IDENTIFICATION

PROVINCE/REGION

DISTRICT

TEHSIL

CLUSTER NUMBER

HOUSEHOLD NUMBER

NAME OF HOUSEHOLD HEAD

NAME AND LINE NUMBER OF MAN

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS
DATE ___
INTERVIEWER'S NAME ____
RESULT _____

NEXT VISIT
DATE ___
TIME ___

FINAL VISIT
DAY __
MONTH __
YEAR ___
INT. NUMBER ___
RESULT __

TOTAL NUMBER OF VISITS __

LANGUAGE OF QUESTIONNAIRE: ENGLISH 6

LANGUAGE OF INTERVIEWER ___

LANGUAGE MAN SPEAKS AT HOME ____

SUPERVISOR
NAME _____

FIELD EDITOR
NAME ____

OFFICE EDITOR

KEYED BY

INFORMED CONSENT

Assalamo Alaikum. My name is ___. I am working with NIPS. We are conducting a survey about health all over Pakistan. The information we collect will help the government to plan health services. Your household is selected for the survey. The questions usually take about 25 to 30 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 now?

SIGNATURE OF INTERVIEWER: ______
DATE: _____

SECTION 1. RESPONDENT'S BACKGROUND

101) RECORD THE TIME.

102) In what month and year were you born?

103) How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

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

105) Is your wife living with you now or is she staying elsewhere?

106) Do you have other wives?

106A) Did you have other wives?

107) Altogether, how many wives do/did you have?

108) CHECK 106 AND 106A:

ONE WIFE: In what month and year did you start living with your (wife)?
MORE THAN ONE WIFE: Now I would like to ask about your first wife. In what month and year did you start living with her?

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

110) Have you ever attended school?

111) What is the highest class you completed?
IF COMPLETED LESS THAN CLASS ONE, WRITE '00'
IF MA, MPHIL, PHD, MBBS, OR BSC/4 YEARS, WRITE '16'

112) CHECK 111:

113) Now I would like 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?

114) CHECK 113:

115) Do you read a newspaper or magazine daily, at least once a week, occasionally or not at all?

116) Do you listen to the radio daily, at least once a week, occasionally or not at all?

117) Do you watch television daily, at least once a week, occasionally or not at all?

118) What is your mother tongue?

SECTION 2. REPRODUCTION

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

202) Do you have any sons or daughters who are now living with you?

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

204) Do you have any sons or daughters who are alive but do not live with you?

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

206) Do you have a son or daughter who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

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

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

209) CHECK 208:

210) Did all of your children have the same biological mother?

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

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

213) CHECK 203 AND 205:

214) How old is your (youngest) child?
IF LESS THAN ONE YEAR, RECORD '00'

215) CHECK 214:

216) What is the name of your (youngest) child?

217) When (NAME)'s mother was pregnant with (NAME), did she have any antenatal check-ups?

218) Were you ever present during any of those antenatal checkups or did you just accompanied your wife to any of those antenatal checkups?

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

220) When a child has diarrhea, how much should he or she be given to drink: more than usual, about the same as usual, less than usual, or nothing to drink at all?

SECTION 2. CONTRACEPTION

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)?
PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.

302) Have you or your wife/wives ever used (METHOD)?

303) In the last few months have you:

304) CHECK 303:

304A) What messages did it convey to you? Anything else?
[CIRCLE ALL MENTIONED]

304B) Do you think that the message you heard or watch or read was effective or not effective in persuading couples to use family planning?

304C) CHECK 104:

305) CHECK 302:

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

307) 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 when she has sexual relations?

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

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

310) CHECK 301 (07): KNOWS CONDOM

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

312) Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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

SECTION 4. FERTILITY PREFERENCES

401) CHECK 104:

402) CHECK 302:

403) Is your wife/are any of your (wives) currently pregnant?

404) Now I have some questions about the future. After the (child/children) you and your (wife/wives) are expecting now, would you like to have another child, or would you prefer not to have any more children?

405) 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?

406) CHECK 106:

407) CHECK 403:

WIFE NOT PREGNANT OR DON'T KNOW __

How long would you like to wait from now before the birth of (a/another) child?
WIFE PREGNANT __
After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?

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

409) 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?

410) 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?

SECTION 5. EMPLOYMENT AND GENDER ROLES

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

502) 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?

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

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

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

506) Are you paid in cash or cash and kind both or kind only for this work or are you not paid at all?

507) CHECK 104:

508) CHECK 506:

509) Who usually decides how the money you earn will be used: you, your wife, or you and your wife jointly or someone else?

510) Who usually make decisions about health care for yourself: you, your wife, you are your wife jointly or someone else?

511) Who usually makes decisions about making major household purchases: you, your wife, you and your wife jointly or someone else?

512) Do you own this or any other house either alone or jointly with someone else?

513) Do you own any land either alone or jointly with someone else?

514) In your opinion, is a husband justified in hitting or beating his wife in the following situations:

SECTION 6. HIV AIDS

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

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

603) Can people get the AIDS virus from mosquito bites?

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

605) Can people get the AIDS virus by sharing food with someone who has AIDS?

606) Can people get the AIDS virus because of witchcraft or other supernatural means?

607) Is it possible for a healthy-looking person to have the AIDS virus?

608) Can the virus that causes AIDS be transmitted from a mother to her baby:

609) CHECK 608:

610) Are there any special drugs that a doctor or a nurse can give to a women infected with the AIDS virus to reduce the risk of transmission to the baby?

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

612) Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

613) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?

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

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

616) 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?

617) CHECK 601:

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?

618) 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?

619) The last time you has problems, did you seek any kind of advice or treatment?

620) Where did you go? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

SECTION 7. OTHER HEALTH ISSUES

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

702) How does tuberculosis spread from one person to another?
PROBE: Any other ways?
[CIRCLE ALL MENTIONED]

703) Can tuberculosis be cured?

704) What is the duration of treatment of TB now a days?
[IF MORE THAN 7 MONTHS, RECORD 7]

705) Have you ever been told by a doctor or nurse or LHV that Gos forbid you have/had tuberculosis?

706) Have you ever heard of an illness called Hepatitis B or C?

707) Is there anything a person can do to avoid getting Hepatitis B or C?

708) What can a person do to avoid getting Hepatitis B or C?
PROBE: Any other ways?
[CIRCLE ALL MENTIONED]

709) 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.

710) 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 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

711) The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

712) Do you presently smoke cigarettes?

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

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

715) What (other) type of tobacco do you currently smoke or use?
[CIRCLE ALL MENTIONED]

716) RECORD THE TIME.