[p. 1]

Bosnia Herzegovina (Roma Settlements) 2011

Woman's information panel: WM

This questionnaire is to be administered to all women age 15 through 49 (see Household Listing Form, column HL7). A separate questionnaire should be used for each eligible woman.

WM1. Cluster number: _ _ _

WM2. Household number: _ _

WM3. Woman's name:
WM4. Woman's line number: _ _

WM5. Interviewer name and code
WM6. Day/month/year of interview _ _ / _ _ / _ _ _ _

Repeat greeting if not already read to this woman:
We are from The Ministry of Human Rights and Refugees of Bosnia and Herzegovina. We are conducting a survey concerned with family health and education. I would like to talk to you about these subjects. This interview will take about 20 minutes. All the information we obtain will remain strictly confidential.

If greeting at the beginning of the household questionnaire has already been read to this woman, then read the following:
Now I would like to talk to you more about your health and other topics. This interview will take about 20 minutes. Again, all the information we obtain will remain strictly confidential.

May I start now?

WM7. Result of woman's interview

WM8. Control carried out by (name and number):
WM9. Data entry operator (name and number):
[p. 2]
WM10. Record the interview start time.
Woman's Background: WB

WB1. In what month and year were you born?

WB2. How old are you?
Probe: How old were you at your last birthday? Compare WB1 and/or WB2 and correct if inconsistent.
WB3. Have you ever attended school or preschool institution?

WB4. What is the highest level of school you attended?

WB5. What is the highest grade you completed at that level?
If less than 1 grade, enter "00"
WB6. Check WB4:
WB7. Now I would like you to read this sentence to me.
Show sentence on the card to the respondent. If respondent cannot read whole sentence, probe: Can you read part of the sentence to me?
[p. 3]
Access to mass media and use of information/communication technology: MT

MT1. Check WB7:
MT2. How often do you read a newspaper or magazine: almost every day, at least once a week, less than once a week or not at all?

MT3. Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?

MT4. How often do you watch television: would you say that you watch almost every day, at least once a week, less than once a week or not at all?

MT5. Check WB2: Is the respondent aged 15-24 years?
MT6. Have you ever used a computer?

MT7. In the last 12 months, have you used a computer from any location?

MT8. During the last one month, how often did you use a computer: almost every day, at least once a week, less than once a week or not at all?

MT9. Have you ever used the internet?

MT10. In the last 12 months, have you used the internet?
If necessary, probe for use of internet from any location, with any device, etc.
MT11. During the last one month, how often did you use the internet: almost every day, at least once a week, less than once a week or not at all?

[p. 4]
Child mortality: CM

This module has to be administered to all women aged 15-49. Questions CM0-CM12 refer to only LIVE births.

CM0. Check cluster number in WM1.
CM0A. Now I would like to ask about all the births you have had during your lifetime. How many live born children have you had in your entire life?
Probe to determine whether respondent is referring to live born children. By live born children, I mean a child who ever breathed or cried or showed other signs of life - even if he or she lived only a few minutes or hours.
If "None", circle '00'.
CM0B. What is the date of your last birth (even if the baby died)?
Month and year must be recorded.
CM0B. Now I would like to ask about all the births you have had during your lifetime. How many live born children have you had in your entire life?

CM1. Now I would like to ask about all the births you have had during your life. Have you ever given birth?

CM2. What was the date of your first birth?
I mean the very first time you gave birth, even if the child is no longer living, or whose father is not your current partner.
Skip to CM4 only if year of first birth is given. Otherwise, continue with CM3.
CM3. How many years ago did you have your first birth?

CM4. Do you have any sons or daughters to whom you have given birth who are now living with you?

CM5. How many sons live with you? How many daughters live with you?
If none, record '00'.
CM6. Do you have any sons or daughters to whom you have given birth who are alive but do not live with you?

CM7. 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'.
CM8. Have you ever given birth to a boy or girl who was born alive but later died?
If "no" probe by asking: I mean, to a child who ever breathed or cried or showed other signs of life -- even if he or she lived only a few minutes or hours?
CM9. How many boys have died? How many girls have died?
If none, record '00'.
CM10. Sum answers to CM5, CM7, and CM9.
[p. 5]
CM11. Just to make sure that I have this right, you have had in total (total number in cm10) live births during your life. Is this correct?

CM12. Of these (total number in CM10) births you have had, when did you deliver the last one (even if he or she has died)?
Month and year must be recorded.
CM12A. Sometimes women have pregnancies that might not end with a live birth, have you ever had any pregnancy that was miscarried, ended in a stillbirth, or that was terminated early (aborted)?

CM12B. How many miscarriages have you had during your lifetime?
By miscarriage, I mean an early and involuntary end of pregnancy within the first 5 months of pregnancy.

CM12C. In how many cases have your pregnancies ended with a stillbirth?
By stillbirth, I mean a birth that took place after the fifth month of pregnancy, but the child did not show any sins of life.

CM12D. And how many early terminations of pregnancy (abortions) have you had during your lifetime?
By early termination of pregnancy (abortion), I mean a pregnancy that was voluntarily terminated within the first 5 months of pregnancy.

CM12E. When do your (last) early termination of pregnancy (abortion) take place?
Month and year must be recorded.
CM12F. Check in CM12E when the last abortion took place and if:
CM12G. If the respondent has mentioned more than one early termination (abortion), i.e. CM12D is higher than 1, then ask her for the exact month and year of each mentioned early termination (abortion) that took place during the last 2 years, i.e. since (the month interviewing) 2009. Write down month and year for each early termination (abortion) that took place in CM12H, starting from the last, and for each recorded early termination (abortion) ask the respondent to tell you how many weeks/months she was pregnant when she had the early termination (abortion) and record this appropriately.

CM12H. What month and year did your (last) early termination (abortion) take place?

CM12I. How many months (weeks) were you pregnant when your pregnancy was aborted?
If the respondent answers in weeks, write down on the appropriate line for weeks, otherwise just record the given months.

CM12J. Check total number of early terminations (abortions) in CM12D and if the total is:
CM12K. In what month and year did you have your first early termination of pregnancy (abortion)?

CM12L. How old were you when you had your first early termination (abortion)?

CM13. Check CM08 or CM12: Last birth occurred within the last 2 years, i.e. since (day and month of interview) in 2009

If the child has died, take special care when referring to this child by name in the following modules. Continue with the next module.

[p. 6]
Desire for last birth: DB

This module is to be administered to all women with a live birth in the 2 years preceding date of interview.
Check child mortality module CM13 and record name of last-born child here ____
Use this child's name in the following questions, where indicated.

DB1. When you got pregnant with (name), did you want to get pregnant at that time?

DB2. Did you want to have a baby later on, or did you not want any (more) children?

DB3. How much longer did you want to wait?

[p. 7]
Maternal and newborn health: MN

This module is to be administered to all women with a live birth in the 2 years preceding date of interview.
Check child mortality module CM13 and record name of last-born child here ____
Use this child's name in the following questions, where indicated.

MN1. Did you see anyone for antenatal care during your pregnancy with (name)?

MN2. Whom did you see?
Probe: Anyone else? Probe for the type of person seen and circle all answers given.
MN3. How many times did you receive antenatal care during this pregnancy?

MN4. As part of your antenatal care during this pregnancy, was any of the following done at least once:

[A] Was your blood pressure measured?

[B] Did you give a urine sample?

[C] Did you give a blood sample?

MN17. Who assisted with the delivery of (name)?
Probe: Anyone else? Probe for the type of person assisting and circle all answers given. If respondent says no one assisted, probe to determine whether any adults were present at the delivery.
[p. 9]
MN18. Where did you give birth to (name)?
Probe to identify the type of source. If unable to determine whether public or private, write the name of the place, institution, organization, etc.
(Name of institution, organization, etc.) ____

MN19. Was (name) delivered by caesarean section? That is, did they cut your belly open to take the baby out?

MN20. When (name) was born, was he/she very large, larger than average, average, smaller than average, or very small?

MN21. Was (name) weighed at birth?

MN22. How much did (name) weigh?
Record weight from health card, if available.
MN23. Has your menstrual period returned since the birth of (name)?

MN24. Did you ever breastfeed (name)?

MN25. How long after birth did you first put (name) to the breast?
If less than 1 hour, record '00' hours. If less than 24 hours, record hours. Otherwise, record days.
[p. 10]
MN26. In the first three days after delivery, was (name) given anything to drink other than breast milk?

MN27. What was (name) given to drink?
Probe: Anything else?
[p. 11]
Illness Symptoms: IS

IS1. Check Household Listing, column HL9
Is the respondent the mother or caretaker of any child under age 5?

IS2. Sometimes children have severe illnesses and should be taken immediately to a health facility. What types of symptoms would cause you to take your child to a health facility right away?
Probe: Any other symptoms? Keep asking for more signs or symptoms until the mother/caretaker cannot recall any additional symptoms. Circle all symptoms mentioned, but do not prompt with any suggestions
[p. 16]
Contraception: CP

CP0. I would like to talk with you about another subject -- family planning.
Couples use different ways or methods in order to postpone or avoid pregnancy.
Have you heard of:

CP1. Are you pregnant now?

CP2. As we mentioned earlier, couples use various ways or methods to delay or avoid a pregnancy. Are you currently doing something or using any method to delay or avoid getting pregnant?

CP3. What are you doing to delay or avoid a pregnancy?
Do not prompt. If more than one method is mentioned, circle each one.
[p. 17]
Unmet need: UN

UN1. Check CP1. Is the respondent currently pregnant?
UN2. Now I would like to talk to you about your current pregnancy. When you got pregnant, did you want to get pregnant at that time?

UN3. Did you want to have a baby later on or did you not want any (more) children?

UN4. Now I would like to ask some questions about the future. After the child you are now expecting, would you like to have another child, or would you prefer not to have any more children?

UN5. Check CP3. Currently using "female sterilization"
UN6. Now I would like to ask you some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

UN7. How long would you like to wait before the birth of (a/another) child?

UN8. Check CP1. Is the respondent currently pregnant?
[p. 18]
UN9. Check CP2. Is the respondent currently using a contraceptive method?
UN10. Do you think you are physically able to get pregnant at this time?

UN11. Why do you think you are not physically able to get pregnant?

UN12. Check UN11. "Never menstruated" mentioned?
UN13. When did your last menstrual period start?

[p. 19]
Attitudes toward domestic violence: DV

DV1. 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:

[A] If she goes out without telling him?

[B] If she neglects the children?

[C] If she argues with him?

[D] If she refuses to have sex with him?

[E] If she burns the food?

[p. 23]
Marriage/union: MA

MA1. Are you currently married or living together with a man as if married?

MA2. How old is your husband/partner?
Probe: how old was your husband/partner on his last birthday?
MA2A. Check cluster number in WM1.
MA3. Besides yourself, does your husband/partner have any other wives or partners or does he live with other women as if married?

MA4. How many other wives or partners does he have?

MA5. Have you ever been married or lived together with a man as if married?

MA6. What is your marital status now: are you widowed, divorced or separated?

MA7. Have you been married or lived with a man only once or more than once?

MA8. In what month and year did you first marry or start living with a man as if married?

MA9. How old were you when you started living with your first husband/partner?

[p. 24]
Sexual behavior: SB

Check for the presence of others. Before continuing, ensure privacy.

SB1. Now I would like to ask you some questions about sexual activity in order to gain a better understanding of some important life issues.
The information you supply will remain strictly confidential.
How old were you when you had sexual intercourse for the very first time?

SB2. The first time you had sexual intercourse, was a condom used?

SB3. When was the last time you had sexual intercourse?
Record 'years ago' only if last intercourse was one or more years ago. If 12 months or more the answer must be recorded inyears.
SB4. The last time you had sexual intercourse, was a condom used?

SB5. What was your relationship to this person with whom you last had sexual intercourse?
Probe to ensure that the response refers to the relationship at the time of sexual intercourse.
If 'boyfriend', then ask: Were you living together as if married? If 'yes', circle '2'. If 'no', circle'3'.
SB6. Check MA1:
SB7. How old is this person?
If response is DK, probe: About how old is this person?
SB8. Have you had sexual intercourse with any other person in the last 12 months?

SB9. The last time you had sexual intercourse with this other person, was a condom used?

[p. 25]
SB10. What was your relationship to this person?
Probe to ensure that the response refers to the relationship at the time of sexual intercourse
If 'boyfriend' then ask: Were you living together as if married? If 'yes', circle '2'. If 'no', circle '3'.
SB11. Check MA1 and MA7:
SB12. How old is this person?
If response is DK, probe: About how old is this person?
SB13. In the last 12 months, have you had sexual intercourse with any other person, other than these two persons?

SB14. In total, with how many different people have you had sexual intercourse in the last 12 months?

SB15. In total, with how many different people have you had sexual intercourse in your lifetime?
If a non-numeric answer is given, probe to get an estimate. If number of partners is 95 or more, write '95'.
[p. 26]
HIV/AIDS: HA

HA1. Now I would like to talk with you about something else.
Have you ever heard of an illness called AIDS (or SIDA)?

HA2. Can people reduce their chance of getting the virus that causes AIDS by having just one uninfected sex partner who has no other sex partners?

HA3. Can people get the AIDS virus because of witchcraft or other supernatural means?

HA4. Can people reduce their chance of getting the virus that causes AIDS by using a condom every time they have sex?

HA5. Can people get the virus that causes AIDS from mosquito bites?

HA6. Can people get the virus that causes AIDS by sharing food with a person who has AIDS?

HA7. Is it possible for a healthy-looking person to have the virus that causes AIDS?

HA8. Can the virus that causes AIDS be transmitted from a mother to her baby:

[A] During pregnancy?

[B] During delivery?

[C] By breastfeeding?

HA9. In your opinion, if a female teacher has the virus that causes AIDS but is not sick, should she be allowed to continue teaching in school?

HA10. Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the virus that causes AIDS?

HA11. If a member of your family got infected with the virus that cuases AIDS, would you want it to remain a secret?

HA12. If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?

[p. 27]
HA13. Check CM13: Did the respondent have any live births in the last 2 years?
HA14. Check MN1: Did the respondent receive antenatal care?
HA15. During any of the antenatal visits for your pregnancy with (name),

Were you given any information about:

[A] Babies getting the virus that causes AIDS from their mother?

[B] Things that you can do to prevent getting the virus that causes AIDS?

[C] Getting tested for the the virus that causes AIDS?

Were you:
[D] Offered a test for the virus that causes AIDS?

HA16. I don't want to know the results, but were you tested for the virus that causes AIDS as part of your antenatal care (pregnancy checks)?

HA17. I don't want to know the results, but did you get the results of the test?

HA18. Regardless of the result, all women who are tested are supposed to receive counseling / attend consultations after getting the result. After you were tested, did you receive counselling / attend consultations?

HA19. Check MN17: Birth delivered by health professional (A or B)?
HA20. I don't want to know the results, but were you tested for the AIDS virus between the time you went for delivery but before the baby was born?

HA21. I don't want to know the results, but did you get the results of the test?

HA22. Have you been tested for the virus that causes AIDS since that time you were tested during your pregnancy?

[p. 28]
HA23. When was the most recent time you were tested for the virus that causes AIDS?

HA24. I don't want to know the results, but have you ever been tested to see if you have the virus that causes AIDS?

HA25. When was the most recent time you were tested?

HA26. I don't want to know the results, but did you get the results of the test?

HA27. Do you know of a place where people can go to get tested for the virus that causes AIDS?

[p. 29]
Tobacco and alcohol use: TA

TA1. Have you ever tried cigarette smoking, even one or two puffs?

TA2. How old were you when you smoked an entire cigarette for the first time?

TA3. Do you currently smoke cigarettes?

TA4. How many cigarettes did you smoke in the last 24 hours?

TA5. On how many days did you smoke cigarettes during the last month?
If less than 10 days, record the number of days. If 10 days or more but less than a month, circle "10". If "everyday" or "almost every day", circle "30"
TA6. Have you ever tried any smoked tobacco products other than cigarettes, such as cigars (e.g. Cuban), a pipe or waterpipe (Narghile/Hookah)?

TA7. During the last one month, did you use any smoked tobacco products?

TA8. What type of smoked tobacco product did you use or smoke during the last month?
Circle all mentioned responses.
TA9. On how many days did you use smoked tobacco products during the last month?
If less than 10 days, record the number of days. If 10 days or more but less than a month, circle "10". If "everyday" or "almost every day", circle "30"
TA10. Have you ever tried any form of smokeless tobacco products, such as chewing tobacco, tobacco for sniffing (snuff) or dipping tobacco?

TA11. Do you use any smokeless tobacco products during the last month?

[p. 32]
TA12. What type of smokeless tobacco product did you use during the last month?
Circle all mentioned.
TA13. On how many days did you use smokeless tobacco products during the last month?
If less than 10 days, record the number of days. If 10 days or more but less than a month, circle "10". If "everyday" or "almost every day", circle "30"
TA14. Now I would like to ask you some questions about drinking alcohol.
Have you ever drunk alcohol?

TA15. We count one drink of alcohol as one can or bottle of beer, one glass of wine, or one shot of strong drink.
How old were you when you had your first drink of alcohol, other than a few sips?

TA16. During the last one month, on how many days did you have at least one drink of alcohol?
If respondent did not drink, circle "00". If less than 10 days, record the number of days. If 10 days or more but less than a month, circle "10". If "everyday" or "almost every day", circle "30"
TA17. In the last one month, on the days that you drank alcohol, how many drinks did you usually have?

[p. 33]
Life satisfaction: LS

LS1. Check WB2: Age of respondent is between 15 and 24?
LS2. I would like to ask you some simple questions on happiness and satisfaction.
First, taking all things together, would you say you are very happy, happy, neither happy nor unhappy, unhappy or very unhappy?
You can also look at these pictures to help you respond.
Show side 1 of response card and explain what each symbol represents. Circle the response code pointed by the respondent. [Image omitted.]

LS3. Now I will ask you questions about your level of satisfaction in different areas.
In each case, we have five possible responses: please tell me, for each question, whether you are very satisfied, satisfied, neither satisfied nor unsatisfied, unsatisfied or very unsatisfied.
Again, you can look at these pictures to help you with your response.
Show side 2 of response card and explain what each symbol represents. For questions LS3 to LS13, circle the response code shown by the respondent. [Image omitted.]
How satisfied are you with your family life?

LS4. How satisfied are you with your friendships?

LS5. During the [current / 2011-2012] school/academic year, did you attend school at any time?

[p. 34]
LS6. How satisfied (are/were) you with your school/university?

LS7. How satisfied are you with your current job?
If the respondent says that he/she does not have a job, circle "0" and continue with the next question. Do not probe to find out how she feels about not having a job, unless she tells you herself.
LS8. How satisfied are you with your health?

LS9. How satisfied are you with where you live?
If necessary, explain that the question refers to the living environment, including the neighbourhood and the dwelling.
LS10. How satisfied are you with how people around you generally treat you?

LS11. How satisfied are you with the way you look?

LS12. How satisfied are you with your life, overall?

LS13. How satisfied are you with your current income?
If the respondent responds that he/she does not have any income, circle "0" and continue with the next question. Do not probe to find out how she feels about not having any income, unless she tells you herself.
LS14. Compared to this time last year, would you say that your life has improved, stayed more or less the same, or worsened, overall?

[p. 35]
LS15. And in one year from now, do you expect that your life will be better, will be more or less the same, or will be worse, overall?

Health Care: HE

HE0. Check cluster number in WM1.
HE1. Do you have a health booklet?

HE2. Do you have health insurance?

HE3. Do you use health care services at the health centre?

HE4. Are you provided with health care services at the nearest health centre of charge?

HE5. Do you use health care services at the hospital?

HE6. Are you provided with health care services at the nearest hospital free of charge?

HE7. Do you use emergency health care services?

HE8. Are you provided with emergency health care services free of charge?

HE9. Do you pay all necessary health care services and medication?

HE10. Do you pay only vital/urgently needed health care services and medications?

HE11. Can you afford medications without one-off financial assistamce?

[p. 36]
WM11. Record the time.
WM12. Check Household Listing Form, column HL9.
Is the respondent the mother or caretaker of any child age 0-4 living in this household?
[p. 37]
Interviewer's observations

Field editor's observations

Supervisor's observations

[p. 38]
Response card:

Side 1

Side 2

Man's information panel: MWM

This questionnaire is to be administered to all men age 15 through 49 (see Household Listing Form, column HL7). A separate questionnaire should be used for each eligible man.

MWM1. Cluster number: _ _ _

MWM2. Household number: _ _

MWM3. Man's name:
MWM4. Man's line number: _ _

MWM5. Interviewer name and code
MWM6. Day/month/year of interview _ _ / _ _ / _ _ _ _

Repeat greeting if not already read to this woman:
We are from The Ministry of Human Rights and Refugees of Bosnia and Herzegovina. We are conducting a survey concerned with family health and education. I would like to talk to you about these subjects. This interview will take about 20 minutes. All the information we obtain will remain strictly confidential.

If greeting at the beginning of the household questionnaire has already been read to this man, then read the following:
Now I would like to talk to you more about your health and other topics. This interview will take about 20 minutes. Again, all the information we obtain will remain strictly confidential. and your answers will never be shared with anyone other than our project team.

May I start now?

MWM7. Result of man's interview

MWM8. Control carried out by (name and number):
MWM9. Data entry operator (name and number):