IDENTIFICATION

PLACE NAME: ____

NAME OF HOUSEHOLD HEAD: ____

PSU CODE: ____

HOUSEHOLD NUMBER: ____

REGION:

URBAN/RURAL

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE

NAME AND LINE NUMBER OF MAN_______

INTERVIEWER VISIT 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE_______
INTERVIEWER'S NAME_______
RESULT_____

NEXT VISIT:
DATE_____
TIME______

FINAL VISIT
DAY______
MONTH_______
YEAR2006

INTERVIEWER NUMBER: _______

TOTAL NIMBER OF VISITS________

RESULT CODES

LANGUAGE OF QUESTIONNAIRE: 2

LANGUAGE OF INTERVIEW: ____

LANGUAGE:

RESPONDENT'S LANGUAGE_______

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 __________ and I am working with the Central Statistical Office. We are conducting a national survey about the health of men, women and children. We would very much appreciate your participation in this survey. I would like to ask you some questions related to health. This information will help the government to plan health services. The survey usually takes about 30 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) How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS.

103) Just before you moved here, did you live in a city, in a town, or in the countryside?

104) In the last 12 months, on how many separate occasions have you traveled away from your home community and slept away?

105) In the last 12 months, have you been away from your home community for more than 1 month at a time?

106) In what month and year were you born?

107) How old were you at your last birthday?
COMPARE AND CORRECT 106 AND/OR 107 IF INCONSISTENT.

108) Have you ever attended school?

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

110) What is the highest (grade/form/year) you completed at that level?

111) CHECK 109:

112) 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 other part of the sentence to me?

113) Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?

114) CHECK 112:

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

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

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

118) What is your religion?

SECTION 2. REPRODUCTION

201) Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours, even if they are not legally yours or do not have your last name.
Have you ever fathered any children with any woman?

202) Do you have any sons or daughters that you have fathered who are now living with you?

203) 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 you have fathered 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 fathered a son or a daughter 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:

210) Did all of the children you have fathered have the same biological mother?

211) In all, how many women have you fathered children with?

212) How old were you when your (first) child was born?

213) I will now read you some statements about pregnancy. Please tell me if you agree or disagree with them.
a) Childbearing is a woman's concern and there is no need for the father to get involved.
b) It is crucial for the mother's and child's health that a woman have assistance from a doctor or nurse at delivery.

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

302) Have you ever used (METHOD)?
Have you ever had an operation to avoid having any more children?

303) CHECK 302 (02):

304) Are you currently doing something or using any method with any partner to delay or avoid a pregnancy?

305) Which methods are you or your partner using to delay or avoid a pregnancy?
Any other method (with any partner)?
CIRCLE ALL MENTIONED.

305A) CIRCLE 'B' FOR MALE STERILIZATION.

306) In the last six months have you heard/seen about family planning:
On the radio?
On the television?
In a newspaper or magazine?

307) In the last six months, have you discussed the practice of family planning with a health worker or health professional?

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

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

310) Do you think that a woman who is breastfeeding her baby can become pregnant?

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

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

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

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

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

405) Do you have more than one wife or do you have more than one woman with whom you are living as if married?

406) In total, how many wives do you have or other partners do you live with now as if married?

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

MORE THAN ONE WIFE/PARTNER____:
Please tell me the name of each of your current wives (and/or of each woman you are living with as if married).

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

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

409) CHECK 407:

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

411) In what month and year did you start living with your wife (partner)?
411A) Now I would like to ask a question about your first wife/partner. In what month and year did you start living with your first wife/ partner?

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

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

414) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family life issues.
How old were you when you had sexual intercourse for the very first time?

415) Do you intend to wait until you get married to have sexual intercourse for the first time?

416) CHECK 107:

417) The first time you had sexual intercourse, was a male/female condom used?

417A) What was the main reason you did not use a condom the first time you had sexual intercourse?

418) How old was the person you first had sexual intercourse with?

419) Was this person older than you, younger than you, or about the same age as you?

420) Would you say this person was ten or more years older than you or less than ten years older than you?

421) 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.

421A) 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.

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

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

423A) What was the main reason you did not use a condom the last time you sexual intercourse?

424) Did you use a condom every time you had sexual intercourse with this person in the last 12 months?

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

426) For how long (have you had/did you have) a sexual relationship with this person?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.

427) CHECK 107:

428) How old is this person?

429) Is this person older than you, younger than you, or about the same age?

430) Would you say this person is ten or more years older than you or less than ten years older than you?

431) The last time you had sexual intercourse with this person, did you or this person drink alcohol or used any other intoxicating substance?

432) Were you or your partner drunk at that time?
IF YES: Who was drunk?

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

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

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

437) CHECK FOR PRESENCE OF OTHERS: DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.

440) CHECK 423, MOST RECENT PARTNER (FIRST COLUMN):

441) You told me that you used a condom the last time you had sex. Do you have the package of condoms you used that time?
IF YES: May I see it?
RECORD NAME OF BRAND IF PACKAGE SEEN.

442) Do you know the brand name of the condom you used that time?
RECORD NAME OF BRAND.

442A) What is the main reason you chose this brand?

443) How many condoms did you get the last time?

444) From where did you obtain the condom the last time?
PROBE TO IDENTIFY TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
WRITE THE NAME OF PLACE

444A) How do you usually dispose the used condoms?

445) CHECK 301(7), KNOWS MALE CONDOM

445A) Do you know of a place where a person can get male condoms?

446) Where is that? Any other place?
PROBE TO IDENTIFY TYPE(S) OF SOURCE(S) AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

447A) CHECK 301(8), KNOW FEMALE CONDOM

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

449) Where is that? Any other place?
PROBE TO IDENTIFY TYPE(S) OF SOURCE(S) AND CIRCLE THE APPROPRIATE CODE(S).WRITE THE NAME OF THE PLACE

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

SECTION 5. FERTILITY PREFERENCES

501) CHECK 407:

502) CHECK 305:

503) (Is your wife (partner)/Are any of your wives (partners)) currently pregnant?

504) CHECK 503:

NO WIFE/PARTNER 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?

WIFE(WIVES)/PARTNER(S) PREGNANT____:
Now I have some questions about the future. After the child(ren) you and your (wife (wives)/partner(s)) is/are expecting now, would you like to have another child, or would you prefer not to have anymore children?

505) How long would you like to wait from now before the birth of (a/another) child?

506) CHECK 208

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 NEVER HAD 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.

507) 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 6. MAN'S WORK

601) Are you currently working?

601A) Have you done any work in the last seven days?

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

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

603A) During the last 12 months, how many months did you work?

603B) What have you been doing for most of the time over the last 12 months?

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

605) CHECK 604:

606) Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else's land?

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

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

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

610) CHECK 401:

611) CHECK 609:

612) Who decides how the money you earn will be used: mainly you, mainly your (wife (wives)/partner(s)), or you and your (wife (wives)/partner(s)) jointly?

612A) On average, how much of your household's expenditures do your earnings pay for: almost none less than half, about half, more than half, or all?

613) 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:

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?
If she has sex with other men?

SECTION 7. HIV AND OTHER SEXUALLY TRANSMITTED INFECTIONS

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

702) Can people reduce their chances of getting the AIDS virus by having just one sex partner who is not infected and who has no other partners?

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

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

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

706) Can people reduce their chance of getting the AIDS virus by abstaining from sexual intercourse?

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

707A) Can people get the AIDS virus from having anal sex?

707B) Can people get the AIDS virus from oral sex?

707C) Can people get the AIDS virus from open wounds or sores of an infected person?

708) Is there anything else a person can do to avoid or reduce the chances of getting the AIDS virus?

709) What can a person do?
Anything else?
RECORD ALL WAYS MENTIONED.

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

711) Can the virus that causes AIDS be transmitted from a mother to her baby:
During pregnancy?
During delivery?
By breastfeeding?

712) CHECK 711:

713) Are there any special medications 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?

714) Have you heard about special antiretroviral drugs (ARV) that people infected with the AIDS virus can get from a doctor or a nurse?

714A) CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY

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

716) When was the last time you were tested?

717) The last time you had the test, did you yourself ask for the test or were you advised to take the test, or was it required?

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

718A) How long did it take to get the results?

719) Where did you go to take the test?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
WRITE THE NAME OF THE PLACE.

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

721) Where is that? Any other place?
PROBE TO IDENTIFY TYPE(S) OF SOURCE(S) AND CIRCLE THE APPROPRIATE CODE(S).
WRITE THE NAME OF THE PLACE.

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

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

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

725) 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?

726) Do you personally know someone who has been denied health services in the last 12 months because he or she is suspected to have the AIDS virus or has the AIDS virus?

727) Do you personally know someone who has been denied involvement in social events, religious services, or community events in the last 12 months because he or she is suspected to have the AIDS virus or has the AIDS virus?

728) Do you personally know someone who has been verbally abused or teased in the last 12 months because he or she is suspected to have the AIDS virus or has the AIDS virus?

729) CHECK 726, 727, AND 728:

730) Do you personally know someone who is suspected to have the AIDS virus or who has the AIDS virus?

731) Do you agree or disagree with the following statement: People with the AIDS virus should be ashamed of themselves?

732) Do you agree or disagree with the following statement: People with the AIDS virus should be blamed for bringing the disease into the community.

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

734) Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid AIDS

735) CHECK 701:

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?

736) CHECK 421A:

737) CHECK 735: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

738) 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?

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

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

741) CHECK 738, 739, AND 740:

742) The last time you had (PROBLEM FROM 738/739/740), did you seek any kind of advice or treatment?

742A) What is the main reason for not seeking advice or treatment?

743) Where did you go? Any other place?
PROBE TO IDENTIFY TYPE(S) OF SOURCE(S) AND CIRCLE THE APPROPRIATE CODE(S).
WRITE THE NAME OF THE PLACE.

743A) When you had (PROBLEM FROM 738/739/740), did you inform the person with whom you were having sex?

743B) When you had (PROBLEM FROM 738/739/740), did you do something to avoid infecting your sexual partner(s)?

743C) What did you do to avoid infecting your partner(s)?
Did you...

Use medicine?
Stop having sex?
Use a condom when having sex?

744) Husbands and wives do not always agree on everything. Please tell me if you think a wife is justified in refusing to have sex with her husband when she knows he has a disease that can be transmitted through sexual contact?

745) When a wife knows her husband has a disease that can be transmitted through sexual contact, is she justified in asking that they use a condom when they have sex?

746) Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?

747) Is a wife justified in refusing sex with her husband when she knows her husband has sex with other women?

748) Do you believe that young men should wait until they are married to have sexual intercourse?

749) Do you think that most young men you know wait until they are married to have sexual intercourse?

750) Do you believe that men who are not married and are having sex should only have sex with one partner?

751) Do you think that most men you know who are not married and are having sex, have sex with only one partner?

752) Do you believe that married men should only have sex with their wives?

753) Do you think that most married men you know have sex only with their wives?

754) Do you believe that young women should wait until they are married to have sexual intercourse?

755) Do you think that most young women you know wait until they are married to have sexual intercourse?

756) Do you believe that women who are not married and are having sex should only have sex with one partner?

757) Do you think that most women you know who are not married and are having sex, have sex with only one partner?

758) Do you believe that married women should only have sex with their husbands?

759) Do you think that most married women you know have sex only with their husbands?

SECTION 8. OTHER HEALTH AND WELFARE ISSUES

801) Some men are circumcised. Are you circumcised?

802) At what age were you circumcised?

803) Who performed the circumcision?

804) What is the main reason you were circumcised?

805) Would you want to get circumcised?

806) What is the main reason you would want to get circumcised?

807) What is the main reason you would not want to get circumcised?

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

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

810) The last time you had an injection given to you by a health worker, where did you go to get the injection?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE
WRITE THE NAME OF THE PLACE.

811) Did the person who gave you that injection take the syringe and needle from a new, unopened package?

812) Do you currently smoke cigarettes?

813) In the last 24 hours, how many cigarettes did you smoke?

814) Do you currently smoke or use any other type of tobacco?

815) What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.

816) Have you ever heard of an illness called tuberculosis or TB?

817) How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORD ALL MENTIONED.

818) Can tuberculosis be cured?

819) If member of your family got tuberculosis, would you want it to remain a secret or not?

820) Are you covered by any medical aid?

821) What type of medical aid?
RECORD ALL MENTIONED.

822) Are you the primary care giver for any children?

823) Are any of these children for whom you are the primary caregiver under the age of 18?

824) Now I would like to ask you about the child(ren) who (is/are) under the age of 18 and for whom you are the primary caregiver.
Have you made arrangements for someone to care for(this child/these children) in the event that you fall sick or are unable to care for (him/her/them)?

825) Are you comfortable talking to the children in your care about sex and HIV/AIDS?

826) 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

OBSERVATIONS: ____

NAME OF SUPERVISOR: ____

DATE: ____

EDITOR'S OBSERVATIONS

OBSERVATIONS ____

NAME OF EDITOR: ____

DATE: ____