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DEMOGRAPHIC AND HEALTH SURVEYS - TANZANIA 2010 - WOMAN'S QUESTIONNAIRE

IDENTIFICATION

REGION_______

DISTRICT________

WARD_______

ENUMERATION AREA______

NAME OF HOUSEHOLD HEAD_____

TDHS NUMBER_____

HOUSEHOLD NUMBER_____

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE

LARGE CITY=1
SMALL CITY=2
TOWN=3
COUNTRYSIDE=4

LARGE CITIES ARE : DAR ES SALAAM, MWANZA, MBEYA AND TANGA.SMALL CITIES ARE: MOROGORO, DODOMA, MOSHI, IRINGA, SHINYANGA, SINGIDA, SONGEA ,MTWARA, TABORA, MUSOMA, SUMBAWANGA, BUKOBA, KIGOMA NA MJINI MAGHARIBI . MIJI MINGINE NI MIJI MIDOGO

NAME AND LINE NUMBER OF WOMAN______

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER NAME
RESULT

RESULT*

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) __________

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT*

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE
TIME

TOTAL NUMBER OF VISITS___

SURPERVISOR
NAME ___________

FIELD EDITOR
NAME ___________

OFFICE EDITOR

KEYED BY

INFORMED CONSENT

Hello. My name is ______. I am working with National Bureau of Statistics. We are conducting a survey about health all over Tanzania. The information we collect will help the government to plan health services.
Your household was selected for the survey. The survey usually takes 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.
Do you have any questions?
May I begin the interview now?
Signature of interviewer: __________
Date: _________

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END INTERVIEW)

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE TIME.

HOUR _______
MINUTES _______
MORNING 1
AFTERNOON 2
EVENING, NIGHT 3

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

NUMBER OF TRIPS ______
NONE 00 (GO TO 106)

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

YES 1
NO 2

106. In what month and year were you born?

MONTH ______
DON'T KNOW MONTH 98
YEAR____
DON'T KNOW YEAR 9998

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

AGE IN COMPLETED YEARS _______

108. Have you ever attended school?

YES 1
NO 2 (GO TO 112)

109. What is the highest level of school you attended?

PREPRIMARY 0
PRIMARY 1
POST-PRIMARY TRAINING 2
SECONDARY 3
POST-SECONDAY TRAINING 4
UNIVERSITY 5

110. What is the highest grade you completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

GRADE ______

111. CHECK 109:

PRIMARY (GO TO 112)
SECONDARY OR HIGHER (GO TO 115)

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

CANNOT READ AT ALL 1
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) __________ 4
BLIND/VISUALLY IMPAIRED 5

114. CHECK 112:

CODE '2', '3' OR '4' CIRCLED (GO TO 115)
CODE '1' OR '5' CIRCLED (GO TO 116)

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

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

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

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

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

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

SECTION 2. REPRODUCTION

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

YES 1
NO 2 (GO TO 206)

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

YES 1
NO 2 (GO TO 204)

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

SONS AT HOME _________
DAUGHTERS AT HOME ____________

204. Do you have any sons or daughters to whom you have given birth who are alive but do not live with you?

YES 1
NO 2 (GO TO 206)

205. How many sons are alive but do not live with you? And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'.

SONS ELSEWHERE _______
DAUGHTERS ELSEWHERE ________

206. Have you ever given birth to a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

YES 1
NO 2 (GO TO 208)

207. How many boys have died? And how many girls have died?
IF NONE, RECORD '00'.

BOYS DEAD ________
GIRLS DEAD _________

208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
IF NONE, RECORD '00'.

TOTAL _______

209. CHECK 208:
Just to make sure that I have this right: you have had in TOTAL _____ births during your life. Is that correct?

YES
NO (PROBE AND CORRECT 201-208 AS NECESSARY.)

210. CHECK 208:

ONE OR MORE NO BIRTHS (GO TO 211)
NO BIRTHS (GO TO 226)

211. Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.
RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW).

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

(NAME) ________

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

BOY 1
GIRL 2

214. Were any of these births twins?

SING 1
MULT 2

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

MONTH ______
YEAR _______

216. Is (NAME) still alive?

YES 1
NO 2 (GO TO 220)

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
NO 2

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

LINE NUMBER ______ (NEXT BIRTH)

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

DAYS 1 _____
MONTHS 2 _______
YEARS 3 _______

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

YES 1 (ADD BIRTH)
NO 2 (NEXT BIRTH)

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

YES 1
NO 2

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

NUMBERS ARE SAME (GO TO 224)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

224. CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2005 OR LATER. IF NONE, RECORD '0' AND SKIP TO 226.

225. FOR EACH BIRTH SINCE JANUARY 2005, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226. Are you pregnant now?

YES 1
NO 2 (GO TO 229)
UNSURE 8 (GO TO 229)

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

MONTHS ________

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

YES 1 (GO TO 229)
NO 2

228A. Did you want to have a baby later on or did you not want any (more) children?

LATER 1
NO MORE 2

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

YES 1
NO 2 (GO TO 237)

230. When did the last such pregnancy end?

MONTH _______
YEAR ________

231. CHECK 230:

LAST PREGNANCY ENDED IN JAN. 2005 OR LATER (GO TO 232)
LAST PREGNANCY ENDED BEFORE JAN. 2005 (GO TO 237)

232. How many months pregnant were you when the last such pregnancy ended?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'T' IN THE CALENDAR IN THE MONTH THAT THE PREGNANC TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

MONTHS __________

233. Since January 2005 have you had any other pregnancies that did not result in a live birth?

YES 1
NO 2 (GO TO 235)

234. ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2005. ENTER 'T' IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

235. Did you have any miscarriages, abortions or stillbirths that ended before 2005?

YES 1
NO 2 (GO TO 237)

236. When did the last such pregnancy that terminated before 2005 end?

MONTH _____
YEAR _____

237. When did your last menstrual period start?

(DATE, IF GIVEN) ________
DAYS AGO 1
WEEKS AGO 2
MONTHS AGO 3
YEARS AGO 4
IN MENOPAUSE/HAS HAD HYSTERECTOMY 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

238. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations?

YES 1
NO 2 (GO TO 301)
DON'T KNOW 8 (GO TO 301)

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

JUST BEFORE HER PERIOD BEGINS 1
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) _______ 6
DON'T KNOW 8

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)?
PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED.

01 Female Sterilization. PROBE: Women can have an operation to avoid having any more children.
YES 1
NO 2
02 Male Sterilization. PROBE : Men can have an operation to avoid having any more children.
YES 1
NO 2
03 Injectables. PROBE: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2
04 Implants. PROBE: 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 IUD. PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
06 PILL. PROBE: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
07 Condom. PROBE: Men can put a rubber sheath on their penis before sexual Intercourse.
YES 1
NO 2
08 Female Condom. PROBE: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2
09 Diaphragm. PROBE: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2
10 Foam or Jelly. PROBE: Women can place a suppository, jelly or cream in their vagina before sexual intercourse.
YES 1
NO 2
11 Lactational Amenorrhea Method (LAM)
YES 1
NO 2
12 Rhythm Method. PROBE: 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
13 Withdrawal. PROBE: Men can be careful and pull out before climax.
YES 1
NO 2
14 Emergency Contraception. PROBE: As an emergency measure after unprotected sexual intercourse, women can take special pills at any time within five days to prevent pregnancy.
YES 1
NO 2
15 Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES (SPECIFY) _________ 1
NO 2

302. CHECK 226:

NOT PREGNANT (GO TO 303)
PREGNANT OR UNSURE (GO TO 309)

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

YES 1
NO 2 (GO TO 309)

304. Which method are you using?
CIRCLE ALL MENTIONED. IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION A (GO TO 305)
MALE STERILIZATION B (GO TO 305)
IUD C (GO TO 306A)
INJECTABLES D (GO TO 306A)
IMPLANTS E (GO TO 306A)
PILL F
CONDOM G (GO TO 304B)
FEMALE CONDOM H (GO TO 306A)
DIAPHRAGM I (GO TO 306A)
FOAM/JELLY J (GO TO 306A)
LACTATIONAL AMEN. METHOD K (GO TO 306A)
RHYTHM METHOD L (GO TO 306A)
WITHDRAWAL M (GO TO 306A)
OTHER TRADITIONAL METHOD (SPECIFY) _______ X (GO TO 306A)
OTHER MODERN METHOD (SPECIFY) _______ Y

304A. What is the brand name of the pills you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

MICROGYNON 01
LO FEMANAL 02
SAFE PLAN 03
MACROVAL 04
OTHER (SPECIFY) _______ 96
DON'T KNOW 98

304B. What is the brand name of the condoms you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

SALAMA 01(GO TO 306A)
MSD 02(GO TO 306A)
DUME 03(GO TO 306A)
ROUGH RIDER 04(GO TO 306A)
FAMILIA 05(GO TO 306A)
OTHER (SPECIFY) ______ 96(GO TO 306A)
DON'T KNOW 98(GO TO 306A)

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

(NAME OF PLACE) ______________
GOVERNMENT/PARASTATAL
REFERRAL/SPEC.HOSPITAL 11
REGIONAL HOSPITAL 12
DISTRICT HOSPITAL 13
HEALTH CENTRE 14
RELIGIOUS/VOLUNTARY
REFERAL/SPEC.HOSPITAL 21
DISTRICT HOSPITAL 22
HEALTH CENTRE 23
PRIVATE
HOSPITAL 31
HEALTH CENTRE 32
OTHER (SPECIFY) _______ 96
DON'T KNOW 98

306. In what month and year was the sterilization performed?

MONTH _____
YEAR _____ (GO TO 307)

306A. Since what month and year have you been using (CURRENT METHOD) without stopping?
PROBE: For how long have you been using (CURRENT METHOD) now without stopping?

MONTH _______
YEAR _______

307. CHECK 306/306A, 215 AND 230:
ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 306/306A

YES (GO BACK TO 306/306A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION).
NO (GO TO 308)

308. CHECK 306/306A:

YEAR IS 2005 OR LATER (ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND IN EACH MONTH BACK TO THE DATE STARTED USING.)

YEAR IS 2004 OR EARLIER (ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK TO JANUARY 2005.
(THEN GO TO 322))

309. I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.

USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2005.
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.
ENTER METHOD USE CODE OR '0' FOR NONUSE IN EACH BLANK MONTH.

ILLUSTRATIVE QUESTIONS:

* When was the last time you used a method? Which method was that?
* When did you start using that method? How long after the birth of (NAME)?
* How long did you use the method then?

309A. CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH

NO METHOD USED (GO TO 309B)
ANY METHOD USED (GO TO 310)

309B. Have you ever used anything or tried in any way to delay or avoid getting pregnant.

YES 1 (GO TO 324)
NO 2 (GO TO 324)

310. CHECK 304:

CIRCLE METHOD CODE:

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

NO CODE CIRCLED 00 (GO TO 324)
FEMALE STERILIZATION 01 (GO TO 313)
MALE STERILIZATION 02 (GO TO 326)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 311A)
RHYTHM METHOD 12 (GO TO 311A)
WITHDRAWAL 13 (GO TO 326)
OTHER MODERN METHOD 95 (GO TO 326)
OTHER TRADITIONAL METHOD 96 (GO TO 326)

311. You first started using (CURRENT METHOD) in (DATE FROM 306/306A). Where did you get it at the time?
311A. Where did you learn how to use the rhythm/lactational amenorhea method?
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) _________
GOVERNMENT/PARASTATAL
REFERRAL/SPEC.HOSPITAL 11
REGIONALHOSPITAL 12
DISTRICTHOSPITAL 13
HEALTHCENTRE 14
DISPENSARY 15
VILLAGEHEALTHPOST 16
CBDWORKER 17
RELIGIOUS/VOLUNTARY
REFERAL/SPEC.HOSPITAL 21
DISTRICTHOSPITAL 22
HEALTHCENTRE 23
DISPENSARY 24
PRIVATE
HOSPITAL 31
HEALTHCENTRE 32
DISPENSARY 33
OTHER
PHARMACY 41
NGO 42
VCTCENTRE 43
SHOP/KIOSK 44
BAR 45
GUESTHOUSE/HOTEL 46
FRIEND/RELATIVE/NEIGHBOUR 47
OTHER (SPECIFY) __________ 96

312. CHECK 304:

CIRCLE METHOD CODE:

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

IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07 (GO TO 323)
FEMALECONDOM 08 (GO TO 316)
DIAPHRAGM 09(GO TO 316)
FOAM/JELLY 10(GO TO 316)
LACTATIONAL AMEN. METHOD 11(GO TO 316)
RHYTHMMETHOD 12(GO TO 316)

313. You obtained (CURRENT METHOD FROM 310) from (SOURCE OF METHOD FROM 305 OR 311) in (DATE FROM 306/306A). At that time, were you told about side effects or problems you might have with the method?

YES 1 (GO TO 315)
NO 2

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

YES 1
NO 2 (GO TO 316)

315. Were you told what to do if you experienced side effects or problems?

YES 1
NO 2

316. CHECK 310:

CODE '01' CIRCLED: At that time, were you told about other methods of family planning that you could use?

CODE '01' NOT CIRCLED: When you obtained (CURRENT METHOD FROM 310) from (SOURCE OF METHOD FROM 305 OR 311) were you told about other methods of family planning that you could use?

YES 1 (GO TO 322)
NO 2

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

YES 1
NO 2

322. CHECK 304:

CIRCLE METHOD CODE:

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

FEMALE STERILIZATION 01 (GO TO 326)
MALESTERILIZATION 02 (GO TO 326)
IUD 03 (GO TO 326)
INJECTABLES 04
IMPLANTS 05 (GO TO 326)
PILL 06
CONDOM 07
FEMALECONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11(GO TO 326)
RHYTHMMETHOD 12(GO TO 326)
WITHDRAWAL 13(GO TO 326)
OTHERMODERNMETHOD 95(GO TO 326)
OTHER TRADITIONAL METHOD 96(GO TO 326)

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

(NAME OF PLACE) _________
GOVERNMENT/PARASTATAL
REFERRAL/SPEC. HOSPITAL 11 (GO TO 326)
REGIONAL HOSPITAL 12 (GO TO 326)
DISTRICT HOSPITAL 13 (GO TO 326)
HEALTH CENTRE 14 (GO TO 326)
DISPENSARY 15 (GO TO 326)
VILLAGE HEALTH POST 16 (GO TO 326)
CBD WORKER 17 (GO TO 326)
RELIGIOUS/VOLUNTARY
REFERAL/SPEC. HOSPITAL 21 (GO TO 326)
DISTRICT HOSPITAL 22 (GO TO 326)
HEALTH CENTRE 23 (GO TO 326)
DISPENSARY 24 (GO TO 326)
PRIVATE
HOSPITAL 31 (GO TO 326)
HEALTH CENTRE 32 (GO TO 326)
DISPENSARY 33 (GO TO 326)
OTHER
PHARMACY 41 (GO TO 326)
NGO 42 (GO TO 326)
VCT CENTRE 43 (GO TO 326)
SHOP/KIOSK 44 (GO TO 326)
BAR 45 (GO TO 326)
GUESTHOUSE/HOTEL 46 (GO TO 326)
FRIEND/RELATIVE/NEIGHBOUR 47 (GO TO 326)
OTHER (SPECIFY) __________ 96 (GO TO 326)

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

YES 1
NO 2 (GO TO 326)

325. 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.

(NAME OF PLACE) _________
GOVERNMENT/PARASTATAL
REFERRAL/SPEC. HOSPITAL A
REGIONAL HOSPITAL B
DISTRICT HOSPITAL C
HEALTH CENTRE D
DISPENSARY E
VILLAGE HEALTH POST F
CBD WORKER G
RELIGIOUS/VOLUNTARY
REFERAL/SPEC. HOSPITAL H
DISTRICT HOSPITAL I
HEALTH CENTRE J
DISPENSARY K
PRIVATE
HOSPITAL L
HEALTH CENTRE M
DISPENSARY N
OTHER
PHARMACY O
NGO P
VCT CENTRE Q
SHOP/KIOSK R
BAR S
GUESTHOUSE/HOTEL T
FRIEND/RELATIVE/NEIGHBOUR U
OTHER (SPECIFY) __________ X

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 401)

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

YES 1
NO 2

SECTION 4. PREGNANCY AND POSTNATAL CARE

401. CHECK 224:

ONE OR MORE BIRTHS IN 2005 OR LATER (GO TO 402)
NO BIRTHS IN 2005 OR LATER (GO TO 576)

402. CHECK 215: ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2005 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

Now I would like to ask some questions about your children born in the last five years. (We will talk about each separately.)

403. BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

BIRTH HISTORY NO. ______

404. FROM 212 AND 216

NAME _________________
LIVING (GO TO 405)
DEAD (GO TO 405)

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

YES 1 (GO TO 407)
NO 2

405A. Did you want to have a baby later on, or did you not want any (more) children?

LATER 1
NO MORE 2 (GO TO 407)

406. How much longer did you want to wait?

MONTH 1 _____
YEARS 2 _____

DON'T KNOW 998

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

YES 1
NO 2 (GO TO 414)

407A. Whom did you see? Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PROFESSIONAL
DOCTOR/AMO A
CLINICAL OFFICER B
ASST. CLINICAL OFFICER C
NURSE/MIDWIFE D
MCH AIDE E
OTHER PERSON
VILLAGE HEALTH WORKER F
TRAINED TBA/TBA G
OTHER (SPECIFY) _________ X
NO ONE Y (GO TO 414)

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

(NAME OF PLACE(S)) ______
HOME A
GOV. PARASTATAL
REFERAL/SPEC. HOSPITAL B
REGIONAL HOSP. C
DISTRICT HOSP D
HEALTH CENT E
DISPENSARY F
VILLAGE HEALTH POST G
CBD WORKER H
RELIGIOUS/VOLUNTARY
REFERAL/SPEC. HOSPITAL I
DISTRICT HOSP J
HEALTH CENT K
DISPENSARY L
PRIVATE
SPECIALISED HOSPITAL M
HEALTH CENT N
DISPENSARY O
OTHER (SPECIFY) __________ X

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

MONTHS ______
DON'T KNOW 98

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

NUMBER OF TIMES ______
DON'T KNOW 98

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

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

BP
YES 1
NO 2
URINE
YES 1
NO 2
BLOOD
YES 1
NO 2

412. During (any of) your antenatal care visit(s), were you told about the signs of pregnancy complications?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 417)
DON'T KNOW 8 (GO TO 417)

415. During this pregnancy, how many times did you get this tetanus injection?

TIMES _______
DON'T KNOW 8

416. CHECK 415:

2 OR MORE TIMES (GO TO 421)
OTHER (GO TO 417)

417. At any time before this pregnancy, did you receive any tetanus injections, either to protect yourself or another baby?

YES 1
NO 2 (GO TO 421)
(GO TO 421)
DON'T KNOW 8

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

TIMES _______
DON'T KNOW 8

419. How many years ago did you receive the last tetanus injection before this pregnancy?

YEARS AGO ______
DON'T KNOW 98

421. During this pregnancy, were you given or did you buy any iron syrup/iron or iron/folate tablets?
SHOW TABLETS/SYRUP.

YES 1
NO 2 (GO TO 423)
DON'T KNOW 8 (GO TO 423)

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

DAYS ______
DON'T KNOW 998

423. During this pregnancy, did you have difficulty with your vision during the daylight?

YES 1
NO 2
DON'T KNOW 8

424. During this pregnancy, did you suffer from night blindness [USE LOCAL TERM]?

YES 1
NO 2
DON'T KNOW 8

426. During this pregnancy, did you take any drugs to keep you from getting malaria?

YES 1
NO 2 (GO TO 432)
DON'T KNOW 8 (GO TO 432)

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

SP/FANSIDAR A
CHLOROQUINE B
OTHER (SPECIFY) _____ X
DON'T KNOW Z

428. CHECK 427:
DRUGS TAKEN FOR MALARIA PREVENTION.

CODE 'A' CIRCLED (GO TO 431)
CODE A' NOT CIRCLED (GO TO 432)

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

TIMES ______

430. CHECK 407A:
ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

CODE 'A-E', CIRCLED (GO TO 431)
OTHER (GO TO 432)

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

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6

432. 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
DON'T KNOW 8

433. Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 435)
DON'T KNOW 8 (GO TO 435)

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

KG FROM CARD ____
KG FROM RECALL _____

DON'T KNOW 99.998

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

HEALTH PROFESSIONAL
DOCTOR/AMO A
CLINICAL OFFICER B
ASST. CLINICAL OFFICER C
NURSE/MIDWIFE D
MCH AIDE E
OTHER PERSON
VILLAGE HEALTH WORKER F
TRAINED TBA/TBA G
RELATIVE/FRIEND H
OTHER (SPECIFY) ________ X
NO ONE Y

436. Where did you give birth to (NAME)?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS DISTRICT PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) __________
HOME
YOUR HOME 11 (GO TO 443)
OTHER HOME 12 (GO TO 443)
GOV.PARASTATAL
REFERAL/SPEC. HOSPITAL 21
REGIONAL HOSP. 22
HOSP. 23
HEALTH CENT 24
DISPENSARY 25
VILLAGE HEALTH POST 26
CBD WORKER 27
RELIGIOUS/VOLUNTARY
REFERRAL/SPEC. HOSPITAL 31
DISTRICT HOSP 32
HEALTH CENT 33
DISPENSARY 34
PRIVATE
SPECIALISED HOSPITAL 41
HEALTH CENT 42
DISPENSARY 43
OTHER (SPECIFY) _________ 96 (GO TO 443)

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

YES 1
NO 2

438A. After you delivered, did the health facility give you a birth notification form for the baby?

YES 1 (GO TO 439)
NO 2
DON'T KNOW 3

438B. Did you get a birth notification form from any other place?

YES 1
NO 2
DON'T KNOW 3

439. Before you were discharged after (NAME) was born, did any health care provider check on your health?

YES 1
NO 2 (GO TO 442)

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

HOURS 1______
DAYS 2______
WEEKS 3_____

DON'T KNOW 998

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

HEALTH PROFESSIONAL
DOCTOR/AMO 11(GO TO 452A)
CLINICAL OFFICER 12(GO TO 452A)
ASST. CLINICAL OFFICER 13(GO TO 452A)
NURSE/MIDWIFE 14(GO TO 452A)
MCH AIDE 15(GO TO 452A)
OTHER PERSON
VILLAGE HEALTH WORKER 21(GO TO 452A)
TRAINED TBA/TBA 22(GO TO 452A)
RELATIVE/FRIEND 23(GO TO 452A)
OTHER (SPECIFY) ________ 96 (GO TO 452A)

442. After you were discharged, did any health care provider or a traditional birth attendant check on your health?

YES 1 (GO TO 445)
NO 2 (GO TO 449)

443. Why didn't you deliver in a health facility?
PROBE: Any other reason?
RECORD ALL MENTIONED.

COST TOO MUCH A
FACILITY NOT OPEN B
TOO FAR/ NO TRANSPORTATION C
DON'T TRUST FACILITY/POOR QUALITY SERVICE D
NO FEMALE PROVIDER AT FACILITY E
HUSBAND/FAMILY DID NOT ALLOW F
NOT NECESSARY G
NOT CUSTOMARY H
OTHER (SPECIFY) _______ X

444. After (NAME) was born, did any health care provider or a traditional birth attendant check on your health?

YES 1
NO 2 (GO TO 449)

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

HOURS 1____
DAYS 2_____
WEEKS 3_____

DON'T KNOW 998

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

HEALTH PROFESSIONAL
DOCTOR/AMO 11
CLINICAL OFFICER 12
ASST. CLINICAL OFFICER 13
NURSE/MIDWIFE 14
MCH AIDE 15
OTHER PERSON
VILLAGE HEALTH WORKER 21
TRAINED TBA/TBA 22
RELATIVE/FRIEND 23
OTHER (SPECIFY) 96

447. Where did this first check take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) ________
HOME
YOUR HOME 11
OTHER HOME 12
GOV.PARASTATAL
REFERAL/SPEC. 21
HOSPITAL REGIONAL HOSP. 22
DISTRICT HOSP. 23
HEALTH CENT. 24
DISPENSARY 25
VILLAGE HEALTH POST 26
CBD WORKER 27
RELIGIOUS/VOLUNTARY
REFERRAL/SPEC. HOSPITAL 31
DISTRICT HOSP 32
HEALTH CENT 33
DISPENSARY 34
PRIVATE
SPECIALISED HOSPITAL 41
HEALTH CENT 42
DISPENSARY 43
OTHER (SPECIFY) __________ 96

448. CHECK 442:

YES (GO TO 452A)
NOT ASKED (GO TO 449)

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

YES 1
NO 2 (GO TO 452A)
DON'T KNOW 8 (GO TO 452A)

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

HRS AFTER BIRTH 1 _______
DAYS AFTER BIRTH 2 _______
WKS AFTER BIRTH 3 _______

DON'T KNOW 998

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

HEALTH PROFESSIONAL
DOCTOR/AMO 11
CLINICAL OFFICER 12
ASST. CLINICAL OFFICER 13
NURSE/MIDWIFE 14
MCH AIDE 15
OTHER PERSON
VILLAGE HEALTH WORKER 21
TRAINED TBA/TBA 22
RELATIVE/FRIEND 23
OTHER (SPECIFY) _______ 96

452. Where did this first check of (NAME) take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) _________
HOME
YOUR HOME 11
OTHER HOME 12
GOV.PARASTATAL
REFERAL/SPEC. HOSPITAL 21
REGIONAL HOSP 22
DISTRICT HOSP 23
HEALTH CENT 24
DISPENSARY 25
VILLAGE HEALTH POST 26
CBD WORKER 27
RELIGIOUS/VOLUNTARY
REFERRAL/SPEC.HOSPITAL 31
DISTRICT HOSP 32
HEALTH CENT 33
DISPENSARY 34
PRIVATE
SPECIALISED HOSPITAL 41
HEALTH CENT 42
DISPENSARY 43
OTHER (SPECIFY) __________ 96

452A. Do you have a birth certificate for (NAME)?
ASK TO SEE CERTIFICATE.

YES, SEEN 1
YES, NOT SEEN 2
NO 3
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1 (GO TO 456)
NO 2 (GO TO 457)

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

YES 1
NO 2 (GO TO 459)

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

MONTHS _____
DON'T KNOW 98

457. CHECK 226:
IS RESPONDENT PREGNANT?

NOT PREGNANT (GO TO 458)
PREGNANT OR UNSURE (GO TO 459)

458. Have you begun to have sexual intercourse again since the birth of (NAME)?

YES 1
NO 2 (GO TO 460)

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

MONTHS _____
DON'T KNOW 98

460. Did you ever breastfeed (NAME)?

YES 1
NO 2 (GO TO 467)

461. How long after birth did you first put (NAME) to the breast?
IF LESS THAN 1 HOUR, RECORD '00' HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS.

IMMEDIATELY 000

HOURS 1_____
DAYS 2____

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

YES 1
NO 2 (GO TO 464)

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

MILK (OTHER THAN BREAST MILK) A
PLAIN WATER B
SUGAR OR GLULIQUIDS COSE WATER C
GRIPE WATER D
SUGAR-SALT-WATER SOLUTION E
FRUIT JUICE F
INFANT FORMULA G
TEA/INFUSIONS H
HONEY I
OTHER (SPECIFY) ______ X

464. CHECK 404:
IS CHILD LIVING?

LIVING (GO TO 465)
DEAD (GO TO 466)

465. Are you still breastfeeding (NAME)?

YES 1 (GO TO 468)
NO 2

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

MONTHS ______

STILL BF 95
DON'T KNOW 98

467. CHECK 404:
IS CHILD LIVING?

LIVING (GO TO 469A)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

468. 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 _________

469. How many times did you breastfeed yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

NUMBER OF DAYLIGHT FEEDINGS _______

469A. How old was (NAME) when s/he was first fed something other than breast milk?
INCLUDES : JUICE, COW'S MILK WATER, SUGAR WATER, SOLID FOODS OR ANYTHING ELSE

MONTHS _____

NOT STARTED GIVING ANYTHING 01
DON'T KNOW 98

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

YES 1
NO 2
DON'T KNOW 8

471. GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501.

SECTION 5. CHILD IMMUNIZATION AND HEALTH AND CHILD'S AND WOMAN'S NUTRITION

501. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2005 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

502. LINE NUMBER FROM 212

BIRTH HISTORY NUMBER _________

503. FROM 212 AND 216

NAME _______
LIVING (GO TO 503A)
DEAD (GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 573)

503A. Did (NAME) receive vitamin A like this during the last 6 months?
(SHOW CAPSULES)

YES 1
NO 2 (GO TO 504)
DON'T KNOW 8 (GO TO 504)

503B. Where did (NAME) the get the drops? During the campaign with other children, during a sick visit or during a routine/healthy visit?

VAC. CAMPAIGN 1
SICK VISIT 2
HEALTHY VISIT 3

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

YES, SEEN 1
YES, NOTSEEN 2(GO TO 508)
NO CARD 3

506. (1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD.
(2) WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED.
(3) IF MORE THAN TWO VITAMIN 'A' DOSES, RECORD DATES FOR MOST RECENT AND SECOND MOST RECENT DOSES.

BCG
DAY ___
MONTH _____
YEAR ______
POLIO 0 (POLIO GIVEN AT BIRTH)
DAY ___
MONTH _____
YEAR ______
POLIO 1
DAY ___
MONTH _____
YEAR ______
POLIO 2
DAY ___
MONTH _____
YEAR ______
POLIO 3
DAY ___
MONTH _____
YEAR ______
DPT-HBIB 1
DAY ___
MONTH _____
YEAR ______
DPT-HBIB 2
DAY ___
MONTH _____
YEAR ______
DPT-HBIB 3
DAY ___
MONTH _____
YEAR ______
DPT-HB1
DAY ___
MONTH _____
YEAR ______
DPT-HB2
DAY ___
MONTH _____
YEAR ______
DPT-HB3
DAY ___
MONTH _____
YEAR ______
MEASLES
DAY ___
MONTH _____
YEAR ______
VITAMIN A (MOST RECENT)
DAY ___
MONTH _____
YEAR ______
VITAMIN A (MOST RECENT)
DAY ___
MONTH _____
YEAR ______

506A. CHECK 506:

BCG TO MEASLES ALL RECORDED (GO TO 516)
OTHER (GO TO 507)

507. Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in a national immunization day campaign?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT-HBIB 1-3, DPT-HB 1-3 AND/OR MEASLES VACCINES.

YES 1 (PROBE FOR (PROBE FOR VACCINATIONS AND WRITE '66' IN THE CORRESPONDING DAY COLUMN IN 506) (GO TO 516)
NO 2 (GO TO 516) (GO TO 516)
DON'T KNOW 8 (GO TO 516)

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

YES 1
NO 2 (GO TO 516)
DON'T KNOW 8(GO TO 516)

509. Please tell me if (NAME) received any of the following vaccinations:
509A. A BCG vaccination against tuberculosis, that is, an injection on the right arm or shoulder that usually causes a scar?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 509E)
DON'T KNOW 8 (GO TO 509E)

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

FIRST 2 WEEKS 1
LATER 2
DON'T KNOW 8

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

NUMBER OF TIMES ______
DON'T KNOW 8

509E. A DPT-HB vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio?

YES 1
NO 2 (GO TO 509G)
DON'T KNOW 8 (GO TO 509G)

509F. How many times was a DPT-HB vaccination received?

NUMBER OF TIMES ______
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 533)
DON'T KNOW 8 (GO TO 533)

519. Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

520. Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk). Was he/she given less than usual to drink, about the same amount, or more than usual to drink? IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'TKNOW 8

521. When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat? IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

MUCHLESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'TKNOW 8

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

YES 1
NO 2 (GO TO 528)
DON'T KNOW 8 (GO TO 528)

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

(NAME OF PLACE(S)) __________
GOV.PARASTATAL
REFERAL/SPEC. HOSPITAL A
REGIONAL HOSP. B
DISTRICT HOSP C
HEALTH CENT D
DISPENSARY E
VILLAGE HEALTH POST F
CBD WORKER G
RELIGIOUS/VOLUNTARY
REFERRAL/SPEC. HOSPITAL H
DISTRICT HOSP I
HEALTH CENT J
DISPENSARY K
PRIVATE
SPECIALISED HOSPITAL L
HEALTH CENT M
DISPENSARY N
OTHER
PHARMACY O
NGO P
OTHER (SPECIFY) _____ X

524. CHECK 523:

TWO OR MORE CODES CIRCLED (GO TO 525)
ONLY ONE CODE CIRCLED (GO TO 528)

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

FIRST PLACE ______

528. Was he/she given any of the following at any time since he/she started having the diarrhea:

a) A fluid made from a special packet called ORS or ORS with zinc?
b) Zinc?
c) A government-recommended homemade fluid such as coconut water/tea/fruit juice?

FLUID FROM ORS PKT
YES 1
NO 2
DON'T KNOW 8
ZINC
YES 1
NO 2
DON'T KNOW 8
HOMEMADE FLUID
YES 1
NO 2
DON'T KNOW 8

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

PILL OR SYRUP A
INJECTION B
(IV) INTRAVENOUS C
HOME REMEDY/HERBAL MEDICINE D
OTHER (SPECIFY) ________ X

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 537)
DON'T KNOW 8 (GO TO 537)

534A. At any time during the illness, did (NAME) have blood taken from his/her finger or heel for testing?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 538)
DON'T KNOW 8 (GO TO 538)

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

CHEST ONLY 1 (GO TO 538)
NOSE ONLY 2 (GO TO 538)
BOTH 3 (GO TO 538)
OTHER (SPECIFY) _________ 4 (GO TO 538)
DON'T KNOW 8 (GO TO 538)

537. CHECK 533:
HAD FEVER?

YES (GO TO 538)
NO OR DON'T KNOW (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 573)

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

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8

539. When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 546)

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

(NAME OF PLACE(S)) _________
GOV.PARASTATAL
REFERAL/SPEC. HOSPITAL A
REGIONAL HOSP B
DISTRICT HOSP C
HEALTH CENT D
DISPENSARY E
VILLAGE HEALTH POST F
RELIGIOUS/VOLUNTARY
REFERRAL/SPEC. HOSPITA G
DISTRICT HOSP H
HEALTH CENT I
DISPENSARY J
PRIVATE
SPECIALISED HOSPITA K
HEALTH CENT L
DISPENSARY M
OTHER
PHARMACY N
NGO O
OTHER X

542. CHECK 541:

TWO OR MORE CODES CIRCLED (GO TO 543)
ONLY ONE CODE CIRCLED (GO TO 546)

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

FIRST PLACE ________

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

YES 1
NO 2 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 573)
DON'TKNOW 8

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

ANTIMALARIAL DRUGS
SP/FANSIDAR A
CHLOROQUIN B
AMODIAQUINE C
QUININE D
ARTESUNATE E
ARTUSENATE AND AMODAQUINE F
ALU G
OTHER ANTI-MALARIAL (SPECIFY) __________ H
OTHER DRUGS
ASPIRIN I
IBUPROFEN/ACETAMINOPHEN/PANADOL/PARACETAMOL J
OTHER (SPECIFY) _______ X
DON'T KNOW Z

550. CHECK 547:
ANY CODE A-H CIRCLED?

YES (GO TO 551)
NO (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 573)

551. CHECK 547:
SP/FANSIDAR ('A') GIVEN

CODE 'A' CIRCLED (GO TO 552)
CODE 'A' NOT CIRCLED (GO TO 554)

552. How long after the fever started did (NAME) first take SP/FANSIDAR?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

554. CHECK 547:
CHLOROQUINE ('B') GIVEN

CODE 'B' CIRCLED (GO TO 555)
CODE 'B' NOT CIRCLED (GO TO 557)

555. How long after the fever started did (NAME) first take chloroquine?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

557. CHECK 547:
AMODIAQUINE ('C') GIVEN

CODE 'C' CIRCLED (GO TO 58)
CODE 'C' NOT CIRCLED (GO TO 560)

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

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

560. CHECK 547:
QUININE ('D') GIVEN

CODE 'D' CIRCLED (GO TO 561)
CODE 'D' NOT CIRCLED (GO TO 566)

561. How long after the fever started did (NAME) first take quinine?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

566. CHECK 547:
ARTESUNATE ('E') GIVEN

CODE 'E' CIRCLED (GO TO 566A)
CODE 'E' NOT CIRCLED (GO TO 568)

566A. How long after the fever started did (NAME) first take ARTESUNATE?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

568. CHECK 547:
ARTESUNATE AND AMODIAQUINE ('F') GIVEN

CODE 'F' CIRCLED (GO TO 569)
CODE 'F' NOT CIRCLED (GO TO 570)

569. How long after the fever started did (NAME) first take ARTESUNATE AND AMODIAQUINE?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

570. CHECK 547:
CORATEM (ALU) ('G') GIVEN

CODE 'G' CIRCLED (GO TO 571)
CODE 'G' NOT CIRCLED (GO TO 572)

571. How long after the fever started did (NAME) first take CORATEM (Alu)

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

572. CHECK 547:
OTHER ANTI-MALARIAL ('H') GIVEN

CODE 'H' CIRCLED (GO TO 572A)
CODE 'H' NOT CIRCLED (GO TO 572B)

572A. How long after the fever started did (NAME) first take (OTHER ANTI-MALARIAL)

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE OR MORE DAYS AFTER FEVER 3
DON'T KNOW 8

572B. GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 573.

573. CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2005 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE RECORD NAME OF YOUNGEST CHILD LIVING WITH HER
(NAME) ___________ (GO TO 574)
NONE (GO TO 576)

574. The last time (NAME FROM 573) passed stools, what was done to dispose of the stools?

CHILD USED TOILET OR LATRINE 01
PUT/RINSED INTO TOILET OR LATRINE 02
PUT/RINSED INTO DRAIN OR DITCH 03
THROWN INTO GARBAGE 04
BURIED 05
LEFT IN THE OPEN 06
USE DISPOSABLE DIAPERS 07
USE WASHABLE DIAPERS 08
NOT DISPOSED OF 09
OTHER (SPECIFY) _________ 96

575. CHECK 528(a)ALL COLUMNS:

NO CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID (GO TO 576)
ANY CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID (GO TO 577)

576. Have you ever heard of a special product called ORS you can get for the treatment of diarrhea?

YES 1
NO 2

577. CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2008 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE RECORD NAME OF YOUNGEST CHILD LIVING WITH HER
(NAME) ___________ (GO TO 578)
NONE (GO TO 576)

578. Now I would like to ask you about liquids or foods (NAME FROM 577) had yesterday during the day or at night. Did (NAME FROM 577) (drink/eat):

a. Plain water?
b. Commercially produced infant formula?
c. Any [BRAND NAME OF COMMERCIALLY FORTIFIED BABY FOOD, E.G., Cerelac]?
d. Any milk from animals
e. Any (other) porridge like ugali?

a. PLAIN WATER
YES 1
NO 2
DON'T KNOW 8
b. FORMULA
YES 1
NO 2
DON'T KNOW 8
c. BABY CEREAL
YES 1
NO 2
DON'T KNOW 8
d. ANIMAL MILK
YES 1
NO 2
DON'T KNOW 8
e. OTHER PORRIDGE/UGALI 1 2
YES 1
NO 2
DON'T KNOW 8

579. Now I would like to ask you about (other) liquids or foods that (NAME FROM 577)/you may have had yesterday during the day or at night. I am interested in whether your child/you had the item even if it was combined with other foods. Did (NAME FROM 577)/you drink (eat):

a) Milk tinned, powdered, fresh animal milk, yogurt, cheese?
YES 1
NO 2
DON'T KNOW 8
b) Tea or coffee?
YES 1
NO 2
DON'T KNOW 8
c) Any other liquids?
YES 1
NO 2
DON'T KNOW 8
d) Food made from roots or tubers, for example cocoyams, irish potatoes, white sweet potatoes, white yams, cassava, or other local roots or tubers?
YES 1
NO 2
DON'T KNOW 8
e) Foods made from maize meal (ugali), porridges, millet, rice, sorghum, or any other food made from grains?
YES 1
NO 2
DON'T KNOW 8
f) Bread, maandazi, chapati, or other foods madefrom wheat flour?
YES 1
NO 2
DON'T KNOW 8
g) Yellow/orange colour fruits or vegetables such as pumpkin, carrots, yellow/orange sweet potato, ripe mangoes or papayas, passion fruit?
YES 1
NO 2
DON'T KNOW 8
h) Any dark green, leafy vegetables such as amaranth, cassava, pumpkin or sweet potato leaves, and spinach ?
YES 1
NO 2
DON'T KNOW 8
i) Any other fruits or vegetables?
YES 1
NO 2
DON'T KNOW 8
j) Meat such as beef, goat, poultry(chicken), fish, shellfish liver?
YES 1
NO 2
DON'T KNOW 8
k) Eggs?
YES 1
NO 2
DON'T KNOW 8
l) Any foods made from beans, peas, lentils, or nuts?
YES 1
NO 2
DON'T KNOW 8
m) Food or drink that you added brown or white sugar to?
YES 1
NO 2
DON'T KNOW 8
n) Any sweets, candies such as chocolates pastries, cakes, or biscuits?
YES 1
NO 2
DON'T KNOW 8
o) Any other solid or semi-solid food?
YES 1
NO 2
DON'T KNOW 8

580. CHECK 578 c AND e AND 579 (CATEGORIES d THROUGH o FOR CHILD):

AT LEAST ONE "YES' (GO TO 581)
NOT A SINGLE "YES" (GO TO 582)

581. How many times did (NAME FROM 577) eat solid, semisolid, or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD '7'.

NUMBER OF TIMES ______
DON'T KNOW 8

582. CHECK Q578 AND 579 NOT A SINGLE 'YES', ASK:
Aside from breastmilk, did (NAME) get anything at all to eat or drink yesterday or last night?

YES 1
NO 2
DON'T KNOW 8

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

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

YES, CURRENTLY MARRIED 1 (GO TO 604)
YES, LIVING WITH A MAN 2 (GO TO 604)
NO, NOT IN UNION 3

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

YES, FORMERLY MARRIED 1
YES, LIVED WITH A MAN 2
NO 3 (GO TO 617)

603. What is your marital status now: are you widowed, divorced, or separated?

WIDOWED 1 (GO TO 609)
DIVORCED 2 (GO TO 609)
SEPARATED 3 (GO TO 609)

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

LIVING WITH HER 1
STAYING ELSEWHERE 2

605. RECORD THE HUSBAND'S/PARTNER'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

NAME ________________
LINE NO _____________

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

YES 1
NO 2 (GO TO 609)
DON'T KNOW 8 (GO TO 609)

607. Including yourself, in total, how many wives or partners does your husband live with now as if married?

TOTAL NUMBER OF WIVES AND LIVE-IN PARTNERS ______
DON'T KNOW 98

608. Are you the first, second, … wife?

RANK _______

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

ONLY ONCE 1
MORE THAN ONCE 2

615. CHECK 609:

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

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

MONTH ______
DON'T KNOW MONTH 98
YEAR _______ (GO TO 617)
DON'T KNOW YEAR 9998

616. How old were you when you first started living with him?

AGE _______

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

618. 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?

NEVER HAD SEXUAL INTERCOURSE 00 (GO TO 641)
AGE IN YEARS ________
FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND/PARTNER 95

618A. 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.

626. 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.

DAYS AGO 1 _____
WEEKS AGO 2 _____
MONTHS AGO 3 ______
YEARS AGO 4 ______ (GO TO 640)

627. When was the last time you had sexual intercourse with this person?

DAYS 1 ______
WEEKS 2 ______
MONTHS 3 ______

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

YES 1
NO 2 (GO TO 630)

629. Did you use a condom every time you had sexual intercourse with this person in the last12 months?

YES 1
NO 2

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

HUSBAND 1
LIVE-IN PARTNER 2
BOYFRIEND NOT LIVING WITH RESPONDENT 3 (GO TO 631A)
CASUAL ACQUAINTANCE 4 (GO TO 631A)
PROSTITUTE 5 (GO TO 631A)
OTHER (SPECIFY) _________ 6 (GO TO 631A)

630A. CHECK 609:

MARRIED ONLY ONCE (GO TO 630B)
MARRIED MORE THAN ONCE (GO TO 631A)

630B. CHECK 618:

1st TIME WHEN STARTED LIVING WITH 1st HUSBAND (GO TO 631B)
OTHER (GO TO 631A)

631A. How long ago did you first have sexual intercourse with this person?

DAYS 1 ______
MONTHS 2 _______
YEARS 3 _______

631B. How many times during the last 12 months did you have sexual intercourse with this person:

NUMBER OF TIMES _______

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

YES 1 (GO BACK TO 627 IN NEXT COLUMN)
NO 2 (GO TO 640)

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

NUMBER OF PARTNERS LAST 12 MONTHS________
DON'T KNOW 98

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

NUMBER OF PARTNERS IN LIFETIME _______
DON'T KNOW 98

641. Do you know of a place where a person can get condoms?

YES 1
NO 2 (GO TO 644)

642. 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.

(NAME OF PLACE(S)) ___________
GOVERNMENT/PARASTATAL
REFERAL/SPEC. HOSPITAL A
REGIONAL HOSPITAL B
DISTRICT HOSPITAL C
HEALTH CENTRE D
DISPENSARY E
VILLAGE HEALTH POST (WORKER) F
CBD WORKER G
RELIGIOUS/VOLUNTARY
REFERAL/SPEC. HOSPITAL H
DISTRICT HOSPITAL I
GOVT. HEALTH CENTRE J
DISPENSARY K
PRIVATE
DISTRICT HOSPITAL L
HEALTH CENTRE M
DISPENSARY N
OTHER
PHARMACY O
NGO P
VCT CENTRE Q
SHOP/KIOSK R
BAR S
GUEST HOUSE/HOTEL T
FRIEND/RELATIVE/NEIGHBOUR U
OTHER (SPECIFY) ___________ X
DON'T KNOW Z

643. If you wanted to, could you yourself get a condom?

YES 1
NO 2
DON'T KNOW/UNSURE 8

644. Do you know of a place where a person can get female condoms?

YES 1
NO 2 (GO TO 701)

645. 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.

(NAME OF PLACE(S)) _________
GOVERNMENT/PARASTATAL
REFERAL/SPEC. HOSPITAL A
REGIONAL HOSPITAL B
DISTRICT HOSPITAL C
HEALTH CENTRE D
DISPENSARY E
VILLAGE HEALTH POST (WORKER) F
CBD WORKER G
RELIGIOUS/VOLUNTARY
REFERAL/SPEC. HOSPITAL H
DISTRICT HOSPITAL I
GOVT. HEALTH CENTRE J
DISPENSARY K
PRIVATE
DISTRICT HOSPITAL L
HEALTH CENTRE M
DISPENSARY N
OTHER
PHARMACY O
NGO P
VCT CENTRE Q
SHOP/KIOSK R
BAR S
GUEST HOUSE/HOTEL T
FRIEND/RELATIVE/NEIGHBOUR U
OTHER (SPECIFY) __________________X
DON'T KNOW Z

646. If you wanted to, could you yourself get a female condom?

YES 1
NO 2
DON'T KNOW/UNSURE 8

SECTION 7. FERTILITY PREFERENCES

701. CHECK 304:

NEITHER STERILIZED (GO TO 702)
HE OR SHE STERILIZED (GO TO 713)

702. CHECK 226:

PREGNANT (GO TO 702A)
NOT PREGNANT OR UNSURE (GO TO 702B)

702A. Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?

HAVE (A/ANOTHER) CHILD 1 (GO TO 703)
NO MORE/NONE 2 (GO TO 709)
UNDECIDED/DON'T KNOW 3 (GO TO 709)

702B. 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?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 705)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 713)
UNDECIDED/DON'T KNOW 8 (GO TO 708)

703. CHECK 702:

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

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

MONTHS 1 _______
YEARS 2 ______

SOON/NOW 993 (GO TO 708)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 713)
AFTER MARRIAGE 995 (GO TO 708)
OTHER 996 (GO TO 708)
DON'T KNOW 998 (GO TO 708)

704. CHECK 702:

NOT PREGNANT OR UNSURE (GO TO 705)
PREGNANT (GO TO 709)

705. CHECK 303:
USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 706)
NOT CURRENTLY USING (GO TO 706)
CURRENTLY USING (GO TO 713)

706. CHECK 703:

NOT ASKED (GO TO 707)
24 OR MORE MONTHS OR 02 OR MORE YEARS (GO TO 707)
00-23 MONTHS OR 00-01 YEAR (GO TO 709)

707. CHECK 702A, 702B AND 703:

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

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

RECORD ALL REASONS MENTIONED.

NOT MARRIED A
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
SAYS SHE CANT GET PREGNANT E
NOT MENSTRUATED SINCE LAST BIRTH F
BREASTFEEDING G
UP TO GOD/FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND/PARTNER OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
HEALTH CONCERNS O
CONCERN ABOUT SIDE EFFECTS P
LACK OF ACCESS/TOO FAR Q
COSTS TOO MUCH R
INCONVENIENT TO USE S
INTERFERES WITH BODY'S NORMAL PROCESSES T
OTHER (SPECIFY) _______ X
DON'T KNOW Z

708. CHECK 310:
USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 709)
NO, NOT CURRENTLY USING (GO TO 709)
YES, CURRENTLY USING (GO TO 713)

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

YES 1
NO 2
DON'T KNOW 8

713. CHECK 216:

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

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

PROBE FOR A NUMERIC RESPONSE.

NONE 00 (GO TO 715A)
NUMBER ______
OTHER (SPECIFY) ______ 96 (GO TO 715A)

714. How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter?

NUMBER OF BOYS____
OTHER (SPECIFY) ______ 96
NUMBER OF GIRLS____
OTHER (SPECIFY) ______ 96
NUMBER OF EITHER SEX____
OTHER (SPECIFY) ______ 96

715A. If you wanted to get information on family planning, who would you like to talk to most:

CBD WORKER 01
CLINIC STAFF 02
TBA 03
HUSBAND/PARTNER 04
FRIEND 05
RELATIVE 06
RELIGIOUS LEADERS 07
OTHER (SPECIFY) _____________ 96

715B. Is it acceptable to you for information on family planning to be provided:

On the radio?
On the television?
In a newspaper or magazine?

RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NEWSPAPER OR MAGAZINE
YES 1
NO 2

715C. In the last six months have you heard about family planning:

a) On the radio?
b) On the television?
c) In a newspaper or magazine?
d) From a poster?
e) From billboards?
f) At community events?
g) From live drama?
h) From a doctor or nurse?
i) From a community health worker?

RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NEWSPAPER OR MAGAZINE
YES 1
NO 2
POSTER
YES 1
NO 2
BILLBOARD
YES 1
NO 2
COMMUNITY EVENT
YES 1
NO 2
DRAMA
YES 1
NO 2
DOCTOR/NURSE
YES 1
NO 2
HEALTH WORKER
YES 1
NO 2

715D. In the past six months, what drama series have you listened to on the radio?
CIRCLE THE SERIES MENTIONED SPONTANEOUSLY. FOR SERIES NOT MENTIONED, ASK: In the last 6 months, have you listened to:

a) Zinduka?
b) Twende na Wakati?
c) Other?

ZINDUKA
YES SPONTANEOUS 1
YES PROBED 2
NO 3
TWENDE NA WAKATI
YES SPONTANEOUS 1
YES PROBED 2
NO 3
OTHER
YES SPONTANEOUS 1
YES PROBED 2
NO 3

715E. CHECK 715D:

LISTENED TO ZINDUKA (CODE '1' OR 2' CIRCLED) (GO TO 715F)
HAS NOT LISTENED TO ZINDUKA (CODE '3' CIRCLED) (GO TO 715I)

715F. How often do you listen to Zinduka?

TWICE A WEEK 1
ONCE A WEEK 2
ONCE OR TWICE A MONTH 3
RARELY 4
DON'T KNOW 8

715G. As a result of listening to Zinduka, did you do anything or take any action related to family planning?

YES 1
NO 2 (GO TO 715I)
DON'T KNOW 8 (GO TO 715I)

715H. What did you do as a result of listening to Zinduka?
RECORD ALL MENTIONED.

TALKED TO PARTNER A
TALKED TO A HEALTH WORKER B
TALKED TO SOMEONE ELSE C
VISITED A CLINIC FOR FAM. PLAN D
BEGAN USING A MOD. METHOD E
CONTINUED USING A MOD. METH F
OTHER (SPECIFY)_____________ X

715I. CHECK 715D:

LISTENED TO TWENDA NA WAKATI (CODE '1' OR '2' CIRCLED) (GO TO 715J)
HAS NOT LISTENED TO TWENDA NA WAKATI (CODE '3' CIRCLED) (GO TO 717)

715J. How often do you listen to Twenda na Wakati?

TWICE A WEEK 1
ONCE A WEEK 2
ONCE OR TWICE A MONTH 3
RARELY 4
DON'T KNOW 8

717. CHECK 601:

YES, CURRENTLY MARRIED (GO TO 718)
YES, LIVING WITH A MAN (GO TO 718)
NO, NOT IN UNION (GO TO 801)

718. CHECK 304:

CODE B, G, OR M CIRCLED (GO TO 720)
NO CODE CIRCLED (GO TO 722)
OTHER (GO TO 719)

719. Does your husband/partner know that you are using a method of family planning?

YES 1
NO 2
DON'T KNOW 8

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

MAINLY RESPONDENT 1
MAINLY HUSBAND/PARTNER 2
JOINT DECISION 3
OTHER (SPECIFY) ______ 6

721. CHECK 304:

NEITHER STERILIZED (GO TO 722)
HE OR SHE STERILIZED (GO TO 801)

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

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8

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

801. CHECK 601 AND 602:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 802)
FORMERLY MARRIED/LIVING WITH A MAN )GO TO 803)
NEVER MARRIED AND NEVER LIVED WITH A MAN (GO TO 807)

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

AGE IN COMPLETED YEARS _______

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

YES 1
NO 2 (GO TO 806)

804. What was the highest level of school he attended: primary, secondary, or higher?

PREPRIMARY 0
PRIMARY 1
POST-PRIMARY TRAINING 2
SECONDARY 3
POST-SECONDARY TRAINING 4
UNIVERSITY 5
DON'T KNOW 8 (GO TO 806)

805. What was the highest (grade/form/year) he completed at that level?

GRADE ______
DON'T KNOW 98

806. CHECK 801:

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

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

OCCUPATION_________________

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

YES 1 (GO TO 811)
NO 2

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

YES 1 (GO TO 811)
NO 2

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

YES 1 (GO TO 811)
NO 2

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

YES 1
NO 2 (GO TO 818)

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

OCCUPATION_________________

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

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

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

THROUGHOUT THE YEAR 1
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3

817. Are you paid in cash or kind for this work or are you not paid at all?

CASH ONLY 1
CASH AND KIND 2
IN KIND ONLY 3
NOT PAID 4

818. CHECK 601:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 819)
NOT IN UNION (GO TO 826A)

819. CHECK 817:

CODE 1 OR 2 CIRCLED (GO TO 820)
OTHER (GO TO 823)

820. Who usually decides how the money you earn will be used: mainly you, mainly your husband/partner, or you and your husband/partner jointly?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND
HUSBAND/PARTNER JOINTLY 3
OTHER (SPECIFY) ________ 6

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

MORE THAN HIM 1
LESS THAN HIM 2
ABOUT THE SAME 3
HUSBAND/PARTNER DOESN'T
BRING IN ANY MONEY 4
DON'T KNOW 8

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

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER 6

824. Who usually makes decisions about making major household purchases?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER 6

826. Who usually makes decisions about visits to your family or relatives?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER 6

826A. Do you own this or any other house either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

826B. Do you own any land either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

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

CHILDREN UNDER 10
PRES./LISTEN. 1
PRES./NOT LISTEN. 2
MOT PRES. 3
HUSBAND
PRES./LISTEN. 1
PRES./NOT LISTEN. 2
MOT PRES. 3
OTHER MALES
PRES./LISTEN. 1
PRES./NOT LISTEN. 2
MOT PRES. 3
OTHER FEMALES
PRES./LISTEN. 1
PRES./NOT LISTEN. 2
MOT PRES. 3

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

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

GOES OUT
YES 1
NO 2
DON'T KNOW 8
NEGL. CHILDREN
YES 1
NO 2
DON'T KNOW 8
ARGUES
YES 1
NO 2
DON'T KNOW 8
REFUSES SEX
YES 1
NO 2
DON'T KNOW 8
BURNS FOOD
YES 1
NO 2
DON'T KNOW 8

SECTION 9. HIV/AIDS

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

YES 1
NO 2 (GO TO 942)

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

907. Can people get the AIDS virus because of witchcraft or other supernatural means?

YES 1
NO 2
DON'T KNOW 8

908. Is it possible for a healthy-looking person to have the AIDS virus?

YES 1
NO 2
DON'T KNOW 8

909. Can the virus that causes AIDS be transmitted from a mother to her baby:

During pregnancy?
During delivery?
By breastfeeding?

DURING PREG
YES 1
NO 2
DON'T KNOW 8
DURING DELIVERY
YES 1
NO 2
DON'T KNOW 8
BREASTFEEDING
YES 1
NO 2
DON'T KNOW 8

910. CHECK 909:

AT LEAST ONE 'YES' (GO TO 911)
OTHER (GO TO 913)

911. 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?

YES 1
NO 2
DON'T KNOW 8

913. CHECK 208 AND 215:

LAST BIRTH SINCE JANUARY 2007 (GO TO 914)
LAST BIRTH BEFORE JANUARY 2007 (GO TO 922)
NO BIRTHS (GO TO 922)

914. CHECK 407 FOR LAST BIRTH:

HAD ANTENATAL CARE (GO TO 914A)
NO ANTENATAL CARE (GO TO 922)

914A. CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

915. During any of the antenatal visits for your last birth, did anyone talk to you about:

Babies getting the AIDS virus from their mother?
Things that you can do to prevent getting the AIDS virus?
Getting tested for the AIDS virus?

AIDS FROM MOTHER
YES 1
NO 2
DON'T KNOW 8
THINGS TO DO
YES 1
NO 2
DON'T KNOW 8
TESTED FOR AIDS
YES 1
NO 2
DON'T KNOW 8

916. Were you offered a test for the AIDS virus as part of your antenatal care?

YES 1
NO 2

917. I don't want to know the results, but were you tested for the AIDS virus as part of your antenatal care?

YES 1
NO 2 (GO TO 922)

917A. Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) ___________
GOVERNMENT/PARASTATAL
REFERAL/SPEC. HOSPITAL 11
REGIONAL HOSPITAL 12
DISTRICT HOSPITAL 13
HEALTH CENTRE 14
DISPENSARY 15
VILLAGE HEALTH POST (WORKER) 16
CBD WORKER 17
RELIGIOUS/VOLUNTARY
REFERAL/SPEC. HOSPITAL 21
DISTRICT HOSPITAL 22
GOVT. HEALTH CENTRE 23
DISPENSARY 24
PRIVATE
HOSPITAL 31
HEALTH CENTRE 32
DISPENSARY 33
OTHER
PRIVATE PHARMACY 41
NGO 42
VCT CENTRE 43
OTHER (SPECIFY) ________________________ 96

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

YES 1
NO 2

918A. Regardless of the result, all women who are tested are supposed to receive counselling after getting the result. Did you receive post-test counselling?

YES 1
NO 2
DON'T KNOW 8

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

YES 1 (GO TO 923)
NO 2

921. When was the last time you were tested for the AIDS virus?

LESS THAN 12 MONTHS AGO 1 (GO TO 929)
12 -23 MONTHS AGO 2(GO TO 929)
2 OR MORE YEARS AGO 3(GO TO 929)

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

YES 1
NO 2 (GO TO 927)

923. When was the last time you were tested?

LESS THAN 12 MONTHS AGO 1
12 -23 MONTHS AGO 2
2 OR MORE YEARS AGO 3

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

YES 1
NO 2

926. Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) ___________
GOVERNMENT/PARASTATAL
REFERAL/SPEC. HOSPITAL 11 (GO TO 929)
REGIONAL HOSPITAL 12(GO TO 929)
DISTRICT HOSPITAL 13(GO TO 929)
HEALTH CENTRE 14(GO TO 929)
DISPENSARY 15(GO TO 929)
VILLAGE HEALTH POST (WORKER) 16(GO TO 929)
CBD WORKER 17(GO TO 929)
RELIGIOUS/VOLUNTARY
REFERAL/SPEC. HOSPITAL 21(GO TO 929)
DISTRICT HOSPITAL 22(GO TO 929)
GOVT. HEALTH CENTRE 23(GO TO 929)
DISPENSARY 24(GO TO 929)
PRIVATE
HOSPITAL 31(GO TO 929)
HEALTH CENTRE 32(GO TO 929)
DISPENSARY 33(GO TO 929)
OTHER
PRIVATE PHARMACY 41(GO TO 929)
NGO 42(GO TO 929)
VCT CENTRE 43(GO TO 929)
OTHER (SPECIFY) ________________________ 96(GO TO 929)

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

YES 1
NO 2

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

(NAME OF PLACE) ___________
GOVERNMENT/PARASTATAL
REFERAL/SPEC. HOSPITAL A
REGIONAL HOSPITAL B
DISTRICT HOSPITAL C
HEALTH CENTRE D
DISPENSARY E
VILLAGE HEALTH POST F
CBD WORKER G
RELIGIOUS/VOLUNTARY
REFERAL/SPEC. HOSPITAL H
DISTRICT HOSPITAL I
GOVT. HEALTH CENTRE J
DISPENSARY K
PRIVATE
HOSPITAL L
HEALTH CENTRE M
DISPENSARY N
OTHER
PRIVATE PHARMACY O
NGO P
VCT CENTRE Q
OTHER (SPECIFY) ________________________ X

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

YES 1
NO 2
DON'T KNOW 8

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

YES, REMAIN A SECRET 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

931. If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?

YES 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

932. 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?

SHOULD BE ALLOWED 1
SHOULD NOT BE ALLOWED 2
DON'T KNOW/NOT SURE/DEPENDS 8

942. CHECK 901:

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

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

YES 1
NO 2

943. CHECK 618:

HAS HAD SEXUAL INTERCOURSE (GO TO 944)
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 951)

944. CHECK 942:
HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

YES (GO TO 945)
NO (GO TO 946)

945. 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?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

948. CHECK 945, 946, AND 947:

HAS HAD AN INFECTION (ANY 'YES') (GO TO 949)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 951)

949. The last time you had (PROBLEM FROM 945/946/947), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 951)

950. 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.

(NAME OF PLACE) __________
GOVERNMENT/PARASTATAL
REFERAL/SPEC. HOSPITAL A
REGIONAL HOSPITAL B
DISTRICT HOSPITAL C
HEALTH CENTRE D
DISPENSARY E
VILLAGE HEALTH POST F
CBD WORKER G
RELIGIOUS/VOLUNTARY
REFERAL/SPEC. HOSPITAL H
DISTRICT HOSPITAL I
GOVT. HEALTH CENTRE J
DISPENSARY K
PRIVATE
HOSPITAL L
HEALTH CENTRE M
DISPENSARY N
OTHER
PRIVATE PHARMACY O
NGO P
VCT CENTRE Q
OTHER (SPECIFY) ________________________ X

951. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?

YES 1
NO 2
DON'T KNOW 8

953. 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?

YES 1
NO 2
DON'T KNOW 8

955. CHECK 601:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 956)
NOT IN UNION (GO TO 1001)

956. Can you say no to your husband/partner if you do not want to have sexual intercourse?

YES 1
NO 2
DEPENDS/NOT SURE 8

957. Could you ask your husband/partner to use a condom if you wanted him to?

YES 1
NO 2
DEPENDS/NOT SURE 8

SECTION 10. DOMESTIC VIOLENCE MODULE

1001. CHECK HH Q.200 AND COVER PAGE OF WOMAN'S QUESTIONNAIRE:

WOMAN SELECTED FOR THIS SECTION (GO TO 1002)
WOMAN NOT SELECTED (GO TO 1101)

1002. CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.

PRIVACY OBTAINED 1
READ TO THE RESPONDENT: Now I would like to ask you questions about some other important aspects of a woman's life. I know that some of these questions are very personal. However, your answers are crucial for helping to understand the condition of women in Tanzania. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else will know that you were asked these questions. (GO TO 1003)
PRIVACY NOTPOSSIBLE 2 (GO TO 1035)

1003. CHECK 601 AND 602:

CURRENTLY MARRIED/ LIVING WITH A MAN (GO TO 1004)
FORMERLY MARRIED/ LIVED WITH A MAN (READ IN PAST TENSE) (GO TO 1004)
NEVER MARRIED/NEVER LIVED WITH A MAN (GO TO 1015)

1004. First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband/partner?

a) He (is/was) jealous or angry if you (talk/talked) to other men?
b) He frequently (accuses/accused) you of being unfaithful?
c) He (does/did) not permit you to meet your female friends?
d) He (tries/tried) to limit your contact with your family?
e) He (insists/insisted) on knowing where you (are/were) at all times?
f) He (does/did) not trust you with any money?

JEALOUS
YES 1
NO 2
DON'T KNOW 8
ACCUSES
YES 1
NO 2
DON'T KNOW 8
NOT MEET FRIENDS
YES 1
NO 2
DON'T KNOW 8
NO FAMILY
YES 1
NO 2
DON'T KNOW 8
WHERE YOU ARE
YES 1
NO 2
DON'T KNOW 8
MONEY
YES 1
NO 2
DON'T KNOW 8

1005. Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner. If we should come to any question that you do not want to answer, just let me know and we will go on to the next question.

A. (Does/did) your (last) husband/partner ever:

a) say or do something to humiliate you in front of others?
YES 1
NO 2
b) threaten to hurt or harm you or someone close to you?
YES 1
NO 2
c) insult you or make you feel bad about yourself?
YES 1
NO 2

B. How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) say or do something to humiliate you in front of others?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
b) threaten to hurt or harm you or someone close to you?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
c) insult you or make you feel bad about yourself?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1006A. (Does/did) your (last) husband/partner ever do any of the following things to you:

a) push you, shake you, or throw something at you?
YES 1
NO 2
b) slap you?
YES 1
NO 2
c) twist your arm or pull your hair?
YES 1
NO 2
d) punch you with his fist or with something that could hurt you?
YES 1
NO 2
e) kick you, drag you or beat you up?
YES 1
NO 2
f) try to choke you or burn you on purpose?
YES 1
NO 2
g) threaten or attack you with a knife, gun, or any other weapon?
YES 1
NO 2
h) physically force you to have sexual intercourse with him even when you did not want to?
YES 1
NO 2
i) force you to perform any sexual acts you did not want to?
YES 1
NO 2

1006B. How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) push you, shake you, or throw something at you?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
b) slap you?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
c) twist your arm or pull your hair?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
d) punch you with his fist or with something that could hurt you?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
e) kick you, drag you or beat you up?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
f) try to choke you or burn you on purpose?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
g) threaten or attack you with a knife, gun, or any other weapon?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
h) physically force you to have sexual intercourse with him even when you did not want to?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
i) force you to perform any sexual acts you did not want to?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1007. CHECK1006 (a-i):

AT LEAST ONE 'YES' (GO TO 1008)
NOT A SINGLE 'YES' (GO TO 1010)

1008. How long after you first (got married to/started living with) your (last) husband/partner did (this/any of these things) first happen?
IF LESS THAN ONE YEAR, RECORD '00'.

NUMBER OF YEARS_____
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95

1009. Did the following ever happen as a result of what your (last) husband/partner did to you:

a) You had cuts, bruises or aches?
YES 1
NO 2
b) You had eye injuries, sprains, dislocations, or burns?
YES 1
NO 2
c) You had deep wounds, broken bones, broken teeth, or any other serious injury?
YES 1
NO 2

1010. Have you ever hit, slapped, kicked, or done anything else to physically hurt your (last) husband/partner at times when he was not already beating or physically hurting you?

YES 1
NO 2 (GO TO 1013)

1011. CHECK 603:

RESPONDENT IS NOT A WIDOW (GO TO 1012)
RESPONDENT IS A WIDOW (GO TO 1013)

1012. In the last 12 months, how often have you done this to your husband/partner: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1013. (Does/Did) your husband/partner drink alcohol?

YES 1
NO 2 (GO TO 1015)

1014. How often (does/did) he get drunk: often, only sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

1015. CHECK 601 AND 602:

EVER MARRIED/LIVED WITH A MAN: From the time you were 15 years old has anyone other than your (current/last) husband/partner hit, slapped, kicked, or done anything to hurt you physically?

NEVER MARRIED/ NEVER LIVED WITH A MAN: From the time you were 15 years old has anyone ever hit, slapped, kicked, or done anything else to hurt you else physically?

YES 1
NO 2 (GO TO 1018)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1018)

1016. Who has hurt you in this way? Anyone else?
RECORD ALL MENTIONED.

MOTHER/STEP-MOTHER A
FATHER/STEP-FATHER B
SISTER/BROTHER C
DAUGHTER/SON D
OTHER RELATIVE E
FORMER HUSBAND/LIVE-IN PARTNER F
CURRENT BOYFRIEND G
FORMER BOYFRIEND H
MOTHER-IN-LAW I
FATHER-IN-LAW J
OTHER IN-LAW K
TEACHER L
EMPLOYER/SOMEONE AT WORK M
POLICE/SOLDIER N
OTHER (SPECIFY) _______ X

1017. In the last 12 months, how often have you been hit, slapped, kicked, or physically hurt by this/these person(s): often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1018. CHECK 201, 226, AND 229:

EVER BEENPREGNANT (YES ON 201 OR 226 OR 229) (GO TO 1019)
NEVER BEEN PREGNANT (GO TO 1021)

1019. Has any one ever hit, slapped, kicked, or done anything else to hurt you physically while you were pregnant?

YES 1
NO 2 (GO TO 1021)

1020. Who has done any of these things to physically hurt you while you were pregnant? Anyone else?
RECORD ALL MENTIONED.

CURRENT HUSBAND/LIVE-IN PARTNER A
MOTHER/STEP-MOTHER B
FATHER/STEP-FATHER C
SISTER/BROTHER D
DAUGHTER/SON E
OTHER RELATIVE F
FORMER HUSBAND/LIVE-IN PARTNER G
CURRENT BOYFRIEND H
FORMER BOYFRIEND I
MOTHER-IN-LAW J
FATHER-IN-LAW K
OTHER IN-LAW L
TEACHER M
EMPLOYER/SOMEONE AT WORK N
POLICE/SOLDIER O
OTHER (SPECIFY) _______ X

1021. CHECK 618:
EVER HAD SEX?

HAS EVER HAD SEX (GO TO 1022)
NEVER HAD SEX (GO TO 1026)

1022. The first time you had sexual intercourse, would you say that you had it because you wanted to, or because you were forced to have it against your will?

WANTED TO 1
FORCED TO 2
REFUSED TO ANSWER/NO RESPONSE 3

1023. CHECK 601 AND 602:

EVER MARRIED/LIVED WITH A MAN: In the last 12 months, has anyone other than your (current/last) husband/ partner forced you to have sexual intercourse against your will?

NEVER MARRIED/ NEVER LIVED WITH A MAN: In the last 12 months has anyone forced you to have sexual intercourse against your will?

YES 1
NO 2
REFUSED TO ANSWER/NO ANSWER 3

1024. CHECK 1022 AND 1023:

1022 ='1' OR '3' AND 1023 ='2' OR '3' (GO TO 1025)
OTHER (GO TO 1027)

1025. CHECK 1006(h) and 1006(i):

1006(h) IS NOT '1' AND 1006(i) IS NOT '1' (GO TO 1026)
OTHER (GO TO 1029)

1026. At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts?

YES 1
NO 2(GO TO 1029)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1029)

1027. How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?

AGE IN COMPLETED YEARS ______
DON'T KNOW 98

1028. Who was the person who was forcing you at that time?

CURRENT HUSBAND/LIVE-IN PARTNER 01
FORMER HUSBAND/LIVE-IN PARTNER 02
CURRENT/FORMER BOYFRIEND 03
FATHER 04
STEP-FATHER 05
OTHER RELATIVE 06
IN-LAW 07
OWN FRIEND/ACQUAINTANCE 08
FAMILY FRIEND 09
TEACHER 10
EMPLOYER/SOMEONE AT WORK 11
POLICE/SOLDIER 12
PRIEST/RELIGIOUS LEADER 13
STRANGER 14
OTHER (SPECIFY) ______ 96

1029. CHECK 1006A (a-i), 1015, 1019, 1023 AND 1026:

AT LEAST ONE 'YES' OR 1022=2 (GO TO 1030)
NOT A SINGLE 'YES' AND 1022 IS NOT EQUAL TO 2 (GO TO 1033)

1030. Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help to stop (the/these) person(s) from doing this to you again?

YES 1
NO 2 (GO TO 1032)

1031. From whom have you sought help? Anyone else?
RECORD ALL MENTIONED.

OWN FAMILY A (GO TO 1033)
HUSBAND/LIVE-IN PARTNER'S FAMILY B (GO TO 1033)
CURRENT/LAST/LATE HUSBAND/LIVE-IN PARTNER C (GO TO 1033)
CURRENT/FORMER BOYFRIEND D (GO TO 1033)
FRIEND E (GO TO 1033)
NEIGHBOR F (GO TO 1033)
RELIGIOUS/LOCAL LEADER G (GO TO 1033)
DOCTOR/MEDICAL PERSONNEL H (GO TO 1033)
POLICE I (GO TO 1033)
LAWYER J (GO TO 1033)
SOCIAL SERVICE ORGANIZATION K (GO TO 1033)
OTHER (SPECIFY) _______ X (GO TO 1033)

1032. Have you ever told any one else about this?

YES 1
NO 2

1033. As far as you know, did your father ever beat your mother?

YES 1
NO 2
DON'T KNOW 8

THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER ABOUT THE CONFIDENTIALITY OF HER ANSWERS. FILL OUT THE QUESTIONS BELOW WITH REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

1034. DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

HUSBAND
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3
OTHER MALE ADULT
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3
FEMALE ADULT
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3

1035. INTERVIEWER'S COMMENTS / EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE
___________________________________

SECTION 11. MATERNAL MORTALITY

1101. Now I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your natural mother, including those who are living with you, those living elsewhere and those who have died. How many children did your mother give birth to, including you?

NUMBER OF BIRTHS TO NATURAL MOTHER ________

1102. CHECK 1101:

TWO OR MORE BIRTHS (GO TO 1103)
ONLY ONE BIRTH (RESPONDENT ONLY) (GO TO 1201)

1103. How many of these births did your mother have before you were born?

NUMBER OF PRECEDING BIRTHS _______

1104. What was the name given to your oldest (next oldest) brother or sister?

NAME_____________

1105. Is (NAME) male or female?

MALE 1
FEMALE 2

1106. Is (NAME) still alive?

YES 1
NO 2 (GO TO 1108)
DON'T KNOW 8 (GO TO NEXT BIRTH)

1107. How old is (NAME)?

AGE_____________ (GO TO NEXT BIRTH)

1108. How many years ago did (NAME) die?

YEARS_____________

1109. How old was (NAME) when he/she died?

AGE_____________ (IF MALE OR DIED BEFORE 12 YEARS OF AGE GO TO NEXT BIRTH)

1110. Was (NAME) pregnant when she died?

YES 1 (GO TO1113)
NO 2

1111. Did (NAME) die during childbirth?

YES 1 (GO TO1113)
NO 2

1112. Did (NAME) die within two months after the end of a pregnancy or childbirth?

YES 1
NO 2

1113. How many live born children did (NAME) give birth to during her lifetime (before this pregnancy)?

NUMBER OF CHILDREN_____________

IF NO MORE BROTHERS OR SISTERS, GO TO 1114.

1114. CHECK Q1110, 1111 AND 1112 FOR ALL SISTERS

ANY YES
Just to make sure I have this right, you told me that your sister(s) _______________ (NAME) died when she was (pregnant/delivering/just delivered). Is that correct?
IF CORRECT, CONTINUE TO 1201.
IF NOT, CORRECT QUESTIONNAIRE AND CONTINUE TO 1201.
ALL NO OR BLANK (GO TO 1201)

SECTION 12. OTHER HEALTH ISSUES

1201. Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS _______
NONE 00 (GO TO 1203)

1202. Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS _______
NONE 00 (GO TO 1203)

1202A. The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

YES 1
NO 2
DON'T KNOW 8

1203. Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 1205)

1204. In the last 24 hours, how many cigarettes did you smoke?

CIGARETTES ________

1205. Do you currently smoke or use any other type of tobacco?

YES 1
NO 2 (GO TO 1207)

1206. What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.

PIPE A
CHEWING TOBACCO B
SNUFF C
OTHER (SPECIFY) ______ X

1207. Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not?

Getting permission to go?
Getting money needed for advice treatment?
The distance to the health facility?
Not wanting to go alone?

PERMISSION TO GO
BIG PROBLEM 1
NOT A BIG PROBLEM 2
NOT A PROBLEM AT LL 3
GETTING MONEY
BIG PROBLEM 1
NOT A BIG PROBLEM 2
NOT A PROBLEM AT LL 3
DISTANCE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
NOT A PROBLEM AT LL 3
GO ALONE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
NOT A PROBLEM AT LL 3

1208. Are you covered by any health insurance?

YES 1
NO 2 (GO TO 1210)

1209. What type of health insurance?
RECORD ALL MENTIONED.

MUTUAL HEALTH ORGANIZATION/COMMUNITY-BASED HEALTH INSURANCE A
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE. D
OTHER (SPECIFY) _______ X

1210. Have you ever heard of female circumcision?

YES 1(GO TO 1213)
NO 2

1211. In a number of countries, there is a practice in which a girl may have part of her genitals cut. Have you heard about this practice?

YES 1
NO 2 (GO TO 1301)

1213. Have you been circumcised?

YES 1
NO 2 (GO TO 1221)

1214. Now I would like to ask you what was done to you at this time. Was any flesh removed from the genital area?

YES 1(GO TO 1218)
NO 2
DON'T KNOW 8

1217. Was the genital area just nicked without removing any flesh?

YES 1
NO 2
DON'T KNOW 8

1218. Was your genital area sewn?

YES 1
NO 2
DON'T KNOW 8 (GO TO 1218)

1219. How old were you when this occurred?
IF THE RESPONDENT DOES NOT KNOW THE EXACT AGE,
PROBE TO GET AN ESTIMATE.

AGE IN COMPLETED YEARS _______

DURING INFANCY 95
DON'T KNOW 98

1220. Who cut (or nicked) the genitals? Who cut (or nicked) the genitals?

TRADITIONAL
TRAD. "CIRCUMCISER" 11
TRAD. BIRTH ATTENDANT 12
OTHER TRAD. (SPECIFY) ____________________ 16
HEALTH PROFESSIONAL
DOCTOR 21
TRAINED NURSE/MIDWIFE 22
OTHER PROF. (SPECIFY) ___________________ 26
DON'T KNOW 98

1221. CHECK 213 AND 216:

HAS AT LEAST ONE LIVING DAUGHTER (GO TO 1222)
HAS NO LIVING DAUGHTER (GO TO 1230)

1222. Has one of your daughters been circumcised?
IF YES: How many?

NUMBER CIRCUMCISED ________
NO DAUGHTER CIRCUMCISED 95 (GO TO 1229)

1223. To which of your daughters did this happen most recently?
INTERVIEWER: CHECK 212 AND RECORD THE BIRTH HISTORY NUMBER FOR THE DAUGHTER.

(DAUGHTER'S NAME) _________
DAUGHTER'S BIRTH HISTORY NUMBER FROM Q212 ______________

1224. Now I would like to ask you what was done to (NAME OF THE DAUGHTER FROM (Q1223) at this time. Was any flesh removed from her genital area?

YES 1 (GO TO 1226)
NO 2
DON'T KNOW 8

1225. Was her genital area just nicked without removing any flesh?

YES 1
NO 2
DON'T KNOW 8

1226. Was her genital area sewn?

YES 1
NO 2
DON'T KNOW 8

1227. How old was (NAME OF DAUGHTER FROM Q1223) when this occurred?
IF THE RESPONDENT DOES NOT KNOW THE AGE, PROBE TO GET AN ESTIMATE.

AGE IN COMPLETED YEARS ___________

DURING INFANCY 95
DON'T KNOW 98

1228. Who cut (or nicked) the genitals?

TRADITIONAL
TRAD. "CIRCUMCISER" 11 (GO TO 1230)
TRAD. BIRTH ATTENDANT 12 (GO TO 1230)
OTHER TRAD. (SPECIFY) ____________________ 16 (GO TO 1230)
HEALTH PROFESSIONAL
DOCTOR 21(GO TO 1230)
TRAINED NURSE/MIDWIFE 22 (GO TO 1230)
OTHER PROF. (SPECIFY) ___________________ 26 (GO TO 1230)
DON'T KNOW 98 (GO TO 1230)

1229. Do you intend to have any of your daughters circumcised in the future?

YES 1
NO 2
DON'T KNOW 8

1230. Do you think that this practice should be continued, or should it be discontinued?

CONTINUED 1
DISCONTINUED 2
DEPENDS 3
DON'T KNOW 8

SECTION 13. FISTULA

1301. Sometimes a woman can have a problem such that she experiences a constant leakage of urine or stool from her vagina during the day and night. This problem usually occurs after a difficult childbirth, but may also occur after a assault or after a pelvic surgery. Have you ever experienced a constant leakage of urine or stool from your vagina during the day and night?

YES 1 (GO TO 1303)
NO 2

1302. Have you ever heard of this kind of problem, such that a woman experiences a constant leakage of urine or stool from her vagina during the day and night?

YES 1 (GO TO 1310)
NO 2 (GO TO 1310)

1303. Did this problem occur:

After a delivery?
After a sexual assault?
After pelvic surgery?
After some other event?

DELIVERY
YES 1 (GO TO 1303A)
NO 2 (GO TO NEXT)
SEXUAL ASSAULT
YES 1 (GO TO 1305)
NO 2 (GO TO NEXT)
PELVIC SURGERY
YES 1 (GO TO 1305)
NO 2 (GO TO NEXT)
OTHER (SPECIFY) ________ 6 (GO TO 1305)

1303A. Did this problem occur after a normal labor and delivery, or after a very difficult labor and delivery?

NORMAL LABOR/DELIVERY 1
VERY DIFFICULT DELIVERY 2

1303B. Was this baby born alive?

YES, BABY BORN ALIVE 1
NO, BABY NOT BORN ALIVE 2

1304. After which delivery did this occur?

DELIVERY NUMBER: _________

1305. How many days after (ANSWER TO Q. 1303) did the leakage start?
(ENTER 95 IF MORE THAN 95 DAYS)

NUMBER OF DAYS AFTER PRECIPITATING EVENT _________

1306. Have you sought treatment for this condition?

YES 1 (GO TO 1308)
NO 2

1307. Why have you not sought treatment?

DID NOT KNOW COULD BE FIXED 1 (GO TO 1310)
DO NOT KNOW WHERE TO GO 2 (GO TO 1310)
TOO EXPENSIVE 3 (GO TO 1310)
TOO FAR 4 (GO TO 1310)
POOR QUALITY OF CARE 5 (GO TO 1310)
COULD NOT GET PERMISSION 6 (GO TO 1310)
EMBARRASSMENT 7 (GO TO 1310)
OTHER (SPECIFY) ______ 8 (GO TO 1310)

1308. From whom did you last seek treatment?

HEALTH PROFESSIONAL
DOCTOR/CLINICAL OFFICER 1
NURSE/MIDWIFE 2
PATIENT ATTENDANT 3
OTHER PERSON
UNTRAINED VILLAGE DOCTOR 4
OTHER 5

1309. Did the treatment stop the problem?

YES, NO MORE LEAKAGE AT ALL 1
YES, BUT STILL SOME LEAKAGE 2
NO, STILL HAVE PROBLEM 3

1310. RECORD THE TIME.

HOUR _______
MINUTES _________
MORNING 1
AFTERNOON 2
EVENING, NIGHT 3

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:
____________________________________

COMMENTS ON SPECIFIC QUESTIONS:
_____________________________________

ANY OTHER COMMENTS:
_____________________________________

SUPERVISOR'S OBSERVATIONS
_____________________________________

NAME OF SUPERVISOR: _______________
DATE:___________

EDITOR'S OBSERVATIONS
_______________________________________

NAME OF EDITOR: ___________
DATE: ____________

INSTRUCTIONS:
ONLY ONE CODE SHOULD APPEAR IN ANY BOX.
ALL MONTHS SHOULD BE FILLED IN.

INFORMATION TO BE CODED FOR EACH COLUMN

BIRTHS, PREGNANCIES, CONTRACEPTIVE USE

B BIRTHS
P PREGNANCIES
T TERMINATIONS
0 NO METHOD
1 FEMALE STERILIZATION
2 MALE STERILIZATION
3 IUD
4 INJECTABLES
5 IMPLANTS
6 PILL
7 CONDOM
8 FEMALE CONDOM
9 DIAPHRAGM
J FOAM OR JELLY
K LACTATIONAL AMENORRHEA METHOD
L RHYTHM METHOD
M WITHDRAWAL
X OTHER