CENTRAL STATISTICAL OFFICE

IDENTIFICATION

PROVINCE

DISTRICT

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD NUMBER

NAME AND LINE NUMBER OF MAN

INTERVIEWER VISITS

FIRST VISIT

DATE
INTERVIEWER NAME
RESULT

NEXT VISIT:
DATE
TIME

SECOND VISIT

DATE
INTERVIEWER NAME
RESULT

NEXT VISIT:
DATE
TIME

THIRD VISIT

DATE
INTERVIEWER NAME
RESULT

NEXT VISIT:
DATE
TIME

FINAL VISIT

DAY
MONTH
YEAR
ID NUMBER
RESULT

TOTAL NUMBER OF VISITS ____

*RESULT CODES:

LANGUAGE OF QUESTIONNAIRE:

LANGUAGE USED FOR INTERVIEW

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 the Central Statistical Office. We are conducting a national survey about the health of men, women, and children. We would very much appreciate your participation in this survey. I would like to ask you some questions related to health. This information will help the government to plan health services. The survey usually takes about 30 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, 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 survey now?

Signature of the interviewer:
Date:

101) RECORD THE TIME.

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

IF LESS THAN ONE MONTH, RECORD '00' MONTHS.

103) Just before you moved here, where did you live? RECORD NAME AND CODE TYPE OF AREA.

PROBE: Is that a city, town, communal land or resettlement area?

104) In the last 12 months, on how many separate occasions have you traveled away from your home community and slept away?

105) In what month and year were you born?

107) How old were you at your last birthday?

COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTANT.

108) Have you ever attended school?

109) What is the highest level of school you attended?

110) What is the highest grade (number of years) you completed at that level?

111) CHECK 109:

112) 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?

113) Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?

114) CHECK 112:

115) Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?

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

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

118) What is your religion?

119) How often have you attended religious services in the past month?

RECORD '00' IF DID NOT ATTEND DURING MONTH.

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

121) 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?

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

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

124) CHECK 123:

125) 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?

126) Are you paid in cash or kind for the work you do, or are you not paid at all?

SECTION 2. REPRODUCTION

201) Now I would like to ask about any children you have had during your life. I am interested only in the children that are biologically yours. 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?

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 you have fathered 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 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?

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:

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

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

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

213) Are you the primary care giver for any children?

214) Are any of these children for whom you are the primary caregiver under the age of 18?

215) Now I would like to ask you about the children who are under the age of 18 and for whom you are the primary caregiver. Have you made arrangements for someone to care for these children in the event that you fall sick or are unable to care for them?

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 IF APPLICABLE.

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 (02):

304) Are you currently doing something or using any method with any partner to delay or avoid pregnancy?

305) Which method are you or your partner using to delay or avoid pregnancy? Any other method (with any partner)?

CIRCLE ALL MENTIONED.

305A) CIRCLE 'B' FOR MALE STERILIZATION.

306) In the last few months have you heard about family planning: On the radio? On the television? In a newspaper or magazine?

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

308) 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 if she has sexual relations?

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

310) Do you think that a woman who is breastfeeding her baby can become pregnant?

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

a) Contraception is a women's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous.
c) A woman is the one who gets pregnant so she should be the one to use contraception.

312) CHECK 301 (07) KNOWS MALE CONDOM

313) If a male condom is used correctly, do you think that it protects against pregnancy most of the time, only sometimes, or not at all?

314) CHECK 301 (08) KNOWS FEMALE CONDOM

315) If a female condom is used correctly, do you think that it protects against pregnancy most of the time, only sometimes, or not at all?

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

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

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

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

405) Do you have more than one wife or do you have more than one woman with whom you are living as if married?

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

407) CHECK 405:

RECORD THE NAME(S) AND THE LINE NUMBER(S) FROM THE HOUSEHOLD QUESTIONNAIRE FOR THE WIFE (WIVES) AND LIVE-IN PARTNER(S).

IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

ASK 408 FOR EACH PERSON.

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

409) CHECK 407:

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

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

411B) 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?

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

413) CHECK FOR THE PRESENCE OF OTHERS.

BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

414) 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 had sexual intercourse for the very first time?

415) Do you intend to wait until you get married to have sexual intercourse for the first time?

416) CHECK 107:

417) The first time you had sexual intercourse, was a condom used?

418) How old was the person you first had sexual intercourse with?

419) Was this person older than you, younger than you, or about the same age as you?

420) Would you say this person was ten or more years older than you or less than ten years older than you?

421) 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.

422) When was the last time you had sexual intercourse with this person?

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

423A) What was the main reason you used a condom on that occasion?

424) Did you use a condom every time you had sexual intercourse with this person in the last 12 months?

425) What was your relationship to this person with whom you had sexual intercourse?

IF BOYFRIEND: Were you living together as if married?

IF YES, CIRCLE '02'
IF NO, CIRCLE '03'

426) For how long (have you had/did you have) a sexual relationship with this person?

IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.

427) CHECK 107:

428) How old is this person?

429) Is this person older than you, younger than you, or about the same age?

430) Would you say this person is ten or more years older than you or less than ten years older than you?

431) The last time you had sexual intercourse with this person, did you or this person drink alcohol?

432) Were you or your partner drunk at that time?

IF YES: Who was drunk?

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

434) 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 GREATER THAN 95, WRITE '95'.

435) CHECK 425:

436) In the last 12 months, did you pay anyone in exchange for sex?

437) The last time you paid someone in exchange for sex, was a condom used?

438) Was a condom used during every time you paid someone in exchange for sex in the last 12 months?

439) 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 GREATER THAN 95, WRITE '95'.

440) CHECK 107:

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

442) In the last 12 months, has anyone forced you to have sexual intercourse against your will?

443) Were you physically forced?

444) CHECK 423, MOST RECENT PARTNER (FIRST COLUMN):

445) The last time you had intercourse you told me you used a condom. Did you or your partner obtain the condom?

446) What brand of condoms did you use at that time?

447) How many condoms did you get the last time?

448) How much did the condoms cost?

449) From where did you obtain the condom the last time.

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

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

RECORD ALL SOURCES MENTIONED.

450) CHECK 302 (02) USING MALE STERILIZATION

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

452) What method did you (your partner) use?

PROBE: Did you use any other method to prevent pregnancy?

453) CHECK 423 COLUMN 1 (CONDOM USE WITH LAST SEXUAL PARTNER)

454) CHECK 301 (07) KNOWS MALE CONDOM

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

456) Where is that? Any other place?

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

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
RECORD ALL SOURCES MENTIONED.

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

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

459) Where is that? Any other place?

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

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

RECORD ALL SOURCES MENTIONED.

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

461) Now I would like to ask you a few questions regarding relationships between men and women.
In a couple, who do you think should have the greater say in each of the following decisions: the husband, the wife, or both equally?

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

463) When a wife knows her husband has a disease that can be transmitted through sexual contact, is she justified in asking that they use a condom?

464) 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 if...

465) Do you think that if a woman refuses to have sex with her husband when he wants her to, he has the right to...

SECTION 5. FERTILITY PREFERENCES

501) CHECK 405:

502) (Is your wife/partner/Are any of your wives/partners) currently pregnant?

503) CHECK 502:

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

505) CHECK 203 AND 205:

506) 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?

SECTION 6. PARTICIPATION IN HEALTH CARE

601) CHECK 209:

602) Please tell me the name and sex of your child (who was born most recently).

603) In what month and year was (NAME OF CHILD) born?

604) Is (NAME OF CHILD) still living?

605) How old was (NAME OF CHILD) when he/she died?

IF '1 YEAR', PROBE: How many months old was (NAME)?

RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

606) What is the name of (NAME OF CHILD)'s mother?

WRITE THE CHILD'S MOTHER'S NAME AND HER LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE.

IF MOTHER IS NOT LISTED IN THE HOUSEHOLD SCHEDULE RECORD '00'.

607) CHECK 603:

609) What is your relationship with (NAME OF CHILD)'s mother?

610) ASK QUESTIONS 610A-612 FIRST FOR PREGNANCY, THEN FOR DELIVERY, AND THEN FOR THE SIX WEEKS AFTER DELIVERY. ALL QUESTIONS REFER TO THE LAST BIRTH..

Now, think back to the time when (NAME OF CHILD'S MOTHER) was pregnant with (NAME OF CHILD).

611) Who mainly provided the money or goods or services to pay for this care?

612) What was the main reason (NAME OF CHILD'S MOTHER) did not receive any advice or care from a doctor or other health care provider during (pregnancy/delivery/the six weeks after delivery?)

613) At any time while (NAME OF CHILD'S MOTHER) was pregnant with (NAME OF CHILD), did you yourself talk with a doctor or any other health care provider about the health of the mother or of the pregnancy?

SECTION 7. HIV/AIDS

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

702) Can people reduce their chances of getting HIV by just having one sex partner who is not infected and who has no other partners?

703) Can people get HIV from mosquito bites?

704) Can people reduce their chances of getting HIV by using a condom every time they have sex?

705) Can people get HIV by sharing food with a person who has AIDS?

706) Can people reduce their chance of getting HIV by abstaining from sexual intercourse?

707) Can people get HIV because of witchcraft or other supernatural means?

708) Is there anything(else) a person can do to avoid or reduce the chances of getting HIV or AIDS?

709) What can a person do? Anything else?

RECORD ALL WAYS MENTIONNED.

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

711) Is it possible for a healthy-looking person to have HIV?

712) Can HIV be transmitted from a mother to her baby: During pregnancy? During delivery? By breastfeeding?

713) CHECK 712:

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

715) Is there any special medication that people infected with HIV can get from a doctor or nurse?

716) Have you ever been tested to see if you have HIV?

717) When was the last time you were tested?

718) The last time you had the test, did you yourself ask for the test, was it offered to you and you accepted, or was it required?

719) Did you get the results of the test?

720) Where was the test done?

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

721) CHECK 719: GOT THE RESULTS OF HIV TEST

722) Did you tell your wife/partner the result of your test?

723) What is the main reason you have not been tested for HIV?

724) Do you know of a place where people can GO TO get tested for HIV?

725) Where is that? Any other places?

RECORD ALL SOURCES MENTIONED

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

726) CHECK 401: CURRENT MARITAL STATUS

727) Did your wife/partner ever have a test for HIV?

728) Did she tell you the result of her test?

729) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?

730) If a member of your family got infected with HIV, would you want others to know about it?

731) If a relative of yours became sick with HIV, would you be willing to care for her or him in your own household?

732) If a female teacher has HIV but is not sick, should she be allowed to continue teaching in the school?

732A) If a male teacher has HIV but is not sick, should he be allowed to continue teaching in the school?

733) Do you personally know someone who has been denied health services in the last 12 months because he or she is suspected to have HIV or AIDS?

734) Do you personally know someone who has been denied involvement in social events, religious services, or community events in the last 12 months because he or she is suspected to have HIV or AIDS?

735) Do you personally know someone who has been verbally abused or teased in the last 12 months because he or she is suspected to have HIV or AIDS.

736) CHECK 733, 734, 735:

737) Do you personally know someone who is suspected to have HIV or AIDS?

738) Do you agree or disagree with the following statement: People with HIV should be ashamed of themselves.

739) Do you agree or disagree with the following statement: People with HIV should be blamed for bringing the disease into the community.

740) Do you agree or disagree with the following statement: In a marriage, it is possible for one partner to be infected with HIV and other person not be infected.

741) Should children age 12-14 be taught about using a condom to avoid HIV infection?

742) Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid HIV infection?

SECTION 8. OTHER HEALTH ISSUES

801) Some men are circumcised. Are you circumcised?

802) CHECK 701:

803) CHECK 419:

804) CHECK 802:

805) 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?

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

807) 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?

808) CHECK 805, 806, 807:

809) The last time you had (PROBLEM(S) FROM 805, 806, 807), did you seek any kind of advice or treatment?

810) Where did you go? Any other places?

RECORD ALL SOURCES MENTIONED.

811) CHECK 701 AND 802:

812) CHECK 301(07) KNOWS MALE CONDOM:

813) Some people use male condoms to prevent sexually transmitted diseases. If a male condom is used correctly, do you think that it protects against these diseases most of the time, only sometimes, or not at all?

814) CHECK 301 (08) KNOWS FEMALE CONDOM

815) Some people use female condoms to prevent sexually transmitted diseases. If a female condom is used correctly, do you think that it protects against these diseases most of the time, only sometimes, or not at all?

816) Now I would like to ask you some questions about any injections you have had in the last six months. Have you had an injection for any reason in the last six months?

IF YES: How many injections have you had?

IF NUMBER OF INJECTIONS IS GREATER THAN 94, OR DAILY FOR 3 MONTHS OR MORE, RECORD '95'.

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

817) 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 GREATER THAN 94, OR DAILY FOR 3 MONTHS OR MORE, RECORD '95'.

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

818) The last time you had an injection given to you by a health worker, where did you GO TO get the injection?

819) Did the person who gave you that injection take the syringe and needle from a new, unopened package?

820) Do you currently smoke cigarettes?

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

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

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

824) Have you ever heard of an illness called tuberculosis or TB?

825) How does tuberculosis spread from one person to another?

PROBE: Any other ways?

RECORD ALL MENTIONED.

826) Can tuberculosis be cured?

827) If a member of your family got tuberculosis, would you want others to know about it?

SECTION 9. ADULT 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 he/she died? (IF MALE OR DIED BEFORE 12 YEARS OF AGE GO TO NEXT CHILD)

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) Was (NAME)'s death due to an accident or violence?

IF NO MORE BROTHERS OR SISTERS, GO TO 914.

914) RECORD THE TIME.

SECTION 10. ANAEMIA AND HIV TESTING

ANTHROPOMETRY

CONSENT FOR ANAEMIA AND HIV TESTS FOR NEVER-MARRIED YOUTH AGE 15-17

ASK CONSENT FOR THE ANAEMIA AND HIV TESTS. FOR NEVER-IN UNION RESPONDENTS AGE 15-17, YOU MUST FIRST OBTAIN THE CONSENT OF A PARENT OR OTHER ADULT RESPONSIBLE FOR THE YOUTH AT THE TIME OF YOUR VISIT.

1001) CHECK 105: AGE

1002) CHECK 401 AND 402: RESPONDENT NEVER-EVER MARRIED AND NEVER LIVED TOGETHER WITH A WOMAN.

1003) CHECK HOUSEHOLD SCHEDULE (COLUMN 1) AND RECORD LINE NUMBER OF THE PARENT OR OTHER ADULT FROM WHOM CONSENT WILL BE REQUESTED.

IF PARENT OR OTHER RESPONSIBLE ADULT IS NOT A HOUSEHOLD MEMBER, WRITE '00'.

1004) READ THE ANAEMIA CONSENT STATEMENT TO THE PARENT OR ADULT RESPONSIBLE FOR THE CHILD.

As part of this survey, we are trying to find out more about anaemia, that is, low blood levels, in men, women, and children.

To know more about this problem in Zimbabwe, we are asking people in this survey all over the country to take a test. For the test, I will take a few drops of blood from (NAME OF ADOLESCENT'S) finger.

The test uses clean and completely safe equipment that is used only once and then thrown away. The blood will be tested with new equipment. The result will be given to (NAME) right after the test is done. We will not tell anyone else the results of the test.

Do you have any questions?

You can say yes or you can say no; it is up to you. If you say yes, it will help the country to develop programs to fight the problem of anaemia.

Do you agree that (NAME) may give blood for the anaemia test?

CIRCLE CODE AND SIGN.

FURTHER DISCUSS ANAEMIA TESTING PROCESS TO PUT RESPONDENT AT EASE.

CONSENT OF PARENT/OTHER ADULT FOR ANAEMIA TEST

1005) READ THE HIV CONSENT STATEMENT TO THE PARENT OR ADULT RESPONSIBLE FOR THE CHILD.

We are also asking people in this survey to help us find out how big the HIV problem is in Zimbabwe. We would like (NAME OF ADOLSCENT) to take part in the HIV test by allowing us to collect a few more drops of blood from his/her finger.

This blood will be tested later in the laboratory. We will not keep any name with the blood. Because there will be no name with the blood when it is tested, we will not be able to give (NAME) the result of the test and no one will be able to trace the test back to (NAME).

If (NAME) wants to know his/her HIV status, I can tell (NAME) where to GO TO get tested for HIV.

Do you have any questions?

You can say yes or you can say no; it is up to you. If you say yes, it will help the country to develop programs to fight the problem of HIV and AIDS.

Do you agree that (NAME) may give blood for the HIV test?

CIRCLE CODE AND SIGN.

FURTHER DISCUSS ANAEMIA TESTING PROCESS TO PUT RESPONDENT AT EASE.

CONSENT OF PARENT/OTHER ADULT FOR HIV TEST

1006) READ THE BLOOD STORAGE CONSENT STATEMENT TO THE PARENT OR ADULT RESPONSIBLE FOR THE CHILD.

Some of the blood that (NAME) gives may be left after the HIV test. We would like to keep that blood at the laboratory to use for other tests later on.

Again, you can say yes or you can say no; it is up to you. If you say yes, it may help the country later on to develop programs to fight HIV/AIDS and other health problems.

Will you agree that we do other tests on (NAME'S) blood later?

CIRCLE CODE AND SIGN.

FURTHER DISCUSS STORAGE PROCESS TO PUT RESPONDENT AT EASE.

CONSENT OF PARENT/OTHER ADULT FOR STORAGE OF BLOOD

RESPONDENT CONSENT FOR ANAEMIA AND HIV TESTS

ASK CONSENT FOR THE ANEMIA AND HIV TESTS FROM RESPONDENT. FOR NEVER-IN-UNION RESPONDENTS AGE 15-17, ASK FOR CONSENT ONLY IF PARENT OR OTHER ADULT RESPONSIBLE FOR THE YOUTH AT THE TIME OF YOUR VISIT HAS GRANTED CONSENT OR THE PARENT OF OTHER ADULT WAS NOT PRESENT.

1007) CHECK 1001 AND 1002: RESPONDENT'S AGE AND UNION STATUS

1008) CHECK 1004: PARENTAL/ADULT CONSENT FOR ANEMIA TEST

1009) READ THE ANAEMIA CONSENT STATEMENT TO THE RESPONDENT.

As part of this survey, we are trying to find out more about anaemia, that is, low blood levels in men, women, and children.

To know more about this problem in Zimbabwe, we are asking people in this survey all over the country to take a test. For the test, I will take a few drops of blood from your finger.

The test uses clean and completely safe equipment that is used only once and then thrown away. The blood will be tested with new equipment. The result will be given to you right after the test is done. We will not tell anyone else the results of the test.

Do you have any questions?

You can say yes or you can say no; it is up to you. If you say yes, it will help the country to develop programs to fight the problem of anaemia.

Do you agree to give blood for the anaemia test?

CIRCLE CODE AND SIGN.

FURTHER DISCUSS ANAEMIA TESTING PROCESS TO PUT RESPONDENT AT EASE.

1010) CHECK 1001 AND 1002: RESPONDENT'S AGE AND UNION STATUS

1011) CHECK 1005: PARENTAL/ADULT CONSENT FOR HIV TEST

READ THE HIV CONSENT STATEMENT TO THE RESPONDENT.

We are also asking people in this survey to help us find out how big the HIV problem is in Zimbabwe. We would like you to take part in the HIV test by allowing us to collect a few more drops of blood from your finger.

This blood will be tested later in the laboratory. We will not keep any name with the blood. Because there will be no name with the blood when it is tested, we will not be able to give you the result of the test and no one will be able to trace the test back to you.

If you want to know your HIV status, I can tell you where to GO TO get tested for HIV.

Do you have any questions?

You can say yes or you can say no; it is up to you. If you say yes, it will help the country to develop programs to fight the problem of HIV and AIDS.

Do you agree to give blood for the HIV test?

CIRCLE CODE AND SIGN.

FURTHER DISCUSS HIV TESTING PROCESS TO PUT RESPONDENT AT EASE.

1013) READ THE BLOOD STORAGE CONSENT STATEMENT TO THE RESPONDENT.

Some of the blood that you give may be left after the HIV test. We would like to keep that blood at the laboratory to use for other tests later on.

Again, you can say yes or you can say no; it is up to you. If you say yes, it may help the country later to develop programs to fight HIV/AIDS and other health problems.

Will you agree that we do other tests on your blood later?

CIRCLE CODE AND SIGN.

FURTHER DISCUSS BLOOD STORAGE TO PUT RESPONDENT AT EASE.

1014) May I provide you with an informational brochure about voluntary HIV testing from the nearest facility offering VCT?

PROVIDE BROCHURE TO ALL RESPONDENTS WHO WANT IT.

1015) CHECK 1004, 1005, 1009 AND 1012 AND INDICATE THE TESTS FOR WHICH CONSENT HAS BEEN GRANTED.

IF BOTH REFUSED, COMPLETE QUESTIONS 1017 AND 1019.

1016) FOR ALL RESPONDENTS WHERE CONSENT WAS OBTAINED, FOLLOW INSTRUCTIONS FOR PASTING THE BAR CODE LABELS AND TAKING THE DBS SPECIMEN.

1017) OUTCOME OF HIV TEST.

1018) RECORD HEMOGLOBIN LEVEL

1019) OUTCOME OF ANAEMIA TEST

1020) CHECK 1018: THE CUTOFF POINT IS 9 G/DL.

1021) We detected a low level of hemoglobin in your blood. This indicates that you have developed severe anaemia, which is a serious health problem. We would like to inform the clinic at ________ about your condition. This will assist you in obtaining help.

AGREES TO REFERAL?

1022) THANK THE RESPONDENT.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT THE RESPONDENT:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

SUPERVISOR'S OBERVATIONS

NAME OF THE SUPERVISOR:
DATE:

EDITOR'S OBSERVATIONS

NAME OF EDITOR:
DATE: