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UGANDA BUREAU OF STATISTICS
2011 UGANDA DEMOGRAPHIC AND HEALTH SURVEY
WOMAN QUESTIONNAIRE-ENGLISH


IDENTIFICATION

EA NAME

NAME OF HOUSEHOLD HEAD

HOUSEHOLD NUMBER

SAMPLED HOUSEHOLD NUMBER

NAME AND LINE NUMBER OF WOMAN

WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE

YES=1
NO=2


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 __ __ __ __
INT. NUMBER __ __ __
RESULT __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

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

LANGUAGE OF THE QUESTIONNAIRE __ __

LANGUAGE USED IN THE INTERVIEW __ __

NATIVE LANGUAGE OF RESPONDENT __ __

TRANSLATOR USED

NOT AT ALL=1
SOMETIMES=2
ALL THE TIME=3

LANGUAGE USED:

01 ATESO
02 LUGANDA
03 LUGBARA
04 LUO
05 RUNYANKOLE-RUKIGA
06 RUNYORO-RUTORO
07 NGAKARAMOJONG
08 ENGLISH
96 OTHER (SPECIFY) ______________

SUPERVISOR

NAME ___________ __ __ __

FIELD EDITOR

NAME ___________ __ __ __

OFFICE EDITOR__ __

KEYED BY __ __


SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello My name is _______________________________________ and I am working with UGANDA BUREAU OF STATISTICS.

We are conducting a survey about health all over Uganda. This information will help the government to plan health services. Your household was selected for the survey. The questions usually take about 60 to 90 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

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

Do you have any questions?

YES
NO

May I begin the interview now?

YES
NO

Signature of interviewer: __________________
Date: ________

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

101) RECORD THE TIME.

HOUR __ __
MINUTES __ __

102) In what month and year were you born?

MONTH __ __
DON'T KNOW MONTH 98
YEAR __ __
DON'T KNOW YEAR 9998

103) How old were you at your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT

AGE IN COMPLETED YEARS __ __

104) Have you ever attended school?

YES 1
NO 2 (GO TO 108)

105) What is the highest level of school you attended: primary, '0' level, 'A' level, or university or tertiary?

PRIMARY 1
'O' LEVEL 2
'A' LEVEL 3
TERTIARY 4
UNIVERSITY 5

106) What is the highest (class/year) you completed at that level?

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'

CLASS/YEAR __ __

107) CHECK 105:

PRIMARY ___
SECONDARY OR HIGHER ___ (GO TO 110)

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

SHOW CARD TO RESPONDENT.

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

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

109) CHECK 108:

CODE '2', '3' OR '4' CIRCLED ___
CODE '1' OR '5' CIRCLED ___ (GO TO 111)

110) 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

111) 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

112) Do you watch/listen to 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

113) What is your religion?

CATHOLIC 1
PROTESTANT 2
MUSLIM 3
PENTECOSTAL 4
SDA 5
OTHER (SPECIFY) ____________ 6

114) What is your tribe?

MUGANDA 1
MUNYANKOLE 2
MUSOGA 3
MUKIGA 4
ATESO 5
OTHER (SPECIFY) _____________ 6

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

NUMBER OF TIMES __ __
NONE 00 (GO TO 201)

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

YES 1
NO 2


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 BIRTHS __ __

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 BIRTHS ___
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 ONSEPARATE ROWS.
(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?

RECORD NAME.

BIRTH HISTORY NUMBER

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: When 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).

HOUSEHOLD LINE NUMBER __ __

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?
[FOR ALL BUT FIRST BIRTH]

YES 1 (ADD BIRTH)
NO 2 (GO TO 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 ___
NUMBERS ARE DIFFERENT ___ (PROBE AND RECONCILE)

224) CHECK 215:

ENTER THE NUMBER OF BIRTHS IN 2006 OR LATER

NUMBER OF BIRTHS ___
NONE 0 (GO TO 226)

225 FOR EACH BIRTH SINCE JANUARY 2006, 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 230)
UNSURE 8 (GO TO 230)

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 230)
NO 2

229) Did you want to have a baby later on or did you not want aborted, any (more) children?

LATER 1
NO MORE 2

230) Have you ever had a pregnancy that miscarried, was or ended in a stillbirth?

YES 1
NO 2 (GO TO 238)

231) When did the last such pregnancy end?

MONTH __ __
YEAR __ __ __ __

232) CHECK 231:

LAST PREGNANCY ENDED IN JAN. 2006 OR LATER ___
LAST PREGNANCY ENDED BEFORE JAN. 2006 ___ (GO TO 238)

233) 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 PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

MONTHS __ __

233A) When the pregnancy ended, did you receive counselling for family planning use?

YES 1
NO 2

234) Since January 2006, have you had any other pregnancies that did not result in a live birth?

YES 1
NO 2 (GO TO 236)

235) ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2006

ENTER 'T' IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236) Did you have any miscarriages, abortions or stillbirths that ended before 2006 ?

YES 1
NO 2 (GO TO 238)

237) When did the last such pregnancy that terminated before 2006 end?

MONTH __ __
YEAR __ __ __ __

238) 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

239) From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant?

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

240) 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)?

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 IUD
PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse
YES 1
NO 2
04 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
05 Implants
PROBE: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years
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 Lactational Amenorrhea Method (LAM)
YES 1
NO 2
10 Rhythm Method/Moon Beads
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
11 Withdrawal
PROBE: Men can be careful and pull out before climax
YES 1
NO 2
12 Emergency Contraception
PROBE: As an emergency measure, within five days after they have unprotected sexual intercourse, intercourse, women can take special pills or loop/coil is placed inside them by a doctor or nurse to prevent pregnancy
YES 1
NO 2
13 Have you heard of any other ways or methods that women or
men can use to avoid pregnancy?
YES 1 (SPECIFY)____________________
NO 2

302) CHECK 226:

NOT PREGNANT OR UNSURE ___
PREGNANT ___ (GO TO 311)

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

YES 1
NO 2 (GO TO 311)

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 307)
MALE STERILIZATION B (GO TO 307)
IUD C (GO TO 308A)
INJECTABLES D (GO TO 308A)
IMPLANTS E (GO TO 308A)
PILL F
CONDOM G (GO TO 306)
FEMALE CONDOM H (GO TO 308A)
DIAPHRAGM I (GO TO 308A)
FOAM/JELLY J (GO TO 308A)
LACTATIONAL AMEN METHOD K (GO TO 308A)
RHYTHM METHOD/MOON BEADS L (GO TO 308A)
WITHDRAWAL M (GO TO 308A)
OTHER (SPECIFY) ____________ X (GO TO 308A)

305) What is the brand name of the pills you are using?

IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

PILPLAN 01 (GO TO 308A)
SOFT SURE 02 (GO TO 308A)
NEWFEM 03 (GO TO 308A)
LO-FEMENOL 04 (GO TO 308A)
MICROGYNON 05 (GO TO 308A)
OVRETTE 06 (GO TO 308A)
MICROLUT 07 (GO TO 308A)
OTHER (SPECIFY) _____________ 96
DON'T KNOW 98

306) What is the brand name of the condoms you are using?

IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

PROTECTOR 01 (GO TO 308A)
LIFE GUARD 02 (GO TO 308A)
ENGABU 03 (GO TO 308A)
TRUST 04 (GO TO 308A)
OTHER (SPECIFY) _____________ 96 (GO TO 308A)
DON'T KNOW 98 (GO TO 308A)

307) 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) ___________________

PUBLIC SECTOR
GOVT HOSPITAL 11
GOVT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
OTHER PUBLIC SECTOR (SPECIFY) ___________ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE DOCTOR'S OFFICE 22
MOBILE CLINIC 23
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____________ 26
OTHER (SPECIFY) ____________ 96

DON'T KNOW 98

308) In what month and year was the sterilization performed?

MONTH __ __
YEAR __ __ __ __

308A) 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 __ __ __ __

309) CHECK 308/308A, 215 AND 231:

ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 308/308A

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

310) CHECK 308/308A:

YEAR IS 2006 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 2005 OR EARLIER ___ (ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK TO JANUARY 2006. THEN SKIP TO 322.)

311) 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 2006.

USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

IN COLUMN 1, 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?

IN COLUMN 2, ENTER CODES FOR DISCONTINUATION NEXT TO THE LAST MONTH OF USE.
NUMBER OF CODES IN COLUMN 2 MUST BE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1

ASK WHY SHE STOPPED USING THE METHOD IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR
DELIBERATELY STOPPED TO GET PREGNANT.

ILLUSTRATIVE QUESTIONS:

Why did you stop using the (METHOD)? Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason?
IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK: How many months did it take you to get pregnant after you stopped using (METHOD)? AND ENTER '0' IN EACH SUCH MONTH IN COLUMN 1.

312) CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH

NO METHOD USED ___
ANY METHOD USED ___ (GO TO 314)

313) 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)

314) 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 317A)
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 315A)
RHYTHM METHOD/MOON BEADS 12 (GO TO 315A)
WITHDRAWAL 13 (GO TO 326)
OTHER METHOD 96 (GO TO 326)

315) You first started using (CURRENT METHOD) in (DATE FROM 308/308A) Where did you get it at that time?

PUBLIC SECTOR
GOVT HOSPITAL 11
GOVT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
OUT REACH 14
FIELDWORKER/VHT 15
OTHER PUBLIC SECTOR (SPECIFY) ____________________16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
OUTREACH 24
FIELDWORKER/VHT 25
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) _________________26
OTHER SOURCE
SHOP 31
CHURCH 32
FRIEND/RELATIVE 33
OTHER (SPECIFY) __________________ 96

315A) Where did you learn how to use the rhythm/lactational amenorheamethod?

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) _________________

PUBLIC SECTOR
GOVT HOSPITAL 11
GOVT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
OUT REACH 14
FIELDWORKER/VHT 15
OTHER PUBLIC SECTOR (SPECIFY) ____________________16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
OUTREACH 24
FIELDWORKER/VHT 25
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) _________________26
OTHER SOURCE
SHOP 31
CHURCH 32
FRIEND/RELATIVE 33
OTHER (SPECIFY) __________________ 96

316) 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)
FEMALE CONDOM 08 (GO TO 320)
DIAPHRAGM 09 (GO TO 320)
FOAM/JELLY 10 (GO TO 320)
LACTATIONAL AMEN. METHOD 11 (GO TO 326)
RHYTHM METHOD/MOON BEADS 12 (GO TO 326)

317) At that time, were you told about side effects or problems you might have with the method?

YES 1 (GO TO 319)
NO 2

317A) When you got sterilized, were you told about side effects or problems you might have with the method?

YES 1 (GO TO 319)
NO 2

318) 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 320)

319) Were you told what to do if you experienced side effects or problems?

YES 1
NO 2

320) CHECK 317:

CODE '1' CIRCLED ___
At that time, were you told about other methods of family planning that you could use?
YES 1 (GO TO 322)
NO 2
CODE '1' NOT CIRCLED
When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?
YES 1
NO 2 (GO TO 322)

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)
MALE STERILIZATION 02 (GO TO 326)
IUD 03 (GO TO 326)
INJECTABLES 04
326
IMPLANTS 05 (GO TO 326)
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 326)
RHYTHM METHOD/MOON BEADS 12 (GO TO 326)
WITHDRAWAL 13 (GO TO 326)
OTHER 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 PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE)

PUBLIC SECTOR
GOVT HOSPITAL 11 (GO TO 326)
GOVT HEALTH CENTER 12 (GO TO 326)
FAMILY PLANNING CLINIC 13 (GO TO 326)
OUT REACH 14 (GO TO 326)
FIELDWORKER/VHT 15 (GO TO 326)
OTHER PUBLIC SECTOR (SPECIFY) _______________ 16 (GO TO 326)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21 (GO TO 326)
PHARMACY 22 (GO TO 326)
PRIVATE DOCTOR 23 (GO TO 326)
OUT REACH 24 (GO TO 326)
FIELDWORKER/VHT 25 (GO TO 326)
OTHER PRIVATE MEDICAL SECTOR 26 (SPECIFY) _____________ (GO TO 326)
OTHER SOURCE
SHOP 31 (GO TO 326)
CHURCH 32 (GO TO 326)
FRIEND/RELATIVE 33 (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(S)) ________________________

PUBLIC SECTOR
GOVT HOSPITAL A
GOVT HEALTH CENTER B
FAMILY PLANNING CLINIC C
OUT REACH D
FIELDWORKER/VHT E
OTHER PUBLIC SECTOR (SPECIFY) _______________ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
OUT REACH J
FIELDWORKER/VHT K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____________ L
OTHER SOURCE
SHOP M
CHURCH N
FRIEND/RELATIVE O
OTHER (SPECIFY) _______________ X

326) In the last 12 months, were you visited by a fieldworker/VHT 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 2006 OR LATER ___
NO BIRTHS IN 2006 OR LATER ___ (GO TO 556)

402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2006 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 birth separately).

403) BIRTH HISTORY FROM 212 IN BIRTH HISTORY

BIRTH HISTORY NUMBER __ __

404) FROM 212 AND 216

NAME ____________________
LIVING ___
DEAD ___

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

YES 1 [GO TO 408 (FOR LAST BIRTH), 430 FOR NEXT-TO-LAST AND SECOND-FROM-LAST BIRTHS]
NO 2

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

LATER 1
NO MORE 2 [GO TO 408 (FOR LAST BIRTH), 430 FOR NEXT-TO-LAST AND SECOND-FROM-LAST BIRTHS]

407) How much longer did you want to wait?

MONTHS 1 __ __
YEARS 2 __ __
DON'T KNOW 998

408) Did you see anyone for antenatal care for this pregnancy?
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 415)

409) Whom did you see?
Anyone else?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PERSONNEL
DOCTOR A
NURSE/MIDWIFE B
MEDICAL ASSISTANT/ CLINICAL OFFICER C
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT D
COMMUNITY/ VILLAGE HEALTH TEAM E
OTHER (SPECIFY) _________________ X

410) Where did you receive antenatal care for this pregnancy?
[FOR LAST BIRTH ONLY]

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
YOUR HOME A
OTHER HOME B
PUBLIC SECTOR
GOVT HOSPITAL C
GOVT HEALTH CENTER D
OTHER PUBLIC SECTOR (SPECIFY) __________ E
PRIVATE MED. SECTOR
PVT HOSPITAL/ CLINIC F
OTHER PRIVATE MED. (SPECIFY) ____________ G
OTHER (SPECIFY) ____________ X

411) How many months pregnant were you when you first received antenatal care for this pregnancy?
[FOR LAST BIRTH ONLY]

MONTHS __ __
DON'T KNOW 98

412) How many times did you receive antenatal care during this pregnancy?
[FOR LAST BIRTH ONLY]

NUMBER OF TIMES __ __
DON'T KNOW 98

413) As part of your antenatal care during this pregnancy, were any of the following done at least once?
[FOR LAST BIRTH ONLY]

Were you weighed?
YES 1
NO 2
Was your blood pressure measured?
YES 1
NO 2
Did you give a urine sample?
YES 1
NO 2
Did you give a blood sample?
YES 1
NO 2

414) During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy?
[FOR LAST BIRTH ONLY]

YES 1
NO 2
DON'T KNOW 8

415) During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 418)
DON'T KNOW 8 (GO TO 418)

416) During this pregnancy, how many times did you get a tetanus injection?
[FOR LAST BIRTH ONLY]

IF 7 OR MORE TIMES, RECORD '7'.

TIMES ___
DON'T KNOW 8

417) CHECK 416:
[FOR LAST BIRTH ONLY]

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

418) At any time before this pregnancy, did you receive any tetanus injections?
[FOR LAST BIRTH]

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

419) Before this pregnancy, how many times did you receive a tetanus injection?
[FOR LAST BIRTH ONLY]

IF 7 OR MORE TIMES, RECORD '7'.

TIMES ___
DON'T KNOW 8

420) How many years ago did you receive the last tetanus injection before this pregnancy?
[FOR LAST BIRTH ONLY]

YEARS AGO __ __

421) During this pregnancy, were you given or did you buy any iron tablets or iron syrup?
[FOR LAST BIRTH ONLY]

SHOW TABLETS/SYRUP.

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

422) During this whole pregnancy, for how many days did you take the tablets or syrup?
[FOR LAST BIRTH ONLY]

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

DAYS __ __ __
DON'T KNOW 998

423) During this pregnancy, did you take any drug for intestinal worms?
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 424)
DON'T KNOW 8 (GO TO 424)

423A) During the whole of this pregnancy, how many doses/times did you take drugs for intestinal worms?
[FOR LAST BIRTH ONLY]

NUMBER __ __
DON'T KNOW 98

424) During this pregnancy, did you take any drugs to keep you from getting malaria?
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 430)
DON'T KNOW 8 (GO TO 430)

425) What drugs did you take?
[FOR LAST BIRTH ONLY]

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

426) CHECK 425:
[FOR LAST BIRTH ONLY]

SP/FANSIDAR TAKEN FOR MALARIA PREVENTION.

CODE 'A' CIRCLED ___
CODE 'A' NOT CIRCLED ___ (GO TO 430)

427) How many times did you take (SP/ Fansidar) during this pregnancy?
[FOR LAST BIRTH]

TIMES __ __

428) CHECK 409:
[FOR LAST BIRTH ONLY]

ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY.

CODE 'A', 'B' OR 'C' CIRCLED ___
OTHER ___ (GO TO 430)

429) Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility or from another source?
[FOR LAST BIRTH ONLY]

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6

430) 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

431) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 433)
DON'T KNOW 8 (GO TO 433)

432) How much did (NAME) weigh?

RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE.

KG FROM CARD 1 __ . __ __ __
KG FROM RECALL 2 __ . __ __ __
DON'T KNOW 99998

433) Who assisted with the delivery of (NAME)?
Anyone else?

PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED.

IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

HEALTH PERSONNEL
DOCTOR A
NURSE/MIDWIFE B
MEDICAL ASSISTANT/ CLINICALOFFICER C
NURSING AIDE D
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT E
RELATIVE/FRIEND F
OTHER (SPECIFY) __________ X
NO ONE ASSISTED Y

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

PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

(NAME OF PLACE) ____________________

HOME
YOUR HOME 11 [GO TO 438(FOR LAST BIRTH), 448 (FOR NEXT-TO-LAST AND SECOND-FROM-LAST BIRTHS)]
TBA'S HOME 12 [GO TO 438(FOR LAST BIRTH), 448 (FOR NEXT-TO-LAST AND SECOND-FROM-LAST BIRTHS)]
OTHER HOME 13 [GO TO 438(FOR LAST BIRTH), 448 (FOR NEXT-TO-LAST AND SECOND-FROM-LAST BIRTHS)]
PUBLIC SECTOR
GOVT HOSPITAL 21
GOVT HEALTH CENTER 22
OTHER PUBLIC (SPECIFY) _____________ 26
PRIVATE MED. SECTOR
PVT HOSPITAL/ CLINIC 31
OTHER PRIVATE (SPECIFY) _____________ 36
OTHER (SPECIFY) ____________ 96 [GO TO 438(FOR LAST BIRTH), 448 (FOR NEXT-TO-LAST AND SECOND-FROM-LAST BIRTHS)]

434A) How long after (NAME) was delivered did you stay there?
[FOR LAST BIRTH ONL7Y]

IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1 __ __
DAYS 2 __ __
WEEKS 3 __ __
DON'T KNOW 998

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

YES 1
NO 2

435A) Before you were discharged were you counselled about family planning use?
[FOR LAST BIRTH ONLY]

YES 1
NO 2

436) I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health while you were still in the facility?
[FOR LAST BIRTH ONLY]

YES 1 (GO TO 439)
NO 2 (GO TO 439)

437) Did anyone check on your health after you left the facility?
[FOR LAST BIRTH ONLY]

YES 1 (GO TO 439)
NO 2 (GO TO 442)

438) I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)?
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 442)

439) Who checked on your health at that time?
[FOR LAST BIRTH ONLY]

PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL
DOCTOR 11
NURSE/MIDWIFE 12
MEDICAL ASSISTANT/ CLINICAL OFFICER 13
NURSING AIDE 14
VHT 15
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
OTHER (SPECIFY) __________ 96

440) How long after delivery did the first check take place?
[FOR LAST BIRTH ONLY]

IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1 __ __
DAYS 2 __ __
WEEKS 3 __ __
DON'T KNOW 998

442) In the two months after (NAME) was born, did any health care provider check on his/her health?
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 446)
DON'T KNOW 8 (GO TO 446)

443) How many hours, days or weeks after the birth of (NAME) did the first check take place?
[FOR LAST BIRTH ONLY]

IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS AFTER BIRTH 1 __ __
DAYS AFTER BIRTH 2 __ __
WEEKS AFTER BIRTH 3 __ __
DON'T KNOW 998

444) Who checked on (NAME)'s health at that time?
[FOR LAST BIRHT ONLY]

PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL
DOCTOR 11
NURSE/MIDWIFE 12
MEDICAL ASSISTANT/ CLINICAL OFFICER 13
NURSING AIDE 14
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21
OTHER (SPECIFY) __________ 96

445) Where did this first check of (NAME) take place?
[FOR LAST BIRTH ONLY]

PROBE TO IDENTIFY THE TYPE OF SOURCE

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

(NAME OF PLACE) ______________________

HOME
YOUR HOME 11
TBA'S HOME 12
OTHER HOME 13
PUBLIC SECTOR
GOVT HOSPITAL 21
GOVT HEALTH CENTER 22
OTHER PUBLIC (SPECIFY) _____________ 26
PRIVATE MED. SECTOR
PVT HOSPITAL/ CLINIC 31
OTHER PRIVATE MED. (SPECIFY) ____________ 36
OTHER (SPECIFY) _____________ 96

446) In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)?
[FOR LAST BIRTH ONLY]

SHOW COMMON TYPES OF AMPULES/CAPSULES

YES 1
NO 2
DON'T KNOW 8

447) Has your menstrual period returned since the birth of (NAME)?
[FOR LAST BIRTH ONLY]

YES 1 (GO TO 449)
NO 2 (GO TO 450)

448) Did your period return between the birth of (NAME) and your next pregnancy?
[FOR NEXT-TO-LAST AND SECOND-FROM-LAST BIRTHS]

YES 1
NO 2 (GO TO 452)

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

MONTHS __ __
DON'T KNOW 98

450) CHECK 226:
[FOR LAST BIRTH ONLY]

IS RESPONDENT PREGNANT?

NOT PREGNANT ___
PREGNANT OR UNSURE ___ (GO TO 452)

451) Have you had sexual intercourse since the birth of (NAME)?
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 453)

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

MONTHS __ __
DON'T KNOW 98

453) Did you ever breastfeed (NAME)?

YES 1 (GO TO 455)
NO 2 (GO TO 455)

454) CHECK 404:
[FOR LAST BIRTH ONLY]

IS CHILD LIVING?

LIVING ___ (GO TO460)
DEAD ___ (GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501)

455) How long after birth did you first put (NAME) to the breast?
[FOR LAST BIRTH ONLY]

IF LESS THAN 1 HOUR, RECORD '00' HOURS.
IF LESS THAN 24 HOURS, RECORD HOURS.
OTHERWISE, RECORD DAYS.

IMMEDIATELY 000
HOURS 1__ __
DAYS 2 __ __

456) In the first three days after delivery, was (NAME) given anything to drink other than breast milk?
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 458)

457) What was (NAME) given to drink?
[FOR LAST BIRTH ONLY]

Anything else?

RECORD ALL LIQUIDS MENTIONED.

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

458) CHECK 404:

IS CHILD LIVING?

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

459) Are you still breastfeeding (NAME)?
[FOR LAST BIRTH ONLY]

YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

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


SECTION 5. CHILD IMMUNIZATION, HEALTH AND NUTRITION

501) ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2006 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) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY.

BIRTH HISTORY NUMBER __ __

503) FROM 212 AND 216

NAME ____________
LIVING ___
DEAD ___(GO TO 503 IN NEXT COLUMN OR, IF NO MORE OR, IF NO MORE BIRTHS, GO TO 553)

504) Do you have a card/ book where (NAME)'s vaccinations are written down?

YES, SEEN 1 (GO TO 506)
YES, NOT SEEN 2 (GO TO 509)
NO CARD 3

505) Did you ever have a vaccination card/book for (NAME)?

YES 1 (GO TO 509)
NO 2 (GO TO 509)

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-HepB-Hib 1
DAY __ __
MONTH __ __
YEAR __ __ __ __
DPT-HepB-Hib 2
DAY __ __
MONTH __ __
YEAR __ __ __ __
DPT-HepB-Hib 3
DAY __ __
MONTH __ __
YEAR __ __ __ __
MEASLES
DAY __ __
MONTH __ __
YEAR __ __ __ __
VITAMIN A (MOST RECENT)
DAY __ __
MONTH __ __
YEAR __ __ __ __
VITAMIN A (2nd MOST RECENT)
DAY __ __
MONTH __ __
YEAR __ __ __ __

507) CHECK 506:

BCG TO MEASLES ALL RECORDED ___ (GO TO 511)
OTHER ___

508) Has (NAME) had any vaccinations that are not on this card/book including vaccinations given in a national immunization day campaign?

RECORD 'YES' ONLY IF THE RESPONDENT MENTIONS BCG, POLIO0-3, DPT-HEPB-HIB 1-3, AND OR MEASLES VACCINES AS HAVING BEEN GIVEN.

YES 1 (PROBE FOR VACCINATIONS AND WRITE '66' IN THE CORRESPONDING DAY COLUMN IN 506, THEN GO TO 511)
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)

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

YES 1
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)

510) Please tell me if (NAME) had any of the following vaccinations:

510A) A BCG vaccination against tuberculosis, that is, an injection in the right upper arm or shoulder that usually causes a scar?
YES 1
NO 2
DON'T KNOW 8
510B) Polio vaccine, that is, drops in the mouth?
YES 1
NO 2 (GO TO 510E)
DON'T KNOW 8 (GO TO 510E)

510C) Was the first polio vaccine given in the first two weeks after birth or later?

FIRST 2 WEEKS 1
LATER 2

510D) How many times was the poliovaccine given?

NUMBER OF TIMES ___

510E) A DPT vaccination, that is, an injection given in the left upper thigh, sometimes at the same time as polio drops?

YES 1
NO 2 (GO TO 510G)
DON'T KNOW 8 (GO TO 510G)

510F) How many times was the DPT vaccination given?

NUMBER OF TIMES ___

510G) A measles injection - 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

511) Within the last six months, was (NAME) given a vitamin A dose like (this/any of these)?

SHOW COMMON TYPES OF AMPULES/CAPSULES

YES 1
NO 2
DON'T KNOW 8

512) In the last seven days, was (NAME) given 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

513) Was (NAME) given any drug for intestinal worms in the last six months?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 525)
DON'T KNOW 8 (GO TO 525)

515) Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

516) 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'T KNOW 8

517) 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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
GAVE RUTF 7
DON'T KNOW 8

518) Did you seek advice or treatment for the diarrhea from any source?

YES 1
NO 2 (GO TO 522)

519) Where did you seek advice or treatment?

Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

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

(NAME OF PLACE(S)) __________________________

PUBLIC SECTOR
GOVT HOSPITAL A
GOVT HEALTH CENTER B
OUT REACH SERVICE C
FIELDWORKER/VHT D
OTHER PUBLIC SECTOR (SPECIFY) ___________ E
PRIVATE MEDICAL SECTOR
PVT HOSPITAL/CLINIC F
PHARMACY G
PVT DOCTOR H
OUT REACH SERVICE COMMUNITY HEALTH I WORKER J
OTHER PRIVATE MED. SECTOR (SPECIFY) ___________ K
OTHER SOURCE
SHOP L
TRADITIONAL PRACTITIONER M
MARKET N
OTHER (SPECIFY) ___________ X

520) CHECK 519:

TWO OR ONLY MORE CODES CIRCLED ___
ONLY ONE CODE CIRCLED ___ (GOTO 522)

521) Where did you first seek advice or treatment?

USE LETTER CODE FROM 519.

FIRST PLACE ___

522) Was he/she given any of the following to drink at any time since he/she started having the diarrhea:

a) A fluid made from a special packet called LOCAL NAME FOR ORS PACKET?
YES 1
NO 2
DON'T KNOW 8
c) A government-recommended homemade fluid?
YES 1
NO 2
DON'T KNOW 8

523) Was anything (else) given to treat the diarrhea?

YES 1
NO 2 (GO TO 525)
DON'T KNOW 8 (GO TO 525)

524) What (else) was given to treat the diarrhea?
Anything else?

RECORD ALL TREATMENTS GIVEN.

PILL OR SYRUP
ANTIBIOTIC A
ANTIMOTILITY B
ZINC C
OTHER (NOT ANTI-BIOTIC, ANTI-MOTILITY, OR ZINC) D
UNKNOWN PILL OR SYRUP E
INJECTION
ANTIBIOTIC F
NON-ANTIBIOTIC G
UNKNOWN INJECTION H
(IV) INTRAVENOUS I

HOME REMEDY/HERBAL MEDICINE J

OTHER (SPECIFY) __________ X

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

YES 1
NO 2 (GO TO 527)
DON'T KNOW 8 (GO TO 527)

526) 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

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

YES 1
NO 2 (GO TO 530)
DON'T KNOW 8 (GO TO 530)

528) 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 531)
DON'T KNOW 8 (GO TO 531)

529) 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 531)
NOSE ONLY 2 (GO TO 531)
BOTH 3 (GO TO 531)
OTHER (SPECIFY) ___________ 6 (GO TO 531)
DON'T KNOW 8 (GO TO 531)

530) CHECK 525:

HAD FEVER?

YES ___
NO OR DON'T KNOW ___ (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

531) 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

532) 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
GAVE RUTF 7
DON'T KNOW 8

533) Did you seek advice or treatment for the illness from any source?

YES 1
NO 2 (GO TO 537)

534) 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)) _________________________

PUBLIC SECTOR
GOVT HOSPITAL A
GOVT HEALTH CENTER B
OUT REACH SERVICE C
FIELDWORKER/VHT D
OTHER PUBLIC SECTOR (SPECIFY) __________ E
PRIVATE MEDICAL SECTOR
PVT HOSPITAL/ CLINIC F
PHARMACY G
PVT DOCTOR H
OUTREACH SERVICE I
COMMUNITY HEALTH WORKER J
OTHER PRIVATE MED. SECTOR (SPECIFY) __________ K
OTHER SOURCE
SHOP L
TRADITIONAL PRACTITIONER M
MARKET N
OTHER (SPECIFY) _________ X

535) CHECK 534:

TWO OR MORE CODES CIRCLED ___
ONLY ONE CODE CIRCLED ___ (GO TO 537)

536) Where did you first seek advice or treatment?

USE LETTER CODE FROM 534.

FIRST PLACE ___

537) 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 553)
DON'T KNOW 8 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

538) What drugs did (NAME) take?
Any other drugs?

RECORD ALL MENTIONED.

ANTIMALARIAL DRUGS
SP/FANSIDAR A
CHLOROQUINE B
CHLOROQUINE WITH FANSIDAR C
COARTEM/ACT D
QUININE E
OTHER ANTI-MALARIAL (SPECIFY) ___________ F
ANTIBIOTIC DRUGS
PILL/SYRUP G
INJECTION H
OTHER DRUGS
ASPIRIN I
PANADOL J
IBUPROFEN K
OTHER (SPECIFY) ___________ X

DON'T KNOW Z

539) CHECK 538:

ANY CODE A-F CIRCLED?

YES ___
NO ___ (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

540) CHECK 538:

SP/FANSIDAR ('A') GIVEN

CODE 'A' CIRCLED ___
CODE 'A' NOT CIRCLED ___ (GO TO 542)

541) 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

542) CHECK 538:

CHLOROQUINE ('B') GIVEN

CODE 'B' CIRCLED ___
CODE 'B' NOT CIRCLED ___ (GO TO 544)

543) 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

544) CHECK 538:

CHLOROQUINE WITH FANSIDAR ("C") GIVEN

CODE 'C' CIRCLED ___
CODE 'C' NOT CIRCLED ___ (GO TO 546)

545) How long after the fever started did (NAME) first take chloroquine with fansidar?

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

546) CHECK 538:

COARTEM/ACTS ('D') GIVEN

CODE 'D' CIRCLED ___
CODE 'D' NOT CIRCLED ___ (GO TO 550)

547) How long after the fever started did (NAME) first take coartem / ACTS?

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

548) CHECK 538:

QUININE ('E') GIVEN

CODE 'E' CIRCLED ___
CODE 'E' NOT CIRCLED (GO TO 550)

549) 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

550) CHECK 538:

OTHER ANTIMALARIAL ('F') GIVEN

CODE 'F' CIRCLED ___
CODE 'F' NOT CIRCLED ___ (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 552)

551) How long after the fever started did (NAME) first take (OTHER ANTIMALARIAL)?

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

552) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553.

553) CHECK 215 AND 218, ALL ROWS:

NUMBER OF CHILDREN BORN IN 2006 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE ___
RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE WITH 554
(NAME) ________________
NONE ___ (GO TO 556)

554) The last time (NAME FROM 553) 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
OTHER (SPECIFY) ____________ 96

555) CHECK 522(a) , ALL COLUMNS:

NO CHILD RECEIVED FLUID FROM ORS PACKET ___
ANY CHILD RECEIVED FLUID FROM ORS PACKET ___ (GO TO 557)

556) Have you ever heard of a special product called ORS PACKET you can get for the treatment of diarrhea?

YES 1
NO 2

557) CHECK 215 AND 218, ALL ROWS:

NUMBER OF CHILDREN BORN IN 2009 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE ___
RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE WITH 558
(NAME) ________________
NONE ___ (GO TO 601)

558) Now I would like to ask you about liquids or foods that (NAME FROM 557) may have had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods.

Did (NAME FROM 557) drink/eat?

(1)BEVERAGE/ LIQUIDS
i) Plain water?
YES 1
NO 2
DON'T KNOW 8
ii) Fresh fruit juice or juice concentrate?
YES 1
NO 2
DON'T KNOW 8
iii) Any kind of soup?
YES 1
NO 2
DON'T KNOW 8
iv) Black tea/coffee?
YES 1
NO 2
DON'T KNOW 8
v) Other beverages/liquids not mentioned above?
YES 1
NO 2
DON'T KNOW 8
(2) MILK AND MILK PRODUCTS
vi) Milk such as tinned,powdered,or fresh animal milk?

IF YES: How many times did (NAME) drink milk?
IF 7 OR MORE TIMES RECORD '7'
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES ___
vii) Yogurt?

IF YES: How many times did (NAME) eat yogurt
IF 7 OR MORE TIMES RECORD '7'
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES ___
viii) cheese or other food made from milk?
YES 1
NO 2
DON'T KNOW 8
ix) Infant formula foods such as CERELAC?

IF YES: How many times did (NAME) drink infant formula
IF 7 OR MORE TIMES RECORD '7'
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES ___
(3) MEAT AND MEAT PRODUCTS
x) Meat (beef, pork, goat, lamb) or other meat?
YES 1
NO 2
DON'T KNOW 8
xi) Liver,Kidney,Heart or other organ meats
YES 1
NO 2
DON'T KNOW 8
xii) meat products such as kebabs, sausages chaps etc?
YES 1
NO 2
DON'T KNOW 8
(4) FISH
xiii) Fresh fish, dry fish or shell fish?
YES 1
NO 2
DON'T KNOW 8
(5) FRUITS
xiv) Orange coloured fruits like ripe mangoes, pawpaw?
YES 1
NO 2
DON'T KNOW 8
xv)Other fruits or vegetables(passion fruit, jack fruit, pineapples, oranges sugarcanes, etc)?
YES 1
NO 2
DON'T KNOW 8
(6) VEGETABLES
xvi) Dark green leafy vegetables like spinach, amaranths cassava leaves, bean leaves?
YES 1
NO 2
DON'T KNOW 8
xvii) Orange coloured vegetables such as pumpkins, carrots?
YES 1
NO 2
DON'T KNOW 8
xviii) Any bio-fortified food (Orange fleshed sweet potatoes)
YES 1
NO 2
DON'T KNOW 8
xix) Other vegetables like cabbages,egg-plants,tomatoes etc?
YES 1
NO 2
DON'T KNOW 8
(7) CEREALS AND GRAINS
xx) Rice, posho, porridge, bread, chapatti, pasta/macaroni, noddles or other foods made from maize, millet, sorghum or other grains such as mandazi, doughnut, pancakes etc?
YES 1
NO 2
DON'T KNOW 8
xxi) Other foods made from grains such as weetabix, cornflakes etc?
YES 1
NO 2
DON'T KNOW 8
(8) LEGUMES
xxii) Beans, peas, cow peas,groundnuts,seeds ,oil seeds soya beans or other legumes or seeds?
YES 1
NO 2
DON'T KNOW 8
xxiii) Any foods made from beans,peas,lentils,or nuts?
YES 1
NO 2
DON'T KNOW 8
(9) POULTRY AND POULTRY PRODUCTS
xxiv) Chicken, duck, Turkey, pigeons, etc)
YES 1
NO 2
DON'T KNOW 8
xxv) Eggs (chicken eggs, duck eggs etc)?
YES 1
NO 2
DON'T KNOW 8
(10) PLANTAIN
xxvi) Banana-Matooke,Ndiizi, Gonja?
YES 1
NO 2
DON'T KNOW 8
(11) ROOTS AND TUBERS
xxvii) Cassava, yams, white sweet potatoes, Irish potatoes, manioc or other roots and tubers?
YES 1
NO 2
DON'T KNOW 8
(12) OILS AND FATS
xxviii) Cooking oil, margarine, butter or other oils/fats?
YES 1
NO 2
DON'T KNOW 8
(13) SUGAR AND OTHER SUGARY PRODUCTS
xxix) Any sugary foods such as chocolates, sweets, candiespastries, cakes or biscuits?
YES 1
NO 2
DON'T KNOW 8

559) CHECK 558 (CATEGORIES "X" THROUGH "XXIX"):

ALL "NO" ___
AT LEAST ONE "YES" OR ALL DON'T KNOWs ___ (GO TO 561)

560) Did (NAME) eat any solid, semi-solid, or soft foods yesterday during the day or at night?

IF 'YES' PROBE: What kind of solid, semi-solid or soft foods did (NAME) eat?

YES 1 (GO BACK TO 558 TO RECORD FOOD EATEN YESTERDAY)
NO 2 (GO TO 601)

561) How many times did (NAME FROM 557) 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


SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

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

YES, CIVIL MARRIAGE 1 (GO TO 604)
YES, CUSTOMARY MARRIAGE 2 (GO TO 604)
YES, RELIGIOUS MARRIAGE 3 (GO TO 604)
YES, LIVING WITH A MAN 4 (GO TO 604)
NO, NOT IN UNION 5

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 612)

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 live-in partners does he have?

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

610) 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 your first (husband/partner). In what month and year did you start living with him?
MONTH __ __
DON'T KNOW MONTH 98
YEAR __ __ __ __ (GO TO 612)
DON'T KNOW YEAR 9998

611) How old were you when you first started living with him?

AGE __ __

612) CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERYEFFORT TO ENSURE PRIVACY.

613) 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 628)
AGE IN YEARS __ __
FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND/PARTNER 95

614) 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.

615) 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 627)

616) When was the last time you had sexual intercourse with this person?
[FOR SECOND-TO-LAST AND THRID-TO-LAST SEXUAL PARTNERS]

DAYS AGO 1 __ __
WEEKS AGO 2 __ __
MONTHS AGO 3 __ __

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

YES 1
NO 2 (GO TO 619)

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

YES 1
NO 2

619) 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 622)
CASUAL ACQUAINTANCE 4 (GO TO 622)
PROSTITUTE 5 (GO TO 622)
OTHER (SPECIFY) ____________ 6 (GO TO 622)

620) CHECK 609:

MARRIED ONLY ONCE ___
MARRIED MORE THAN ONCE ___ (GO TO 622)

621) CHECK 613:

FIRST TIME WHEN STARTED LIVING WITH FIRST HUSBAND ___ (GO TO 623)
OTHER ___

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

DAYS AGO 1 __ __
WEEKS AGO 2 __ __
MONTHS AGOS 3 __ __
YEARS AGO 4 __ __

623) How many times during the last 12 months did you have sexual intercourse with this person?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF TIMES IS 95 OR MORE, WRITE '95'.

NUMBER OF TIMES __ __

624) How old is this person?

AGE OF PARTNER __ __
DON'T KNOW 98

625) Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?
[FOR LAST AND SECOND-TO-LAST SEXUAL PARTNERS]

YES 1 (GO BACK TO 616 IN NEXT COLUMN)
NO 2 (GO TO 627)

626) In total, with how many different people have you had sexual intercourse in the last 12 months?
[FOR THIRD-TO-LAST SEXUAL PARTNER ONLY]

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95'.

NUMBER OF PARTNERS LAST 12 MONTHS __ __
DON'T KNOW 98

627) 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 95 OR MORE, WRITE '95'.

NUMBER OF PARTNERS IN LIFETIME __ __
DON'T KNOW 98

628) PRESENCE OF OTHERS DURING THIS SECTION

CHILDREN UNDER 10
YES 1
NO 2
MALE ADULTS
YES 1
NO 2
FEMALE ADULTS
YES 1
NO 2

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

YES 1
NO 2 (GO TO 631A)

630) 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)) _________________________

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVT HEALTH CENTER B
FAMILY PLANNING CLINIC C
OUT REACH D
VILLAGE HEALTH TEAM E
OTHER PUBLIC SECTOR (SPECIFY) ___________ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
OUT REACH J
NGO COMMUNITY BASED DISTRIBUTOR K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) __________ L
OTHER SOURCE
SHOP M
RELIGIOUS INSTITUTION N
FRIENDS/RELATIVES O
STREET VENDOR P
LODGE Q
OTHER (SPECIFY) ___________ X

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

YES 1
NO 2
DON'T KNOW/UNSURE 8

631A) Sometimes a woman can have a problem of 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 sexual assault or after pelvic surgery.

Have you ever experienced a constant leakage of urine or stool from your vagina during the day and night?

YES 1
NO 2 (GO TO 631D)
DON'T KNOW 8 (GO TO 631D)

631B) Have you sought treatment for this condition?

YES 1 (GO TO 613D)
NO 2

631C) Why have you not sought treatment?

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

631D) Have you ever heard of female circumcision?

YES 1 (GO TO 631F)
NO 2
DON'T KNOW 3

631E) In some countries, there is a practice in which a girl may have part of her genitals cut. Have you ever heard about this practice?

YES 1
NO 2 (GO TO 701)

631F) Have you yourself ever been circumcised?

YES 1
NO 2

631G) Do you think that female circumcision should be continued, or should it be stopped?

CONTINUED 1
STOPPED 2
DEPENDS 3
DON'T KNOW 8

631H) CHECK 213, 215 AND 216:

HAS ONE OR MORE LIVING DAUGHTERS BORN IN 1996 OR LATER ____
HAS NO LIVING DAUGHTERS BORN IN 1996 OR LATER ___ (GO TO 701)

631I) How many of your daugther(s) aged between 0 and 14 years have undergone circumcision?

NUMBER OF DAUGHTERS __ __


SECTION 7. FERTILITY PREFERENCES

701) CHECK 304:

NEITHER STERILIZED ___
HE OR SHE STERILIZED ___ (GO TO 712)

702) CHECK 226:

PREGNANT ___
NOT PREGNANT OR UNSURE ___ (GO TO 704)

703) 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 ANOTHER CHILD 1 (GO TO 705)
NO MORE 2 (GO TO 711)
UNDECIDED/DON'T KNOW 8 (GO TO 711)

704) 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 707)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 712)
UNDECIDED/DON'T KNOW 8 (GO TO 710)

705) CHECK 226:

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 710)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 712)
AFTER MARRIAGE 995 (GO TO 710)
OTHER (SPECIFY) __________________ 996 (GO TO 710)
DON'T KNOW 998 (GO TO 710)

706) CHECK 226:

NOT PREGNANT OR UNSURE ___
PREGNANT ___ (GO TO 711)

707) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT CURRENTLY USING ___
CURRENTLY USING ___ (GO TO 712)

708) CHECK 705:

NOT ASKED ___
24 OR MORE MONTHS OR 02 OR MORE YEARS ___
00-23 MONTHS OR 00-01 YEAR 711 ___ (GO TO 711)

709) CHECK 703 AND 704:

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
CAN'T 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
SIDE EFFECTS/HEALTH CONCERNS O
LACK OF ACCESS/TOO FAR P
COSTS TOO MUCH Q
PREFERRED METHOD NOT AVAILABLE R
NO METHOD AVAILABLE S
INCONVENIENT TO USE T
INTERFERES WITH BODY'S NORMAL PROCESSES U
OTHER (SPECIFY) ______________ X
DON'T KNOW Z

710) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT ASKED ___
NO, NOT CURRENTLY USING ___
YES, CURRENTLY USING ___ (GO TO 712)

711) 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

712) 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 714)
NUMBER __ __
OTHER (SPECIFY) __________________ 96 (GO TO 714)

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

BOYS
NUMBER __ __
OTHER (SPECIFY) ________________ 96
GIRLS
NUMBER __ __
OTHER (SPECIFY) ________________ 96
EITHER
NUMBER __ __
OTHER (SPECIFY) ________________ 96

714) In the last six months have you:

a) Heard about family planning on the radio?
YES 1
NO 2
b) Seen anything about family planning on the television?
YES 1
NO 2
c) Seen anything about family planning in a video/film ?
YES 1
NO 2
d) Read about family planning in a newspaper or magazine?
YES 1
NO 2

716) CHECK 601:

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

717) CHECK 303: USING A CONTRACEPTIVE METHOD?

CURRENTLY USING ___
NOT CURRENTLY USING OR NOT ASKED ___ (GO TO 720)

718) 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

719) CHECK 304:

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

720) 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 ___
FORMERLY MARRIED/LIVED 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, O level, A level, university or tertiary?

PRIMARY 1
'O' LEVEL 2
'A' LEVEL 3
TERTIARY 4
UNIVERSITY 5
DON'T KNOW 8 (GO TO 806)

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

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

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?

__________________ __ __

807) Apart 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 815)

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

____________________ __ __

812) 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

813) 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

814) 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

815) CHECK 601:

CURRENTLY MARRIED/LIVING WITH A MAN ___
NOT IN UNION ___ (GO TO 823)

816) CHECK 814:

CODE 1 OR 2 CIRCLED ___
OTHER ___ (GO TO 819)

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

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

818) 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 (GO TO 820)
DON'T KNOW 8

819) Who usually decides how your (husband's/partner's) earnings will be used: you, your (husband/partner), or you and your (husband/partner) jointly?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
HUSBAND/PARTNER HAS NO EARNINGS 4
OTHER (SPECIFY) ____________ 6

820) 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

821) 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

822) Who usually makes decisions about visits to your family or relatives?

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

823) 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

824) 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

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

CHILDREN UNDER 10
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
HUSBAND
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
OTHER MALES
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
OTHER FEMALES
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3

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

If she goes out without telling him?
YES 1
NO 2
DON'T KNOW 8
If she neglects the children?
YES 1
NO 2
DON'T KNOW 8
If she argues with him?
YES 1
NO 2
DON'T KNOW 8
If she refuses to have sex with him?
YES 1
NO 2
DON'T KNOW 8
If she burns the 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 937)

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

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

908) Can the virus that causes AIDS be transmitted from a mother to her baby:

During pregnancy?
YES 1
NO 2
DON'T KNOW 8
During delivery?
YES 1
NO 2
DON'T KNOW 8
By breastfeeding?
YES 1
NO 2
DON'T KNOW 8

909) CHECK 908:

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

910) 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

911) CHECK 208 AND 215:

NO BIRTHS ___ (GO TO 926)
LAST BIRTH SINCE JANUARY 2009 ___
LAST BIRTH BEFORE JANUARY 2009 ___ (GO TO 926)

912) CHECK 408 FOR LAST BIRTH:

HAD ANTENATAL CARE ___
NO ANTENATAL CARE ___ (GO TO 920)

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

914) During any of the antenatal visits for your last birth were you given any information about:

Babies getting the AIDS virus from their mother?
YES 1
NO 2
DON'T KNOW 8
Things that you can do to prevent getting the AIDS virus?
YES 1
NO 2
DON'T KNOW 8
Getting tested for the AIDS virus?
YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2

916) 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 920)

916A) Usually pregnant women receive counseling before being tested. Before you were tested, did you receive counseling?

YES 1
NO 2
DON'T KNOW 8

917) 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) _________________________

PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVT. HEALTH CENTER 12
STAND-ALONE VCT CENTER 13
FAMILY PLANNING CLINIC 14
OUT REACH 15
VILLAGE HEALTH TEAM 16
OTHER PUBLIC (SPECIFY) ___________ 17
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
STAND-ALONE VCT CENTER 22
PHARMACY/DRUG SHOP 23
PRIVATE DOCTOR/NURSE/MIDWIFE 24
OUT REACH 25
TASO 26
AIDS INFORMATION CENTRE 27
OTHER PRIVATE/NGO MEDICAL (SPECIFY) _____________ 28
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 (GO TO 924)

919) All women are supposed to receive counseling after being tested. After you were tested, did you receive counseling?

YES 1 (GO TO 924)
NO 2 (GO TO 924)
DON'T KNOW 8 (GO TO 924)

920) CHECK 434 FOR LAST BIRTH:

ANY CODE 21-36 CIRCLED ___
OTHER ___ (GO TO 926)

921) Between the time you went for delivery but before the baby was born, were you offered a test for the AIDS virus?

YES 1
NO 2

922) I don't want to know the results, but were you tested for the AIDS virus at that time?

YES 1
NO 2 (GO TO 926)

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

YES 1
NO 2

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

YES 1 (GO TO 927)
NO 2

925) How many months ago was your most recent HIV test?

MONTHS AGO __ __ (GO TO 932)
TWO OR MORE YEARS 95 (GO TO 932)

926) 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 930)

927) How many months ago was your most recent HIV test?

MONTHS AGO __ __
TWO OR MORE YEARS 95

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

YES 1
NO 2

929) 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) ___________________

PUBLIC SECTOR
GOVERNMENT HOSPITAL 11 (GO TO 932)
GOVT. HEALTH CENTER 12 (GO TO 932)
STAND-ALONE VCT CENTER 13 (GO TO 932)
FAMILY PLANNING CLINIC 14 (GO TO 932)
OUT REACH 15 (GO TO 932)
VILLAGE HEALTH TEAM 16 (GO TO 932)
OTHER PUBLIC (SPECIFY) ___________ 17 (GO TO 932)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21 (GO TO 932)
STAND-ALONE VCT CENTER 22 (GO TO 932)
PHARMACY/DRUG SHOP 23 (GO TO 932)
PRIVATE DOCTOR/NURSE/MIDWIFE 24 (GO TO 932)
OUT REACH 25 (GO TO 932)
TASO 26 (GO TO 932)
AIDS INFORMATION CENTRE 27 (GO TO 932)
OTHER PRIVATE/NGO MEDICAL (SPECIFY) _____________ 28 (GO TO 932)
OTHER (SPECIFY) ____________ 96 (GO TO 932)

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

YES 1
NO 2 (GO TO 932)

931) 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)) ______________________

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVT. HEALTH CENTER B
STAND-ALONE VCT CENTER C
FAMILY PLANNING CLINIC D
OUT REACH E
VILLAGE HEALTH TEAM F
OTHER PUBLIC (SPECIFY) ___________ G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC H
STAND-ALONE VCT CENTER I
PHARMACY/DRUG SHOP J
PRIVATE DOCTOR/NURSE/MIDWIFE K
OUT REACH L
TASO M
AIDS INFORMATION CENTRE N
OTHER PRIVATE/NGO MEDICAL (SPECIFY) ______________ O
OTHER (SPECIFY) _____________ X

932) 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

933) 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

934) 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

935) 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

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

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

937) CHECK 901:

HEARD ABOUT AIDS ___
Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?
YES 1
NO 2
NOT HEARD ABOUT AIDS ____
Have you heard about infections that can be transmitted through sexual contact?
YES 1
NO 2

938) CHECK 613:

HAS HAD SEXUAL INTERCOURSE ___
NEVER HAD SEXUAL INTERCOURSE ___ (GO TO 946)

939) CHECK 937: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

YES ___
NO ___ (GO TO 941)

940) 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

941) 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

942) 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

943) CHECK 940, 941, AND 942:

HAS HAD AN INFECTION (ANY 'YES') ___
HAS NOT HAD AN INFECTION OR DOES NOT KNOW ___ (GO TO 946)

944) The last time you had (PROBLEM FROM 940/941/942), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 946)

945) Where did you go?
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)) __________________________

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVT HEALTH CENTER B
STAND-ALONE VCT CENTER C
FAMILY PLANNING CLINIC D
OUT REACH E
VILLAGE HEALTH TEAM F
OTHER PUBLIC (SPECIFY) ____________ G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC H
STAND-ALONE VCT CENTER I
PHARMACY/DRUG SHOP J
PRIVATE DOCTOR/NURSE/ MIDWIFE K
OUT REACH L
TASO M
AIDS INFORMATION CENTRE N
OTHER PRIVATE/NGO MEDICAL (SPECIFY) ______________ O
OTHER SOURCE
SHOP P
OTHER (SPECIFY) _____________ X

946) 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

947) Is a wife justified in refusing to have sex with her husband when she knows he has sex with other women?

YES 1
NO 2
DON'T KNOW 8

948 CHECK 601:

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

949) 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

950) 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. OTHER HEALTH ISSUES

1001) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?

IF YES: How many injections have you had?

IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS __ __
NONE 00 (GO TO 1004)

1001A) Who administered the last injection you got?

DOCTOR 11
NURSE/MIDWIFE 12
MEDICAL ASSISTANT/CLINICAL OFFICER 13
NURSING AIDE 14
NON-MEDICAL PERSONNEL 15 (GO TO 1004)

1003) 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

1003A) Did you develop any complications as a result of an injection?

YES 1
NO 2

1004) Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 1006)

1005) In the last 24 hours, how many cigarettes did you smoke?

NUMBER OF CIGARETTES __ __

1006) Do you currently smoke or use any (other) type of tobacco?

YES 1
NO 2 (GO TO 1008)

1007) What (other) type of tobacco do you currently smoke or use?

RECORD ALL MENTIONED.

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

1008) 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?

a) Getting permission to go to the health facility?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
b) Getting money needed for treatment or transport?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
c) The distance to the health facility?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
d) Not wanting to go alone?
BIG PROBLEM 1
NOT A BIG PROBLEM 2

1009) Are you covered by any health insurance?

YES 1
NO 2 (GO TO 1100)

1010) What type of health insurance are you covered by?

RECORD ALL MENTIONED.

COMMUNITY-BASED HEALTH INSURANCE A
PRIVATE COMMERCIAL HEALTH INSURANCE B
OTHER (SPECIFY) ____________ X


SECTION 11: DOMESTIC VIOLENCE

1100) CHECK FRONT COVER:

WOMAN SELECTED FOR THIS SECTION ___
WOMAN NOT SELECTED ___ (GO TO 1201A)

1101) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

PRIVACY OBTAINED 1
PRIVACY NOT POSSIBLE 2 (GO TO 1132)

READ TO THE RESPONDENT
Now I would like to ask you questions about some other important aspects of a woman's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in Uganda. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions.

1102) CHECK 601 AND 602:

CURRENTLY MARRIED/LIVING WITH A MAN ___
FORMERLY MARRIED/LIVED WITH A MAN (READ IN PAST TENSE AND USE 'LAST' WITH HUSBAND/PARTNER) ___
NEVER MARRIED/NEVER LIVED WITH A MAN ___ (GO TO 1116)

1103) 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?
YES 1
NO 2
DON'T KNOW 8
b) He frequently (accuses/accused) you of being unfaithful?
YES 1
NO 2
DON'T KNOW 8
c) He (does/did) not permit you to meet your female friends?
YES 1
NO 2
DON'T KNOW 8
d) He (tries/tried) to limit your contact with your family?
YES 1
NO 2
DON'T KNOW 8
e) He (insists/insisted) on knowing where you (are/were) at all times?
YES 1
NO 2
DON'T KNOW 8

1104) Now I need to ask some more questions about your relationship with your (last) husband/partner.

A) Did your (last) husband/partner ever:

a) say or do something to humiliate you in front of others?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
b) threaten to hurt or harm you or someone you care about?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
c) insult you or make you feel bad about yourself?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2

1105) A) 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
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
b) slap you?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
c) twist your arm or pull your hair?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
d) punch you with his fist or with something that could hurt you?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
e) kick you, drag you, or beat you up?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
f) try to choke you or burn you on purpose?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
g) threaten or attack you with a knife, gun, or other weapon?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
h) physically force you to have sexual intercourse with him when you did not want to?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
i) physically force you to perform any other sexual acts you did not want to?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2
j) force you with threats or in any other way to perform sexual acts you did not want to?
YES 1
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NO 2

1106) CHECK 1105A (a-j):

AT LEAST ONE 'YES' ___
NOT A SINGLE 'YES' ___ (GO TO 1109)

1107) How long after you first got married/started living together 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

1108) 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

1109) 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 1111)

1110) In the last 12 months, how often have you done this to your (last) husband/partner: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1111) Does (did) your (last) husband/partner drink alcohol?

YES 1
NO 2 (GO TO 1113)

1112) How often does (did) he get drunk: often, only sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

1113) Are (were) you afraid of your (last) husband/partner: most of the time, sometimes, or never?

MOST OF THE TIME AFRAID 1
SOMETIMES AFRAID 2
NEVER AFRAID 3

1114) CHECK 609:

MARRIED MORE THAN ONCE ___
MARRIED ONLY ONCE ___ (GO TO 1116)

1115) A) So far we have been talking about the behavior of your current/last husband/partner. Now I want to ask you about the behavior of any previous husband/partner.

a) Did any previous husband/partner ever hit, slap, kick, or do anything else to
hurt you physically?
YES 1
B) How long ago did this last happen?
0-11 MONTHS AGO 1
12+ MONTHS AGO 2
DON'T REMEMBER 3
NO 2
b) Did any previous husband/partner physically force you to have intercourse or perform any other sexual acts against your will?
YES 1
B) How long ago did this last happen?
0-11 MONTHS AGO 1
12+ MONTHS AGO 2
DON'T REMEMBER 3
NO 2

1116) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN ___
From the time you were 15 years old has anyone other than your/any husband/partner hit you, slapped you, kicked you, or done anything else to hurt you physically?
YES 1
NO 2 (GO TO 1119)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1119)
NEVER MARRIED/ NEVER LIVED WITH A MAN ___
From the time you were 15 years old has anyone hit you, slapped you, kicked you, or done anything else to hurt you physically?
YES 1
NO 2 (GO TO 1119)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1119)

1117) 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
CURRENT BOYFRIEND F
FORMER BOYFRIEND G
MOTHER-IN-LAW H
FATHER-IN-LAW I
OTHER IN-LAW J
TEACHER K
EMPLOYER/SOMEONE AT WORK L
POLICE/SOLDIER M
OTHER (SPECIFY) __________ X

1118) In the last 12 months, how often has this person/have these person physically hurt you: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1119) CHECK 201, 226, AND 230:

EVER BEEN PREGNANT (YES ON 201 OR 226 OR 230) ___
NEVER BEEN PREGNANT ___ (GO TO 1122)

1120) 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 1122)

1121) Who has done any of these things to physically hurt you while you were pregnant?
Anyone else?

RECORD ALL MENTIONED.

CURRENT HUSBAND/PARTNER A
MOTHER/STEP-MOTHER B
FATHER/STEP-FATHER C
SISTER/BROTHER D
DAUGHTER/SON E
OTHER RELATIVE F
FORMER HUSBAND/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

1122) CHECK 601 AND 602

EVER MARRIED/EVER LIVED WITH A MAN ___
Now I want to ask you about things that may have been done to you by someone other than your/any husband/partner.
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 when you did not want to?
YES 1
NO 2 (GO TO 1126)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1126)
NEVER MARRIED/NEVER LIVED WITH A MAN ___
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 when you did not want to?
YES 1
NO 2 (GO TO 1126)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1126)

1123) 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

1124) Who was the person who was forcing you at that time?

CURRENT HUSBAND/PARTNER 01
FORMER HUSBAND/PARTNER 02
CURRENT/FORMER BOYFRIEND 03
FATHER/STEP-FATHER 04
BROTHER/STEP-BROTHER 05
OTHER RELATIVE 06
IN-LAW 07
OWN FRIEND/ACQUAINTANCE 08
FAMILY FRIEND 09
TEACHER 1-
EMPLOYER/SOMEONE AT WORK 11
POLICE/SOLDIER 12
PRIEST/RELIGIOUS LEADER 13
STRANGER 14
OTHER (SPECIFY) ____________ 96

1125) CHECK 601 AND 602

EVER MARRIED/EVER LIVED WITH A MAN ___
In the last 12 months, has anyone other than your/any husband/partner physically you to have sexual intercourse when you did not want to?
YES 1
NO 2
NEVER MARRIED/NEVER LIVED WITH A MAN ___
In the last 12 months, has anyone physically you to have sexual intercourse when you did not want to?
YES 1
NO 2

1126) CHECK 1105A (a-j), 1115, 1116, 1120, 1122, AND 1125:

AT LEAST ONE 'YES' ___
NOT A SINGLE 'YES' ___ (GO TO 1130)

1127) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?

YES 1
NO 2 (GO TO 1129)

1128) From whom have you sought help?
Anyone else?

RECORD ALL MENTIONED.

OWN FAMILY A (GO TO 1130)
HUSBAND'S/PARTNER'S FAMILY B (GO TO 1130)
CURRENT/FORMER HUSBAND/PARTNER C (GO TO 1130)
CURRENT/FORMER BOYFRIEND D (GO TO 1130)
FRIEND E (GO TO 1130)
NEIGHBOR F (GO TO 1130)
RELIGIOUS LEADER G (GO TO 1130)
DOCTOR/MEDICAL PERSONNEL H (GO TO 1130)
POLICE I (GO TO 1130)
LAWYER J (GO TO 1130)
SOCIAL SERVICE ORGANIZATION K (GO TO 1130)
OTHER (SPECIFY) ____________ X (GO TO 1130)

1129) Have you ever told anyone about this?

YES 1
NO 2

1130) As far as you know, did your father ever beat your mother?

YES 1
NO 2
DON'T KNOW 8

1130A) CHECK IF CODE 1 IS CIRCLED IN 1122

CODE "1" CIRCLED ___
CODE "1" NOT CIRCLED ___ (GO TO 1132)

1131) After being forced to have sexual intercourse or to perform a sexual act, have you ever sought help from a doctor or medical personnel?

YES 1
NO 2 (GO TO 1132)

1131A) How long after you were forced to have a sexual intercourse did you seek help?

WITHIN 3 DAYS 1
AFTER 3 DAYS OR MORE 2

1131B) Were you offered drugs to prevent you from getting the AIDS virus?

YES 1
NO 2

1131C) Were you offered a test for the AIDS virus after the violence?

YES 1
NO 2

1131D) Were you pregnant when you were forced to have sexual intercourse?

YES 1
NO 2 (GO TO 1132)

1131E) Were you offered a pill to stop you from becoming pregnant?

YES 1
NO 2

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.

1132) 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

1133) INTERVIEWER'S COMMENTS /EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE
__________________________________________


SECTION 12: MATERNAL MORTALITY

1201A) 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.

Did your mother give birth to any children other than yourself?

YES 1
NO 2 (GO TO 1214)

1201B) How many children did your mother give birth to, including you?

NUMBER OF BIRTHS TO NATURAL MOTHER __ __

1202) CHECK 1201 B:

TWO OR MORE BIRTHS ___
ONLY ONE BIRTH (RESPONDENT ONLY) ___ (GO TO 1214)

1203) How many of these births did your mother have before you were born?

NUMBER OF PRECEDING BIRTHS __ __

1204) What was the name given to your oldest (next oldest) brother or sister?

_____________________

1205) Is (NAME) male or female?

MALE 1
FEMALE 2

1206) Is (NAME) still alive?

YES 1
NO 2 (GO TO 1208)
DON’T KNO2 8 (GO TO NEXT SIBLING)

1207) How old is (NAME)?

__ __ (GO TO NEXT SIBLING)

1208) How many years ago did (NAME) die?

__ __

1209 How old was (NAME) when he/she died?

__ __ (IF MALE OR DIED BEFORE 12 YEARS OF AGE GO TO NEXT SIBLING)

1210) Was (NAME) pregnant when she died?

YES 1 (GO TO 1213)
NO 2

1211) Did (NAME) die during childbirth?

YES 1 (GO TO 1213)
NO 2

1212) Did (NAME) die within two months after the end of a pregnancy or child birth?

YES 1
NO 2

1213) How many live borne children did (NAME) give birth to during her lifetime (before this pregnancy)?

__ __

IF NO MORE BROTHERS OR SISTERS, GO TO NEXT ELIGIBLE WOMAN IF NO MORE ELIGIBLE WOMAN,END INTERVIEW.

1214) END TIME

HOUR __ __
MINUTES __ __


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.
COLUMN 1 REQUIRES A CODE IN EVERY MONTH.

INFORMATION TO BE CODED FOR EACH COLUMN

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE**

B BIRTHS
P PREGNANCIES
T TERMINATIONS

0 NO METHOD
1 FEMALE STERILIZATION
2 MALE STERILIZATION
3IUD
4 INJECTABLES
5 IMPLANTS
6PILL
7 CONDOM
8 FEMALE CONDOM
9 DIAPHRAGM
J FOAM OR JELLY
K LACTATIONAL AMENORRHEA METHOD
L RHYTHM METHOD/MOONBEADS
M WITHDRAWAL
X OTHER MODERN METHOD
Y OTHER TRADITIONAL METHOD

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE

0 INFREQUENT SEX/HUSBAND AWAY
1 BECAME PREGNANT WHILE USING
2 WANTED TO BECOME PREGNANT
3 HUSBAND/PARTNER DISAPPROVED
4 WANTED MORE EFFECTIVE METHOD
5 SIDE EFFECTS/HEALTH CONCERNS
6 LACK OF ACCESS/TOO FAR
7 COSTS TOO MUCH
8 INCONVENIENT TO USE
F UP TO GOD/FATALISTIC
A DIFFICULT TO GET PREGNANT/MENOPAUSAL
D MARITAL DISSOLUTION/SEPARATION
X OTHER (SPECIFY) ______________
Z DON'T KNOW

2011 12
12 DEC 01 ___ ___
11 NOV 02 ___ ___
10 OCT 03 ___ ___
09 SEP 04 ___ ___
08 AUG 05 ___ ___
07 JUL 06 ___ ___
06 JUN 07 ___ ___
05 MAY 08 ___ ___
04 APR 09 ___ ___
03 MAR 10 ___ ___
02 FEB 11 ___ ___
01 JAN 12 ___ ___

2010 12
12 DEC 13 ___ ___
11 NOV 14 ___ ___
10 OCT 15 ___ ___
09 SEP 16 ___ ___
08 AUG 17 ___ ___
07 JUL 18 ___ ___
06 JUN 19 ___ ___
05 MAY 20 ___ ___
04 APR 21 ___ ___
03 MAR 22 ___ ___
02 FEB 23 ___ ___
01 JAN 24 ___ ___

2009 12
12 DEC 25 ___ ___
11 NOV 26 ___ ___
10 OCT 27 ___ ___
09 SEP 28 ___ ___
08 AUG 29 ___ ___
07 JUL 30 ___ ___
06 JUN 31 ___ ___
05 MAY 32 ___ ___
04 APR 33 ___ ___
03 MAR 34 ___ ___
02 FEB 35 ___ ___
01 JAN 36 ___ ___

2008 12
12 DEC 37 ___ ___
11 NOV 38 ___ ___
10 OCT 39 ___ ___
09 SEP 40 ___ ___
08 AUG 41 ___ ___
07 JUL 42 ___ ___
06 JUN 43 ___ ___
05 MAY 44 ___ ___
04 APR 45 ___ ___
03 MAR 46 ___ ___
02 FEB 47 ___ ___
01 JAN 48 ___ ___

2007 12
12 DEC 49 ___ ___
11 NOV 50 ___ ___
10 OCT 51 ___ ___
09 SEP 52 ___ ___
08 AUG 53 ___ ___
07 JUL 54 ___ ___
06 JUN 55 ___ ___
05 MAY 56 ___ ___
04 APR 57 ___ ___
03 MAR 58 ___ ___
02 FEB 59 ___ ___
01 JAN 60 ___ ___

2006 12
12 DEC 61 ___ ___
11 NOV 62 ___ ___
10 OCT 63 ___ ___
09 SEP 64 ___ ___
08 AUG 65 ___ ___
07 JUL 66 ___ ___
06 JUN 67 ___ ___
05 MAY 68 ___ ___
04 APR 69 ___ ___
03 MAR 70 ___ ___
02 FEB 71 ___ ___
01 JAN 72 ___ ___


UGANDA BUREAU OF STATISTICS 2011 UGANDA DEMOGRAPHIC AND HEALTH SURVEY MATERNAL MORTALITY-ENGLISH


IDENTIFICATION

DISTRICT

RESIDENCE STATUS

RURAL=3
URBAN=1

COUNTY

SUBCOUNTY/TOWN

PARISH/LC1 NAME

EA NAME

NAME OF HOUSEHOLD HEAD

HOUSEHOLD NUMBER

SAMPLED HOUSEHOLD NUMBER


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 __ __ __ __
INT. NUMBER __ __ __
RESULT __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _________________

TOTAL PERSONS IN HOUSEHOLD __ __

TOTAL ELIGIBLE WOMEN __ __

LINE NO. OF RESPONDENT TO HOUSEHOLD SCHEDULE __ __

LANGUAGE OF THE QUESTIONNAIRE __ __

LANGUAGE USED IN THE INTERVIEW __ __

NATIVE LANGUAGE OF RESPONDENT __ __

TRANSLATOR USED

NOT AT ALL=1
SOMETIMES=2
ALL THE TIME=3

LANGUAGE USED:

01 ATESO
02 LUGANDA
03 LUGBARA
04 LUO
05 RUNYANKOLE-RUKIGA
06 RUNYORO-RUTORO
07 NGAKARAMOJONG
08 ENGLISH
96 OTHER(SPECIFY) _________________

NO. OF ELIGIBLE WOMEN INTERVIEWED __ __

SUPERVISOR

NAME ____________________ __ __ __

FIELD EDITOR

NAME ____________________ __ __ __

OFFICE EDITOR __ __

KEYED BY __ __


INTRODUCTION AND CONSENT

Hello. My name is _______________________________________ I am working with Uganda Bureau of Statistics. We are conducting a survey about health all over UGANDA. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 5 to 10 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?

___ YES
___ NO

May I begin the interview now?

___ YES
___ NO

SIGNATURE OF INTERVIEWER: _________________________________
DATE: ____________

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

RECORD THE START TIME

HOURS __ __
MINUTES __ __


HOUSEHOLD SCHEDULE E

1) LINE NO.

2) USUAL RESIDENTS AND VISITORS

Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-9 FOR EACH PERSON.

3) REALTIONSHIP TO HEAD OF HOUSEHOLD

What is the relationship of (NAME) to the head of the household?

SEE CODES BELOW

__ __

4) SEX

Is (NAME) male or female?

MALE 1
FEMALE 2

RESIDENCE

5) Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

7) AGE

How old is (NAME)?

IF 95 OR MORE RECORD '95'

YEARS __ __

8) MARITAL STATUS
[IF AGE 15 OR OLDER]

What is (NAME'S) current marital status?

1 = MARRIED OR LIVING TOGETHER
2 = DIVORCED/ SEPARATED
3 = WIDOWED
4 = NEVER-MARRIED AND NEVER LIVED TOGETHER

9) ELIGIBILITY

CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

(2A) Just to make sure that I have a complete listing. Are there any other persons such as small children or infants that we have not listed?

YES ___ (ADD TO TABLE)
NO ___

2B) Are there any other people who may not be YES ADD TO members of your family, such as domestic servants, lodgers, or friends who usually live here?

YES ___ (ADD TO TABLE)
NO ___

2C) Are there any guests or temporary visitors YES ADD TO staying here, or anyone else who stayed here last night, who have not been listed?

YES ___ (ADD TO TABLE)
NO ___

CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD

01=HEAD
02=WIFE OR HUSBAND
03=SON OR DAUGHTER
04=SON-IN-LAW OR DAUGHTER-IN-LAW
05=GRANDCHILD
06=PARENT
07=PARENT-IN-LAW
08=BROTHER OR SISTER
09=NIECE/NEPHEW BY BLOOD
10=NIECE/NEPHEW BY MARRIAGE
11=CO-WIFE
12=OTHER RELATIVE
13=ADOPTED/FOSTER/STEPCHILD
14=NOT RELATED
98=DON'T KNOW
00=MOTHER NOT LISTED


NAME OF ELIGIBLE WOMAN ________________________

LINE NUMBER OF WOMAN __ __

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 __ __ __ __
INT. NUMBER __ __ __
RESULT __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

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

1201A) 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.

Did your mother give birth to any children other than yourself?

YES 1
NO 2 (GO TO 1214)

1201B) How many children did your mother give birth to, including you?

NUMBER OF BIRTHS TO NATURAL MOTHER __ __

1202) CHECK 1201 B:

TWO OR MORE BIRTHS ___
ONLY ONE BIRTH (RESPONDENT ONLY) ___ (GO TO 1214)

1203) How many of these births did your mother have before you were born?

NUMBER OF PRECEDING BIRTHS __ __

1204) What was the name given to your oldest (next oldest) brother or sister?

_____________________

1205) Is (NAME) male or female?

MALE 1
FEMALE 2

1206) Is (NAME) still alive?

YES 1
NO 2 (GO TO 1208)
DON'T KNOW 8 (GO TO 1208)

1207) How old is (NAME)?

__ __ (GO TO NEXT BROTHER OR SISTER)

1208) How many years ago did (NAME) die?

__ __

1209) How old was (NAME) when he/she died?

__ __

1210) Was (NAME) pregnant when she died?

YES 1 (GO TO 1213)
NO 2

1211) Did (NAME) die during childbirth?

YES 1 (GO TO 1213)
NO 2

1212) Did (NAME) die within two months after the end of a pregnancy or childbirth?

YES 1
NO 2

1213) How many live born children did (NAME) give birth to during her lifetime (before this pregnancy)?

__ __

1214) CHECK (X) HERE IF CONTINUATION SHEET USED ___

IF NO MORE BROTHERS OR SISTERS, GO TO NEXT ELIGIBLE WOMAN IF NO MORE ELIGIBLE WOMAN, END INTERVIEW.

END TIME

HOUR __ __
MINUTES __ __