National Office of Statistics
Demographic and Health Survey
Woman's Questionnaire
IDENTIFICATION
NAME OF PROVINCE______
NAME OF LOCATION______
NAME OF HEAD OF HOUSEHOLD_____
CLUSTER NUMBER_____
STRUCTURE NUMBER______
HOUSEHOLD NUMBER______
WOMAN'S NAME AND LINE NUMBER____
CHECK HOUSEHOLD QUESTIONNAIRE (Q 300):
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE:
No
INTERVIEWER VISITS
DATE_______
INTERVIEWER'S NAME_______
RESULT
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)
NEXT VISIT
DATE_____
TIME______
FINAL VISIT
DAY_____
MONTH_____
YEAR ______
INT. NUMBER ______
RESULT
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)
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 ___. I am working for the Demographic and Health Survey, supported by the government and its partners. We are conducting a survey about health all over Gabon. The information we collect will help the government to improve health services. Your household was selected for the survey. The questions usually take about 45 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.
In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.
Do you have any questions?
May I begin the interview?
SIGNATURE OF INTERVIEWER__________ DATE________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2- (END)
MINUTES______
102) In what month and year were you born?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
103) How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT
104) Have you ever attended school?
NO 2- (SKIP TO 108)
105) What is the highest level of school you attended: Primary, Secondary, or Higher?
SECONDARY 1ST CYCLE/TECHNICAL MIDDLE SCHOOL 2
SECONDARY 2ND CYCLE/TECHNICAL HIGH SCHOOL 3
HIGHER 4
106) What is the highest (grade/form/year) you completed at this level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 00
GRADE/FORM/YEAR_____________
GRADE
1=1ST YEAR/CP1
2=2ND YEAR/CP2
3=3RD YEAR/CE1
4=4TH YEAR/CE2/CE
5=5TH YEAR/CM1
6=6TH YEAR/CM2
2=5TH/2ND YEAR
3=4TH/3RD YEAR
4=3RD/4TH YEAR
2=1ST/2ND YEAR
3=FINALE/3RD YEAR
2=2ND YEAR
3=3RD YEAR OR MORE
25 YEARS OLD OR MORE-SKIP TO 107
106b) Do you always go to school?
NO 2
106c) What is the main reason for which you stopped going to school?
GOT PREGNANT 02
HAD TO WATCH YOUNGER CHILDREN 03
FAMILY NEEDED HELP WITH WORK 04
COULD NOT PAY FOR SCHOOL 05
NEEDED TO EARN MONEY 06
HAD ENOUGH SCHOOL 07
DIDN'T LIKE SCHOOL 08
SCHOOL NOT ACCESSIBLE/TOO FAR 09
HEALTH CONCERNS 10
OTHER_______ (SPECIFY) 96
DON'T KNOW 98
SECONDARY OR HIGHER -- (SKIP 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?
ABLE TO READ ONLY PART OF SENTENCE 2
ABEL TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) 4
BLIND/VISUALLY IMPAIRED 5
CODE '1' OR '5' CIRCLED - (SKIP 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?
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?
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?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
PROTESTANT 2
OTHER CHRISTIAN 3
MUSLIM 4
ANIMIST 5
OTHER 6
NO RELIGION 7
CAMEROONIAN 02- (SKIP TO 115)
CONGOLESE (BRAZZA.) 03- (SKIP TO 115)
CONGOLESE (KINSHA.) 04- (SKIP TO 115)
EQUATOGUINEAN 05- (SKIP TO 115)
BENINESE 06- (SKIP TO 115)
MALIAN 07 - (SKIP TO 115)
NIGERIEN 08- (SKIP TO 115)
SENEGALESE 09- (SKIP TO 115)
TOGOLESE 10- (SKIP TO 115)
OTHER AFRICAN 11- (SKIP TO 115)
FRENCH 12- (SKIP TO 115)
LEBANESE 13- (SKIP TO 115)
OTHER 16- (SKIP TO 115)
114a) Are you originally Gabonese?
NO 2-SKIP TO 115
KOTA-KELE 02
MBEDE-TEKE 03
MYENE 04
NZABI-DUMA 05
OKANDE-TSOGHO 06
SHIRA-PUNU/VILI 07
PYGMY 08
OTHER 96
115) In the last 12 months, how many times have you been away from for one or more nights?
NONE 00-SKIP TO 201
116) In the last 12 months, have you been away from home for more than one month at a time?
NO 2
201) Now I would like to ask you about all the births you have had during your life. Have you ever given birth?
NO 2- (SKIP TO 206)
202) Do you have any sons or daughters to whom you have given birth who are now living with you?
NO 2- (SKIP TO 204)
203) How many sons live with you?
And how many daughters live with you?
IF NONE, RECORD '00'
DAUGHTERS AT HOME_____
204) Do you have any sons or daughters to whom you have given birth who are alive but do not live with you?
NO 2- (SKIP 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, RECODE '00'
DAUGHTERS ELSEWHERE______
206) Have you ever given birth to a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?
NO 2- (SKIP TO 208)
207) How many boys have died?
And how many girls have died?
IF NONE, RECORD '00'
GIRLS DEAD____
208) SUM ANSWERS TO 203, 205, AND 207 AND ENTER TOTAL.
IF NONE, RECORD 00
209) CHECK 208:
Just to makes sure that I have this right: you have had in total ____births during your life. Is that correct?
NO- (PROBE AND CORRECT 201-208 AS NECESSARY)
NO BIRTHS- (SKIP TO 226)
211) Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS.
(IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.)
212) What name was given to you (FIRST/NEXT) baby?
BIRTH HISTORY NUMBER_______
213) Is (NAME) a boy or a girl?
GIRL 2
214) Were any of these births twins?
MULT 2
215) In what month and year was (NAME) born?
PROBE: What is his/her birthday?
YEAR_____
NO 2- (SKIP TO 220)
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?
NO 2
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.
_____MONTHS 2
_____YEARS 3
221) Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth?
NO 2- (NEXT BIRTH)
222) Have you had any live births since the birth of (NAME OF LAST BIRTH)? IF YES, RECORD BIRTHS IN TABLE.
NO 2
223) COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK.
NUMBERS ARE DIFFERENT-(PROBE AND RECONCILE)
224) CHECK 215:
ENTER THE NUMBER OF BIRTHS IN 2007 OR LATER.
NONE 0
NO 2- (SKIP TO 230)
UNSURE 8- (SKIP TO 230)
227) How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.
228) When you got pregnant, did you want to get pregnant at that time?
NO 2
229) Did you want to have a baby later on or did you not want any (more) children?
NO MORE 2
230) Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?
NO 2- (SKIP TO 253)
231) How many such pregnancies have you had in your life?
231a) CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.
232) CHECK 231:
ONE SINGLE PREGNANCY-Did this pregnancy end with an abortion, a miscarriage, or a stillbirth?
SEVERAL PREGNANCIES-Among these pregnancies, how many ended with an abortion, a miscarriage, or a stillbirth?
MISCARRIAGE______
STILLBIRTH_____
NOT A SINGLE ABORTION- (SKIP TO 253)
234) CHECK 232:
ONE SINGLE ABORTION-How old were you when your pregnancy ended with an abortion?
SEVERAL ABORTIONS-How old were you when you had your first pregnancy that ended with an abortion?
235) CHECK 232:
A SINGLE ABORTION-When did this abortion take place?
SEVERAL ABORTIONS-When did the last abortion take place?
YEAR______
LAST ABORTION BEFORE JANUARY 2007
A SINGLE ABORTION-How many months pregnant where you when the abortion took place?
SEVERAL ABORTIONS-We are going to talk about your last abortion. How many months pregnant where you when your last abortion took place?
238) Did you, yourself, decide to have this abortion, or were you pushed or forced by someone else to have this (last) abortion?
SOMEONE ELSE 2
239) Who pushed or forced you to have this (last) abortion?
FATHER 2
MOTHER 3
HUSBAND/PARTNER 4
FRIENDS 5
OTHER_____ (SPECIFY) 6
240) What is the main reason you decided to end this pregnancy?
TOO YOUNG TO HAVE A CHILD 02
TOO OLD TO HAVE A CHILD 03
ALREADY HAS TOO MANY CHILDREN 04
BIRTHS TOO CLOSE TOGETHER 05
AFRAID OF PARENTS 06
HUSBAND/PARTNER DIDN'T WANT CHILD 07
TO PURSUE EDUCATION 08
TO CONTINUE WORKING 09
ECONOMIC DIFFICULTIES/LACK OF MONEY 10
OTHER 96
241) Can you tell me what means or procedures were used to terminate this pregnancy?
SUCTION B
PROBE C
INJECTIONS D
PILLS E
PLANTS/INFUSION F
OTHER X
DON'T KNOW Z
242) Where did the abortion take place?
MILITARY INFIRMARY 12
FAMILY PLANNING CENTER 13
MOTHER-INFANT CENTER 14
FREE CLINIC 15
HEALTH HUT 16
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER 22
PRIVATE DOCTOR'S OFFICE 32
NURSE'S OFFICE 33
GABONESE MOVEMENT FOR FAMILY WELL-BEING 34
AT THE SPIRITUAL HEALER/ABORTIONIST'S HOME 42
OTHER HOME 43
243) CHECK 242:
CODES 11 TO 34 OR 42 CIRCLED: Who helped you at the time of the (last) abortion?
PROBE: Anyone else?
CODES 41, 43, OR 96 CIRCLED: Was anyone present to help you during the (last) abortion?
IF YES: Who helped you at the time of the (last) abortion?
PROBE: Anyone else?
PROBE TO DETERMINE THE TYPE OF PERSON.
RECORD ALL PERSONS LISTED
MIDWIFE B
NURSE C
NURSE'S AIDE D
ROOM ATTENDANT/STRETCHER BEARER F
ABORTIONIST K
RELATIVES/FRIENDS L
NO/NO ONE Y
244) How much did this (last) abortion cost?
IF 999 000 OR MORE, RECORD 999000.
IF THE ABORTION WAS FREE (DIDN'T COST ANYTHING), RECORD 000000
DON'T KNOW 999998
245) After the abortion, did you have a consultation?
NO 2- (SKIP TO 250)
246) Who consulted with you?
PROBE: Anyone else?
PROBE TO OBTAIN THE TYPE OF PERSON.
RECORD ALL PERSONS LISTED
OTHER DOCTOR B
MIDWIFE C
NURSE D
NURSE'S AIDE E
MATRON F
TRADITIONAL BIRTH ATTENDANT G
SPIRITUAL HEALER/ABORTIONIST H
OTHER PERSONS_______ (SPECIFY) X
247) Where did you go for this consultation?
MILITARY INFIRMARY 12
FAMILY PLANNING CENTER 13
MOTHER-INFANT CENTER 14
FREE CLINIC 15
HEALTH HUT 16
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER 22
PRIVATE DOCTOR'S OFFICE 32
NURSE'S OFFICE 33
GABONESE MOVEMENT FOR FAMILY WELL-BEING 34
AT THE SPIRITUAL HEALER/ABORTIONIST'S HOME 42- (SKIP TO 250)
OTHER HOME 43- (SKIP TO 250)
248) Where you satisfied with the services you received from (NAME OF ESTABLISHMENT FROM Q 247) at the time of the consultation?
NO 2
249) What were the main reasons for which you were unsatisfied?
TOO EXPENSIVE 02
WAIT TIMES TOO LONG 03
BAD EQUIPMENT 04
ESSENTIAL DRUGS NOT AVAILABLE 05
LACK OF HYGIENE 06
LACK OF CONFIDENTIALITY/PRIVACY 07
LACK OF PERSONNEL 08
PERSONNEL NOT QUALIFIED 09
PERSONNEL NOT FRIENDLY 10
OTHER 96
DON'T KNOW 98
250) After the abortion, did you have any complications, like, for example, excessive bleeding or an infection?
NO 2
251) If you had another unwanted pregnancy, would you be prepared to have another abortion?
NO 2
CAN'T GET PREGNANT 3
DON'T KNOW 8
ONE SINGLE ABORTION-Other than this pregnancy that ended in an abortion, did you undergo any other attempted abortions that failed?
IF YES: Other than the pregnancy that ended in an abortion, how many other attempted abortions did you undergo?
SEVERAL ABORTIONS-Other than the pregnancies than ended in abortions, did you undergo any other attempted abortions that failed?
IF YES: Other than the pregnancies that ended in abortions, how many other attempted abortions did you undergo?
NO 95-- (SKIP TO 255)
253) In your life, have you undergone any failed abortions?
IF YES: In total, in your entire life, how many failed abortions did you undergo?
NO 95
254) If you had an unwanted pregnancy, would you be prepared to undergo an abortion?
NO 2
CAN'T GET PREGNANT 3
DON'T KNOW 8
255) When did your last menstrual period start?
(DATE, IF GIVEN)______
______WEEKS AGO 2
______MONTHS AGO 3
______YEARS AGO 4
IN MENOPAUSE/HAS HAD HYSTERECTOMY 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996
256) 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?
NO 2 -- (SKIP TO 301)
DON'T KNOW 8- (SKIP TO 301)
257) Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods?
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAD ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) 6
DON'T KNOW 8
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)?
PROBE: Women can have an operation to avoid having any more children
Have you ever heard of (method)?
NO 2
PROBE: Men can have an operation to avoid having any more children
Have you ever heard of (method)?
NO 2
PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse.
Have you ever heard of (METHOD)?
NO 2
PROBE: Women can have an injection by a heath provider that stops them from becoming pregnant for one or more months.
Have you ever heard of (METHOD)?
NO 2
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.
Have you ever heard of (METHOD)?
NO 2
PROBE: Women can take a pill every day to avoid becoming pregnant
Have you ever heard of (METHOD)?
NO 2
PROBE: Men can put a rubber sheath on their penis before sexual intercourse.
Have you ever heard of (METHOD)?
No 2
PROBE: Women can place a sheath in their vagina before sexual intercourse.
Have you ever heard of (METHOD)?
NO 2
PROBE: To avoid pregnancy, women do not have sexual intercourse on the days of the month they think they can get pregnant.
Have you ever heard of (METHOD)?
NO 2
PROBE: Men can be careful and pull out before climax.
Have you ever heard of (METHOD)?
NO 2
PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
Have you ever heard of (Method)?
NO 2
_____(SPECIFY)
_____(SPECIFY)
NO 2
PREGNANT- (SKIP TO 313)
303) Are you currently doing something or using any method to delay or avoid getting pregnant?
NO 2- (SKIP TO 313)
304) Which method are you using?
CIRCLE ALL MENTIONED
IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.
MALE STERILIZATION B
IUD C -- (SKIP TO 308A)
INJECTABLES D-- (SKIP TO 308A)
IMPLANTS E-- (SKIP TO 308A)
PILL F-- (SKIP TO 308A)
CONDOM G-- (SKIP TO 308A)
FEMALE CONDOM H-- (SKIP TO 308A)
DIAPHRAGM I-- (SKIP TO 308A)
FOAM/JELLY J-- (SKIP TO 308A)
RHYTHM METHOD K-- (SKIP TO 308A)
WITHDRAWAL L-- (SKIP TO 308A)
OTHER MODERN METHOD X-- (SKIP TO 308A)
OTHER TRADITIONAL METHOD Y-- (SKIP TO 308A)
307) In what facility did the sterilization take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE
(NAME OF PLACE)________
PRIVATE DOCTOR'S OFFICE 32
DON'T KNOW 98
308) In what month and year was the sterilization performed?
308a) Since what month and year did you start using (CURRENT METHOD) without stopping?
PROBE: For how long have you been using (CURRENT METHOD FIRST MENTIONED) now without stopping?
YEAR_______- (SKIP TO 314)
313) Have you ever used anything or tried in any way to delay or avoid getting pregnant?
No 2- (skip to 324)
314) CHECK 304:
CIRCLE METHOD CODE.
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.
MALE STERILIZATION 02- (SKIP TO 327)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
RHYTHM METHOD 11- (SKIP TO 315A)
WITHDRAWAL 12-- (SKIP TO 327)
OTHER MODERN METHOD 95-- (SKIP TO 327)
OTHER TRADITIONAL METHOD 96-- (SKIP TO 327)
315) You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time?
315a) Where did you learn how to use the rhythm method?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE)_________
MILITARY INFIRMARY 12
FAMILY PLANNING CENTER 13
MOTHER-INFANT CENTER 14
FREE CLINIC 15
HEALTH HUT 16
HOSPITAL/HEALTH CENTER PHARMACY 17
OTHER PUBLIC 18
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER 22
NATIONAL SOCIAL SECURITY PHARMACY 23
PRIVATE DOCTOR'S OFFICE 32
NURSE'S OFFICE 33
PRIVATE PHARMACY 34
OTHER PRIVATE MEDICAL 35
SHOP/MARKET 51
FRIENDS/RELATIVES 61
OTHER PLACE__________ (SPECIFY) 96
316) CHECK 304:
CIRCLE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07 -- (SKIP TO 323)
FEMALE CONDOM 08- (SKIP TO 320)
DIAPHRAGM 09- (SKIP TO 320)
FOAM/JELLY 10- (SKIP TO 320)
RHYTHM METHOD 11- (SKIP TO 326)
317) At that time, where you told about side effects or problems you might have with the method?
317a) When you got sterilized, were you told about side effects or problems you might have with the method?
NO 2
318) Were you ever told by a health or family planning worker about side effects or problems you might have with the method?
NO 2- (SKIP TO 320)
319) Were you told what to do if you experienced side effects or problems?
NO 2
320) CHECK 317:
CODE 1 CIRCLED- At that time, were you told about other methods of family planning that you could use?
CODE '2' CIRCLED-When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?
NO 2
321) Were you ever told by a health or family planning worker about other methods of family planning that you could use?
NO 2
322) CHECK 304:
CIRCLE METHOD CODE.
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.
IUD 03-SKIP TO 327
INJECTABLES 04
IMPLANTS 05- (SKIP TO 326)
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
323) Where did you obtain (CURRENT METHOD) the last time?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE)________
MILITARY INFIRMARY 12-- (SKIP TO 327)
FAMILY PLANNING CENTER 13-- (SKIP TO 327)
MOTHER-INFANT CENTER 14-- (SKIP TO 327)
FREE CLINIC 15-- (SKIP TO 327)
HEALTH HUT 16-- (SKIP TO 327)
HOSPITAL/HEALTH CENTER PHARMACY 17-- (SKIP TO 327)
OTHER PUBLIC 18-- (SKIP TO 327)
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER 22-- (SKIP TO 327)
NATIONAL SOCIAL SECURITY PHARMACY 23-- (SKIP TO 327)
PRIVATE DOCTOR'S OFFICE 32-- (SKIP TO 327)
NURSE'S OFFICE 33-- (SKIP TO 327)
PRIVATE PHARMACY 34-- (SKIP TO 327)
OTHER PRIVATE MEDICAL 35-- (SKIP TO 327)
SHOP/MARKET 51-- (SKIP TO 327)
FRIENDS/RELATIVES 61-- (SKIP TO 327)
OTHER PLACE ______(SPECIFY) 96-- (SKIP TO 327)
324) Do you know of a place where you can obtain a method of family planning?
NO 2-SKIP TO 326
325) Where is that?
ANY OTHER PLACE?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE(S))
MILITARY INFIRMARY B
FAMILY PLANNING CENTER C
MOTHER-INFANT CENTER D
FREE CLINIC E
HEALTH HUT F
HOSPITAL/HEALTH CENTER PHARMACY G
OTHER PUBLIC H
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER J
NATIONAL SOCIAL SECURITY PHARMACY K
PRIVATE DOCTOR'S OFFICE M
NURSE'S OFFICE N
PRIVATE PHARMACY O
OTHER PRIVATE MEDICAL P
SHOP/MARKET R
FRIENDS/RELATIVES S
OTHER PLACE ________(SPECIFY) X
327) In the last 12 months, have you visited a health care facility for care for yourself (or your children)?
NO 2- (SKIP TO 401)
328) Did any staff member at the health facility speak to you about family planning methods?
NO 2
SECTION 4. PREGNANCY AND POSTNATAL CARE
401) CHECK 224:
NO BIRTHS IN 2007 OR LATER- (SKIP TO 556)
402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2007 OR LATER. ASK THE QUESTIONS ABOUT ALL THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).
Now I would like to ask some questions about your children born in the last five years. (We will talk about each separately).
403) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY
DEAD
405) When you got pregnant with (NAME), did you want to become pregnant at that time?
NO 2
406) Did you want to have a baby later on, or did you not want any (more) children?
NO MORE 2- (SKIP TO 408)
407) How much longer did you want to wait?
_______YEARS 2
DON'T KNOW 998
408) Did you see anyone for antenatal care for this pregnancy?
NO 2- (SKIP TO 415)
409) Whom did you see?
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
MIDWIFE B
NURSE/NURSE'S ASSISTANT C
SPIRITUAL HEALER/MARABOUT F
OTHER (SPECIFY) X
410) Where did you receive this antenatal care for this pregnancy?
Anywhere else?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE(S))_______
OTHER HOME B
HEALTH CENTER D
FREE CLINIC F
MOTHER-INFANT CENTER G
OTHER PUBLIC SECTOR H
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER J
PRIVATE DOCTOR'S OFFICE L
NURSE'S OFFICE M
OTHER PRIVATE MEDICAL N
411) How many months pregnant were when you first received antenatal care?
DON'T KNOW 98
412) How many times did you receive antenatal care during this pregnancy?
DON'T KNOW 98
413) As part of your antenatal care 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?
Did you get a vaginal exam?
Did they examine your conjunctive and your mucus membrane?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
414) Were you told about the signs of pregnancy complications?
NO 2
DON'T KNOW 8
415) During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?
NO 2- (SKIP TO 418)
DON'T KNOW 8- (SKIP TO 418)
416) During this pregnancy, how many times did you get this injection?
DON'T KNOW 8
OTHER
418) At any time before this pregnancy, did you receive any tetanus injections?
NO 2- (SKIP TO 421)
DON'T KNOW 8- (SKIP TO 421)
419) Before this pregnancy, how many times did you receive a tetanus injection?
IF 7 OR MORE TIMES, RECORD 7
DON'T KNOW 8
420) How many years ago did you receive the last tetanus injection before this pregnancy?
421) During this pregnancy, were you given or did you buy iron tablets or iron syrup?
SHOW TABLES/SYRUP
NO 2- (SKIP TO 423)
DON'T KNOW 8- (SKIP TO 423)
422) During the whole pregnancy, for how many days did you take the tables or syrup?
IF ANSWER NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.
DON'T KNOW 998
423) During this pregnancy, did you take any drug for intestinal worms?
SHOW TABLETS/SYRUP
NO 2
DON'T KNOW 8
424) During this pregnancy, did you take any drugs to keep you from getting malaria?
NO 2- (SKIP TO 430)
DON'T KNOW 8- (SKIP TO 430)
425) What drugs did you take?
RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.
SP/FANSIDAR B
MALOXINE C
AMODIAQUINE/FLAVOQ/CAMOQUIN D
CHLOROQUINE/NIVAQUINE E
QUININE/QUINIMAX F
COARTEM G
OTHER (SPECIFY) X
DRUG UNKNOWN Z
426) CHECK 425:
SP/FANSIDAR TAKEN FOR MALARIA PREVENTION
CODE A OR B NOT CIRCLED- (SKIP TO 430)
427) How many times did you take (SP/Fansidar) during this pregnancy?
CODE A, B, C OR D CIRCLED
OTHER- (SKIP TO 430)
429) Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility, or from another source?
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6
430) When (NAME) was born, was he/she very large, larger than average, average, smaller than average, or very small?
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON'T KNOW 8
431) Was (NAME) weighed at birth?
NO 2- (SKIP TO 433)
DON'T KNOW 8- (SKIP TO 433)
432) How much did (NAME) weigh?
RECORD WEIGHT FROM HEALTH CARD, IF AVAILABLE
________GRAMS FROM RECALL 2
DON'T KNOW 99998
433) Who assisted with the delivery of (NAME)?
Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSON ASSISTING.
IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.
OTHER DOCTOR B
MIDWIFE C
NURSE/NURSE'S ASSISTANT D
SPIRITUAL HEALER/MARABOUT G
FRIEND/RELATIVES H
NO ONE ASSISTED Y
434) Where did you give birth to (NAME)?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE(S))____________
OTHER HOME 12- (SKIP TO 435C)
HEALTH CENTER 22
FREE CLINIC 23
HEALTH HUT 24
MOTHER-INFANT CENTER 25
OTHER PUBLIC SECTOR 26
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER 32
PRIVATE DOCTOR'S OFFICE 42
NURSE'S OFFICE 43
OTHER PRIVATE MEDICAL 44
434a) How long after (NAME) was delivered did you stay there?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.
_______DAYS 2
_______WEEKS 3
DON'T KNOW 998
435) Was (NAME) delivered by caesarean, that is, did they cut your belly open to take the baby out?
NO 2-- (SKIP TO 448)
435a) Were you satisfied with the services you received from (NAME OF ESTABLISHMENT FORM Q. 434) during (NAME)'s delivery?
NO 2
435b) What were the main reasons for which you were unsatisfied?
TOO EXPENSIVE 02
WAIT TIMES TOO LONG 03
BAD EQUIPMENT 04
ESSENTIAL DRUGS NOT AVAILABLE 05
LACK OF HYGIENE 06
LACK OF CONFIDENTIALITY/PRIVACY 07
LACK OF PERSONNEL 08
PERSONNEL NOT QUALIFIED 09
PERSONNEL NOT FRIENDLY 10
OTHER 96
DON'T KNOW 98
435c) CHECK 434: LOCATION OF DELIVERY?
OTHER CODES-SKIP TO 436
435d) What is the main reason for which you did not delivery (NAME) in a sanitary structure?
TOO EXPENSIVE 02-- (SKIP TO 438)
WAIT TIMES TOO LONG 03-- (SKIP TO 438)
BAD EQUIPMENT 04-- (SKIP TO 438)
ESSENTIAL DRUGS NOT AVAILAB-- (SKIP TO 438)LE 05
LACK OF HYGIENE 06-- (SKIP TO 438)
LACK OF CONFIDENTIALITY/PRIVACY 07-- (SKIP TO 438)
LACK OF PERSONNEL 08-- (SKIP TO 438)
PERSONNEL NOT QUALIFIED 09-- (SKIP TO 438)
PERSONNEL NOT FRIENDLY 10-- (SKIP TO 438)
PREFERRED HOME 11-- (SKIP TO 438)
NOT ENOUGH TIME TO GET THERE 12-- (SKIP TO 438)
OTHER 96-- (SKIP TO 438)
DON'T KNOW 98-- (SKIP TO 438)
436) I would like to talk to you about check on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health while you were still in the facility?
NO 2- (SKIP TO 439)
437) Did anyone check on your health after you left the facility?
NO 2- (SKIP TO 442)
438) I would like to talk to you about check on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)?
NO 2- (SKIP TO 442)
439) Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.
OTHER DOCTOR 12
MIDWIFE 13
NURSE/NURSE'S ASSISTANT 14
440) How long after delivery did the first check take place?
IF LESS THAN ONE DAY, RECORD IN HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.
________DAYS 2
________WEEKS 3
DON'T KNOW 998
442) In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health?
NO 2- (SKIP TO 446)
DON'T KNOW 8- (SKIP TO 446)
443) How many hours, days, or weeks after the birth of (NAME) did the first check take place?
IF LESS THAN ONE DAY, RECORD IN HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.
_______DAYS AFTER BIRTH 2
_______WEEKS AFTER BIRTH 3
_______DON'T KNOW 998
444) Who checked on (NAME)'s health at that time?
PROBE FOR THE MOST QUALIFIED PERSON.
OTHER DOCTOR 12
MIDWIFE 13
NURSE/NURSE'S ASSISTANT 14
445) Where did this first check of (NAME) take place?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE(S))__________
OTHER HOME 12
HEALTH CENTER 22
FREE CLINIC 23
HEALTH HUT 24
MOTHER-INFANT CENTER 25
OTHER PUBLIC SECTOR 26
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER 32
PRIVATE DOCTOR'S OFFICE 42
NURSE'S OFFICE 43
OTHER PRIVATE MEDICAL 44
446) In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)?
SHOW COMMON TYPES OF AMPOULES/CAPSULES/SYRUPS
NO 2
DON'T KNOW 8
447) Has your menstrual period returned since the birth of (NAME)?
NO 2- (SKIP TO 450)
448) Did your period return between the birth of (NAME) and your next pregnancy?
NO 2- (SKIP TO 452)
449) For how many months after the birth of (NAME) did you not have a period?
DON'T KNOW 98
450) CHECK 226:
IS RESPONDENT PREGNANT?
PREGNANT OR NOT SURE- (SKIP TO 452)
451) Have you had sexual intercourse since the birth of (NAME)?
NO 2- (SKIP TO 453)
452) For how many months after the birth of (NAME) did you not have sexual intercourse?
DON'T KNOW 98
453) Did you ever breastfeed (NAME)?
NO 2
453a) Why did you not breastfeed (NAME)?
PROBE FOR MAIN REASON.
NO MILK 12
MILK NOT GOOD/POISONED 13
HEALTH PROBLEMS/FATIGUE 14
CHILD'S FATHER REFUSED 15
FAMILY MEMBER REFUSED 16
ARTIFICIAL MILK GIVEN BY HEALTH CARE PERSONNEL 17
ARTIFICIAL MILK ADVISED BY HEALTH CARE PERSONNEL 18
AESTHETICS OF BREASTS 19
OTHER__________ (SPECIFY) 96
454) CHECK 404: IS CHILD LIVING?
DEAD-(GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501)
455) How long after birth did you first put (NAME) to the breast?
IF LESS THAN 1 HOUR, RECORD 00 HOURS.
IF LESS THAN 24 HOURS, RECORD HOURS.
OTHERWISE, RECORD DAYS.
_________HOURS 1
_______DAYS 2
455a) Did you give (NAME) the first yellow milk?
NO 2
455b) Why didn't you give (NAME) the first yellow milk?
BAD FOR CHILD'S HEALTH 2
OTHER___________ (SPECIFY) 6
456) In the first three days after delivery, was (NAME) given anything to drink other than breast milk?
NO 2- (SKIP TO 458)
457) What was (NAME) given to drink?
Anything else?
RECORD ALL LIQUIDS MENTIONED.
PLAIN WATER B
SUGAR OR GLUCOSE WATER C
GRIPE WATER D
SUGAR-SALT-WATER SOLUTION E
FRUIT JUICE F
INFANT FORMULA G
TEA/INFUSIONS H
COFFEE I
HONEY J
OTHER________ (SPECIFY) X
458) CHECK 404: IS CHILD LIVING?
DEAD- (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)
459) Are you still breastfeeding (NAME)?
NO 2
460) Did (NAME) drink anything from a bottle with a nipple yesterday or last night?
NO 2
DON'T KNOW 8
461) (GO BACK TO 405 IN NEXT COLUMN, OR, IF NO MORE BIRTHS, GO TO 501)
SECTION 5. CHILD IMMUNIZATION, HEALTH AND NUTRITION
501) ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2007 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES.)
502) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY
DEAD-(GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 555)
504) Do you have a card where (NAME)'s vaccinations are written down? IF YES: May I see it please?
YES, NOT SEEN 2- (SKIP TO 509)
NO CARD 3
505) Did you ever have a vaccination card for (NAME)?
NO 2
506)
1) COPY DATES FROM THE CARD
2) WRITE 44 IN DAY COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
_________MONTH
__________YEAR
508) Has (NAME) received any vaccines that are not recorded on this card, including vaccinations received in a national immunization day campaign?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 506 THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.
NO 2- (SKIP TO 511)
DON'T KNOW 8- (SKIP TO 511)
509) Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases, including vaccinations received in a national immunization day campaign?
NO 2- (SKIP TO 511)
DON'T KNOW 8- (SKIP TO 511)
510) Please tell me if (NAME) had any of the following vaccinations:
510a) A BCG vaccination against tuberculosis, that is, an injection in the inner left forearm that usually causes a scar?
NO 2
DON'T KNOW 8
510b) Polio vaccine, that is, drops in the mouth?
NO 2
DON'T KNOW 8
510c) Was the first polio vaccine given in the first two weeks after birth or later?
LATER 2
510d) How many times was the polio vaccine given?
510e) A DTCoq vaccination, that is, an injection given in the thigh or shoulder, sometimes at the same time as polio drops?
NO 2- (SKIP TO 510G)
DON'T KNOW 3- (SKIP TO 510G)
510f) How many times was the DTCoq vaccination given?
510g) A TETRACOQ vaccination, that is, an injection given in the thigh or should, to protect against several illnesses at once?
NO 2- (SKIP TO 510I)
DON'T KNOW 3- (SKIP TO 510I)
510h) How many times was the TETRACOQ vaccination given?
510i) A PENTACOQ or PENTAVALENT vaccination, that is, an injection given in the thigh or should, to protect against several illnesses at once?
NO 2- (SKIP TO 510K)
DON'T KNOW 3- (SKIP TO 510K)
510j) How many times was the PENTACOQ or PENTAVALENT vaccination given?
510k) A hepatitis B vaccination, that is, an injection generally given in the thigh or the shoulder and protects against hepatitis B?
NO 2- (SKIP TO 510M)
DON'T KNOW 3- (SKIP TO 510M)
510l) How many times was the hepatitis B vaccination given?
510m) An ACT-HIB vaccination, that is, an injection generally given in the thigh or the shoulder and protects against meningitis?
NO 2- (SKIP TO 510P)
DON'T KNOW 3- (SKIP TO 510P)
510n) How many times was the ACT-HIB vaccination given?
510p) An measles injection or an Rouvax injection- that is, a shot in the arm or thigh at the age of 9 months or older,- to prevent him/her from getting measles?
NO 2
DON'T KNOW 8
510q) The yellow fever vaccination, that is, an injection in the shoulder or thigh at the age of 9 months or older to prevent him/her from getting yellow fever?
NO 2
DON'T KNOW 8
511) Within the last six months, was (NAME) given a vitamin A dose like (THIS/ANY OF THESE)?
SHOW COMMON TYPES OF AMPOULES/CAPSULES/SYRUPS.
NO 2
DON'T KNOW 8
512) In the last seven days, was (NAME) given iron pills, sprinkles with iron, or iron syrup like (THIS/ANY OF THESE)?
SHOW COMMON TYPES OF PILLS/SPRINKLES/SYRUPS.
NO 2
DON'T KNOW 8
513) Was (NAME) given any drug for intestinal worms in the last six months?
NO 2
DON'T KNOW 8
514) Has (NAME) had diarrhea in the last 2 weeks?
NO 2- (SKIP TO 525)
DON'T KNOW -- (SKIP TO 525)
515) Was there any blood in the stools?
NO 2
DON'T KNOW 8
516) Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk). Was he/she given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8
517) When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8
518) Did you seek advice or treatment for the diarrhea from any source?
NO 2- (SKIP TO 522)
519) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE(S))____________
DISPENSARY B
MOTHER-INFANT CENTER C
MILITARY INFIRMARY D
HEALTH HUT E
HOSPITAL PHARMACY F
OTHER PUBLIC G
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER I
NATIONAL SOCIAL SECURITY PHARMACY J
PRIVATE DOCTOR'S OFFICE L
NURSE'S OFFICE M
PHARMACY N
OTHER PRIVATE MEDICAL O
SPIRITUAL HEALER/MARABOUT P
SHOP/MARKET Q
OTHER X
ONLY ONE CODE CIRCLED- (SKIP TO 522)
521) Where did you first seek advice or treatment?
USE LETTER CODE FROM 519
522) Was he/she given any of the following to drink at any time since he/she started having the diarrhea?
a) A fluid made from a special packet called ORS
b) A homemade sugar salt solution?
c) Rice water
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
523) Was anything (else) given to treat the diarrhea?
NO 2- (SKIP TO 525)
DON'T KNOW 8- (SKIP TO 525)
524) What (else) was given to treat the diarrhea?
Anything else?
RECORD ALL TREATMENTS GIVEN.
INJECTION B
DRIP/(IV) INTRAVENOUS/FEEDING TUBE C
HOME REMEDY/HERBAL MEDICINE D
OTHER (SPECIFY) X
525) Has (name) been ill with a fever at any time in the last 2 weeks?
NO 2- (SKIP TO 527)
DON'T KNOW 8- (SKIP TO 527)
526) At any time during the illness, did (NAME) have blood taken from his/her finger or heal for testing?
NO 2
DON'T KNOW 8
527) Has (NAME) had an illness with a cough at any time in the last 2 weeks?
NO 2- (SKIP TO 530)
DON'T KNOW 8- (SKIP TO 530)
528) When (NAME) had an illness with a cough, did he/she breath faster than usual with short, rapid breaths?
NO 2- (SKIP TO 531)
DON'T KNOW 8- (SKIP TO 531)
529) Was the fast or difficult breathing due to a problem in the chest or to a blocked or runny nose?
NOSE ONLY 2-- (SKIP TO 531)
BOTH 3-- (SKIP TO 531)
OTHER (SPECIFY) 6-- (SKIP TO 531)
DON'T KNOW 8-- (SKIP TO 531)
NO OR DON'T KNOW- (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 555)
531) Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). Was he/she given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8
532) When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8
533) Did you seek advice or treatment for the diarrhea from any source?
NO 2- (SKIP TO 537)
534) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE(S))___________
DISPENSARY B
MOTHER-INFANT CENTER C
MILITARY INFIRMARY D
HEALTH HUT E
HOSPITAL PHARMACY F
OTHER PUBLIC G
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER I
NATIONAL SOCIAL SECURITY PHARMACY J
PRIVATE DOCTOR'S OFFICE L
NURSE'S OFFICE M
PHARMACY N
OTHER PRIVATE MEDICAL O
SHOP/MARKET Q
OTHER X
ONLY ONE CODE CIRCLED- (SKIP TO 537)
536) Where did you first seek advice or treatment?
USE LETTER CODE FROM 534
537) At any time during the illness, did (NAME) take any drugs for the illness?
NO 2- (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 555)
DON'T KNOW 8- (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 555)
538) What drugs did (NAME) take?
Any other drugs?
RECORD ALL MENTIONED
COARTEM B
QUINIMAX D
SP/FANSIDAR E
CHLOROQUINE F
AMODIAQUINE/FLAVOQUINE/CAMOQUINE/MALOXINE/NIVAQUINE G
OTHER H
INJECTION J
OTHER X
DON'T KNOW Z
3 CODES A, B, AND/OR C
OTHER- (SKIP TO 542)
538b) Which drug was given first?
USE CODES FROM 538
538c) Which drug was given second?
USE CODES FROM 538
538d) Which drug was given third?
USE CODES FROM 538
2 CODES A, B, AND/OR C
OTHER- (SKIP TO 539)
538f) Which drug was given first?
USE CODES FROM 538
538g) Which drug was given second?
USE CODES FROM 538
539) CHECK 538: ANY CODE A-F CIRCLED?
NO-(GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 555)
540) CHECK 538: ARSUCAM (A) GIVEN
CODE A NOT CIRCLED- (SKIP TO 542)
541) How long after the fever started did (NAME) first take (Arsucam)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
542) CHECK 538: COARTEM (B) GIVEN
CODE B NOT CIRCLED- (SKIP TO 544)
543) How long after the fever started did (NAME) first take (Coartem)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
544) CHECK 538: QUININE (C) GIVEN
CODE C NOT CIRCLED- (SKIP TO 546)
545) How long after the fever started did (NAME) first take (Quinine)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
546) CHECK 538: QUINIMAX (D) GIVEN
CODE D NOT CIRCLED- (SKIP TO 548)
547) How long after the fever started did (name) first take (Quinimax)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
548) CHECK 538: SP/FANSIDAR (E) GIVEN
CODE E NOT CIRCLED- (SKIP TO 550)
549) How long after the fever started did (name) first take (SP/Fansidar)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
550) CHECK 538: CHLOROQUINE (F) GIVEN
CODE F NOT CIRCLED- (SKIP TO 551A)
551) How long after the fever started did (NAME) first take (Chloroquine)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
551a) CHECK 538: AMODIAQUINE/FLAVOQUINE/CAMOQUINE/MALOXINE/NIVAQUINE (G) GIVEN
CODE G NOT CIRCLED- (SKIP TO 551C)
551b) How long after the fever started did (NAME) first take (Amodiaquine/Flavoquine/Camoquine/Maloxine/Nivaquine)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
551c) CHECK 538: OTHER ANTIMALARIAL (H) GIVEN
CODE H NOT CIRCLED- (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 555.)
551d) How long after the fever started did (NAME) first take (chloroquine)?
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8
552) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 555.
555) CHECK 522A, ALL COLUMNS:
ANY CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID- (SKIP TO 557)
556) Have you ever heard of a special product called ORS you can get for the treatment of diarrhea?
NO 2
557) CHECK 215 AND 218, ALL ROWS:
ONE OR MORE- (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE TO 558)
NONE- (SKIP TO 601)
558) Now I would like to ask you about liquids or foods that (name from 557) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods.
Did (NAME FROM 557) (drink/eat):
a) plain water?
b) juice or juice drinks?
c) clear broth?
d) milk such as tinned, powdered, or fresh animal milk?
e) Infant formula?
f) Any other liquids?
g) Yogurt?
h) Any commercially fortified baby food, e.g. Cerelac or Bledina]?
i) Gruel made from corn or rice, potatoes, rice, bread, oats, or any other foods made from millet or sorghum?
j) sweet potatoes, pumpkin, carrots, squash or other tubers that are yellow or orange inside?
k) manioc, yams, taro, potatoes, or any other foods made from white tubers?
l) manioc, amaranth, spinach, taro leaves, or any other dark green leaves?
m) mangoes, papayas oranges?
n) any other fruits or vegetables?
o) liver, kidney, heart or any other organ meats?
p) any meat, such as beef, pork, lamb, goat, chicken, turkey, duck?
q) eggs?
r) fresh or dried fish or shellfish?
s) any foods made from beans, peas, lentils, or nuts?
t) cheese or other food made from milk?
u) any other solid, semi-solid, or soft food?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
559) CHECK 558 (CATEGORIES G THROUGH U)
AT LEAST ONE YES- (SKIP TO 561)
560) Did (NAME) eat any solid, semi-solid or soft foods yesterday during the day or at night?
IF YES, PROBE: What kind of solid, semi-solid, or soft foods did (NAME) eat?
NO-2- (SKIP TO 601)
561) How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD 7
DON'T KNOW 8
Section 6. Marriage and sexual activity
601) Are you currently married?
NO 2- (SKIP TO 601B)
601a) Is your marriage civil, religious, or traditional?
RECORD ALL RESPONSES.
RELIGIOUS 2-- (SKIP TO 604)
TRADITIONAL 3-- (SKIP TO 604)
601b) Are you currently living with a man as if married?
NO 2
602) Have you ever been married or lived together with a man as if married?
YES, LIVED WITH A MAN- 2
NO 3- (SKIP TO 612)
603) What is your current marital status: are you a widow, divorced, or separated?
DIVORCED 2- (SKIP TO 609)
SEPARATED 3- (SKIP TO 609)
604) Is your husband/partner living with you now or is he staying elsewhere?
STAYING ELSEWHERE 2
605) RECORD THE LINE NUMBER OF HER HUSBAND/PARTNER ACCORDING TO THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT A LISTED IN THE HOUSEHOLD, RECORD '00'.
LINE NO___________
606) Does your husband/partner have other wives or does he live with other women as if married?
NO 2- (SKIP TO 609)
DON'T KNOW 8- (SKIP TO 609)
607) Including yourself, in total how many wives or live-in partners does he have?
DON'T KNOW- (SKIP TO 609)
608) Are you the first, second?wife?
609) Have you been married or have you lived with a man only once or more than once?
MORE THAN ONCE 2
610) CHECK 609:
MARRIED/LIVED WITH MAN ONLY ONCE --In what month and year did you start living with your (husband/partner)?
MARRIED/LIVED WITH MAN MORE THAN ONCE --I would like to talk about your first (husband/partner). In what month and year were you married or did you start living with him?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
611) How old were you when you started living with him?
611a) CHECK 603: IS RESPONDENT CURRENTLY A WIDOW?
WIDOW- (SKIP TO 611D)
MARRIED/LIVED WITH A MAN ONLY ONCE- (SKIP TO 612)
611c) How did your previous union/marriage end?
DIVORCE 2- (SKIP TO 612)
SEPARATION 3- (SKIP TO 612)
611d) Were you in a civil, religious, or traditional marriage, or did you live with this man as if you were married?
RELIGIOUS MARRIAGE B
TRADITIONAL MARRIAGE C
LIVING WITH MAN D
611e) Who inherited the majority of your late husband/partner's assets?
ASSETS SHARED BETWEEN SELF AND OTHER WIVES 02- (SKIP TO 612)
ASSETS SHARED BETWEEN SELF AND CHILDREN 03- (SKIP TO 612)
ASSETS SHARED BETWEEN SELF AND FAMILY 04- (SKIP TO 612)
OTHER WIFE 05
MY CHILDREN 06
HUSBAND'S OTHER CHILDREN 07
HUSBAND'S OTHER FAMILY 08
OTHER MEMBER OF THE FAMILY 09
OTHER NON-RELATED PEOPLE 10
HUSBAND DIDN'T' HAVE ANYTHING (NO ASSETS) 11- (SKIP TO 612)
OTHER__________ (SPECIFY) 96
611f) Did you receive any of your late husband's assets or valuables?
NO 2
612) CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.
613) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues.
How old were you when you had sexual intercourse for the very first time?
AGE IN YEARS____________
FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND/PARTNER 95
614) Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question.
615) When was the last time you had sexual intercourse.
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.
__________WEEKS AGO 2
_________MONTHS AGO 3
_________YEARS AGO 4- (SKIP TO 627)
616) When was the last time you had sexual intercourse with this person?
______WEEKS AGO 2
______MONTHS AGO 3
617) The last time you had sexual intercourse (with this second/third) person, was a condom used?
NO 2- (SKIP TO 619)
618) Did you use a condom every time you had sexual intercourse with this person in the last 12 months?
NO 2
619) What was your relationship to this person with whom you had sexual intercourse?
IF BOYFRIEND: Were you living together as if married?
IF YES, CIRCLE 2
IF NO, CIRCLE 3
LIVE-IN PARTNER 2
BOYFRIEND NOT LIVING WITH RESPONDENT 3-- (SKIP TO 622)
CASUAL ACQUAINTANCE 4-- (SKIP TO 622)
CLIENT/PROSTITUTE 5-- (SKIP TO 622)
OTHER___________ (SPECIFY) 6-- (SKIP TO 622)
MARRIED MORE THAN ONCE (SKIP TO 622)
OTHER
622) How long ago did you first have sexual intercourse with this (second/third) person?
_______WEEKS AGO 2
_______MONTHS AGO 3
_______YEARS AGO 4
623) How many times during the last 12 months did you have sexual intercourse with this person?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, WRITE 95.
DON'T KNOW 98
625) Apart from (this person/these two people), have you had sexual intercourse with any other persons in the last 12 months?
NO 2 --(SKIP TO 627)
626) In total, how many different people have you had sexual intercourse with in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE 95
DON'T KNOW 98
627) In total, how many different people have you had sexual intercourse with in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE 95
DON'T KNOW 98
628) PRESENCE OF OTHERS DURING THIS SECTION
NO 2
NO 2
NO 2
629) Do you know of a place where a person can get condoms
NO 2- (SKIP TO 632)
630) Where is that?
Any other place?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE(S))___________
MILITARY INFIRMARY B
MOTHER-INFANT CENTER C
FAMILY PLANNING CENTER D
FREE CLINIC E
HEALTH HUT F
CTA-TRAVELING TREATMENT CENTER G
HOSPITAL/HEALTH CENTER PHARMACY H
OTHER PUBLIC I
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER K
NATIONAL SOCIAL SECURITY PHARMACY L
PRIVATE DOCTOR'S OFFICE N
NURSE'S OFFICE P
PRIVATE PHARMACY P
OTHER PRIVATE MEDICAL Q
SHOP/MARKET/DISPLAY S
BAR/NIGHTCLUB/HOTEL T
VENDING MACHINE U
FRIENDS/RELATIVES V
OTHER__________ (SPECIFY) X
631) If you wanted to, could you yourself get a condom?
NO 2
DON'T KNOW/UNSURE 8
Section 7. Fertility preferences
701) CHECK 304:
NEITHER STERILIZED (CODES A AND B NOT CIRCLED)
HE OR SHE STERILIZED (CODES A AND B CIRCLED)-- (SKIP TO 712)
NOT PREGNANT OR UNSURE -- (SKIP TO 704)
703) Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?
NO MORE 2-SKIP TO 711
UNDECIDED/DON'T KNOW 8- (SKIP TO 711)
704) Now I have some question about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?
NO MORE/NONE 2- (SKIP TO 707)
SAYS SHE CAN'T GET PREGNANT 3- (SKIP TO 712)
UNDECIDED/DON'T KNOW -- (SKIP TO 710)
705) CHECK 226:
NOT PREGNANT OR NOT SURE- How long would you like to wait from now before the birth of (a/another) child?
PREGNANT- After the birth of this child you are expecting now, how long would you like to wait before the birth of another child?
________YEARS 2
SOON/NOW 993- (SKIP TO 710)
SAYS SHE CAN'T GET PREGNANT 994- (SKIP TO 712)
AFTER MARRIAGE 995- (SKIP TO 710)
OTHER___________ (SPECIFY) 996- (SKIP TO 710)
DON'T KNOW 998- (SKIP TO 710)
PREGNANT-SKIP TO 711
707) CHECK 303: USING A CONTRACEPTIVE METHOD?
CURRENTLY USING- (SKIP TO 712)
24 OR MORE MONTHS OR 02 OR MORE YEARS
00-23 MONTHS OR 00-01 YEARS- (SKIP TO 711)
709) CHECK 704:
WANTS TO HAVE A/ANOTHER CHILD--You have said that you do not want (a/another) child soon. Can you tell me why you are not using a method to prevent pregnancy?
Any other reason?
WANTS NO MORE/NONE--You have said that you do not want any (more) children. Can you tell me why you are not using a method to prevent pregnancy?
Any other reason?
RECORD ALL REASONS MENTIONED.
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
CAN'T GET PREGNANT E
NOT MENSTRUATED SINCE LAST BIRTH F
BREASTFEEDING G
UP TO GOD/FATALISTIC H
HUSBAND/PARTNER OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
KNOWS NO SOURCE N
LACK OF ACCESS/TOO FAR P
COSTS TOO MUCH Q
PREFERRED METHOD NOT AVAILABLE R
NO METHOD AVAILABLE S
INCONVENIENT TO USE T
INTERFERES WITH BODY'S NORMAL PROCESSES U
DON'____________T KNOW Z
710) CHECK 303: USING A CONTRACEPTIVE METHOD?
NO, NOT CURRENTLY USING
YES, CURRENTLY USING- (SKIP TO 712)
711) Do you think you will use a method to delay or avoid pregnancy at any time in the future?
NO 2
DON'T KNOW 8
712) CHECK 216:
HAS LIVING CHILDREN- If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?
NO LIVING CHILDREN-If you could choose exactly the number of children to have in your whole life, how many would that be?
PROBE FOR A NUMERIC RESPONSE.
NUMBER________
OTHER_______ (SPECIFY) 96- (SKIP TO 714)
713) How many of these children would you like to be boys, how many would you like to be girls, and for how many would it not matter if it's a boy or a girl?
NUMBER GIRLS_____
NUMBER EITHER______
714) In the last three months have you
Heard about family planning on the radio?
Heard about family planning on the television?
Read something on family planning in a newspaper or magazine?
Seen something on family planning on posters?
Heard about family planning in educational conversations?
NO 2
NO 2
NO 2
NO 2
NO 2
715) Have you heard of the Family Planning center, located at the Chinese hospital of Libreville?
NO 2
716) CHECK 601: YES, CURRENTLY MARRIED
NO, NOT IN UNION- (SKIP TO 801)
717) CHECK 303: USING A CONTRACEPTIVE METHOD?
NOT CURRENTLY USING OR NOT ASKED- (SKIP TO 720)
718) Would you say that using contraception is mainly your decision, mainly your (husband's/partner's) decision, or did you both decide together?
MAINLY HUSBAND/PARTNER 2
JOINT DECISION 3
OTHER__________ (SPECIFY) 6
NEITHER STERILIZED (CODE A OR B NOT CIRCLED)
HE OR SHE STERILIZED (CODE A OR B CIRCLED)-- (SKIP TO 801)
720) Does your (husband/partner) want the same number of children that you want, or does he want more or fewer than you want?
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8
SECTION 8. HUSBAND'S BACKGROUND AND WOMAN'S WORK
801) CHECK 601 AND 602:
FORMERLY MARRIED/LIVING WITH A MAN- (SKIP TO 803)
NEVER MARRIED AND NEVER LIVED WITH A MAN- (SKIP TO 807)
802) How old was your (husband/partner) on his last birthday?
803) Did your (last) (husband/partner) ever attend school?
NO 2- (SKIP TO 806)
804) What is the highest level of school he attended: Primary, Secondary, or Higher?
SECONDARY 1ST CYCLE/TECHNICAL MIDDLE SCHOOL 2
SECONDARY 2ND CYCLE/TECHNICAL HIGH SCHOOL 3
HIGHER 4- (SKIP TO 806)
805) What is the highest (grade/form/year) he completed at this level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 00
806) CHECK 801:
CURRENTLY MARRIED/LIVING WITH A MAN: What is your (husband's/partner's) occupation? That is, what kind of work does he mainly do?
FORMERLY MARRIED/LIVED WITH A MAN: What was your (last) (husband's/partner's) occupation? That is, what kind of work did he mainly do?
807) Aside from your own housework, have you done any work in the last seven days?
NO 2
808) As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work?
NO 2
809) Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, maternity leave, or any other such reason?
NO 2
810) Have you done any work in the last 12 months?
NO 2- (SKIP TO 815)
811) What is your occupation, that is, what kind of work do you mainly do?
812) Do you do this work for a member of your family, for someone else, or are you self-employed?
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3
813) Do you usually work throughout the year, or do you work seasonally, or only once in a while?
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3
814) Are you paid in cash or kind for this work or are you not paid at all?
CASH AND KIND 2
IN KIND ONLY 3
NOT PAID 4
NOT IN UNION- (SKIP TO 823)
OTHER- (SKIP TO 819)
817) Who usually decides how the money you earn will be used: you, your (husband/partner), or you and your (husband/partner) jointly?
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
OTHER___________ (SPECIFY) 6
818) Would you say that the money that you earn is more than what your (husband/partner) earns, less than what he earns, or about the same?
LESS THAN HIM 2
ABOUT THE SAME 3
HUSBAND/PARTNER HAS NO EARNINGS 4-SKIP TO 820
DON'T KNOW 8
819) Who usually decides how the money your (husband/partner) earnings will be used: you, your (husband/partner), or you and your (husband/partner) jointly?
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
HUSBAND HAS NO EARNINGS 4
OTHER___________ (SPECIFY) 6
820) Who usually makes decisions about health care for yourself: you, your (husband/partner), you and your (husband/partner) jointly, or someone else?
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER_________ (SPECIFY) 6
821) Who usually makes decisions about making major household purchases?
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER_________ (SPECIFY) 6
822) Who usually makes decisions about visits to your family or relatives?
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER____________ (SPECIFY) 6
823) Do you own this or any other house either alone or jointly with someone else?
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4
824) Do you own any land either alone or jointly with someone else?
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4
825) PRESENCE OF OTHERS AT THIS POINT (PRESENT AND LISTENING, PRESENT BUT NOT LISTENING, OR NOT PRESENT)
PRES./NOT LISTEN 2
NOT PRES. 3
PRESENT/NOT LISTEN 2
NOT PRESENT 3
PRESENT/NOT LISTEN 2
NOT PRESENT 3
PRESENT/NOT LISTEN 2
NOT PRESENT 3
826) In your opinion, is a husband justified in hitting or beating his wife in the following situations:
If she goes out without telling him?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
901) Now I would like to talk about something else.
Have you ever heard of an illness called AIDS?
NO 2- (SKIP TO 937)
902) Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?
NO 2
DON'T KNOW 8
903) Can people get the AIDS virus from mosquito bites?
NO 2
DON'T KNOW 8
904) Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?
NO 2
DON'T KNOW 8
905) Can people get the AIDS virus by sharing food with a person who has AIDS?
NO 2
DON'T KNOW 8
906) Can people get the AIDS virus because of witchcraft or other supernatural means?
NO 2
DON'T KNOW 8
907) Is it possible for a healthy-looking person to have the AIDS virus?
NO 2
DON'T KNOW 8
908) Can the virus that causes AIDS be transmitted from a mother to a baby?
During pregnancy?
During delivery?
By breastfeeding?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
OTHER- (SKIP TO 911)
910) Are there any special drugs that a doctor or a nurse can give to a woman infected with the AIDS virus to reduce the risk of transmission to the baby?
NO 2
DON'T KNOW 8
NO BIRTHS -- (SKIP TO 926)
LAST BIRTH BEFORE JANUARY 2009- (SKIP TO 926)
NO ANTENATAL CARE- (SKIP TO 920)
913) CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.
914) During any of the antenatal visits for your last birth were you given any information about:
Babies getting the AIDS virus from their mother?
Things that you can do to prevent getting the AIDS virus?
Getting tested for the AIDS virus?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
915) Were you offered a test for that AIDS virus as part of your antenatal care?
NO 2
916) I don't want to know the results, but were you tested for the AIDS virus as part of your antenatal care?
NO 2- (SKIP TO 920)
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)____________
FAMILY PLANNING CENTER 12
MOTHER-INFANT CENTER 13
PUBLIC LABORATORY 14
TRAVELING TREATMENT CENTER (CTA) 15
OTHER PUBLIC 15
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER 22
PRIVATE LABORATORY 32
OTHER PRIVATE MEDICAL 33
OTHER PLACE___________ (SPECIFY) 96
918) I don't want to know the results, but did you get the results of the test?
NO 2- (SKIP TO 924)
919) All women are supposed to receive counseling after being tested. After you were tested, did you receive counseling?
NO 2-- (SKIP TO 924)
DON'T KNOW 8-- (SKIP TO 924)
OTHER- (SKIP TO 926)
921) Between the time you went for delivery but before the baby was born, were you offered a test for the AIDS virus?
NO 2
922) I don't want to know the results, but were you tested for the AIDS virus at that time?
NO 2- (SKIP TO 926)
923) I don't want to know the results, but did you get the results of the test?
NO 2
924) Have you been tested for the AIDS virus since that time you were tested during your pregnancy?
NO 2
925) How many months ago was your most recent HIV test?
TWO OR MORE YEAR AGO 95 -- (SKIP TO 932)
926) I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?
NO 2- (SKIP TO 930)
927) How many months ago was your most recent HIV test?
TWO OR MORE YEARS AGO 95
928) I don't want to know the results, but did you get the results of the test?
NO 2
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)______________
FAMILY PLANNING CENTER 12
MOTHER-INFANT CENTER 13
PUBLIC LABORATORY 14
TRAVELING TREATMENT CENTER (CTA) 15
OTHER PUBLIC 15
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER 22
PRIVATE LABORATORY 32
OTHER PRIVATE MEDICAL 33
OTHER PLACE _____________(SPECIFY) 96
930) Do you know of a place where people can go to get tested for the AIDS virus?
NO 2- (SKIP TO 932)
931) 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))_________
MILITARY INFIRMARY B
FAMILY PLANNING CENTER C
MOTHER-INFANT CENTER D
PUBLIC LABORATORY E
TRAVELING TREATMENT CENTER (CTA) F
PLIST/VIHSIDA [ORGANIZATIONS THAT FIGHT SEXUALLY TRANSMITTED INFECTIONS AND HIV/AIDS] G
FREE CLINIC H
HEALTH HUT I
HOSPITAL/HEALTH CENTER PHARMACY J
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER L
NATIONAL SOCIAL SECURITY PHARMACY M
PRIVATE DOCTOR'S OFFICE O
NURSE'S OFFICE P
PRIVATE LABORATORY Q
PRIVATE PHARMACY R
CHURCH T
SPIRITUAL HEALER U
OTHER PLACE X
932) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?
NO 2
DON'T KNOW 8
933) If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
934) If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
935) In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?
SHOULD BE ALLOWED 2
DON'T KNOW/NOT SURE/DEPENDS 8
936) Should children age 12-14 be taught about using a condom to avoid getting AIDS?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
937) Check 901:
Heard about AIDS- Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?
Not heard about AIDS- Have you heard about infections that can be transmitted through sexual contact?
NO 2
NEVER HAD SEXUAL INTERCOURSE- (SKIP TO 946)
939) CHECK 937: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?
NO -- (SKIP TO 941)
940) Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact?
NO 2
DON'T KNOW 8
941) Sometimes women experience a bad-smelling abnormal genital discharge. During the last 12 months, have you had a bad-smelling abnormal genital discharge?
NO 2
DON'T KNOW 8
942) Sometimes women have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?
NO 2
DON'T KNOW 8
HAS NOT HAD AN INFECTION OR DOES NOT KNOW- (SKIP TO 946)
944) The last time you had (infection from 940/941/942), did you seek any kind of advice or treatment?
NO 2- (SKIP TO 946)
Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE
(NAME OF PLACE(S))________________
MILITARY INFIRMARY B
MOTHER-INFANT CENTER C
FAMILY PLANNING CENTER D
PUBLIC LABORATORY E
TRAVELING TREATMENT CENTER (CTA) F
PLIST/VIHSIDA [ORGANIZATIONS THAT FIGHT SEXUALLY TRANSMITTED INFECTIONS AND HIV/AIDS] G
FREE CLINIC H
HEALTH HUT I
HOSPITAL/HEALTH CENTER PHARMACY J
NATIONAL SOCIAL SECURITY MEDICAL-SOCIAL CENTER L
NATIONAL SOCIAL SECURITY PHARMACY M
PRIVATE DOCTOR'S OFFICE O
NURSE'S OFFICE P
PRIVATE LABORATORY Q
PRIVATE PHARMACY R
CHURCH T
SPIRITUAL HEALER U
MARKET/SHOP/DISPLAY V
OTHER PLACE X
946) If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?
NO 2
DON'T KNOW 8
946a) If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sexual intercourse with him?
NO 2
DON'T KNOW 8
947) Is a wife justified in refusing to have sex with her husband when she knows he has sex with other women?
NO 2
DON'T KNOW 8
NOT IN UNION- (SKIP TO 1001)
949) Can you say no to your (husband/partner) if you do not want to have sexual intercourse?
NO 2
DEPENDS/NOT SURE 8
950) Can you ask your (husband/partner) to use a condom if you wanted him to?
NO 2
DEPENDS/NOT SURE 8
SECTION 10. OTHER HEALTH ISSUES
1001) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD 90.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
NONE 00- (SKIP TO 1004)
1002) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or another healthcare worker?
IF THE NUMBER OF INJECTIONS IS OVER 90 OR IF THERE WERE DAILY INJECTIONS IN THE LAST 3 MONTHS OR LONGER, RECORD 90.
IF THE RESPONSE IS NOT NUMERIC, PROBE TO OBTAIN AN ESTIMATE.
NONE-00- (SKIP TO 1004)
1003) The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?
NO 2
DON'T KNOW 8
1004) Do you currently smoke cigarettes?
NO 2- (SKIP TO 1006)
1005) In the last 24 hours, how many cigarettes did you smoke?
1006) Do you currently smoke or use any (other) type of tobacco?
NO 2- (SKIP TO 1008)
1007) What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.
CHEWING TOBACCO B
SNUFF C
OTHER______________ (SPECIFY) X
1008) Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not?
Getting permission to go to the doctor?
Getting money needed for advice or treatment
The distance to the health facility
Not being able to go alone?
Not wanting to go alone?
NOT A BIG PROBLEM 2
NOT A BIG PROBLEM 2
NOT A BIG PROBLEM 2
NOT A BIG PROBLEM 2
NOT A BIG PROBLEM 2
1009) Are you covered by any health insurance?
NO 2
1009a) In the last 12 months, have you been to a public health establishment for yourself or for a member of your family?
NO 2- (SKIP TO 1100)
1009b) Where you satisfied with the services you received during this visit?
NO 2- (SKIP TO 1100)
1009c) What was the main reason for which you were unsatisfied?
TOO EXPENSIVE 02
WAIT TIMES TOO LONG 03
BAD EQUIPMENT 04
ESSENTIAL DRUGS NOT AVAILABLE 05
LACK OF HYGIENE 06
LACK OF CONFIDENTIALITY/PRIVACY 07
LACK OF PERSONNEL 08
PERSONNEL NOT QUALIFIED 09
PERSONNEL NOT FRIENDLY 10
OTHER 96
DON'T KNOW 98
SECTION 11. MATERNAL MORTALITY
1100) 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.
Did your mother give birth to any children other than yourself?
NO 2- (SKIP TO 1107)
1101) How many boys did your mother have who are still living?
1102) Other than yourself, how many girls did your mother have who are still living?
1103) How many boys did your mother have who died?
1104) How many girls did your mother have who died?
1105) Did your mother give birth to any other children, who you don't know if they are living or dead?
NO 2- (SKIP TO 1107)
1106) How many other children did your mother give birth do, who you don't know if they are living or dead?
1107) ADD THE ANSWERS FORM 1101, 1102, 1103, 1104, AND 1106
ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL
1108) CHECK 1107:
Just to make sure that I've understood, including yourself, your mother gave birth to _____ children total. Is that correct?
NO_______- (PROBE AND CORRECT 1100-1107 AS NECESSARY)
ONLY ONE BIRTH (RESPONDENT ONLY)- (SKIP TO 1200)
1110) How many of these births did your mother have before you were born?
Now I would like to make a list of all your brothers and sisters, whether they are still alive or not, starting with the oldest.
RECORD THE NAME OF ALL BROTHERS AND SISTERS FROM THE SAME BIOLOGICAL MOTHER.
1111) What was the name given to your oldest (next oldest) brother or sister?
1112) Is (NAME) male or female?
FEMALE 2
NO 2- (GO TO 1115)
DON'T KNOW 8- (GO TO NEXT SIBLING)
1115) How many years ago did (NAME) die?
1116) How old was (NAME) when he/she died?
IF DON'T KNOW, PROBE:
Did (Name) die before the age of 12?
IF YES, RECORD 95.
IF NO, ASK OTHER QUESTIONS TO GET AN ESTIMATE, FOR EXAMPLE: Did (Name) die before getting married?
IF MAN, OR WOMAN DECEASED BEFORE AGED 12, GO TO 2, 3, 4,ETC
1117) Was (NAME) pregnant when she died?
NO 2
1118) Did (NAME) die during childbirth?
NO 2
1119) Did (Name) die within two months after the end of a pregnancy or childbirth?
NO 2
1120) How many live born children did (name) give birth to during her lifetime?
IF NO OTHER BROTHERS OR SISTERS, GO TO 1200
1200) CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE:
WOMAN NOT SELECTED- (SKIP TO 1233)
1201) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.
PRIVACY NOT POSSIBLE (RETURN ONCE YOU ARE SURE TO BE ALONE WITH RESPONDENT) 2- (SKIP TO 1232)
READ TO THE RESPONDENT:
Now I would like to ask you some questions about some other important aspects of a woman's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in Gabon. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions.
1202) CHECK 601, 601B, AND 602:
FORMERLY IN UNION/LIVED WITH A MAN (READ IN PAST TENSE AND USE 'LAST' WITH HUSBAND/PARTNER)
NEVER MARRIED/NEVER LIVED WITH A MAN- (SKIP TO 1216)
1203) First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) (husband/partner)?
a) He (is/was) jealous or angry if you (talk/talked) to other men?
b) He frequently (accuses/accused) you of being unfaithful?
c) He (does/did) not permit you to meet your female friends?
d) He (tries/tried) to limit your contact with your family?
e) He (insists/insisted) on knowing where you (are/where) at all times?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
1204) Now I need to ask some more questions about your relationship with your (last) (husband/partner).
A) Did your (last) (husband/partner) ever
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
a) say or do something to humiliate you in front of others?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) Threaten to hurt or harm you or someone you care about?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) insult you or make you feel bad about yourself?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
1205)
A) did your (last) (husband/partner) ever do any of the following things to you:
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
a) push you, shake you, or throw something at you?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) slap you
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) twist your arm or pull your hair?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
d) punch you with his fist or with something that could hurt you?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
e) kick you, drag you, or beat you up?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
f) try to chock you or burn you on purpose?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
g) threaten you with a knife, gun, or other type of weapon?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
h) physically force you to have sexual intercourse with him even when you did not want to?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
i) physically force you to perform other sexual acts you did not want to?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
j) Force you with threats or in any other way to perform sexual acts you did not want to?
NO 2
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NOT A SINGLE YES- (SKIP TO 1209)
1207) How long after you first (got married to/started living together) with your (last) (husband/partner) did (this/any of these things) first happen?
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95
1208) Did the following ever happen as a result of what your (last) husband/partner did to you:
NO 2
NO 2
NO 2
1209) Have you ever hit, slapped, kicked or done anything else to physically hurt your (last) (husband/partner) at times when he was not already beating or physically hurting you?
NO 2- (SKIP TO 1211)
1210) In the last 12 months, how often have you done this to your (last) (husband/partner): often, only sometimes, or not at all?
SOMETIMES 2
NOT AT ALL 3
1211) Does (did) your (husband/partner) drink (alcohol)?
NO 2 -- (SKIP TO 1213)
1212) How often does (did) he get drunk: often, only sometimes, or never?
SOMETIMES 2
NEVER 3
1213) Are (were) you afraid of your (last) (husband/partner): many times, sometimes, or never?
SOMETIMES AFRAID 2
NEVER AFRAID 3
MARRIED ONLY ONCE- (SKIP TO 1216)
1215) a) So far we have been talking about the behavior of your (current/last) (husband/partner). Now I want to ask you about the behavior of any previous (husband/partner).
b) How long ago did this last happen?
a) Did any previous (husband/partner) ever hit, slap, kick or do anything else to hurt you physically?
b) How long ago did this last happen?
NO 2
12 OR MORE MONTHS AGO 2
DON'T REMEMBER 3
b) Did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?
b) How long ago did this last happen?
NO 2
12 OR MORE MONTHS AGO 2
DON'T REMEMBER 3
1216) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN:
From the time you were 15 years old has anyone other than (your/any) (husband/partner) hit you, slapped you, kicked you, or done anything else to hurt you physically?
NEVER MARRIED/NEVER LIVED WITH A MAN:
From the time you were 15 years old has anyone hit you, slapped you, kicked you, or done anything else to hurt you physically?
NO 2- (SKIP TO 1219)
REFUSED TO ANSWER/NO ANSWER 6- (SKIP TO 1219)
1217) Who has physically hurt you in this way?
Anyone else?
RECORD ALL MENTIONED
FATHER'S WIFE/PARTNER B
FATHER C
MOTHER'S HUSBAND/PARTNER D
SISTER/BROTHER E
DAUGHTER/SON F
AUNT/UNCLE G
GRANDPARENTS H
OTHER RELATIVE I
CURRENT BOYFRIEND J
EX-BOYFRIEND K
MOTHER-IN-LAW L
FATHER-IN-LAW M
OTHER IN-LAWS N
TEACHER O
EMPLOYER/SOMEONE AT WORK P
POLICE/SOLDIER Q
PRIEST/RELIGIOUS LEADER R
STRANGER IN THE STREET S
OTHER ___________(SPECIFY) X
1218) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?
SOMETIMES 2
NOT AT ALL 3
1219) CHECK 201, 226, AND 230:
NEVER BEEN PREGNANT- (SKIP TO 1222)
1220) Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?
NO 2 -- (SKIP TO 1222)
1221) Who has done any of these things to physically hurt you while you were pregnant?
Anyone else?
RECORD ALL MENTIONED
EX-HUSBAND/PARTNER B
MOTHER C
FATHER'S WIFE/PARTNER D
FATHER E
MOTHER'S HUSBAND/PARTNER F
SISTER/BROTHER G
DAUGHTER/SON H
AUNT/UNCLE I
GRANDPARENTS J
OTHER RELATIVE K
CURRENT BOYFRIEND L
EX-BOYFRIEND M
MOTHER-IN-LAW N
FATHER-IN-LAW O
OTHER IN-LAWS P
TEACHER Q
EMPLOYER/SOMEONE AT WORK R
POLICE/SOLDIER S
PRIEST/RELIGIOUS LEADER T
STRANGER IN THE STREET U
OTHER_________ (SPECIFY) X
1222) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN: Now I want to ask you about things that may have been done to you by someone other than (your/any) (husband/partner).
At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?
NEVER MARRIED/NEVER LIVED WITH A MAN: At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?
NO 2- (SKIP TO 1226)
REFUSED TO ANSWER/NO ANSWER 3- (SKIP TO 1226)
1223) How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?
DON'T KNOW 98
1224) Who was the person who was forcing you at that time?
FORMER HUSBAND/ PARTNER 02
CURRENT BOYFRIEND 03
FORMER BOYFRIEND 04
FATHER 05
MOTHER'S HUSBAND/PARTNER 06
BROTHER/STEP-BROTHER 07
UNCLE 08
GRANDFATHER 09
OTHER RELATIVE 10
IN-LAW 11
OWN FRIEND/ACQUAINTANCE 12
FAMILY FRIEND 13
TEACHER 14
EMPLOYER/SOMEONE AT WORK 15
POLICE/SOLDIER 16
PRIEST/RELIGIOUS LEADER 17
STRANGER 18
OTHER___________ (SPECIFY) X
1225) CHECK 601, 601B AND 602:
EVER MARRIED/EVER LIVED WITH A MAN: In the last 12 months, has anyone other than (your/any) (husband/partner) physically forced you to have sexual intercourse when you did not want to?
NEVER MARRIED/NEVER LIVED WITH A MAN: In the last 12 months, has anyone physically forced you to have sexual intercourse when you did not want to?
NO 2- (SKIP TO 1226)
1225a) Did you ever get pregnant after being forced to have sexual intercourse?
NO 2
REFUSED TO ANSWER/NO ANSWER 3
1226) CHECK 1205 (A-J), 1215, 1216, 1220, 1222, AND 1225:
NOT A SINGLE YES- (SKIP TO 1230)
1227) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?
NO 2- (SKIP TO 1229)
1228) From whom have you sought help?
Anyone else?
RECORD ALL MENTIONED.
HUSBAND'S/PARTNER'S FAMILY B-- (SKIP TO 1230)
CURRENT/FORMER HUSBAND/PARTNER C-- (SKIP TO 1230)
CURRENT/FORMER BOYFRIEND D-- (SKIP TO 1230)
FRIEND E-- (SKIP TO 1230)
NEIGHBOR F-- (SKIP TO 1230)
RELIGIOUS LEADER G-- (SKIP TO 1230)
DOCTOR/MEDICAL PERSONNEL H-- (SKIP TO 1230)
POLICE I-- (SKIP TO 1230)
LAWYER J-- (SKIP TO 1230)
NGO/ASSOCIATION K-- (SKIP TO 1230)
SOCIAL SERVICE ORGANIZATION L-- (SKIP TO 1230)
OTHER_____________ (SPECIFY) X-- (SKIP TO 1230)
1229) Have you ever told anyone about this?
NO 2
1230) As far as you know, did your father ever beat your mother?
NO 2
DON'T KNOW 8
Thank the respondent for her cooperation and reassure her about the confidentiality of her answers. Fill out the questions below with reference to the domestic violence module only.
1231) Did you have to interrupt the interview because some adult was trying to listen, or came into the room, or interfered in any other way?
YES, MORE THAN ONCE 2
NO 3
YES, MORE THAN ONCE 2
NO 3
YES, MORE THAN ONCE 2
NO 3
1232) INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE
MINUTE________
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______________