Data Cart

Your data extract

0 variables
0 samples
View Cart


2013 ZAMBIA DEMOGRAPHIC AND HEALTH SURVEY MAN'S QUESTIONNAIRE WITH HIV/AIDS

Ministry of Health/Central Statistical Office

May 2013

IDENTIFICATION

LOCALITY NAME________
NAME OF HOUSEHOLD HEAD___________
CLUSTER NUMBER __ __ __
PROVINCE__ __

RURAL/URBAN

RURAL 1
URBAN 2

LOCALITY

LUSAKA 1
OTHER CITY 2
TOWN 3
VILLAGE 4

NAME AND LINE NUMBER OF MAN:
NAME_______
LINE 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 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)___________

LANGUAGE OF QUESTIONNAIRE

01 ENGLISH
02 BEMBA
03 KAONDE
04 LOZI
05 LUNDA
06 LUVALE
07 NYANJA
08 TONGA
09 OTHER

LANGUAGE OF INTERVIEW:

01 ENGLISH
02 BEMBA
03 KAONDE
04 LOZI
05 LUNDA
06 LUVALE
07 NYANJA
08 TONGA
09 OTHER

NATIVE LANGUAGE OF RESPONDENT

01 ENGLISH
02 BEMBA
03 KAONDE
04 LOZI
05 LUNDA
06 LUVALE
07 NYANJA
08 TONGA
09 OTHER

TRANSLATOR USED:

YES 1
NO 2

SUPERVISOR
NAME_______
DATE__ __ __

FIELD EDITOR
NAME_______
DATE__ __ __

OFFICER EDITOR____
KEYED BY____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

Hello. My name is__________. I am working with the Ministry of Health in collaboration with Central Statistical Office (CSO). We are conducting a survey about health all over Zambia. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 20 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 questions 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 give to your household.
Do you have any questions?

SIGNATURE OF INTERVIEWER:__________
DATE:__________

May I begin the interview now?

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

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, secondary, or higher?

PRIMARY 1
SECONDARY 2
HIGHER 3

106. What is the highest grade you completed at that level?

GRADE____

107. CHECK 105:

PRIMARY (GO TO 108)
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 (GO TO 110)
CODE '1' OR '5' (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 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
OTHER (SPECIFY)___________6

114. What tribe do you belong to?

TRIBE_____________

114A.
How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?

IF LESS THAN ONE YEAR, RECORD '00' YEARS

YEARS__________
ALWAYS 95 (GO TO 115)
VISITOR 96 (GO TO 115)

114B Just before you moved here, did you live in Lusaka, another city, in a town, or in a village?

LUSAKA 1
OTHER CITY 2
TOWN 3
VILLAGE 4

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

NUMBER OF TRIPS __ __
NONE (GO TO 201)

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

YES 1
NO 2

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?

YES 1
NO 2 (GO TO 206)
DON'T KNOW 8 (GO TO 206)

202. Do you have any sons or daughters that you have fathered 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 that you have fathered 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 fathered a son or a daughter 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)
DON'T KNOW 8 (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 CHILDREN_________

209. CHECK 208:

HAS HAD MORE THAN ONE CHILD (GO TO 210)
HAS HAD ONLY ONE CHILD (GO TO 212)
HAS NOT HAD ANY CHILDREN (GO TO 301)

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

YES 1 (GO TO 212)
NO 2

211. In all, how many women have you fathered children with?

NUMBER OF WOMEN_______

212. How old were you when your (first) child was born?

AGE IN YEARS_______

213. CHECK 203 AND 205:

AT LEAST ONE LIVING CHILD (GO TO 214)
NO LIVING CHILDREN (GO TO 301)

214. How old is your (youngest) child?

AGE IN YEARS_______

215. CHECK 214:

(YOUNGEST) CHILD IS AGE 0-2 YEARS (GO TO 216)
OTHER (GO TO 301)

216. What is the name of your (youngest) child?

(NAME OF (YOUNGEST) CHILD)______________

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

YES 1
NO 2 (GO TO 219)
DON'T KNOW 8 (GO TO 219)

218. Were you ever present during any of those antenatal check-ups?

PRESENT 1
NOT PRESENT 2

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

HOSPITAL/HEALTH FACILITY 1 (GO TO 220)
DON'T KNOW 6 (GO TO 220)
OTHER 8

219A. Why didn't (NAME)'s mother deliver in a health facility?
PROBE: Any other reason?

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

220. When a child has diarrhoea, how much should he or she be given to drink: more than usual, the same amount as usual, less than usual, or should he or she not be given anything to drink at all?

MORE THAN USUAL 1
ABOUT THE SAME 2
LESS THAN USUAL 3
NOTHING TO DRINK 4
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 coli placed inside them by a doctor or 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 being pregnant.
YES 1
NO 2
07) MALE 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) STANDARD DAYS METHOD (CYCLE BEADS): A women uses string of colored beads to know the days she can get pregnant. On the days she can get pregnant, she uses a condom or does not have sexual intercourse.
YES 1
NO 2
10) LACTATIONAL AMENORRHEA METHOD (LAM).
YES 1
NO 2
11) RHYTHM METHOD. PROBE: Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
12) WITHDRAWAl. PROBE: Men can be careful and pull out before climax.
YES 1
NO 2
13. EMERGENCY CONTRACEPTION. PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
YES 1
NO 2
14. Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES (SPECIFY)_____________________1
NO 2

302. In the last few months have you:

Heard about family planning on the radio?
Seen anything about family planning on the television?
Read about family planning in a newspaper or magazine?

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

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

YES 1
NO 2

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 women is more likely to become pregnant if she has sexual relations?

YES 1
NO 2 (GO TO 305A)
DON'T KNOW 8 (GO TO 305A)

305. 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

305A. Do you think that a woman who is breastfeeding her baby can become pregnant?

YES 1
NO 2
DON'T KNOW 8

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

a) Contraception is women's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous

CONTRACEPTION WOMAN'S BUSINESS
AGREE 1
DISAGREE 2
DON'T KNOW 8
WOMAN MAY BECOME PROMISCUOUS
AGREE 1
DISAGREE 2
DON'T KNOW 8

307. CHECK 301 (07) KNOWS MALE CONDOM

YES 1 (GO TO 308)
NO (GO TO 311)

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

YES 1
NO 2 ( GO TO 311)

309. Where is that? Any other place?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE
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/POST B
MOBILE HOSPITAL/CLINIC C
FAMILY PLANNING CLINIC D
COMMUNITY BASED AGENT/FIELDWORKER E
OTHER PUBLIC SECTOR (SPECIFY)___________F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
MISSION HOSPITAL/CLINIC H
PHARMACY I
PRIVATE DOCTOR J
COMMUNITY BASED AGENT/FIELDWORKER K
MOBILE HOSPITAL/CLINIC L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)________M
OTHER SOURCE
SHOP N
CHURCH O
FRIENDS/RELATIVES P
OTHER (SPECIFY)____________X

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

YES 1
NO 2

311. CHECK 301 (08) KNOWS FEMALE CONDOM

YES 1 (GO TO 312)
NO 2 (GO TO 401)

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

YES 1
NO 2 (GO TO 401)

313. Where is that? Any other place?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE
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/POST B
MOBILE HOSPITAL/CLINIC C
FAMILY PLANNING CLINIC D
COMMUNITY BASED AGENT/FIELDWORKER E
OTHER PUBLIC SECTOR (SPECIFY)___________F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
MISSION HOSPITAL/CLINIC H
PHARMACY I
PRIVATE DOCTOR J
COMMUNITY BASED AGENT/FIELDWORKER K
MOBILE HOSPITAL/CLINIC L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)________M
OTHER SOURCE
SHOP N
CHURCH O
FRIENDS/RELATIVES P
OTHER (SPECIFY)____________X

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

YES 1
NO 2

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401. Are you currently married or living together with a woman if married?

YES, CURRENTLY MARRIED 1 (GO TO 404)
YES, LIVING WITH A WOMAN 2 (GO TO 404)
NO, NOT IN UNION 3

402. Have you ever been married or lived together with a woman as if married?

YES, FORMERLY MARRIED 1
YES, LIVED WITH A WOMAN 2
NO 3 (GO TO 413)

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

WIDOWED 1 (GO TO 410)
DIVORCED 2 (GO TO 410)
SEPARATED 3 (GO TO 410)

404. Is your wife/partner living with you now or is she staying elsewhere?

LIVING WITH HIM 1
STAYING ELSEWHERE 2

405. Do you have more than one wife or woman you live with as if married?

YES 1
NO 2 (GO TO 407)

406. Altogether, how many wives do you have or other partners do you live with as if married?

TOTAL NUMBER OF WIVES AND LIVE-IN PARTNERS __ __

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 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.'

ASK 408 FOR EACH PERSON.

NAME___________
LINE NUMBER_________

408. How old was (NAME) on her last birthday?

AGE __ __

409. CHECK 407:

ONE WIFE/PARTNER (GO TO 410)
MORE THAN ONE WIFE/PARTNER (GO TO 411A)

410. Have you been married or lived with a woman only once or more than once?

ONLY ONCE 1
MORE THAN ONCE 2 (GO TO 411A)

411. In what month and year did you start living with your wife/partner?
411A. Now I would like to ask a question about your first wife/partner. In what month and year did you start living with your first wife/partner?

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

412. How old were you when you first started living with her?

AGE __ __

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

Now I would like to ask you some questions about sexual activity in order to gain a better understanding of some family life issue.

414. How old were you when you had sexual intercourse for the very first time?

NEVER HAD SEXUAL INTERCOURSE 00
AGE IN YEAR __ __ (GO TO 414C)
FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE/PARTNER 95 (GO TO 414C)

414A. CHECK 103:

15-24 YEARS OLD (GO TO 414B)
25-59 YEARS OLD (GO TO 501)

414B. Do you intend to wait until you get married to have sexual intercourse for the first time?

YES 1 (GO TO 501)
NO 2 (GO TO 501)
DON'T KNOW/UNSURE 8 (GO TO 501)

414C. CHECK 103:

15-24 YEARS OLD (GO TO 414D)
25-59 YEARS OLD (GO TO 415)

414D. The first time you had sexual intercourse, was a female or male condom used?

YES 1
NO 2
DON'T KNOW/DON'T REMEMBER 8

415. 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.

416. 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 __ __
YEARS AGO 4 __ __ (GO TO 430)

Refer to Last Sexual Partner through Third-to-Last Sexual Partner for Questions 417 to 427.

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

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

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

YES 1
NO 2 (SKIP TO 420)

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

YES 1
NO 2

420. What was your relationship to this person with whom you had sexual intercourse?

IF GIRLFRIEND: Were you living together as if married?
IF YES, CIRCLE '02'.
IF NO, CIRCLE '03'

WIFE 1
LIVE-IN PARTNER 2
LINE NUMBER OF WIFE/PARTNER __ __
GIRLFRIEND NOT LIVING WITH RESPONDENT 3 (GO TO 423)
CASUAL ACQUAINTANCE 4 (GO TO 423)
SEX WORKER 5 (GO TO 423)
OTHER (SPECIFY)___________ 6 (GO TO 423)

421. CHECK 410:

MARRIED ONLY ONCE (GO TO 422)
MARRIED MORE THAN ONCE OR BLANK (SKIP TO 423)

422. CHECK 414:

FIRST TIME WHEN STARTED LIVING WITH FIRST WIFE (SKIP 423A)
OTHER (GO TO 423)

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

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

423A. The last time you had sexual intercourse with this (second/third) person did you or this person drink alcohol?

YES 1
NO 2 (SKIP TO 424)

423B. Were you or your partner drunk at that time?
IF YES: Who was drunk?

RESPONDENT ONLY 1
PARTNER ONLY 2
RESPONDENT AND PARTNER BOTH 3
NEITHER 4

424. 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 __ __

425. How old is this person?

AGE OF PARTNER __ __
DON'T KNOW 98

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

YES 1 (GO BACK TO 417 IN NEXT COLUMN)
NO 2 (SKIP TO 428)

427. 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, WRITE '95'.

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

428. CHECK 420 (ALL COLUMNS):

AT LEAST ONE PARTNER IS A SEX WORKER (GO TO 429)
NO PARTNERS ARE SEX WORKERS (GO TO 430)

429. CHECK 420 AND 418 (ALL COLUMNS):

CONDOM USED WITH EVERY SEX WORKER (GO TO 433)
OTHER (434)

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

YES 1 (GO TO 432)
NO 2

431. Have you ever paid anyone in exchange for having sexual intercourse?

YES 1 (GO TO 434)
NO 2 (GO TO 434)

432. The last time you paid you someone in exchange for having sexual intercourse, was a female or male condom used?

YES 1
NO 2 (GO TO 434)

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

YES 1
NO 2
DON'T KNOW 8

434. In total, with you 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

435. CHECK 418, MOST RECENT PARTNER (FIRST COLUMN):

CONDOM USED (GO TO 436)
NOT ASKED (GO 438)
NO CONDOM USED (GO TO 438)

436. You told me that a condom was used the last time you had sex. What brand name of the female or male condoms did you use?

ASK TO SEE THE PACKAGE IF RESPONDENT DOES NOT REMEMBER NAME OF BRAND.

MAXIMUM CLASSIC 01
MAXIMUM SCENTED 02
ROUGH RIDER 03
DUREX 04
CARE FEMALE CONDOM 05
FEMIDOM 06
REALITY 07
PUBLIC SECTOR: UNBRANDED (WHITE COLOUR FOIL) 08
OTHER (SPECIFY)___________96
DON'T KNOW 98

437. From where did you obtain the female or male condom the last time?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____________________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER/POST 12
MOBILE HOSPITAL/CLINIC 13
FAMILY PLANNING CLINIC 14
COMMUNITY BASED AGENT/FIELD WORKER 15
OTHER PUBLIC SECTOR (SPECIFY)____________16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
MISSION HOSPITAL/CLINIC 22
PHARMACY 23
PRIVATE DOCTOR 24
COMMUNITY BASED AGENT/FIELDWORKER 25
MOBILE HOSPITAL/CLINIC 26
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)_____________27
OTHER SOURCE
SHOP 31
CHURCH 32
FRIENDS/RELATIVES 33
OTHER (SPECIFY)________________ 96

438. The last time you had sex did you or your partners use any method (other than a condom) to avoid or prevent a pregnancy?

YES 1
NO 2 (GO TO 501)
DON'T KNOW 8 (GO TO 501)

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

FEMALE STERILIZATION A
MALE STERILIZATION B
IUD C
INJECTABLES D
IMPLANTS E
PILL F
CONDOM G
FEMALE CONDOM H
DIAPHRAGM I
FOAM/JELLY J
STANDARD DAYS K
LAM L
RHYTHM METHOD M
WITHDRAWAL N
OTHER MODERN METHOD X
OTHER TRADITIONAL METHOD Y

SECTION 5. FERTILITY PREFERENCES:

501. CHECK 401:

CURRENTLY MARRIED OR LIVING WITH A PARTNER (GO TO 502)
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 509)

502. CHECK 439:

MAN NOT STERILIZED (GO TO 503)
MAN STERILIZED (GO TO 509)

503: (Is your wife (partner)/are any of your wives (partners)) currently pregnant?

YES 1
NO 2 (GO TO 505)
DON'T KNOW (GO TO 505)

504. Now I have some questions about the future. After the (child/children) you and your (wife(wives)/partner(s)) 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 506)
NO MORE 2 (GO TO 509)
UNDECIDED/DON'T KNOW 8 (GO TO 509)

505. 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 509)
SAYS COUPLE CAN'T PREGNANT 3 (GO TO 509)
WIFE (WIVES)/PARTNER(S) STERILIZED 4 (GO TO 509)
UNDECIDED/DON'T KNOW 8 (GO TO 509)

506. CHECK 407:

ONE WIFE/PARTNER (GO TO 507)
MORE THAN ONE WIFE/PARTNER (GO TO 508)

507. CHECK 503:

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

WIFE/PARTNER 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 __ __ (GO TO 509)
YEARS 2 __ __ (GO TO 509)
SOON/NOW 993 (GO TO 509)
COUPLE/INFECUND 994 (GO TO 509)
OTHER (SPECIFY)____________996 (GO TO 509)
DON'T KNOW 998 (GO TO 509)

508. How long would you wait from now before the birth of (a/another) child?

MONTHS 1 __ __
YEARS 2 __ __
SOON/NOW 993
HE/ALL HIS WIVES/PARTNERS ARE INFECUND 994
OTHER (SPECIFY)____________996
DON'T KNOW 998

509. 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 child 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 601)
NUMBER __ __
OTHER (SPECIFY)_______________ (GO TO 601)

510. How many of these children would 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 girl?

BOYS NUMBER__ __
GIRLS NUMBER__ __
EITHER NUMBER__ __
OTHER (SPECIFY)_________________ 96

SECTION 6. EMPLOYMENT AND GENDER ROLES

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

YES 1 (GO TO 604)
NO 2

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

YES 1 (GO TO 604)
NO 2

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

YES 1
NO 2 (GO TO 607)

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

________________________________________________

605. 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

606. 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

607. CHECK 401:

CURRENTLY MARRIED OR LIVING WITH A PARTNER (GO TO 608)
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 612)

608. CHECK 606:

CODE 1 OR 2 CIRCLED (GO TO 609)
OTHER (GO TO 610)

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

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
OTHER (SPECIFY)_________________ 6

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

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_______________ 6

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

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_____________6

611A. Who usually makes decisions about making purchases for daily household needs?

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_____________6

611B. Who usually makes decisions about visits to your family or relatives?

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_____________6

612. 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

613. Do you own this land either alone or jointly with someone else?

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

614. 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 7. HIV/AIDS

Now I would like to talk about something else

701.. Have you ever heard of an illness called AIDS?

YES 1
NO 2 (GO TO 723)

702. Can people reduce their chances 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

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

YES 1
NO 2
DON'T KNOW 8

704. 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

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

YES 1
NO 2
DON'T KNOW 8

705A. Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

707A. Do you think your risk of getting infected with HIV is low, medium or high, or do you have no risk at all?

LOW 1
MEDIUM 2
HIGH 3
NO RISK 4
OTHER 6
DON'T KNOW 8

708. 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

709. CHECK 708:

AT LEAST ONE 'YES' (GO TO 710)
OTHER (GO TO 710A)

710. 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

710A. Have you heard about the antiretroviral drugs (ARVs) that people infected with the AIDS virus can get from a doctor or a nurse to help them live longer?

YES 1
NO 2 (GO TO 711)
DON'T KNOW 8 (GO TO 711)

710B. Do you know anyone on antiretroviral (ART) treatment?

YES 1
NO 2
DON'T KNOW 8

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 to see if you have the AIDS virus?

YES 1
NO 2 (GO TO 716)

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

MONTHS AGO __ __
TWO OR MORE YEARS 95

713A. For your most recent test, did you yourself ask for the test, was it offered to you and you accepted, or was it required?

ASKED FOR THE TEST 1
OFFERED AND ACCEPTED 2
REQUIRED 3

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

YES 1
NO 2

715. Where was the test done?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

NAME OF PLACE___________________________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER/POST 12
STAND-ALONE VCT CENTRE 13
FAMILY PLANNING CLINIC 14
MOBILE HOSPITAL/CLINIC 15
COMMUNITY BASED AGENT/FIELDWORKER 16
OTHER PUBLIC SECTOR (SPECIFY)_________________17
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR 21 (GO TO 718)
MISSION HOSPITAL/CLINIC 22
STAND-ALONE VCT CENTRE 23
MOBILE HOSPITAL/CLINIC 24
COMMUNITY BASED AGENT/FIELDWORKER 25
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)___________________ 26
OTHER SOURCE
PRISON 31
OTHER (SPECIFY)__________________96

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

YES 1
NO 2 (GO TO 718)

717. Where is that? Any other place?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

NAME OF PLACE_______________________
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER/POST B
STAND-ALONE VCT CENTRE C
FAMILY PLANNING CLINIC D
MOBILE HOSPITAL/CLINIC E
COMMUNITY BASED AGENT/FIELDWORKER F
OTHER PUBLIC SECTOR (SPECIFY)_________________G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR H
MISSION HOSPITAL/CLINIC I
STAND-ALONE VCT CENTRE J
MOBILE HOSPITAL/CLINIC K
COMMUNITY BASED AGENT/FIELDWORKER L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)___________________ M
OTHER SOURCE
PRISON N
OTHER (SPECIFY)__________________X

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

YES 1
NO 2
DON'T KNOW 8

719. 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

720. 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

721. 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

721A. Do you personally know someone who has or is suspected to have the AIDS virus?

YES 1
NO 2

721B. Do you agree or disagree with the following statement: People with the AIDS virus should be blamed for bringing the disease into the community.

AGREE 1
DISAGREE 2
DON'T KNOW 8

722. Should children age 12-14 be taught about using a condom to avoid getting the AIDS virus?

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

722A. Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid getting AIDS virus?

YES 1
NO 2
DON'T KNOW 8

722B. Some individuals would choose not to go for HIV testing. Why in your opinion is this so?
(CIRCLE ALL THAT ARE MENTIONED)
(MORE THAN ONE ANSWER POSSIBLE)

FEEL THEY ARE NOT AT RISK A
FEAR OF RESULTS B
FEAR OF STIGMA/DISCRIMINATION C
DON'T KNOW WHERE TO GO D
OTHER (SPECIFY) X

723. CHECK 701:

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

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

YES 1
NO 2

724. CHECK 414:

HAS HAD SEXUAL INTERCOURSE (GO TO 725)
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 732)

725. CHECK 723: HEARD ABOUT OTHER SEXUAL TRANSMITTED INFECTIONS?

YES (GO TO 726)
NO (GO TO 727)

Now I would like to ask you some questions about your health in the last 12 months.

726. During the last 12 months, have you had a disease which you got through sexual contact?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

729. CHECK 726, 727, AND 728:

HAS HAD AN INFECTION (ANY 'YES') (GO TO 729)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 732)

730. The last time you had (PROBLEM FROM 726/727/728), did you seek any kind of advice or treatment?

YES 1
NO (GO TO 732)

731. Where did you go? Any other place?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

NAME OF PLACE(S)____________
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER/POST B
STAND-ALONE VCT CENTRE C
FAMILY PLANNING CLINIC D
MOBILE HOSPITAL/CLINIC E
COMMUNITY BASED AGENT/FIELDWORKER F
OTHER PUBLIC SECTOR (SPECIFY)_________________G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR H
MISSION HOSPITAL/CLINIC I
STAND-ALONE VCT CENTRE J
MOBILE HOSPITAL/CLINIC K
COMMUNITY BASED AGENT/FIELDWORKER L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)___________________ M
OTHER SOURCE
SHOP N
OTHER (SPECIFY)__________________X

732. 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

732A. Husband and wives do not always agree in everything. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?

YES 1
NO 2
DON'T KNOW 8

733. Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women other than his wife/wives?

YES 1
NO 2
DON'T KNOW 8

733A. Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?

YES 1
NO 2
DON'T KNOW 8

SECTION 8. OTHER HEALTH ISSUES:

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

YES 1
NO 2 (GO TO 805)
DON'T KNOW (GO TO 805)

802. How old were you when you got circumcised?

AGE CIRCUMCISED __ __
DURING CHILDHOOD (LESS THAN 5 YEARS) 95
DON'T KNOW 98

802A. Why were you circumcised?

TRADITIONAL CUSTOM A
TREATMENT FOR DISEASE B
HYGIENE C
PREVENTION FROM A DISEASE D
INCREASE SEXUAL PLEASURE E
OTHER (SPECIFY)_______________X
DON'T KNOW Z

803. Who performed your circumcision?

HEALTH PROFESSIONAL
DOCTOR 11
TRAINED NURSE/MIDWIFE 12
OTHER HEALTH PROFESSIONAL (SPECIFY)_____________16
TRADITIONAL
TRADITIONAL CIRCUMCISOR 21
OTHER TRADITIONAL (SPECIFY)___________26
OTHER 36

804. Where was it performed?

HEALTH FACILITY 1
HOME OF A HEALTH WORKER/PROFESSIONAL 2
CIRCUMCISION DONE AT HOME 3
RITUAL SITE 4
OTHER HOME/PLACE 5
OTHER 6
DON'T KNOW 8

805. 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 808)

806. Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?

IF NUMBER OF INJECTIONS IS 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 808)

806A. The last time you had an injection give to you by a trained health worker where did you go to get the injection?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

NAME OF PLACE________________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER/POST 12
MOBILE HOSPITAL/CLINIC 13
OTHER PUBLIC SECTOR (SPECIFY)______________16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR 21
MISSION HOSPITAL/CLINIC 22
DENTAL CLINIC/OFFICE 23
MOBILE HOSPITAL/CLINIC 24
PHARMACY 25
OFFICE OR HOME OF NURSE/HEALTH WORKER 26
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)_____________ 27
OTHER SOURCE
AT HOME 31
OTHER (SPECIFY)_________________ 96

807. 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

808. Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 810)

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

NUMBER OF CIGARETTES __ __

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

YES 1
NO 2 (GO TO 811A)

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

PIPE A
CHEWING TOBACCO B
SNUFF C
OTHER (SPECIFY)____________X

811A. Do you drink alcohol?

YES 1
NO 2 (GO TO 811C)

811B. In the last one week how many days did you drink alcohol?

NUMBER OF DAYS __ __

811C. Have you ever heard of an illness called tuberculosis or TB?

YES 1
NO 2 (GO TO 812)

811D. How does tuberculosis spread from one person to another?

PROBE: Any other ways?

RECORD ALL MENTIONED.

THROUGH THE AIR WHEN COUGHING OR SNEEZING A
THROUGH SHARING UTENSILS B
THROUGH TOUCHING A PERSON WITH TB C
THROUGH FOOD D
THROUGH SEXUAL CONTACT E
THROUGH MOSQUITO BITES F
OTHER (SPECIFY)______________X
DON'T KNOW Z

811E. Can tuberculosis be cured?

YES 1
NO 2
DON'T KNOW 8

811F. If a member of your family got tuberculosis, would you want it to remain a secret or not?

YES, REMAIN A SECRET 1
NO 2
DON'T KNOW 8

811G. If a member of your family got tuberculosis, would you care for them?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

812. Are you covered by any health (insurance/scheme)?

YES 1
NO 2 (GO TO 813A)

813. What type of health (insurance/scheme)?

RECORD ALL MENTIONED.

MUTUAL HEALTH ORGANIZATION/COMMUNITY BASED HEALTH INSURANCE A
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
LOW COST PRE-PAYMENT SCHEME/STANDARD E
HIGH COST PRE-PAYMENT SCHEME/PREMIUM F
OTHER (SPECIFY)_____________X

813A. CHECK 214:

(YOUNGEST) CHILD IS AGE 0-17 (GO TO 813B)
OTHER (GO TO 813C)

813B. Now I would like to ask you about your own child(ren) who (is/are) under the age of 18
Have you made arrangements for someone to care for (him/her/them) in the event that you fall sick or are unable to care for (him/her/them)?

YES 1
NO 2
UNSURE 8

813C. (Besides your own child/children), are you the primary caregiver for any children under the age of 18?

YES 1
NO (GO TO 901)

813D. Have you made any arrangements for someone to care for (this child/these children) in the event that you fall sick or unable to care for (him/her/them)?

YES 1
NO 2
UNSURE 8

SECTION 9. MATERNAL MORTALITY

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.

901. How many children did your mother give birth to, including you?

NUMBER OF BIRTHS TO NATURAL MOTHER __ __

902. CHECK 901:

TWO OR MORE BIRTHS (GO TO 903)
ONLY ONE BIRTH (RESPONDENT ONLY) (GO TO 914)

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

NUMBER OF PRECEDING BIRTHS __ __

QUESTIONS 904 THROUGH 913 USE FOR BROTHER OR SISTER 1-14:

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

_____________

905. Is (NAME) male or female?

MALE 1
FEMALE 2

906. Is (NAME) still alive?

YES 1
NO 2 (GO TO 908)
DON'T KNOW 8 (GO TO (NEXT SIBLING))

907. How old is (NAME)?

__ __ (GO TO (NEXT SIBLING))

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

__ __

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

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

__ __

910. Was (NAME) pregnant when she died?

YES 1 (GO TO 913)
NO 2

911. Did (NAME) die during childbirth?

YES 1 (GO TO 913)
NO 2

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

YES 1
NO 2

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

__ __

914. RECORD THE TIME.

HOURS __ __
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: ________________