IDENTIFICATION

PLACE NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
SEQUENTIAL NUMBER OF THE HOUSEHOLD WITHIN THE CLUSTER_____
BUILDING NUMBER _____
HOUSEHOLD UNIT NUMBER _____
REGION _____
VILLAGE _____

ANTANANARIVO/OTHER CITY/RURAL AREA?

NAME AND LINE NUMBER OF RESPONDENT:

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____

RESULT _____

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INTERVIEWER CODE _____
RESULT _____

TOTAL NUMBER OF VISITS _____

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____
KEYED BY _____

SECTION 1: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENT

INTRODUCTION AND CONSENT

CONSENT AFTER INFORMATION:
Hello. My name is ______ and I am working with (NAME OF ORGANIZATION). We are in the process of conducting a national survey in which we ask women (and men) questions about health-related problems. We would very much appreciate your participation in this survey. This information will be very useful to the government in order to put health services in place. The survey usually takes between 30 and 60 minutes to complete. The information you will give us is strictly confidential and will not be shared with anyone other than the survey team.

Participation in this survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important to us.

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

SIGNATURE OF INTERVIEWER______
DATE ______

101. RECORD THE TIME:

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

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

106. In what month and year were you born?

107. How old were you at your last birthday?
COMPARE AND CORRECT 106 AND/OR 107 IF INCONSISTENT.

108. Have you ever attended school?

109. What is the highest level of school you attended: primary, middle school, high school, or higher?

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

111. CHECK 109:

112. Now I would like you to read this sentence to me; read as much as you can.

SHOW CARD TO RESPONDENT.

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

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

114. CHECK 112:

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

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

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

118. What is your religion?

SECTION 2. REPRODUCTION

Now I would like to ask about all the children you have had during your life. I want to know about all of your biological children, even if they are not legally yours or do not have your last name.

201. Do you have/have you had any children?

202. Do you have any sons or daughters of whom you are the father who are now living with you?

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

204. Do you have any sons or daughters of whom you are the father and are alive but do not live with you?

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

206. Have you ever fathered a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life at birth but did not survive?

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

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

209. CHECK 208:

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

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

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

213. CHECK 203 AND 205:

214. How old is your youngest child?

215. CHECK 214:

216. What is the name of your (youngest) child?
WRITE NAME OF (YOUNGEST) CHILD.

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

218. Were you ever present during any of those antenatal checkups?

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

220. What was the main reason why (NAME)'s mother did not deliver in a hospital or health facility?

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

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.

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

CIRCLE CODE '1' IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE '1' IF METHOD IS RECOGNIZED AND CODE '2' IF NOT RECOGNIZED. THEN, FOR METHODS 02, 07, 10, AND 11 WITH CODE '1' CIRCLED IN 301, ASK 302.

302. Have you ever used (METHOD)?
THIS QUESTION IS ASKED ABOUT METHODS 02, 07, 10, AND 11 IN 301 WITH '1' CIRCLED.

303. In the last few months have you:

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

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

Now I would like to ask you about a woman's risk of pregnancy.

305. 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?

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

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

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

A. Contraception is a woman's business and a man should not have to worry about it.
B. Women who use contraception may become promiscuous.

309. CHECK 301 (07):
KNOWS MALE CONDOM?

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

311. Where is that?
Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE INSTITUTION, WRITE THE NAME OF THE PLACE.

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

SECTION 4: MARRIAGE AND SEXUAL ACTIVITY

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

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

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

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

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

406. In total, how many wives do you have or partners do you live with now as if married?

407. CHECK 405:

ONE WIFE/PARTNER: Please tell me the name of your wife (the woman you are living with as if married).

MORE THAN ONE WIFE/PARTNER: Please tell me the names of each of your current wives (and/or of each woman you are living with as if married).

RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER. IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'. ASK 408 FOR EACH PERSON.

408. How old was (NAME) on her last birthday?
ASK FOR SPOUSE(S)/PARTNER(S) OF RESPONDENT.

409. CHECK 407:

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

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

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

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

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

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

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

415. CHECK 107:

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

417. CHECK 107:

418. The first time you had sexual intercourse, was a condom used?

419. 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.

420. 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. (GO TO 422)

421. When was the last time you had sexual intercourse with this person?
ASK FOR PAST SEXUAL PARTNERS ONLY.

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

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

424. What was your relationship to this person with whom you had sexual intercourse?
IF GIRLFRIEND: Were you living together as if married?
IF YES, CIRCLE '2'. IF NO, CIRCLE '3'.

425. For how long (have you had/did you have) a sexual relationship with this person?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.

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

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

428. Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?
DO NOT ASK FOR LAST PARTNER.

429. In total, with how many people have you had sexual intercourse in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.
[DO NOT ASK FOR MOST RECENT OR SECOND-MOST-RECENT PARTNER]

429A. In total, with how many people have you had sexual intercourse in the last month?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.
[DO NOT ASK FOR MOST RECENT PARTNER]

430. CHECK 424 (ALL PARTNERS):

431. CHECK 424 AND 422 (ALL PARTNERS):

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

433. The last time you paid someone in exchange for having sexual intercourse, was a condom used?

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

435. In total, with how many different people have you had sexual intercourse in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.

436. CHECK 422:
MOST RECENT PARTNER (FIRST COLUMN):

437. You told me that a condom was used the last time you had sex. May I see the package of condoms you were using at that time?
RECORD NAME OF BRAND IF PACKAGE SEEN.

438. Do you know the brand name of the condom used at that time?
RECORD NAME OF BRAND.

439. How many condoms did you get the last time?

440. The last time you obtained the condoms, how much did you pay in total, including the cost of the condom(s) and any consultation you may have had?

441. From where did you obtain the condom the last time?

PROBE TO IDENTIFY TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE INSTITUTION, WRITE THE NAME OF THE PLACE.

442. CHECK 302 (02):
RESPONDENT IS STERILIZED?

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

444. What method did you or your partner use?
PROBE: Did you or your partner use another method to prevent pregnancy?

SECTION 5: FERTILITY PREFERENCES

501. CHECK 407:

502. CHECK 302:

503. Is (your wife(partner)/one of your wives(partners) currently pregnant?

504. CHECK 503:

NO WIFE/PARTNER PREGNANT OR DOESN'T KNOW: 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?

WIFE(WIVES)/PARTNER(S) PREGNANT: Now I have some questions about the future. After the child(ren) you and your (wife(wives)/partner(s)) are expecting now, would you like to have another child, or would you prefer not to have any more children?

505. CHECK 407:

506. CHECK 503:

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

WIFE/PARTNER PREGNANT: After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?

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

508. 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.

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

SECTION 6: EMPLOYMENT AND GENDER ROLES

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

602. 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?

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

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

605. CHECK 604:

606. 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?

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

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

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

610. CHECK 407:

611. CHECK 609:

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

613. 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:

A. Making major household purchases?
B. Making purchases for daily household needs?
C. Deciding about visits to the wife's family or relatives?
D. Deciding what to do with the money she earns for her work?
E. Deciding how many children to have?

614. I will now read you some statements about pregnancy. Please tell me if you agree or disagree with them:

A. Childbearing is a woman's concern and there is no need for the father to get involved.
B. It is crucial for the mother's and child's health that a woman has assistance from a doctor or nurse at delivery.

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

If she goes out 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?

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

A. Get angry and reprimand her?
B. Refuse to give her money or other means of support?
C. Use force to have sex with her even if she doesn't want to?
D. Go ahead and have sex with another woman?

SECTION 7: HIV/AIDS

Now I would like to talk about something else.

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

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

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

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

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

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

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

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

709. Can the virus that causes AIDS be transmitted from a mother to her baby:

During pregnancy?
During delivery?
By breastfeeding?

710. CHECK 709:

711. 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?

712. Have you heard about special antiretroviral drugs that people infected with the AIDS virus can get from a doctor or a nurse to help them live longer?

712A. CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

713. I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?

714. When was the last time you were tested?

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

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

717 Where was the test done?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE INSTITUTION, WRITE THE NAME OF THE PLACE.

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

719. Where is that?
Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE INSTITUTION, WRITE THE NAME OF THE PLACE.

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

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

722. If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?

723. 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?

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

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

733. CHECK 701:

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

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

733A. What are the signs or symptoms in a man that make you think he may have a sexually transmitted infection?
INSIST: Anything else?
RECORD ALL MENTIONED.

733B. What are the signs or symptoms in a woman that make you think she may have a sexually transmitted infection?
INSIST: Anything else?
RECORD ALL MENTIONED.

733C. Have you obtained any free condoms within the last 12 months?

734. CHECK 414:

735. CHECK 733:
HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

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

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

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

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

739. CHECK 736, 737, AND 738:

740. The last time you had (PROBLEM FROM 736/737/738) did you seek any kind of advice or treatment?

741. Where did you go?
Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE INSTITUTION, WRITE THE NAME OF THE PLACE.

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

743. 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?

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

745. Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women?

SECTION 8: OTHER HEALTH ISSUES

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

802. How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORD ALL MENTIONED.

803. Can tuberculosis be cured?

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

805. Some men are circumcised.
Are you circumcised?

Now I would like to ask you some other questions relating to health matters.

806. 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 GREATER THAN 90, OR DAILY FOR THREE MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

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

IF NUMBER OF INJECTIONS IS GREATER THAN '90', OR DAILY FOR THREE MONTHS OR MORE, RECORD '09'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

808. The last time you had an injection given to you by a health worker, where did you go to get the injection?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE INSTITUTION, WRITE THE NAME OF THE PLACE.

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

810. Do you currently smoke cigarettes?

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

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

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

814. Are you covered by health insurance?

815. What type of health insurance?
RECORD ALL MENTIONED.

816. 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 _____
DATE _____

EDITOR'S OBSERVATIONS _____
NAME _____
DATE _____