IDENTIFICATION

LOCALITY NAME ___________________ ___

NAME OF HOUSEHOLD HEAD ____________________ ___

CLUSTER NUMBER ___

HOUSEHOLD NUMBER ___

PROVINCE _________________ ___

URBAN/RURAL

LUSAKA/OTHER CITY/TOWN/VILLAGE

NAME AND LINE NUMBER OF WOMAN _______________ ___

WOMAN SELECTED FOR Qs. 720A-720L?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT*___

RESULT* ______________

NEXT VISIT:
DATE ______
TIME _____

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
NAME ___
RESULT* ____

TOTAL NUMBER OF VISITS __

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

LANGUAGE USED IN INTERVIEW

RESPONDENT'S LOCAL LANGUAGE

TRANSLATOR USED

SUPERVISOR
NAME ________ ___
DATE ________

FIELD EDITOR
NAME ________ ___
DATE ________

OFFICE EDITOR

KEYED BY

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT
Hello. My name is ____________ and I am working with CBOH/CSO. We are conducting a national survey about the health of women and children. We would very much appreciate your participation in this survey. I would like to ask you about your health (and the health of your children). This information will help the government to plan health services. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

We hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey?

May I begin the interview now?

Signature of interviewer: ______________ Date: __________

101. RECORD THE TIME.

103. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS.

104. Just before you moved here, did you live in Lusaka, in another city, in a town, or in a village?

105. In what month and year were you born?

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

107. Have you ever attended school?

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

109. What is the highest grade 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. Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?

113. CHECK 111:

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

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

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

117. What is your religion?

118. What tribe do you belong to?

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?

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

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

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

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

206. Have you ever 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?

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

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

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

210. CHECK 208:

211. Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.
RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.

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

213. Were any of these births twins?

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

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

216. Is (NAME) still alive?

217. IF ALIVE: How old was (NAME) at his/her last birthday?
RECORD AGE IN COMPLETED YEARS.

218. IF ALIVE: Is (NAME) living with you?

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

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.

221. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)?

222. Have you had any live births since the birth of (NAME OF LAST BIRTH)?

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

224. CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 1996 OR LATER.
IF NONE, RECORD '0'.

226. Are you pregnant now?

227. How many months pregnant are you?

228. At the time you became pregnant did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all?

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

230. When did the last such pregnancy end?

231. How many months pregnant were you when the last such pregnancy ended?

232. CHECK 230:

233. Have you ever had any other pregnancies that did not result in a live birth?

234. When did the previous such pregnancy end?

235. How many months pregnant were you when that pregnancy ended?

237. When did your last menstrual period start?

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

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

SECTION 3. CONTRACEPTION

Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy.
CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.

301. Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?

302. Have you ever used (METHOD)?

303. CHECK 302:

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

306. What have you used or done?
CORRECT 302 AND 303 (AND 301 IF NECESSARY).

307. Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant. How many living children did you have at that time, if any?

308. CHECK 302 (01):

309. CHECK 226:

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

311. Which method are you using?
IF MORE THAN ONE METHOD MENTIONED, FOLLOW GO INSTRUCTION FOR HIGHEST METHOD ON LIST.
311A. CIRCLE 'A' FOR FEMALE STERILIZATION.

312. What brand of pills are you using?
ASK TO SEE THE PACKAGE IF RESPONDENT DOES NOT REMEMBER NAME OF BRAND.

313. In what facility did the sterilization take place?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

314. CHECK 311:

CODE 'A' CIRCLED: Before your sterilization operation, were you told that you would not be able to have any (more) children because of the operation?

CODE 'A' NOT CIRCLED: Before the sterilization operation, was your husband/partner told that he would not be able to have any (more) children because of the operation?

316. In what month and year was the sterilization performed?
316A. In what month and year did you start using (CURRENT METHOD) without stopping?
PROBE: For how long have you been using (CURRENT METHOD) now without stopping?

317. CHECK 316/316A:

319. CHECK 311/311A:

CIRCLE METHOD CODE.

IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

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

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

327. CHECK 311/311A:

CIRCLE METHOD CODE.

328. Where did you obtain (CURRENT METHOD) the last time?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
328A. Where did you learn to use Lactational Amenorrhea Method?

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

330. Where is that? Any other place?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
RECORD ALL PLACES MENTIONED

331. In the last 12 months, was anybody in your house visited by a member of the community who is a health worker?

331A. What services did they provide?
RECORD ALL MENTIONED.

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

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

SECTION 4A. PREGNANCY, POSTNATAL CARE AND BREASTFEEDING

401. CHECK 224:

402. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 1996 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 3 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES).

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

403. LINE NUMBER FROM 212

404. FROM 212 AND 216

405. At the time you became pregnant with (NAME), did you want to become pregnant then,
did you want to wait until later, or did you not want to have any (more) children at all?

406. How much longer would you like to have waited?

407. Did you see anyone for antenatal care for this pregnancy?
IF YES: Whom did you see? Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN.
[Last Birth Only]

407A. Where did the first antenatal visit take place?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
[Last Birth Only]

408. How many months pregnant were you when you first received antenatal care for this pregnancy?
[Last Birth Only]

409. How many times did you receive antenatal care during this pregnancy?
[Last Birth Only]

410. CHECK 409:
NUMBER OF TIMES RECEIVED ANTENATAL CARE
[Last Birth Only]

411. How many months pregnant were you the last time you received antenatal care?
[Last Birth Only]

412. During this pregnancy, were any of the following done at least once?

Were you weighed?
Was your height measured?
Was your blood pressure measured?
Did you give a urine sample?
Did you give a blood sample?
[Last Birth Only]

412A. During this pregnancy, were you offered counseling and testing for the virus that causes AIDS?
[Last Birth Only]

414A. CHECK 407A:
DID RESPONDENT RECEIVE ANTENATAL CARE AT HOME?

414B. What is the main reason you did not go to a health facility for antenatal care?
[Last Birth Only]

414C. Did you ever try to go for antenatal care but the health facility staff told you to go away and come back another day?
[Last Birth Only]

415. During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, spasms or jerks in the first month after birth?
[Last Birth Only]

416. During this pregnancy, how many times did you get this injection?
[Last Birth Only]

417. During this pregnancy, were you given or did you buy any iron tablets or iron syrup or folic acid?
SHOW TABLET/SYRUP.
[Last Birth Only]

418. During the whole pregnancy, for how many days did you take the iron tablets or iron syrup?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS
[Last Birth Only]

421. During this pregnancy, did you take any drugs to prevent you from getting malaria?
[Last Birth Only]

422. What drugs did you take?
RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW
TYPICAL ANTI-MALARIAL DRUGS TO RESPONDENT.
[Last Birth Only]

422A. CHECK 407:
DID YOU SEE ANYONE FOR ANTENATAL CARE DURING THIS PREGNANCY?
[Last Birth Only]

422B. Did you get these drugs during an antenatal visit, another visit to health facility
or from some other source?
[Last Birth Only]

423. When (NAME) was born, was he/she very large, larger than average, average, smaller than
average, or very small?

424. Was (NAME) weighed at birth?

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

426. Who assisted with the delivery of (NAME)?
Anyone else?
IF RELATIVE OR FRIEND, PROBE TO SEE IF BELONGS TO ANOTHER CATEGORY.

427. Where did you give birth to (NAME)?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

428. Was (NAME) delivered by caesarean section?
[Last Birth Only]

429. After (NAME) was born, did a health professional or a traditional birth attendant check on your health?
[Last Birth Only]

430. How many days or weeks after delivery did the first check take place?
RECORD '00' DAYS IF SAME DAY.

431. Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.
[Last Birth Only]

432. Where did this first check take place?
IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
[Last Birth Only]

433. In the first one month after delivery, did you receive a vitamin A dose like this?
SHOW CAPSULE.
[Last Birth Only]

434. Has your period returned since the birth of (NAME)?
[Last Birth Only]

435. Did your period return between the birth of (NAME) and your next pregnancy?
[Exclude Last Birth]

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

437. CHECK 226:
IS RESPONDENT PREGNANT?
[Last Birth Only]

438. Have you resumed sexual relations since the birth of (NAME)?
[Last Birth Only]

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

440. Did you ever breastfeed (NAME)?

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

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

443. What was (NAME) given to drink before your milk began flowing regularly?
Anything else?
RECORD ALL LIQUIDS MENTIONED.

444. CHECK 404
CHILD ALIVE?

445. Are you still breastfeeding (NAME)?

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

447. CHECK 404:
IS CHILD LIVING?

448. How many times did you breastfeed last night between sunset and sunrise?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER

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

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

451. Was sugar added to any of the foods or liquids (NAME) ate yesterday?

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

453. GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 454.

SECTION 4B. IMMUNIZATION, HEALTH AND NUTRITION

454. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 1996 OR LATER. (IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES).

455. LINE NUMBER FROM 212

456. FROM 212 AND 216

458. Do you have an Under 5 Card where (NAME'S) vaccinations are written down?
IF YES: May l see it please?

459. Did you ever have an Under 5 Card for (NAME)?

460. (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.

461. Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in a national immunization day, 'Bye Bye Polio' or in a Child Health Week campaign?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3, AND/OR MEASLES VACCINE(S).

462. Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases, including vaccinations received in a national immunization day, 'Bye Bye Polio' or in a Child Health Week campaign?

463. Please tell me if (NAME) received any of the following vaccinations:

463A. A BCG vaccination against tuberculosis, that is, an injection in the forearm that usually causes a scar?

463B. Polio vaccine, that is, drops in the mouth?

463C. When was the first polio vaccine received, just after birth or later?

463D. How many times was the polio vaccine received?

463E. A DPT vaccination, that is, an injection given in the thigh, sometimes at the same time as polio drops?

463F. How many times?

463G. An injection in the upper arm to prevent measles?

464. Do you remember the most recent 'Bye Bye Polio' or Child Health Week campaign in February (August) this year?

465. Did (NAME) receive a Vitamin A supplement at this event?

465A. How was Vitamin A given?
RECORD ALL MENTIONED.
DO NOT READ RESPONSES TO RESPONDENT.A

465B. Did (NAME) receive any immunizations during this campaign?

465C. Did (NAME) receive:

465D. CHECK 465:

'YES' IN 465: You told me that (NAME) received a Vitamin A capsule. Did this happen in the last six months?

'NO/DON'T KNOW' IN 465 : In the last six months, did (NAME) receive a Vitamin A red or blue capsule?

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

466A. Does (NAME) have a fever now?

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

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

469. CHECK 466 AND 467
FEVER OR COUGH?

470. Did you seek advice or treatment for the fever/cough?

471. Where did you seek advice or treatment?
Anywhere else?
RECORD ALL SOURCES MENTIONED

471A. Has (NAME) been ill with convulsions or fits at any time in the last 2 weeks?

472A. CHECK 466 AND 471A:
HAD FEVER OR CONVULSIONS OR FITS?

473. Did (NAME) take any medicine for the (fever/convulsions/fits)?

474. What drugs did (NAME) take?
RECORD ALL MENTIONED.ASK TO SEE DRUG(S) IF TYPE OF DRUG IS NOT KNOWN. IF TYPE OF DRUG IS STILL NOT DETERMINED, SHOW TYPICAL ANTI-MALARIAL DRUGS TO RESPONDENT.

474A. Did (NAME) get any injection or suppository for the (fever/convulsions/fits)?

474B. CHECK 474:
CHLOROQUINE?

474C. How long after the (fever/convulsions/fits) started did (NAME) first take Chloroquine?

474D. For how many days did (NAME) take the Chloroquine?
IF 7 OR MORE DAYS, RECORD '7'.

474E. Did you have the chloroquine at home or you got it from somewhere else?

474F. CHECK 474:
FANSIDAR?

474G. How long after the (fever/convulsions/fits) started did (NAME) first take Fansidar?

474H. For how many days did (NAME) take Fansidar?
IF 7 OR MORE DAYS, RECORD '7'.

474I. Did you have Fansidar at home or you got it from somewhere else?
IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you get the Fansidar first?

474J. CHECK 474:
QUININE?

474K. How long after the (fever/convulsions/fits) started did (NAME) first take Quinine?

474L. For how many days did (NAME) take Quinine?
IF 7 OR MORE DAYS, RECORD '7'.

474M. Did you have the Quinine at home or you got it from somewhere else?

474N. Was anything else done about (NAME)'s (fever/convulsions/fits)?

474O. What was done about (NAME)'s (fever/convulsions/fits)?

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

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

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

478. Was he/she given a fluid made from a special packet called Madzi-a-Moyo or ORS?

479. Was anything (else) given to treat the diarrhea?

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

481. Did you seek advice or treatment for the diarrhea?

482. Where did you seek advice or treatment?
IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

482A. Has (NAME) received any injection in the past 3 months?

482B. Did you bring your own syringe and needle for this injection or was it provided at the facility?

482C. Had the syringe and needle been used before or was it a new syringe and needle?

482D. Did you keep this needle and syringe after it was used?

483. GO BACK TO 456 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 484.

484. CHECK 456, ALL COLUMNS:
NUMBER OF LIVING CHILDREN BORN IN 1996 OR LATER

486. CHECK 478:

487. Have you ever heard of a special product called Madzi-a-Moyo or ORS you can get for the treatment of diarrhea?

488. When a child is sick with a fever, what signs of illness would tell you that she or he should be taken to a health facility or a health worker?
RECORD ALL MENTIONED.

490. Now I would like to ask you some questions about medical care for you yourself.
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 for you?

491. CHECK 215 AND 218:

492. Now I would like to ask you about liquids (NAME FROM Q.491) drank yesterday. In total, how many times yesterday during the day or at night did (NAME FROM Q.491) drink (ITEM)?
IF 7 OR MORE TIMES, RECORD '7'.\ IF DON'T KNOW, RECORD '8'.

493. Now I would like to ask you about the types of foods (NAME FROM Q.491) ate yesterday.
In total, how many times yesterday during the day or at night did (NAME FROM Q.491) eat (ITEM)?
IF 7 OR MORE TIMES, RECORD '7'. IF DON'T KNOW, RECORD '8'.

494. In your whole life, how many tetanus injections have you received?

496. Do you currently smoke cigarettes or tobacco?
IF YES: What type of tobacco do you smoke?
RECORD ALL TYPES MENTIONED.

497. CHECK 496:

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

499A. Have you ever drunk alcohol?

499B. In the last month, on how many days did you drink alcohol?
IF EVERY DAY: RECORD '30'.

499C. Have you ever gotten 'drunk' from drinking alcohol?

499D. CHECK 499B:

499E. In the last month, on how many occasions did you get 'drunk'?

SECTION 5. MARRIAGE AND SEXUAL ACTIVITY

501. Are you currently married or living with a man?

502. Have you ever been married or lived with a man?

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

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

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

507. Does your husband/partner have any other wives besides yourself?

508. How many other wives does he have?

509. Are you the first, second, ... wife?

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

511. CHECK 510:

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 we will talk about your first husband/partner. In what month and year did you start living with him?

512. How old were you when you started living with him?

514. Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family life issues. How old were you when you first had sexual intercourse (if ever)?

515. When was the last time you had sexual intercourse?
RECORD 'YEARS AGO' ONLY IF LAST INTERCOURSE WAS ONE OR MORE YEARS AGO. IF 12 MONTHS OR MORE, ANSWER MUST BE RECORDED IN YEARS.

516. The last time you had sexual intercourse, was a condom used?
IF YES, PROBE FOR TYPE OF CONDOM USED.

516A. What was the main reason you used a condom on that occasion?

516B. What is the main reason you did not use a condom that time?

517. What is your relationship to the man with whom you last had sex?
IF MAN IS 'BOYFRIEND' OR 'FIANCE', ASK: Was your boyfriend/fiance living with you when you last had sex?
IF YES, CIRCLE '01'. IF NO, CIRCLE '02'.

518. For how long have you had sexual relations with this man?

519. Have you had sex with any other man in the last 12 months?

520. The last time you had sexual intercourse with this other man, was a condom used?

520A. What was the main reason you used a condom on that occasion?

520B. What is the main reason you did not use a condom that time?

521. What is your relationship to this man?
IF MAN IS 'BOYFRIEND' OR 'FIANCE', ASK: Was your boyfriend/fiance living with you when you last had sex with him?
IF YES, CIRCLE '01'. IF NO, CIRCLE '02'.

522. For how long have you had sexual relations with this man?

522A. Other than these two men, have you had sex with any other man in the last 12 months?

522B. The last time you had sex with this other man, was a condom used?

522C. What was the main reason you used a condom on that occasion?

522D. What is the main reason you did not use a condom that time?

522E. What is your relationship to this man?
IF MAN IS 'BOYFRIEND' OR 'FIANCE', ASK: Was your boyfriend/fiance living with you when you last had sex with him?
IF YES, CIRCLE '01'. IF NO, CIRCLE '02'.

522F. For how long have you had sexual relations with this man?

523. In total, with how many different men have you had sex in the last 12 months?

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

525. Where is that? Any other place?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
RECORD ALL SOURCES MENTIONED.

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

526A. Why not?

526B. Do you think you could ask your partner to use a condom?

527. CHECK 301(08):
EVER HEARD OF FEMALE CONDOM

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

529. Where is that? Any other place?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. RECORD ALL SOURCES MENTIONED.

530. Which brand of female condom have you heard of?
RECORD ALL MENTIONED.
ASK Q.531 IF 'CARE' IS MENTIONED.

531. Where have you seen or heard messages about CARE female condom?

SECTION 6. FERTILITY PREFERENCES

601. CHECK 311/311A:

602. CHECK 226:

NOT PREGNANT OR UNSURE: 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?

PREGNANT: 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?

603. 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?

604. CHECK 226:

605. CHECK 310:
USING A CONTRACEPTIVE METHOD?

606. CHECK 603:

607. CHECK 602:

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

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

RECORD ALL REASONS MENTIONED.

608. In the next few weeks, if you discovered that you were pregnant, would that be a big problem, a small problem, or no problem for you?

609. CHECK 310:
USING A CONTRACEPTIVE METHOD?

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

611. Which contraceptive method would you prefer to use?

612. What is the main reason that you think you will not use a contraceptive method at any time in the future?

613. Would you ever use a contraceptive method if you were married?

614. 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.

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

616. Would you say that you approve or disapprove of couples using a contraceptive method to avoid getting pregnant?

617. In the last few months, have you discussed the practice of family planning with your friends, neighbors, or relatives?

618. With whom?
Anyone else?
RECORD ALL PERSONS MENTIONED.

619. CHECK 501:

620. CHECK 311/311A:

621. You have told me that you are currently using contraception. Would you say that using contraception is mainly your decision, mainly your husband's/partner's decision or did you both decide together?

622. Now I want to ask you about your husband's/partner's views on family planning. Do you think that your husband/partner approves or disapproves of couples using a contraceptive method to avoid pregnancy?

623. How often have you talked to your husband/partner about family planning in the past year?

625. Do you think your husband/partner wants the same number of children that you want, or does he want more or fewer than you want?

626. In the last few months have you heard about family planning:

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

626A. Have you ever heard of an oral contraception pill called Safeplan?

627. In the last six months, have you listened to the following programs on the radio?

Your health matters?
Lifeline?
AIDS and the family?
Our neighborhood?

628. In the last six months, have you seen any of the following programs on television?

Your health matters?
Lifeline?
Soul city?
X-plosion?

629. Have you ever seen a newspaper called 'Trendsetters' aimed at young people?

630. Is there a Neighborhood Health Committee (NHC) in your neighborhood?

631. Have you ever attended a meeting organized by the NHC?

632. Husbands and wives do not always agree on everything. Please tell me if you think a wife is justified in refusing to have sex with her husband when:

She knows her husband has a sexually transmitted disease?
She knows her husband has sex with other women?
She has recently given birth?
She is tired or not in the mood?

SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK

701. CHECK 501 AND 502:

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

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

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

705. What was the highest grade he completed at that level?

706. CHECK 701:

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 it, what kind of work did he mainly do?

707. Aside from your own housework, are you currently working?

708. 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. Are you currently doing any of these things or any other work?

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

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

711. CHECK 710:

712. Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else's land?

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

714. Do you usually work at home or away from home?

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

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

717. Who mainly decides how the money you earn will be used?

718. On average, how much of your household's expenditures do your earnings pay for: almost none, less than half, about half, more than half, or all?

719. Who in your family usually has the final say on the following decisions:

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

720A. CHECK 720 FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL RESPONDENT IS ALONE.

720B. CHECK 501 AND 502:

720C. CHECK 720B:

CURRENTLY MARRIED/LIVING WITH A MAN: Has your husband/partner ever slapped you, hit you, kicked you, thrown things at you, or done anything else to physically hurt you?

FORMERLY MARRIED/LIVED WITH A MAN: Has you last husband/partner ever slapped you, hit you, kicked you, thrown things at your, or done anything else to physically hurt you?

720D. In the last 12 months, how many times did this happen?

720E. CHECK 701:

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

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

720EX. Who did this to you?
RECORD ALL MENTIONED.

720F. In the last 12 months, how many times did this happen?

720G. Have you ever been forced by a man to have sexual intercourse with him when you did not want to?

720H. Who did this to you?
RECORD ALL MENTIONED.
Anyone else?

720I. In the last 12 months, how many times did this happen?

720J. Has anyone ever made you have sexual intercourse with some other person when you did not want to?

720K. Who was the person that made you have sexual intercourse with some other person?
RECORD ALL MENTIONED.
Anyone else?

720L. In the last 12 months, how many times did this happen?

721. Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

If she goes out with another man?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she cooks bad food or food is late?

SECTION 8. AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES

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

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

803. What can a person do?
Anything else?
RECORD ALL WAYS MENTIONED.

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

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

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

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

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

810. Do you know someone personally who has the virus that causes AIDS or someone who died of AIDS?

811. Can the virus that causes AIDS be transmitted from a mother to a child?

812. Can the virus that causes AIDS be transmitted from a mother to a child:

During pregnancy?
During delivery?
By breastfeeding?

812A. Is there anything that can be done to reduce the chances that a mother would transmit the AIDS virus to her child?

813. CHECK 501:

814. Have you ever talked with (your husband/the man you are living with) about ways to prevent getting the virus that causes AIDS?

814A. In your opinion, is it acceptable or unacceptable for condoms to be discussed:

on the radio?
on the TV?
in newspapers?

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

816. If a relative of yours became sick with the virus that causes AIDS, would you be willing to care for her or him in your own household?

816A. If a worker is sick with AIDS, should he/she be allowed to work?

816B. If you knew that a shopkeeper or food seller has the AIDS virus, would you buy food items from them?

816C. In the last six months, have you seen any adverts about sexual abstinence, condom use or HIV/AIDS?

816D. Can you describe which ones?
DO NOT READ RESPONSES TO RESPONDENT.
RECORD ALL MENTIONED.

816E. Should youth age 12-14 be taught about using a condom to avoid AIDS?

816F. Do you think your chances of getting AIDS are small, moderate, great, or do you think that you have no chance of getting it at all?

816G. Why do you think your chances of getting AIDS are low?
RECORD ALL MENTIONED.

816H. Have you ever been tested to see if you have the AIDS virus?

816I. Would you want to be tested for the AIDS virus?

816J. Do you know a place where you could go to get an AIDS test?

816K. Where can you go for the test?
RECORD ONLY FIRST RESPONSE GIVEN.
816KX. Where did you go for the test?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

817. (Apart from AIDS), have you heard about other infections that can be transmitted through sexual contact?

818. If a man has a sexually transmitted disease, what symptoms might he have?
Any others?
RECORD ALL SYMPTOMS MENTIONED.

819. If a woman has a sexually transmitted disease, what symptoms might she have?
Any others?
RECORD ALL SYMPTOMS MENTIONED.

819A. CHECK 514:

819B. 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 sexually-transmitted disease?

819C. Sometimes, women experience a heavy or bad smelling genital discharge.
During the last 12 months, have you had a heavy or bad smelling genital discharge?

819D. Sometimes women have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?

819E. CHECK 819B, 819C, 819D:

819F. The last time you had (PROBLEM FROM 819B/819C/819D), did you seek any kind of advice or treatment?

819G. The last time you had (PROBLEM FROM 819B/819C/819D), did you do any of the following? Did you....

Go to a clinic, hospital or private doctor?
Consult a traditional healer?
Seek advice or buy medicines in a shop or pharmacy?
Ask for advice from friends or relatives?

819H. When you had (PROBLEM FROM 819B/819C/819D), did you inform the person with whom you were having sex?

819I. When you had (PROBLEM FROM 819B/819C/819D), did you do something to avoid infecting your sexual partner(s)?

819J. What did you do to avoid infecting your partner(s)? Did you....

Use medicine?
Stop having sex?
Use a condom when having sex?

SECTION 9. MATERNAL MORTALITY

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

902. CHECK 901:

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

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

905. Is (NAME) male or female?

906. Is (NAME) still alive?

907. How old is (NAME)?

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

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

910. Was (NAME) pregnant when she died?

911. Did (NAME) die during childbirth?

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

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

IF NO MORE BROTHERS OR SISTERS, GO TO 914.

914. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:
__________________________________

COMMENTS ON SPECIFIC QUESTIONS:
_______________________________

ANY OTHER COMMENTS:
_______________________________

SUPERVISOR'S OBSERVATIONS
_______________________________

NAME OF THE SUPERVISOR:__________ DATE:____________________

EDITOR'S OBSERVATIONS
_______________________________

NAME OF EDITOR:________________________DATE:_____________________