Ministry of Health/Central Statistical Office
LOCALITY NAME________
NAME OF HOUSEHOLD HEAD___________
CLUSTER NUMBER __ __ __
PROVINCE__ __
URBAN 2
OTHER CITY 2
TOWN 3
VILLAGE 4
NAME AND LINE NUMBER OF MAN:
NAME_______
LINE NUMBER_______
FIRST VISIT
DATE________
INTERVIEWER'S NAME________
RESULT*__________
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)___________ 7
NEXT VISIT:
DATE________
TIME_________
SECOND VISIT:
DATE________
INTERVIEWER'S NAME_________
RESULT*__________
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)___________ 7
NEXT VISIT:
DATE__________
TIME___________
THIRD VISIT:
DATE________
INTERVIEWER'S NAME_________
RESULT*__________
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)___________ 7
FINAL VISIT:
DAY__ __
MONTH__ __
YEAR__ __
INT. NUMBER__ __ __
RESULT*____
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)___________ 7
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)___________ 7
BEMBA 02
KAONDE 03
LOZI 04
LUNDA 05
LUVALE 06
NYANJA 07
TONGA 08
OTHER 09
BEMBA 02
KAONDE 03
LOZI 04
LUNDA 05
LUVALE 06
NYANJA 07
TONGA 08
OTHER 09
BEMBA 02
KAONDE 03
LOZI 04
LUNDA 05
LUVALE 06
NYANJA 07
TONGA 08
OTHER 09
NO 2
SUPERVISOR
NAME_______
DATE__ __ __
FIELD EDITOR
NAME_______
DATE__ __ __
OFFICER EDITOR____
KEYED BY____
SECTION 1. RESPONDENT'S BACKGROUND
Hello. My name is__________. I am working with the Ministry of Health in collaboration with Central Statistical Office (CSO). We are conducting a survey about health all over Zambia. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 20 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 questions 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 give to your household.
Do you have any questions?
DATE:__________
May I begin the interview now?
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END SURVEY)
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 103 IF INCONSISTENT
104. Have you ever attended school?
NO 2 (GO TO 108)
105. What is the highest level of school you attended: primary, secondary, or higher?
SECONDARY 2
HIGHER 3
106. What is the highest grade you completed at that level?
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' (GO TO 111)
110. Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
111. Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
112. Do you watch television almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
PROTESTANT 2
MUSLIM 3
OTHER (SPECIFY)___________6
114. What tribe do you belong to?
114A.
How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS
ALWAYS 95 (GO TO 115)
VISITOR 96 (GO TO 115)
114B Just before you moved here, did you live in Lusaka, another city, in a town, or in a village?
OTHER CITY 2
TOWN 3
VILLAGE 4
115. In the last 12 months, on how may separate occasions have you traveled away from your home community and slept away?
NONE (GO TO 201)
116. In the last 12 months, have you been away from your home community for more than one month at a time?
NO 2
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, even if they are not legally yours or do not have your last name.
Have you ever fathered any children with any woman?
NO 2 (GO TO 206)
DON'T KNOW 8 (GO TO 206)
202. Do you have any sons or daughters that you have fathered 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 you have fathered who are alive but do not live with you?
NO 2 (GO TO 206)
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. 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 did not survive
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 ENTER TOTAL.
IF NONE, RECORD '00'
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 all, how many women have you fathered children with?
212. How old were you when your (first) child was born?
NO LIVING CHILDREN (GO TO 301)
214. How old is your (youngest) child?
OTHER (GO TO 301)
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?
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?
DON'T KNOW 6 (GO TO 220)
OTHER 8
219A. Why didn't (NAME)'s mother deliver in a health facility?
PROBE: Any other reason?
FACILITY NOT OPEN B
TOO FAR/NO TRANSPORTATION C
DON'T TRUST FACILITY/POOR QUALITY SERVICE D
NO FEMALE PROVIDER AT FACILITY E
I/FAMILY DID NOT ALLOW F
SHORT LABOUR G
NOT NECESSARY H
NOT CUSTOMARY I
OTHER (SPECIFY)______________X
220. When a child has diarrhoea, 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 a pregnancy.
Have you ever 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:
Heard about family planning on the radio?
Seen anything about family planning on the television?
Read about family planning in a newspaper or magazine?
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 women is more likely to become pregnant if she has sexual relations?
NO 2 (GO TO 305A)
DON'T KNOW 8 (GO TO 305A)
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)_____________6
DON'T KNOW 8
305A. Do you think that a woman who is breastfeeding her baby can become pregnant?
NO 2
DON'T KNOW 8
306. I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.
a) Contraception is women's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous
DISAGREE 2
DON'T KNOW 8
DISAGREE 2
DON'T KNOW 8
307. CHECK 301 (07) KNOWS MALE CONDOM
NO (GO TO 311)
308. Do you know of a place where a person can get male condoms?
NO 2 ( GO TO 311)
309. Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
GOVT. HEALTH CENTER/POST B
MOBILE HOSPITAL/CLINIC C
FAMILY PLANNING CLINIC D
COMMUNITY BASED AGENT/FIELDWORKER E
OTHER PUBLIC SECTOR (SPECIFY)___________F
MISSION HOSPITAL/CLINIC H
PHARMACY I
PRIVATE DOCTOR J
COMMUNITY BASED AGENT/FIELDWORKER K
MOBILE HOSPITAL/CLINIC L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)________M
CHURCH O
FRIENDS/RELATIVES P
310. If you wanted to, could you yourself get a male condom?
NO 2
311. CHECK 301 (08) KNOWS FEMALE CONDOM
NO 2 (GO TO 401)
312. Do you know of a place where a person can get female condoms?
NO 2 (GO TO 401)
313. Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
NAME OF PLACE(S)_______________________
GOVT. HEALTH CENTER/POST B
MOBILE HOSPITAL/CLINIC C
FAMILY PLANNING CLINIC D
COMMUNITY BASED AGENT/FIELDWORKER E
OTHER PUBLIC SECTOR (SPECIFY)___________F
MISSION HOSPITAL/CLINIC H
PHARMACY I
PRIVATE DOCTOR J
COMMUNITY BASED AGENT/FIELDWORKER K
MOBILE HOSPITAL/CLINIC L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)________M
CHURCH O
FRIENDS/RELATIVES P
314. If you wanted to, could you yourself get a female condom?
NO 2
SECTION 4. MARRIAGE AND SEXUAL ACTIVITY
401. Are you currently married or living together with a woman 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
NO 3 (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?
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 name of each your wives 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 PERSON.
LINE NUMBER_________
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
Now I would like to ask you some questions about sexual activity in order to gain a better understanding of some family life issue.
414. How old were you when you had sexual intercourse for the very first time?
AGE IN YEAR __ __ (GO TO 414C)
FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE/PARTNER 95 (GO TO 414C)
25-59 YEARS OLD (GO TO 501)
414B. Do you intend to wait until you get married to have sexual intercourse for the first time?
NO 2 (GO TO 501)
DON'T KNOW/UNSURE 8 (GO TO 501)
25-59 YEARS OLD (GO TO 415)
414D. The first time you had sexual intercourse, was a female or male condom used?
NO 2
DON'T KNOW/DON'T REMEMBER 8
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 that 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 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.
WEEKS AGO 2 __ __
MONTHS AGO __ __
YEARS AGO 4 __ __ (GO TO 430)
Refer to Last Sexual Partner through Third-to-Last Sexual Partner for Questions 417 to 427.
417. When was the last time you had sexual intercourse with this person?
WEEKS AGO 2 __ __
MONTHS AGO 3 __ __
418. The last time you had sexual intercourse with this (second/third) person, was a female or male condom used?
NO 2 (SKIP TO 420)
419. Was a condom used every time you had sexual intercourse with this person in the last 12 months?
NO 2
420. 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 '02'.
IF NO, CIRCLE '03'
LIVE-IN PARTNER 2
LINE NUMBER OF WIFE/PARTNER __ __
GIRLFRIEND NOT LIVING WITH RESPONDENT 3 (GO TO 423)
CASUAL ACQUAINTANCE 4 (GO TO 423)
SEX WORKER 5 (GO TO 423)
OTHER (SPECIFY)___________ 6 (GO TO 423)
MARRIED MORE THAN ONCE OR BLANK (SKIP TO 423)
OTHER (GO TO 423)
423. How long ago did you first have sexual intercourse with this (second/third) person?
WEEKS AGO 2 __ __
MONTHS AGO 3 __ __
YEARS AGO 4 __ __
423A. The last time you had sexual intercourse with this (second/third) person did you or this person drink alcohol?
NO 2 (SKIP TO 424)
423B. Were you or your partner drunk at that time?
IF YES: Who was drunk?
PARTNER ONLY 2
RESPONDENT AND PARTNER BOTH 3
NEITHER 4
424. How many times during the last 12 months did you have sexual intercourse with this person?
IF NON-NUMERIC ANSWER PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, WRITE '95'.
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 (SKIP 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 95 OR MORE, WRITE '95'.
DON'T KNOW 98
NO PARTNERS ARE SEX WORKERS (GO TO 430)
429. CHECK 420 AND 418 (ALL COLUMNS):
OTHER (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 you someone in exchange for having sexual intercourse, was a female or male 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 you 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 95 OR MORE, WRITE '95.'
DON'T KNOW 98
435. CHECK 418, MOST RECENT PARTNER (FIRST COLUMN):
NOT ASKED (GO 438)
NO CONDOM USED (GO TO 438)
436. You told me that a condom was used the last time you had sex. What brand name of the female or male condoms did you use?
ASK TO SEE THE PACKAGE IF RESPONDENT DOES NOT REMEMBER NAME OF BRAND.
MAXIMUM SCENTED 02
ROUGH RIDER 03
DUREX 04
CARE FEMALE CONDOM 05
FEMIDOM 06
REALITY 07
PUBLIC SECTOR: UNBRANDED (WHITE COLOUR FOIL) 08
OTHER (SPECIFY)___________96
DON'T KNOW 98
437. From where did you obtain the female or male condom the last time?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
GOVERNMENT HEALTH CENTER/POST 12
MOBILE HOSPITAL/CLINIC 13
FAMILY PLANNING CLINIC 14
COMMUNITY BASED AGENT/FIELD WORKER 15
OTHER PUBLIC SECTOR (SPECIFY)____________16
MISSION HOSPITAL/CLINIC 22
PHARMACY 23
PRIVATE DOCTOR 24
COMMUNITY BASED AGENT/FIELDWORKER 25
MOBILE HOSPITAL/CLINIC 26
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)_____________27
CHURCH 32
FRIENDS/RELATIVES 33
OTHER (SPECIFY)________________ 96
438. The last time you had sex did you or your partners 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 use any other method to prevent pregnancy?
RECORD ALL MENTIONED.
MALE STERILIZATION B
IUD C
INJECTABLES D
IMPLANTS E
PILL F
CONDOM G
FEMALE CONDOM H
DIAPHRAGM I
FOAM/JELLY J
STANDARD DAYS K
LAM L
RHYTHM METHOD M
WITHDRAWAL N
OTHER MODERN METHOD X
OTHER TRADITIONAL METHOD Y
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 (GO TO 505)
504. Now I have some questions about the future. After the (child/children) 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?
NO MORE 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)
SAYS COUPLE CAN'T PREGNANT 3 (GO TO 509)
WIFE (WIVES)/PARTNER(S) 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
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 994 (GO TO 509)
OTHER (SPECIFY)____________996 (GO TO 509)
DON'T KNOW 998 (GO TO 509)
508. How long would you 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 child 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)_______________ (GO TO 601)
510. How many of these children would 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 girl?
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 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 607)
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 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: you, your (wife/partner), or you and your (wife/partner) jointly?
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
OTHER (SPECIFY)_________________ 6
610. Who usually makes decisions about health care for yourself: you, your (wife/partner), you and your (wife/partner) jointly, or someone else?
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_______________ 6
611. Who usually makes decisions about making major household purchases?
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_____________6
611A. Who usually makes decisions about making purchases for daily household needs?
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_____________6
611B. Who usually makes decisions about visits to your family or relatives?
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 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 this 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 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
Now I would like to talk about something else
701.. Have you ever heard of an illness called AIDS?
NO 2 (GO TO 723)
702. Can people reduce their chances 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 chance 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
705A. Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?
NO 2
DON'T KNOW 8
706. Can people get 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
707A. Do you think your risk of getting infected with HIV is low, medium or high, or do you have no risk at all?
MEDIUM 2
HIGH 3
NO RISK 4
OTHER 6
DON'T KNOW 8
708. Can the virus that causes AIDS be transmitted from a mother to her baby:
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
OTHER (GO TO 710A)
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
710A. Have you heard about the antiretroviral drugs (ARVs) that people infected with the AIDS virus can get from a doctor or a nurse to help them live longer?
NO 2 (GO TO 711)
DON'T KNOW 8 (GO TO 711)
710B. Do you know anyone on antiretroviral (ART) treatment?
NO 2
DON'T KNOW 8
711. CHECK FOR 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 95
713A. For your most recent test, did you yourself ask for the test, was it offered to you and you accepted, or was it required?
OFFERED AND ACCEPTED 2
REQUIRED 3
714. I don't want to know the results, but did you get the results of the test?
NO 2
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
GOVERNMENT HEALTH CENTER/POST 12
STAND-ALONE VCT CENTRE 13
FAMILY PLANNING CLINIC 14
MOBILE HOSPITAL/CLINIC 15
COMMUNITY BASED AGENT/FIELDWORKER 16
OTHER PUBLIC SECTOR (SPECIFY)_________________17
MISSION HOSPITAL/CLINIC 22
STAND-ALONE VCT CENTRE 23
MOBILE HOSPITAL/CLINIC 24
COMMUNITY BASED AGENT/FIELDWORKER 25
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)___________________ 26
716. Do you know of a place where people can go to get tested for the AIDS virus?
NO 2 (GO TO 718)
717. Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
GOVERNMENT HEALTH CENTER/POST B
STAND-ALONE VCT CENTRE C
FAMILY PLANNING CLINIC D
MOBILE HOSPITAL/CLINIC E
COMMUNITY BASED AGENT/FIELDWORKER F
OTHER PUBLIC SECTOR (SPECIFY)_________________G
MISSION HOSPITAL/CLINIC I
STAND-ALONE VCT CENTRE J
MOBILE HOSPITAL/CLINIC K
COMMUNITY BASED AGENT/FIELDWORKER L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)___________________ M
718. Would you buy fresh from a shopkeeper 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
721A. Do you personally know someone who has or is suspected to have the AIDS virus?
NO 2
721B. Do you agree or disagree with the following statement: People with the AIDS virus should be blamed for bringing the disease into the community.
DISAGREE 2
DON'T KNOW 8
722. Should children age 12-14 be taught about using a condom to avoid getting the AIDS virus?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
722A. Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid getting AIDS virus?
NO 2
DON'T KNOW 8
722B. Some individuals would choose not to go for HIV testing. Why in your opinion is this so?
(CIRCLE ALL THAT ARE MENTIONED)
(MORE THAN ONE ANSWER POSSIBLE)
FEAR OF RESULTS B
FEAR OF STIGMA/DISCRIMINATION C
DON'T KNOW WHERE TO GO D
OTHER (SPECIFY) X
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?
NO 2
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 732)
725. CHECK 723: HEARD ABOUT OTHER SEXUAL TRANSMITTED INFECTIONS?
NO (GO TO 727)
Now I would like to ask you some questions about your health in the last 12 months.
726. 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 an abnormal discharge from their penis. During the last 12 months, have you had an 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 (PROBLEM FROM 726/727/728), did you seek any kind of advice or treatment?
NO (GO TO 732)
731. Where did you go? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
GOVERNMENT HEALTH CENTER/POST B
STAND-ALONE VCT CENTRE C
FAMILY PLANNING CLINIC D
MOBILE HOSPITAL/CLINIC E
COMMUNITY BASED AGENT/FIELDWORKER F
OTHER PUBLIC SECTOR (SPECIFY)_________________G
MISSION HOSPITAL/CLINIC I
STAND-ALONE VCT CENTRE J
MOBILE HOSPITAL/CLINIC K
COMMUNITY BASED AGENT/FIELDWORKER L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)___________________ M
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
732A. Husband and wives do not always agree in 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?
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 other than his wife/wives?
NO 2
DON'T KNOW 8
733A. Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?
NO 2
DON'T KNOW 8
SECTION 8. OTHER HEALTH ISSUES:
801. Some men are circumcised, that is, foreskin is completely removed from the penis. Are you circumcised?
NO 2 (GO TO 805)
DON'T KNOW (GO TO 805)
802. How old were you when you got circumcised?
DURING CHILDHOOD (LESS THAN 5 YEARS) 95
DON'T KNOW 98
802A. Why were you circumcised?
TREATMENT FOR DISEASE B
HYGIENE C
PREVENTION FROM A DISEASE D
INCREASE SEXUAL PLEASURE E
OTHER (SPECIFY)_______________X
DON'T KNOW Z
803. Who performed your circumcision?
TRAINED NURSE/MIDWIFE 12
OTHER HEALTH PROFESSIONAL (SPECIFY)_____________16
OTHER TRADITIONAL (SPECIFY)___________26
HOME OF A HEALTH WORKER/PROFESSIONAL 2
CIRCUMCISION DONE AT HOME 3
RITUAL SITE 4
OTHER HOME/PLACE 5
OTHER 6
DON'T KNOW 8
805. 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
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 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE
NONE 00 (GO TO 808)
806A. The last time you had an injection give to you by a trained health worker where did you go to get the injection?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
GOVERNMENT HEALTH CENTER/POST 12
MOBILE HOSPITAL/CLINIC 13
OTHER PUBLIC SECTOR (SPECIFY)______________16
MISSION HOSPITAL/CLINIC 22
DENTAL CLINIC/OFFICE 23
MOBILE HOSPITAL/CLINIC 24
PHARMACY 25
OFFICE OR HOME OF NURSE/HEALTH WORKER 26
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)_____________ 27
807. The last time you got an injection from a health worker, did he/she 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 811A)
811. What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED
CHEWING TOBACCO B
SNUFF C
OTHER (SPECIFY)____________X
NO 2 (GO TO 811C)
811B. In the last one week how many days did you drink alcohol?
811C. Have you ever heard of an illness called tuberculosis or TB?
NO 2 (GO TO 812)
811D. How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORD ALL MENTIONED.
THROUGH SHARING UTENSILS B
THROUGH TOUCHING A PERSON WITH TB C
THROUGH FOOD D
THROUGH SEXUAL CONTACT E
THROUGH MOSQUITO BITES F
OTHER (SPECIFY)______________X
DON'T KNOW Z
811E. Can tuberculosis be cured?
NO 2
DON'T KNOW 8
811F. If a member of your family got tuberculosis, would you want it to remain a secret or not?
NO 2
DON'T KNOW 8
811G. If a member of your family got tuberculosis, would you care for them?
NO 2
DON'T KNOW/DEPENDS 8
812. Are you covered by any health (insurance/scheme)?
NO 2 (GO TO 813A)
813. What type of health (insurance/scheme)?
RECORD ALL MENTIONED.
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
LOW COST PRE-PAYMENT SCHEME/STANDARD E
HIGH COST PRE-PAYMENT SCHEME/PREMIUM F
OTHER (SPECIFY)_____________X
OTHER (GO TO 813C)
813B. Now I would like to ask you about your own child(ren) who (is/are) under the age of 18
Have you made arrangements for someone to care for (him/her/them) in the event that you fall sick or are unable to care for (him/her/them)?
NO 2
UNSURE 8
813C. (Besides your own child/children), are you the primary caregiver for any children under the age of 18?
NO (GO TO 901)
813D. Have you made any arrangements for someone to care for (this child/these children) in the event that you fall sick or unable to care for (him/her/them)?
NO 2
UNSURE 8
Now I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your natural mother, including those who are living with you, those living elsewhere and those who have died.
901. How many children did your mother give birth to, including you?
ONLY ONE BIRTH (RESPONDENT ONLY) (GO TO 914)
903. How many births did your mother have before you were born?
QUESTIONS 904 THROUGH 913 USE FOR BROTHER OR SISTER 1-14:
904. What was the name give to your oldest (next oldest) brother or sister?
905. Is (NAME) male or female?
FEMALE 2
NO 2 (GO TO 908)
DON'T KNOW 8 (GO TO (NEXT SIBLING))
908. How many years ago did (NAME) die?
909. How old was (NAME) when he/she died?
IF MALE OR DIED BEFORE 12 YEARS OF AGE GO TO (NEXT SIBLING)
910. Was (NAME) pregnant when she died?
NO 2
911. Did (NAME) die during childbirth?
NO 2
912. Did (NAME) die within two months after the end of a pregnancy or childbirth?
NO 2
913. How many live born children did (NAME) give birth to during her lifetime?
MINUTES __ __
TO BE FILLED IN AFTER COMPLETING INTERVIEW.
COMMENTS ABOUT RESPONDENT
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COMMENTS ON SPECIFIC QUESTIONS
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ANY OTHER COMMENTS
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SUPERVISOR'S OBSERVATIONS
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NAME OF SUPERVISOR: ________________
DATE: ________________
EDITOR'S OBSERVATIONS
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NAME OF EDITOR: ________________
DATE: ________________