QUESTIONNAIRE Section: I A. Identification 1. Name of Household Head: 2. Name of Respondent: 3. District: Sindhupalchowk Date: Ward No: 4. Religion: 5.

Caste\ Ethnicity: B. Household Information S.N. 1 1 2 3 4 5 6 7 8 9 10 Codes 3- (Household head-1, Spouse-2, son/daughter-3, mother/father in law-4, father/mother-5, brother/sister-6) 4- (Male-1, Female-2) 6- (Illiterate-1, Literate-2, Primary pass-3, Secondary pass-4, above S.L.C.-5) 7- (Married-1, Unmarried-2, Divorce-3, Seperated-4, Widow/Widower-5) 8- (Agriculture-1, Services-2, Students-3, Business-4, Remittance-5)
Name Of the Respondent 2 Relation to HH head 3 Age (completed years) 4 Sex 5 Education 6 Marital Status 7 Main Occupation 8

Type of family:

Ill=1 Lit=2

Class

Section: II Individual Questionnaire S.N. Questions What is your date of birth? 1

Description .Years .Months Years Yes No Yes No Grade Passed .

Code 1 2 1 1 2 1 2 1

Remarks

2 3 4 5

What is your completed age? Can you read and write? Can your husband read and write? If Yes, which level has he passed?

6 7 8

How old were you at the time of your first marriage? How old was your husband at the time of marriage? What is your husbands occupation?

..Years ..Years Agriculture Service Students Business Remittance Others(specify) Yes No ..Years Son Daughter Yes No Son Daughter Son Daughter

1 1 1 2 3 4 5 6 1 2 1 1 2 1 2 1 2 1 2 If No, go to Section III

9 10 11 12 13 14

Have you given birth to any child? How old were you at the time of first pregnancy? How many children have you given birth? Are all the children still alive? If No, how of them have died? How many children live with you?

Section: III Socio- Economic Condition of Respondent S.N. Questions 1 What is your main occupation? Description Agriculture Service Students Business Remittance Others(specify) In Rs Yes No . Ropani .. Months Yes No Yes No Rs Brick+Cement Wood Mud Stone Others Electricity T.V. Radio Telephone Others Yes No Yes No . (Please specify) Yes No Pakki Ardha PAkki Kachhi Others Male Female Both Others 1 2 (If No go to Q.No.5) Code 1 2 3 4 5 6 Remarks

2 3 4 5 6 7 8 9

How much do you earn in a year? Do you have cultivated land? If Yes, how much? How many manths does it maintain your food? Does your family have domestic animals? Does your family sell them? How much monthly income do you get from selling domestic animals? Which type of house do you have?

1 2 1 2 1 1 2 3 4 1 2 3 4 5 1 2 1 2 1 1 2 1 2 3 4 1 2 3 4

10

Do you have modern facilities in your house?

Multiple response

11 12 13 14 15

Do you usually listen to radio every day? Do you usually watch television? What is the main source of drinking water? Do you have toilet facilities in your house? If yes what kind of toilet facilities you hh have?

16

Who is the decision maker in your family?

Section: IV Knowledge of Contraception S.N. Questions Have you got any information about 1 Contraception methods? If Yes, would you tell me the name of 2 modern contraceptive methods?

Description Yes No
I.Any modern methods Pills Condom Norplant Foam IUD Depo provera Sterilization of male\female II.Any natural methods Withdrawal method Safe period method

Code Remarks 1 (If No go 2 to Q.No.7) 1 2 3 4 5 6 7 1 2 1 2 3 4 5 6 7 8 1 2 1 2 3 4 5 6 7 8 1 2 3 1 2 3 4 5

Multiple Response

What are the sources of information about Contraception?

4 5

Do you know the sources of contraceptive suppliers? If Yes, what are they?

When did you know about contraception? What is the best child bearing age of women?

Radio Television Newspaper Health workers Health center Teachers Relatives Others Yes No Health Post Health Center Hospital Health Workers Health center Doctor\ Nurses Mobile health clinic Others After marriage Before marriage Do not remember Under 20 years 20------30 years. 30-------35 years. Above 35 years. Dont know.

Multiple Response

(If Yes go to Q.No.6)

Section: V Attitude Towards Contraception S.N. Questions 1 Which sex do you prefer first? 2 3 4 5

9 10

Description Son Daughter Do you want additional children now Yes. No.. If Yes, how many child do you want? Son. Daughter.. Which child do you additional now? Son. Daughter.. What are the main reasons of unwanted Acknowledge and high pregnancy Not available Husband disagree Wife disagree Expensive Religious factors Others Which is the safest method of Pills contraception is your opinion? Condom Why.. Norplant Foam IUD Depo provera Sterilization of male\female What methods would you suggest to Dont know promote the use of contraception? Strengthening PF\ RH education Making FP services easily available Providing facilities for treatment side effect Encouraging both FP providers and users How long does it usually take to travel Minutes. time from your home to go to the FP Hours. sources? Days.. Did you discuss your pregnancy with Yes. an FCHV? No. How many children do you prefer for Son. ideal family? Daughter.

Code 1 2 1 2 1 2 1 2 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 1 2 3 1 2 1 2

Remarks

Section: VI Use of Contraception S.N. Questions Have you\your husband ever used 1 any contraceptive methods? Does your husband suggest to use 2 contraception methods? 3 4 5 Which one?(specify) How often do you\your husband use the contraception? If Yes, which method are you using?

Description Yes No Yes No

Code 1 2 1 2

Remarks ( If No go to Q.No.13)

6 7

Why are you using this methods? When do you use contraceptives?

Regularly. Sometime. Pills Condom Norplant Foam IUD Depo provera Sterilization of Male\female Every time Only during unsecured period Month. Day..

1 2 1 2 3 4 5 6 7

Multiple Response

1 2 1 2

After last delivery, how many days later did you use contraceptives? Did you experience any side effects of contraceptives? If yes, what are they?

9 10

Yes No Irregular menstruation Over bleeding Headache Vomiting Weakness Others Yes No Yes No Importance of son Importance of daughter Expensive Fear of side effect Feeling of shyness Sexual displeasure Against the religion Others

1 2 1 2 3 4 5 6 1 2 1 2 1 2 3 4 5 6 7 8

( If No go to Q.No.12)

11 12 13

Did you consult the doctor about the side effect? Are you satisfied with it? If No, why?