PROVINCE ______
DEPARTMENT ______
COMMUNE/URBAN CENTER ______
CLUSTER NUMBER ______
VILLAGE/SECTOR ______
HOUSEHOLD UNIT NUMBER ______
OUAGA, BOBO/KOUD, OTHER CITIES, OR RURAL?
BOBO/KOUD 2
OTHER CITIES 3
RURAL 4
NAME OF MAN INTERVIEWED ______
LINE NUMBER OF MALE RESPONDENT ______
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
RESULT _____
2 NOT AT HOME
3 DEFERRED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ______
NEXT VISIT
DATE _____
TIME _____
FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER _____
RESULT _____
TOTAL NUMBER OF VISITS _____
LANGUAGE OF INTERVIEW:
MOORE 2
DIOULA 3
FULFULDE 4
OTHERS 5
INTERPRETER USED?
NO 2
SUPERVISOR
NAME _____
DATE _____
FIELD EDITOR
NAME _____
DATE _____
KEYED BY (NAME) _____
KEYED BY (DATE) _____
KEYED BY (CODE) _____
SECTION 1: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS
101. RECORD THE TIME:
102. In what month and year were you born?
DOESN'T KNOW MONTH 98
DOESN'T KNOW YEAR 98
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 107)
105. What is the highest level of school you attended: primary, middle school, high school, or higher?
MIDDLE SCHOOL 2
HIGH SCHOOL 3
HIGHER 4
106. What is the highest grade you completed at that level?
1 CP1
2 CP2
3 CE1
4 CE2
5 CM1
6 CM2
8 DOESN'T KNOW
1 6TH
2 5TH
3 4TH
4 3RD
8 DOESN'T KNOW
1 2ND
2 1ST
3 FINAL
8 DOESN'T KNOW
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
8 DOESN'T KNOW
107. What is your primary line of work?
CHRISTIAN 2
ANIMIST 3
OTHER (SPECIFY) _____ 4
109. What is your nationality?
TOGOLESE 02 (GO TO 111)
BENINESE 03 (GO TO 111)
MALIAN 04 (GO TO 111)
NIGERIAN 05 (GO TO 111)
OTHER AFRICAN (SPECIFY) _____ 06 (GO TO 111)
OTHER (SPECIFY) _____ 07 (GO TO 111)
DIOULA 02
FULFULDE/PEUL 03
GOURMANTCHE 04
GOUROUNSI 05
LOBI 06
MOSSI 07
SENOUFO 08
TOUARAG/BELLA 09
OTHER (SPECIFY) _____ 10
Now I would like to ask you questions about marriage.
111. Are you currently married or are you currently living with a woman?
NO 2 (GO TO 115)
112. How many wives/spouses do you currently have?
113. LINE NUMBER(S) OF THE WOMAN/WOMEN FROM THE HOUSEHOLD QUESTIONNAIRE :
114. Do you intend to take more wives/partners in the future?
NO 2 (GO TO 117)
115. Have you ever been married?
NO 2 (GO TO 122)
116. Are you widowed, divorced, or separated?
DIVORCED 2
SEPARATED 3
117. In what month and year did you consummate your (first) union?
DOESN'T KNOW MONTH 98
DOESN'T KNOW YEAR 98
118. How old were you when you consummated your (first) union?
DOESN'T KNOW AGE 98
119. CHECK 117 AND 118:
YEAR AND AGE OF CONSUMMATION OF MARRIAGE GIVEN?
NO (GO TO 121)
120. CHECK COHERENCE OF 117 AND 118:
YEAR OF BIRTH (102) + AGE AT MARRIAGE (118) = CALCULATED YEAR OF MARRIAGE :
IF NECESSARY, CALCULATE YEAR OF BIRTH:
CURRENT YEAR - CURRENT AGE (103) = CALCULATED YEAR OF BIRTH
IS THE CALCULATED YEAR OF MARRIAGE WITHIN A YEAR OF THE RECORDED YEAR OF MARRIAGE (117)?
NO (CHECK AND CORRECT 117 AND 118, THEN GO TO 121)
IS MARRIED OR LIVING IN UNION (GO TO 123)
122. At this time, do you have a regular partner, one or more occasional partners, or no partner at all?
ONE OR MORE OCCASIONAL PARTNERS 2
NO PARTNER 3
NO 2 (GO TO 201)
124. How many boys do you have?
How many girls do you have?
Now I would like to talk about family planning and the various ways or methods that a couple can use to delay or avoid a pregnancy.
201. What are the ways or methods that you have heard about?
CIRCLE CODE '1' IN 202 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN THE COLUMN, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE '2' IF METHOD IS RECOGNIZED AND CODE '3' IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE '1' OR '2' CIRCLED IN 202, ASK 203 BEFORE CONTINUING TO THE NEXT METHOD.
202. Have you ever heard of (METHOD)?
READ THE DESCRIPTION OF EACH METHOD.
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
NO 3 (GO TO 204)
203. Have you ever used (METHOD)?
[THIS QUESTION IS ASKED ABOUT EACH METHOD IN 201 WITH '1' or '2' CIRCLED.]
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
NO 2
DOESN'T KNOW 8
NO 2
NO 2
DOESN'T KNOW 8
NO 2
NO 2
NO 2
DOESN'T KNOW 8
NO 2
AT LEAST ONE "YES" (EVER USED) (GO TO 207)
205. Have you or your spouse(s)/partner(s) ever used anything or tried in any way to delay or avoid getting pregnant?
NO ___ (GO TO 209)
206. What have you used or done?
CORRECT 203-204 (AND 202 IF NECESSARY).
207. Are you or your spouse(s)/partner(s) currently doing something or using any method to delay or avoid getting pregnant?
NO 2 (GO TO 209)
208. Which method are you currently using?
IUD 02 (GO TO 212)
INJECTABLES 03 (GO TO 212)
MOUSSE/FOAM/JELLY 04 (GO TO 212)
CONDOM 05 (GO TO 212)
FEMALE STERILIZATION 06 (GO TO 212)
MALE STERILIZATION 07 (GO TO 212)
RHYTHM METHOD 08 (GO TO 212)
WITHDRAWAL 09 (GO TO 212)
PROLONGED ABSTINENCE 10 (GO TO 212)
CHARM/AMULET 11 (GO TO 212)
OTHER (SPECIFY) _____ 12 (GO TO 212)
209. Do you or your spouse(s)/partner(s) intend to use contraception in the future?
NO 2 (GO TO 211)
DOESN'T KNOW 8 (GO TO 212)
210. Which method would you prefer to use?
IUD 02 (GO TO 212)
INJECTABLES 03 (GO TO 212)
MOUSSE/FOAM/JELLY 04 (GO TO 212)
CONDOM 05 (GO TO 212)
FEMALE STERILIZATION 06 (GO TO 212)
MALE STERILIZATION 07 (GO TO 212)
RHYTHM METHOD 08 (GO TO 212)
WITHDRAWAL 09 (GO TO 212)
PROLONGED ABSTINENCE 10 (GO TO 212)
CHARM/AMULET 11 (GO TO 212)
OTHER (SPECIFY) _____ 12 (GO TO 212)
DOESN'T KNOW (GO TO 212)
211. What is the main reason that you do not intend to use a contraceptive method?
LACK OF INFORMATION 02
PARTNER DISAPPROVES 03
COST TOO HIGH 04
SIDE EFFECTS 05
HEALTH PROBLEMS 06
DIFFICULT TO OBTAIN 07
RELIGION 08
OPPOSES FAMILY PLANNING 09
FATALIST 10
OTHERS DISAPPROVE 11
INFREQUENT SEXUAL INTERCOURSE 12
WOMAN HAS DIFFICULTY GETTING PREGNANT 13
WOMAN IN MENOPAUSE/HAD HYSTERECTOMY 14
NOT CONVENIENT 15
STERILE/CANNOT HAVE CHILDREN 16
OTHER (SPECIFY) _____ 17
DOESN'T KNOW 98
212. Are you for or against information about family planning being given out on the radio or television?
AGAINST 2
DOESN'T KNOW 8
213. What is your main source of information about family planning?
RADIO/TELEVISION 02
NEWSPAPERS 03
RELATIVES/NEIGHBORS/FRIENDS 04
DOESN'T KNOW OF FAMILY PLANNING 05
OTHER (SPECIFY) ______ 06
DOESN'T KNOW 98
SECTION 3: FERTILITY PREFERENCES
301. Would you like to have a/another child, or would you prefer not to have any (more) children?
NO MORE/NONE 2 (GO TO 303)
SAYS HIS WIFE CAN'T GET PREGNANT 3 (GO TO 303)
SAYS HE CAN NO LONGER HAVE CHILDREN 4 (GO TO 303)
UNDECIDED/DOESN'T KNOW 8 (GO TO 303)
302. How long would you like to wait from now before the birth of (a/another) child?
YEARS 2 ____
SOON/NOW 994
SAYS HE OR WIFE CAN NO LONGER HAVE CHILDREN 995
OTHER (SPECIFY) _____ 996
DOESN'T KNOW 998
NOT MARRIED/NOT IN UNION AND NO REGULAR PARTNER (GO TO 308)
304. Do you think your wife (wives)/partner(s) approve(s) or disapprove(s) of couples that use a method to avoid becoming pregnant?
DISAPPROVE(S) 2
DOESN'T KNOW 3
305. How many times over the last year have you discussed family planning with your wife (wives)/partner(s)?
ONE OR TWO TIMES 2
MORE OFTEN 3
306. Have you already discussed the number of children you want with your wife (wives)/partner(s)?
NO 2
307. Do you think that your wife (wives)/partner(s) want(s) the same number of children that you want, or more or fewer than you want?
MORE CHILDREN 2
FEWER CHILDREN 3
DOESN'T KNOW 8
308. After the birth of a child, how long should a couple wait to begin having sexual intercourse?
YEARS 2 ____
OTHER (SPECIFY) _____ 996
309. Should a mother wait until she is completely done breastfeeding before restarting sexual relations or does it not matter?
NO IMPORTANCE 2
310. In general, do you approve or disapprove of couples that use a method to avoid becoming pregnant?
DISAPPROVES 2
311. CHECK 123 AND CHECK THE BOX:
NO LIVING CHILDREN: If you could choose exactly the number of children to have in your whole life, how many would that be?
HAS LIVING CHILDREN: If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?
RECORD JUST A NUMBER OR ANOTHER RESPONSE.
OTHER (SPECIFY) _____ 96
312. In your opinion, what is the best interval in months or years between the birth of one child and the birth of the next child?
YEARS 2 ____
OTHER (SPECIFY) ______ 996
SECTION 4: KNOWLEDGE AND ATTITUDES ABOUT AIDS
Now I would like to ask you some questions about a very important subject.
401. Have you ever heard of an illness called AIDS?
NO 2 (GO TO 410)
402. Who have you heard talking about it?
HEALTH AGENT 02
RADIO/TELEVISION 03
NEWSPAPERS 04
FRIEND/RELATIVE/COUSIN 05
POSTERS/ADVERTISING CAMPAIGNS 06
OTHER (SPECIFY) _____ 07
DOESN'T KNOW 98
403. Have you previously attended meetings or talks about AIDS?
NO 2
DOESN'T KNOW 8
404. In your opinion, how can someone get AIDS?
RECORD ALL MENTIONED.
SEXUAL INTERCOURSE WITH PROSTITUTES B
SEXUAL INTERCOURSE WITH DIFFERENT PARTNERS C
HOMOSEXUAL RELATIONS D
BLOOD TRANSFUSIONS E
EAT FROM THE SAME PLATE AS SOMEONE WITH AIDS F
WEAR THE CLOTHES OF SOMEONE WITH AIDS G
USE NON-STERILIZED SYRINGES OR NEEDLES H
MOTHER TO CHILD I
MOSQUITO/INSECT BITES J
OTHER (SPECIFY) _____ K
DOESN'T KNOW L
405. In your opinion, what should one do to avoid contracting AIDS?
RECORD EVERYTHING MENTIONED.
HAVE ONE PARTNER B
AVOID PROSTITUTES C
NOT USE NON-STERILIZED SYRINGES OR NEEDLES D
DON'T TOUCH CONTAMINATED BLOOD E
OTHER (SPECIFY) _____ F
DOESN'T KNOW G
406. How can one recognize someone who has AIDS?
RECORD ALL MENTIONED.
DIARRHEA B
VOMITING C
CHILLS AND FEVER D
BLOOD TEST E
SPOTS ON THE SKIN F
PERSISTENT COUGH G
OTHER (SPECIFY) _____ H
DOESN'T KNOW I
407. Can a woman who has AIDS give birth to a baby with AIDS?
NO 2
DOESN'T KNOW 8
408. Is it possible for a healthy-looking person to have AIDS?
NO 2
DOESN'T KNOW 8
409. In your opinion, what should be done with people sick with AIDS?
KEEP THEM AT HOME 2
ISOLATE THEM 3
OTHER (SPECIFY) _____ 4
DOESN'T KNOW 8
410. In the last 2 months have you received an injection for any reason whatsoever?
NO 2 (GO TO 412)
411. Who gave you this injection?
NURSE'S OFFICE 22
412. Have you had sexual intercourse within the last two months?
NO 2 (GO TO 419)
413. During the sexual intercourse you've had in the last two months, have you used condoms?
NO 2 (GO TO 418)
414. Have you used them every time, sometimes, or rarely?
SOMETIMES 2
RARELY 3
415. Why did you use these condoms?
RECORD ALL MENTIONED.
AVOID STDS B
AVOID AIDS C
OTHER (SPECIFY) _____ D
DOESN'T KNOW E
416. Where did you obtain these condoms?
COMMUNITY PHARMACAUTICAL DEPOT 12
RELATIVES/FRIENDS 32
PARTNER HAD THEM 33
DOESN'T KNOW 98
417. What brand of condoms do you use?
SULTAN 2
OTHERS (SPECIFY) ____ 3
DOESN'T KNOW 8
418. With how many partners have you had sexual intercourse in the last two months?
WIFE/PARTNER ONLY 95
SEVERAL 96
419. RECORD TIME OF END OF INTERVIEW:
TO BE FILLED IN AFTER COMPLETING INTERVIEW.
COMMENTS ABOUT RESPONDENT _____
COMMENTS ON SPECIFIC QUESTIONS _____
ANY OTHER COMMENTS _____
NAME OF INTERVIEWER _____
DATE _____
SUPERVISOR'S OBSERVATIONS _____
NAME OF SUPERVISOR _____
DATE _____
EDITOR'S OBSERVATIONS _____
NAME OF EDITOR _____
DATE _____