Ministry of Planning
Ministry of Health and Social Action
ICF

IDENTIFICATION

PLACE NAME ________
NAME OF HEAD OF HOUSEHOLD _________
HOUSEHOLD NUMBER __________
PLOT NUMBER ___________
CLUSTER NUMBER ____________
REGION_________
DEPARTMENT________
SANITARY DISTRICT _________

URBAN/RURAL

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

WOMAN'S NAME AND LINE NUMBER ______________

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_________
INTERVIEWER'S NAME___________
RESULT* ___

RESULT*

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE ___
TIME ____

FINAL VISIT
DAY ____
MONTH ____
YEAR 201__
INT. NUMBER_____
RESULT* _____

TOTAL NUMBER OF VISITS ______

LANGUAGE OF QUESTIONNAIRE

LANGUAGE OF INTERVIEW

INTERPRETER?

SUPERVISOR
NAME ___________
DATE ____________

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is ___. I am working with the National Agency for Statistics and Demography in collaboration with the Ministry of Health and Social Action. We are conducting a survey about health all over Senegal. 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 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. 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.

In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.

Do you have any questions?
May I begin the interview?

101) RECORD THE TIME

102) In what month and year were you born?

103) How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT

104) Have you ever attended school?

105) What is the highest level of school you attended: primary, secondary 1, secondary 2, or higher?

106) What is the highest (grade/form/year) you completed at this level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 00

107) CHECK 105:

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

108A) Have you ever participated in a literacy program or any other program that included learning how to read and right (not including primary school)?

108B) In what languages were these literacy programs?
PROBE: Any other?
RECORD ALL MENTIONED

109) CHECK 108:

110) Do you read a newspaper, the Internet, or a magazine at least once a week, less than once a week or not at all?

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

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

113) What is your religion?

114A) Are you Senegalese?

114) What is your ethnicity?

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

116) 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 you 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 live with you?
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 makes 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 ROWS. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.)

212) What name was given to you (first/next) baby?
BIRTH HISTORY NUMBER

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

214) Were any of these births twins?

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)

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 live births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth?

[##translator note: same questions repeated on next page, with 08-12 in q. 212 for larger families]

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

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

224) CHECK 215:
ENTER THE NUMBER OF BIRTHS IN 2009 OR LATER.

224A) CHECK 217:
CURRENT AGE

224B) Who participates most often in (NAME FROM 224A)'s activities?

224C) What are these activities?

225) FOR EACH BIRTH SINCE JANUARY 2009, ENTER B IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE CODE B FOR EACH BIRTH. ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD P IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF THE PREGNANCY. (NOTE: THE NUMBER OF PS MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226) Are you pregnant now?

227) How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS. ENTER PS IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

228) When you got pregnant, did you want to get pregnant at that time?

229) Did you want to have a baby later on or did you not want any (more) children?

230) Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?

231) When did the last such pregnancy end?

232) CHECK 231:

233) How many months pregnant were you when the last such pregnancy ended?
RECORD THE NUMBER OF COMPLETED MONTHS. ENTER T IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND P FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

234) Since January 2009, have you had any other pregnancies that did not result in a live birth?

235) ASK THE DATE AND DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2009. ENTER T IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND P FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236) Did you have any miscarriages, abortions or stillbirths that ended before 2009?

237) When did the last such pregnancy that terminated before 2009 end?

238) When did you last menstrual period start?

239) From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant?

240) 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

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) CHECK 226:

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

303A) Why are you not using something or a contraceptive method to delay or prevent a pregnancy?

304) Which method are you using?

CIRCLE ALL MENTIONED.

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

305) What is the brand name of the pills you are using?
IF DON'T KNOW BRAND, ASK TO SEE THE PACKAGE.

306) What is the brand name of the condoms you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

307) In what facility did the sterilization take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

308) In what month and year was the sterilization performed?
308A) Since what month and year did you start using (CURRENT METHOD) without stopping?
PROBE: FOR HOW LONG HAVE YOU BEEN USING (CURRENT METHOD FIRST MENTIONED) NOW WITHOUT STOPPING?

309) CHECK 308/308A, 215, 231:
ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 308/308A.

310) CHECK 308/308A:

311) I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.
USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2009
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

IN COLUMN 1, ENTER METHOD USE CODE OR 0 FOR NONUSE IN EACH BLANK MONTH.
Illustrative questions:

IN COLUMN 2, ENTER CODES FOR DISCONTINUATION NEXT TO THE LAST MONTH OF USE. NUMBER OF CODES IN COLUMN 2 MUST BE THE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1.

ASK WHY SHE STOPPED USING THE METHOD. IF PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT.

Illustrative questions:

312) CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH.

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

314) CHECK 304:

CIRCLE METHOD CODE.

IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

315) You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time?
315A) Where did you learn how to use the cycle beads/rhythm/lactational amenorrhea method?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

316) CHECK 304:

CIRCLE METHOD CODE:

IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

317) At that time, where you told about side effects or problems you might have with the method?
317A) When you got sterilized, were you told about side effects or problems you might have with the method?

318) Were you ever told by a health or family planning worker about side effects or problems you might have with the method?

319) Were you told what to do if you experienced side effects or problems?

320) CHECK 317:

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

CODE '1' NOT CIRCLED: When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?

321) Were you ever told by a health or family planning worker about other methods of family planning that you could use?

322) CHECK 304:

CIRCLE METHOD CODE.

IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

323) Where did you obtain (CURRENT METHOD) the last time?
PROBE TO IDENTITY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

324) Do you know of a place where you can obtain a method of family planning?

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

326) In the last 12 months, were you visited by a fieldworker who talked to you about family planning?

327) In the last 12 months, have you visited a health facility for care for yourself (or your children)?

328) Did any staff member at the health facility speak to you about family planning methods?

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2009 OR LATER. ASK THE QUESTIONS ABOUT ALL 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 some questions about your children born in the last five years. (We will talk about each separately).

403) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

404) FROM 212 AND 216

405) When you got pregnant with (NAME), did you want to become pregnant at that time?

406) Did you want to have a baby later on, or did you not want any (more) children?

407) How much longer did you want to wait?

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

409) Whom did you see? Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

410) Where did you receive this antenatal care for this pregnancy? Anywhere else?
PROBE TO IDENTITY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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

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

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

Was your blood pressure measured?
Did you give a urine sample?
Did you give a blood sample?

414) During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy?

415) During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?

416) During this pregnancy, how many times did you get a tetanus injection?

417) CHECK 416:

418) At any time before this pregnancy, did you receive any tetanus injections?

419) Before this pregnancy, how many times did you receive a tetanus injection?
IF 7 OR MORE TIMES, RECORD '7'

420) How many years ago did you receive the last tetanus injection before this pregnancy?

"">421) During this pregnancy, were you given or did you buy iron tablets or iron syrup?
SHOW TABLES/SYRUP

421A) From where were the iron tablets or the iron syrup purchased or obtained?
PROBE TO IDENTITY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

422) During the whole pregnancy, for how many days did you take the tables or syrup?
IF ANSWER NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

423) During this pregnancy, did you take any drug for intestinal worms?

424) During this pregnancy, did you take any drugs to keep you from getting malaria?

425) What drugs did you take?
RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

426) CHECK 425:
SP/FANSIDAR TAKEN FOR MALARIA PREVENTION

427) How many times did you take (SP/Fansidar) during this pregnancy?

427A) During this pregnancy, did you receive a free mosquito net during a antenatal exam?

428) CHECK 409:
ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

429) Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility, or from another source?

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

431) Was (NAME) weighed at birth?

432) How much did (NAME) weigh?
RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE

432a) Was (NAME)'s birth ever declared?

433) Who assisted with the delivery of (NAME)? Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS ASSISTING. IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

434) Where did you give birth to (NAME)?
PROBE TO IDENTITY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

435) Was (NAME) delivered by caesarean, that is, did they cut your belly open to take the baby out?

436) After you delivered (NAME), did anyone check on your health while you were still in the facility?

437) Did anyone check on your health after you left the facility?

438) Did anyone check on your health after you gave birth to (NAME)?

439) Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.

440) How long after delivery did the first check take place?
IF LESS THAN ONE DAY, RECORD IN HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

441) CHECK 437:

442) In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health?

443) How many hours, days, or weeks after the birth of (NAME) did the first check take place?
IF LESS THAN ONE DAY, RECORD IN HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

444) Who checked on (NAME)'s health at that time?
PROBE FOR THE MOST QUALIFIED PERSON.

445) Where did this first check of (NAME) take place?
PROBE TO IDENTITY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

446) In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)?
SHOW COMMON TYPES OF AMPOULES/CAPSULES/SYRUPS

447) Has your menstrual period returned since the birth of (NAME)?

448) Did your period return between the birth of (NAME) and your next pregnancy?

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

450) CHECK 226:
IS RESPONDENT PREGNANT?

451) Have you had sexual intercourse since the birth of (NAME)?

452) For how many months after the birth of (NAME) did you not have sexual intercourse?

453) Did you ever breastfeed (NAME)?

454) CHECK 404:
CHILD IS LIVING?

455) 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

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

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

458) CHECK 404:
IS CHILD LIVING?

459) Are you still breastfeeding (NAME)?

459A) For how many months did you breastfeed (NAME)?

459B) CHECK 404:
IS CHILD LIVING?

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

461) (GO BACK TO 405 IN NEXT COLUMN, OR, IF NO MORE BIRTHS, GO TO 501)

SECTION 5. CHILD HEALTH AND IMMUNIZATION

501) ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2009 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) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

503) FROM 212 AND 216

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

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

506)
1) COPY DATES FROM THE CARD
2) WRITE 44 IN DAY COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

507) CHECK 506:

508) Has (NAME) received any vaccines that are not recorded on this card, including vaccinations received in a national immunization day campaign?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 506 THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

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

510) Please tell me if (NAME) had any of the following vaccinations:

510A) A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

510B) Polio vaccine, that is, two drops in the mouth?

510C) Was the first polio vaccine given in the first two weeks after birth or later?

510D) How many times was the polio vaccine given?

510D) A pentavalent vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops?

510F) How many times was the pentavalent vaccination given?

510G) An 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?

510H) A yellow fever vaccination?

511) Within the last six months, was (NAME) given a vitamin A dose like (this/any of these)?
SHOW COMMON TYPES OF AMPOULES/CAPSULES/SYRUPS.

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

513) Was (NAME) given any drug for intestinal worms in the last six months?

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

515) Was there any blood in the stools?

516) Now I would like to know how much (Name) was given to drink during the diarrhea (including breastmilk). 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?

517) 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?

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

519) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

520) CHECK 519:

521) Where did you first seek advice or treatment?

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

a) A fluid made from a special packet called (local name for ORS packet)?
b) A pre-packaged ORS liquid?
c) A government-recommended homemade fluid?

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

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

524a) If you child had diarrhea, what would you have done?
RECORD ALL MENTIONED.

524b) Can you list the advantages of using ORS/Zinc for the treatment of diarrhea?
RECORD ALL MENTIONED.

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

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

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

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

530) CHECK 525:
HAD FEVER?

531) 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?

532) 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?

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

534) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

535) CHECK 534:

536) Where did you first seek advice or treatment?

536A) At any time during his/her illness, did someone take blood from his/her finger or heal?

536B) Did someone perform a malaria diagnostic test on (NAME)?

536c) What was the result?

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

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

539) CHECK 538:
ANY CODE A-E CIRCLED?

540) CHECK 538:
ACT (A) GIVEN

541) How long after the fever started did (NAME) first take ACT?

542) CHECK 538:
QUININE (B) GIVEN

543) How long after the fever started did (NAME) first take Quinine?

544) CHECK 538:
AMODIAQUINE (C) GIVEN

545) How long after the fever started did (NAME) first take Amodiaquine?

546) CHECK 538:
SF/FANSIDAR (D) GIVEN

547) How long after the fever started did (NAME) first take SF/Fansidar?

550) CHECK 538:
OTHER ANTIMALARIAL (E) GIVEN

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

552) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553.

553) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2009 OR LATER LIVING WITH THE RESPONDENT

554) The last time (NAME FROM 553) passed stools, what was done to dispose of the stools?

555) CHECK 522A AND 522B, ALL COLUMNS:

556) Have you ever heard of a special product called [local name for ORS packet or pre-packaged ORS liquid] you can get for the treatment of diarrhea?

557) CHECK 215 AND 218, ALL ROWS:

558) Now I would like to ask you about liquids or foods that (name from 557) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods.

Did (name from 557) (drink/eat):

559) CHECK 558 (CATEGORIES G THROUGH U)

560) Did (NAME) eat any solid, semi-solid or soft foods yesterday during the day or at night?
IF YES, PROBE: What kind of solid, semi-solid, or soft foods did (NAME FROM 557) eat?

561) How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD 7

[##translator note: questions 563 and 564 crossed out on French document and not available on standard English version, not translated]

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

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

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

603) What is your current marital status: are you a widow, divorced, or separated?

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

605) RECORD THE LINE NUMBER OF HER HUSBAND/PARTNER ACCORDING TO THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT A LISTED IN THE HOUSEHOLD, RECORD '00'.

606) Does your husband/partner have other wives or does he live with other women as if married?

607) Including yourself, in total how many wives or live-in partners does he have?

608) Are you the first, second?wife?

609) Have you been married or have you lived with a man only once or more than once?

610) CHECK 609:

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

MARRIED/LIVED WITH MAN MORE THAN ONCE: Now I would like to talk about your first (husband/partner). In what month and year did you start living with him?

611) How old were you when you first started living with him?

612) CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

613) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues.

How old were you when you had sexual intercourse for the very first time?

613A) How old was your partner?

613B) Did you use a condom (male or female)?

614) Now I would like to ask you some questions about your recent sexual activity. 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.

615) 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.

616) When was the last time you had sexual intercourse with this person?

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

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

619) What was your relationship to this person with whom you had sexual intercourse?
IF BOYFRIEND: Were you living together as if married?
IF YES, CIRCLE 2. IF NO, CIRCLE 3

620) CHECK 609:

621) CHECK 613

622) How long ago did you first have sexual intercourse with this (second/third) person?

623) 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 96 OR MORE, WRITE 95.

624) How old is this person?

625) Apart from (this person/these two people), have you had sexual intercourse with any other persons in the last 12 months?

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

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

628) PRESENCE OF OTHERS DURING THIS SECTION

629) Do you know of a place where a person can get male condoms?

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

631) If you wanted to, could you yourself get a male condom?

632) Do you know of a place where a person can get female condoms?

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

634) If you wanted to, could you yourself get a female condom?

SECTION 7. FERTILITY PREFERENCES

701) CHECK 304:

702) CHECK 226:

703) 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?

704) Now I have some question about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

705) CHECK 226:
NOT PREGNANT OR NOT SURE: How long would you like to wait from now before the birth of (a/another) child?

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

706) CHECK 226:

707) CHECK 303:
USING A CONTRACEPTIVE METHOD?

708) CHECK 705:
NOT ASKED

709) CHECK 704:
WANTS TO HAVE A/ANOTHER CHILD: You have said that you do not want (a/another) child soon. Can you tell me why you are not using a method to prevent pregnancy?

Any other reason?

WANTS NO MORE/NONE: You have said that you do not want any (more) children. Can you tell me why you are not using a method to prevent pregnancy?

Any other reason?
RECORD ALL REASONS MENTIONED.

710) CHECK 303:
USING A CONTRACEPTIVE METHOD?

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

712) CHECK 216:
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?

PROBE FOR A NUMERIC RESPONSE.

713) 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?

714) In the last few months have you:

715) COUNTRY-SPECIFIC QUESTIONS ON MEDIA MESSAGES ABOUT FAMILY PLANNING

716) CHECK 601:

717) CHECK 303:
USING A CONTRACEPTIVE METHOD?

718) Would you say that using contraception is mainly your decision, mainly your (husband's/partner's) decision, or did you both decide together?

719) CHECK 304:

720) Does your (husband/partner) want the same number of children that you want, or does he want more or fewer than you want?

SECTION 8. HUSBAND'S BACKGROUND AND WOMAN'S WORK

801) CHECK 601 AND 602:

802) How old was your (husband/partner) on his last birthday?

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

804) What is the highest level of school you attended: Primary, Secondary, or higher?

805) What is the highest (grade/form/year) you completed at this level?*
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 0

806) CHECK 801:

CURRENTLY MARRIED/LIVING WITH A MAN: What is your (husband's/partner's) occupation? That is, what kind of work does he mainly do?

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

807) Aside from your own housework, have you done any work in the last seven days?

808) As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work?

809) 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, maternity leave, or any other such reason?

810) Have you done any work in the last 12 months?

811) What is your occupation, that is, what kind of work do you mainly do?

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

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

814) Are you paid or do you ear in cash or in kind for this work or are you not paid at all?

815) CHECK 601:

816) CHECK 814:

817) Who usually decides how the money you earn will be used: you, your (husband/partner), or you and your (husband/partner) jointly?

818) Would you say that the money that you earn is more than what your (husband/partner) earns, less than what he earns, or about the same?

819) Who usually decides how the money your (husband/partner) earnings will be used: you, your (husband/partner), or you and your (husband/partner) jointly?

820) Who usually makes decisions about health care for yourself: you, your (husband/partner), you and your (husband/partner) jointly, or someone else?

821) Who usually makes decisions about making major household purchases?

822) Who usually makes decisions about visits to your family or relatives?

823) Do you own this or any other house either alone or jointly with someone else?

824) Do you own any land either alone or jointly with someone else?

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

826) In your opinion, is a husband justified in hitting or beating his wife in the following situations:

If she goes out without telling him?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

SECTION 9. HIV/AIDS

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

902) Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

903) Can people get the AIDS virus from mosquito bites?

904) Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?

905) Can people get the AIDS virus by sharing food with a person who has AIDS?

906) Can people get the AIDS virus because of witchcraft or other supernatural means?

907) Is it possible for a healthy-looking person to have the AIDS virus?

908) Can the virus that causes AIDS be transmitted from a mother to a baby?

909) CHECK 908:

910) Are there any special drugs that a doctor or a nurse can give to a woman infected with the AIDS virus to reduce the risk of transmission to the baby?

911) CHECK 208 AND 215:

912) CHECK 408 FOR LAST BIRTH

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

914) During any of the antenatal visits for your last birth were you given any information about:

915) Were you offered a test for that AIDS virus as part of your antenatal care?

916) Were you tested for the AIDS virus as part of your antenatal care?

917) 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.

918) Did you get the results of the test?

919) All women are supposed to receive counseling after being tested. After you were tested, did you receive counseling?

920) CHECK 434 FOR LAST BIRTH

921) Between the time you went for delivery but before the baby was born, were you offered a test for the AIDS virus?

922) I don't want to know the results, but were you tested for the AIDS virus at that time?

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

924) Have you been tested for the AIDS virus since that time you were tested during your pregnancy?

925) How many months ago was your most recent HIV test?

926) I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?

927) How many months ago was your most recent HIV test?

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

929) 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

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

931) 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

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

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

934) If a member of your family became sick with the virus that causes AIDS, would you be willing to care for her or him in your own household?

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

936) Should children age 12-14 be taught about using a condom to avoid getting AIDS?

937) CHECK 901:

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

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

938) CHECK 613:

939) CHECK 937:
HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

940) 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?

941) Sometimes women experience a bad-smelling abnormal genital discharge. During the last 12 months, have you had a bad-smelling abnormal genital discharge?

942) Sometimes women have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?

943) CHECK 940, 941, AND 942:

944) The last time you had (INFECTION FROM 940/941/942), did you seek any kind of advice or treatment?

945) 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

946) 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?

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

948) CHECK 601:

949) Can you say no to your (husband/partner) if you do not want to have sexual intercourse?

950) Could you ask your (husband/partner) to use a condom if you wanted him to?

SECTION 10. FEMALE GENITAL CUTTING

1001) Have you ever heard of female circumcision?

1002) In some countries, there is a practice in which a girl may have part of her genitals cut. Have you ever heard about this practice?

1003) Have you yourself ever been circumcised?

1004) Now I would like to ask you what was done to you at that time. Was any flesh removed from the genital area?

1005) Was the genital area just nicked without removing any flesh?

1006) Was your genital area sewn closed?

1007) How old were you when you were circumcised?
IF THE RESPONDENT DOES NOT KNOW THE EXACT AGE, PROBE TO GET AN ESTIMATE.

1008) Who performed the circumcision?

1009) CHECK 213, 215 AND 216:

CHECK 213, 215, 216: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER AND NAME OF EACH LIVING DAUGHTER BORN IN 1998 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE DAUGHTERS. BEGIN WITH THE YOUNGEST DAUGHTER. (IF THERE ARE MORE THAN 6 DAUGHTERS, USE ADDITIONAL QUESTIONNAIRES).

Now I would like to ask you some questions about your (daughter/daughters).

1010) BIRTH HISTORY NUMBER AND NAME OF EACH LIVING DAUGHTER BORN IN 1999 OR LATER

1011) Is (NAME OF DAUGHTER) circumcised?

1012) How old was (NAME OF DAUGHTER) when she was circumcised?
IF THE RESPONDENT DOES NOT KNOW THE AGE, PROBE TO GET AN ESTIMATE.

1013) Was her genital area sewn closed?
PROBE: WAS THE GENITAL AREA CLOSED?

1014) Who performed the circumcision?

1015) GO BACK TO 1011 IN NEXT COLUMN; OR, IF NO MORE DAUGHTERS, GO TO 1016

=[##translator note: Questions 1011-1015 repeated on next page to accommodate families with more than 3 daughters]

1016) Do you believe that female circumcision is required by your religion?

1017) Do you think that female circumcision should be continued, or should it be stopped?

1018) 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:

Editor's observations

Instructions:
Only one code should appear in any box
Column 1 requires a code in every month.

Information to be coded for each column.

2014*
12 Dec 01
11 Nov 02
10 Oct 03
09 Sept 04
08 Aug 05
07 Jul 06
06 Jun 07
05 May 08
04 Apr 09
03 Mar 10
02 Feb 11
01 Jan 12

[##translator note: repeated for each year]
2013
2012
2011
2010
2009

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE**

B BIRTH
P PREGNANCIES
T TERMINATIONS

0 NO METHOD
1 FEMALE STERILIZATION
2 MALE STERILIZATION
3 IUD
4 INJECTABLES
5 IMPLANTS
6 PILL
7 CONDOM
8 FEMALE CONDOM
9 DIAPHRAGM
J FOAM OR JELLY
K LACTATIONAL AMENORRHEA METHOD
L RHYTHM METHOD
M WITHDRAWAL
X OTHER MODERN METHOD
Y OTHER TRADITIONAL METHOD

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE

0 INFREQUENT SEX/HUSBAND AWAY
1 BECAME PREGNANT WHILE USING
2 WANTED TO BECOME PREGNANT
3 HUSBAND/PARTNER DISAPPROVED
4 WANTED MORE EFFECTIVE METHOD
5 SIDE EFFECTS/HEALTH CONCERNS
6 LACK OF ACCESS/TOO FAR
7 COSTS TOO MUCH
8 INCONVENIENT TO USE
F UP TO GOD/FATALIST
A DIFFICULT TO GET PREGNANT/MENOPAUSAL
D MARITAL DISSOLUTION/SEPARATION
X OTHER (SPECIFY)
Z DON'T KNOW