NAME OF HOUSEHOLD HEAD_______
PLACE NAME ________
PROVINCE_______
URBAN/RURAL
RURAL 2
NAME AND NUMBER OF ENUMERATION AREA (DHS I.D.)_____
HOUSEHOLD NUMBER_______
NAME AND LINE NUMBER OF MAN_______
HOUSEHOLD SELECTED TO INTERVIEW MEN____
MAN SELECTED FOR DOMESTIC VIOLENCE MODULE___
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_________
INTERVIEWER'S NAME_________
RESULT___
ABSENT 2
POSTPONED 3
REFUSED COMPLETELY 4
REFUSED DURING INTERVIEW 5
PARTLY COMPLETED/INCOMPLETE 6
INCAPACITATED 7
OTHER (SPECIFY) ________ 8
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE_________
TIME_________
FINAL VISIT
DAY_________
MONTH_________
YEAR 2011
CODE_________
RESULT_________
TOTAL NUMBER OF VISITS_________
SUPERVISOR
NAME_________
DATE_________
SECTION 1: RESPONDENT'S BACKGROUND
INTRODUCTION AND CONSENT
Good morning/afternoon. My name is _________(SAY YOUR NAME) and I am working with the INE and here is my identification (SHOW YOUR ID BADGE). We are conducting a survey about health all over the country.The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 to 45 minutes to complete. All of the answers you give will be kept strictly confidential and will not be shared with anyone other than members of our survey team. We hope that you will participate in this survey since your views are important. If I ask you a 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 that you need more information about the survey, you may contact the province delegate of Statistics.
Do you have any questions? May I begin the interview now?
SIGNATURE OF INTERVIEWER:____________
DATE:________________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END INTERVIEW)
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 03 IF INCONSISTENT
104. Have you ever attended school?
NO 2 (GO TO 108)
105. What is the highest level of school you attended?
PRIMARY EP1 01
PRIMARY EP2 02
SECONDARY ESG1 03
SECONDARY ESG2 04
TECHNICAL ELEMENTARY 05
TECHNICAL BASIC 06
TECHNICAL ADVANCED 07
TEACHER PREP 08
HIGHER 09
DON'T KNOW 98
106. What is the highest grade/year you completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'
SECONDARY OR HIGHER (GO TO 110)
108. Now I would like you to read this sentence to me.
SHOW CARD TO RESPONDENT IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE)_____ 4
BLIND/VISUALLY IMPAIRED 5
CODE '1' OR '5' CIRCLED (GO TO 111)
110. Do you read the newspaper or magazine at least once a week, less than once a week or not at all?
LESS THAN ONCE A WEEK 2
NOT AT ALL 3
111. Do you listen to the radio at least once a week, less than once a week or not at all?
LESS THAN ONCE A WEEK 2
NOT AT ALL 3
112. Do you watch television at least once a week, less than once a week or not at all?
LESS THAN ONCE A WEEK 2
NOT AT ALL 3
MUSLIM 02
ZION 03
EVANGELICAL/PENTECOSTAL 04
ANGLICAN 05
NO RELIGION 06 (GO TO 114)
OTHER (SPECIFY) _____96
113B. How often do you go to the church/mosque?
MORE THAN ONCE A MONTH 2
ONLY DURING HOLIDAY 3
NEVER 4
114. What language did you grow up speaking?
PORTUGUESE 02
XINCHANGANA 03
CISENA 04
ELOMWE 05
ECHUWABO 06
SHONA 07
OTHER (SPECIFY) _____96
115. In the last 12 months, how many times have you been away from home for one or more nights?
NONE 00 (GO TO 201)
116. In the last 12 months, have you been away from home for one month at a time?
NO 2
201. Now I would like to ask about all the children you have had/fathered during your life (and if the children are still alive). Do you have any children (male or female)?
NO 2 (GO TO 206)
DON'T KNOW 8 (GO TO 206)
202. Do you have any sons or daughters who are now living with you?
NO 2 (GO TO 204)
203. How many sons live with you? And how many daughters live with you?
IF NONE RECORD '00'
204. Do you have any sons or daughters that do not live with you?
NO 2 (GO TO 206)
205. How many sons are living somewhere else? And how many daughters are living somewhere else?
IF NONE RECORD '00'
206. Have you ever had a boy or a girl 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?
NO 2 (GO TO 208)
DON'T KNOW 8 (GO TO 208)
207. How many boys have died? And how many girls have died?
IF NONE RECORD '00'
208. SUM ANSWERS TO 203, 205, AND 207 AND RECORD THE TOTAL. IF NONE, RECORD '00'
209. CHECK 208 IF ONE OR MORE BORN ALIVE:
HAS HAD ONLY ONE CHILD (GO TO 212)
HAS NOT HAD ANY CHILDREN (GO TO 301)
210. Did all of the children you have fathered have the same biological mother?
NO 2
211. In total, with how many women/partners do you have children?
212. How old were you when your first child was born?
NO LIVING CHILDREN (GO TO 301)
214. How many years old is your (youngest) child?
OTHER (GO TO 301)
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 check-ups?
NO 2 (GO TO 219)
DON'T KNOW 8 (GO TO 219)
218. Were you ever present during any of those antenatal check-ups?
NOT PRESENT 2
219. Was (NAME) born in a hospital or health facility?
OTHER (SPECIFY) ___ 2
220. When a child has diarrhea, how much should he or she be given to drink: more than usual, the same amount as usual, less than usual, or should he or she not be given anything to drink at all?
ABOUT THE SAME 2
LESS THAN USUAL 3
NOTHING TO DRINK 4
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 pregnancy. Have you heard of (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
'
NO 2
NO 2
NO 2
NO 2
NO 2
302. In the last few months have you:
NO 2
NO 2
NO 2
NO 2
NO 2
303. In the last few months have you discussed the practice of family planning with a health worker or health professional?
NO 2
304. Now I would like to ask you about a woman's risk of pregnancy. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations?
NO 2 (GO TO 306)
DON'T KNOW 8 (GO TO 306)
305. 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 HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY)____ 5
DON'T KNOW 8
306. I will now read some sentences about contraception. Please tell me if you agree or disagree with each one.
DISAGREE 2
DON'T KNOW 8
DISAGREE 2
DON'T KNOW 8
307. CHECK 301 (07):
KNOWS MALE CONDOM
NO (GO TO 401)
308. Do you know of a place where a person can get condoms?
NO 2 (GO TO 401)
309. Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
PROVINCIAL/GENERAL HOSPITAL B
RURAL HOSPITAL C
HEALTH CENTER/POST D
PHARMACY E
MOBILE CLINIC F
OTHER (SPECIFY)____ G
PRIVATE DOCTOR I
PRIVATE NURSE J
PRIVATE PHARMACY K
OTHER (SPECIFY)____L
CHURCH N
SCHOOL O
FRIEND/RELATIVE P
TRADITIONAL HEALER Q
PARTNER R
INFORMATION STAND/BOOTH S
SHOP T
BAR/ DISCOTHEQUE U
GAS STATION V
ADOLESCENT SPECIAL SERVICES Z
310. If you wanted to, could you yourself get a condom?
NO 2
DON'T KNOW 3
SECTION 4. MARRIAGE AND SEXUAL ACTIVITY
401. Are you currently married or living together with a woman as if married?
YES, LIVING WITH A WOMAN 2 (GO TO 404)
NO, NOT IN UNION 3
402. Have you ever been married or lived together with a woman as if married?
YES, LIVED WITH A WOMAN 2
YES, BOTH
NO 4 (GO TO 413)
403. What is your marital status now: are you widowed, divorced, or separated?
DIVORCED 2 (GO TO 410)
SEPARATED 3 (GO TO 410)
404. Is your wife/partner living with you now or is she staying elsewhere?
STAYING ELSEWHERE 2
405. Do you have more than one wife or woman you live with as if married?
NO 2 (GO TO 407)
406. Altogether, how many wives do you have or other partners do you live with as if married?
ONE WIFE/PARTNER: Please, tell me the name of your wife/partner (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/partners (and/or each woman you are living with as if married).
RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER. IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'. ASK 408 FOR EACH WIFE/PARTNER.
408. How old was (NAME) on her last birthday?
MORE THAN ONE WIFE/PARTNER (GO TO 411A)
410. Have you been married or lived with a woman only once or more than once?
MORE THAN ONCE 2 (GO TO 411A)
411. In what month and year did you start living with your (wife/partner)?
411A. Now I would like to ask a question about your first wife/partner. In what month and year did you start living with your first wife/partner?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
412. How old were you when you first started living with her?
413. CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.
414. Now I would like 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) WIFE/PARTNER 95
415. Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question you don't want to answer, just let me know and we will go to the next question.
416. When was the last time you had sexual intercourse?
IF ANSWER IS IN LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS OR MONTHS. IF IS 12 OR MORE MONTHS ANSWER MUST BE RECORDED IN YEARS. IF ANSWER IS SAME DAY, RECORD '00'.
WEEKS AGO 2___
MONTHS AGO 3____
YEARS AGO 4_____ (GO TO 430)
417. When was the last time you had sexual intercourse with this person?
WEEKS 2_____
MONTHS 3____
418. The last time you had sexual intercourse (with this second/third person), was a condom used?
NO 2 (GO TO 420)
419. Did you use a condom every time you had sexual intercourse with this person in the last 12 months?
NO 2
420. What was your relationship to this (second/third) person with whom you had sexual intercourse? IF GIRLFRIEND: Were you living together as if married?
IF YES, CIRCLE '2', IF NO, CIRCLE '3'
LIVE-IN PARTNER 2
GIRLFRIEND NOT LIVING WITH RESPONDENT 3 (GO TO 423)
CASUAL ACQUAINTANCE 4 (GO TO 423)
PROSTITUTE 5 (GO TO 423)
OTHER (SPECIFY)_____ 6 (GO TO 423)
MARRIED MORE THAN ONCE (GO TO 423)
OTHER (GO TO 423)
423. How long ago (have you had/did you have) a sexual relationship with this (second/third) person?
IF ONLY MORE THAN 95 TIMES, RECORD '95'.
MONTHS 2____
YEARS 3____
424. How many times during the last 12 months did you have sexual intercourse with this person?
DON'T KNOW 98
426. Apart from [this person/these two people], have you had sexual intercourse with any other person in the last 12 months?
NO 2 (GO TO 428)
427. In total, with how many different people have you had sexual intercourse in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'
DON'T KNOW 98
NO PARTNERS ARE PROSTITUTES (GO TO 430)
429. CHECK 420 AND 418 (ALL COLUMNS):
OTHER (GO TO 434)
430. In the last 12 months, did you pay anyone in exchange for having sexual intercourse?
NO 2
431. Have you ever paid anyone in exchange for having sexual intercourse?
NO 2 (GO TO 434)
432. The last time you paid someone in exchange for having sexual intercourse, was a condom used?
NO 2 (GO TO 434)
433. Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse in the last 12 months?
NO 2
DON'T KNOW 8
434. 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'
DON'T KNOW 98
435. CHECK 418, MOST RECENT PARTNER (FIRST COLUMN):
NOT ASKED (GO TO 438)
NO CONDOM USED (GO TO 438)
436. You told me that a condom was used the last time you had sex. Do you know the brand name of the condom used at that time?
IF BRAND IS NOT KNOWN, ASK TO SEE PACKAGE.
RECORD ALL MENTIONED.
TRUST B
DUREX C
CONDOMI D
MANOBRA E
CONFIANÇA F
PRODENCE G
KAMA SUTRA H
OTHER (SPECIFY)____X
DON'T KNOW Y
437. From where did you obtain the condoms the last time? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
PROVINCIAL/GENERAL HOSPITAL 12
RURAL HOSPITAL 13
HEALTH CENTER/POST 14
MOBILE CLINIC15
PHARMACY 16
OTHER (SPECIFY)____ 17
PRIVATE DOCTOR 22
PRIVATE NURSE 23
PRIVATE PHARMACY 24
STORE 25
GAS STATION 26
BAR/ DISCOTHEQUE 27
INFORMATION STAND/BOOTH 28
OTHER (SPECIFY)____29
MARKET/STORE 32
CHURCH 33
FRIEND/RELATIVE 34
TRADITIONAL HEALER 35
ADOLESCENT SPECIAL SERVICES 36
438. The last time you had sex did you or your partner use any method (other than a condom to avoid or prevent a pregnancy?
NO 2 (GO TO 501)
DON'T KNOW 8 (GO TO 501)
439. What method did you or your partner use?
PROBE: Did you or your partner use any other method to prevent pregnancy?
RECORD ALL MENTIONED.
MALE STERILIZATION B
IUD C
INJECTABLES D
IMPLANTS E
PILL F
MALE CONDOM G
FEMALE CONDOM H
LACTATIONAL AMEN. METHOD I
PERIODIC ABSTINENCE J
WITHDRAWAL K
EMERGENCY CONTRACEPTIVE L
DIAPHRAGM M
OTHER METHODS N
DON'T KNOW X
SECTION 5 FERTILITY PREFERENCES
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 509)
MAN STERILIZED (GO TO 509)
503. Is your wife/partner (Are any of your wives/partners) currently pregnant?
NO 2 (GO TO 505)
DON'T KNOW 8 (GO TO 505)
504. Now I have some questions about the future. After the child you and your wife/partner are expecting now, would you like to have another child or would you prefer not to have any more children?
NO MORE/NONE 2 (GO TO 509)
UNDECIDED/DON'T KNOW 8 (GO TO 509)
505. Now I have some questions about the future. Would you like to have (a/another) child or would you prefer not to have any (more) children?
NO MORE/NONE 2 (GO TO 509)
WIFE/PARTNER CAN'T GET PREGNANT 3 (GO TO 509)
WIFE/PARTNER STERILIZED 4 (GO TO 509)
UNDECIDED/DON'T KNOW 8 (GO TO 509)
MORE THAN ONE WIFE/PARTNER (GO TO 508)
WIFE/PARTNER NOT PREGNANT OR DON'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?
YEARS 2____ (GO TO 509)
SOON/NOW 993 (GO TO 509)
COUPLE INFECUND 993 (GO TO 509)
OTHER (SPECIFY)____ 996 (GO TO 509)
DON'T KNOW 998 (GO TO 509)
508. How long would you like to wait from now before the birth of (a/another) child?
YEARS 2_____
SOON/NOW 993
HE/ALL HIS WIVES/PARTNERS ARE INFECUND 994
OTHER: (SPECIFY)____996
DON'T KNOW 998
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 (GO TO 601)
510. How many of these children would you like to be boys, how many would you like to be girls and for how would it not matter?
OTHER (SPECIFY) ______96
OTHER (SPECIFY) ______96
OTHER (SPECIFY) ______96
SECTION 6. EMPLOYMENT AND GENDER ROLES
601. Have you done any work in the last seven days?
NO 2
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, or any other such reason?
NO 2
603. Have you done any work in the last 12 months?
NO 2 (GO TO 610)
604. What is your occupation, that is what kind of work do you mainly do?
605. Do you usually work throughout the year, or do you work seasonally, or only once in a while?
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3
606. Are you paid or do you earn 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 CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 612)
OTHER (GO TO 610)
609. Who usually decides how the money you earn will be used: mainly you, mainly your (wife (wives)/partner(s)), you and your (wife (wives)/partner(s)) jointly?
WIFE (WIVES)/PARTNER(S) 2
RESPONDENT AND WIFE (WIVES)/PARTNER(S) JOINTLY 3
OTHER (SPECIFY)_____6
610. Who usually makes decisions about health care for yourself: you, your wife/partner, you and your husband/partner jointly, or someone else?
WIFE (WIVES)/PARTNER(S) 2
RESPONDENT AND WIFE (WIVES)/PARTNER(S) JOINTLY 3
SOMEONE ELSE DECIDES 4
OTHER (SPECIFY) 6
611. Who usually makes decisions about making major household purchases?
WIFE (WIVES)/PARTNER(S) 2
RESPONDENT AND WIFE (WIVES)/PARTNER(S) JOINTLY 3
SOMEONE ELSE DECIDES 4
OTHER (SPECIFY) 6
612. 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
613. Do you own any land either alone or jointly with someone else?
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4
614. In your opinion, is a husband justified in hitting or beating his wife/partner in the following situations:
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
701. Now I would like to talk about something else. Have you ever heard of an illness called AIDS?
NO 2 (GO TO 723)
702. 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
703. Can people get the AIDS virus from mosquito bites?
NO 2
DON'T KNOW 8
704. Can people reduce their chances of getting the AIDS virus by using a condom every time they have sex?
NO 2
DON'T KNOW 8
705. Can people get the AIDS virus by sharing food with a person who has AIDS?
NO 2
DON'T KNOW 8
706. Can people avoid the AIDS virus because of witchcraft or other supernatural means?
NO 2
DON'T KNOW 8
707. Is it possible for a healthy-looking person to have the AIDS virus?
NO 2
DON'T KNOW 8
708. Can the virus that causes AIDS be transmitted from mother to a child:
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
OTHER (GO TO 711)
710. Are there any special drugs that a doctor or a nurse can give to a woman infected with the AIDS virus to reduce the risk of transmission to the baby?
NO 2
DON'T KNOW 8
711. CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.
712. I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?
NO 2 (GO TO 716)
713. How many months ago was your most recent HIV test?
TWO OR MORE YEARS 96
714. I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?
NO 2
HOSPITAL/HEALTH CENTER 12 (GO TO 718)
BLOOD DONATION BOOTH 13 (GO TO 718)
PRIVATE CLINIC/LABORATORY 14 (GO TO 718)
SAAJ 15 (GO TO 718)
GATV/ATS STANDS 16 (GO TO 718)
PTV 17 (GO TO 718)
COMMUNITY ATS 18 (GO TO 718)
OTHER (SPECIFY)____ 19 (GO TO 718)
716. Do you know of a place where people can go get tested for the AIDS virus?
NO 2 (GO TO 718)
HOSPITAL/HEALTH CENTER B
BLOOD DONATION BOOTH C
PRIVATE CLINIC/LABORATORY D
SAAJ E
GATV/ATS STANDS F
PTV G
COMMUNITY ATS H
OTHER (SPECIFY)____ I
718. 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
719. 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
720. If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
721. In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?
SHOULD NOT BE ALLOWED 2
DON'T KNOW/NOT SURE/DEPENDS 8
722. Should children age 12-14 be taught about using a condom to avoid getting AIDS?
NO 2
DON'T KNOW/ NOT SURE/DEPENDS 8
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 other infections that can be transmitted through sexual contact?
NO 2
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 732)
725. CHECK 723:
HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?
NO (GO TO 727)
726. Now I would like to ask you 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
727. Sometimes men experience a bad smelling abnormal discharge from their penis. During the last 12 months, have you had a bad smelling abnormal discharge from your penis?
NO 2
DON'T KNOW 8
728. Sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer near your penis?
NO 2
DON'T KNOW 8
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 732)
730. The last time you had those problems (PROBLEMS MENTIONED IN 726/727/278), did you seek advice or treatment?
NO 2 (GO TO 732)
731. Where did you seek advice or treatment? Anywhere else?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
PROVINCIAL/GENERAL HOSPITAL B
RURAL HOSPITAL B
HEALTH CENTER/POST D
PHARMACY E
MOBILE CLINIC F
OTHER (SPECIFY)____ G
PRIVATE DOCTOR I
PRIVATE NURSE J
PHARMACY K
OTHER (SPECIFY) ______ L
CHURCH N
SCHOOL O
FRIEND/RELATIVE P
TRADITIONAL HEALER Q
PARTNER R
INFORMATION STAND/BOOTH S
SHOP T
BAR/ DISCOTHEQUE U
GAS STATION V
ADOLESCENT SPECIAL SERVICES Z
732. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?
NO 2
DON'T KNOW 8
733. Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women?
NO 2
DON'T KNOW 8
SECTION 8. OTHER HEALTH ISSUES
801. Some people are circumcised. Are you circumcised?
NO 2 (GO TO 805)
DON'T KNOW 8 (GO TO 805)
802. How old were you when you were circumcised?
DURING CHILDHOOD (LESS THAN 5 YEARS OLD) 996
DON'T KNOW 998
803. Who did the circumcision?
HEALTH WORKER/PROFESSIONAL 2
OTHER (SPECIFY)___3
DON'T KNOW 8
HOME OF HEALTH WORKER/PROFESSIONAL 2
CIRCUMCISION DONE AT HOME 3
RITUAL SITE 4
OTHER (SPECIFY)___5
DON'T KNOW 8
805. Now I would like to ask you some 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 GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
NONE 00 (GO TO 808)
806. Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
NONE 00 (GO TO 808)
807. Did the person who gave you that injection take the syringe and needle from a new, unopened package?
NO 2
DON'T KNOW 8
808. Do you currently smoke cigarettes?
NO 2 (GO TO 810)
809. In the last 24 hours, how many cigarettes did you smoke?
810. Do you currently smoke or use any other type of tobacco?
NO 2 (GO TO 812)
811. What (other) type of tobacco do you currently smoke or use?
RECORD ALL ANSWERS MENTIONED.
HAND ROLLED CIGARETTE B
CIGAR C
SNUFF D
OTHER (SPECIFY) ______X
814. Are you covered by any medical assistance or health insurance?
NO 2
SECTION 12. DOMESTIC VIOLENCE MODULE
MAN NOT SELECTED (GO TO 1234)
1201. CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED. RECORD THE CORRECT CODE AND FOLLOW THE INSTRUCTIONS
DIVORCED/SEPARATED (GO TO 1203)
NEVER MARRIED/NEVER LIVED WITH A WOMAN (GO TO 1213)
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) wife/partner?
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
1204. Now if you will permit me, I need to ask some more questions about your relationship with your (last) wife/partner.
A. (Does/did) your (last) wife/partner ever:
NO 2
NO 2
NO 2
B. How often did this happen during the last 12 months: often, only sometimes, rarely, or not at all?
SOMETIMES 2
RARELY 3
NOT AT ALL 4
NOT APPLICABLE 5
SOMETIMES 2
RARELY 3
NOT AT ALL 4
NOT APPLICABLE 5
SOMETIMES 2
RARELY 3
NOT AT ALL 4
NOT APPLICABLE 5
1205. A. (Does/did) your (last) wife/partner ever:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
B. How often did this happen during the last 12 months: often, only sometimes, rarely, or not at all?
SOMETIMES 2
RARELY 3
NOT AT ALL 4
SOMETIMES 2
RARELY 3
NOT AT ALL 4
SOMETIMES 2
RARELY 3
NOT AT ALL 4
SOMETIMES 2
RARELY 3
NOT AT ALL 4
SOMETIMES 2
RARELY 3
NOT AT ALL 4
SOMETIMES 2
RARELY 3
NOT AT ALL 4
SOMETIMES 2
RARELY 3
NOT AT ALL 4
SOMETIMES 2
RARELY 3
NOT AT ALL 4
SOMETIMES 2
RARELY 3
NOT AT ALL 4
NOT A SINGLE 'YES' (GO TO 1209)
1207. How long after you first got married to/started living with your (last) wife/partner did (this/any of these things) first happen?
IF LESS THAN 1 YEAR, RECORD '00'.
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95
1208. Did the following ever happen as a result of what your (last) wife/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) wife/partner at times when she was not already beating or physically hurting you?
NO 2 (GO TO 1211)
1210. In the last 12 months, how many times have you done this to your wife/partner: many times, sometimes, rarely, never?
SOMETIMES 2
RARELY 3
NEVER 4
1211. Does (did) your wife/partner drink beer, wine, or any other alcoholic beverage?
NO 2 (GO TO 1213)
1212. During the last month how often does (did) she get drunk: often, only sometimes, rarely or not at all?
SOMETIMES 2
RARELY 3
NEVER 4
1212A. Some woman can be violent when they drink alcohol or are drunk. Has your wife/partner, during the last 12 months, become violent after drinking alcoholic beverages?
NO 2 (GO TO 1213)
1212B. In the last 12 months how many times did your wife/partner became violent after drinking alcoholic beverages: often, only sometimes, rarely or not at all?
SOMETIMES 2
RARELY 3
NEVER 4
EVER MARRIED/LIVED WITH A WOMAN/SEPARATED/DIVORCED/WIDOW: From the time you were 15 years old has anyone other than your (current/last) wife/partner hit, slapped, kicked or done anything else to hurt you physically?
NEVER MARRIED/NEVER LIVED WITH A WOMAN: From the time you were 15 years old has anyone hit, slapped, kicked or done anything else to hurt you physically?
NO 2 (GO TO 1219)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1219)
1214. Who has hurt you in this way?
Anyone else?
RECORD ALL MENTIONED.
FATHER/STEP-FATHER B
SISTER/BROTHER C
DAUGHTER/SON D
OTHER RELATIVE E
FORMER WIFE/PARTNER F
CURRENT GIRLFRIEND G
FORMER GIRLFRIEND/ CURRENT SEXUAL PARTNER H
MOTHER-IN-LAW I
FATHER-IN-LAW J
OTHER IN-LAW K
TEACHER L
EMPLOYER M
POLICE/SOLDIER N
OTHER (SPECIFY)___ X
1215. In the past 12 months, how often were you hit, slapped, kicked or hurt physically: often, only sometimes, rarely or not at all?
SOMETIMES 2
RARELY 3
NEVER 4
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 1224)
1220. The first time you had sexual intercourse, would you say that you had it because you wanted to, or because you were forced to have it against your will?
FORCED TO 2
REFUSED TO ANSWER/NO RESPONSE 3
EVER MARRIED/LIVED WITH A WOMAN: In the last 12 months, has anyone other than your (current/last) wife/partner forced you to have sexual intercourse against your will?
NEVER MARRIED/NEVER LIVED WITH A WOMAN: In the last 12 months, has anyone forced you to have sexual intercourse against your will?
NO 2
REFUSED TO ANSWER/NO RESPONSE 3
OTHER (GO TO 1225)
1223. CHECK 1025(h) AND 1205(i):
OTHER (GO TO 1227)
1224. 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?
NO 2 (GO TO 1227)
REFUSED TO ANSWER/NO RESPONSE 3 (GO TO 1227)
1225. How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?
DON'T KNOW 98
1226. Who was the person who was forcing you at that time?
FORMER WIFE/PARTNER 02
CURRENT/FORMER GIRLFRIEND 03
MOTHER 04
MOTHER-IN-LAW 05
OTHER RELATIVES 06
OTHER IN-LAW 07
OWN FRIEND/ACQUAINTANCE 08
FAMILY FRIEND 09
TEACHER 10
EMPLOYER 11
POLICE/SOLDIER 12
PASTOR/RELIGIOUS LEADER 13
STRANGER 14
OTHER (SPECIFY)___ 96
1226A.Were you forced to have sexual intercourse or perform any other sexual acts: often, only sometimes, rarely or not at all?
SOMETIMES 2
RARELY 3
NEVER 4
1226B. Did you seek for medical help after (the last time) you were forced to have sexual intercourse or perform any other sexual acts?
NO 2 (GO TO 1227)
1226C. How long after you were forced to have sexual intercourse did you seek for medical help?
ONE DAY AFTER 2
TWO DAYS AFTER 3
THREE DAYS AFTER 4
FOUR OR MORE DAYS AFTER 5
1227. CHECK 1205A, 1213, 1217, 1221 AND 1224:
NOT A SINGLE 'YES' AND 1220 IS DIFFERENT THAN '2' (GO TO 1231)
1228. Thinking about what you yourself have experienced among different things we have been talking about, have you ever tried to seek help to stop (the/these) person(s) from doing this to you again?
NO 2 (GO TO 1229A)
1229. From whom have you sought help? Anyone else?
RECORD ALL MENTIONED.
WIFE/PARTNER'S FAMILY B (GO TO 1231)
CURRENT/LAST/LATE WIFE/PARTNER C (GO TO 1231)
CURRENT/FORMER GIRLFRIEND D (GO TO 1231)
FRIEND E (GO TO 1231)
NEIGHBOR F (GO TO 1231)
RELIGIOUS LEADER G (GO TO 1231)
DOCTORAL/MEDICAL PERSONNEL H (GO TO 1231)
POLICE I (GO TO 1231)
LAWYER J (GO TO 1231)
SOCIAL SERVICE ORGANIZATION K (GO TO 1231)
TRADITIONAL HEALER Y (GO TO 1231)
OTHER (SPECIFY)___ X (GO TO 1231)
1229A. What was the reason you did not seek any help?
RECORD ALL MENTIONED.
THOUGHT THAT THE VIOLENCE WOULD NEVER OCCUR AGAIN B
FEAR OF ABANDONMENT BY WIFE/PARTNER C
THOUGHT YOU COULD PROTECT YOURSELF ALONE E
DID NOT THINK THAT OTHER PEOPLE COULD HELP F
DOES NOT TRUST AUTHORITIES G
OTHER (SPECIFY)___ X
1230. Have you ever told anyone else about this?
NO 2
1231. As far as you know, did your father ever beat your mother?
NO 2
DON'T KNOW 8
THANK THE RESPONDENT FOR HIS COOPERATION AND REASSURE HIM ABOUT THE CONFIDENTIALITY OF HIS ANSWERS. FILL OUT THE QUESTIONS BELOW REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.
1232. 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
1233. INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE__________________________________________
MINUTES____
To be filled in after completing interview
Comments about the interview:__________________
Comments on Specific Questions:_________________
Any other comments:___________
SUPERVISOR'S OBSERVATIONS_______________________________________
Name of Supervisor:__________________
Date:________
EDITOR'S OBSERVATIONS________________________________________
Name of Editor:__________________
Date:________