PROVINCE _____
DEPARTMENT _____
COMMUNE/URBAN CENTER _____
VILLAGE/SECTOR _____
CLUSTER NUMBER _____
NAME OF HEAD OF CONCESSION _____
CONCESSION NUMBER _____
NAME OF HEAD OF HOUSEHOLD _____
HOUSEHOLD UNIT NUMBER _____
URBAN/RURAL:
RURAL 2
OUAGA/BOBO/OTHER CITIES/RURAL:
BOBO 2
OTHER CITIES 3
RURAL 4
INTERVENTION ZONE:
NO 2
NAME OF MALE RESPONDENT _____
LINE NUMBER OF MALE RESPONDENT _____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
RESULT _____
NOT AT HOME 2
DEFERRED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
NEXT VISIT
DATE _____
TIME _____
FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER _____
RESULT _____
NOT AT HOME 2
DEFERRED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
TOTAL NUMBER OF VISITS _____
MOORE 2
DIOULA 3
FULFULDE 4
OTHERS 5
INTERPRETER USED:
NO 2
SUPERVISOR
NAME _____
DATE _____
FIELD EDITOR
NAME _____
DATE _____
OFFICE EDITOR _____
KEYED BY _____
SECTION 1: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENT
101. RECORD THE TIME:
To begin, I would like to ask you questions about yourself.
103. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
ALWAYS 95
VISITOR 96
105. In what month and year were you born?
DOESN'T KNOW MONTH 98
DOESN'T KNOW YEAR 9998
106. How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.
106A. Do you understand French?
NO 2
107. Have you ever attended school?
NO 2 (GO TO 111)
108. What is the highest level of school you attended: primary, middle school, high school, or higher?
MIDDLE SCHOOL 2
HIGH SCHOOL 3
HIGHER 4
109. What is the highest grade you completed at that level?
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
8 DOESN'T KNOW
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
8 DOESN'T KNOW
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
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
SECONDARY OR HIGHER (GO TO 111A)
111. Can you read and understand a letter or newspaper easily, with difficulty, or not at all?
WITH DIFFICULTY 2
NOT AT ALL 3 (GO TO 112A)
111A. Do you read a newspaper or magazine at least once a month?
NO 2 (GO TO 112A)
112. Do you read a newspaper or magazine at least once a week?
NO 2
112A. Do you listen to the radio?
NO 2 (GO TO 113G)
113. Do you listen to the radio every day?
NO 2
113A. On what days of the week do you listen to the radio?
RECORD ALL GIVEN RESPONSES. IF THE RESPONSE IS: "IT DEPENDS", "WHENEVER" OR "DOESN'T KNOW", YOU SHOULD ONLY CIRCLE ONE CODE.
TUESDAY B
WEDNESDAY C
THURSDAY D
FRIDAY E
SATURDAY F
SUNDAY G
IT DEPENDS/WHENEVER X
DOESN'T KNOW Z
113B. At what times do you usually listen to the radio?
RECORD ALL GIVEN RESPONSES. IF THE RESPONSE IS: "ALL DAY", "IT DEPENDS", "WHENEVER" OR "DOESN'T KNOW", YOU SHOULD ONLY CIRCLE ONE CODE.
FROM 8 TO NOON B
FROM NOON TO 2:00 PM C
FROM 2:00-6:00 PM D
FROM 6:00-8:00 PM E
AFTER 8:00 PM F
ALL DAY G
DEPENDS/WHENEVER X
DOESN'T KNOW Z
113C. What types of radio programs do you usually listen to?
PROBE TO GET THE TYPES OF SHOWS. RECORD ALL TYPES MENTIONED.
SPORTS B
NEWS D
REPORTING E
HEALTH PROGRAMMING F
OTHER (SPECIFY) ____ X
113CA. What radio stations do you usually listen to?
RECORD ALL RESPONSES.
PULSAR B
RADIO MARIA C
ARC-EN-CIEL [RAINBOW] D
HORIZON FM E
SALANKOLOTO F
ENERGIE G
RADIO EVANGILE DEVELOPPEMENT H
LUMIERE VIE ET DEVELOPPEMENT I
FOREIGN STATIONS J
113D. Have you ever had the chance to hear the radio program "Yamba Songo"?
NO 2 (GO TO 113G)
DOESN'T KNOW THE SHOW (GO TO 113G)
113E. According to you is this series educational in nature or is it just entertainment?
ENTERTAINMENT 2 (GO TO 113G)
BOTH 3
DOESN'T KNOW 8 (GO TO 113G)
113F. In your opinion, which problems does "Yamba Songo" discuss?
RECORD ALL RESPONSES. IF THE RESPONSE IS "DOESN'T KNOW", YOU SHOULD ONLY CIRCLE THAT CODE.
HIV/AIDS B
SEXUALLY TRANSMITTED DISEASES C
ORS/TREATMENT OF DIARRHEA D
HEALTH PROBLEMS E
OTHER (SPECIFY) _____ X
DOESN'T KNOW Z
113G. Do you watch the television?
NO 2 (GO TO 115)
114. Do you watch the television at least once a week?
NO 2
114A. On what days of the week do you watch the television?
RECORD ALL GIVEN RESPONSES. IF THE RESPONSE IS "IT DEPENDS", "WHENEVER" OR "DOESN'T KNOW", YOU SHOULD ONLY CIRCLE ONE CODE.
TUESDAY B
WEDNESDAY C
THURSDAY D
FRIDAY E
SATURDAY F
SUNDAY G
EVERYDAY I
IT DEPENDS/WHENEVER X
DOESN'T KNOW Z
114B. At what times do you usually watch the television?
RECORD ALL GIVEN RESPONSES. IF THE RESPONSE IS "ALL DAY", "IT DEPENDS", "WHENEVER" OR "DOESN'T KNOW": YOU SHOULD ONLY CIRCLE ONE CODE.
FROM NOON TO 2:00 PM C
FROM 2:00-6:00 PM D
FROM 6:00-8:00 PM E
AFTER 8:00 PM F
ALL DAY G
DEPENDS/WHENEVER X
DOESN'T KNOW Z
114C. What types of television programs do you usually watch?
PROBE TO GET THE TYPES OF SHOWS. RECORD ALL TYPES MENTIONED.
SPORTS B
FILMS/SERIES C
NEWS D
REPORTING E
HEALTH PROGRAMMING F
OTHER (SPECIFY) ____ X
114D. What television stations do you usually watch?
FOREIGN STATIONS B
NO 2
116. Have you done work of any kind during the last 12 months?
NO 2 (GO TO 125)
117. What is your occupation, that is, what kind of work do you mainly do?
DOES NOT WORK IN AGRICULTURE (GO TO 120)
119. Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else's land?
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
NOT APPLICABLE 5
120. Do you do this work for a member of your family, for someone else, or are you self-employed?
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3
121. 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
PROTESTANT 2
MUSLIM 3
TRADITIONAL 4
NOT RELIGIOUS 5
OTHER (SPECIFY) _____ 6
125A. What is your nationality?
NIGERIAN 02 (GO TO 201)
TOGOLESE 03 (GO TO 201)
BENINESE 04 (GO TO 201)
MALIAN 05 (GO TO 201)
IVOIRIAN 06 (GO TO 201)
GHANAN 07 (GO TO 201)
OTHER AFRICAN (SPECIFY) _____ 08 (GO TO 201)
OTHER (SPECIFY) _____ 09 (GO TO 201)
125B. What is your ethnicity?
WRITE DECLARED ETHNICITY, THEN CIRCLE CORRESPONDING CODE.
DIOULA 02
FULFULDE/PEUL 03
GOURMATCHE 04
GOUROUNSI 05
LOBI 06
MOSSI 07
SENOUFO 08
TOUAREG/BELLA 09
OTHER (SPECIFY) _____ 10
DOESN'T KNOW 98
Now I would like to ask you about your children. I am only interested in the children of whom you are the biological father.
201. Have you had any children?
NO 2 (GO TO 206)
202. Do you have any sons or daughters who are now living with you?
NO 2 (GO TO 204)
203. How many of your sons live with you?
How many of your daughters live with you?
IF NONE, RECORD '00'.
204. Do you have any sons or daughters of whom you are the father and are alive but do not live with you?
NO 2 (GO TO 206)
205. How many of your sons are alive but do not live with you?
How many of your daughters are alive but do not live with you?
IF NONE, RECORD '00'.
206. Have you ever had a son or daughter who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life at birth but did not survive more than several hours or days?
NO 2 (GO TO 208)
207. How many sons have died?
And how many daughters have died?
IF NONE, RECORD '00'.
208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
IF NONE, RECORD '00'.
209. CHECK 208:
Just to make sure that I have this right: you have had in TOTAL _____ children during your life. Is that correct?
NO (PROBE AND CORRECT 201-208 AS NECESSARY)
HAS NOT HAD CHILDREN (GO TO 300)
210A. In what month and year was your last child born?
BEFORE JANUARY 1993 (GO TO 300)
211. At the time you were expecting your last child, did you want that child at that precise time, did you want to wait longer, or did you not want another child at all?
LATER 2
NOT AT ALL 3
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.
CIRCLE CODE '1' IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 302, 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 301 OR 302, ASK 303.
301. What are the ways or methods you have heard about?
302. Have you ever heard of (METHOD)?
YES PROMPTED 2
NO 3 (GO TO NEXT METHOD)
YES PROMPTED 2
NO 3 (GO TO NEXT METHOD)
YES PROMPTED 2
NO 3 (GO TO NEXT METHOD)
YES PROMPTED 2
NO 3 (GO TO NEXT METHOD)
YES PROMPTED 2
NO 3 (GO TO NEXT METHOD)
YES PROMPTED 2
NO 3 (GO TO NEXT METHOD)
YES PROMPTED 2
NO 3 (GO TO NEXT METHOD)
YES PROMPTED 2
NO 3 (GO TO NEXT METHOD)
YES PROMPTED 2
NO 3 (GO TO NEXT METHOD)
NO 3 (GO TO 304)
303. Have you ever used (METHOD)?
THIS QUESTION IS ASKED ABOUT EACH METHOD IN 301 OR 302 WITH '1' OR '2' CIRCLED.
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
AT LEAST ONE "YES" (EVER USED) (GO TO 307)
305. Have you or one of your partners ever used anything or tried in any way to delay or avoid getting pregnant?
NO 2 (GO TO 309)
306. What have you used or done?
CORRECT 302, 303 AND 304 IF NECESSARY.
307. Are you or your partner currently doing something or using any method to delay or avoid a pregnancy?
NO 2 (GO TO 309)
308. Which method are you currently using?
IUD 02
INJECTABLES 03
MOUSSE/FOAM/JELLY 04
CONDOM 05
FEMALE STERILIZATION 06
MALE STERILIZATION 07
RHYTHM METHOD 08
WITHDRAWAL 09
OTHER (SPECIFY) _____ 96
308A. Why do you use the (METHOD IN 308) over another method?
AVAILABILITY NOT A PROBLEM 02 (GO TO 401)
WAS PRESCRIBED TO RESPONDENT 03 (GO TO 401)
MORE EFFECTIVE 04 (GO TO 401)
NO SIDE EFFECTS 05 (GO TO 401)
CONVENIENCE 06 (GO TO 401)
ONLY METHOD KNOWN 07 (GO TO 401)
REVERSIBLE METHOD 08 (GO TO 401)
PROTECTS AGAINST AIDS/STDS 09 (GO TO 401)
OTHER (SPECIFY) ______ 96 (GO TO 401)
309. What is the main reason that you are not currently using a method to avoid pregnancy?
INFREQUENT SEX 22
MENOPAUSAL/HYSTERECTOMY 23
SUB-FECUND/IN FECUND 24
POSTPARTUM/BREASTFEEDING 25
WANTS (OTHER) CHILDREN 26
WOMAN IS PREGNANT 27
SPOUSE/PARTNER OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
CULTURAL TABOOS 35
KNOWS NO SOURCE 42
FEAR OF SIDE EFFECTS 52
LACK OF ACCESS/TOO FAR 53
COSTS TOO MUCH 54
INCONVENIENT TO USE 55
INTERFERES WITH BODY'S NORMAL PROCESSES 56
OTHER (SPECIFY) ______ 96
DOESN'T KNOW 98
401. Are you currently married or living with a woman?
YES, LIVING WITH A WOMAN 2 (GO TO 402A)
FIRST MARRIAGE NOT CONSUMMATED 3 (GO TO 410F)
NO, NOT IN UNION 4 (GO TO 404)
402. How many wives do you have?
402A. With how many women do you live as if married?
403. RECORD THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH OF HIS WIVES/PARTNERS. IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'. THE NUMBER OF BOXES FILLED IN SHOULD BE THE SAME AS THE NUMBER OF WIVES/SPOUSES.
404. Do you currently have a regular sexual partner, an occasional sexual partner, or no sexual partner at all?
OCCASIONAL SEXUAL PARTNER 2
NO SEXUAL PARTNER 3
405. Have you ever been married or lived with a woman as if married?
YES, LIVED WITH A WOMAN 2
NO 3 (GO TO 410F)
406. What is your marital status now: are you widowed, divorced, or separated?
DIVORCED 2
SEPARATED 3
407. Have you been married or lived with a woman only once or more than once?
MORE THAN ONCE 2
MARRIED/LIVED WITH A WOMAN ONLY ONCE: In what month and year did you start living with your wife/partner?
MARRIED/LIVED WITH A WOMAN MORE THAN ONCE: Now I would like to ask you about when you started living with your first wife/partner. In what month and year was that?
DOESN'T KNOW MONTH 98
DOESN'T KNOW YEAR 9998
409. How old were you when you first started living with her?
NOT IN UNION (GO TO 410F)
Now I need to ask you some questions about sexual activity in order to better understand certain problems relating to family planning.
410. How long has it been since the last time you had sexual intercourse with your wife/the woman with whom you live?
IF NEVER HAD SEXUAL RELATIONS, RETURN TO 401, CIRCLE CODE '3' (MARRIAGE NOT CONSUMMATED) AND FOLLOW THE NEW INSTRUCTIONS BEGINNING AT 401.
WEEKS AGO 2 _____
MONTHS AGO 3 _____
YEARS AGO 4 _____
YES, HAS HEARD OF CONDOMS: Did you use a condom during your last sexual encounter with your wife/the woman with whom you live?
NO, HAS NEVER HEARD OF CONDOMS: Certain men use a condom, that is, they put a rubber sheath on their penis before having sexual intercourse. Did you use a condom during your last sexual encounter with your wife/the woman with whom you live?
NO 2 (GO TO 410B)
DOESN'T KNOW/UNSURE 8 (GO TO 410B)
410AA. During your last sexual encounter, who proposed using the condom?
PARTNER/WIFE 2
BOTH 3
410B. Have you had sexual intercourse with someone other than your wife/the woman with whom you live in the last 12 months?
NO 2 (GO TO 410J)
410C. When was the last time you had sexual intercourse with someone other than your wife/the woman with whom you live?
WEEKS AGO 2 _____
MONTHS AGO 3 _____
410D. Did you use a condom on this occasion?
NO 2 (GO TO 410E)
DOESN'T KNOW/UNSURE 8 (GO TO 410E)
410DA. During this last sexual encounter, who proposed using the condom?
PARTNER 2
BOTH 3
410E. With how many different people other than your wife/the woman with whom you live have you had sexual intercourse in the last 12 months?
DOESN'T KNOW 98 (GO TO 410J)
Now I would like to ask you some questions about your sexual activity in order to gain a better understanding of certain problems related to family planning.
410F. How long has it been since the last time you had sexual intercourse (if you have ever had sexual intercourse)?
DAYS AGO 1 _____
WEEKS AGO 2 _____
MONTHS AGO 3 _____
YEARS AGO 4 _____
YES, HAS HEARD OF CONDOMS: Did you use a condom during your last sexual encounter?
NO, HAS NEVER HEARD OF CONDOMS: Certain men use a condom, that is, they put a rubber sheath on their penis before having sexual intercourse. Did you use a condom during your last sexual encounter?
NO 2 (GO TO 410H)
DOESN'T KNOW/UNSURE 8 (GO TO 410H)
410GA. During this last sexual encounter, who proposed using the condom?
PARTNER 2
BOTH 3
12 MONTHS OR MORE SINCE LAST SEXUAL ENCOUNTER (GO TO 410J)
410I. In total, with how many people have you had sexual intercourse in the last 12 months?
DOESN'T KNOW 98
CURRENTLY MARRIED OR LIVING WITH A WOMAN: The last time you had sexual intercourse, was it with your wife/woman with whom you live, a regular partner, an acquaintance, someone you paid or someone else?
NOT CURRENTLY MARRIED OR LIVING WITH A WOMAN: The last time you had sexual intercourse, was it with a regular partner, an acquaintance, someone you paid or someone else?
REGULAR PARTNER 2
ACQUAINTANCE 3
SOMEONE PAID FOR SEXUAL RELATIONS 4
SOMEONE ELSE 5
413. Do you know of a place where you can get condoms?
NO 2 (GO TO 415)
414. Where is that?
RECORD ALL MENTIONED.
EACH TIME A HOSPITAL, HEALTH CENTER, A CSPS OR A CLINIC IS MENTIONED, PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.
HEALTH CENTER B
CSPS C
SMI D
DISPENSARY/MATERNITY POST E
COMMUNITY PHARMACEUTICAL DEPOT F
OTHER PUBLIC (SPECIFY) _____ G
FAMILY PLANNING CLINIC I
PHARMACY J
NURSE'S OFFICE K
OTHER PRIVATE (SPECIFY) _____ L
BAR/NIGHTCLUB N
KIOSK O
HOTEL/ROOM FOR RENT P
INFORMAL RETAIL CIRCUIT Q
FRIENDS/RELATIVES R
OTHER (SPECIFY) ______ X
OTHER (SPECIFY) ______ Y
414A. CHECK 410A, 410D, AND 410G:
NO 'YES' (GO TO 415)
414B. Where did you obtain condoms the last time?
IF IT IS A HOSPITAL, HEALTH CENTER, A CSPS OR A CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.
HEALTH CENTER 12
CSPS 13
SMI 14
DISPENSARY/MATERNITY POST 15
COMMUNITY PHARMACEUTICAL DEPOT 16
OTHER PUBLIC (SPECIFY) ______ 17
FAMILY PLANNING CLINIC 22
PHARMACY 23
NURSE'S OFFICE 24
OTHER PRIVATE (SPECIFY) ______ 27
BAR/NIGHTCLUB 32
KIOSK 33
HOTEL/ROOM FOR RENT 34
INFORMAL RETAIL CIRCUIT 35
FRIENDS/RELATIVES 36
PARTNER HAD CONDOM 41 (GO TO 415)
OTHER (SPECIFY) _____ 96
414C. What is the brand name of the condoms you used the last time?
PACKAGING IS ALL WHITE 2
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98
414D. The last time you bought condoms, how many did you buy?
DETERMINE THE NUMBER OF CONDOMS AND RECORD THIS NUMBER.
DOESN'T KNOW 998
FREE 9996 (GO TO 415)
DOESN'T KNOW 9998
414F. If condoms were offered to you for free, would you accept them?
IF THE RESPONSE IS NO, PROBE TO DETERMINE THE REASON AND CIRCLE THE CORRESPONDING CODE.
NO, ALREADY SPOILED 2
NO, QUALITY SUSPICIOUS 3
OTHER (SPECIFY) _____ 4
415. What age were you when you had your first sexual encounter?
FIRST TIME WHILE MARRIED 96
SECTION 5: FERTILITY PREFERENCES
501. CHECK 401:
CURRENTLY MARRIED/LIVING WITH A WOMAN (GO TO 503)
OCCASIONAL SEXUAL PARTNER (GO TO 503)
NO SEXUAL PARTNER (GO TO 505(A))
503. Is your wife/partner (one of your wives/partners) currently pregnant?
NO 2 (GO TO 505(A))
DOESN'T KNOW 8 (GO TO 505(A))
504. When she became pregnant, did you want her to become pregnant at that time, did you want her to become pregnant later, or did you not want her to become pregnant at all?
LATER 2 (GO TO 505(B))
NOT AT ALL 3 (GO TO 505(B))
505(A). WIFE/PARTNER NOT PREGNANT/DOESN'T KNOW/NO WIFE/PARTNER: 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 507)
WIFE/PARTNER CAN'T GET PREGNANT 3 (GO TO 507)
SAYS HE CAN NO LONGER HAVE CHILDREN 4 (GO TO 507)
UNDECIDED/DOESN'T KNOW 8 (GO TO 507)
505(B). WIFE/PARTNER PREGNANT: Now I have some questions about the future. After the child you and your wife/partner are expecting now, would you like to have another child, or would you prefer not to have any more children?
NO MORE/NONE 2 (GO TO 507)
WIFE/PARTNER CAN'T GET PREGNANT 3 (GO TO 507)
SAYS HE CAN NO LONGER HAVE CHILDREN 4 (GO TO 507)
UNDECIDED/DOESN'T KNOW 8 (GO TO 507)
WIFE/PARTNER NOT PREGNANT/DOESN'T KNOW/NO WIFE/PARTNER: 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 ____
SOON/NOW 993
SAYS WIFE CAN'T GET PREGNANT 994
AFTER MARRIAGE 995
OTHER (SPECIFY) ______ 996
DOESN'T KNOW 998
507. CHECK 308:
CURRENTLY USING A CONTRACEPTIVE METHOD?
NOT CURRENTLY USING (GO TO 508)
CURRENTLY USING (GO TO 512)
508. Do you think you will use a contraceptive method to delay or avoid pregnancy at any time in the next 12 months?
NO 2
DOESN'T KNOW 8
509. Do you think you will use a contraceptive method in the future?
NO 2 (GO TO 511)
DOESN'T KNOW 8 (GO TO 511)
510. Which method would you prefer to use?
IUD 02 (GO TO 512)
INJECTABLES 03 (GO TO 512)
MOUSSE/FOAM/JELLY 04 (GO TO 512)
CONDOM 05 (GO TO 512)
FEMALE STERILIZATION 06 (GO TO 512)
MALE STERILIZATION 07 (GO TO 512)
RHYTHM METHOD 08 (GO TO 512)
WITHDRAWAL 09 (GO TO 512)
OTHER (SPECIFY) _____ 96 (GO TO 512)
UNSURE 98 (GO TO 512)
511. What is the main reason that you think you will never use a contraceptive method?
MENOPAUSAL/HYSTERECTOMY 23
SUB-FECUND/IN FECUND 24
WANTS (OTHER) CHILDREN 26
WIFE/PARTNER OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
CULTURAL TABOOS 35
KNOWS NO SOURCE 42
FEAR OF SIDE EFFECTS 52
LACK OF ACCESS/TOO FAR 53
COSTS TOO MUCH 54
INCONVENIENT TO USE 55
INTERFERES WITH BODY'S NORMAL PROCESSES 56
OTHER (SPECIFY) ______ 96
DOESN'T KNOW 98
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?
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.
OTHER (SPECIFY) ______ 96 (GO TO 514)
513. How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter?
OTHER (SPECIFY) _____ 96
OTHER (SPECIFY) _____ 96
OTHER (SPECIFY) _____ 96
514. In general, do you approve or disapprove of couples that use a method to avoid becoming pregnant?
DISAPPROVE 2
NO OPINION 3
515. In your opinion, is it appropriate or inappropriate to speak of family planning:
a) On the radio?
b) On television?
INAPPROPRIATE 2
DOESN'T KNOW 8
INAPPROPRIATE 2
DOESN'T KNOW 8
516. Over the last few months, have you heard or read messages about family planning:
On the radio?
On the television?
In a newspaper or magazine?
On a poster?
In brochures?
On a billboard?
At a community meeting/association?
From a health center/by a health agent?
At the mosque, church or temple?
At school/by a teacher?
At the workplace?
By a relative/friend?
By a neighbor?
During a theatrical performance?
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
516A. What is your principal source of information on family planning?
PUBLIC HEALTH PROFESSIONAL 02
PRIVATE HEALTH PROFESSIONAL 03
COMMUNITY HEALTH PROFESSIONAL 04
FAMILY PLANNING CLINIC 05
WIFE/PARTNER 06
OTHER RELATIVES 07
FRIENDS/ACQUAINTANCES 08
RADIO 09
TELEVISION 10
NEWSPAPER/POSTERS 11
SCHOOL/TEACHER 12
COMMUNITY MEETING 13
PROMACO TEAM 14
THEATER 15
DOLOTIERE (COUNSELOR?) 16
CAMEL DRIVER 17
TRADITIONAL STORYTELLER 18
HOTEL OWNER 19
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98
516B. If you had to choose, from what source would you like to receive information on family planning? IF MORE THAN ONE SOURCE CITED, ASK WHICH IS THE MOST PREFERRED AND CIRCLE THE CORRESPONDING CODE.
PUBLIC HEALTH PROFESSIONAL 02
PRIVATE HEALTH PROFESSIONAL 03
COMMUNITY HEALTH PROFESSIONAL 04
FAMILY PLANNING CLINIC 05
WIFE/PARTNER 06
OTHER RELATIVES 07
FRIENDS/ACQUAINTANCES 08
RADIO 09
TELEVISION 10
NEWSPAPER/POSTERS 11
SCHOOL/LIBRARY 12
COMMUNITY MEETING 13
PROMACO TEAM 14
THEATER 15
DOLOTIERE (COUNSELOR?) 16
CAMEL DRIVER 17
TRADITIONAL STORYTELLER 18
HOTEL OWNER 19
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98
518. Over the last 12 months, have you discussed family planning with anyone?
NO 2 (GO TO 520)
519. With whom did you discuss it? Anyone else?
RECORD ALL PERSONS MENTIONED.
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER F
SON G
MOTHER-IN-LAW H
FATHER-IN-LAW I
FRIEND(S)/NEIGHBOR(S) J
OTHER (SPECIFY) ______ X
YES, LIVING WITH A WOMAN (GO TO 521)
NO, NOT IN UNION (GO TO 601A)
Spouses don't always agree on everything. Now I would like to ask you some questions about your wife's/partner's opinions on family planning.
521. Do you think that your wife/wives/partner(s) approve(s) or disapprove(s) of couples that use a method to avoid a pregnancy?
DISAPPROVE(S) 2
CERTAIN APPROVE, OTHERS DISAPPROVE 3
DOESN'T KNOW 8
522. How many times over the last 12 months have you discussed family planning with your wife/wives/partner(s) that you live with?
ONE OR TWO TIMES 2
MORE OFTEN 3
SECTION 6: AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS
601A. Have you ever heard about infections that can be transmitted through sexual contact?
NO 2 (GO TO 601F)
601B. Which ones do you know of?
RECORD ALL MENTIONED.
GONORRHEA B
AIDS C
CONDYLOMA (GENITAL WARTS) D
DISCHARGE E
ULCERS F
LOWER ABDOMINAL PAIN G
OTHER (SPECIFY) _____ W
OTHER (SPECIFY) _____ X
DOESN'T KNOW Z
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 601F)
601D. In the last 12 months, have you had one of these infections?
NO 2 (GO TO 601F)
DOESN'T KNOW 8 (GO TO 601F)
601E. Which infections did you have?
RECORD ALL MENTIONED.
GONORRHEA B
AIDS C
CONDYLOMA (GENITAL WARTS) D
DISCHARGE E
ULCERS F
LOWER ABDOMINAL PAIN G
OTHER (SPECIFY) _____ W
OTHER (SPECIFY) _____ X
DOESN'T KNOW Z
601F. During the last 12 months, have you had an abnormal discharge from your penis?
NO 2
DOESN'T KNOW 8
601G. During the last 12 months, have you had a sore or ulcer near your penis?
NO 2
DOESN'T KNOW 8
601H. CHECK 601E, 601F, AND 601G:
HAS NOT HAD AN INFECTION (GO TO 601N)
601I. The last time you had (INFECTION FROM 601E/DISCHARGE/ULCER), did you seek advice or treatment?
NO 2 (GO TO 601JA)
601J. Where did you seek advice or treatment?
Any other place/Anywhere else?
RECORD ALL MENTIONED.
HEALTH CENTER B
CSPS C
SMI D
DISPENSARY/MATERNITY POST E
COMMUNITY PHARMACEUTICAL DEPOT F
OTHER PUBLIC (SPECIFY) ______ G
FAMILY PLANNING CLINIC I
PHARMACY J
NURSE'S OFFICE K
OTHER PRIVATE (SPECIFY) ______ L
BAR/NIGHTCLUB N
KIOSK O
HOTEL/ROOM FOR RENT P
INFORMAL RETAIL CIRCUIT Q
FRIENDS/RELATIVES R
OTHER (SPECIFY) ______ X
OTHER (SPECIFY) ______ Y
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 601N)
601K. When you had (INFECTION FROM 601E/DISCHARGE/ULCER), did you inform your sexual partner(s)?
NO 2
601L. When you had (INFECTION FROM 601E/DISCHARGE/ULCER), did you do anything to avoid infecting your sexual partner(s)?
NO 2 (GO TO 601N)
PARTNER ALREADY INFECTED 3 (GO TO 601N)
601M. What did you do?
RECORD ALL MENTIONED.
USED CONDOMS B
TOOK MEDICATION C
OTHER (SPECIFY) ______ X
MENTIONED "AIDS" (GO TO 602)
601O. Have you ever heard of an illness called AIDS?
NO 2 (GO TO 611C)
602. From which sources have you heard about AIDS?
INSIST: Any other sources?
RECORD ALL MENTIONED.
PRIVATE HEALTH PROFESSIONAL B
COMMUNITY HEALTH PROFESSIONAL C
FAMILY PLANNING CLINIC D
WIFE/PARTNER F
OTHER RELATIVES G
FRIENDS/RELATIONS H
RADIO I
TELEVISION J
NEWSPAPER/JOURNALS K
BROCHURES L
MOSQUE/CHURCH/TEMPLE M
SCHOOL/TEACHER N
ASSOCIATION MEETING O
THEATER P
WORK PLACE Q
PROMACO TEAM R
DOLOTIERE (COUNSELOR) S
CAMEL DRIVER T
TRADITIONAL STORYTELLER U
HOTEL/RESTAURANT OWNER V
OTHER (SPECIFY) _____ X
602AA. INTERVIEWER: IF YOU HAVE ONLY CIRCLED ONE CODE IN 602, CIRCLE THE CODE CORRESPONDING TO THE SAME RESPONSE HERE AND CONTINUE TO
602AB.
IF YOU CIRCLED MULTIPLE CODES IN 602, ASK THE FOLLOWING QUESTION AND CIRCLE THE CODE THAT CORRESPONDS TO THE RESPONSE: Amongst the sources you cited, which is the primary source?
PRIVATE HEALTH PROFESSIONAL 03
COMMUNITY HEALTH PROFESSIONAL 04
FAMILY PLANNING CLINIC 05
WIFE/PARTNER 06
OTHER RELATIVES 07
FRIENDS/RELATIONS 08
RADIO 09
TELEVISION 10
NEWSPAPER/JOURNALS 11
BROCHURES 12
MOSQUE/CHURCH/TEMPLE 13
SCHOOL/TEACHER 14
ASSOCIATION MEETING 15
THEATER 16
WORK PLACE 17
PROMACO TEAM 18
DOLOTIERE (COUNSELOR?) 19
CAMEL DRIVER 20
TRADITIONAL STORYTELLER 21
HOTEL/RESTAURANT OWNER 22
OTHER (SPECIFY) _____ 96
602A. If you had to choose, from which source would you prefer to receive information on AIDS? IF MULTIPLE SOURCES ARE CITED, ASK WHICH IS THE PREFERRED SOURCE AND CIRCLE THE CORRESPONDING CODE.
PUBLIC HEALTH PROFESSIONAL 02
PRIVATE HEALTH PROFESSIONAL 03
COMMUNITY HEALTH PROFESSIONAL 04
FAMILY PLANNING CLINIC 05
WIFE/PARTNER 06
OTHER RELATIVES 07
FRIENDS/RELATIONS 08
RADIO 09
TELEVISION 10
NEWSPAPER/JOURNALS 11
BROCHURES 12
MOSQUE/CHURCH/TEMPLE 13
SCHOOL/TEACHER 14
ASSOCIATION MEETING 15
THEATER 16
WORK PLACE 17
PROMACO TEAM 18
DOLOTIERE (COUNSELOR?) 19
CAMEL DRIVER 20
TRADITIONAL STORYTELLER 21
HOTEL/RESTAURANT OWNER 22
OTHER (SPECIFY) _____ 96
602B. In your opinion, how can someone get AIDS?
INSIST: Any other way?
RECORD ALL MENTIONED.
SEXUAL INTERCOURSE WITH MULTIPLE PARTNERS B
SEXUAL INTERCOURSE WITH PROSTITUTES C
NOT USING A CONDOM D
HOMOSEXUAL RELATIONS E
BLOOD INFUSIONS F
INJECTIONS G
KISSING H
MOSQUITO BITES I
DIRTY BLADES, SCISSORS, KNIVES, AND OTHER CUTTING IMPLEMENTS K
OTHER (SPECIFY) ______ W
OTHER (SPECIFY) ______ X
DOESN'T KNOW Z
603. Is there something people can do to avoid contracting AIDS or the virus that causes AIDS?
NO 2 (GO TO 607)
DOESN'T KNOW 8 (GO TO 607)
604. In your opinion, what can one do?
PROBE: Anything else?
RECORD ALL MENTIONED.
ABSTAIN FROM HAVING SEX B
USE CONDOMS C
AVOID MULTIPLE PARTNERS D
AVOID PROSTITUTES E
AVOID HOMOSEXUAL RELATIONS F
AVOID BLOOD TRANSFUSIONS G
AVOID INJECTIONS H
AVOID KISSING I
AVOID MOSQUITO BITES J
AVOID DIRTY BLADES/SCISSORS/KNIVES/OTHER CUTTING INSTRUMENTS K
SEEK PROTECTION FROM TRADITIONAL HEALERS L
OTHER (SPECIFY) _____ W
OTHER (SPECIFY) _____ X
DOESN'T KNOW Z
607. Is it possible for a healthy-looking person to have AIDS?
NO 2
DOESN'T KNOW 8
608. Do you think that a person with AIDS almost never dies from it, sometimes dies from it, or almost always dies from it?
SOMETIMES 2
ALMOST ALWAYS 3
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
608B. Can AIDS be passed from mother to child?
NO 2
DOESN'T KNOW 8
608C. Do you personally know anyone who has AIDS or has died of AIDS?
NO 2
DOESN'T KNOW 8
608D. In your opinion, what should be done with people sick with AIDS?
KEEP THEM AT HOME 2
ISOLATE THEM 3
MORALLY SUPPORT THEM 4
OTHER (SPECIFY) _____ 5
DOESN'T KNOW 8
609. Do you think your risk of getting AIDS is small, moderate, significant, or do you think you run no risk at all in contracting AIDS?
MODERATE 2 (GO TO 609C)
SIGNIFICANT 3 (GO TO 609C)
NO RISK AT ALL 4
HAS AIDS 5 (GO TO 611A)
609B. Why do you think your risk of getting AIDS is small/Why do you think you run no risk of getting AIDS? Are there other reasons?
RECORD ALL MENTIONED.
ABSTAINS FROM SEX B (GO TO 611A)
USES CONDOMS C (GO TO 611A)
ONLY HAS SEX WITH ONE PARTNER D (GO TO 611A)
LIMITS NUMBER OF SEXUAL PARTNERS E (GO TO 611A)
AVOIDS SEX WITH PROSTITUTES F (GO TO 611A)
PARTNER HAS NO OTHER PARTNERS G (GO TO 611A
DOESN'T HAVE HOMOSEXUAL RELATIONS H (GO TO 611A)
AVOIDS BLOOD TRANSFUSIONS I (GO TO 611A)
AVOIDS INJECTIONS J (GO TO 611A)
AVOIDS DIRTY BLADES/SCISSORS/OTHER CUTTING IMPLEMENTS K (GO TO 611A)
OTHER (SPECIFY) _____ X (GO TO 611A)
609C. Why do you think your risk of getting AIDS is moderate/Why do you think your risk of getting AIDS is significant? Are there other reasons?
RECORD ALL MENTIONED.
DOESN'T USE CONDOMS C
HAS MORE THAN ONE PARTNER D
HAS NUMEROUS PARTNERS E
HAS SEX WITH PROSTITUTE F
PARTNER HAS OTHER PARTNERS G
HOMOSEXUAL RELATIONS H
BLOOD TRANSFUSIONS I
INJECTIONS J
USES DIRTY BLADES, SCISSORS, KNIVES, OTHER CUTTING IMPLEMENTS K
OTHER (SPECIFY) _____ X
611A. Since you've heard about AIDS, have you changed your behavior in order to avoid getting the illness?
IF YES, INSIST: What have you done? Anything else?
RECORD ALL MENTIONED.
STOPPED HAVING SEX B (GO TO 611C)
STARTED TO USE CONDOMS C (GO TO 611C)
LIMITS SEX TO ONE PARTNER D (GO TO 611C)
REDUCED NUMBER OF PARTNERS E (GO TO 611C)
AVOIDS PROSTITUTES F (GO TO 611C)
DEMANDED PARTNER TO BE FAITHFUL G (GO TO 611C)
STOPPED HOMOSEXUAL RELATIONS H (GO TO 611C)
STOPPED INJECTIONS J
AVOIDS DIRTY BLADES/SCISSORS/KNIVES/OTHER CUTTING IMPLEMENTS K
OTHER (SPECIFY) ____ W
OTHER (SPECIFY) ____ X
NO CHANGE Y
611B. Has knowing about AIDS influenced or changed your decision to have sexual relations or your sexual behavior?
IF YES: In what way?
RECORD ALL MENTIONED.
STOPPED HAVING SEX B
STARTED TO USE CONDOMS C
LIMITS SEX TO ONE PARTNER D
REDUCED NUMBER OF PARTNERS E
AVOIDS PROSTITUTES F
STOPPED HOMOSEXUAL RELATIONS H
OTHER (SPECIFY) _____ X
NOT CHANGED SEXUAL BEHAVIOR Y
DOESN'T KNOW Z
611C. Some people use a condom during sexual intercourse to protect themselves from AIDS and other sexually transmitted infections. Have you already heard of this?
NO 2 (GO TO 611F)
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 613)
611E. We might have already talked about this. Have you ever used a condom during sexual relations to avoid catching or transmitting illnesses such as AIDS?
NO 2 (GO TO 611G)
611EA. Do you use a condom from time to time, often, or every time you have sexual relations?
OFTEN 2 (GO TO 611G)
EVERY TIME 3 (GO TO 611G)
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 613)
611G. During the last 12 months, have you given or received money, gifts or favors in exchange for sexual intercourse?
NO 2
SECTION 7: MEN'S OPINIONS ON THE PRACTICE OF FEMALE CIRCUMCISION
Now I would like to ask you questions about female circumcision, which consists of the total or partial removal of the external parts of a woman's genitalia. This practice exists within certain societies in Burkina and other countries.
701. Have you ever heard of female circumcision?
NO 2 (GO TO 706A)
701A. Who makes the decision to circumcise a girl?
FATHER 2
BOTH (MOTHER/FATHER) 3
AUNT 4
UNCLE 5
GRANDPARENTS 6
OTHER (SPECIFY) _____ 7
702. Do you think that the practice of female circumcision should continue to be practiced, or on the contrary, that it should not continue to be practiced?
STOPPED 2 (GO TO 705)
DOESN'T KNOW 8 (GO TO 706A)
703. Why do you think that the practice of female circumcision should continue to be practiced? Any other reason? RECORD ALL MENTIONED.
CUSTOM AND TRADITION B
RELIGIOUS NECESSITY C (GO TO 706A)
HYGIENE D (GO TO 706A)
BETTER MARRIAGE PROSPECTS E (GO TO 706A)
MORE PLEASURE FOR HUSBAND F (GO TO 706A)
PRESERVE VIRGINITY/AVOID IMMORALITY G (GO TO 706A)
OTHER (SPECIFY) _____ X (GO TO 706A)
DOESN'T KNOW Y (GO TO 706A)
704. What do you mean by "GOOD TRADITION/CUSTOM AND TRADITION"?
RECORD ALL RESPONSES MENTIONED.
RELIGIOUS NECESSITY C (GO TO 706A)
HYGIENE D (GO TO 706A)
BETTER MARRIAGE PROSPECTS E (GO TO 706A)
MORE PLEASURE FOR HUSBAND F (GO TO 706A)
PRESERVE VIRGINITY/AVOID IMMORALITY G (GO TO 706A)
OTHER (SPECIFY) _____ X (GO TO 706A)
DOESN'T KNOW Y (GO TO 706A)
705. Why do you think that the practice of female circumcision should be stopped?
Any other reason? RECORD ALL MENTIONED.
AGAINST RELIGION B (GO TO 706A)
MEDICAL COMPLICATIONS C (GO TO 706A)
OWN PAINFUL EXPERIENCE D (GO TO 706A)
AGAINST THE DIGNITY OF WOMEN E (GO TO 706A)
IMPEDES SEXUAL SATISFACTION F (GO TO 706A)
LAW EXISTS AGAINST THE PRACTICE G (GO TO 706A)
OTHER (SPECIFY) _____ X (GO TO 706A)
DOESN'T KNOW Y (GO TO 706A)
706. What do you mean by "BAD TRADITION"?
RECORD ALL MENTIONED.
MEDICAL COMPLICATIONS C
OWN PAINFUL EXPERIENCE D
AGAINST THE DIGNITY OF WOMEN E
IMPEDES SEXUAL SATISFACTION F
OTHER (SPECIFY) _____ X
DOESN'T KNOW Y
706A. What is your principal source of information on female circumcision?
PUBLIC HEALTH PROFESSIONAL 02
PRIVATE HEALTH PROFESSIONAL 03
COMMUNITY HEALTH PROFESSIONAL 04
FAMILY PLANNING CLINIC 05
WIFE/PARTNER 06
OTHER RELATIVES 07
FRIENDS/RELATIONS 08
RADIO 09
TELEVISION 10
NEWSPAPER/POSTERS 11
SCHOOL/TEACHER 12
COMMUNITY MEETING 13
PROMACO TEAM 14
THEATER 15
DOLOTIERE (COUNSELOR?) 16
CAMEL DRIVER 17
TRADITIONAL STORYTELLER 18
HOTEL OWNER 19
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98
706B. If you had to choose, from what source would you prefer to receive information on female circumcision?
PUBLIC HEALTH PROFESSIONAL 02
PRIVATE HEALTH PROFESSIONAL 03
COMMUNITY HEALTH PROFESSIONAL 04
FAMILY PLANNING CLINIC 05
WIFE/PARTNER 06
OTHER RELATIVES 07
FRIENDS/RELATIONS 08
RADIO 09
TELEVISION 10
NEWSPAPER/POSTERS 11
SCHOOL/TEACHER 12
COMMUNITY MEETING 13
PROMACO TEAM 14
THEATER 15
DOLOTIERE (COUNSELOR?) 16
CAMEL DRIVER 17
TRADITIONAL STORYTELLER 18
HOTEL OWNER 19
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98
706C. Do you know that a law exists in Burkina that prohibits female circumcision?
NO 2
TO BE FILLED IN AFTER COMPLETING INTERVIEW.
COMMENTS ABOUT RESPONDENT _____
COMMENTS ON SPECIFIC QUESTIONS _____
ANY OTHER COMMENTS _____
SUPERVISOR'S OBSERVATIONS _____
NAME _____
DATE _____
EDITOR'S OBSERVATIONS _____
NAME _____
DATE _____