Data Cart

Your data extract

0 variables
0 samples
View Cart

HEALTH AND DEMOGRAPHIC SURVEY
WOMEN'S QUESTIONNAIRE

REPUBLIC OF CHAD
MINISTRY OF PLANNING AND COOPERATION
DIRECTORATE OF STATISTICS, ECONOMIC STUDIES, AND DEMOGRAPHICS
CENTRAL CENSUS BUREAU

IDENTIFICATION:

LOCALITY NAME ___
NAME OF HEAD OF HOUSEHOLD ___
PREFECTURE ___
SUB-PREFECTURE ___
CANTON ___
CLUSTER NUMBER (ENUMERATION DISTRICT) ___
STRUCTURE NUMBER ___
RESIDENCE NUMBER ___

CENSUS ZONE NUMBER ___

N'DJAMENA 1
ABECHE/MOUNFOU/SARH 2
SMALL TOWNS 3
RURAL 4

NAME AND LINE NUMBER OF WOMAN ___

INTERVIEWER VISITS:

INTERVIEWER 1:
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___

RESULT:

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY): ___

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]:
DATE__
TIME__

FINAL VISIT:
DAY__
MONTH__
YEAR __
NAME__

RESULT:

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY): ___

TOTAL NUMBER OF VISITS ___

LANGUAGE OF INTERVIEW:

FRENCH 01
CHADIAN ARABIC 02
SAR 03
BORNOU 04
GOR 05
GORANE 06
GOULEY 07
KANEMBOU 08
LELE 09
MABA (OUADDAIAN) 10
MBAY 11
MOUNDANG 12
MOUSSEYE 13
NGAMBAY 14
TOUPOURI 15
OTHER LANGUAGES 16

INTERPRETER:

YES 1
NO 2

FIELD EDITED BY:
NAME ___
DATE ___

OFFICE EDITED BY:
NAME ___
DATE ___

KEYED BY:
NAME ___
DATE ___

SECTION 1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENT

101) RECORD TIME:

HOUR: ___
MINUTES: ___

102) To begin, I'd like to ask you some questions about yourself and your household.
During the majority of the first 12 years of your life, did you live in the city of N'Djamena, in Abeche, in Moundou, in Sarh, in another city, in a village, or abroad?

N'DJAMENA 1
ABECHE/MOUNDOU/SARH 2
TOWN 3
VILLAGE 4
ABROAD 5

103) For how long have you been a long-term resident of (NAME OF CURRENT RESIDENCE)?

NUMBER OF YEARS: ___
ALWAYS 95 (GO TO 105)
JUST VISITING 96 (GO TO 105)

104) Just before moving (NAME OF CURRENT RESIDENCE), did you live in N'Djamena, in Abeche, in Moundou, in Sarh, in another city, in a village, or abroad?

N'DJAMENA 1
ABECHE/MOUNDOU/SARH 2
TOWN 3
VILLAGE 4
ABROAD 5

105) In what month and year were you born?

MONTH: ___
DK MONTH 98
YEAR: ___
DK YEAR 98

106) How old were you at your last birthday?

COMPARE AND CORRECT IF 105 AND/OR 106 ARE INCOMPATIBLE.

AGE IN COMPLETED YEARS: ___

107) Have you ever attended school?

YES 1 (GO TO 108)
NO 2

107A) Why have you never attended school?

SCHOOL NON-EXISTENT 01 (GO TO 114)
SCHOOL INACCESSIBLE/TOO FAR 02 (GO TO 114)
COULD NOT PAY FEES 03 (GO TO 114)
HAD TO WORK 04 (GO TO 114)
PARENTS REFUSED 05 (GO TO 114)
OTHER (SPECIFY): ___ 96 (GO TO 114)
DK 98 (GO TO 114)

108) What is the highest level of education that you have attained: primary, secondary, higher, secondary-level professional, higher-level professional, or madrassa?

PRIMARY 1
SECONDARY 2
HIGHER 3
SECONDARY-LEVEL PROFESSIONAL 4
HIGHER-LEVEL PROFESSIONAL 5
MADRASSA 6 (GO TO 114)

109) What was the last class you completed at this level?

PRIMARY (INCLUDING MADRASAS)
LESS THAN A YEAR COMPLETED IN THE CORRESPONDING LEVEL 0
INTRODUCTORY CLASS 1
PREPARATORY CLASS 2
ELEMENTARY CLASS 1 3
ELEMENTARY CLASS 2 4
MIDDLE-LEVEL CLASS 1 5
MIDDLE-LEVEL CLASS 2 6
SECONDARY (INCLUDING MADRASAS)
LESS THAN A YEAR COMPLETED IN THE CORRESPONDING LEVEL 0
6TH 1
5TH 2
4TH 3
3RD 4
2ND 5
1ST 6
FINAL YEAR 7
HIGHER (INCLUDING MADRASAS)
LESS THAN A YEAR COMPLETED IN THE CORRESPONDING LEVEL 0
FIRST YEAR 1
SECOND YEAR 2
THIRD YEAR 3
FOURTH YEAR AND + 4
SECONDARY-LEVEL PROFESSIONAL
LESS THAN A YEAR COMPLETED IN THE CORRESPONDING LEVEL 0
6TH OR 1ST YEAR 1
5TH OR 2ND YEAR 2
4TH OR 3RD YEAR 3
3RD OR 4TH YEAR 4
2ND OR 5TH YEAR 5
1ST OR 6TH YEAR 6
FINAL YEAR OR 7TH YEAR 7
HIGHER-LEVEL PROFESSIONAL
LESS THAN A YEAR COMPLETED IN THE CORRESPONDING LEVEL 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH YEAR OR + 4

110) CHECK 106:

AGE 29 OR BELOW: ___ (GO TO NEXT QUESTION)
AGE 30 OR ABOVE: ___ (GO TO 113)

111) Are you currently attending school?

YES 1 (GO TO 113)
NO 2

112) What is the main reason why you stopped attending school?

GOT PREGNANT 01
GOT MARRIED 02
TO CARE FOR YOUNGER CHILDREN 03
FAMILY NEEDED HELP ON FARM OR IN BUSINESS 04
COULD NOT PAY SCHOOL FEES 05
NEEDED TO EARN MONEY 06
GRADUATED/ HAD ENOUGH SCHOOLING 07
FAILED AT SCHOOL 08
DID NOT LIKE SCHOOL 09
SCHOOL NOT ACCESSIBLE/TOO FAR 10
LACK OF TUTOR 11
OTHER (SPECIFY): ___ 96
DK 98

113) CHECK 108:

PRIMARY: ___ (GO TO NEXT QUESTION)
SECONDARY OR HIGHER: ___ (GO TO 115)

114) Do you know how to read and understand a letter or a newspaper easily, with difficulty, or not at all?

EASILY 1
WITH DIFFICULTY 2
NOT AT ALL 3 (GO TO 116)

114A) In what language do you mainly know how to read?

IF MORE THAN ONE LANGUAGE IS CITED, ONLY CIRCLE THE CODE OF THE LANGUAGE FIRST ON THE LIST.

FRENCH 1
ARABIC 2
OTHER LANGUAGE 3

115) Do you usually read a journal or magazine at least once a week?

YES 1
NO 2

116) Do you usually listen to the radio every day?

YES 1
NO 2

117) Do you watch television at least once a week?

YES 1
NO 2

118) What is your religion?

CATHOLIC 1
PROTESTANT 2
MUSLIM 3
ANIMIST 4
NO RELIGION 5
OTHER (SPECIFY): ___ 6

119) What is your ethnicity?

____

119A) Sometimes children who play normally during the day have trouble seeing or moving around at nighttime, at nightfall, or after sunset. In the evening, these children sometimes sit by themselves, or hold on to their mother's clothing. They are unable to find their toys, or to see well enough to eat.

Are you familiar with this problem?

YES 1
NO 2 (GO TO 120)

119B) What do you call this problem?

TRY TO OBTAIN THE LOCAL NAME OF ILLNESS.

_____ 96
DK 98

120) CHECK 4 IN THE HOUSEHOLD QUESTIONNAIRE:

THE WOMAN INTERVIEWED IS NOT A USUAL RESIDENT: ___ (GO TO NEXT QUESTION)
THE WOMAN INTERVIEWED IS A USUAL RESIDENT: ___ (GO TO 201)

121) Now I would like to ask you some questions about the place that you usually live.
What is the name of the place in which you usually live?

IF DIFFERENT FROM N'DJAMENA, ABECHE, MOUDOU, SARH, OR ABROAD, ASK:
Is this a town/city or village?

NAME OF PLACE: ___
N'DJAMENA 1 (GO TO 123)
ABECHE/MOUNDOU/SARH 2
SMALL TOWN 3
VILLAGE 4
ABROAD 5 (GO TO 123)

122) In which prefecture is it located?

BATHA 01
BET 02
BILTINE 03
CHARI BAGUIRMI 04
GUERA 05
KANEM 06
LAC 07
WESTERN LOGONE 08
EASTERN LOGONE 09
MAYO KEBBI 10
MIDDLE CHARI 11
OUADDAI 12
SALAMAT 13
TANDJILE 14

123) Now I would like to ask you about the household in which you usually live.

What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO THE RESIDENCE/YARD/ALLOTMENT 11 (GO TO 125)
PUBLIC TAP 12
WELL WATER
TRADITIONAL WELL IN RESIDENCE/YARD/ALLOTMENT 21 (GO TO 125)
MODERN WELL/BOREHOLE IN RESIDENCE/YARD/ALLOTMENT 22 (GO TO 125)
PUBLIC/ COMMUNITY TRADITIONAL WELL 23
PUBLIC /COMMUNITY WELL/BOREHOLE 24
SURFACE WATER
SPRING/RIVER/STREAM 31
POND/LAKE/BACKWATER POOL 32
RAINWATER 41 (GO TO 125)
TANK TRUCK 51
WATER VENDOR 61 (GO TO 125)
OTHER (SPECIFY): ___ 96

124) How long does it take to go there, get water, and come back?

MINUTES: ___
ON PREMISE 996

125) What kind of toilet facility does your household have?

FLUSH TOILET
OWN FLUSH TOILET 11
SHARED FLUSH TOILET 12
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/NATURE 31
OTHER (SPECIFY): ___ 96

126) Does your household have:

Grid power?
Personal electricity: (power generator, solar panel, batteries)?
A radio?
A television?
Telephone?
A refrigerator/freezer?

GRID POWER
YES 1
NO 2
PERSONAL ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE
YES 1
NO 2
REFRIGERATOR/FREEZER
YES 1
NO 2

126A) In your household, what kind of lighting do you mainly use?

ELECTRICITY 1
GAS LAMP 2
KEROSENE LAMP 3
FLASHLIGHT (BATTERIES) 4
WOOD/PLANT STEMS/STRAW 5
OTHER (SPECIFY): ___ 6

126B) In your household, how many rooms are used for sleeping?

NUMBER OF ROOMS: ___

127) Could you describe the floor of your home?

NATURAL FLOOR
EARTH/SAND 11
FINISHED FLOOR
TILE 21
CEMENT 22
OTHER (SPECIFY): ___ 96

127A) Could you describe the roof of your home?

TRADITIONAL ROOF
STRAW 11
BANCO 12
MODERN ROOF
SHEET METAL 21
CONCRETE 22
OTHER (SPECIFY): ___ 96

127B) Could you describe the walls of your home?

TRADITIONAL WALL
STRAW 11
BANCO 12
SEMIHARD WALL 13
MODERN WALL
HARD WALL 21
OTHER (SPECIFY): ___ 96

128) Is there someone in your household who owns:

A bicycle?
A scooter/motorcycle?
A car?
A canoe?
A cart?
A camel/horse/donkey?

BICYCLE
YES 1
NO 2
SCOOTER/MOTORCYCLE
YES 1
NO 2
CAR
YES 1
NO 2
CANOE
YES 1
NO 2
CART
YES 1
NO 2
CAMEL/HORSE/DONKEY
YES 1
NO 2

SECTION 2. REPRODUCTION

201) Now I'd like to ask you some questions about all the children you've given birth to in your life. Have you ever given birth?

YES 1
NO 2 (GO TO 206)

202) Did you give birth to sons or daughters currently living with you?

YES 1
NO 2 (GO TO 204)

203) How many sons live with you?
And how many daughters?

IF NONE, ENTER '00'.

SONS AT HOME: ___
DAUGHTERS AT HOME: ___

204) Have you given birth to sons or daughters who are still living and do not currently live with you?

YES 1
NO 2 (GO TO 206)

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'.

SONS ELSEWHERE: ___
DAUGHTERS ELSEWHERE: ___

206) Have you given birth to a son or daughter who later died?

IF NO, PROBE: Any baby who cried or showed signs of life but who only survived a few hours or days?

YES 1
NO 2 (GO TO 208)

207) How many of your sons have died?
And how many of your daughters have died?

IF NONE, WRITE '00'.

SONS DECEASED: ___
DAUGHTERS DECEASED: ___

208) SUM ANSWERS TO 203, 205, and 207 AND ENTER TOTAL:

IF NONE, RECORD '00'.

TOTAL: ___

209) CHECK 208:

I want to make sure I understood: you have had in TOTAL___ births in your life. Is that correct?

YES: ___ (GO TO NEXT QUESTION)
NO: ___ (PROBE AND CORRECT 201-208 AS NECESSARY)

210) CHECK 208:

ONE OR MORE BIRTHS: ___ (GO TO NEXT QUESTION)
NO BIRTHS: ___ (GO TO 227)

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, WRITING THE NAMES OF TWINS OR TRIPLETS ON SEPARATE LINES.

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

NAME: ___

213) Were any of these births twins?

SINGLE 1
MULTIPLE 2

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

BOY 1
GIRL 2

215) In what month and year was (NAME) born?

PROBE: What is his or her birthday?
OR: In what season was he/she born?

MONTH: ___
YEAR: ___

216) Is (NAME) still alive?

YES 1
NO 2 (GO TO 219)

217) IF ALIVE:

How old was (NAME) at his/her last birthday?

RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS: ___

218) IF ALIVE:

Is (NAME) living with you?

YES 1 (GO TO NEXT BIRTH)
NO 2 (GO TO NEXT BIRTH)

219) IF DECEASED:

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

IF "1YR", INSIST: How old was (NAME) in months?

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

DAYS: ___ 1
MONTHS: ___ 2
YEARS: ___ 3

220) FROM YEAR OF BIRTH OF (NAME) SUBTRACT YEAR OF PREVIOUS BIRTH.
IS THE DIFFERENCE 4 OR MORE?

YES 1
NO 2 (GO TO NEXT BIRTH FOR MOST RECENT BIRTH, TO 220 FOR ALL OTHERS)

221) Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)?

YES 1
NO 2

222) SUBTRACT THE YEAR OF THE BIRTH OF THE LAST CHILD FROM THE YEAR OF THE INTERVIEW. IS THE DIFFERENCE 4 OR MORE YEARS?

YES 1 (GO TO 223)
NO 2 (GO TO 224)

223) Have you had any live births since the birth of (NAME OF LAST BIRTH)?

YES 1
NO 2

224) COMPARE 208 WITH THE NUMBER OF BIRTHS RECORDED IN THE TABLE ABOVE AND NOTE:

THE NUMBERS ARE THE SAME: ___
CHECK: FOR EACH BIRTH: THE YEAR OF BIRTH IS RECORDED: ___
FOR EACH LIVING CHILD: THE CURRENT AGE IS RECORDED: ___
FOR EACH DECEASED CHILD: THE AGE OF DEATH IS RECORDED: ___
AGE AT DEATH 12 MONTHS OR 1 YEAR: CHECK TO DETERMINE THE EXACT NUMBER OF MONTHS: ___
THE NUMBERS ARE DIFFERENT: ___ (CHECK AND CORRECT)

225) CHECK 215 AND ENTER THE NUMBER OF LIVING BIRTHS SINCE JANUARY 1991. IF THERE ARE NONE, RECORD '0'.

___

227) Are you pregnant now?

YES 1
NO 2 (GO TO 236)
UNSURE 8 (GO TO 236)

228) How many months pregnant are you?

RECORD IN COMPLETED MONTHS.

MONTHS: ___

229) 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 any more children at all?

THEN 1
LATER 2
NOT AT ALL 3

236) When did your last period start?

RECORD THE DATE, IF IT IS GIVEN: ___
DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
YEARS: ___ 4
IN MENOPAUSE 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

237) Between the first day of a woman's period and the first day of her NEXT period, are there certain times when she has a greater chance of becoming pregnant than at other times?

YES 1
NO 2 (GO TO 239)
DK 8 (GO TO 239)

238) During which times of the month does a woman have the greatest chance of becoming pregnant?

DURING HER PERIOD 01
RIGHT AFTER HER PERIOD HAS ENDED 02
IN THE MIDDLE OF THE CYCLE 03
JUST BEFORE HER PERIOD BEGINS 04
OTHER (SPECIFY): ___ 96
DK 98

239) Did you have any pregnancies that did not end with a live birth?

YES 1
NO 2 (GO TO 301)

240) How many pregnancies have you had that did not end with a live birth?

NUMBER OF PREGNANCIES: ___

241) Among these pregnancies, how many ended with:

- a voluntary induced abortion?
- a spontaneous abortion, that is to say, a miscarriage?
- a stillbirth?

INDUCED ABORTION: ___
MISCARRIAGE: ___
STILLBIRTH: ___

SECTION 3. CONTRACEPTION

Now I would like to talk to you 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?

CIRCLE CODE 1 IN 302 FOR EACH METHOD MENTIONED SPONTANEOUSLY.
THEN PROCEED DOWN THE COLUMN, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY.

CIRCLE CODE 2 IF METHOD IS RECOGNIZED, AND CODE 3 IF NOT RECOGNIZED.

THEN FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 301 OR 302, ASK QUESTION 303.

301) Which ways or methods have you heard about?

302) Have you ever heard of (METHOD)?

01. PILL Women can take a pill every day.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3
02. IUD Women can have a sterilet that a doctor or nurse places inside their uterus.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3
03. INJECTABLES Women can have an injection by a health provider which stops them from becoming pregnant for one or more months.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3
04. IMPLANTS/NORPLANT Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3
05. DIAPHRAGM, FOAM OR GEL Women can place a sponge, a suppository, a diaphragm, gel, or cream in their vagina before intercourse.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3
06. CONDOM Men can put a rubber sheath on their penis before sexual intercourse.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3
07. FEMALE STERILIZATION Women can have an operation to avoid having any more children.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3
08. MALE STERILIZATION Men can have an operation to avoid having any more children.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3
09. RHYTHM/PERIODIC ABSTINENCE Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3
10. WITHDRAWAL Men can be careful and pull out before climax.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3
11. Have you ever heard of any other methods that men or women use to avoid pregnancy?
YES (SPECIFY): ___ 1
NO 3

303) Have you ever used (METHOD)?

01. PILL Women can take a pill every day.
YES 1
NO 2
02. IUD Women can have a sterilet that a doctor or nurse places inside their uterus.
YES 1
NO 2
03. INJECTABLES Women can have an injection by a health provider which stops them from becoming pregnant for one or more months.
YES 1
NO 2
04. IMPLANTS/NORPLANT Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2
05. DIAPHRAGM, FOAM OR GEL Women can place a sponge, a suppository, a diaphragm, gel, or cream in their vagina before intercourse.
YES 1
NO 2
06. CONDOM Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
07. FEMALE STERILIZATION Have you ever had an operation to avoid having any more children?
YES 1
NO 2
08. MALE STERILIZATION Have you ever had a partner who had an operation to avoid having any more children?
YES 1
NO 2
09. RHYTHM/PERIODIC ABSTINENCE Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
10. WITHDRAWAL Men can be careful and pull out before climax.
YES 1
NO 2
11. Have you heard of any other methods that men or women can use to avoid pregnancy?
YES 1
NO 2

304) CHECK 303:

NOT A SINGLE 'YES' (NEVER USED): ___ (GO TO NEXT QUESTION)
AT LEAST ONE 'YES' (EVER USED): ___ (GO TO 309)

305) Have you ever used or tried any way to delay or avoid getting pregnant?

YES 1
NO 2 (GO TO 331)

307) What have you done or used?

CORRECT 303-304 (AND 302 IF NECESSARY).

309) Now I would like to speak to you about the time when you first did something or used a method to avoid getting pregnant. How many living children did you have at that time?

IF NONE, RECORD '00'.

NUMBER OF CHILDREN: ___

310) When you first used family planning, was it because you wanted to have another child but at a later time, or because you did not want to have another child at all?

WANTED CHILD LATER 1
DID NOT WANT ANOTHER CHILD 2
OTHER (SPECIFY): ___ 6

311) CHECK 303:

WOMAN NOT STERILIZED: ___ (GO TO NEXT QUESTION)
WOMAN STERILIZED: ___ (GO TO 314A)

312) CHECK 227:

NOT PREGNANT OR UNSURE: ___ (GO TO NEXT QUESTION)
PREGNANT: ___ (GO TO 332)

313) Are you currently doing something or using a method to avoid pregnancy?

YES 1
NO 2 (GO TO 331)

314) What method are you using?

314A) CIRCLE '07' FOR FEMALE STERILIZATION.

PILL 01
IUD 02 (GO TO 326)
INJECTABLES 03 (GO TO 326)
IMPLANT/NORPLANT 04 (GO TO 326)
DIAPHRAGM/FOAM/GEL 05 (GO TO 326)
CONDOM 06 (GO TO 326)
FEMALE STERILIZATION 07 (GO TO 318)
MALE STERILIZATION 08 (GO TO 318)
PERIODIC ABSTINENCE 09 (GO TO 323)
WITHDRAWAL 10 (GO TO 326)
OTHER (SPECIFY): ___ 96 (GO TO 326)

315) May I see the package of pills you are using now?

RECORD NAME OF BRAND IF PACKAGE IS SEEN.

PACKAGE SEEN 1
BRAND NAME: ___ (GO TO 317)
PACKAGE NOT SEEN 2

316) Do you know the brand name of the pills that you are now using?

RECORD BRAND.

BRAND NAME: ___
DK 98

317) How much does one packet (cycle) of pills cost you?

COST: ___ (GO TO 326)
FREE 9996 (GO TO 326)
DK 9998 (GO TO 326)

318) Where did the sterilization take place?

NAME OF PLACE: ___
PUBLIC SECTOR
PUBLIC HOSPITAL/MATERNITY CLINIC 11
OTHER PUBLIC (SPECIFY): ___ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
CLINIC/PRIVATE DOCTOR'S OFFICE 22
OTHER PRIVATE MEDICAL (SPECIFY): ___ 26
OTHER (SPECIFY): ___ 96
DK 98

319) Do you regret that (you/your husband) had the operation to not have any more children?

YES 1
NO 2 (GO TO 321)

320) Why do you regret it?

RESPONDENT WANTS ANOTHER CHILD 01
PARTNER WANTS ANOTHER CHILD 02
SIDE EFFECTS 03
CHILD DIED 04
OTHER REASON (SPECIFY): ___ 96

321) In what month and year was the sterilization operation performed?

MONTH: ___ (GO TO 337)
YEAR: ___ (GO TO 337)

323) How do you determine which days of your monthly cycle not to have sexual relations?

BASED ON CALENDAR 01
BASED ON BODY TEMPERATURE 02
BASED ON CERVICAL MUCUS (BILLINGS METHOD) 03
BASED ON BODY TEMPERATURE AND CERVICAL MUCUS 04
NO SPECIFIC SYSTEM 05
OTHER (SPECIFY): ___ 96

326) For how many months have you been using (CURRENT METHOD) continuously?

IF LESS THAN A MONTH, RECORD '00'.

MONTHS: ___
8 YEARS OR MORE 96

327) CHECK 314:

CIRCLE METHOD CODE.

PILL 01
IUD 02
INJECTABLES 03
IMPLANT/NORPLANT 04
DIAPHRAGM/FOAM/GEL 05
CONDOM 06
FEMALE STERILIZATION 07 (GO TO 329A)
MALE STERILIZATION 08 (GO TO 329A)
PERIODIC ABSTINENCE 09 (GO TO 332)
WITHDRAWAL 10 (GO TO 332)
OTHER METHOD 96 (GO TO 332)

328) Where did you obtain (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

PLEASE NOTE:
IF RESPONSE IS 'MILITARY HOSPITAL/GARRISON,' CIRCLE '12' FOR N'DJAMENA AND THE CODE '13' FOR OTHER CITIES.

PLEASE NOTE:
IF THE RESPONSE IS 'NURSE', PROBE TO DETERMINE IF A REAL NURSE (CODE '25' 'WORKPLACE HEALTH CENTER'), A HOSPITAL, OR A PUBLIC HEALTH CENTER.

NAME OF PLACE: ___
PUBLIC SECTOR
PUBLIC HOSPITAL/MATERNITY CLINIC 11
MILITARY HOSPITAL/GARRISON 12
HEALTH CENTER/DISPENSARY/GARRISON 13
WALK-IN CLINIC 14
HOSPITAL OR HEALTH CENTER PHARMACY 15
OTHER PUBLIC (SPECIFY): ___ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
CLINIC/PRIVATE DOCTOR'S OFFICE 22
CHADIAN FAMILY WELFARE ASSOCIATION 23
PRIVATE HEALTH CENTER 24
WORKPLACE HEALTH CENTER 25
PHARMACY/PHARMACEUTICAL DEPOT 26
OTHER PRIVATE MEDICAL (SPECIFY): ___ 27
PUBLIC/PRIVATE SECTOR
VILLAGE PHARMACY/HEALTH CENTER 31
OTHER
SHOP/BAR/MARKET 41
FIRST AID WORKER 42
TRAVELING SALESMAN 43
FRIENDS/NEIGHBORS/RELATIVES 44
OTHER (SPECIFY): ___ 96
DK 98

329) Do you know of another place where you could have obtained (METHOD) the last time?

329A) At the time of the sterilization operation, did you know of another place where you could have received the operation?

YES 1
NO 2 (GO TO 335)

330) People select the place where they get family planning services for various reasons.

What was the main reason you went to (NAME OF PLACE IN 328 OR IN 318) instead of another place you know about?

RECORD RESPONSE AND CIRCLE CODE.

ACCESS-RELATED REASONS
CLOSER TO HOME 11 (GO TO 335)
CLOSER TO MARKET/WORK 12 (GO TO 335)
AVAILABILITY OF TRANSPORT 13 (GO TO 335)
SERVICE-RELATED REASONS
STAFF MORE COMPETENT/FRIENDLY 21 (GO TO 335)
CLEANER FACILITY 22 (GO TO 335)
OFFERS MORE PRIVACY 23 (GO TO 335)
SHORTER WAITING TIME 24 (GO TO 335)
LONGER HRS. OF OPERATION 25 (GO TO 335)
USE OTHER SERVICES AT FACILITY 26 (GO TO 335)
LOWER COST/CHEAPER 31 (GO TO 335)
WANTED ANONYMITY 41 (GO TO 335)
OTHER (SPECIFY): ___ 96 (GO TO 335)
DK 98 (GO TO 335)

331) What is the main reason you are not using a method?

NOT MARRIED 11
FERTILITY-RELATED REASONS
NOT HAVING SEX 21
INFREQUENT SEX 22
MENOPAUSAL/HYSTERECTOMY 23
SUBFECUND/STERILE 24
POSTPARTUM/BREASTFEEDING 25
WANTS (MORE) CHILDREN 26
PREGNANT 27
OPPOSITION TO USE
RESPONDENT OPPOSED 31
HUSBAND OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
LACK OF KNOWLEDGE
KNOWS NO METHOD 41
KNOWS NO SOURCE 42
METHOD-RELATED REASONS
HEALTH CONCERNS 51
FEAR OF SIDE EFFECTS 52
LACK OF ACCESS/TOO FAR 53
COST TOO MUCH 54
INCONVENIENT TO USE 55
INTERFERES WITH BODY'S NORMAL PROCESSES 56
OTHER (SPECIFY): ___ 96
DK 98

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

YES 1
NO 2 (GO TO 335)

333) 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.

PLEASE NOTE:
IF RESPONSE IS 'MILITARY HOSPITAL/GARRISON,' CIRCLE '12' FOR N'DJAMENA AND THE CODE '13' FOR OTHER CITIES.

PLEASE NOTE:
IF THE RESPONSE IS 'NURSE,' PROBE TO DETERMINE IF A REAL NURSE (CODE '25' 'WORKPLACE HEALTH CENTRE), A HOSPITAL, OR A PUBLIC HEALTH CENTRE

NAME OF PLACE: ___
PUBLIC SECTOR
PUBLIC HOSPITAL/MATERNITY CLINIC 11
MILITARY HOSPITAL/GARRISON 12
HEALTH CENTER/ DISPENSARY/GARRISON 13
WALK-IN CLINIC 14
HOSPITAL OR HEALTH CENTER PHARMACY 15
OTHER PUBLIC (SPECIFY): ___ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
CLINIC/PRIVATE DOCTOR'S OFFICE 22
CHADIAN FAMILY WELFARE ASSOCIATION 23
PRIVATE HEALTH CENTER 24
WORKPLACE HEALTH CENTER 25
PHARMACY/PHARMACEUTICAL DEPOT 26
OTHER PRIVATE MEDICAL (SPECIFY): ___ 27
PUBLIC/PRIVATE SECTOR
VILLAGE PHARMACY/HEALTH CENTER 31
OTHER
SHOP/BAR/MARKET 41
FIRST AID WORKER 42
TRAVELING SALESMAN 43
FRIENDS/NEIGHBORS/RELATIVES 44
OTHER (SPECIFY): ___ 96
DK 98

335) Have you been in a health facility for any reason in the last 12 months?

YES 1
NO 2 (GO TO 337)

336) Did someone at the health facility speak to you about family planning methods?

YES 1
NO 2

337) Do you thing that breastfeeding can affect a woman's chance of becoming pregnant?

YES 1
NO 2 (GO TO 401)
DK 8

338) Do you think that a woman's chance of becoming pregnant is increased or diminished by breastfeeding?

INCREASED 1 (GO TO 401)
DECREASED 2
DEPENDS 3
DK 8

339) CHECK 210:

ONE OR MORE BIRTHS: ___ (GO TO NEXT QUESTION)
NO BIRTHS: ___ (GO TO 401)

340) Have you ever relied on breastfeeding as a method to avoid pregnancy?

YES 1
NO 2 (GO TO 401)

341) CHECK 227 AND 311:

NOT PREGNANT OR UNSURE AND NOT STERILIZED: ___ (GO TO NEXT QUESTION)
EITHER PREGNANT OR STERILIZED: ___ (GO TO 401)

342) Are you currently relying on breastfeeding to avoid getting pregnant?

YES 1
NO 2

SECTION 4A. PREGNANCY AND BREASTFEEDING

401) CHECK 225:

ONE OR MORE BIRTHS SINCE JAN. 1991: ___ (GO TO NEXT QUESTION)
NO BIRTHS SINCE JAN 1991: ___ (GO TO 465)

402) ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1991 IN THE TABLE. ASK THE QUESTIONS OF ALL THESE BIRTHS, BEGINNING WITH THE LAST BIRTH.

(IF THERE ARE MORE THAN 3 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE)

Now I would like to ask you some more questions about the health of all of the children you have had in the past 5 years. (We will talk about one child at a time)

403) SEE SECTION 2:

LINE NUMBER FROM QUESTION 212: ___

404)
FROM 212: NAME OF (LAST/NEXT-TO-LAST/-SECOND-FROM-LAST) BIRTH:

NAME: ___

AND 216:

LIVING: ___
DECEASED: ___

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 want no (more) children at all?

THEN 1 (GO TO 407)
LATER 2
NO MORE 3 (GO TO 407)

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

MONTHS: ___ 1
YEARS: ___ 2
DK 998

407) When you were pregnant with (NAME), did you see anyone for a consultation about this pregnancy?

IF YES, Whom did you see? Anyone else?

PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN.
IF 'TRADITIONAL BIRTH ATTENDANT' PROBE TO DETERMINE IF SHE RECEIVED TRAINING.

- SOMETIMES TRAINED BIRTH ATTENDANTS HAVE A CASE CONTAINING VARIOUS DRUGS.

- ASK IF THE BIRTH ATTENDANT HAS CONTACTS WITH REGIONAL HEAD NURSE

HEALTH PROFESSIONAL
DOCTOR A
MIDWIFE B
NURSE C
MATRON/HOSPITAL/HEALTH CENTER WORKER D
TRAINED TRADITIONAL BIRTH ATTENDANT E
UNTRAINED TRADITIONAL BIRTH ATTENDANT F
VILLAGE HEALTH WORKER G
FIRST AID WORKER H
HEALER I
OTHER (SPECIFY): ___ X
NO ONE Y (GO TO 410)

408) How many months pregnant were you when you first received antenatal care?

MONTHS: ___
DK 98

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

NUMBER OF TIMES: ___
DK 98

410) When you were pregnant with (NAME) were you given an injection in the arm or backside to prevent the baby from getting tetanus, that is, convulsions after birth?

YES 1
NO 2 (GO TO 412)
DK 8 (GO TO 412)

411) During this pregnancy, how many times did you receive this injection?

NUMBER: ___
DK 8

412) Where did you give birth to (NAME)?

PLEASE NOTE:
IF RESPONSE IS 'MILITARY HOSPITAL/GARRISON,' CIRCLE '22' FOR N'DJAMENA AND THE CODE '23' FOR OTHER CITIES.

PLEASE NOTE:
IF THE RESPONSE IS 'NURSE,' PROBE TO DETERMINE IF A REAL NURSE (CODE '34', OR IF A HOSPITAL ('21'), OR A PUBLIC HEALTH CENTRE ('23')

HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
HOSPITAL/MATERNITY WARD 21
MILITARY HOSPITAL/GARRISON 22
HEALTH CENTER/DISPENSARY/GARRISON 23
WALK-IN HEALTH CENTER 24
OTHER PUBLIC (SPECIFY): ___ 26
PRIVATE SECTOR
PRIVATE HOSPITAL 31
CLINIC/DOCTOR'S OFFICE 32
PRIVATE HEALTH CENTER 33
WORKPLACE HEALTH CENTER 34
OTHER PRIVATE (SPECIFY): ___ 36
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER 41
OTHER (SPECIFY): ___ 96

413) Who assisted you in the delivery of (NAME)?

Anyone else?

PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS ASSISTING.

IF 'TRADITIONAL BIRTH ATTENDANT' PROBE TO DETERMINE IF SHE RECEIVED TRAINING.
- SOMETIMES TRAINED BIRTH ATTENDANTS HAVE A CASE CONTAINING VARIOUS DRUGS.
- ASK IF THE BIRTH ATTENDANT HAS CONTACTS WITH REGIONAL HEAD NURSE

HEALTH PROFESSIONAL
DOCTOR A
MIDWIFE B
NURSE C
MATRON/HOSPITAL/HEALTH CENTER WORKER D
TRAINED TRADITIONAL BIRTH ATTENDANT E
UNTRAINED TRADITIONAL BIRTH ATTENDANT F
VILLAGE HEALTH WORKER G
FIRST AID WORKER H
HEALER I
FRIENDS/NEIGHBORS/RELATIVES J
OTHER (SPECIFY): ___ X
NO ONE Y (GO TO 410)

414) At the time of the birth of (NAME) did you have any of the following health problems?

Long labor, that is, did your regular contractions last more than 12 hours?
Excessive bleeding that was so much that you feared it was life-threatening?
A high fever with bad-smelling vaginal discharge?
Convulsions not caused by fever?

LONG LABOR
YES 1
NO 2
EXCESSIVE BLEEDING
YES 1
NO 2
HIGH FEVER WITH VAG. DISCHARGE
YES 1
NO 2
CONVULSIONS
YES 1
NO 2

415) Was (NAME) delivered by caesarean section?

YES 1
NO 2

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

VERY LARGE 1
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DK 8

417) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 419)

418) How much did he/she weigh?

RECORD WEIGHT FROM HEALTH CARD, IF AVAILABLE.

GRAMS FROM CARD: ___
GRAMS FROM RECALL: ___
DK 99998

419) FOR MOST RECENT BIRTH ONLY: Has your period returned after the birth of (NAME)?

YES 1 (GO TO 421)
NO 2 (GO TO 422)

420) SKIP FOR MOST RECENT BIRTH: Did your period return between the birth of (NAME) and the next pregnancy?

YES 1
NO 2 (GO TO 424)

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

MONTHS: ___
DK 98

422) CHECK 227:
WOMAN PREGNANT?

NOT PREGNANT: ___ (GO TO NEXT QUESTION)
PREGNANT OR UNSURE: ___ (GO TO 424)

423) FOR MOST RECENT BIRTH ONLY: Have you resumed sexual relations since the birth of (NAME)?

YES 1
NO 2 (GO TO 425)

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

MONTHS: ___
DK 98

425) Did you breastfeed (NAME)?

YES 1
NO 2 (GO TO 431)

426) How long after the 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.

IMMEDIATELY 000
HOURS: ___ 1
DAYS: ___ 2

427) CHECK 404:
CHILD ALIVE?

LIVING: ___ (GO TO NEXT QUESTION)
DECEASED: ___ (GO TO 429)

428) Do you still breastfeed (NAME)?

YES 1 (GO TO 432)
NO 2

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

MONTHS: ___
DK 98

430) Why did you stop breastfeeding (NAME)?

MOTHER ILL/WEAK 01
CHILD ILL/WEAK 02
CHILD DIED 03
NIPPLE/BREAST PROBLEM 04
INSUFFICIENT MILK 05
MOTHER WORKING 06
CHILD REFUSED 07
WEANING AGE/AGE TO STOP 08
BECAME PREGNANT 09
STARTED USING CONTRACEPTION 10
OTHER (SPECIFY): ___ 96

431) CHECK 404:
CHILD ALIVE?

LIVING: ___ (GO TO 434)
DECEASED: ___ (GO BACK TO 405 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 440)

432) How many times did you breastfeed last night between sunset and sunrise?

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

NUMBER OF NIGHTTIME FEEDINGS: ___

433) How many times did you breastfeed yesterday, during the daylight hours?

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

NUMBER OF DAYLIGHT FEEDINGS: ___

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

YES 1
NO 2
DK 8

434A) CHECK 428:
CHILD BREASTFED?

'YES' ON 428: ___ (GO TO NEXT QUESTION)
'NO' ON 428 OR QUESTION NOT ASKED: ___ (GO TO 435)

434B) Was (NAME) given water or anything else to drink or eat other than breast milk yesterday or last night?

YES 1
NO 2 (GO TO 438)

435) At any time yesterday or last night, was (NAME) given any of the following foods or beverages?

Plain water?
Sugar water?
Juice?
Herbal tea?
Baby formula?
Tinned or powdered milk?
Fresh (animal) milk?
Other liquids?
Gruel, dumplings, bread, or doughnut made from wheat, sorghum, millet, corn, or rice?
Gruel, puree, or dumplings made from manioc, plantain, yam, potato, or taro?
Eggs, fish, or poultry?
Meat?
Other solid or semisolid food specially made for the child?

PLAIN WATER
YES 1
NO 2
DK 8
SUGAR WATER
YES 1
NO 2
DK 8
JUICE
YES 1
NO 2
DK 8
HERBAL TEA
YES 1
NO 2
DK 8
BABY FORMULA
YES 1
NO 2
DK 8
TINNED/POWDERED MILK
YES 1
NO 2
DK 8
FRESH MILK
YES 1
NO 2
DK 8
OTHER LIQUID
YES 1
NO 2
DK 8
FOOD MADE FROM WHEAT/SORGHUM/MILLET/CORN/RICE
YES 1
NO 2
DK 8
FOOD MADE FROM MANIOC/PLANTAIN/YAM/POTATO/TARO
YES 1
NO 2
DK 8
EGGS/FISH/POULTRY
YES 1
NO 2
DK 8
MEAT
YES 1
NO 2
DK 8
OTHER SOLID OR SEMISOLID FOOD SPECIALLY MADE FOR THE CHILD
YES 1
NO 2
DK 8

436) CHECK 435:
FOOD OR LIQUID GIVEN YESTERDAY?

'YES' TO ONE OR MORE: ___
NO TO ALL: ___ (GO TO 438)

437) (Aside from breast milk), how many times did (NAME) eat yesterday, including both meals and snacks like gruel, doughnuts, cookies?

IF 7 OR MORE TIMES, RECORD '7'.

NUMBER: ___
DK 8

438) On how many days during the last 7 days was (NAME) given the following?

Plain water?
Milk (other than breast milk)?
Other liquids?
Gruel, dumplings, bread, or doughnut made from wheat, sorghum, millet, corn, or rice?
Gruel, puree, or dumplings made from manioc, plantain, yam, potato, or taro?
Eggs, fish, or poultry?
Meat?
Green leafy vegetables?
Carrots?
Mango (including its juice)?
Papaya?
Melon?
Other solid or semisolid food specially made for the child?

PLAIN WATER MILK: ___
OTHER LIQUID: ___
FOOD MADE FROM WHEAT/SORGHUM/MILLET/CORN/RICE: ___
FOOD MADE FROM MANIOC/PLANTAIN/YAM/POTATO/TARO: ___
EGGS/FISH/POULTRY: ___
MEAT: ___
GREEN LEAFY VEG: ___
CARROT: ___
MANGO: ___
PAPAYA: ___
MELON: ___
OTHER SOLID OR SEMISOLID FOOD: ___

439) GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 440.

SECTION 4B. IMMUNIZATION AND HEALTH

440) ENTER THE LINE NUMBER AND NAME OF EACH BIRTH SINCE JANUARY 1991 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL FORMS).

441) SEE SECTION 2: LINE NUMBER FROM QUESTION 212

___

442) FROM 212 AND 216:

NAME: ___
LIVING: ___ (GO TO NEXT QUESTION)
DECEASED: ___ (GO TO 442 IN THE NEXT COLUMN, OR IF NO MORE BIRTHS, GO TO 465)

443) Do you have a booklet or card where (NAME)'s vaccinations are written down?

IF YES: May I see it, please?

YES, SEEN 1 (GO TO 445)
YES, NOT SEEN 2 (GO TO 447)
NO CARD 3

444) Did you ever have a vaccination booklet or card for (NAME)?

YES 1 (GO TO 447)
NO 2 (GO TO 447)

445)
(1) COPY THE VACCINATION DATES FOR EACH VACCINE FROM THE CARD.
(2) WRITE '44' IN THE 'DAY' COLUMN IF THE CARD SHOWS THAT A VACCINATION WAS GIVEN BUT THE DATE WAS NOT RECORDED.

BCG
DAY: ___
MONTH: ___
YEAR: ___
POLIO 0 (at birth)
DAY: ___
MONTH: ___
YEAR: ___
POLIO 1
DAY: ___
MONTH: ___
YEAR: ___
POLIO 2
DAY: ___
MONTH: ___
YEAR: ___
POLIO 3
DAY: ___
MONTH: ___
YEAR: ___
DPT 1
DAY: ___
MONTH: ___
YEAR: ___
DPT 2
DAY: ___
MONTH: ___
YEAR: ___
DPT 3
DAY: ___
MONTH: ___
YEAR: ___
DTAP 1
DAY: ___
MONTH: ___
YEAR: ___
DTAP 2
DAY: ___
MONTH: ___
YEAR: ___
MEASLES
DAY: ___
MONTH: ___
YEAR: ___
YELLOW FEVER
DAY: ___
MONTH: ___
YEAR: ___
LAST VITAMIN A
DAY: ___
MONTH: ___
YEAR: ___

446) Has (NAME) received a vaccination that is not recorded on this card?

RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3, DTAP 1-2, MEASLES, YELLOW FEVER, AND/OR VIT. A.

YES 1(PROBE VACCINATIONS AND WRITE '66' IN THE CORRESPONDING DAY IN THE COLUMN IN 445, THEN GO TO 448K)
NO 2 (GO TO 448K)
DK 8 (GO TO 448K)

447) Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases?

YES 1
NO 2 (GO TO 448L)
DK 8 (GO TO 448L)

448) Please tell me if (NAME) has received one of the following vaccinations:

448A) A BCG vaccination against tuberculosis, that is an injection in the left forearm that left a scar?

YES 1
NO 2
DK 8

448B) Polio vaccine, that is, drops in the mouth?

YES 1
NO 2 (GO TO 448E)
DK 8 (GO TO 448E)

448C) How many times?

NUMBER OF TIMES: ___

448D) When was the first polio vaccination given, just after birth or later?

JUST AFTER BIRTH 1
LATER 2

448E) DPT vaccine, that is, an injection usually given at the same time as the polio drops?

YES 1
NO 2 (GO TO 448G)
DK 8 (GO TO 448G)

448F) How many times?

NUMBER OF TIMES: ___

448G) The DTAP vaccine, that is, an injection given against several illnesses, including tetanus, pertussis, and polio?

YES 1
NO 2 (GO TO 448I)
DK 8 (GO TO 448I)

448H) How many times?

NUMBER OF TIMES: ___

448I) An injection against measles?

YES 1
NO 2
DK 8

448J) An injection against yellow fever?

YES 1
NO 2
DK 8

448K)
CHECK 445:
VITAMIN A RECORDED?

NO: ___ (GO TO NEXT QUESTION)
YES: ___ (GO TO 449)

448L) Did (NAME) receive a capsule like this one?

SHOW GEL CAP OF VITAMIN A.

YES 1
NO 2 (GO TO 449)
DK 8 (GO TO 449)

448M) How long ago did (NAME) receive a gel cap like this the last time?

RECORD THE RESPONSE IN MONTHS OR YEARS.

MONTH: ___ 1
YEAR: ___ 2

449) Has (NAME) had a fever any time during the last two weeks?

YES 1
NO 2
DK 8

450) Has (NAME) been ill with a cough any time during the last 24 hours?

YES 1
NO 2 (GO TO 454)
DK 8 (GO TO 454)

451) When (NAME) had the illness with a cough, did he/she breathe faster than usual (short, rapid breaths)?

YES 1
NO 2
DK 8

452) Did you seek advice or treatment for the cough?

YES 1
NO 2 (GO TO 454)

453) Where did you seek advice or treatment?

Anywhere else?

RECORD ALL MENTIONED.

PLEASE NOTE:
IF RESPONSE IS 'MILITARY HOSPITAL/GARRISON,' CIRCLE 'B' FOR N'DJAMENA AND THE CODE 'C' FOR OTHER CITIES.

PLEASE NOTE:
IF THE RESPONSE IS 'NURSE,' PROBE TO DETERMINE IF A REAL NURSE (CODE 'J' 'A HOSPITAL ('A'), OR A PUBLIC HEALTH CENTRE ('C').

PUBLIC SECTOR
PUBLIC HOSPITAL/MATERNITY CLINIC A
MILITARY HOSPITAL/GARRISON B
HEALTH CENTER/ DISPENSARY/GARRISON C
WALK-IN CLINIC D
HOSPITAL OR HEALTH CENTER PHARMACY E
OTHER PUBLIC (SPECIFY): ___ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL G
CLINIC/PRIVATE DOCTOR'S OFFICE H
PRIVATE HEALTH CENTER I
WORKPLACE HEALTH CENTER J
PHARMACY/PHARMACEUTICAL DEPOT K
OTHER PRIVATE MEDICAL (SPECIFY): ___ L
PUBLIC/PRIVATE SECTOR
VILLAGE PHARMACY/HEALTH CENTER M
OTHER
SHOP/BAR/MARKET N
FIRST AID WORKER O
TRAVELING SALESMAN P
FRIENDS/NEIGHBORS/RELATIVES Q
OTHER (SPECIFY): ___ X

454 Has (NAME) had diarrhea in the last two weeks?

YES 1
NO 2 (GO TO 463A)
DK 8 (GO TO 463A)

455) Was there any blood in the stool?

YES 1
NO 2
DK 8

456) On the worst day of the diarrhea, how many bowel movements did (NAME) have?

NUMBER OF BOWEL MOVEMENTS: ___
DK 98

457) Was he/she given the same amount to drink as before the diarrhea, or more, or less?

SAME 1
MORE 2
LESS 3
DK 8

458) Did you give him/her the same amount to eat as before the diarrhea, or more, or less?

SAME 1
MORE 2
LESS 3
DK 8

458A) CHECK 428: CHILD BREASTFED?

'YES' TO 428: ___ (GO TO NEXT QUESTION)
'NO' TO 428 OR 428 NOT ASKED: ___ (GO TO 459)

458B) When (NAME) had diarrhea, did he/she receive the same amount of breast milk, or more or less?

SAME 1
MORE 2
LESS 3

459) When (NAME) had diarrhea, was he/she given any of the following to drink?

A fluid made from a ORS packet like this one here? SHOW ORS PACKET
Grain-based Soup/gruel?
Sugar-salt-water solution (Oral rehydration solution)?
Rice water?
Milk/curdled milk (kefir)/yoghurt/or infant formula?

FLUID FROM ORS PACKET
YES 1
NO 2
DK 8
SOUP/GRUEL
YES 1
NO 2
DK 8
SUGAR-SALT-WATER SOLUTION
YES 1
NO 2
DK 8
RICE WATER
YES 1
NO 2
DK 8
MILK/CURDLED MILK/YOGURT/INFANT FORMULA
YES 1
NO 2
DK 8
HERBAL TEA/DECOCTION
YES 1
NO 2
DK 8
WATER
YES 1
NO 2
DK 8
OTHER LIQUIDS
YES 1
NO 2
DK 8

460) Was anything else given to treat the diarrhea?

YES 1
NO 2 (GO TO 462)
DK 8 (GO TO 462)

461) What was given or made to treat the diarrhea?

Anything else?

RECORD ALL MENTIONED.

PILL OR SYRUP A
INJECTION B
(I.V.) INTRAVENOUS/DRIP C
HOME REMEDY/HERBAL MEDICINE D
OTHER (SPECIFY): ___ X

462) Did you seek advice or treatment for the diarrhea?

YES 1
NO 2 (GO TO 463A)

463) Where did you seek advice or treatment?

Anywhere else?

RECORD ALL MENTIONED.

PLEASE NOTE:
IF RESPONSE IS 'MILITARY HOSPITAL/GARRISON,' CIRCLE 'B' FOR N'DJAMENA AND THE CODE 'C' FOR OTHER CITIES.

PLEASE NOTE:
IF THE RESPONSE IS 'NURSE,' PROBE TO DETERMINE IF A REAL NURSE (CODE 'J' 'A HOSPITAL ('A'), OR A PUBLIC HEALTH CENTER ('C').

PUBLIC SECTOR
PUBLIC HOSPITAL/MATERNITY CLINIC A
MILITARY HOSPITAL/GARRISON B
HEALTH CENTER/ DISPENSARY/GARRISON C
WALK-IN CLINIC D
HOSPITAL OR HEALTH CENTER PHARMACY E
OTHER PUBLIC (SPECIFY): ___ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL G
CLINIC/PRIVATE DOCTOR'S OFFICE H
PRIVATE HEALTH CENTER I
WORKPLACE HEALTH CENTER J
PHARMACY/PHARMACEUTICAL DEPOT K
OTHER PRIVATE MEDICAL (SPECIFY): ___ L
PUBLIC/PRIVATE SECTOR
VILLAGE PHARMACY/HEALTH CENTER M
OTHER
SHOP/BAR/MARKET N
FIRST AID WORKER O
TRAVELING SALESMAN P
FRIENDS/NEIGHBORS/RELATIVES Q
OTHER (SPECIFY): ___ X

463A) CHECK 119A AND 119B:
NIGHT BLINDNESS KNOWN?

'YES' ON 119A: ___ (GO TO NEXT QUESTION)
'NO' ON 119A: ___ (GO TO 464)

463B) Does (NAME) suffer from (NAME OF ILLNESS FROM 119B)?

YES 1
NO 2
DK 8

464) GO BACK TO 442 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 465.

465) When a child has diarrhea, should he/she be given less to drink than usual, about the same amount, or more than usual?

LESS TO DRINK 1
ABOUT THE SAME AMOUNT TO DRINK 2
MORE TO DRINK 3
DK 8

466) When a child has diarrhea, should he/she be given less to eat than usual, about the same amount, or more than usual?

LESS TO EAT 1
ABOUT THE SAME AMOUNT TO EAT 2
MORE TO EAT 3
DK 8

467) When a child is sick with diarrhea, what signs of illness would tell you that he/she should be taken to a health facility or health worker?

RECORD ALL MENTIONED.

REPEATED WATERY STOOLS A
ANY WATERY STOOLS B
REPEATED VOMITING C
ANY VOMITING D
BLOOD IN STOOLS E
FEVER F
MARKED THIRST G
NOT EATING/NOT DRINKING WELL H
GETTING SICKER/VERY SICK I
NOT GETTING BETTER J
OTHER (SPECIFY): ___ X
DK Z

468) When a child is sick with a cough, what signs of illness would tell you that he or she should be taken to a health facility or health worker?

RAPID BREATHING A
DIFFICULT BREATHING B
NOISY BREATHING C
FEVER D
UNABLE TO DRINK E
NOT EATING/NOT DRINKING WELL F
GETTING SICKER/VERY SICK G
NOT GETTING BETTER H
OTHER (SPECIFY): ___ X
DK Z

469) CHECK 459, ALL COLUMNS:

NO CHILD RECEIVED ORS: ___ (GO TO NEXT QUESTION)
ANY CHILD RECEIVED ORS: ___ (GO TO 471)

470) Have you heard of a special product called ORS packets that you can get for the treatment of diarrhea?

SHOW ORS PACKET.

YES 1
NO 2

471) Have you heard messages about certain foods good for eyesight and for avoiding night blindness?

YES 1
NO 2 (GO TO 473)

472) Can you name some of these foods?

Any others?

RECORD ALL MENTIONED.

CARROT A
CHIVE B
CABBAGE C
MANIOC ROOT D
MANGO E
PAPAYA F
MELON G
MEAT H
LIVER I
FISH J
EGG K
OTHER (SPECIFY): ___ X
DK Z

SECTION 4C. CAUSES OF DEATH OF CHILDREN BORN AND WHO HAVE DIED IN LAST 5 YEARS

473) RECORD THE LINE, THE NAME AND SURVIVAL STATUS OF EACH CHILD BORN SINCE JANUARY 1991 ACCORDING TO THE REPRODUCTION TABLE.
ASK THE QUESTIONS ABOUT ALL THESE BIRTHS ENDING IN DEATH. IF 3 OR MORE, BEGIN WITH THE LAST (IF MORE THAN 3 BIRTHS, USE ANOTHER QUESTIONNAIRE).

LINE NUMBER FROM 212:

___

ACCORDING TO 212 AND 216:

NAME: ___
LIVING: ___ (GO TO NEXT COLUMN; IF NO MORE BIRTHS GO TO 501)
DECEASED: ___ (GO TO NEXT QUESTION)

474) I know it can be difficult to talk about children that you have had who have died, but this information is very important for health programs and to avoid the deaths of other children.

I would like to ask you some questions about what happened and what symptoms your child presented before they died. (We will talk about only one child at a time)

475) In your opinion, what was the cause of (NAME)'s death?

_____

476) During the illness that preceded the death of (NAME), did you seek advice or treatment?

IF YES: Where did you go/who did you see?

PUBLIC SECTOR
HOSPITAL/MATERNITY WARD A
MILITARY HOSPITAL/GARRISON B
HEALTH CENTER/DISPENSARY/GARRISON C
WALK-IN HEALTH CENTER D
HOSPITAL/HEALTH CENTER PHARMACY E
OTHER PUBLIC (SPECIFY): ___ F
PRIVATE SECTOR
PRIVATE HOSPITAL G
CLINIC/DOCTOR'S OFFICE H
PRIVATE HEALTH CENTER I
WORKPLACE HEALTH CENTER J
PHARMACY/PHARMACEUTICAL WAREHOUSE K
OTHER PRIVATE (SPECIFY): ___ L
PUBLIC/PRIVATE SECTOR
VILLAGE PHARMACY/HEALTH CENTER M
OTHER
SHOP/MARKET N
FIRST AID WORKER O
TRAVELING SALESMAN P
FRIENDS/NEIGHBORS/RELATIVES Q
OTHER (SPECIFY): ___ X
NO Z

477) Where did (NAME)'s death happen?

AT HOME 1
IN HEALTH FACILITY 2
ON THE WAY TO HEALTH FACILITY 3
OTHER (SPECIFY): ___ 4

478) CHECK 219: AGE AT DEATH

LESS THAN ONE MONTH: ___
ONE MONTH OR MORE: ___

479) Was (NAME) born in a difficult delivery?

YES 1
NO 2
DK 8

480) Did (NAME) have any kind of malformation?

IF 'YES,' SPECIFY:

YES (SPECIFY): ___ 1
NO 2
DK 8

481) In the first days of life, did (NAME) breastfeed or drink normally?

YES 1
NO 2
DK 8

482) Did (NAME) at least breastfeed or did he/she have difficulty breastfeeding in the days
preceding death?

YES 1
NO 2
DK 8

483) In the illness preceding death, did (NAME) have convulsions or spasms?

YES 1
NO 2
DK 8

484) In the illness preceding death, did (NAME) have a cough?

YES 1
NO 2 (GO TO 488)
DK 8 (GO TO 488)

485) For how many days did the cough last?

IF LESS THAN A DAY, RECORD '00'.

DAYS: ___

486) When (NAME) had a cough, did he/she have difficulty breathing/rapid breathing?

YES 1
NO 2 (GO TO 488)
DK 8 (GO TO 488)

487) For how many days did he/she have difficulty breathing/rapid breathing?

IF LESS THAN A DAY, RECORD '1'.

DAYS: ___

488) RETURN TO 475 FOR THE FOLLOWING DECEASED CHILD. IF NO MORE DECEASED CHILDREN, GO TO 501.

489) During the illness that preceded the death, did (NAME) have very soft or liquid stool, that is, did he/she have diarrhea?

YES 1
NO 2 (GO TO 493)
DK 8 (GO TO 493)

490) Was the episode of diarrhea moderate or serious?

MODERATE 1
SERIOUS 2
DK 8

491) How long did the diarrhea last?

IF LESS THAN A DAY, RECORD 00 FOR 'DAY'.

DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
DK 998

492) Was there any blood in the stool?

YES 1
NO 2
DK 8

493) During the illness that preceded the death, did (NAME) have a cough?

YES 1
NO 2 (GO TO 497)
DK 8 (GO TO 497)

494) How long did the cough last?

IF LESS THAN A DAY, RECORD 00 FOR 'DAY'.

DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
DK 998

495) When (NAME) had a cough, did he/she have difficulty breathing or labored/rapid breaths?

YES 1
NO 2 (GO TO 497)
DK 8 (GO TO 497)

496) How long did he/she have difficulty breathing or labored/rapid breaths?

IF LESS THAN A DAY, RECORD 00 FOR 'DAY'.

DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
DK 998

497) During the illness that led to his/her death, did (NAME) have a fever?

YES 1
NO 2 (GO TO 498)
DK 8 (GO TO 498)

497A) Was the fever mild or high?

MILD 1
HIGH 2
DK 8

497B) How long did the fever last?

IF LESS THAN A DAY, RECORD 00 FOR 'DAY'.

DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
DK 998

498) In the illness that preceded death, was (NAME) unconscious?

YES 1
NO 2
DK 8

498A) In the illness that preceded death, did (NAME) have convulsions?

YES 1
NO 2
DK 8

498B) In the illness that preceded death, did (NAME) have a rash all over the body/face?

YES 1
NO 2 (GO TO 498D)
DK 8 (GO TO 498D)

498C) How long did the rash last?

IF LESS THAN A DAY, RECORD 00 FOR 'DAY'.

DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
DK 998

498D) In the illness that preceded death, was (NAME) very thin?

YES 1
NO 2 (GO TO 498F)
DK 8 (GO TO 498F)

498E) How long was he/she very thin?

IF LESS THAN A DAY, RECORD 00 FOR 'DAY'.

DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
DK 998

498F) In the illness that preceded death, did (NAME) have swollen feet or legs?

YES 1
NO 2 (GO TO 499)
DK 8 (GO TO 499)

498G) How long did he/she have swollen feet or legs?

IF LESS THAN A DAY, RECORD 00 FOR 'DAY'.

DAYS: ___ 1
WEEKS: ___ 2
MONTHS: ___ 3
DK 998

499) RETURN TO 475 FOR THE NEXT DECEASED CHILD; IF NO MORE DECEASED CHILDREN, GO TO 501.

SECTION 5. MARRIAGE

501) PRESENCE OF OTHERS AT THIS POINT.

CHILDREN UNDER 10
YES 1
NO 2
HUSBAND/PARTNER
YES 1
NO 2
OTHER MALES
YES 1
NO 2
OTHER FEMALES
YES 1
NO 2

502) Are you currently married or living with a man?

YES, CURRENTLY MARRIED 1 (GO TO 507)
YES, LIVING WITH A MAN 2 (GO TO 507)
NON-CONSUMMATED MARRIAGE 3 (GO TO 515F)
NO, NOT IN UNION 4

503) Do you currently have a regular sexual partner, an occasional sexual partner, or no sexual partner at all?

REGULAR SEXUAL PARTNER 1
OCCASIONAL SEXUAL PARTNER 2
NO SEXUAL PARTNER 3

504) Have you ever been married or lived in a union with a man?

YES, FORMERLY MARRIED 1
YES, LIVED WITH A MAN 2 (GO TO 511)
NO 3 (GO TO 515F)

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

WIDOWED 1 (GO TO 511)
DIVORCED 2
SEPARATED 3

506A) Who initiated the divorce/separation?

RESPONDENT/WIFE 1
HUSBAND/PARTNER 2
WIFE AND HUSBAND/JOINT DECISION 3
FAMILY 4

506B) What was the cause of your divorce/separation?

WIFE/RESPONDENT STERILITY 01 (GO TO 511)
HUSBAND/PARTNER STERILITY 02 (GO TO 511)
HUSBAND/PARTNER IMPOTENCE 03 (GO TO 511)
MATERIAL/FINANCIAL CAUSE 04 (GO TO 511)
MARITAL PROBLEM 05 (GO TO 511)
FAMILY PRESSURE 06 (GO TO 511)
OTHER (SPECIFY): ___ 96 (GO TO 511)

507) Does your husband/partner live with you, or is he staying elsewhere?

LIVES WITH HER 1
STAYING ELSEWHERE 2 (GO TO 508)

507A) RECORD THE LINE NUMBER OF HER HUSBAND FROM THE HOUSEHOLD QUESTIONNAIRE. IF NOT THERE, RECORD '00'.

___

508) Does your husband/partner have other wives besides you?

YES 1
NO 2 (GO TO 511)

509) How many other wives does he have?

NUMBER: ___
DK 98 (GO TO 511)

510) Are you the first, second, third…spouse?

RANK: ___

511) Have you been married or lived with a man only once, or more than one?

IF ONCE, RECORD '1'.
IF SEVERAL TIMES, ASK AND RECORD NUMBER.

NUMBER OF TIMES: ___

512) CHECK 511:

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

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

MONTH: ___
DK MONTH 98

YEAR: ___ (GO TO 514)
DK YEAR 98

513) How old were you when you started living with your (first) husband/partner?

AGE: ___

514) CHECK 502 AND 506:

502: CURRENTLY MARRIED/LIVING WITH A MAN: ___ (GO TO NEXT QUESTION)
506: WIDOW, DIVORCEE, OR SEPARATED: ___ (GO TO 515F)

515) Now I would like to ask you some questions about your sexual activity in order to gain a better understanding of some family planning issues.

When did you last have sexual relations with your (husband/man you live with)?

IF RESPONSE IS 'NEVER,' RETURN TO 502, RECORD 'NON-CONSUMMATED MARRIAGE' AND FOLLOW THE NEW PATH INSTRUCTIONS.

DAYS AGO: ___ 1
WEEKS AGO: ___ 2
MONTHS AGO: ___ 3
YEARS AGO: ___ 4
BEFORE LAST BIRTH 996

515A) CHECK 301 AND 302:

KNOWS CONDOM:
The last time you had sex, was a condom used?

DOES NOT KNOW CONDOM:
Some men use a condom, which means that the put a rubber sheath on their penis during sexual intercourse. The last time you had sex, was a condom used?

YES 1
NO 2
DK 8

515B) Have you had sexual relations with anyone else besides your (husband/man you live with) in the past 12 months?

YES 1
NO 2 (GO TO 517)

515C) When did you last have sexual relations with someone besides your (husband/man you live with)?

DAYS AGO: ___ 1
WEEKS AGO: ___ 2
MONTHS AGO: ___ 3
YEARS AGO: ___ 4
BEFORE LAST BIRTH 996

515D) Was a condom used at this time?

YES 1
NO 2
DK 8

515E) Over the past 12 months, with how many different people besides your (husband/man you live with) did you have sexual relations?

NUMBER OF PEOPLE: ___ (GO TO 517)
DK 98 (GO TO 517)

515F) Now I would like to ask you some questions about your sexual activity in order to gain a better understanding of some family planning issues.

When did you last have sexual relations (if ever)?

NEVER 000 (GO TO 608)
DAYS AGO: ___ 1
WEEKS AGO: ___ 2
MONTHS AGO: ___ 3
YEARS AGO: ___ 4
BEFORE LAST BIRTH 996

515G) CHECK 301 AND 302:

KNOWS CONDOM:
The last time you had sex, was a condom used?

DOES NOT KNOW CONDOM:
Some men use a condom, which means that the put a rubber sheath on their penis during sexual intercourse. The last time you had sex, was a condom used?

YES 1
NO 2
DK 8

515H) CHECK 515F:

FEWER THAN 12 MONTHS SINCE LAST SEXUAL RELATIONS: ___ (GO TO NEXT QUESTION)
12 MONTHS OR MORE SINCE LAST SEXUAL RELATIONS: ___ (GO TO 517)

515I) Over the past 12 months, with how many different people did you have sexual relations?

NUMBER OF PEOPLE: ___
DK 98

517) Do you know of a place where you can get condoms?

YES 1
NO 2 (GO TO 519)

518) 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.

PLEASE NOTE:
IF RESPONSE IS 'MILITARY HOSPITAL/GARRISON,' CIRCLE '12' FOR N'DJAMENA AND THE CODE '13' FOR OTHER CITIES.

PLEASE NOTE:
IF THE RESPONSE IS 'NURSE,' PROBE TO DETERMINE IF A REAL NURSE (CODE '25' 'WORKPLACE HEALTH CENTER), A HOSPITAL, OR A PUBLIC HEALTH CENTER.

NAME OF PLACE: ___
PUBLIC SECTOR
PUBLIC HOSPITAL/MATERNITY CLINIC 11
MILITARY HOSPITAL/GARRISON 12
HEALTH CENTER/ DISPENSARY/GARRISON 13
WALK-IN CLINIC 14
HOSPITAL OR HEALTH CENTER PHARMACY 15
OTHER PUBLIC (SPECIFY): ___ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
CLINIC/PRIVATE DOCTOR'S OFFICE 22
CHADIAN FAMILY WELFARE ASSOCIATION 23
PRIVATE HEALTH CENTER 24
WORKPLACE HEALTH CENTER 25
PHARMACY/PHARMACEUTICAL DEPOT 26
OTHER PRIVATE MEDICAL (SPECIFY): ___ 27
PUBLIC/PRIVATE SECTOR
VILLAGE PHARMACY/HEALTH CENTER 31
OTHER
SHOP/BAR/MARKET 41
FIRST AID WORKER 42 (GO TO 518C)
TRAVELING SALESMAN 43 (GO TO 518C)
FRIENDS/NEIGHBORS/RELATIVES 44 (GO TO 518C)
OTHER (SPECIFY): ___ 96

518A) How far away is (NAME OF PLACE IN 518)?

RECORD '95' FOR 95 KILOMETERS OR MORE.

DISTANCE IN KM: ___
DK 98

518B) How long does it take to get to (NAME OF PLACE IN 518)?

RECORD '300' FOR 5 HOURS OR MORE.

TIME IN MINUTES: ___
DK 998

518C) How much does one condom cost?

PRICE IN CAF (CENTRAL AFRICAN FRANCS): ___
FREE 996
DK 998

519) How old were you when you first had sexual intercourse?

AGE: ___
FIRST TIME WHEN MARRIED 96

SECTION 6. FERTILITY PREFERENCES

601) CHECK 314:

NEITHER STERILIZED: ___ (GO TO NEXT QUESTION)
HIM OR HER STERILIZED: ___ (GO TO 612)

602) CHECK 227:

NOT PREGNANT OR UNSURE:
Now I have some questions about the future. Would you like to have (a/nother) child or would you prefer not have any (more) children?

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

HAVE (ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 606)
SHE SAYS SHE CAN'T GET PREGNANT 3 (GO TO 606)
UNDECIDED OR DK 8 (GO TO 604)

603) CHECK 227:

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

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

MONTHS: ___ 1
YEARS: ___ 2
SOON/NOW 993 (GO TO 606)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 606)
AFTER MARRIAGE 995
OTHER (SPECIFY): ___ 996
DK 998

604) CHECK 227:

NOT PREGNANT OR UNSURE: ___ (GO TO NEXT QUESTION)
PREGNANT: ___ (GO TO 607)

605) If you became pregnant in the next few weeks, would you be happy, unhappy, or would it not matter very much?

HAPPY 1
NOT HAPPY 2
WOULD NOT MATTER 3

606) CHECK 313: USING A METHOD?

NOT ASKED: ___ (GO TO NEXT QUESTION)
NOT CURRENTLY USING: ___ (GO TO NEXT QUESTION)
CURRENTLY USING: ___ (GO TO 612)

607) Do you think you will use a method to delay or avoid pregnancy in the next 12 months?

YES 1 (GO TO 609)
NO 2
DK 8

608) Do you think you will use a method in the future?

YES 1
NO 2 (GO TO 610)
DK 8 (GO TO 610)

609) What method would you prefer to use?

PILL 01 (GO TO 612)
IUD 02 (GO TO 612)
INJECTABLES 03 (GO TO 612)
IMPLANT 04 (GO TO 612)
DIAPHRAGM/FOAM/GEL 05 (GO TO 612)
CONDOM 06 (GO TO 612)
FEMALE STERILIZATION 07 (GO TO 612)
MALE STERILIZATION 08 (GO TO 612)
PERIODIC ABSTINENCE 09 (GO TO 612)
WITHDRAWAL 10 (GO TO 612)
OTHER (SPECIFY): ____ 96 (GO TO 612)
DK/UNSURE 98 (GO TO 612)

610) What is the main reason you think you will never use a method?

NOT MARRIED 11
FERTILITY-RELATED REASONS
INFREQUENT SEX 22 (GO TO 612)
MENOPAUSAL/HYSTERECTOMY 23 (GO TO 612)
SUBFECUND/STERILE 24 (GO TO 612)
WANTS (MORE) CHILDREN 26 (GO TO 612)
OPPOSITION TO USE
RESPONDENT OPPOSED 31 (GO TO 612)
HUSBAND OPPOSED 32 (GO TO 612)
OTHERS OPPOSED 33 (GO TO 612)
RELIGIOUS PROHIBITION 34 (GO TO 612)
LACK OF KNOWLEDGE
KNOWS NO METHOD 41 (GO TO 612)
KNOWS NO SOURCE 42 (GO TO 612)
METHOD-RELATED REASONS
HEALTH CONCERNS 51 (GO TO 612)
FEAR OF SIDE EFFECTS 52 (GO TO 612)
LACK OF ACCESS/TOO FAR 53 (GO TO 612)
COST TOO MUCH 54 (GO TO 612)
INCONVENIENT TO USE 55 (GO TO 612)
INTERFERES WITH BODY'S NORMAL PROCESSES 56 (GO TO 612)
OTHER (SPECIFY): ___ 96 (GO TO 612)
DK 98 (GO TO 612)

611) Would you use a method if you were married?

YES 1
NO 2
DK 8

612) CHECK 216:

HAS LIVING CHILDREN:
If you could go back to the time when 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.

NUMBER: ___
OTHER (SPECIFY): ___ 96 (GO TO 614)

612A) What is the main reason you would like to have (NUMBER OF CHILDREN FROM 612)?

ECONOMIC/FINANCIAL REASONS 01
SUPPORT IN OLD AGE 02
HELP IN WORK 03
SUPPLEMENTAL WORK 04
TO BE ABLE TO WORK 05
UNCERTAINTY ABOUT FUTURE 06
ENSURE GOOD FUTURE/EDUCATION FOR CHILDREN 07
FAMILY PRESTIGE/SOCIAL STANDING 08
WILL OF GOD 09
RELIGIOUS/SOCIAL OBLIGATION 10
AFFECTION/COMPANY 11
HEALTH PROBLEMS LINKED TO MOTHERHOOD 12
ILLNESS/DEATH OF CHILDREN 13
OTHER (SPECIFY): ___ 96
DK 98

613) Among the (NUMBER OF CHILDREN FROM 612), of children that you want, how many would you like to be boys, how many would you like to be girls, and for how many would it not matter?

ADD 'BOYS' AND 'GIRLS' AND 'EITHER'. THIS NUMBER SHOULD BE EQUAL TO NUMBER IN 612. IF 'NO', CHECK AND CORRECT.

NUMBER OF BOYS: ___
OTHER (SPECIFY): ___ 96
NUMBER OF GIRLS: ___
OTHER (SPECIFY): ___ 96
NUMBER OF EITHER: ___
OTHER (SPECIFY): ___ 96

614) In general, do you approve or disapprove of couples using a method to avoid getting pregnant?

APPROVE 1
DISAPPROVE 2
NO OPINION 3

615) Do you find it acceptable or not acceptable that information on family planning is broadcast :
On the radio?
On television?

RADIO
ACCEPTABLE 1
NOT ACCEPTABLE 2
DK 8
TELEVISION
ACCEPTABLE 1
NOT ACCEPTABLE 2
DK 8

616) In the last few months, have you heard anything about family planning:

On the radio?
On television?
In newspapers or magazines?
From a poster?
From a leaflet or brochure?

RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NEWSPAPER OR MAGAZINE
YES 1
NO 2
POSTER
YES 1
NO 2
LEAFLET OR BROCHURE
YES 1
NO 2

616A) CHECK 616:

RADIO 'YES': ___ (GO TO NEXT QUESTION)
RADIO 'NO': ___ (GO TO 618)

617) In the last few months, have you heard a message on the radio promoting:
Birth spacing?
Mother's health?

BIRTH SPACING
YES 1
NO 2
MOTHER'S HEALTH
YES 1
NO 2

618) In the last few months, have you discussed the practice of family planning with your friends, neighbors, or relatives?

YES 1
NO 2 (GO TO 620)

619) With whom have you discussed it?
Anyone else?

RECORD ALL MENTIONED.

HUSBAND/PARTNER A
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER D
MOTHER-IN-LAW G
FRIENDS/NEIGHBORS H
OTHER (SPECIFY): ___ X

620) CHECK 502:

YES, CURRENTLY MARRIED: ___ (GO TO NEXT QUESTION)
YES, LIVING WITH A MAN: ___ (GO TO NEXT QUESTION)
NO, NOT IN UNION/MARRIAGE NOT CONSUMMATED: ___ (GO TO 701)

621) Spouses/partners do not always agree on everything. Now I want to ask you some questions about your husband/partner's point of views on family planning.

Do you think that your husband/partner approves or disapproves of couples using a method to avoid pregnancy?

APPROVES 1
DISAPPROVES 2
DK 8

622) How often have you talked to your husband/partner about this subject in the last 12 months?

NEVER 1
ONCE OR TWICE 2
MORE OFTEN 3

623) Do you think your husband/partner wants the SAME number of children that you want, or does he want MORE or FEWER than you want?

SAME 1
MORE 2
LESS 3
DK 8

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

701) CHECK 502 AND 504:

CURRENTLY MARRIED/ IVING TOGETHER: ___ (GO TO NEXT QUESTION)
FORMERLY MARRIED OR LIVED WITH A MAN: ___ (GO TO 703)
NEVER MARRIED AND NEVER LIVED TOGETHER/ NON-CONSUMMATED MARRIAGE: ___ (GO TO 709)

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

AGE: ___

703) Did your husband/partner go to school?

YES 1
NO 2 (GO TO 706)

704) What is the highest level of school that he reached: primary, secondary, higher, secondary-level professional, higher-level professional, or madrassa?

PRIMARY 1
SECONDARY 2
HIGHER 3
SECONDARY-LEVEL PROFESSIONAL 4
HIGHER-LEVEL PROFESSIONAL 5
MADRASSA 6 (GO TO 706)
DK 8 (GO TO 706)

705) What was the last (grade, year) that he completed at that level?

PRIMARY (INCLUDING MADRASA)
LESS THAN A YEAR COMPLETED IN THE CORRESPONDING LEVEL 0
INTRODUCTORY CLASS 1
PREPARATORY CLASS 2
ELEMENTARY CLASS 1 3
ELEMENTARY CLASS 2 4
MIDDLE-LEVEL CLASS 1 5
MIDDLE-LEVEL CLASS 2 6
SECONDARY (INCLUDING MADRASA)
LESS THAN A YEAR COMPLETED IN THE CORRESPONDING LEVEL 0
6TH 1
5TH 2
4TH 3
3RD 4
2ND 5
1ST 6
FINAL YEAR 7
HIGHER (INCLUDING MADRASA)
LESS THAN A YEAR COMPLETED IN THE CORRESPONDING LEVEL 0
FIRST YEAR 1
SECOND YEAR 2
THIRD YEAR 3
FOURTH YEAR AND + 4
SECONDARY-LEVEL PROFESSIONAL
LESS THAN A YEAR COMPLETED IN THE CORRESPONDING LEVEL 0
6TH OR 1ST YEAR 1
5TH OR 2ND YEAR 2
4TH OR 3RD YEAR 3
3RD OR 4TH YEAR 4
2ND OR 5TH YEAR 5
1ST OR 6TH YEAR 6
FINAL YEAR OR 7TH YEAR 7
HIGHER-LEVEL PROFESSIONAL
LESS THAN A YEAR COMPLETED IN THE CORRESPONDING LEVEL 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH YEAR OR + 4

706) What is/was your husband/partner's main occupation, that is, what kind of work does (did) he mainly do?

_____

707) CHECK 706:

WORKS (WORKED) IN AGRICULTURE: ___ (GO TO NEXT QUESTION)
DOES (DID) NOT WORK IN AGRICULTURE: ___ (GO TO 709)

708) (Does/did) your husband/partner work mainly on his own land or on family land or does/did he rent land, or does/did he work on someone else's land?

HIS LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4

709) Aside from your own housework, are you currently working?

YES 1 (GO TO 712)
NO 2

710) As you know, some women take up jobs for which there are paid in cash or in kind. Others sell things, have a small business or work on the family farm or in the family business.

Are you currently doing any of these things or any other work aside from your own housework?

YES 1 (GO TO 712)
NO 2

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

YES 1
NO 2 (GO TO 801A)

712) What is your main occupation, that is, what kind of work do you do?

_____

713) CHECK 712:

WORKS IN AGRICULTURE: ___ (GO TO NEXT QUESTION)
DOES NOT WORK IN AGRICULTURE: ___ (GO TO 715)

714) Do you work on your own land or on family land, or do you rent land, or do you work on someone else's land?

OWN LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4

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

FOR FAMILY MEMBER 1
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3

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

THROUGHOUT THE YEAR 1 (GO TO 718)
SEASONAL WORK 2
ONCE IN A WHILE 3 (GO TO 719)

717) In the last 12 months, how many months did you work?

NUMBER OF MONTHS: ___

718) (In the months that you worked), how many days per month did you work?

NUMBER OF DAYS: ___ (GO TO 720)

719) During the past 12 months, approximately how many days did you work?

NUMBER OF DAYS: ___

720) Do you earn money for this work? That is, do you earn cash or something else in kind for this work?

YES 1
NO 2 (GO TO 723)

721) How much do you usually earn for this work?

-IF WOMAN IS PAID IN KIND, CIRCLE '0'.

-IF WOMAN EARNS CASH, PROBE:
Is this by the hour, by the day, by the week, by the month, or by the year?

RECORD THE CORRESPONDING CODE AND RECORD THE SUM, PRECEDED BY'0' IF NECESSARY.

IN KIND 0
PER HOUR: ___ 1
PER DAY: ___ 2
PER WEEK: ___ 3
PER MONTH: ___ 4
PER YEAR: ___ 5
OTHER (SPECIFY): ___ 6

722) CHECK 502:

YES, CURRENTLY MARRIED,
YES, LIVING WITH A MAN:
Who mainly decides how the money you earn will be used: you, your husband/partner, you and your husband/partner jointly, or someone else?

NO, NOT IN UNION/ IN NON-CONSUMMATED MARRIAGE:
Who mainly decides how the money you earn will be used: you, someone else, or you and someone else together?

RESPONDENT DECIDES 1
HUSBAND/PARTNER DECIDES 2
JOINTLY WITH HUSBAND/PARTNER 3
SOMEONE ELSE DECIDES 4
JOINTLY WITH SOMEONE ELSE 5

723) Do you do this work at home or away from home?

HOME 1
AWAY 2

724) CHECK 217 AND 218: IS A CHILD LIVING AT HOME WHO IS AGE 5 OR LESS?

YES: ___ (GO TO NEXT QUESTION)
NO: ___ (GO TO 801A)

725) Who usually takes care of (NAME OF YOUNGEST CHILD AT HOME) while you are working?

RESPONDENT 01
HUSBAND/PARTNER 02
OLDER FEMALE CHILD 03
OTHER MALE CHILD 04
OTHER RELATIVES 05
NEIGHBORS 06
FRIENDS 07
SERVANT/HIRED HELP 08
CHILD IS IN SCHOOL 09
INSTITUTIONAL CHILDCARE 10
HAS NOT WORKED SINCE LAST BIRTH 95
OTHER (SPECIFY): ___ 96

SECTION 8. AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES

801A) Have you ever heard of illnesses that can be sexually transmitted?

YES 1
NO 2 (GO TO 801K)

801B) What illnesses do you know about?

RECORD ALL MENTIONED.

SYPHILIS/POX A
GONORRHEA/BLENNORRAGY B
AIDS C
GENITAL WART/TUMOR D
OTHER (SPECIFY): ___ W
OTHER (SPECIFY): ___ X
DK Z

801C) CHECK 515 AND 515F:

HAS HAD SEXUAL RELATIONS: ___ (GO TO NEXT QUESTION)
HAS NEVER HAD SEXUAL RELATIONS: ___ (GO TO 801K)

801D) In the last 12 months, have you had any of these illnesses?

YES 1
NO 2 (GO TO 801K)
DK 8 (GO TO 801K)

801E) What illnesses have you had?

RECORD ALL MENTIONED.

SYPHILIS/POX A
GONORRHEA/BLENNORRAGY B
AIDS C
GENITAL WART /GENITAL TUMOR D
OTHER (SPECIFY): ___ W
DK Z

801F) The last time that you had (DISEASE FROM 801E) did you seek advice or treatment?

YES 1
NO 2 (GO TO 801H)

801G) Where did you seek advice or treatment?

Anywhere else? From anyone else?

RECORD ALL MENTIONED.

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

PLEASE NOTE:
IF RESPONSE IS 'MILITARY HOSPITAL/GARRISON,' CIRCLE 'B' FOR N'DJAMENA AND THE CODE 'C' FOR OTHER CITIES.

PLEASE NOTE:
IF THE RESPONSE IS 'NURSE,' PROBE TO DETERMINE IF A REAL NURSE (CODE 'K' "WORKPLACE HEALTH CENTER") OF IF A HOSPITAL OR A PUBLIC HEALTH CENTER.

PUBLIC SECTOR
PUBLIC HOSPITAL/MATERNITY CLINIC A
MILITARY HOSPITAL/GARRISON B
HEALTH CENTER/DISPENSARY/GARRISON C
WALK-IN CLINIC D
HOSPITAL OR HEALTH CENTER PHARMACY E
OTHER PUBLIC (SPECIFY): ___ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL G
CLINIC/PRIVATE DOCTOR'S OFFICE H
CHADIAN FAMILY WELFARE ASSOCIATION I
PRIVATE HEALTH CENTER J
WORKPLACE HEALTH CENTER K
PHARMACY/PHARMACEUTICAL DEPOT L
OTHER PRIVATE MEDICAL (SPECIFY): ___ M
PUBLIC/PRIVATE SECTOR
VILLAGE PHARMACY/HEALTH CENTER N
OTHER
SHOP/BAR/MARKET O
FIRST AID WORKER P
TRAVELING SALESMAN Q
FRIENDS/NEIGHBORS/RELATIVES R
HEALER S
OTHER (SPECIFY): ___ X

801GA) In all, how much did the treatment cost you?

IF MORE THAN 99,994 CFA, RECORD '99994'.

TOTAL COST (CFA): ___
FREE 99995
DK 99998

810H) When you had the (DISEASE(S) FROM 801E), did you tell your partner(s)?

YES 1
NO 2

810I) When you had the (DISEASE(S) FROM 801E), did you do something to avoid infecting your partner(s)?

YES 1
NO 2 (GO TO 801K)
PARTNER ALREADY INFECTED 3 (GO TO 801K)

801J) What did you do?

RECORD ALL MENTIONED.

ABSTAINED FROM SEXUAL RELATIONS A
USED CONDOMS B
TOOK MEDICATION C
OTHER (SPECIFY): ___ X

801K) CHECK 801B:

DID NOT MENTION AIDS: ___ (GO TO NEXT QUESTION)
MENTIONED AIDS: ___ (GO TO 801LA)

801L) Have you ever heard of an illness called AIDS?

YES 1
NO 2 (GO TO 811C)

801LA) Where did you hear about AIDS for the first time?

RADIO 01
TV 02
NEWSPAPERS/MAGAZINES 03
PAMPHLETS/BROCHURES 04
HEALTH WORKER 05
MOSQUE/CHURCH 06
SCHOOLS/TEACHER 07
COMMUNITY MEETINGS 08
FRIENDS/RELATIVES 09
WORK PLACE 10
OTHER (SPECIFY): ___ 96

802) From which sources of information have you learned most about AIDS?

Any other sources?

RECORD ALL MENTIONED.

RADIO A
TV B
NEWSPAPERS/MAGAZINES C
PAMPHLETS/BROCHURES D
HEALTH WORKER E
MOSQUE/CHURCH F
SCHOOLS/TEACHER G
COMMUNITY MEETINGS H
FRIENDS/RELATIVES I
WORK PLACE J
OTHER (SPECIFY): ___ X

802B) How can one catch AIDS?

Any other way?

RECORD ALL MENTIONED.

SEX B
NOT USING CONDOMS C
SEX WITH MULTIPLE PARTNERS E
SEX WITH PROSTITUTES G
HOMOSEXUAL SEX H
BLOOD TRANSFUSIONS I
INJECTIONS J
FROM MOTHER TO CHILD K
KISSING L
MOSQUITO BITES M
LIVING WITH SOMEONE WITH AIDS N
CONTAMINATED BLADES, SCISSORS, KNIVES, OTHER CUTTING INSTRUMENTS Q
EXCISION/CIRCUMCISION/EAR-PIERCING R
EATING/DRINKING FROM SAME DISHES AS SOMEONE INFECTED WITH AIDS S
OTHER (SPECIFY): ___ X
DK Z

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

YES 1
NO 2 (GO TO 807)
DK 8 (GO TO 807)

804) What can a person do?

Anything else?

RECORD ALL MENTIONED.

ABSTAIN FROM SEX B
USE CONDOMS C
HAVE ONLY ONE SEX PARTNER D
BE FAITHFUL F
AVOID SEX WITH PROSTITUTES G
AVOID SEX WITH HOMOSEXUALS H
AVOID BLOOD TRANSFUSIONS I
AVOID INJECTIONS J
AVOID KISSING L
AVOID MOSQUITO BITES M
AVOID LIVING WITH PEOPLE WITH AIDS N
SEEK PROTECTION FROM GOD/PRAY P
AVOID CONTAMINATED BLADES, SCISSORS, KNIVES, CUTTING INSTRUMENTS Q
AVOID EXCISION/CIRCUMCISION/EAR-PIERCING R
AVOID EATING/DRINKING FROM SAME DISHES AS SOMEONE INFECTED WITH AIDS S
OTHER (SPECIFY): ___ X
DK Z

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

YES 1
NO 2
DK 8

808) Do you think that a person with AIDS almost never die from the disease, sometimes die, or almost always die from the disease?

ALMOST NEVER 1
SOMETIMES 2
ALMOST ALWAYS 3
DK 8

808A) Can one be cured of AIDS?

YES 1
NO 2
DK 8

808B) Can AIDS be transmitted from mother to child during pregnancy or birth?

YES 1
NO 2
DK 8

808C) Do you know someone personally who has AIDS or who died of AIDS?

YES 1
NO 2
DK 8

809) Do you think your chances of getting AIDS are small, moderate, great, or no risk at all?

SMALL 1
MODERATE 2 (GO TO 809C)
GREAT 3 (GO TO 809C)
NO RISK AT ALL 4
HAS AIDS 5 (GO TO 811A)

809B) Why do you think that you have (NO/LITTLE) risk of getting AIDS?

Any other reason?

RECORD ALL MENTIONED.

ABSTAINS FROM SEX B (GO TO 809CA)
USES CONDOMS C (GO TO 809CA)
HAS ONLY 1 SEX PARTNER D (GO TO 809CA)
HAS LIMITED NUMBER OF SEX PARTNERS E (GO TO 809CA)
PARTNER HAS NO OTHER PARTNERS F (GO TO 809CA)
DOES NOT HAVE SEX WITH HOMOSEXUALS H (GO TO 809CA)
DOES NOT HAVE BLOOD TRANSFUSIONS I (GO TO 809CA)
DOES NOT HAVE INJECTIONS J (GO TO 809CA)
PROTECTED BY TRADITIONAL HEALERS O (GO TO 809CA)
PROTECTED BY GOD P (GO TO 809CA)
AVOIDS CONTAMINATED BLADES, SCISSORS, KNIVES, CUTTING INSTRUMENTS Q (GO TO 809CA)
AVOIDS EXCISION/CIRCUMCISION/EAR-PIERCING R (GO TO 809CA)
AVOIDS EATING/DRINKING FROM SAME DISHES AS SOMEONE INFECTED WITH AIDS S (GO TO 809CA)
OTHER (SPECIFY): ___ X (GO TO 809CA)

809C) Why do you think that you have (MODERATE/GREAT) risk of getting AIDS?

Any other way?

RECORD ALL MENTIONED.

DOES NOT USE CONDOMS C
MORE THAN 1 SEX PARTNER D
MANY SEX PARTNERS E
PARTNER HAS OTHER PARTNERS(S) F
SEX WITH HOMOSEXUALS H
BLOOD TRANSFUSIONS I
INJECTIONS J
CONTAMINATED BLADES, SCISSORS, KNIVES, CUTTING INSTRUMENTS Q
EXCISION/CIRCUMCISION/EAR PIERCING R
EATS/DRINKS FROM SAME DISHES AS SOMEONE INFECTED WITH AIDS S
OTHER (SPECIFY): ___ X

809CA) In your opinion, what should be done with people sick with AIDS?

SEND THEM TO HOSPITAL 01
KEEP THEM AT HOME 02
ISOLATE THEM 03
HELP THEM 04
OTHER (SPECIFY): ___ 96

811A) Since you have heard about AIDS, have you changed your behavior to avoid getting AIDS?

IF YES, What have you done?

RECORD ALL MENTIONED.

DID NOT START SEX A (GO TO 811C)
STOPPED ALL SEX B (GO TO 811C)
STARTED USING CONDOMS C (GO TO 811C)
RESTRICTED SEX TO 1 PARTNER D (GO TO 811C)
REDUCED NUMBER OF PARTNERS E (GO TO 811C)
ASKED PARTNER TO BE FAITHFUL F (GO TO 811C)
STOPPED SEX WITH HOMOSEXUALS H (GO TO 811C)
STOPPED INJECTIONS J
SOUGHT PROTECTION FROM TRADITIONAL HEALERS O
SOUGHT PROTECTION FROM GOD/PRAYER P
AVOIDS CONTAMINATED BLADES/SCISSORS/KNIVES/CUTTING TOOLS Q
AVOIDS EXCISION/CIRCUMCISION/EAR-PIERCING R
AVOIDS EATING/DRINKING FROM SAME DISHES AS PERSON WITH AIDS S
OTHER (SPECIFY): ___ X
NO CHANGE Y

811B) Has your knowledge of AIDS influenced or changed your decision to have sex or your sexual behavior?

IF YES, in what way?

RECORD ALL MENTIONED.

DID NOT START SEX A
STOPPED ALL SEX B
STARTED USING CONDOMS C
RESTRICTED SEX TO 1 PARTNER D
REDUCED NUMBER OF PARTNERS E
ASKED PARTNER TO BE FAITHFUL F
STOPPED SEX WITH HOMOSEXUALS H
OTHER (SPECIFY): ___ X
NO CHANGE Y

811C) Some people use a condom during sexual relations to avoid getting AIDS or other sexually transmitted diseases. Have you ever heard about them?

YES 1
NO 2 (GO TO 811F)

811D) CHECK 515 AND 515F:

HAS HAD SEX: ___ (GO TO NEXT QUESTION)
HAS NEVER HAD SEX: ___ (GO TO 901)

811E) It is possible that we have already talked about this. Have you ever used a condom during sex to avoid getting or transmitting illnesses, such as AIDS?

YES 1 (GO TO 811G)
NO 2 (GO TO 811G)

811F) CHECK 515 AND 515F:

HAS HAD SEX: ___ (GO TO NEXT QUESTION)
HAS NEVER HAD SEX: ___ (GO TO 901)

811G) In the last 12 months, have you given or received money, presents, or favors in exchange for sex?

YES 1
NO 2

SECTION 9. MATERNAL MORTALITY

901) Now, I want to ask you questions about your brothers and sisters, that is to say, all children born to your natural mother. Please give me the names of all the brothers and sisters who live with you, those who live elsewhere and those who died.

How many children did your mother give birth to, including you?

NATURAL MOTHER BIRTH NUMBER: ___

902) CHECK 901:

TWO OR MORE BIRTHS: ___ (GO TO NEXT QUESTION)
ONLY ONE BIRTH (RESPONDENT ONLY): ___ (GO TO 916)

903) How many of these births did your mother have before your birth?

NUMBER OF PRECEDING BIRTHS: ___

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

_____

905) Is (NAME) male or female?

MALE 1
FEMALE 2

906) Is (NAME) still alive?

YES 1
NO 2 (GO TO 908)
DK 8 (GO TO NEXT SIBLING)

907) How old is (NAME)?

___ (GO TO NEXT SIBLING)

908) In what year did (NAME) die?

19___ (GO TO 910)
DK (GO TO NEXT SIBLING)

909) How many years ago did (NAME) die?

_____

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

_____ (IF MALE OR DIED BEFORE THE AGE OF 12, GO TO NEXT SIBLING)

911) Was (NAME) pregnant when she died?

YES 1 (GO TO 914)
NO 2

912) Did (NAME) die in childbirth?

YES 1 (GO TO 915)
NO 2

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

YES 1
NO 2 (GO TO 915)

914) Was the death related to pregnancy or delivery complications?

YES 1
NO 2

915) To how many children has (NAME) given birth in her life?

_____

915A) Where did this death occur?

HOME 1
HEALTH FACILITY 2
ON THE WAY TO HEALTH FACILITY 3
OTHER 4 (GO TO NEXT SIBLING)

IF NO MORE BROTHERS/SISTERS, GO TO 916.

916) RECORD TIME:

HOURS: ___
MINUTES: ___

SECTION A. WEIGHT AND HEIGHT

A01) CHECK 215:

ONE OR MORE LIVE BIRTHS SINCE JANUARY 1991: ___ (GO TO NEXT QUESTION)
NO LIVE BIRTHS SINCE JANUARY 1991: ___ (END)

INTERVIEWER:
IN A02 (COLUMNS 2-4) RECORD THE LINE NUMBER FOR EACH CHILD BORN AFTER JANUARY 1991 AND STILL ALIVE.
IN A03 AND A04, RECORD THE NAME AND BIRTH DATE OF RESPONDENT AND FOR ALL LIVING CHILDREN BORN SINCE JANUARY 1991.
IN A06 AND A08, RECORD THE HEIGHT AND WEIGHT OF THE RESPONDENT AND THE LIVING CHILDREN.

NOTES:
-ALL OF THE RESPONDENTS WITH ONE OR MORE BIRTH SINCE JANUARY 1991 SHOULD BE WEIGHED AND MEASURED EVEN IF ALL THE CHILDREN HAVE DIED.
-IF THERE ARE MORE THAN 3 LIVING CHILDREN BORN SINCE JANUARY 1991, USE AN ADDITIONAL FORM.

A02) LINE NUMBER FROM 212 SECTION 2:

RESPONDENT: ___
YOUNGEST LIVING CHILD: ___
NEXT TO YOUNGEST LIVING CHILD: ___
SECOND-TO-NEXT-YOUNGEST LIVING CHILD: ___

A03) NAME (FROM 212 FOR CHILDREN)

NAME: ___

A04) BIRTH DATE:

FROM 215 FOR CHILDREN, AND ASK THE DAY OF BIRTH.

DAY: ___
MONTH: ___
YEAR: ___

A05) BCG SCAR ON ARM:

SCAR SEEN 1
NO SCAR 2

A06) HEIGHT (IN CENTIMETERS)

___

A07) WAS HEIGHT/LENGTH OF CHILD MEASURED LYING DOWN OR STANDING UP?

LYING 1
STANDING 2

A08) WEIGHT (IN KILOGRAMS)

___

A09) DATE WEIGHED AND MEASURED

DAY: ___
MONTH: ___
YEAR: ___

A10) RESULT:

RESPONDENT
MEASURED 1
NOT PRESENT 2
REFUSED 4
OTHER (SPECIFY): ___ 6
CHILDREN
MEASURED 1
SICK 2
NOT PRESENT 3
CHILD REFUSED 4
MOTHER REFUSED 5
OTHER (SPECIFY): ___ 6

A11)

NAME OF MEASURER: ___
NAME OF ASSISTANT: ___
MOTHER 90
OTHER MEMBERS OF HOUSEHOLD 91
OTHER PEOPLE 92

INTERVIEWER'S OBSERVATIONS:
(To be filled in after completing interview)

COMMENTS ABOUT RESPONDENT: ___
COMMENTS ON SPECIFIC QUESTIONS: ___
ANY OTHER COMMENTS: ___

NAME OF INTERVIEWER: ___
TEAM LEADER OBSERVATIONS: ___
TEAM LEADER NAME: ___
DATE: ___

SUPERVISOR'S OBSERVATION: ___
NAME OF SUPERVISOR: ___
DATE: ___