IDENTIFICATION

REGION NAME____________

LOCALITY NAME (NEIGHBORHOOD/VILLAGE)_____________

NAME OF HEAD OF HOUSEHOLD_____________

CLUSTER NUMBER __ __

HOUSEHOLD NUMBER

HOUSEHOLD NUMBER (SEQUENTIAL IN THE CLUSTER)__ __

URBAN/RURAL

N'DJAMENA-MOUNDOU/SARH/ABECHE-OTHER CITY-RURAL

MAN'S NAME AND LINE NUMBER__________________________ __ __

INTERVIEWER VISITS
1 2 3
DATE_____

INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY__ __
MONTH__ __
YEAR 201__
INT. NUMBER__ __
CODE RESULT

NEXT VISIT
DATE_______
TIME________

TOTAL NO. OF VISITS___

*RESULT CODES:

LANGUAGE OF INTERVIEW

INTERPRETER

SUPERVISOR
NAME____________
DATE_______

FIELD EDITOR
NAME____________
DATE_______

OFFICE EDITOR_______

KEYED BY_____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT
INFORMED CONSENT

Hello. My name is ___. I am working with the National Institute of Statistics, Economic and Demographic Study (INSEED). We are conducting a survey about health all over Chad. The information we collect will help the government to improve health services. Your household was selected for the survey. The questions usually take about 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

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

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

SIGNATURE OF INTERVIEWER________________
DATE______

101) RECORD THE TIME

102) In what month and year were you born?

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

104) Have you ever attended school?

105) What is the highest level of education you attended: primary, secondary, technical secondary, professional secondary, higher, or professional higher?

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

107) CHECK 105:
PRIMARY
SECONDARY OR TECHNICAL SECONDARY OR PROFESSIONAL SECONDARY OR HIGHER OR PROFESSIONAL HIGHER?-SKIP TO 110

CODE FOR Q. 106
LEVEL
1=PRIMARY
2=SECONDARY
3=SECONDARY TECHNICAL
4=SECONDARY PROFESSIONAL
5=HIGHER
6=HIGHER PROFESSIONAL
8-DON'T KNOW

00=LESS THAN ONE YEAR COMPLETED

GRADE
01=CP1
02=CP2
03=CE1
04=CE2
05=CM1
06=CM2
98=DON'T KNOW

01=6TH
02=5TH
03=4TH
04=3RD
05=SECOND
06=1ST
07=FINAL
98=DON'T KNOW

01=1ST YEAR
02=2ND YEAR
03=3RD YEAR
04=4TH YEAR
05=5TH YEAR
06=6TH YEAR
07=7TH YEAR OR HIGHER
98=DON'T KNOW

01=6TH OR 1ST YEAR
02=5TH OR 2ND YEAR
03=4TH OR 3RD YEAR
04=3RD OR 4TH YEAR
05=SECOND OR 5TH YEAR
06=1ST OR 6TH YEAR
07=FINAL OR 7TH YEAR
98=DON'T KNOW

01=1ST YEAR
02=2ND YEAR
03=3RD YEAR
04=4TH YEAR
05=5TH YEAR
06=6TH YEAR
07=7TH YEAR OR HIGHER
98=DON'T KNOW

01=1ST YEAR
02=2ND YEAR
03=3RD YEAR
04=4TH YEAR
05=5TH YEAR
06=6TH YEAR OR HIGHER
98=DON'T KNOW

108) Now I would like you to read this sentence to me.

SHOW CARD TO RESPONDENT

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE:
Can you read any part of the sentence to me?

109) CHECK 108:

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

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

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

113) What is your religion?

114) What is your ethnicity?
IF YOU CANNOT CLASSIFY THE ETHNICITY DECLARED BY THE RESPONDENT AMONG THE CATEGORIES LISTED, RECORD IT IN THE SPACE PROVIDED.
(ETHNICITY DECLARED BY THE RESPONDENT)

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

116) In the last 12 months, have you been away from home for more than one month at a time?

SECTION 2. REPRODUCTION

201) Now I would like to ask 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 that you have fathered who are not 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, RECODE '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) CHECK 203 AND 205:

214) How old is your (youngest) child?

215) CHECK 214:

216) What is the name of your (youngest) child?
WRITE NAME OF (YOUNGEST) CHILD

217) When (name)'s mother was pregnant with (name), did she have any antenatal check-ups?

218) Were you ever present during any of those antenatal check-ups?

219) Was (name) born in a hospital or a health facility?

220) When a child has diarrhea, how much should he or she be given to drink: more than usual, about the same as usual, less than usual or nothing to drink at all?

SECTION 3: CONTRACEPTION

301) Now I would like to talk about family planning-the various ways or methods that a couple can use to delay or avoid a pregnancy.

Have you ever heard of (METHOD)?

01) FEMALE STERILIZATION
PROBE: Women can have an operation to avoid having any more children
Have you ever heard of (METHOD)?

02) MALE STERILIZATION
PROBE: Men can have an operation to avoid having any more children
Have you ever heard of (method)?

03) IUD
PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse.
Have you ever heard of (method)?

04) INJECTABLES
PROBE: Women can have an injection by a heath provider that stops them from becoming pregnant for one or more months.
Have you ever heard of (METHOD)?

05) IMPLANTS
Probe: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
Have you ever heard of (METHOD)?

06) PILL
PROBE: Women can take a pill every day to avoid becoming pregnant
Have you ever heard of (method)?

07) CONDOM
PROBE: Men can put a rubber sheath on their penis before sexual intercourse.
Have you ever heard of (METHOD)?

08) FEMALE CONDOM
Probe: Women can place a sheath in their vagina before sexual intercourse.
Have you ever heard of (method)?

09) LACTATIONAL AMENORRHEA METHOD (LAM)
Have you ever heard of (METHOD)?

10) RHYTHM METHOD
PROBE: To avoid pregnancy, women do not have sexual intercourse on days of the month they think they can get pregnant.
Have you ever heard of (METHOD)?

11) WITHDRAWAL
PROBE: Men can be careful and pull out before climax.
Have you ever heard of (METHOD)?

12) EMERGENCY CONTRACEPTION
PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
Have you ever heard of (METHOD)?

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

302) In the last few months have you

303) In the last few months, have you discussed family planning with a health worker or health professional?

304) 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 when she has sexual relations?

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

306) I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.

307) CHECK 301 (07): KNOW MALE CONDOM

308) Do you know a place where a person can get condoms?

309) Where is that?
ANY OTHER PLACE?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

310) If you wanted, could you yourself get a condom?

311) CHECK 301 (08): KNOWS FEMALE CONDOM

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

313) Where is that?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

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

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401) Are you currently married or living 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?

ALL SKIP TO 410

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

405) Do you have other wives or do you live with other women as if married?

406) Altogether, how many wives or live-in partners do you have?

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 wives or each woman you are living with as if married.

RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER.
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 you a question about your first (wife/partner). In what month and year did you start living with her?

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 would like to ask some questions about sexual activity in order to gain a better understanding of some important life issues.
How old were you when you had sexual intercourse for the very first time?

415) 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.

416) 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.

LAST SEXUAL PARTNER

SECOND-TO-LAST SEXUAL PARTNER

THIRD-TO-LAST SEXUAL PARTNER

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

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

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

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

3-6-SKIP TO 423

421) CHECK 410:

422) CHECK 414:

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

424) How many times during the last 12 months did you have sexual intercourse with this person?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF THE NUMBER OF TIMES IS 95 OR MORE, WRITE 95.

425) How old is this person?

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

427) 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 95 OR MORE, WRITE 95

428) CHECK 420 (ALL COLUMNS):

429) Check 420 and 418 (all columns)
Other-skip to 434
Condom used with every prostitute-skip to 433

430) In the last 12 months, did you pay anyone in exchange for having sexual intercourse?

431) Have you ever paid anyone in exchange for having sexual intercourse?

432) The last time you paid someone in exchange for having sexual intercourse, was a condom used?

433) Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse in the last 12 months?

434) In total, with how many different people have you had sexual intercourse in your life?
IF NON-NUMERIC NUMBER, PROBE TO GET AN ESTIMATE

435) CHECK 418, MOST RECENT PARTNER (FIRST COLUMN):

436) You told me that a condom was used the last time you had sex. What is the brand name of the condom used at that time?
IF BRAND NOT KNOWN, ASK TO SEE THE PACKAGE.

437) From where did you obtain the condom the last time?

PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

438) The last time you had sex did you or your partner use any method (other than a condom) to avoid or prevent a pregnancy?

439) What method did you or your partner use?
PROBE: Did you or your partner use any other method to prevent pregnancy?
RECORD ALL MENTIONED

SECTION 5. FERTILITY PREFERENCES

501) CHECK 401:

502) CHECK 439:

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

504) Now I have some questions about the future. After the (child/children) you and your (wife(wives)/partner(s)) are expecting now, would you like to have another child, or would you prefer not have any more children?

505) 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?

506) CHECK 407:

507) CHECK 503:
WIFE/PARTNER NOT PREGNANT OR DON'T KNOW-How long would you like to wait from now before the birth of (a/another) child?

WIFE/PARTNER PREGNANT-After the birth of the child you are expecting now, how long would you wait before the birth of another child?

ALL SKIP TO 509

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

509) CHECK 203 AND 205:
HAS LIVING CHILDREN-If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?

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

PROBE FOR A NUMERIC RESPONSE.

510) How many of these children would you like to be boys, how many would you like to be girls, and for how many would it not matter if it's a boy or a girl?

SECTION 6. EMPLOYMENT AND GENDER ROLES

601) 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?

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

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

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

607) CHECK 401:

608) CHECK 606:

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

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

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

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

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

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

SECTION 7. HIV/AIDS

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

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

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

704) Can people reduce their chance 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 get the AIDS virus because of witchcraft or other supernatural means?

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

708) Can the virus that causes AIDS be transmitted from a mother to a child?

709) CHECK 708:

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

711) Check for presence of others. Before continuing, make every effort to ensure privacy

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

713) How many months ago was your most recent HIV text?

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

715) Where was the test done?

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

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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

717) Where is that?
Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

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

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

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

721) 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?

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

723) 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?

724) CHECK 414:

725) CHECK 723: Heard about other sexually transmitted infections?

726) 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?

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

728) 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?

729) CHECK 726, 727, AND 728:

730) The last time you had (infection from 726/727/728), did you seek any kind of advice or treatment?

731) Where did you go?
Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

732) If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

733) Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with (another woman/women other than his spouse(s))?

SECTION 8. OTHER HEALTH ISSUES

801) Some men are circumcised, that is, the foreskin is completely removed from the penis. Are you circumcised?

802) How old were you when you got circumcised?

803) Who did the circumcision?

804) Where was it done?

805) 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 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD 90
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

806) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or another healthcare worker?

IF THE NUMBER OF INJECTIONS IS OVER 90 OR IF THERE WERE DAILY INJECTIONS IN THE LAST 3 MONTHS OR LONGER, RECORD 90.
IF THE RESPONSE IS NOT NUMERIC, PROBE TO OBTAIN AN ESTIMATE.

807) The last time you got an injection from a health worker, did he/she take the syringe and needle form a new, unopened package?

808) Are you covered by any health insurance?

809) What type of health insurance are you covered by?
RECORD ALL MENTIONED

810) RECORD THE TIME

TO BE FILLED IN AFTER COMPLETING INTERVIEW:

COMMENTS ABOUT RESPONDENT:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

SUPERVISOR'S OBSERVATIONS

NAME OF SUPERVISOR______________
DATE_______

EDITOR'S OBSERVATIONS

NAME OF EDITOR_______________
DATE___________