IDENTIFICATION

PLACE NAME_____

NAME OF HEAD OF HOUSEHOLD____

PREFECTURE (ADMINISTRATIVE CENTER) ____

TOWN OR MUNICIPALITY____

SECTOR____

SUB-SECTOR____

HOUSEHOLD NUMBER___

URBAN/RURAL

LARGE CITY, OTHER CITY, OR RURAL?

NAME AND LINE NUMBER OF MAN___

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER NAME____
RESULT___

RESULT

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE___
TIME___

FINAL VISIT
DAY___
MONTH___
YEAR: 2000
NAME___
RESULT___

TOTAL NUMBER OF VISITS___

LANGUAGE OF INTERVIEW:

INTERPRETER USED?

FIELD EDITOR
NAME___
DATE___

SUPERVISOR
NAME___
DATE___

OFFICE EDITOR____

KEYED BY___

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello, my name is _____ and I work for (NAME OF ORGANIZATION). We are conducting a national survey on the health of men, women, and children. We hope you will participate in this survey. I would like to ask you some questions about your health and your family. This information will help the government to plan health services. The interview takes generally between 10 and 20 minutes. The information that you provide will be kept strictly confidential and will not be shared with anyone.

Participation is voluntary and you can refuse to answer any particular question or all the questions. We hope, however, that you will participate in this survey as your opinion is important to us.

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

SIGNATURE OF INTERVIEWER:_______
DATE:______

101. RECORD THE TIME.

102. To begin, I would like to ask you some questions about yourself and your household. Until the age of 12, did you mostly live in Kigali, in another city, or in a rural area?

103. For how long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?

104. Just before moving here, did you live in the city of Kigali, another city, or a rural area?

104A. In the past 12 months, have you been away from your community for more than a month at a time?

104B. In the past 12 months, how many times did you travel and sleep outside your community?

107. In what month and year were you born?

108. How old were you at your last birthday?
COMPARE AND CORRECT 107 AND/OR 108 IF INCONSISTENT

109. Have you ever attended school?

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

111. What was the last (class/year) you successfully completed at this level?

112. CHECK 110:

113. Now I would like you to read this sentence to me; read as much as you can.
SHOW CARD TO RESPONDENT

114. Have you ever participated in a literacy program or any other program that involved learning to read and 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. Do you currently have a job, whatever it may be, for which you earn money?

120. In the past 12 months, have you had a job, whatever it might be, for which you earned money?

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, do you work on land that you rent from someone else, or do you work on someone else's land?

125. Do you do this work for family member, somebody else, or are you self-employed?

126. Do you usually work throughout the year, seasonally, or only from time to time?

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

128. How many people, including yourself, depend on the money you earn?

129. Do you think what you earn is sufficient for your needs (and for the needs of your dependents)?

130. On average, how much of your household expenses are paid with the money you earn: almost none, less than half, nearly half, more than half, or all?

131. Have you ever drunk alcohol?

132. Have you ever gotten drunk after drinking alcoholic beverages?

133. In the past three months, how many days did you drink alcoholic beverages?

134. CHECK 132:

135. Over the past 3 months, how many times have you been drunk?

136. During the last 3 months, have you had an injection?

137. During the last 3 months, how many times have you had an injection?

138. The last time you had an injection who gave you the shot?

SECTION 2: REPRODUCTION

201. Now, I would like to ask about your children. I am interested only in the children that are biologically yours. Do you have or did you have children?

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? How many daughters live with you?
IF NONE, RECORD '00'

204. Do you have any sons or daughters whom you have fathered who are still alive but do not live with you?

205. How many sons are alive but do not live with you? How many daughters are alive but do not live with you?
IF NONE, RECORD '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 only survived a few hours or days?

207. How many boys have died? 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:
I want to make sure I have this right: during your life, you have had in TOTAL _____ children of which you were the father. Is that correct?

210. CHECK 208:

211. Do all the children of whom you are the father have the same biological mother?

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

213. In what month and year was your first child born?

214. Now I would like to ask you about the risks of pregnancy. Between one menstrual cycle and the next, is there a time when a woman is more likely to get pregnant than others if she has sexual relations?

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

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
RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. 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. CHECK 302:

304. Have you or any of your partners ever used a method or tried in any way to delay or avoid getting pregnant?

306. What have you done or used?
CORRECT 302 AND 303 (AND 301 IF NECESSARY)

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

402. How many wives do you currently have?

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

404. With how many women do you live as if you were married?

405. WRITE THE LINE NUMBER OF HIS WIFE/PARTNER OR HIS WIVES/PARTNERS FROM THE HOUSEHOLD QUESTIONNAIRE. IF A WIFE/PARTNER IS NOT LISTED IN THE HOUSEHOLD SCHEDULE, RECORD '00' IN THE CORRESPONDING BOXES. THE NUMBER OF LINES FILLED IN MUST BE EQUAL TO THE NUMBER OF WIVES AND PARTNERS.

IF THE SUM OF 402 AND 404 IS EQUAL TO 1: Please tell me the name of your wife/partner.

IF THE SUM OF 402 AND 404 IS EQUAL TO 2 OR MORE: Please tell me the names of your wives and live-in partners. LIST UP TO 7 WIVES/PARTNERS.

406. Do you currently have a regular sexual partner, an occasional sexual partner, or no sexual partner at all?

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

410. Have you been married to or lived with a woman other than those we just listed?

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

412. CHECK 401, 409:

MARRIED/LIVED WITH A WOMAN ONLY ONCE: In what month and year did you start living with your wife/partner?

MARRIED/LIVED WITH A WOMAN MORE THAN ONCE: Now, we are going to talk about your first wife/partner. In what month and year did you start living with her?

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

414. Now I would like 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 (if ever)?

415. When was the last time you had sexual relations with a woman?
RECORD IN ''NUMBER OF YEARS'' ONLY IF MORE THAN 12 MONTHS OR ONE YEAR.

416. The last time that you had sexual relations with a woman, was a condom used?

417. What was the main reason you used a condom at that time?

418. The last time you had sexual relations together, did you or your partner do something or use a method to avoid pregnancy?

419. What method was used to avoid pregnancy?

420. What is the main reason you did not use a method of contraception to avoid pregnancy?

421. What is your relationship to the woman with whom you last had sexual intercourse?
IF "GIRLFRIEND'' OR "FIANCÉE" ASK:
Was your girlfriend/fiancée living with you when you last had sexual relations?
IF "YES", RECORD '1'
IF "NO", RECORD '2'

422. For how long have you had sexual relations with this woman?

423. In the past 12 months, have you had sex with anyone else?

424. The last time you had sex with this other woman, was a condom used?

425. What is the main reason you used a condom at that time?

426. The last time you had sexual relations with this woman, did you or your partner do something or use a method to avoid pregnancy?

427. What method was used to avoid pregnancy?

428. What is the main reason you did not use a method of contraception to avoid pregnancy?

429. What is your relationship to this woman?
IF "GIRLFRIEND'' OR "FIANCÉE" ASK:
Was your girlfriend/fiancée living with you when you last had sexual relations?
IF "YES", RECORD '1'
IF "NO", RECORD '2'

430. For how long have you had sexual relations with this woman?

431. In the past 12 months, other than these two women, have you had sex with anyone else?

432. The last time you had sex with this other woman, was a condom used?

433. What is the main reason you used a condom at that time?

434. The last time you had sexual relations with this woman, did you or your partner do something or use a method to avoid pregnancy?

435. What method was used to avoid pregnancy?

436. What is the main reason you did not use a method of contraception to avoid pregnancy?

437. What is your relationship to this woman?
IF "GIRLFRIEND'' OR "FIANCÉE" ASK:
Was your girlfriend/fiancée living with you when you last had sexual relations with her?
IF "YES", RECORD '1'
IF "NO", RECORD '2'

438. For how long have you had sexual relations with this woman?

439. In all, how many sexual partners have you had in the last 12 months?

440. Have you ever paid to have sexual relations?

441. How long have you been paying to have sexual relations?

442. The last time you paid for sex, was a condom used?

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

444. Where is that?
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.

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

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

447. Where is that?
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____

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

450. Do you know of a place where one can go on foot and get condoms?

451. Where is that?
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____

452. How long does it take to get to this place on foot?

SECTION 5. FERTILITY PREFERENCES

501. CHECK 401:

502. CHECK 406:

503. CHECK 401, 405, AND 406:

A. HAS A WIFE OR LIVES WITH A WOMAN: Is your wife/live-in partner currently pregnant? Is one of your wives/live-in partners currently pregnant?

B. HAS A REGULAR SEX PARTNER: Is your regular sex partner currently pregnant? Is one of your regular sex partners currently pregnant?

504. At the time your partner became pregnant did you want her to become pregnant then,
did you want to have a child later, or did you not want to have a child at all?

505. CHECK 502 AND 503:

A. WIFE/PARTNER NOT PREGNANT OR UNSURE OR DOESN'T HAVE WIFE OR REGULAR SEX PARTNER: Now I have some questions about the future. Do you want to have a/another child, or would you prefer not to have a/another child?

B. WIFE/PARTNER PREGNANT: Now I have some questions about the future. After the child your wife/partner is expecting, would you like to have another child or would you prefer not to have another child?

506. CHECK 502 AND 503:

WIFE/PARTNER NOT PREGNANT OR UNSURE OR DOESN'T HAVE WIFE OR REGULAR SEX PARTNER: How long do you want to wait before the birth of a child? How long do you want to wait before the birth of another child?

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

507. CHECK 414, 416, 424, 426, 432, AND 434:
HAS USED A METHOD WITH AT LEAST ONE PARTNER

508. In the next 12 months, do you think that you will use a method to delay or avoid pregnancy?

509. Do you think that at any time in the future you will use a method to delay or avoid pregnancy?

510. What method would you prefer to use?

511. What is the main reason you thing you will never use a method?

512. CHECK 203 AND 205:

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

HAS NO LIVING CHILDREN: If you could choose exactly the number of children to have in your life, how many would you want to have?

PROBE FOR A NUMERIC RESPONSE.

513. 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?

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

515. In the past month, have you heard about family planning:

517. In the past month, have you discussed the practice of family planning with your friend(s), neighbor(s), or relative(s)?

518. With whom did you discuss it? Anyone else?
RECORD ALL MENTIONED

519. CHECK 401, 402, AND 404:
MARITAL STATUS AND NUMBER OF WIVES/PARTNERS

520. Now I would like to ask you about your wife's/partner's opinion on family planning. Would you say your wife/partner approves or disapproves of couples using a method to avoid getting pregnant?

521. In the last 12 months, how many times have you discussed the practice of family planning with your wife/partner?

522. Do you think that your wife/partner wants the same number of children as you, more, or fewer than you want?

SECTION 6. PARTICIPATION IN HEALTH CARE

601. CHECK 201 AND 209:

602. What is the name and sex of your last child?

603. In what month and year was your last child born?

604. Is (NAME OF LAST CHILD) still alive?

605. How old was (NAME OF LAST CHILD) when he or she died?

606. Who is the mother of (NAME OF LAST CHILD)?
WRITE THE NAME OF THE MOTHER OF THE CHILD AND HER LINE NUMBER AS NOTED IN Q. 405. IF THE MOTHER IS NOT A MEMBER OF THE HOUSEHOLD, RECORD '00'.

607. CHECK 603:

608. CHECK 606:

609. What is your relationship to (NAME OF MOTHER OF LAST CHILD)?

610. When (NAME OF MOTHER OF LAST CHILD) became pregnant with (NAME OF LAST CHILD), did you want to have a child then, did you want to have a child but later, or did you not want to have a/another child at all?

611. How long would you liked to have waited?

612. Did (NAME OF MOTHER OF LAST CHILD) go to a health establishment for antenatal care for this pregnancy?

613. During this pregnancy, did you accompany (NAME OF MOTHER OF LAST CHILD) when she went to the establishment for antenatal care?

614. When (NAME OF MOTHER OF LAST CHILD) was pregnant, did you speak to a health professional about the health of the mother and her pregnancy?

615. During this pregnancy, how many times did you speak to (NAME OF MOTHER OF LAST CHILD) about her health and pregnancy?

616. In your opinion, was this pregnancy normal or were there health complications more serious than those occurring in most pregnancies?

617. Where did (NAME OF MOTHER OF LAST CHILD) give birth to (NAME OF LAST CHILD)?

618. When (NAME OF MOTHER OF LAST CHILD) gave birth, did you go with her to the (HOSPITAL/CLINIC/HEALTH CENTER)?

619. CHECK 603:

620. In the two months following the birth of (NAME OF LAST CHILD), did (NAME OF MOTHER OF LAST CHILD) go to a health establishment to be examined or have her child examined?

621. Did you accompany (NAME OF MOTHER OF LAST CHILD) during these visits?

622. During the first two months after the birth of (NAME OF LAST CHILD), did you speak to a health professional about the health of the baby or that of (NAME OF MOTHER OF LAST CHILD)?

623. During the first two months after the birth of (NAME OF LAST CHILD), did you speak often, sometimes, or never about her health and the baby's growth with (NAME OF MOTHER OF LAST CHILD)?

624. In your opinion, is (NAME OF LAST CHILD) a healthy or unhealthy child?

625. Did (NAME OF LAST CHILD) receive vaccinations to protect him/her from certain illnesses?

626. Were any vaccinations given at a health establishment?

627. The last time that (NAME OF LAST CHILD) received a vaccination in a health establishment, who accompanied him/her?
RECORD ALL MENTIONED

628. Has (NAME OF LAST CHILD) suffered from a fever, cough, or diarrhea during the past two weeks?

629. Who takes care of (NAME OF LAST CHILD) when he/she is sick?
RECORD ALL MENTIONED

630. Was (NAME OF LAST CHILD) examined by a health professional when he or she was sick?

631. Who decided that (NAME OF LAST CHILD) needed to be examined by a doctor?
RECORD ALL MENTIONED

632. Were you present when (NAME OF LAST CHILD) was examined by a health professional?

633. Did you speak with the health professional about the child's illness?

SECTION 7. HIV/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 be done? Anything else?
RECORD ALL MENTIONED

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

705. Can a person get the AIDS virus by being bitten by mosquitoes?

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

707. Can a person reduce their chances of getting the AIDS virus by not sharing food with someone with AIDS?

708. Can people protect themselves from the AIDS virus by abstaining from sex completely?

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

711. Do you personally know someone who has the AIDS virus or someone who has died of AIDS?

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

713. When can the virus that causes AIDS can be transmitted from mother to child?
Can it be transmitted:

714. CHECK 401:

715. Have you ever talked about ways to avoid contracting the AIDS virus with your wife/live-in partner?

715A. In your opinion, is it acceptable or unacceptable to talk about AIDS:

716. If a person learns that he/she is infected with the virus that causes AIDS, should that person be permitted to keep his/her condition a secret or should the information be shared with the community?

717. If someone in your family contracted the virus that causes AIDS, would you be willing to take care of him/her in your own household?

717A. Should people with AIDS who work with other people in shops, offices, or farms be allowed to continue their work or no?

717B. Should we educate children ages 12 to 14 on the use of condoms to avoid contracting AIDS?

717C. Have you ever been tested to see if you have the AIDS virus?

717D. Would you like to be tested for the AIDS virus?

717E. Do you know of a place where you can get tested for AIDS?

717F. Where can you go for this test?
717FX. Where did you go for this test?
IF SOURCE IS A HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO DETERMINE THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
RECORD ALL MENTIONED

718. (Apart from AIDS), have you heard of (other) infections that can be transmitted by sexual contact?

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

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

721. CHECK 414:

722. Now, I would like to ask you questions about your health in the past 12 months. In the past 12 months, have you had a sexually transmitted disease?

723. Sometimes men have an abnormal discharge from their penis. In the past 12 months, have you had an abnormal discharge from your penis?

724. Sometimes men have a genital sore or ulcer in near their penis. In the past 12 months, have you had a genital sore or ulcer?

725. CHECK 722, 723, 724:

726. The last time you had (INFECTION FROM 722/723/724), did you seek advice or treatment?

727. The last time you had (INFECTION FROM 722/723/724), did you do any of the following?
Did you:

728. When you had (INFECTION FROM 722/723/724), did you inform the person(s) with whom you were having sex?

729. When you had (INFECTION FROM 722/723/724), did you do anything to avoid infecting your sexual partner(s)?

730. What did you do to avoid infecting your partner(s)?
Did you:

SECTION 8. ATTITUDES TOWARDS GENDER ROLES

Now I would like to ask you questions about relations between husbands and wives. People have very different opinions on this subject and I would like to know what you think.

801. When a husband cannot provide enough money, do you think it is acceptable for his wife to work outside the home to earn money?

802. When, for whatever reason, a husband cannot provide enough money for the family, do you think it is acceptable for his wife to work outside the home to earn money?

803. Within a couple, do you think a woman should have a say in the following decisions?

804. 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:

805. Please tell me if you think it is normal for a woman to refuse to have sex with her husband/ partner when:

806. Do you think that if a wife refuses to have sexual relations with her husband he has the right to :

807. In a household, who, according to you, should have the primary responsibility for disciplining the children: the man, the woman, or both?

808. Within a couple, who, according to you, should have the primary responsibility for watching and caring for the children?

809. In a couple, who, according to you, should have the primary responsibility for cooking, cleaning, and washing dishes and laundry every day?

809A. Have you ever beaten, hit, kicked, or done anything else to physically attack your (last) wife/partner when she had not beaten or attacked you physically?

810. As far as you remember, did your father ever beat your mother?

811. 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 SUPERVISOR:___
DATE:____

EDITOR'S OBSERVATIONS___

NAME OF EDITOR:____
DATE:____