NATIONAL INSTITUTE OF STATISTICS RWANDA

IDENTIFICATION

VILLAGE NAME

NAME OF HOUSEHOLD HEAD

PROVINCE

DISTRICT

CLUSTER NUMBER

STRUCTURE NUMBER

HOUSEHOLD NUMBER

URBAN/RURAL

CITY OF KIGALI/OTHER CITY/RURAL

NAME AND LINE NUMBER OF WOMAN

INTERVIEWER VISITS

FIRST VISIT
DATE
NAME OF THE INTERVIWER
RESULT*

NEXT VISIT:
DATE
HOURS

SECOND VISIT
DATE
NAME OF THE INTERVIEWER
RESULT*

NEXT VISIT:
DATE
HOURS

THIRD VISIT
DATE
NAME OF THE INTERVIWER
RESULT*

FINAL VISIT
DAY
MONTH
YEAR
CODE
RESULT

TOTAL NUMBER OF VISITS

*RESULT CODES:

LANGUAGE OF INTERVIEW

WAS A TRANSLATOR USED?

SUPERVISOR
NAME
DATE

FIELD EDITOR
NAME
DATE

OFFICE EDITOR

KEYED BY

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is ____________________________. I am working with the National Institute of Statistics of Rwanda. We are conducting a national survey that asks women and men about various health issues. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes between 10 and 15 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 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 questions; or you can stop the interview at any time. However, we hope that you will participate in this survey since your views are important. I should add that in the coming few months someone from our office will probably come back to ask additional questions on health of children.
At this time, do you want to ask me anything about this survey?
May I begin the interview now?
Signature of interviewer: _______________________________ Date: _____________________

100) RECORD THE TIME

HOURS
MINUTES

102) In what month and year were you born?

102) How old were you at your last birthday? COMPARE AND CORRECT 101 AND/OR 102 IF INCONSISTENT.

103) Have you ever attended school?

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

105) What is the highest grade/year you completed at that level?

106) What is your religion?

107) Are you currently married or living together with a man as if married?

108) Have you ever been married or lived together with a man as if married?

109) What is your marital status now: are you widowed, divorced, or separated?

110) Is your husband/partner living with you now or is he staying elsewhere?

SECTION 2. REPRODUCTION

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

202) Do you have any sons or daughters to whom you have given birth who are now living with you?

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

204) Do you have any sons or daughters to whom you have given birth 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 alive but do not live with you? IF NONE, RECORD '00.'

206) Have you ever given birth to a boy or girl 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: Just to make sure that I have this right: you have had in total _____ births during your life. Is that correct?

210) CHECK 208:

211) Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.

RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.)

212) What was the name given to your (first/next) baby? RECORD NAME.
NAME ____________

213) Were any of these births twins?

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

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

216) Is (NAME) still alive?

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

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

219) IF ALIVE: RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD).

LINE NUMBER ________

220) IF DEAD: How old was (NAME) when he/she died? IF '1 YR,' PROBE: How many months old was (NAME)? RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

221) Were there any other lives births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth?

222) Have you had any live births since the birth of (NAME OF LAST BIRTH)? IF YES, RECORD BIRTH(S) IN TABLE.

223) COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

NUMBERS ARE SAME

CHECK: FOR EACH BIRTH: YEAR OF BIRTH IS RECORDED.
FOR EACH BIRTH SINCE JANUARY 2002: MONTH AND YEAR OF BIRTH ARE RECORDED.
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED.
FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED

NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

224) CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2002 OR LATER. IF NONE, RECORD '0' AND SKIP TO 226.

225) Are you pregnant now?

226) How many months pregnant are you?

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.

301) Which ways or methods have you heard about? (1)
FOR METHODS NOT HEARD OF SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?

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

302) Have you ever used (METHOD)?

Have you ever used any other ways or methods that women or men can use to avoid pregnancy?

303) CHECK 302:

304) Have you ever used anything or tried in any way to delay or avoid getting pregnant?

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

306) CHECK 302 (METHOD 1):

307) CHECK 225:

308) Are you currently doing something or using any method to delay or avoid getting pregnant?

309) Which method are you using? CIRCLE ALL MENTIONED.
309A) CIRCLE 'A' FOR FEMALE STERILIZATION.

IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.

310) In what facility did the sterilization take place?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

IN UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE

311) CHECK 309/309A:

CIRCLE METHOD CODE:

IF MORE THAN ONE METHOD CODE CIRCLED IN 309/309A, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

312) Where did you obtain (CURRENT METHOD) when you started using it?
312A) Where did you learn how to use the rhythm/lactational amenorrhea method?
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC IF PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

313) CHECK 309/309A:

NEITHER STERILIZED (GO TO 314)
HE OR SHE STERILIZED (GO TO 325)

314) CHECK 225

NOT PREGNANT OR UNSURE: 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?

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

315) CHECK 225:

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

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

316) CHECK 225:

317) CHECK 308: USING A CONTRACEPTIVE METHOD?

318) CHECK 315:

319) CHECK 314: RECORD ALL REASONS MENTIONED

WANTS TO HAVE A/ANOTHER CHILD: You have said that you do not want (a/another) child soon, but you are not using any method to avoid pregnancy.

Can you tell me why you are not using a method?

Any other reason?

WANTS NO MORE/NONE: You have said that you do not want any (more) children, but you are not using any method to avoid pregnancy.

Can you tell me why you are not using a method?

Any other reason?

320) CHECK 309: USING A CONTRACEPTIVE METHOD?

321) Do you think you will use a contraceptive method to delay or avoid pregnancy at any time in the future?

322) What method do you prefer to use?

323) What is the main reason that you think you will not use a contraceptive method at any time in the future?

324) Would you ever use a contraceptive method if you were married?

325) CHECK 216: PROBE FOR A NUMERIC RESPONSE

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?

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

326) 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 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

402) CHECK 215: ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2002 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS 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 212

LINE NO. _________

404) FROM 212 AND 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 any (more) children at all?

406) How much longer would you have liked to wait?

407) Did you see anyone for antenatal care for this pregnancy?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
[FOR LAST BIRTH ONLY]

408) Where did you receive antenatal care for this pregnancy?
Anywhere else?

PROBE TO IDENTIFY TYPE(S) OF SOURCE(S) AND CIRCLE THE APPROPRITATE CODE(S).

IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

409) How many months pregnant were you when you first received antenatal care for this pregnancy?

410) How many times did you receive antenatal care during this pregnancy?

411) As part of your antenatal care during this pregnancy, were any of the following done at least once?

412) During (any of) your antenatal care visit(s), were you told about the signs of pregnancy complications?
[FOR LAST BIRTH ONLY]

413) Were you told where to go if you had any of these complications?
[FOR LAST BIRTH ONLY]

414) 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]

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

416) CHECK 415:
[FOR LAST BIRTH ONLY]

417) At any time before this pregnancy, did you receive any tetanus injections, either to protect yourself or another baby?
[FOR LAST BIRTH ONLY]

418) Before this pregnancy, how many other times did you receive a tetanus injection?
IF 7 OR MORE TIMES, RECORD '7.'
[FOR LAST BIRTH ONLY]

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

422) During the whole pregnancy, for how many days did you take the tablets or syrup? IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.
[FOR LAST BIRTH ONLY]

423) During this pregnancy, did you take any drug for intestinal worms?
[FOR LAST BIRTH ONLY]

424) During this pregnancy, did you have any difficulty with your vision during daylight?
[FOR LAST BIRTH ONLY]

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

425A) During this pregnancy, did you have the fever?
[FOR LAST BIRTH ONLY]

425B) In which trimester did you have the fever?
[FOR LAST BIRTH ONLY]

426) During this pregnancy, did you take any drugs to keep you from getting malaria?
[FOR LAST BIRTH ONLY]

427) What drugs did you take? RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.
[FOR LAST BIRTH ONLY]

428) CHECK 427: DRUGS TAKEN FOR MALARIA PREVENTION.
[FOR LAST BIRTH ONLY]

429) How many times did you take (SP/Fansidar) during this pregnancy?
[FOR LAST BIRTH ONLY]

430) CHECK 407: ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY
[FOR LAST BIRTH ONLY]

431) Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility or from another source?
[FOR LAST BIRTH ONLY]

435) Who assisted with the delivery of (NAME)?
Anyone else?

PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED. IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

436) Where did you give birth to (NAME)? (2)

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

(NAME OF PLACE) ___________

437) Did the mutuelle pay for the delivery of (NAME)?

460) Did you ever breastfeed (NAME)?

461) How long after birth did you first put (NAME) to breast?

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

462) In the first three days after delivery, was (NAME) given anything to drink other than breast milk?

463) What was (NAME) given to drink?
Anything else?
RECORD ALL LIQUIDS MENTIONED.

464) CHECK 404: IS CHILD LIVING?

465) Are you still breastfeeding (NAME)?

466) For how many months did you breastfeed (NAME)?

SECTION 5. VACCINATION OF CHILDREN AND HEALTH AND NUTRITION OF WOMEN AND CHILDREN

501) ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2002 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES.)

502) LINE NUMBER FROM 212

LINE NUMBER ________

503) FROM 212 AND 216

504) Do you have a card where (NAME'S) VACCINATIONS ARE WRITTEN DOWN? (2)
IF YES: May I see it please?

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

506)
(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.
(3) IF MORE THAN TWO VITAMIN 'A' DOSES, RECORD DATES FOR MOST RECENT AND SECOND MOST RECENT DOSES.

507) 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 MEALSES VACCINES.

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

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

509A) A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

509B) Polio vaccine, that is, drops in the mouth?

509C) Was the first polio vaccine received in the first two weeks after birth or later?

509D) How many times was the polio vaccine received?

509E) A DPT vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same times as polio drops?

509F) How many times was a DPT vaccination received?

509G) A measles injection or an MMR injection--that is, a shot in the arm at the age of 9 months or older--to prevent him/her from getting measles?

512) CHECK 506: DATE SHOWN FOR VITAMIN A DOSE

513) According to (NAME'S) health card, he/she received a vitamin A dose (like this/any of these) in (MONTH AND YEAR OF MOST RECENT DOSE FROM CARD). Has (NAME) received another vitamin A dose since then? SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS.

514) Has (NAME) ever received a vitamin A dose (like this/any of these)? SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS.

515) Did (NAME) receive a vitamin A dose within the last six months?

516) In the last seven days, did (NAME) take iron pills, sprinkles with iron, or iron syrup (like this/any of these)? SHOW COMMON TYPES OF PILLS/SPRINKLES/SYRUPS.

517) Has (NAME) taken any drug for intestinal worms in the last six months?

518) Has (NAME) had diarrhea in the last 2 weeks? (6)

519) Was there any blood in the stools?

520) Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk).

Was he/she given less than the usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was he/she given much less to drink or somewhat less?

521) When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?

IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

522) Did you seek advice or treatment for the diarrhea from any source?

523) Where did you seek advice or treatment? Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) ______________

524) CHECK 523:

525) Where did you first seek advice or treatment? USE LETTER CODE FROM 523.

526) How many days after the diarrhea began did you first seek advice or treatment for (NAME)? IF THE SAME DAY, RECORD '00.'

527) Does (NAME) still have diarrhea?

528) Was he/she given any of the following to drink at any time since he/she started having diarrhea?

529) Was anything (else) given to treat the diarrhea?

530) What (else) was given to treat the diarrhea? Anything else? RECORD ALL TREATMENTS GIVEN.

531) CHECK 530: GIVEN ZINC?

532) How many times was (NAME) given zinc?

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

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

535) When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?

536) Was the fast or difficult breathing due to a problem in the chest or to a blocked or runny nose?

537) CHECK 533: HAD FEVER OR COUGH?

538) Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). Was he/she given less than usual to drink, about the same amount, or more than usual to drink?

IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

539) When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?

IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

540) Did you seek advice or treatment for the illness from any source?

541) Where did you seek advice or treatment? Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE HERE.

(NAME OF PLACE(S)) ____________

542) CHECK 541:

543) Where did you first seek advice or treatment? USE LETTER CODE FROM 541.

544) How many days after the illness began did you first seek advice or treatment for (NAME)? IF THE SAME DAY, RECORD '00.'

545) Is (NAME) still sick with a (fever/cough)?

546) At any time during the illness, did (NAME) take any drugs for the illness?

547) What drugs did (NAME) take? Any other drugs? RECORD ALL MENTIONED.

548) CHECK 547: ANY CODE A-E CIRCLED?

549) Did you already have (NAME OF DRUG FROM 547) at home when the child became ill? (10)
ASK SEPARATELY FOR EACH OF THE DRUGS 'A' THROUGH 'E' THAT THE CHILD IS RECORDED AS HAVING TAKEN IN 547. IF YES FOR ANY DRUG, CIRCLE CODE FOR THAT DRUG. IF NO FOR ALL DRUGS, CIRCLE 'Y.'

569) CHECK 547: OTHER ANTIMALARIAL ('D') GIVEN

570) How long after the fever started did (NAME) first take (OTHER ANTIMALARIAL)?

571) For how many days did (NAME) take the (OTHER ANTIMALARIAL)? IF 7 DAYS OR MORE, RECORD 7.

572) Is (NAME) covered by the mutuelle when he is sick and you have to take him to a health facility for treatment?

573) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, END OF INTERVIEW AND GO TO 547.

574) 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 OBSERVATIONS: ___________

NAME OF SUPERVISOR: _________
DATE: _________

EDITOR'S OBSERVATIONS: ______________

NAME OF EDITOR: _________
DATE: __________