Ministry of Health/Central Statistical Office

May 2013

IDENTIFICATION

LOCALITY NAME________
NAME OF HOUSEHOLD HEAD___________
CLUSTER NUMBER __ __ __
PROVINCE__ __

RURAL/URBAN

LOCALITY

NAME AND LINE NUMBER OF MAN:
NAME_______
LINE NUMBER_______

INTERVIEWER VISITS

FIRST VISIT
DATE________
INTERVIEWER'S NAME________
RESULT*__________

NEXT VISIT:
DATE________
TIME_________

SECOND VISIT:
DATE________
INTERVIEWER'S NAME_________
RESULT*__________

NEXT VISIT:
DATE__________
TIME___________

THIRD VISIT:
DATE________
INTERVIEWER'S NAME_________
RESULT*__________

FINAL VISIT:
DAY__ __
MONTH__ __
YEAR__ __
INT. NUMBER__ __ __
RESULT*____

TOTAL NUMBER OF VISITS____

*RESULT CODES

LANGUAGE OF QUESTIONNAIRE

LANGUAGE OF INTERVIEW:

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED:

SUPERVISOR
NAME_______
DATE__ __ __

FIELD EDITOR
NAME_______
DATE__ __ __

OFFICER EDITOR____
KEYED BY____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

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?

May I begin the interview now?

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. Have you ever attended school?

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

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

107. CHECK 105:

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?

109. CHECK 108:

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?

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

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

113. What is your religion?

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

114B Just before you moved here, did you live in Lusaka, another city, in a town, or in a village?

115. In the last 12 months, on how may separate occasions have you traveled away from your home community and slept away?

116. In the last 12 months, have you been away from your home community for more than one month at a time?

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, even if they are not legally yours or do not have your last name.

Have you ever fathered any children with any woman?

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? 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?

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

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

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

209. CHECK 208:

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

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

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

213. CHECK 203 AND 205:

214. How old is your (youngest) child?

215. CHECK 214:

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

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 check-ups?

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

219A. Why didn't (NAME)'s mother deliver in a health facility?
PROBE: Any other reason?

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?

SECTION 3. 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)?

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?

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

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?

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

305A. Do you think that a woman who is breastfeeding her baby can become pregnant?

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

307. CHECK 301 (07) KNOWS MALE CONDOM

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

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.

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

311. CHECK 301 (08) KNOWS FEMALE CONDOM

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

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)_______________________

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

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

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

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

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

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

406. 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.

408. How old was (NAME) on her last birthday?

409. CHECK 407:

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

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

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

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

Now I 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?

414A. CHECK 103:

414B. Do you intend to wait until you get married to have sexual intercourse for the first time?

414C. CHECK 103:

414D. The first time you had sexual intercourse, was a female or male condom used?

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.

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?

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

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

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'

421. CHECK 410:

422. CHECK 414:

423. How long ago did you first have sexual intercourse with this (second/third) person?

423A. The last time you had sexual intercourse with this (second/third) person did you or this person drink alcohol?

423B. Were you or your partner drunk at that time?
IF YES: Who was drunk?

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'.

425. How old is this person?

426. Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?

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'.

428. CHECK 420 (ALL COLUMNS):

429. CHECK 420 AND 418 (ALL COLUMNS):

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

431. Have you ever paid anyone in exchange for having sexual intercourse?

432. The last time you paid you someone in exchange for having sexual intercourse, was a female or male condom used?

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

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.'

435. CHECK 418, MOST RECENT PARTNER (FIRST COLUMN):

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.

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.

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?

439. What method did you or your partner use?
PROBE: Did you use any other method to prevent pregnancy?
RECORD ALL MENTIONED.

SECTION 5. FERTILITY PREFERENCES:

501. CHECK 401:

502. CHECK 439:

503: (Is your wife (partner)/are any of your wives (partners)) currently pregnant?

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?

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?

506. CHECK 407:

507. CHECK 503:

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?

508. How long would you wait from now before the birth of (a/another) child?

509. 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 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.

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?

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?

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

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

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

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

607. CHECK 401:

608. CHECK 606:

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

610. Who usually makes decisions about health care for yourself: you, your (wife/partner), you and your (wife/partner) jointly, or someone else?

611. Who usually makes decisions about making major household purchases?

611A. Who usually makes decisions about making purchases for daily household needs?

611B. Who usually makes decisions about visits to your family or relatives?

612. Do you own this or any other house either alone or jointly with someone else?

613. Do you own this land either alone or jointly with someone else?

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

SECTION 7. HIV/AIDS

Now I would like to talk about something else

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

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

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

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

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

705A. Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

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

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

707A. Do you think your risk of getting infected with HIV is low, medium or high, or do you have no risk at all?

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

709. CHECK 708:

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?

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?

710B. Do you know anyone on antiretroviral (ART) treatment?

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?

713. How many months ago was your most recent HIV test?

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?

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

715. Where was the test done?

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.

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

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.

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

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

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?

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?

721A. Do you personally know someone who has or is suspected to have the AIDS virus?

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.

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

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?

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)

723. CHECK 701:

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?

724. CHECK 414:

725. CHECK 723: HEARD ABOUT OTHER SEXUAL TRANSMITTED INFECTIONS?

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?

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

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?

729. CHECK 726, 727, AND 728:

730. The last time you had (PROBLEM FROM 726/727/728), did you seek any kind of advice or treatment?

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.

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?

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?

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?

733A. Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?

SECTION 8. OTHER HEALTH ISSUES:

801. Some men are circumcised, that is, foreskin is completely removed from the penis. Are you circumcised?

802. How old were you when you got circumcised?

802A. Why were you circumcised?

803. Who performed your circumcision?

804. Where was it performed?

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

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

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.

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?

808. Do you currently smoke cigarettes?

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

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

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

811A. Do you drink alcohol?

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?

811D. How does tuberculosis spread from one person to another?

PROBE: Any other ways?

RECORD ALL MENTIONED.

811E. Can tuberculosis be cured?

811F. If a member of your family got tuberculosis, would you want it to remain a secret or not?

811G. If a member of your family got tuberculosis, would you care for them?

812. Are you covered by any health (insurance/scheme)?

813. What type of health (insurance/scheme)?

RECORD ALL MENTIONED.

813A. CHECK 214:

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)?

813C. (Besides your own child/children), are you the primary caregiver for any children under the age of 18?

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)?

SECTION 9. MATERNAL MORTALITY

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?

902. CHECK 901:

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?

906. Is (NAME) still alive?

907. How old is (NAME)?

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?

911. Did (NAME) die during childbirth?

912. Did (NAME) die within two months after the end of a pregnancy or childbirth?

913. How many live born children did (NAME) give birth to during her lifetime?

914. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS:

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: ________________