DEPARTMENT
SUB-PREFECTURE/URBAN DISTRICT
RURAL/URBAN MUNICIPALITY
TOWN/NEIGHBORHOOD
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
NAME OF HEAD OF HOUSEHOLD ___________________
NAME AND LINE NUMBER OF MAN_____________________
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME_____
RESULT ____
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ______________ 7
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ____
RESULT __
ADJA 2
BARIBA 3
FON 4
DENDI 5
DITAMARI 6
YORUBA 7
OTHER 8
NO 2
SUPERVISOR
NAME _____________________
DATE ________
FIELD EDITOR
NAME _____________________
DATE ________
OFFICE EDITOR ____
KEYED BY ____
SECTION 1. RESPONDENT'S BACKGROUND
MINUTES __
102) First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in COTONOU, in another city, in a rural location, or abroad?
MEDIUM SIZED CITY 2
OTHER CITY 3
RURAL 4
ABROAD 5
103) How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)
104) Just before you moved to (NAME OF CURRENT PLACE OF RESIDENCE), did you live in COTONOU, in another city, in a rural location, or abroad?
MEDIUM SIZED CITY 2
OTHER CITY 3
RURAL 4
ABROAD 5
105) In what month and year were you born?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 98
106) How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.
107) Have you ever attended school?
NO 2 (GO TO 111)
108) What is the highest level of school you attended: primary, secondary, or higher?
SECONDARY 2
HIGHER 3
109) What is the highest (grade/form/year) you completed at this level?
(CONVERT TO NUMBER OF YEARS COMPLETED)
SECONDARY OR HIGHER (GO TO 112)
111) Can you read and understand a letter or a newspaper easily, with difficulty, or not at all?
WITH DIFFICULTY 2
NOT AT ALL 3 (GO TO 113)
112) Do you read a newspaper or magazine at least once a week?
NO 2
113) Do you listen to the radio often, sometimes, or never?
SOMETIMES 2
NEVER 3
113B) Do you watch television often, sometimes, or never?
SOMETIMES 2
NEVER 3
ISLAM 2
CATHOLIC 3
PROTESTANT METHODIST 4
OTHER CHRISTIAN 5
OTHER (SPECIFY) ______________ 6
NONE 7
114B) What is your nationality?
OTHER (SPECIFY) _________ 2 (GO TO 115)
BARIBA AND SIMILAR 02
DENDI AND SIMILAR 03
FON AND SIMILAR 04
YOA AND LOKPA AND SIMILAR 05
BETAMARIBE AND SIMILAR 06
PEULH AND SIMILAR 07
YORUBA AND SIMILAR 08
OTHER (SPECIFY) _______________ 96
115) Are you currently working?
NO 2
116) Have you done any type of work in the last 12 months?
NO 2 (GO TO 201)
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
120) Do you do this work for a family member, for someone else, or are you self-employed?
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3
121) Do you usually work throughout the year, seasonally, or only once in a while?
SEASONALLY 2
ONCE IN A WHILE 3 (GO TO 124)
122) During the last 12 months, how many months did you work?
123) In the months that you worked, how many days a week did you usually work?
124) During the last 12 months, approximately how many days did you work?
125) Do you earn cash for your work?
PROBE: Do you make money for working?
NO 2 (GO TO 201)
126) How much do you usually earn for this work?
PROBE: Is this per hour, per day, per week, per month, or per year?
PER DAY 2 __ __ __ __ __ __ __
PER WEEK 3 __ __ __ __ __ __ __
PER MONTH 4 __ __ __ __ __ __ __
PER YEAR 5 __ __ __ __ __ __ __
OTHER (SPECIFY) ____________ 99999996
201) Now I would like to ask you about your children. I'm only interested in your biological children. Do you have or have you had 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 sons live with you? And how many daughters live with you?
IF NONE, RECORD '00'
204) Do you have any sons or daughters who are alive but do not live with you?
NO 2 (GO TO 206)
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", CODE '00'
206) Have you ever had any children who were born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but survived only a few hours or days?
NO 2 (GO TO 208)
207) How many boys have died? And how many girls have died?
IF "NONE", RECORD '00'
208) SUM ANSWERS TO Q. 203, 205 AND 207, AND ENTER THE TOTAL.
IF "NONE", RECORD '00'
209) CHECK 208:
Just to makes 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)
NEVER HAD CHILDREN (GO TO 301)
210A) In what month and year was your last child born?
BEFORE JANUARY 1993 (GO TO 301)
211) At the time you were expecting this last child, did you want a child then, did you want to wait until later, or did you not want to have any (more) children?
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) Which ways or methods have you heard about?
302) Have you ever heard of (METHOD)?
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
NO 3
303) Have you ever used (METHOD)?
NO 2
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 any 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 done or used?
CORRECT 303 AND 304 (AND 302 IF NECESSARY)
307) Are you or your partner currently doing something or using any method to delay or avoid getting pregnant?
NO 2 (GO TO 309)
308) Which method are you using?
(CHECK THAT THE METHOD LISTED IS KNOWN AND ALREADY USED)
(CIRCLE "08" FOR MALE STERILIZATION)
IUD 02 (GO TO 401)
INJECTABLES 03 (GO TO 401)
NORPLANT 04 (GO TO 401)
DIAPHRAGM/FOAM/JELLY 05 (GO TO 401)
CONDOM 06 (GO TO 401)
FEMALE STERILIZATION 07 (GO TO 401)
MALE STERILIZATION 08 (GO TO 401)
PERIODIC ABSTINENCE 09 (GO TO 401)
WITHDRAWAL 10 (GO TO 401)
OTHER (SPECIFY) ___________ 96 (GO TO 401)
309) What is the main reason that you do not use a contraceptive method?
INFREQUENT SEX 22
WIFE MENOPAUSAL/HAD HYSTERECTOMY 23
WIFE SUBFECUND/INFECUND 24
WIFE POST-PARTUM/BREASTFEEDING 25
WANTS (MORE) CHILDREN 26
WIFE PREGNANT 27
SPOUSE/PARTNER OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
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
DON'T KNOW 98
401) Are you currently married or living with a woman?
YES, LIVING WITH A WOMAN 2 (GO TO 402A)
NO, NOT IN UNION 3 (GO TO 404)
402) How many wives do you currently have?
402A) How many women do you live with as if married?
403) WRITE THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE OF HIS WIFE/WIVES.
IF A WIFE/WOMAN DOES NOT LIVE IN THE HOUSEHOLD, RECORD '00'.
THE NUMBER OF SPACES FILLED SHOULD BE EQUAL TO THE NUMBER OF WOMEN.
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?
YES, LIVED WITH A WOMAN 2 (GO TO 407)
NO 3 (GO TO 410F)
406) What is your current marital status: are you a widow, divorced, or separated?
DIVORCED 2
SEPARATED 3
407) Have you been married or lived with a woman only once or more than once (including your current union)?
MORE THAN ONCE 2
MARRIED/LIVED WITH WOMAN ONLY ONCE: In what month and year did you start living with your wife/partner?
MARRIED/LIVED WITH WOMAN MORE THAN ONCE: Now we will talk about your first wife/partner. In what month and year did you start living with her?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 98
409) How old were you when you started living with her?
NOT IN A UNION (GO TO 410F)
410) Now I would like to ask you some questions about sexual activity in order to gain a better understanding of some family planning issues. When was the last time you had sexual intercourse with (your spouse/the woman with whom you live)?
WEEKS AGO 2 ____
MONTHS AGO 3 ____
YEARS AGO 4 ____
KNOWS CONDOM: The last time you had sex with (your spouse/the woman with whom you live), was a condom used?
DOES NOT KNOW CONDOM: Some men use a condom, which means they put a rubber sheath on their penis during sexual intercourse. The last time you had sex with (your spouse/the woman with whom you live), was a condom used?
NO 2
DON'T KNOW 8
410B) Have you had sexual relations with someone other than (your spouse/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 relations with someone other than (your spouse/the woman with whom you live)?
WEEKS AGO 2 ____
MONTHS AGO 3 ____
YEARS AGO 4 ____
410D) Was a condom used on this occasion?
NO 2
DON'T KNOW 8
410E) During the last 12 months, how many different people other than (your spouse/the woman with whom you live) did you have sexual relations with?
DON'T KNOW 98 (GO TO 410J)
410F) Now I would like to ask you some questions about sexual activity in order to gain a better understanding of some family planning issues. When was the last time you had sexual intercourse (if ever)?
DAYS AGO 1 ____
WEEKS AGO 2 ____
MONTHS AGO 3 ____
YEARS AGO 4 ____
KNOWS CONDOM: The last time you had sex, was a condom used?
DOES NOT KNOW CONDOM: Some men use a condom, which means they put a rubber sheath on their penis during sexual intercourse. The last time you had sex, was a condom used?
NO 2
DON'T KNOW 8
12 MONTHS OR MORE SINCE LAST SEXUAL RELATIONS (GO TO 410J)
410I) In total, with how many different people have you had sex in the last 12 months?
DON'T KNOW 98
CURRENTLY MARRIED OR LIVES WITH A WOMAN: The last time you had sexual relations, was it with (your spouse/the woman with whom you live), a regular partner, an acquaintance, someone who you paid, or someone else?
NOT CURRENTLY MARRIED/NOT LIVING WITH A WOMAN: The last time you had sexual relations, was it a regular partner, an acquaintance, someone who you paid, or someone else?
REGULAR PARTNER 2
ACQUAINTANCE 3
SOMEONE PAID 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?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
FIELDWORKER 14
COMMUNITY CENTER 15
OTHER PUBLIC (SPECIFY) ____________ 16
RELIGIOUS HOSPITAL 22
PHARMACY 23
ABPF (BENIN FAMILY ADVOCACY ASSOCIATION) 24
DOCTOR'S OFFICE 25
FIELDWORKER 26
OTHER PRIVATE MEDICAL (SPECIFY) ______________ 27
CHURCH 32
RELATIVES/FRIENDS 33
GAS STATION 34
415) How old were you when you first had sexual intercourse?
FIRST TIME WHEN MARRIED 96
SECTION 5. FERTILITY PREFERENCES
CURRENTLY MARRIED OR LIVING WITH A WOMAN (GO TO 503)
HAS OCCASIONAL SEX PARTNER (GO TO 503)
DOES NOT HAVE SEX PARTNER (GO TO 505A)
503) Is your spouse (or one of your spouses/partners) currently pregnant?
NO 2 (GO TO 505A)
UNSURE 8 (GO TO 505A)
504) When she became pregnant did you want her to get pregnant then, did you want to wait until later, or did you not want her to get pregnant?
LATER 2 (GO TO 505B)
NOT AT ALL 3 (GO TO 505B)
505A) SPOUSE/PARTNER NOT PREGNANT OR UNSURE OR NO SPOUSE/PARTNER: Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not have any (more) children?
NO (MORE) 2 (GO TO 509
SAYS WIFE CANNOT GET PREGNANT 3 (GO TO 507)
SAYS HE CANNOT HAVE ANY CHILDREN 4 (GO TO 507)
UNDECIDED/DON'T KNOW 8 (GO TO 507)
505B) SPOUSE/PARTNER PREGNANT: Now I have some questions about the future. After the child your wife/partner is expecting now, would you like to have another child, or would you prefer not have any more children?
NO (MORE) 2 (GO TO 507)
SAYS WIFE CANNOT GET PREGNANT 3 (GO TO 507)
SAYS HE CANNOT HAVE ANY CHILDREN 4 (GO TO 507)
UNDECIDED/DON'T KNOW 8 (GO TO 507)
SPOUSE/PARTNER NOT PREGNANT OR UNSURE OR NO SPOUSE/PARTNER: How long would you like to wait from now before the birth of (a/another) child?
SPOUSE/PARTNER PREGNANT: After the birth of the child your spouse/partner is 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
DON'T KNOW 998
507) CHECK 308:
USES A 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 in the next 12 months?
NO 2
DON'T KNOW 8
509) Do you think you will use a contraceptive method to delay or avoid pregnancy at any time in the future?
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)
510) Which contraceptive method would you prefer to use?
IUD 02 (GO TO 512)
INJECTABLES 03 (GO TO 512)
NORPLANT 04 (GO TO 512)
DIAPHRAGM/FOAM/JELLY 05 (GO TO 512)
CONDOM 06 (GO TO 512)
FEMALE STERILIZATION 07 (GO TO 512)
MALE STERILIZATION 08 (GO TO 512)
PERIODIC ABSTINENCE 09 (GO TO 512)
WITHDRAWAL 10 (GO TO 512)
OTHER (SPECIFY) _______________ 96 (GO TO 512)
DON'T KNOW 98 (GO TO 512)
511) What is the main reason that you think you would never use a method of contraception to avoid pregnancy?
WIFE MENOPAUSAL/HAD HYSTERECTOMY 23
WIFE SUBFECUND/INFECUND 24
WANTS CHILDREN 26
HUSBAND/PARTNER OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
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
DON'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 it not matter?
OTHER (SPECIFY)____ 96
OTHER (SPECIFY)___ 96
OTHER (SPECIFY)____ 96
514) Would you say that you approve or disapprove of couples using a contraceptive method to avoid getting pregnant?
DISAPPROVE 2
NO OPINION 3
515) Is it acceptable or not acceptable to you for information on family planning to be provided:
NOT ACCEPTABLE 2
DON'T KNOW 8
NOT ACCEPTABLE 2
DON'T KNOW 8
516) In the last few months have you heard about family planning:
NO 2
NO 2
NO 2
NO 2
NO 2
518) In the last few months, have you discussed the practice of family planning with your friends, your neighbors, or your relatives?
NO 2 (GO TO 520)
519) With whom? Anyone else?
RECORD ALL PERSONS MENTIONED.
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTERS F
SON G
MOTHER-IN-LAW H
FATHER-IN-LAW I
FRIENDS/NEIGHBORS J
OTHER (SPECIFY) _________ X
LIVING WITH A WOMAN (GO TO 521)
NO, NOT IN A UNION (GO TO 601)
521) Spouses/partners do not always agree on everything. Now I want to ask you about your wife's/partner's views on family planning. Do you think your wife/partner approves or disapproves of couples using a contraceptive method to avoid pregnancy?
DISAPPROVES 2
INDIFFERENT 3
DON'T KNOW 8
522) How often have you talked to your wife/partner about family planning in the last twelve months?
ONCE OR TWICE 2
MORE OFTEN 3
523) Do you think your spouse/partner wants the same number of children that you want, or does she want more or fewer than you want?
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8
SECTION 6. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS
601A) Have you ever heard of any illnesses that you can get from having sex?
NO 2 (GO TO 601F)
601B) What illnesses have you heard of?
RECORD ALL RESPONSES.
GONORRHEA B
AIDS C
VAGINAL TRICHOMONIASIS D
GENITAL ULCERS E
OTHER (SPECIFY) ________________ X
DON'T KNOW Z
HAS NEVER HAD SEXUAL INTERCOURSE (GO TO 601F)
601D) Over the last 12 months, have you had any of these illnesses?
NO 2 (GO TO 601F)
DON'T KNOW 8 (GO TO 601F)
601E) Which illnesses did you have?
RECORD ALL RESPONSES.
GONORRHEA B
AIDS C
VAGINAL TRICHOMONIASIS D
GENITAL ULCERS E
OTHER (SPECIFY) _____________ X
DON'T KNOW Z
601F) Have you had any discharge from your penis in the last 12 months?
NO 2
DON'T KNOW 8
601G) During the last 12 months, have you had a sore or ulcer near your penis?
NO 2
DON'T KNOW 8
HAS NOT HAD ANY INFECTION (GO TO 601N)
601I) The last time you had (INFECTION FROM 601E/DISCHARGE/SORE), did you seek any kind of advice or treatment?
NO 2 (GO TO 601JA)
601J) Where did you go? Any other place/Anyone else?
CIRCLE ALL MENTIONED.
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
FIELDWORKER D
COMMUNITY CENTER E
OTHER PUBLIC (SPECIFY) ______________ F
RELIGIOUS HOSPITAL H
PHARMACY I
ABPF (BENIN FAMILY ADVOCACY ASSOCIATION) J
DOCTOR'S OFFICE K
FIELDWORKER L
OTHER PRIVATE MEDICAL (SPECIFY) _____________ M
RELATIVES/FRIENDS O
TRADITIONAL PRACTITIONER P
DON'T KNOW Z
HAS NOT HAD SEXUAL RELATIONS (GO TO 601N)
601K) When you had (INFECTION(S) FROM 601E/DISCHARGE/SORE), did you inform the person/people you were having sexual intercourse with?
NO 2
601L) When you had (INFECTION(S) FROM 601E/DISCHARGE/SORE), did you do something to avoid infecting your sexual partner(s)?
NO 2 (GO TO 601N)
PARTNER(S) ALREADY INFECTED 3 (GO TO 601N)
601M) What did you do?
RECORD ALL MENTIONED.
USED CONDOMS B
TOOK DRUGS 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 of information have you learned most about AIDS? Any other sources?
RECORD ALL MENTIONED.
TV B
NEWSPAPERS/MAGAZINES C
PAMPHLETS/POSTERS D
HEALTH WORKERS E
MOSQUES/CHURCHES F
SCHOOLS/TEACHERS G
COMMUNITY MEETINGS H
FRIENDS/RELATIVES I
WORK PLACE J
OTHER (SPECIFY) ____________ X
602B) How can you get AIDS? Any other way?
RECORD ALL MENTIONED.
SEXUAL INTERCOURSE WITH SEVERAL PARTNERS B
SEXUAL INTERCOURSE WITH PROSTITUTES C
NOT USING A CONDOM D
SEXUAL RELATIONS WITH HOMOSEXUALS E
BLOOD TRANSFUSIONS F
INJECTIONS G
KISSING H
MOSQUITO BITES I
SOILED OBJECTS J
OTHER (SPECIFY) _____________ X
DON'T KNOW Z
603) Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?
NO 2 (GO TO 607)
DON'T KNOW 8 (GO TO 607)
604) What can a person do? Anything else?
RECORD ALL WAYS MENTIONED.
USE CONDOMS C
AVOID MULTIPLE PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH HOMOSEXUALS F
AVOID BLOOD TRANSFUSIONS G
AVOID INJECTIONS H
AVOID KISSING I
AVOID MOSQUITO BITES J
SEEK PROTECTION FROM TRADITIONAL PRACTITIONER K
OTHER (SPECIFY) _____________ X
DON'T KNOW Z
607) Is it possible for a healthy-looking person to have the AIDS virus?
NO 2
DON'T KNOW 8
608) Do you think that persons with AIDS almost never die from the disease, sometimes die, or almost always die from the disease?
SOMETIMES 2
ALMOST ALWAYS 3
DON'T KNOW 8
NO 2
DON'T' KNOW 8
608B) Can AIDS be transmitted from a mother to a child?
NO 2
DON'T KNOW 8
608C) Do you know someone personally who has AIDS or someone who died of AIDS?
NO 2
609) Do you think your chances of getting AIDS are small, moderate, great, or no risk at all?
MODERATE 2 (GO TO 609C)
GREAT 3 (GO TO 609C)
NO RISK AT ALL 4
HAS AIDS 5 (GO TO 611A)
609B) Why do you think that you (HAVE NO RISK/HAVE SMALL RISK) of getting AIDS? Any other reason?
RECORD ALL MENTIONED.
USES CONDOMS C (GO TO 611A)
ONLY HAS ONE SEXUAL PARTNER D (GO TO 611A)
HAS A LIMITED NUMBER OF SEXUAL PARTNERS E (GO TO 611A)
AVOIDS PROSTITUTES F (GO TO 611A)
PARTNER DOESN'T HAVE OTHER PARTNERS G (GO TO 611A)
DOESN'T HAVE HOMOSEXUAL RELATIONS H (GO TO 611A)
DOESN'T GET BLOOD TRANSFUSIONS I (GO TO 611A)
DOESN'T GET INJECTIONS J (GO TO 611A)
OTHER (SPECIFY) _____________ X (GO TO 611A)
609C) Why do you think you have (MODERATE/GREAT) risk of getting AIDS? Any other reason?
RECORD ALL MENTIONED.
HAS MORE THAN 1 SEXUAL PARTNER D
HAS SEVERAL SEXUAL PARTNERS E
GOES TO PROSTITUTES F
PARTNER HAS OTHER PARTNER(S) G
HAS HOMOSEXUAL RELATIONS H
BLOOD TRANSFUSIONS I
INJECTIONS J
OTHER (SPECIFY) ____________ X
611A) Ever since you heard of AIDS, have you changed your behavior to avoid getting AIDS?
IF YES, What have you done? Anything else?
RECORD ALL MENTIONED.
STOPPED HAVING SEX B (GO TO 611C)
STARTED USING CONDOMS C (GO TO 611C)
RESTRICTED SEX TO ONE PARTNER D (GO TO 611C)
REDUCED NUMBER OF SEXUAL PARTNERS E (GO TO 611C)
AVOIDED PROSTITUTES F (GO TO 611C)
ASKED PARTNER TO BE FAITHFUL G (GO TO 611C)
STOPPED HOMOSEXUAL RELATIONSHIPS H (GO TO 611C)
STOPPED INJECTIONS I
OTHER (SPECIFY) _____________ X
NO CHANGE Y
611B) Has your knowledge of AIDS influenced or changed your decisions about having sex or sexual behavior?
IF YES, In what way?
RECORD ALL MENTIONED.
STOPPED ALL SEX B
STARTED USING CONDOMS C
RESTRICTED SEX TO ONE PARTNER D
REDUCED NUMBER OF PARTNERS E
AVOIDED PROSTITUTES F
STOPPED HOMOSEXUAL RELATIONS G
STOPPED INJECTIONS H
OTHER (SPECIFY) _______________ X
NO CHANGE IN SEXUAL BEHAVIOR Y
DON'T KNOW Z
611C) Some people use condoms during sex to avoid getting AIDS or other sexually transmitted illnesses. Have you ever heard of condoms?
NO 2 (GO TO 611I)
HAS NOT HAD SEX (GO TO 613)
611E) We may have already discussed this. Have you ever used a condom during sexual relations to avoid getting or transmitting illnesses, like AIDS?
NO 2 (GO TO 611I)
611F) Do you know the brand name of the condoms that you used at that time?
RECORD NAME OF BRAND.
OTHER 6 (GO TO 611I)
DON'T KNOW 8 (GO TO 611I)
611G) Do you think that PRUDENCE is of superior quality, the same quality, or inferior quality than other brands of condoms?
SAME 2
INFERIOR 3
DON'T KNOW 8
611H) In the last 4 weeks, how many PRUDENCE brand condoms have you used?
RECORD THE NUMBER
DON'T KNOW 98
611I) Have you given or received money, gifts, or favors in exchange for sexual relations in the last 12 months?
NO 2
MINUTES ____
To be filled out after completing interview
Comments about respondent:______________________________________
Comments on specific questions:______________________________________
Any other comments:______________________________________
Supervisor's observations:______________________________________
Name of supervisor: _____________________
Date: __________
Editor's observations:______________________________________
Name of editor: ___________________
Date: ___________