IDENTIFICATION

PLACE NAME _______________

NAME OF HOUSEHOLD HEAD ________________

CLUSTER NUMBER ________

NAME AND LINE NUMBER OF MAN _________ ____

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 201__
INT. NUMBER____
RESULT

TOTAL NUMBER OF VISITS____

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

LANGUAGE OF INTERVIEW ____

HOME LANGUAGE OF RESPONDENT ____

TRANSLATOR USED

SUPERVISOR
NAME ____
NUMBER ________

100A) CHECK RESPONDENT'S AGE AND MARITAL STATUS IN HOUSEHOLD QUESTIONNAIRE.

INTRODUCTION AND CONSENT (PARENT/GUARDIAN)

Hello. My name is ______________. I am working with Statistics South Africa. We are conducting a survey about health and other topics all over South Africa. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to talk to (NAME OF MINOR) about his health and well-being. The questions usually take about 30 to 40 minutes. All of the answers (NAME OF MINOR) gives will be confidential and will not be shared with anyone other than members of our survey team. (NAME OF MINOR) doesn't have to be in the survey, but we hope you will agree to allow (NAME OF MINOR) to answer the questions since (NAME OF MINOR)'S views are important.

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

Do you have any questions?
May I begin the interview with (NAME OF MINOR) now?

SIGNATURE OF INTERVIEWER _________
DATE ____

PARENT/GUARDIAN AGREES MINOR MAY BE INTERVIEWED 1 (CONTINUE)
PARENT/GUARDIAN DOES NOT AGREE TO ALLOW MINOR BE INTERVIEWED 2 (END)

INTRODUCTION AND CONSENT

Hello. My name is ______________. I am working with Statistics South Africa. We are conducting a survey about health and other topics all over South Africa. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 to 40 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 this information sheet.

GIVE INFORMATION SHEET.

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

SIGNATURE OF INTERVIEWER _____________
DATE ____

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

SECTION 1. RESPONDENT'S BACKGROUND

101) RECORD THE TIME.

102) How long have you been living continuously in (NAME OF CURRENT CITY, TOWN OR VILLAGE OF RESIDENCE)? IF LESS THAN ONE YEAR, RECORD '00' YEARS.

103) Just before you moved here, where did you live? PROBE: Is that a city, a town, a rural area, a farm, a tribal area, or an informal settlement?

104) Before you moved here, which province did you live in?

105) On what day, month, and year were you born?

106) How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

106A) Which population group do you consider yourself: black, white, coloured, Indian or something else?

107) Have you ever attended an educational institution?

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

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

110) CHECK 108:

111) 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?

112) CHECK 111:

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

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

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

116) Do you own a cell phone?

117) Do you use your cell phone for any financial transactions?

118) Do you have an account in a bank or other financial institution that you yourself use?

119) Have you ever used the internet?

120) In the last 12 months, have you used the internet? IF NECESSARY, PROBE FOR USE FROM ANY LOCATION, WITH ANY DEVICE.

121) During the last one month, how often did you use the internet: almost every day, at least once a week, less than once a week, or not at all?

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

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

126) CHECK 106: AGE OF RESPONDENT:

SECTION 2. REPRODUCTION

201) Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours, even if they are not legally yours or do not have your last name. Have you ever fathered any children with any woman?

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

203A) How many sons live with you?
IF NONE, RECORD '00'.

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

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

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

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

206) Have you ever fathered a son or daughter who was born alive but later died?
IF NO, PROBE: Any baby who cried, who made any movement, sound, or effort to breathe, or who showed any other signs of life even if for a very short time?

207A) How many boys have died?
IF NONE, RECORD '00'.

207B) And how many girls have died?
IF NONE, RECORD '00'.

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

209) CHECK 208:

210) Did all of the children you have fathered have the same biological mother?

211) CHECK 208:

HAS HAD MORE THAN ONE CHILD: How old were you when your first child was born?
HAS HAD ONLY ONE CHILD: How old were you when your child was born?

212) CHECK 203 AND 205:

213) CHECK 203 AND 205:

MORE THAN ONE LIVING CHILD: How old is your youngest child?
ONLY ONE LIVING CHILD: How old is your child?

214) CHECK 213:

215) CHECK 203 AND 205:

MORE THAN ONE LIVING CHILD: What is the name of your youngest child?
ONLY ONE LIVING CHILD: What is the name of your child?

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

217) Were you ever present during any of those antenatal checkups?

218) Was (NAME) born in a hospital or health facility?

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

220) CHECK 203:

221) Do you have at least one child you is biologically yours and is less than age 18 who lives with you?

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. Which ways or methods have you heard about? MARK ALL METHODS DECLARED BY THE RESPONDENT.

FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?

302) In the last few months have you:

a) Heard about family planning on the radio?
b) Seen anything about family planning on the television?
c) Read about family planning in a newspaper or magazine?
d) Heard about family planning from a community health worker?

302A) CHECK Q18 IN HOUSEHOLD QUESTIONNAIRE:

302) e) Heard about family planning at school?

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

304) Now I would like to ask you about a woman's risk of pregnancy. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant when she has sexual relations?

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

306) After the birth of a child, can a woman become pregnant before her menstrual period has returned?

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

a) Contraception is a woman's concern and a man should not have to worry about it.
b) Woman who use contraception may become promiscuous.

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401) Are you currently married or living together with someone as if married?

401A) Do you have a regular girlfriend/partner or fiancée?

401B) Is this person a woman or a man?

401c) CHECK 401: RESPONDENT'S CURRENT MARITAL STATUS

402) Have you ever been married or lived together with someone as if married?

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

403A) CHECK 106: AGE OF RESPONDENT

403B) CHECK 401 AND 402:

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

404A) CHECK 401A: SEX OF SPOUSE/PARTNER

404B) RECORD THE SPOUSE'S/PARTNER'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

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

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

407) CHECK 405:

ONE WIFE/PARTNER: Please tell me the name of (your wife/the woman you are living with as if married).
MORE THAN ONE WIFE/PARTNER: Please tell me the name of each of your wives or each woman you are living with as if married.

RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER.
IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

408) How old was (NAME) on her last birthday?
ASK 408 FOR EACH PERSON (LISTED IN 407).

409) CHECK 405:

410) Have you been married or lived with someone only once or more than once?

411) CHECK 405 AND 410:

405 DOES NOT EQUAL 1 AND 410 EQUALS 2: In what month and year did you start living with your (spouse/partner)?
OTHER: Now I would like to ask about your first (spouse/partner). In what month and year did you start living with your first (spouse/partner)?

412) How old were you when you first started living together?

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

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

415) I would like to ask you about your recent sexual activity. 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.

416) When was the last time you had sexual intercourse with this person?
(DON'T ASK FOR LAST SEXUAL PARTNER)

417) The last time you had sexual intercourse with this person, was a condom used?

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

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

420) How long ago did you first have sexual intercourse with this person?

421) 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, RECORD '95'.

422) How old is this person?

423) Apart from this person, have you had sexual intercourse with any other person in the last 12 months?

424) In total, with how many different people have you had sexual intercourse in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS 95 OR MORE, RECORD '95'.
(ONLY ASK FOR THIRD-TO-LAST SEXUAL PARTNER)

425) CHECK 419 (ALL COLUMNS):

426) CHECK 419 AND 417 (ALL COLUMNS):

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

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

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

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

431) In the past 12 months have you given any gifts or other goods in order to have sex or to become sexually involved with anyone?

432) Have you ever given any gifts or other goods in order to have sex or to become sexually involved with anyone?

433) 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, RECORD '95'.

434) CHECK 417: MOST RECENT PARTNER (FIRST CONDOM):

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

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

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

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

SECTION 5. FERTILITY PREFERENCES

501) CHECK 401, 401A AND 401B:

502) CHECK 440:

503) CHECK 407:

504) Is your (wife/partner) currently pregnant?

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

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

507) CHECK 208:

HAS FATHERED CHILDREN: Now I have some questions about the future. Would you like to have another child, or would you prefer not to have any more children?
HAS NOT FATHERED CHILDREN: Now I have some questions about the future. Would you like to have a child, or would you prefer not to have any children?

508) CHECK 508:

HAS FATHERED CHILDREN: How long would you like to wait from now before the birth of another child?
HAS NOT FATHERED CHILDREN: How long would you like to wait from now before the birth of a child?

509) Are any of your (wives/partners) currently pregnant?

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

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

512) CHECK 208:

HAS FATHERED CHILDREN: Now I have some questions about the future. Would you like to have another child, or would you prefer not to have any more children?
HAS NOT FATHERED CHILDREN: Now I have some questions about the future. Would you like to have a child, or would you prefer not to have any children?

513) CHECK 208:

HAS FATHERED CHILDREN: How long would you like to wait from now before the birth of another child?
HAS NOT FATHERED CHILDREN: How long would you like to wait from now before the birth of a child?

514) CHECK 203 AND 205:

HAS LIVING CHILDREN: If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?
NO LIVING CHILDREN: If you could choose exactly the number of children to have in your whole life, how many would that be?

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

SECTION 6. EMPLOYMENT AND GENDER ROLES

601) Have you done any work in the last seven days?

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

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

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

604A) CHECK 106: AGE OF RESPONDENT

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

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

607) CHECK 401, 401A AND 401B:

608) CHECK 606:

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

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

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

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

613) Do you have a title deed or documents for any house you own?

614) Is your name on the title deed or documents?

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

a) If she goes out without telling him?
b) If she neglects the children?
c) If she argues with him?
d) If she refused to have sex with him?
e) If she burns the food?

616) CHECK 203 AND 221:

617) Now I would like to ask you questions about how you discipline or punish your (child/children). In the past 12 months, have you ever:

a) Hit or slapped your (child/children) with your hand to punish or discipline the child?
b) Hit or beat your (child/children) using a belt, spoon, stick, shoe or any other implement to punish or discipline the child?

SECTION 7. HIV/AIDS

701) Now I would like to talk about something else. Have you ever heard of HIV or AIDS?

708) Can HIV be transmitted from a mother to her baby:

a) During pregnancy?
b) During delivery?
c) By breastfeeding?

709) CHECK 708:

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

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

712) I don't want to know the results, but have you ever been tested for HIV?

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

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

715) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, RECORD 96 AND WRITE THE NAME OF THE PLACE.

716) Do you know of a place where people can go to get an HIV test?

717) Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO IDENTIFY IF PUBLIC OR PRIVATE SECTOR, RECORD 'X' AND WRITE THE NAME OF THE PLACE(S).

718) Have you heard of test kits people can use to test themselves for HIV?

719) Have you ever tested yourself for HIV using a self-test kit?

727) CHECK 701:

HEARD ABOUT HIV OR AIDS: Apart from HIV, have you heard about other infections that can be transmitted through sexual contact?
NOT HEARD ABOUT HIV OR AIDS: Have you heard about infections that can be transmitted through sexual contact?

728) CHECK 414:

729) CHECK 727: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

730) 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?

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

732) Sometimes men have a sore or ulcer on or near their penis. During the last 12 months, have you had a sore or ulcer on or near your penis?

733) CHECK 730, 731 AND 732:

734) The last time you had (PROBLEM FROM 730/731/732), did you seek any kind of advice or treatment?

735) Where did you go? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, RECORD 'X' AND WRITE THE NAME OF THE PLACE(S).

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

739) How old were you when you got circumcised?

740) Who did the circumcision?

SECTION 9. TOBACCO AND ALCOHOL

901) Would you say your health is poor, average, good, or excellent?

902) Do you personally think you are underweight, normal weight, overweight, or obese?

903) Do you currently smoke tobacco every day, some days, or not at all?

904) In the past, have you smoked tobacco every day?

905) In the past, have you ever smoked tobacco every day, some days, or not at all?

906) On average, how many of the following products do you currently smoke each day? Also, let me know if you use the product, but not every day.
IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY DAY, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.

a) Manufactured cigarettes?
b) Hand-rolled cigarettes?
c) Pipes full of tobacco?
d) Cigars or cigarillos?
e) Number of hookah, hubbly-bubbly or water pipe sessions?
f) Any others? (SPECIFY) ____

907) On average, how many of the following products do you currently smoke each week? Also, let me know if you use the product, but not every week.
IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY WEEK, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.

a) Manufactured cigarettes?
b) Hand-rolled cigarettes?
c) Pipes full of tobacco?
d) Cigars or cigarillos?
e) Number of hookah, hubbly-bubbly or water pipe sessions?
f) Any others? (SPECIFY) ____

908) Do you currently use snuff, chewing tobacco or other smokeless tobacco products every day, some days, or not at all?

909) In the past, have you used snuff, chewing tobacco or other smokeless tobacco products every day, some days, or not at all?

910) On average, how many times a day do you use the following products? Also, let me know if you use the product, but not every day.
IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY DAY, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.

a) Snuff, by mouth?
b) Snuff, by nose?
c) Chewing tobacco?
d) Any others? (SPECIFY) ____

911) On average, how many times a week do you use the following products? Also, let me know if you use the product, but not every week.
IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY WEEK, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.

a) Snuff, by mouth?
b) Snuff, by nose?
c) Chewing tobacco?
d) Any others? (SPECIFY) ____

912) Do you currently work in a job where other people smoke tobacco around you?

913) Have you ever worked in a job where you were regularly exposed to smoke, dust, fumes, or strong smells?

914) How many years did you work at a job where you were regularly exposed to smoke, dust, fumes or strong smells?
IF LESS THAN 1 YEAR, RECORD '00'.

915) Do you currently use e-cigarettes every day, some days, or not at all?

916) Have you ever consumed a drink that contains alcohol such as beer, wine, spirits, or sorgum beer? PROBE: Even one drink?

917) Was this within the last 12 months?

918) In the last 12 months, how frequently have you had at least one drink?
PROBE: Five or more days a week, 1-4 days a week, 1-3 days a month, or less often than once a month?

919) During each of the last 7 days, how many standard drinks did you have?
USE SHOWCARD. RECORD TOTAL NUMBER OF DRINKS CONSUMED EACH DAY STARTING WITH THE DAY BEFORE THE DAY OF THE INTERVIEW AND PROCEEDING BACKWARDS.
IF NONE, RECORD '00'.

919H) During the last 7 days, how many standard homemade beers or other homemade alcohol did you have?
USE SHOWCARD.

919I) CHECK 918 AND 919: CODE 3 OR 4 RECORD IN 918 AND CONSUMED 0-1 DRINKS IN THE LAST 7 DAYS IN 919?

920) Have you ever felt that you should cut down on your drinking?

921) Have people annoyed you by criticizing your drinking?

922) Have you ever felt bad or guilty about your drinking?

923) Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

923A) CHECK 919: FIVE OR MORE DRINKS IN ONE DAY DURING LAST 7 DAYS?

924) In the past 30 days, have you consumed five or more standard drinks on at least one occasion?

SECTION 10. FAT, SALT, SUGAR, FRUIT AND VEGETABLE CONSUMPTION

1001) Now I would like to ask you some questions about the foods that you eat. There are no right or wrong answers. USE SHOWCARD.

1004) How often do you eat fried foods such as hot chips, fried fish, fried chicken, fried meat, vetkoek or doughnuts?

1005) How often do you eat fast-foods or take-away foods from places like Chicken Licken, KFC, Captain DoRego's, Steers, Nando's, McDonalds, pizza delivery, etc?

1006) How often do you eat chips such as a packet of crispy chips or similar salty snacks such as Doritos, cheese curls, salted nuts, salty biscuits, etc?

1007) How often do you eat processed meat such as polony, viennas, meat pies, or sausage rolls?

1008) Which of the following statements best describes your approach towards salt consumption:

1) I am not interested in lowering salt in my food.
2) I am interested in lowering salt in my food within the next six months.
3) I am interested in lowering salt in my food within the next month.
4) I have started lowering salt within the last six months.
5) I have already lowered my salt intake for longer than six months.

1009) Yesterday, how many types of fruit did you eat?
USE SHOWCARD. IF NONE, RECORD '00'.

1010) Yesterday, how many types of vegetables, excluding potatoes, did you eat?
USE SHOWCARD. IF NONE, RECORD '00'.

1011) Yesterday, did you drink any sugar-sweetened drinks? Sugar-sweetened drinks include fizzy drinks like Coke or drinks like Squash where water is added, but not diet or unsweetened cold drinks.

1011A) How many and what size sugar-sweetened drinks did you drink?
PROBE FOR BEVERAGE SIZE.

1012) Yesterday, did you drink any fruit juice?

1012A) How many and what size fruit juices did you drink?
PROBE FOR BEVERAGE NUMBER AND SIZE.

SECTION 11. HEALTH CARE

1101) Are you covered by Medical Aid, Medical Benefit Scheme, Provident Scheme, or Hospital Plan that helps you pay for health care or drug services?

1102) During the last month, have you received health, medical, or dental care without staying overnight?

1103) Where have you received health, medical, or dental care?
PROBE: Anywhere else?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, RECORD 'X' AND WRITE THE NAME OF THE PLACE(S).

1104) During the last month, have you had any visits by a home-based care giver or a community-based care giver?

1105) Has a doctor, nurse or health worker told you that you have TB?

1106) When was the last time you were told you had TB?

1107) Did you get medical treatment the last time you had TB?

1108) Has a doctor, nurse or health worker told you that you have or have had any of the following conditions:

a) High blood pressure?
b) Heart attack or angina/chest pains?
c) Cancer?
d) Stroke?
e) High blood cholesterol or fats in the blood?
f) Diabetes or blood sugar?
g) Chronic bronchitis, emphysema, or COPD?
h) Asthma?

1109) CHECK 1108:
ANY QUESTION a-h ANSWERED YES?

1110) CHECK 1108a:
RESPONDENT HAS HAD HIGH BLOOD PRESSURE.

1111) Did you receive treatment for high blood pressure at the time of the diagnosis?

1112) CHECK 1108b:
RESPONDENT HAS HAD HEART ATTACK OR ANGINA.

1113) Did you receive treatment for the heart attack, angina/chest pains at the time of diagnosis?

1114) CHECK 1108c: RESPONDENT HAS HAD CANCER.

1115) Did you receive treatment for the cancer at the time of the diagnosis?

1116) CHECK 1108d: RESPONDENT HAS HAD STROKE.

1117) Did you receive treatment for the stroke at the time of the diagnosis?

1118) CHECK 1108e:
RESPONDENT HAS HAD HIGH BLOOD CHOLESTEROL.

1119) Did you receive treatment for high blood cholesterol or fats in the blood at the time of the diagnosis?

1120) CHECK 1108f:
RESPONDENT HAS HAD DIABETES.

1121) Did you receive treatment for the diabetes or blood sugar at the time of the diagnosis?

1122) CHECK 1108g:
RESPONDENT HAS HAD CHRONIC BRONCHITIS.

1123) Did you receive treatment for the chronic bronchitis, emphysema, or COPD at the time of the diagnosis?

1124) CHECK 1108h:
RESPONDENT HAS HAD ASTHMA.

1125) Did you receive treatment for the asthma at the time of the diagnosis?

1127) Compared with other people your age, do you feel you have less breath when exerting yourself? PROBE: By exercising or moving a lot?

1128) During the last 12 months, have you had wheezing when you breathe?

1129) Were you also short of breath when the wheezing noise was present?

1130) Have you had the wheezing when you did not have a cold?

1131) Have you woken up with a feeling of tightness in your chest at any time in the last 12 months?

1132) Have you been woken by an attack of shortness of breath at any time in the last 12 months?

1133) Have you been woken by an attack of coughing at any time in the last 12 months?

1134) Do you usually cough on most days?

1135) When you cough, do you usually bring up phlegm from your chest?

1136) Have you brought up phlegm every day for at least three months during the last year?

1137) For how many years have you brought up phlegm in this way?
IF LESS THAN 1 YEAR, RECORD '00'.

1138) Are you currently troubled by pain or discomfort, either all the time or on and off?

1139) Have you had this pain or discomfort for more than 3 months?

1140) Where is this pain or discomfort?
RECORD ALL MENTIONED.

1141) In the past 12 months, did your teeth or your moth cause you any pain or discomfort?

1142) Did you get treatment the last time that you had the problem?

1143) Who did you see for treatment?
RECORD ALL MENTIONED.

1144) What was the main reason that you did not get treatment?

1145) Now I would like to ask you about any medication you take. Do you use any medicine daily or regularly that has been prescribed by a doctor or nurse?

1146) How many different medicines do you use daily or regularly?

1147) Who pays for most of these medications?

1148) In the last 12 months, have you ever been sent away from the clinic without a medication because they did not have stock?

1149) How many times has this happened to you in the last 12 months?
PROBE FOR ESTIMATE OF NUMBER OF TIMES.

1150) In the last 12 months, have you used any medications containing codeine to treat a medical condition?
USE SHOWCARD.

1152) In the last 12 months, have you used any of these medications for the experience or feeling it gave you rather than for their medical effect?

1153) In the last 12 months, which codeine-containing medications have you used for the experience or feeling rather than for their medical effect?
RECORD ALL MENTIONED.

1154) In the last 12 months, have you sought treatment for your problems related to the use of codeine-containing medicines for non-medical purposes?

1155) RECORD TIME

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW: ____

COMMENTS ON SPECIFIC QUESTIONS: ____

ANY OTHER COMMENTS: ____

SUPERVISOR'S OBSERVATIONS: ____