IDENTIFICATION

PROVINCE* _________________

DISTRICT ___________________
LOCATION/TOWN ___________________
SUBLOCATION/WARD _______________
NASSEP CLUSTER NUMBER ______________
KDHS CLUSTER NUMBER __________________
HOUSEHOLD NUMBER _______________

LOCATION

NAME OF HOUSEHOLD HEAD _____________

NAME AND LINE NUMBER OF MAN _________________

HOUSEHOLD NUMBER __

INTERVIEWER VISITS

INTERVIEW VISIT 1 (REPEAT FOR INTERVIEW VISIT 2 AND VISIT 3)

DATE ______________
INTERVIEWER'S NAME _______________
RESULT** ______________

NEXT VISIT:
DATE ______
TIME _____

FINAL VISIT
DAY ____
MONTH ____
YEAR (2003) ___
INT. CODE ___
RESULT** ____

TOTAL NUMBER OF VISITS __

**RESULT CODES:

LANGUAGE

LANGUAGE OF QUESTIONNAIRE: ENGLISH

LANGUAGE OF INTERVIEW *** ______________

HOME LANGUAGE OF RESPONDENT*** ____________

WAS A TRANSLATOR USED?

*** LANGUAGE CODES:

SUPERVISOR
NAME ________________

FIELD EDITOR
NAME ________________

OFFICE EDITOR __

KEYED BY ___

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

Hello. My name is ___________ and I am working with the Central Bureau of Statistics. 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 about yourself and your family. This information will help the government to plan health services. The survey usually takes between 30 and 40 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

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

Signature of interviewer: __________
Date: __________

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

101. RECORD THE TIME

102. First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in a city, in a town, or in the countryside?

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

104. Just before you moved here, did you live in a city, in a town, or in the countryside?

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

106. In the last 12 months, have you been away from your home community for more than 1 month at a time?

107. In what month and year were you born?

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

109. Have you ever attended school?

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

111. What is the highest (standard/form/year) you completed at that level?

112. CHECK 110:

113. Now I would like you to read this sentence to me.
SHOW SENTENCES TO RESPONDENT.

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE:
Can you read any part of the sentence to me?

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

115. CHECK 113:

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

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

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

119. Are you currently working?

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

121. What have you been doing for most of the time over the last 12 months?

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

123. CHECK 122:

124. 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?

125. During the last 12 months, how many months did you work?

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

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

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

129. What is your religion?

130. What is your ethnic group/tribe?

SENTENCES FOR LITERACY TEST (Q.113)

ENGLISH
1. The child is reading a book.
2. The rains came late this year.
3. Parents must care for their children.
4. Farming is hard work.

KISWAHILI
1. Mtoto anasoma kitabu.
2. Mvua ilichelewa mwaka huu.
3. Nilazima wazazi watunze watoto wao.
4. Ukilima ni kazi ngumu.

SECTION 2. REPRODUCTION AND PREFERENCES

201. Now I would like to ask about any children you have had. 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, WRITE '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, WRITE '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 survived only a few hours or days?

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

208. (In addition to the children that you have just told me about), do you have any (other) sons or daughters who are biologically your children but who are not legally yours or do not have your name?

Did you have any children who died who were biologically your children but who were not legally yours or did not have your name?

IF YES, CORRECT 201-207.

209. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
IF NONE, WRITE '00'.

210. CHECK 209:

211. Do the children that you have fathered all have the same biological mother?

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

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

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 RECOGNISED, AND CODE 2 IF NOT RECOGNISED.

THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.

301. Which ways or methods have you heard about?

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

302. Have you ever used (METHOD)?

303. Now I would like to ask you about when a woman is most likely to get pregnant.
From one menstrual period to the next, are there certain days when a woman is more likely to get pregnant if she has sexual relations?

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

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

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

307. CHECK 301(02) AND 302(02): KNOWLEDGE AND USE OF MALE STERILISATION

308. Once you have had all the children you want, would you yourself ever consider getting sterilised?

309. Why would you never consider getting sterilised?
PROBE: Any other reasons?

RECORD ALL REASONS MENTIONED.

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

402. Do you have one wife or more than one wife?
IF ONLY ONE WIFE, ENTER '01'.
IF MORE THAN ONE, ASK: How many wives do you currently have?

403. Are there any other women with whom you live as if married?

404. Are you living with one (other) woman or more than one (other) woman as if married?
IF ONE LIVE-IN PARTNER, ENTER '01'.

IF MORE THAN ONE, ASK: How many women are you living with as if you were married?

405. Apart from the woman/women you have already mentioned, do you currently have any other regular or occasional sexual partners?

406. Do you currently have regular, occasional, or no sexual partners?

407. Have you ever been married or lived with a woman?

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

409. WRITE THE LINE NUMBERS FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE/PARTNER REPORTED IN QUESTIONS 402 AND 404 ONLY.

IF A WIFE/PARTNER IS NOT LISTED IN THE HOUSEHOLD SCHEDULE, ENTER '00' IN THE LINE NUMBER BOXES. THE NUMBER OF LINES FILLED IN MUST BE EQUAL TO THE NUMBER OF WIVES AND PARTNERS.

(IF RESPONDENT HAS MORE THAN FIVE WIVES/PARTNERS USE ADDITIONAL QUESTIONNAIRE(S).

CHECK 402 AND 404
SUM OF 402 AND 404 = 01 ___
Please tell me the name of your wife/partner.

SUM OF 402 AND 404 GREATER THAN 01 __
Please tell me the name of each wife/partner that you live with as if married, starting with the one you lived with first.

410. CHECK 409:

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

412. Have you ever been married to or lived as if married to any woman other than those you have just mentioned?

413. In total, how many women have you been married to or lived with as if married in your whole life?

414. CHECK 409 AND 411:

ONLY ONE WIFE/PARTNER AND 411=ONCE __
In what month and year did you start living with your wife/partner?

OTHER ___
Now we will talk about your first wife/partner. In what month and year did you start living with her?

415. How old were you when you started living with her?

416. Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family life issues.

How old were you when you first had sexual intercourse with a woman (if ever)?

416A. CHECK 108:

416B. The first time you had sexual intercourse, did you use a condom?

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

418. The last time you had sexual intercourse with a woman, did you use a condom?

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

420. CHECK 302(02):

421. The last time you had sexual intercourse with a woman, did you or she do something or use any method to avoid a pregnancy?

422. What method was used?
IF MORE THAN ONE METHOD USED, RECORD THE HIGHEST METHOD ON THE LIST.

423. What is the main reason a method was not used?

424. What is your relationship to the woman with whom you last had sex?

IF WOMAN IS 'GIRLFRIEND' OR 'FIANCE', ASK:
Was your girlfriend/fiancé living with you when you last had sex?

IF YES, RECORD '01'.
IF NO, RECORD '02'.

425. For how long have you had (or did you have) a sexual relationship with this woman?
IF ONLY HAD SEX WITH THIS WOMAN ONCE, WRITE '01' DAYS.

426. Have you had sex with any other woman in the last 12 months?

427. The last time you had sexual intercourse with another woman, did you use a condom?

428. What is the main reason you used a condom on that occasion?

429. CHECK 302(02):

430. The last time you had sexual intercourse with this woman, did you or she do something or use any method to avoid a pregnancy?

431. What method was used?
IF MORE THAN ONE METHOD USED, CIRCLE THE HIGHEST METHOD ON THE LIST.

432. What is the main reason a method was not used?

433. What is your relationship to this other woman?
IF WOMAN IS 'GIRLFRIEND' OR 'FIANCE', ASK:

Was your girlfriend/fiancé living with you when you last had sex?
IF YES, RECORD '01'.
IF NO, RECORD '02'.

434. For how long have you had (or did you have) a sexual relationship with this woman?
IF ONLY HAD SEX WITH THIS WOMAN ONCE, WRITE '01' DAYS.

435. Other than these two women, have you had sex with any other woman in the last 12 months?

436. The last time you had sexual intercourse with this third woman, did you use a condom?

437. What is the main reason you used a condom on that occasion?

438. CHECK 302(02):

439. The last time you had sexual intercourse with this third woman, did you or she do something or use any method to avoid a pregnancy?

440. What method was used?
IF MORE THAN ONE METHOD USED, RECORD THE HIGHEST METHOD ON THE LIST.

441. What is the main reason a method was not used?

442. What is your relationship to this woman?

IF WOMAN IS 'GIRLFRIEND' OR 'FIANCE', ASK:
Was your girlfriend/fiancé living with you when you last had sex?

IF YES, RECORD '01'. IF NO, RECORD '02'.

443. For how long have you had (or did you have) a sexual relationship with this woman?
IF ONLY HAD SEX WITH THIS WOMAN ONCE, WRITE '01' DAYS.

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

445. Have you ever paid for sex?

446. How long ago was the last time you paid for sex?

447. The last time that you paid for sex, did you use a condom on that occasion?

448. Do you know of a place where one can get condoms?

449. What places do you know of where a person can get condoms? Any other place?

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

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

451. CHECK 302(07), 416B, 418, 427, 436, AND 447: EVER USED A CONDOM?

452. How old were you when you used a condom for the first time?

453. Why did you use a condom that first time?
PROBE: Any other reason?
RECORD ALL REASONS MENTIONED.

454. Have you ever experienced any problems with using condoms?
IF YES: What problems have you experienced?
PROBE: Any other problems?
CIRCLE ALL PROBLEMS MENTIONED.

455. What brand of condom do you usually use?
ASK TO SEE CONDOM PACKET IF BRAND NOT KNOWN.

456. Where do you usually get the condoms?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
(NAME OF PLACE) ________

457. How much do you usually pay for a packet of condoms?

458. How many condoms are in each packet?

459. Do you think that at this price condoms are inexpensive, just affordable, or too expensive?

460. I will now read you some statements about condom use. Please tell me if you agree or disagree with each.

461. In your opinion, is it acceptable or unacceptable for condoms to be advertised:

on the radio?
on the TV?
in newspapers?

SECTION 5. FERTILITY PREFERENCES

501. CHECK 401:

502. Is your wife/partner currently pregnant?
IF MORE THAN ONE WIFE/PARTNER, ASK: Are any of your wives/partners currently pregnant?

503. CHECK 502:

WIFE NOT PREGNANT/ NOT SURE (CODE '2' OR '3') __
Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

YES, WIFE PREGNANT (CODE '1') __
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?

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

505. CHECK 203 AND 205:

HAS LIVING CHILDREN __
If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?

NO LIVING CHILDREN __
If you could choose exactly the number of children to have in your whole life, how many would that be?

PROBE FOR A NUMERIC RESPONSE.

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?

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

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

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

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

SECTION 6. HEALTH ISSUES

601. Now I would like to ask you some questions about health. When a child has diarrhea, should he or she be given less to drink than usual, about the same amount, or more to drink than usual?

602. Have you ever heard of a special product called [LOCAL NAME FOR ORS] you can get for the treatment of diarrhea?

603. Now please tell me about yourself. Do you smoke cigarettes or use tobacco?
IF YES: What type of tobacco do you smoke?
CIRCLE ALL TYPES MENTIONED.

604. CHECK 603:

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

606. Have you ever drunk any kind of alcohol like beer, wine, whiskey, gin, vodka, etc.?

607. In the last month, on how many days did you drink any alcohol-containing beverage?
IF EVERY DAY, RECORD '30'.

SECTION 7. AIDS AND OTHER SEXUALLY-TRANSMITTED DISEASES

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

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

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

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

705. Can a person get the AIDS virus from mosquito or other insect bites?

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

707. Can a person get the AIDS virus by sharing utensils with a person who has AIDS?

708. Can people reduce their chances of getting the AIDS virus by not having sex at all?

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

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

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

712. Can the virus that causes AIDS be transmitted from a mother to her child...

During pregnancy?
During delivery?
By breastfeeding?

712A. Can a mother who is infected with the AIDS virus reduce the risk of giving the virus to the baby by taking certain drugs during pregnancy?

713. CHECK 401:

714. Have you ever talked with (your wife/woman you are living with) about ways to prevent getting the virus that causes AIDS?
IF MORE THAN ONE WIFE/PARTNER, ASK ABOUT ANY OF HIS WIVES/PARTNERS.

714A. Would you buy fresh vegetables from a vendor who has the AIDS virus?

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

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

716A. If a female teacher has the AIDS virus, should she be allowed to continue teaching in school?

716B. Should children aged 12-14 be taught about using a condom to avoid AIDS?

716B1. Do you think your chances of getting AIDS are small, moderate, great, or no risk at all?

716B2. Why do you think that you have (no risk/a small chance) of getting AIDS?
Any other reasons?
CIRCLE ALL MENTIONED.

716B3. Why do you think that you have a (moderate, great) chance of getting AIDS?
Any other reasons?
CIRCLE ALL MENTIONED.

716B4. Have you ever heard of VCT?

716C. I do not want to know the results, but have you ever been tested to see if you have the AIDS virus?

716C1. When was the last time you were tested?

716C2. The last time you were tested, did you ask for the test, was it offered to you and you accepted, or was it required?

716C3. I do not want to know the results, but did you get the results of the test?

716D. Would you want to be tested for the AIDS virus?

716E. Do you know a place where you could go to get an AIDS test?

716F. Where can you go for the test?

716FX. Where did you go for the test?
IF SOURCE IS HOSPITAL, HEALTH CENTRE, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

718. If a man has a sexually transmitted disease, what symptoms might he have?
Any others?
CIRCLE ALL MENTIONED.

719. If a woman has a sexually transmitted disease, what symptoms might she have?
Any others?
CIRCLE ALL MENTIONED.

719A. CHECK 416:

719B. Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a sexually-transmitted disease?

719C. Sometimes, men experience an abnormal discharge from their penis. During the last 12 months, have you had an abnormal discharge from your penis?

719D. 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?

719E. CHECK 719B/719C/719D:

719F. The last time you had (PROBLEM(S) FROM 719B/719C/719D), did you seek any kind of advice or treatment?

719G. The last time you had (PROBLEM(S) FROM 719B/719C/719D), did you do any of the following? Did you...

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

719H. When you had (PROBLEM(S) FROM 719B/719C/719D), did you tell the person(s) with whom you were having sex?

719I. When you had (PROBLEM(S) FROM 719B/719C/719D), did you do anything to avoid infecting your sexual partner(s)?

719J. What did you do to avoid infecting your partner(s)? Did you...

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

720. Are you circumcised?

721. In many communities, girls are also circumcised. In your community, is female circumcision practiced?

722. CHECK 203 AND 205:

723. Has your eldest daughter been circumcised?

724. Do you plan to have your eldest daughter circumcised?

SECTION 8. ATTITUDES TOWARDS WOMEN

801. 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:

802. 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...

803. When a wife knows her husband has a sexually transmitted disease, is she justified in asking her husband to use a condom?

804. 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...

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

806. RECORD THE TIME

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:
__________________________________

COMMENTS ON SPECIFIC QUESTIONS:
_______________________________

ANY OTHER COMMENTS:
_______________________________

SUPERVISOR'S OBSERVATIONS

_______________________________

NAME OF THE SUPERVISOR:__________
DATE:____________________

EDITOR'S OBSERVATIONS

_______________________________

NAME OF EDITOR:________________________

DATE:_____________________