do not live with you?

205. How many sons are alive but not living with you? How many daughters are alive but not living with you?
IF NONE, ENTER '00'.

206. Have you ever given birth to a boy or girl who was born alive but later died?
IF NO, PROBE: Any child that cried at birth or showed signs of life but only lived a few hours or days?

207 How many boys have died? How many girls have died?
IF NONE, WRITE '00'

208. SUM ANSWERS FROM 203, 205, AND 207 AND RECORD THE TOTAL.
IF NONE, RECORD '00'.

209. CHECK 208:
I want to make sure I have this right: you have had in TOTAL ___ births in your life. Is that correct?

210. CHECK 208:

211. Now I would like to talk to you about your children, whether they are still alive or not, beginning with the first birth that you had.
IN 212, WRITE THE NAME OF EACH CHILD. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.

212. What name was given to your (first/next) baby?

213. Among these births, were there any twins?

214. Is (NAME) a boy or a girl?

215. In what month and year was (NAME) born?
PROBE: What is his or her birthday?

216. Is (NAME) still alive?

217. IF ALIVE: How old was (NAME) on his/her last birthday?
RECORD AGE IN COMPLETED YEARS

218. IF ALIVE: Is (NAME) living with you?

219. IF ALIVE: RECORD THE LINE NUMBER OF CHILD FROM THE HOUSEHOLD SCHEDULE.
RECORD '00' IF CHILD IS NOT LISTED IN THE HOUSEHOLD

220. IF DEAD: How old was (NAME) when he/she died?
IF "1 YEAR," PROBE: How many months old was (NAME)?

RECORD DAYS IF LESS THAN ONE MONTH, MONTHS IF LESS THAN TWO YEARS, OR IN YEARS

221. Were there any other live births between (NAME OF LAST BIRTH) and (NAME)?
[FOR ALL BIRTHS EXCEPT THE FIRST BIRTH]

222. Have you had any other births after the birth of (NAME OF LAST BIRTH)?

223. COMPARE 208 WITH THE NUMBER OF BIRTHS RECORDED IN THE TABLE ABOVE AND CHECK:

224. CHECK 215 AND RECORD THE NUMBER OF LIVE BIRTHS SINCE JANUARY 1995. IF NONE, RECORD '0'.

225. FOR EACH BIRTH SINCE JANUARY 1995, RECORD 'B' IN THE BIRTH MONTH ON THE CALENDAR. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF THE PREGNANCY.

(NOTE: THE NUMBER OF 'G's MUST BE 1 LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED). RECORD THE NAME OF THE CHILD ON THE LEFT OF THE CODE 'B'.

226. Are you pregnant now?

227. How many months pregnant are you?

RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P' IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

228. At the time you became pregnant did you want to become pregnant then, did you want to wait until later, or did you not want to have a/another child at all?

229. Have you ever had a pregnancy that ended in a miscarriage, abortion, or stillbirth?

230. When did the last pregnancy of this kind end?

231. CHECK 230:

232. How many months pregnant were you when the last pregnancy of this kind ended?
RECORD THE NUMBER OF COMPLETED MONTHS. ENTER 'T' ON THE CALENDAR ON THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS

233. Have you had any other pregnancies that did not end in a live birth?

234. ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 1995.

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

235. IN THE BOXES ON THE BOTTOM OF THE CALENDAR, RECORD THE MONTH AND YEAR OF THE END OF THE LAST PREGNANCY BEFORE JANUARY 1995 THAT DID NOT END IN A LIVE BIRTH

236. When did your last menstrual period start?
RECORD THE DATE, IF GIVEN

237. From one menstrual period to the next, is there a time when a woman is more likely to become pregnant than others if she has sexual relations?

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

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.

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.

301. Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK:
Have you ever heard of (METHOD)?

302. Have you ever used (METHOD)?

303. CHECK 302:

304. Have you ever used a method or tried in any way to delay or avoid getting pregnant?

306. What have you done or used?
CORRECT 302, 303, (AND 301 IF NECESSARY)

307. Now I would like to ask you about the time when you first did something or used a method to avoid getting pregnant. How many children did you have at that time?
IF NONE, RECORD '00'

308. CHECK 301(01):

309. CHECK 226:

310. Are you currently doing something or using a method to avoid pregnancy?

311. What method are you using?
311A. CIRCLE 'A' FOR FEMALE STERILIZATION
CIRCLE 'B' FOR MALE STERILIZATION

IF MORE THAN ONE METHOD MENTIONED, FOLLOW THE CORRESPONDING SKIP INSTRUCTION FOR THE FIRST METHOD ON THE LIST

313. Where did the sterilization take place?

IF SOURCE IS GOVERNMENTAL HOSPITAL, GOVERNMENT-APPROVED HOSPITAL, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

IF CODES 'A' AND 'B' WERE BOTH CIRCLED IN 311, ASK 313-317 ABOUT FEMALE STERILIZATION ONLY

314. CHECK 311:

CODE 'A' CIRCLED: Before your sterilization operation, were you told that you would not be able to have any (more) children because of the operation?

CODE 'B' CIRCLED: Before the sterilization operation, was your husband/partner told that he would not be able to have any (more) children because of the operation?

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

317. CHECK 316:

319. Where did you obtain (CURRENT METHOD) when you first started using it?

IF SOURCE IS GOVERNMENT HOSPITAL, GOVERNMENT-APPROVED HOSPITAL, CLINIC, OR HEALTH CENTER, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

319A. Where did you learn to use the lactational amenorrhea method (LAM)?

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

319B. How long have you been using (METHOD) continuously?
IF LESS THAN 1 MONTH, RECORD '00'

320. CHECK 311/311A:

CIRCLE METHOD CODE:

IF MORE THAN ONE CODE CIRCLED FOR A METHOD IN 331/311A, CIRCLE THE CODE FOR THE FIRST METHOD ON THE LIST

321. CHECK 319B:

322. You first obtained (CURRENT METHOD) from (SOURCE OF METHOD FROM Q. 313 OR 319). At that time, were you told about any side effects or problems you might have with the method?

323. Were you told what to do if you experienced side effects or problems?

324. CHECK 319B:

325. CHECK 320:

ANY CODE FROM '1' TO '6' CIRCLED: At that time, were you told about other methods of family planning that you could use?

ANY CODE '8' TO '11' CIRCLED: In the beginning, you obtained (CURRENT METHOD) from (SOURCE OF METHOD FROM Q. 313 OR 319). At that time, were you told about other methods of family planning that you could use?

326. CHECK 311/311A:

CIRCLE METHOD CODE:

327. Where did you obtain (CURRENT METHOD) the last time?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE

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

329. Where is that?

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE

330. During the past 12 months, have you had a visit from a fieldworker who spoke to you about family planning?

331. In the past 12 months, have you gone to a health center to receive care for yourself (or your children)?

332. Did someone at the health center speak to you about family planning methods?

SECTION 4A. PREGNANCY, POSTNATAL CARE, AND BREASTFEEDING

401. CHECK 224:

402. RECORD THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE 1995 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS BEGIN WITH THE LAST BIRTH.

(IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES)

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

403. LINE NUMBER FROM Q. 212

404. FROM Q. 212 AND Q. 216:

405. At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later, or did you not want to have a/another child at all?

406. How much longer would you like to have waited?

407 Did you see anyone for antenatal care for this pregnancy?
IF YES: Whom did you see? Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN
[FOR LAST BIRTH ONLY]

408. How many months pregnant were you when you first received antenatal care for this pregnancy?
[FOR LAST BIRTH ONLY]

409. How many times did you receive antenatal care during this pregnancy?
[FOR LAST BIRTH ONLY]

410. CHECK 409:
NUMBER OF TIMES RECEIVED ANTENATAL CARE
[FOR LAST BIRTH ONLY]

411. How many months pregnant were you the last time you received antenatal care?
[FOR LAST BIRTH ONLY]

412. During this pregnancy, were any of the following done at least once?
[FOR LAST BIRTH ONLY]

413. Were you told about the signs of pregnancy complications?
[FOR LAST BIRTH ONLY]

414. Were you told where to go if you had these complications?
[FOR LAST BIRTH ONLY]

415. During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?
[FOR LAST BIRTH ONLY]

415A. During this pregnancy, how many times did you get this injection?
[FOR LAST BIRTH ONLY]

416. During this pregnancy, were you given or did you buy iron tablets or syrup containing iron?
SHOW TABLETS/SYRUP.
[FOR LAST BIRTH ONLY]

417. During the whole pregnancy, for how many days did you take iron in tablets or syrup?
IF ANSWER IS NON-NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS
[FOR LAST BIRTH ONLY]

418. During this pregnancy, did you have difficulty with your vision during the daylight?
[FOR LAST BIRTH ONLY]

419. During this pregnancy, did you suffer from night blindness?
(USE LOCAL TERM)
[FOR LAST BIRTH ONLY]

420. During this pregnancy, did you take any drugs to prevent you from getting malaria?
[FOR LAST BIRTH ONLY]

421. What drugs did you take?
RECORD ALL MENTIONED
[FOR LAST BIRTH ONLY]

422. When (NAME) was born, was he/she very large, larger than average, average, smaller than average, or very small?

423. Was (NAME) weighed at birth?

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

425. Who assisted with the delivery of (NAME)? Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS MENTIONED

426. Where did you give birth to (NAME)?

IF SOURCE IS GOVERNMENT HOSPITAL, GOVERNMENT HEALTH CENTER, OR PRIVATE CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

427. Was (NAME) delivered by caesarian section?

428. After (NAME) was born, did a health professional or a traditional birth attendant check on your health?

429. How many days or weeks after the delivery did the first postnatal check take place?
RECORD '00' DAYS IF SAME DAY.
[FOR LAST BIRTH ONLY]

430. Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.
[FOR LAST BIRTH ONLY]

431. Where did this first visit take place?
[FOR LAST BIRTH ONLY]

432. In the first two months after delivery, did you receive a vitamin A dose like this?
SHOW AMPULE/CAPSULE/SYRUP.
[FOR LAST BIRTH ONLY]

433. Has your period returned since the birth of (NAME)?
[FOR LAST BIRTH ONLY]

434. Did your period return between the birth of (NAME OF NEXT-TO-LAST BIRTH) and your next pregnancy? [FOR ALL BIRTHS EXCEPT LAST BIRTH]

435. For how many months after the birth of (NAME) did you not have a period?

436. CHECK 226:
RESPONDENT PREGNANT?
[FOR LAST BIRTH ONLY]

437. Have you resumed sexual relations since the birth of (NAME)?
[FOR LAST BIRTH ONLY]

438. For how long after the birth of (NAME) did you not have sexual relations?

439. Did you breastfeed (NAME)?

440. How long after birth did you first put (NAME) to the breast?

IF LESS THAN 1 HOUR, RECORD '00' HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS

441. CHECK 404:
CHILD LIVING?

442. Are you still breastfeeding (NAME)?

443. For how many months did you breastfeed (NAME)?

444. CHECK 404:
CHILD LIVING?

445. How many times did you breastfeed last night between sunset and sunrise?
IF ANSWER IS NON-NUMERIC, PROBE FOR APPROXIMATE NUMBER

446. How many times did you breastfeed yesterday during the daylight hours?
IF ANSWER IS NON-NUMERIC, PROBE FOR APPROXIMATE NUMBER

447. Did (NAME) drink anything from a bottle with a nipple yesterday or last night?

448. Now I would like to ask you about the food (NAME) received during the past 7 days, including yesterday. How many days during the past 7 days did (NAME) receive the following foods and/or liquids?

FOR EACH FOOD RECEIVED AT LEAST ONCE IN THE PAST 7 DAYS, ASK:
In total, yesterday, during the day or night, how many times did (NAME) receive:

IF 7 OR MORE TIMES, RECORD '7'. IF RESPONDENT DOESN'T KNOW, RECORD '8'

450. GO BACK TO 405 IN THE NEXT COLUMN; OR, IF NO OTHER BIRTHS, GO TO 451

SECTION 4B. IMMUNIZATION AND HEALTH

451. ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1995 IN THE TABLE. (IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES)

452. LINE NUMBER FROM Q. 212

453. FROM Q. 212 AND Q. 216:

454. Did (NAME) receive a vitamin A dose like this during the last 6 months?
SHOW AMPULE/CAPSULE/SYRUP

455. Do you have a card where (NAME)'s vaccinations are written down?
IF YES: May I see it please?

456. Did you ever have a vaccination card for (NAME)?

457. (1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD
(2) WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED

458. Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in a national immunization day campaign?

RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3, AND/OR MEASLES VACCINE(S).

459. Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases, including vaccinations received in a national immunization day campaign?

460. Please tell me if (NAME) received any of the following vaccinations:

460A. A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually leaves a scar?

460B. Polio vaccine, that is, drops in the mouth?

460C. When was the first polio vaccine given, just after birth or later?

460D. How many times was the polio vaccine given?

460E. A DPT vaccination, that is, an injection given in the thigh or buttocks, generally given at the same time as polio drops?

460F. How many times?

460G. An injection to prevent measles?

461. Did (NAME) receive any of these vaccinations in the past two years during a national vaccination day campaign?

462. During which national vaccination day campaigns in the past two years has (NAME) received these vaccinations?
RECORD ALL MENTIONED.

463. Has (NAME) been ill with a fever at any time in the last 2 weeks?

463A. Does (NAME) have a fever right now?

463B. Have you done anything for (NAME)'s fever?

463C. What have you done? What was done first? What was done afterwards?
CIRCLE A CODE IN EACH COLUMN FOR EACH OF THE FIRST THREE ACTIONS

463D. CHECK 463C:

463E. What medicine was given to (NAME)?
ASK TO SEE THE MEDICINE(S). IF NOT SEEN, SHOW MEDICINE(S) TO THE RESPONDENT
RECORD ALL MENTIONED

FOR EACH ANTI-MALARIAL GIVEN, ASK:
How long after the fever started did (NAME) start taking (NAME OF MEDICINE)?

463EA. How much did you spend on the over-the-counter medicine that you gave to (NAME)?

463F. CHECK 463C

463G. How long after you noticed (NAME)'s fever was he taken to a health center?

463GA. Why did you wait this long before taking (NAME) to a health center?

463H. Did (NAME) receive medicine or a prescription at the health center?

463I. What medicines or prescriptions did (NAME) receive at the health center?
ASK TO SEE THE MEDICINE(S). IF NOT SEEN, SHOW MEDICINE(S) TO RESPONDENT.
RECORD ALL MENTIONED.

FOR EACH ANTI-MALARIAL, ASK:
How long after the fever started did (NAME) start taking (NAME OF MEDICINE)?

463HA. Did you buy all of these medicines, some of the medicines, or none of the prescription medicines to treat (NAME)'s fever?

463HB. How much did you spend on the medicine you gave to (NAME)?

463HC. Why didn't you buy medicine or a prescription to treat (NAME)'s fever?

463HD. How much did you pay for (NAME)'s consultation fees at the health center?

463J. Did (NAME) receive an injection at the health center?

463K. CHECK 463C:

463L. How long after you noticed (NAME)'s fever did you consult a private doctor?

463LA. Why did you wait this long before taking (NAME) to a health center?

463M. Did (NAME) receive medicine or a prescription from the private doctor?

463N. What medicines or prescriptions did (NAME) receive from the private doctor?
ASK TO SEE THE MEDICINE(S). IF NOT SEEN, SHOW MEDICINE(S) TO RESPONDENT.
RECORD ALL MENTIONED.

FOR EACH ANTI-MALARIAL, ASK:
How long after the fever started did (NAME) start taking (NAME OF MEDICINE)?

463MA. Did you buy all of these medicines, some of the medicines, or none of the prescription medicines to treat (NAME)'s fever?

463MB. How much did you spend on the medicine you gave to (NAME)?

463MC. Why didn't you buy medicine or a prescription to treat (NAME)'s fever?

463MD. How much did you pay for (NAME)'s consultation fees from the private doctor?

463O. Did (NAME) receive an injection from the private doctor?

463P. CHECK 463C:

463Q. How long after you noticed (NAME)'s fever did you consult a community health worker?

463R. What did the community health worker do?
RECORD ALL MENTIONED

463S. CHECK 463R:

463T. What medicines or prescriptions was (NAME) given or recommended by the community health worker?
ASK TO SEE THE MEDICINE(S). IF NOT SEEN, SHOW MEDICINE(S) TO RESPONDENT.
RECORD ALL MENTIONED.

FOR EACH ANTI-MALARIAL, ASK:
How long after the fever started did (NAME) start taking (NAME OF MEDICINE)?

464. Has (NAME) had an illness with a cough at any time in the last 2 weeks?

465. When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, fast breaths?

467. Did you seek advice or treatment for the cough?

468. Where did you seek advice or treatment? Anywhere else?
RECORD ALL MENTIONED

472. Has (NAME) had diarrhea in the past two weeks?

473. Now, I want to know how much liquid (NAME) received when he/she had diarrhea. Did you give him/her less than usual, about the same amount, or more than usual?
IF LESS, PROBE: Did you give him/her much less than usual to drink or a little less than usual?

474. When (NAME) had diarrhea, did you give him/her less to eat than usual, about the same amount, more than usual, or nothing to eat at all?
IF LESS, PROBE: Did you give him/her much less than usual or a little less than usual?

475. Did you give (NAME) one of the following things to drink?

476. Was anything else given to treat the diarrhea?

477. What was given to treat diarrhea? Anything else?
RECORD ALL MENTIONED

478. Did you seek advice or treatment for the diarrhea?

479. Where did you seek advice or treatment? Anywhere else?
RECORD ALL MENTIONED

480A. Does (NAME) usually sleep under a mosquito net?

480B. Did (NAME) sleep under a mosquito net last night?

480C. Was the net (NAME) slept under last night purchased at the market or received free?

480D. How long ago did your household obtain the mosquito net?
IF MORE THAN 84 MONTHS, RECORD '95.' IF LESS THAN A MONTH, ENTER '00'.

480E. Since you got the mosquito net, was it soaked or dipped in a liquid to repel mosquitoes or bugs?

480F. How long ago was the net last soaked or dipped?
IF MORE THAN 84 MONTHS, RECORD '95.' IF LESS THAN A MONTH, ENTER '00'

480G. GO BACK TO 453 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 481

481. CHECK 453, ALL COLUMNS:
NUMBER OF LIVING CHILDREN BORN SINCE JANUARY 1995

482. The last time you fed your child(ren), did you wash your hands just before feeding?

483. The last time you cleaned (your child/any of your children) after he or she defecated, did you wash your hands immediately afterwards?

484. What do you generally with the stools of your (youngest) child when he/she does not use the toilet?

485. CHECK 475A, ALL COLUMNS:

486. Have you ever heard of a special product called [LOCAL NAME] that you can get to treat diarrhea?

487. CHECK 218:

488. When (your child/one of your children) is seriously ill, can you decide by yourself whether or not the child should be taken for medical treatment?

IF SAYS NO CHILD EVER SERIOUSLY ILL, ASK: If (your child/one of your children) became seriously ill, could you decide by yourself whether the child should be taken for medical treatment?

489. Now I would like to ask you some questions about medical care for yourself. Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem, a small problem, or not a problem?

491. Do you currently smoke cigarettes or tobacco?
IF YES: What do you smoke?
RECORD ALL MENTIONED

492. CHECK 491:

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

494. The last time you prepared a meal for your family, did you wash your hands before you started?

494A. Do you know how people get malaria in your community?

495. How can they get malaria?
RECORD ALL MENTIONED

496. What can a person do to avoid getting malaria?
RECORD ALL MENTIONED

497. How long does one need to take chloroquine to treat malaria?

498. CHECK 226:

498A. Have you suffered from a fever, at any time during the last two weeks?

498B. Did you take any drugs for the fever?

498C. What drugs did you take?
ASK TO SEE MEDICATION(S). IF NOT SEEN, SHOW MEDICATION(S) TO THE RESPONDENT.

RECORD ALL MENTIONED.

FOR EACH ANTI-MALARIAL, ASK:
How long after the fever started did (NAME) start taking (NAME OF MEDICINE)?

498D. How many times did you take this medicine?

498E. Did you sleep under a mosquito net last night?

498F. Was the net you slept under last night purchased at the market or received free?

498G. How long ago did you purchased or received the net?
IF MORE THAN 84 MONTHS, RECORD 95.

498H. Has the net been dipped or soaked in insecticide since you've had it?

498I. How long ago was the screen last dipped or soaked in insecticide?
IF MORE THAN 84 MONTHS, CODE 95

SECTION 5. MARRIAGE SEXUAL ACTIVITY

501. Are you currently married or living with a man?

502. Have you ever been married or lived with a man?

503. What is your marital status now: are you widowed, divorced, or separated?

505. Does your husband/partner live with you now, or is he living elsewhere?

506. RECORD THE NAME AND LINE NUMBER OF THE HUSBAND/PARTNER FROM THE HOUSEHOLD SCHEDULE. IF NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

506A. Does your husband /partner have other spouses/wives other than yourself?

506B. How many other wives does he have?

 506C. Are you the first, second,? wife?

507. Have you been married or lived with a man once or more than once?

508. CHECK 507:

MARRIED/LIVED WITH A MAN ONLY ONCE: In what month and year did you start living with your husband/partner?

MARRIED/LIVED WITH A MAN MORE THAN ONCE: Now, let's talk about your first husband/partner. In what month and year did you start living with him?

509. How old were you when you started living with him?

511. CHECK 501:

512. CHECK 311/311A:

513. You told me that you are currently using contraception. Would you say that the decision to use contraception is mainly yours, mainly your husband's/partner's decision, or have you decided together?

514. Now, I want to ask you some questions about sexual activity to better understand some of the problems of family life. How old were you when you had your first sexual intercourse (if ever)?

515. How long ago did you last have sex?
RECORD "NUMBER OF YEARS'' ONLY IF THE LATEST RELATIONS TOOK PLACE A YEAR AGO OR MORE.

516. The last time you had sex, was a condom used?

516A. What is the main reason you used a condom at that time?

517. What is your relationship with the man with whom you last had sexual intercourse?
IF "BOYFRIEND'' OR "FIANCÉ," ASK: Was your boyfriend/fiancé living with you last had sex with him?
IF "YES", RECORD '1'
IF "NO", RECORD '2'

518. When did you start having sexual relations with this man? Or for how long have you had sexual relations with this man?

519. In the past 12 months, have you had sex with anyone else?

520. The last time you had sex with another man, was a condom used?

520A. What was the main reason you used a condom at that time?

521. What is your relationship with this man?
IF "BOYFRIEND'' OR "FIANCÉ", ASK: Was your boyfriend/fiancé living with you when you last had sex with him?

IF "YES", RECORD '1'
IF "NO", RECORD '2'

522. For how long have you been having sex with this man? Or for how long did you have sex with this man?

522A. Apart from these two men did you have sex with someone else in the past 12 months?

522B. The last time you had sex with this other man, was a condom used?

522C. What is the main reason you used a condom at that time?

522D. What is your relationship with this man?
IF "BOYFRIEND OR "FIANCÉ'' ASK: Was your boyfriend/fiancé living with you when you last had sexual relations with him?
IF "YES", RECORD '1'
IF "NO", RECORD '2'

522E. For how long have you been having sex with this man? Or for how long did you have sex with this man?

523. In total, with how many different men have you had sex in the past 12 months?

524. Do you know of a place where one can get condoms?

525. Where is that? Anywhere else?

IF SOURCE IS A HOSPITAL, CLINIC, OR HEALTH CENTER, WRITE THE NAME OF THE PLACE. PROBE TO DETERMINE THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

RECORD ALL MENTIONED

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

530. Do you know of a place where one can go on foot and get condoms?

531. Where is that?

532. How long does it take to get to this place on foot?

SECTION 6. FERTILITY PREFERENCES

601. CHECK 311/311A:

602. CHECK 226:

NOT PREGNANT OR UNSURE: Now I have some questions about the future. Do you want to have a/another child, or would you prefer not to have a/another child?

PREGNANT: Now I have some questions about the future. After the child you are expecting, would you like to have another child or would you prefer not to have another child?

603. CHECK 226:

NOT PREGNANT OR UNSURE: How long would you wait from now before the birth of a/another child?

PREGNANT: After the birth of the child you are expecting, how long would you wait before the birth of another child?

604. CHECK 226:

605. CHECK 310:
USING A METHOD?

606. CHECK 603:

607. CHECK 602:

WANTS A/ANOTHER CHILD: You said that in the immediate future, you do not want to have a/another child, but you are not using a method to avoid pregnancy. Can you tell me why?

DOES NOT WANT A/ANOTHER CHILD: You said that you do not want to have a/another child, but you are not using a method to avoid pregnancy can you tell me why?

RECORD ALL MENTIONED

608. In the coming weeks, if you discover that you are pregnant, would it be a big problem, a small problem, or it would do be no problem?

609. CHECK 310:
USING A METHOD?

610. Do you think that in the future, you will use a method to delay or avoid pregnancy?

611. What method would you prefer to use?

612. What is the main reason you think that you will not use a method in the future?

613. Would you use a method if you were married?

614. CHECK 216:

HAS LIVING CHILDREN: If you could go back to when you did not have any children and could choose exactly the number of children to have in your life, how many would you have wanted?

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

PROBE FOR A NUMERICAL ANSWER

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

616. Would you say you approve or disapprove of young couples using a method to avoid getting pregnant?

617. In the past month, have you heard about family planning:

619. In the past month, have you discussed the practice of family planning with your friend(s), neighbor(s), or relative(s)?

620. With whom did you discuss it? Anyone else?
RECORD ALL MENTIONED

621. CHECK 501:

622. Now I want to talk about your husband's/partner's views on family planning. Do you think your husband/partner approves or disapproves of couples using a method to avoid pregnancy?

623. How many times in the past 12 months, have you discussed family planning with your husband/partner?

624. Do you think your husband/partner wants the same number of children as you, more, or less than you?

625. Husbands and wives do not always agree on everything. Please tell me if you think it is normal for a woman to refuse to have sex with her husband/partner when:

SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK

701. CHECK 501 AND 502:

702. How old was your husband/partner on his last birthday?

703. Did your (last) husband/partner ever attend school?

704. What is the highest level of school he attended: primary, post-primary, secondary, or higher?

705. What was the last (class/year) he completed at that level?

706. CHECK 701:

CURRENTLY MARRIED/LIVING WITH A MAN: What is the occupation of your husband/partner, that is, what kind of work does he mainly do?

WAS MARRIED/LIVED WITH A MAN: What was the occupation of your (last) husband/partner? That is to say, what kind of work did he mainly do?

707. Aside from your own housework, are you currently working?

708. As you know, some women have jobs for which they are paid in cash or kind. Others have a small business, or work on family land or in the family business. Do you do something like this or any other kind work?

709. Have you done any work in the past 12 months?

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

711. CHECK 710:

712. Do you work mostly on your own land, or on family land, or do you work on land that you rent, or are do you work on someone else's land?

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

714. Do you usually work throughout the year, seasonally, or only from time to time?

715. For this work, are you paid in cash, in kind, or are you not paid at all?

716. Who decides mainly how the money you earn will be used?

717. On average, how much of your household expenses are paid by what you earn: almost nothing, less than half, nearly half, more than half, or all?

718. Do you usually work at home or away from home?

719. In your family, who usually has the last word in the following decisions:

720. PRESENCE OF OTHERS AT THIS POINT (PRESENT AND LISTENING, PRESENT BUT NOT LISTENING, OR NOT PRESENT)

721. 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:

SECTION 8. HIV/AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES

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

802. Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?

803. What can be done? Anything else?
RECORD ALL MENTIONED

804. Can people reduce their chances of getting the AIDS virus by having just one sexual partner who has no other partners?

805. Can a person get the AIDS virus from mosquito bites?

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

807. Can a person contract the AIDS virus by sharing food with someone with AIDS?

808. Can people protect themselves from the AIDS virus by abstaining from sex completely?

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

811. Do you personally know someone who has the AIDS virus or someone who has died of AIDS?

812. Can the virus that causes AIDS be transmitted from mother to child?

813A. When can the virus that causes AIDS can be transmitted from mother to child?
Can it be transmitted:

814. CHECK 501:

815. Have you ever talked about ways to avoid contracting the AIDS virus with your (husband/live-in partner)?

815A. In your opinion, is it acceptable or unacceptable to talk about AIDS:

816. If a person learns that he or she is infected with the virus that causes AIDS, should that person be permitted to keep his condition a secret, or should the information be shared with the community?

817. If someone in your family contracted the virus that causes AIDS, would you be willing to take care of him/her in your own household?

817A. Should people with AIDS who work with other people in shops, offices, or on farms be allowed to continue their work or not?

817B. Should children aged 12 to 14 be educated on the use of condoms to avoid contracting AIDS?

817C. Have you ever been tested to see if you have the AIDS virus?

817D. Would you like to be tested for the AIDS virus?

817E. Do you know of a place where you could be tested for AIDS?

817F. Where can you go for this test?
817FX. Where did you go for this test?

IF SOURCE IS A HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO DETERMINE THE TYPE OF SOURCE AND CRICLE THE APPROPRIATE CODE.

RECORD ALL MENTIONED

818. (Apart from AIDS), have you heard of any (other) infections that can be transmitted by sexual contact?

819. If a man has a sexually transmitted disease, what symptoms might he have? Any others?
RECORD ALL MENTIONED.

820. If a woman has a sexually transmitted disease, what symptoms might she have? Any others?
RECORD ALL MENTIONED.

820A. CHECK 514:

820B. Now, I would like to ask you questions about your health in the past 12 months. In the past 12 months, have you had a sexually transmitted disease?

820C. Sometimes women can have vaginal discharge. In the past 12 months, have you had vaginal discharge?

820D. Sometimes women can have a genital sore or ulcer. In the past 12 months, have you had a genital sore or ulcer?

820E. CHECK 820B, 820C, 820D:

820F. The last time you had (INFECTION FROM 820B, 820C, 820D), did you seek advice or treatment?

820G. The last time you had (INFECTION FROM 820B, 820C, 820D) did you do any of the following? Did you:

820H. When you had (INFECTION FROM 820B, 820C, 820D), did you inform the person(s) with whom you have sex?

820I. When you had (INFECTION FROM 820B, 820C, 820D) did you do anything to avoid infecting your sexual partner(s)?

820J. What did you do to avoid infecting your partner(s)? Did you:

SECTION 9. MATERNAL MORTALITY

901. Now, I want to ask you questions about your brothers and sisters, that is, all the children born to your natural mother, including those who live with you, those who live elsewhere, and those who died. To how many children has your own mother given birth, including yourself?

902. CHECK 901:

903. How many of these births did your mother have before you were born?

904. What was the name given to your (next) oldest brother or sister?

905. Is (NAME) male or female?

906. Is (NAME) still alive?

907. How old is (NAME)?

908. How long ago did (NAME) die?

909. How old was (NAME) when he/she died?

910. Was (NAME) pregnant when she died?

911. Did (NAME) die in childbirth?

912. Did (NAME) die in the two months following the end of pregnancy or of a birth?

913. How many live children did (NAME) give birth to in her lifetime (before this pregnancy)?

IF NO MORE BROTHERS OR SISTERS, GO TO 914

914. RECORD THE TIME

INSTRUCTIONS: ONLY ONE CODE SHOULD APPEAR IN ANY BOX.

BIRTHS AND PREGNANCIES

END OF LAST PREGNANCY THAT DID NOT END IN A LIVE BIRTH BEFORE JANUARY 1994:
IF THERE WAS NO SUCH PREGNANCY, RECORD '00' FOR THE MONTH AND '0000' FOR THE YEAR

1999

1998

1997

1996

1995

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:___

COMMENTS ON SPECIFIC QUESTIONS:____

ANY OTHER COMMENTS:___

SUPERVISOR'S OBSERVATIONS___

NAME OF SUPERVISOR:___
DATE:____

EDITOR'S OBSERVATIONS___

NAME OF EDITOR:____
DATE:____