IDENTIFICATION

REGION _____

DISTRICT _____

COUNTY _____

SUB-COUNTY/TOWN _____

PARISH/RC2 NAME _____

EA NAME _____

UDHS NUMBER

URBAN/ RURAL

CITY/MUNICIPALITY/TOWN/COUNTRYSIDE

HOUSEHOLD NUMBER

NAME OF HOUSEHOLD HEAD ______

NAME AND LINE NUMBER OF MAN ______

NAME AND LINE NUMBER OF FIRST WIFE ______

NAME AND LINE NUMBER OF SECOND WIFE ______

NAME AND LINE NUMBER OF THIRD WIFE ______

NAME AND LINE NUMBER OF FOURTH WIFE ______

INTERVIEWER VISITS

FIRST VISIT:
DATE
INTERVIEWER'S NAME
RESULT

NEXT VISIT:
DATE
TIME

SECOND VISIT:
DATE
INTERVIEWER'S NAME
RESULT

NEXT VISIT:
DATE
TIME

THIRD VISIT:
DATE
INTERVIEWER'S NAME
RESULT

FINAL VISIT:
DAY
MONTH
YEAR
NAME
RESULT

TOTAL NUMBER OF VISITS

LANGUAGE OF QUESTIONNAIRE: ENGLISH

LANGUAGE USED IN INTERVIEW

RESPONDENT'S LOCAL LANGUAGE

TRANSLATOR USED

SUPERVISOR

FIELD EDITOR

OFFICE EDITOR

KEYED BY

SECTION 1. RESPONDENT'S BACKGROUND

101) RECORD THE TIME.

102) First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in a city, in a municipality, in a town or in the countryside?

103) How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?

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

105) In what month and year were you born?

106) How old were you at your last birthday?

COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

107) Have you ever attended school?

108) What is the highest level of school you attended: primary, junior, secondary or university?

109) What is the highest grade you completed at that level?

110) CHECK 108:

111) Would you please read this sentence?

SHOW SENTENCE TO RESPONDENT AND CIRCLE CORRECT CODE.

112) Do you usually read a newspaper or magazine at least once a week?

113A) How often do you listen to the radio?

113B) What times do you usually listen to the radio? (CIRCLE ALL TIMES MENTIONED)

113C) What day of the week do you usually like to listen to the radio? (CIRCLE ALL DAYS MENTIONED)

114A) How often do you watch television (TV)?

114B) What times do you usually watch TV? (CIRCLE ALL TIMES MENTIONED)

114C) What days of the week do you usually watch TV? (CIRCLE ALL DAYS MENTIONED)

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

116) CHECK 115:

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

118) Do you earn cash for this work?

119) What is your religion?

120) What is your nationality?

121) What is your tribe?

SECTION 2. REPRODUCTION

201) Now I would like to ask about all the children you have had during your life. I mean your own children, not ones you many have adopted or care for as a father but whose real father is someone else. Do you have children?

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

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

204) Do you have any sons or daughters who are alive but do not live with you?

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

206) Have you ever had a son or daughter who was born alive but later died?

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

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

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

209) CHECK 208:

Just to make sure that I have this right: you have had in TOTAL ____ children during your life. Is that correct?

SECTION 3. CONTRACEPTION

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.

CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 302, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 2 IF METHOD IS RECOGNIZED, AND CODE 3 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 301 OR 302, ASK 303.

301) Which ways or methods have you heard about?

302) Have you ever heard of (METHOD)?

303) Have you ever used (METHOD)?

304) CHECK 303:

305) Have you ever used anything or tried anything in any way to delay or avoid having a child?

306) What have you used or done? CORRECT 303-304 (AND 302 IF NECESSARY)

307) Are you currently doing something or using any method to delay or avoid having a child?

308) Which method are you using? Anything else?

RECORD FIRST, SECOND, THIRD AND FOURTH PARTNER IN SEPERATE COLUMNS

SECTION 4. MARRIAGE AND SEXUAL BEHAVIOUR

401) PRESENCE OF OTHERS AT THIS POINT.

402) Are you currently married or living with a woman?

403) Have you ever been married or living with a woman?

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

405) How many wives do you have?

407) In what month and year did you start living with your (first) wife/partner?

408) How old were you when you started living with her?

409) Do you have a regular partner (apart from your wife/wives)? I mean someone with whom you have been having sex for about a year or more?

410) How many regular partners do you have (aside from your wife/wives)?

411) CHECK 402 AND 409

412) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family planning issues.

When was the last time you had sexual intercourse with your (wife/regular partner)?

IF RESPONDENT HAS BOTH WIFE AND REGULAR PARTNER, ASK WHEN HE LAST HAD SEX WITH EITHER.

413) For that sexual intercourse, was a condom used?

414) Have you had sexual intercourse with anyone (else) in the last 6 months? (I mean, with someone other than your wife or regular partner that you mentioned earlier)

415) With how many different people have you had sexual intercourse in the last 6 months (apart from your wife or regular partners)?

416) Was a condom used with any of these women?

417) When was the last time you had sexual intercourse (apart from your wife/regular partner)?

418) For that last sexual intercourse, did you give money, gifts or favours in return for sex?

419) Was this person someone you had met before or someone you met for the first time?

420) Was a condom used for that last sexual intercourse?

421) What was the main reason that you did not use a condom that time?

421A) CHECK 412 AND 417

422) In the last four weeks, how many times have you had sexual intercourse?

423) Was a condom used on any of these occasion? IF YES: Was it each time or sometimes?

424) Who did you have sex with the last time you had sexual intercourse? Was it with (your wife / the woman you are living with) or was it with someone else?

425) CHECK 303:

426) Do you know where you can get condoms?

427) Where is that?

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

(NAME OF PLACE) ____________________

428) Have you heard of a condom called 'Protector'?

429) In general, do you think that most women like men to use condoms, they don't like men to use condoms, or does it not matter?

430) Now think back to the past. How old were you when you had sexual intercourse for the first time?

SECTION 5: FERTILITY PREFERENCES

501) CHECK 402 AND 409:

502) Spouses/partners do not always agree on everything. Now I want to ask you about your wife's/partner's views on family planning. Do you think that your wife/partner approves or disapproves of couples using a method to avoid pregnancy?

503) Do you think your wives/partners wants the same number of children that you want, or does she want more or fewer that you want?

504A) CHECK 308

504B) 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?

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

506) CHECK 307: USING A METHOD?

507) Do you intend to use a method to delay or avoid pregnancy within the next 12 months?

508) Do you intend to use a method at any time in the future?

509) Which method would you prefer to use?

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

511) CHECK 203 AND 205:

512) How many of these children would you like to be boys and how many would you like to be girls?

513) In general, do you approve or disapprove of couples using a method to avoid pregnancy?

514) Is it acceptable or not acceptable to you for information on family planning to be provided:

515) In the last six months have you heard or learned about family planning:

516) CHECK 515:

517) Which program or message have you heard? Any others?

ON THE RADIO AND TELEVISION.

518) Do you think that the using of family planning will make a woman more promiscuous?

519) Do you think that the using of family planning will make a man more promiscuous?

520) What do you understand by the term "family planning"? RECORD ALL MENTIONED

521) In a relationship, who do you think should have the major role using family planning?

522) Who should be responsible in getting information about family planning?

523) Have you seen/heard about the Yellow Family Planning Flower?

524) Can you describe it?

525) What does it mean?

SECTION 6. AIDS

601) Have you heard about disease that can be transmitted through sex?

602) Which diseases do you know?

RECORD ALL RESPONSES

603) CHECK 424:

604) During the last 12 months, did you have any of these diseases?

605) Which?

RECORD ALL RESPONSES

606) During the last 12 months, did you have a discharge from your penis?

607) During the last 12 months, did you have a sore or ulcer on your penis?

608) CHECK 605, 606 AND 607:

609) When you had the most recent episode of (DISEASE FROM 605, 606, AND 607) did you seek advice or treatment?

610) Where did you seek advice or treatment? Any other place or person?

RECORD ALL MENTIONED

610A) Why did not you seek advice or treatment?

610B) CHECK 424:

611) When you had the most recent episode of (DISEASE FROM 605, 606, AND 607) did you inform your partner?

612) When you had the most recent episode of (DISEASE FROM 605, 606, AND 607) did you do something not to infect your partner?

613) What did you do?

614) CHECK 602:

615) Have you ever heard of an illness called AIDS?

616) From which sources of information have you learned most about AIDS? Any other sources?

RECORD ALL MENTIONED.

617) How can a person get AIDS? Any other ways?

RECORD ALL RESPONSES

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

619) What can a person do to avoid getting AIDS or the virus that causes AIDS? Any other ways?

RECORD ALL MENTIONED

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

621) Is AIDS a fatal disease, that is, do all people with AIDS die from the disease?

622) Can AIDS be transmitted from mother to child?

623) Can AIDS be transmitted through breastfeeding?

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

624A) What relationship to you?

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

626) Why do you think that you have (NO RISK/A SMALL CHANCE) of getting AIDS? Any other reasons?

RECORD ALL MENTIONED.

627) Why do you think that you have a (MODERATE/GREAT) chance of getting AIDS? Any other reasons?

RECORD ALL MENTIONED.

628) Since you heard of AIDS, have you changed your sexual behaviour to prevent getting AIDS?

629) What did you do? Anything else?

RECORD ALL MENTIONED

630) Some people use a condom during sexual intercourse to avoid getting AIDS or other sexually transmitted diseases? Have you ever heard of this?

630A) CHECK 424:

631) Have you ever used a condom during sex to avoid getting or transmitting diseases, such as AIDS?

632) Have you ever been tested to see if you have the AIDS virus?

633) Would you like to be tested for the AIDS virus?

634) Do you know a place where you could go to get an AIDS test?

635) Where could you go?

636) What do you suggest is the most important thing the government should do for people who have AIDS?

637) If a member of your family is suffering from AIDS would you be willing to care for him or her at home?

SECTION 7. MATERNAL MORTALITY

701) 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?

702) CHECK 701:

703) How many of these births did your mother have before you were born?

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

705) Is (NAME) male or female?

706) Is (NAME) still alive?

707) How old is (NAME)?

708) In what year did (NAME) die?

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

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

711) Was (NAME) pregnant when she died?

712) Did (NAME) die during childbirth?

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

714) Was her death due to complications of pregnancy or childbirth?

715) How many children did (NAME) give birth to during her lifetime?

716) RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS

To be filled in after completing interview

Comments about Respondent:

Comments on Specific Questions:

Any Other Comments:

SUPERVISOR'S OBSERVATIONS

Name of Supervisor: ______________________

Date: _________

EDITOR'S OBSERVATIONS

Name of Editor: __________________________

Date: _________