MAN'S QUESTIONNAIRE
MINISTRY OF PLANNING
CONGO DEMOCRATIC REPUBLIC
RESPONDENT POOL _________
NAME OF LOCATION (NEIGHBORHOOD/VILLAGE) _________
NAME OF HOUSEHOLD HEAD ___________
CLUSTER NUMBER _____
HOUSEHOLD NUMBER ______
PROVINCE _____
RURAL 2
PROVINCIAL CAPITAL 2
OTHER CITIES 3
CITY 4
RURAL 5
LINE NUMBER OF MAN ____
FIRST VISIT: (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
INTERVIEWER'S NAME _______________
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
NEXT VISIT: (FOR INTERVIEWS 1 AND 2)
DATE _____
TIME _____
FINAL VISIT:
DAY _____
MONTH _____
YEAR 2007
INT. NUMBER ____
RESULT ___
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
LANGUAGE OF INTERVIEW: _________
KIKONGO 2
LINGALA 3
SWAHILI 4
TSHILUBA 5
OTHERS 6
NO 2
SUPERVISOR
NAME _________
DATE _____
FIELD EDITOR
NAME ________
DATE _____
OFFICE EDITOR ____
KEYED BY ____
SECTION 1. RESPONDENT'S BACKGROUND
INTRODUCTION AND CONSENT
INFORMED CONSENT
Hello. My name is ______ and I am working with the Ministry of Planning. We are conducting a national survey about men's, women's, and children's health. We would very much appreciate your participation in this survey. I would like to ask you some questions about your health (and your children's health). The information will help the government to plan health services. The questions usually take about 20 to 45 minutes. Whatever information you provide will be kept strictly confidential and will not be shared with anyone.
Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey?
May I begin the interview now?
SIGNATURE OF INTERVIEWER: _____________
DATE: __________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
101) RECORD THE TIME.
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 a large city, a city, or a rural location?
CITY 2
RURAL 3
103) How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS.
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)
104) Just before you moved here, did you live in a large city, a city, or a rural location?
CITY 2
RURAL 3
105) In the last 12 months, how many times have you traveled out of your home location and slept somewhere other than your home?
NO TRIPS 00 (GO TO 107)
106) Have you been outside of your home location for more than one continuous month in the last 12 months?
NO 2
107) In what month and what year were you born?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
108) How old were you at your last birthday?
COMPARE AND CORRECT 107 AND/OR 108 IF INCONSISTENT.
109) Have you ever attended school?
NO 2 (GO TO 113)
110) What is the highest level of school you attended: primary, secondary, or higher?
SECONDARY 2
HIGHER 3
111) What is the highest (grade/form/year) you completed at this level?
SECONDARY OR HIGHER (GO TO 116)
113) Now I would like you to read this sentence to me.
SHOW CARD TO RESPONDENT.
IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?
ABLE TO READ ONLY PART OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) _______ 4
BLIND/VISUALLY IMPAIRED 5
114) Have you ever participated in a literacy program or any other program that involved learning to read or write (not including primary school)?
NO 2
CODE '1' OR '5' CIRCLED (GO TO 117)
116) Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
117) Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
118) Do you watch television almost every day, at least once a week, less than once a week, or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
119) Do you currently have a job of any kind, for which you earn money?
NO 2
120) Have you had any kind of job in the last 12 months for which you earned money?
NO 2
121) What have you done most of the time in the last 12 months?
LOOKED FOR WORK 2 (GO TO 129)
INACTIVE 3 (GO TO 129)
COULDN'T WORK/HANDICAPPED 4 (GO TO 129)
HOUSEWORK/CHILDCARE 5 (GO TO 129)
OTHER (SPECIFY) _____ 6 (GO TO 129)
122) What is (was) your occupation, that is, what kind of work do (did) you mainly do?
DOES NOT WORK IN AGRICULTURE (GO TO 125)
124) 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
OTHER 6
125) How many months have you worked in the last 12 months?
126) Are you paid or do you earn in cash or in kind for this work or are you not paid at all?
CASH AND KIND 2
IN KIND ONLY 3 (GO TO 129)
NOT PAID 4 (GO TO 129)
127) Who mainly decides how the money you earn will be used?
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
128) On average, how much of your household's expenditures do your earnings pay for: almost none, less than half, about half, more than half, or all?
LESS THAN HALF 2
ABOUT HALF 3
MORE THAN HALF 4
ALL 5
NONE, HIS INCOME IS ALL SAVED 6
PROTESTANT 02
SALVATION ARMY 03
KIMBANGUIST 04
OTHER CHRISTIAN 05
ISLAM 06
ANIMIST 07
NO RELIGION 08
OTHER (SPECIFY) ____ 96
BAS-KASAI AND KWILU-KWANGO 02
CENTRAL CUVETTE 03
UBANGI AND ITIMBIRI-NGIRI 04
UELE: LAKE ALBERT 05
BASELE-KOMO, MANIEMA AND KIVU 06
KASAI, KATANGA, TANGANIKA 07
LUNDA 08
PYGMY 09
OTHER (SPECIFY) _____ 96
130A) I would like to ask you a question about the tribe of your biological parents. Do (did) they belong to the same tribe?
NO 2
130B) Have you been ill in the last 2 weeks?
NO 2 (GO TO 201)
130C) Did you receive medical treatment?
NO 2 (GO TO 130E)
130D) How much did you pay for the medical care (consultations, drugs, etc)?
FREE 99995 (GO TO 201)
DON'T KNOW 99998 (GO TO 201)
103E) Why did you not received medical care?
Any other reason?
RECORD ALL MENTIONED.
DISTANCE B
HEALTH CARE PERSONNEL NOT WELCOMING C
OTHER (SPECIFY) _____ X
201) Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours. Have you fathered any children?
NO 2 (GO TO 206)
DON'T KNOW (GO TO 206)
202) Do you have any sons or daughters that you have fathered 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, RECORD '00'.
206) Have you ever had any sons or daughters who were born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life at birth but did not survive?
NO 2 (GO TO 208)
DON'T KNOW 8 (GO TO 208)
207) How many boys have died?
And how many girls have died?
IF NONE, RECORD '00'.
208) (Other than the children you just listed), did you have any:
a) other boys or girls who are still alive, who you are the biological father, but who you didn't recognize and who don't have your name?
b) other boys or girls who were born alive but later died, who you are the biological father, but who you wouldn't have recognized and who don't have your name?
YES TO AT LEAST ONE OF TWO (INSIST AND CORRECT 201 TO 207 AS NECESSARY)
209) SUM ANSWERS TO 203, 205, AND 207 AND ENTER TOTAL.
IF NONE, RECORD '00'.
HAS HAD ONLY ONE CHILD (GO TO 213)
HAS NOT HAD ANY CHILDREN (GO TO 301)
211) Do all of the children you have fathered have the same biological mother?
NO 2
212) In all, how many women have you fathered children with?
213) How old were you when your (first) child was born?
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 2013 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 301, ASK 302.
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 CONTINUE DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE '1' IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.
301) Which ways or methods have you heard about? FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you heard of (METHOD)?
NO 2 (GO TO 02)
NO 2 (GO TO 03)
NO 2 (GO TO 04)
NO 2 (GO TO 05)
NO 2 (GO TO 06)
NO 2 (GO TO 07)
NO 2 (GO TO 08)
NO 2 (GO TO 09)
NO 2 (GO TO 10)
NO 2 (GO TO 12)
NO 2 (GO TO 13)
NO 2 (GO TO 14)
NO 2 (GO TO 15)
NO 2
302) Have you ever used (METHOD)?
NO 2 (GO TO 02)
NO 2 (GO TO 03)
NO 2 (GO TO 04)
NO 2 (GO TO 05)
NO 2 (GO TO 06)
NO 2 (GO TO 07)
NO 2 (GO TO 08)
NO 2 (GO TO 09)
NO 2 (GO TO 10)
NO 2 (GO TO 12)
NO 2 (GO TO 13)
NO 2 (GO TO 14)
NO 2 (GO TO 15)
NO 2
303) Now I would like to ask you about a woman's risk of pregnancy.
From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations?
NO 2 (GO TO 305)
DON'T KNOW 8 (GO TO 305)
304) Is this time just before her period begins, during her period, right after her period had ended, or halfway between two periods?
DURING PERIOD 2
RIGHT AFTER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) _____ 6
DON'T KNOW 8
305) Do you think that a woman who is breastfeeding her baby can become pregnant?
NO 2
DEPENDS 3
DON'T KNOW 8
306) Now I would like to read you some statements about contraception. Please tell me if you agree or disagree with each one.
DISAGREE 2
DON'T KNOW 3
DISAGREE 2
DON'T KNOW 3
DISAGREE 2
DON'T KNOW 3
SECTION 4. MARRIAGE AND SEXUAL ACTIVITY
401) Are you currently married or living with a woman?
YES, LIVING WITH A WOMAN 2 (GO TO 404)
NO, NOT IN UNION 3 (GO TO 406)
402) How many spouses/wives live with you total?
IF ONLY ONE SPOUSE, RECORD '01'.
403) Are there other women with whom you live with as if you were married?
NO 2 (GO TO 405)
404) Altogether, how many wives do you have or other partners do you live with as if married?
IF ONLY ONE SPOUSE/PARTNER, RECORD '01'.
405) Other than the wives/partners that you just mentioned, are there currently any other women with whom you have regular or occasional sexual intercourse?
OCCASIONAL PARTNER(S) ONLY 2 (GO TO 409)
REGULAR AND OCCASIONAL PARTNER(S) 3 (GO TO 409)
NO OTHER SEXUAL PARTNER 4 (GO TO 409)
406) Do you currently have a regular or occasional sexual partner, or no sexual partner at all?
OCCASIONAL PARTNER(S) ONLY 2
REGULAR AND OCCASIONAL PARTNER(S) 3
NO OTHER SEXUAL PARTNER 4
407) Have you ever been married or lived with a woman?
YES, LIVED WITH A WOMAN 2 (GO TO 411)
YES, BOTH 3
NO 4 (GO TO 416)
408) What is your marital status now: are you widowed, divorced, or separated?
DIVORCED 2 (GO TO 411)
SEPARATED 3 (GO TO 411)
409) BASED ON THE HOUSEHOLD QUESTIONNAIRE, RECORD THE NAME AND LINE NUMBER OF EACH WIFE/PARTNER PROVIDED IN QUESTIONS 402 AND 404 ONLY. IF A WIFE/PARTNER DOESN'T LIVE IN THE HOUSEHOLD, RECORD '00' IN THE SPACE CORRESPONDING TO THAT WIFE/PARTNER. THE NUMBER OF SPACES FILLED OUT SHOULD BE EQUAL TO THE NUMBER OF WIVES AND PARTNERS.
SUM OF 402 AND 404 EQUALS 1: Please tell me the name of your wife/partner.
SUM OF 402 AND 404 EQUALS 2 OR MORE: Please tell me the name of each of your current wives and of each women you are living with). Start with the one who is the first you lived with.
PARTNER 2
410A) How old was your wife/partner on her last birthday?
2 OR MORE WIVES/PARTNERS (GO TO 414)
411) Have you been married or lived with a woman only once, or more than once?
MORE THAN ONCE 2
MARRIED/LIVED WITH 1 WOMAN ONLY ONCE AND 411=1: In what month and year did you start living with your wife/partner?
OTHER: Now I would like to ask a question about the first time you were married or lived with a woman as if married. In what month and year did you start living with your first wife/partner?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
415) How old were you when you started living with her?
416) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family life issues.
How old were you when you first had sexual intercourse (if ever)?
AGE IN YEARS ____ (GO TO 416B)
FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE/PARTNER 95 (GO TO 416B)
416A) Do you intend to wait until you get married to have sexual intercourse for the first time?
NO 2 (GO TO 439)
DON'T KNOW/NOT SURE (GO TO 439)
AGE 25-59 YEARS (GO TO 417)
416C) Was a condom used the first time you had sexual intercourse?
NO 2
416D) How old was the person you first had sexual intercourse with?
DON'T KNOW 98
417) When was the last time you had sexual intercourse?
IF 12 MONTHS OR MORE, ANSWER MUST BE RECORDED IN YEARS.
WEEKS AGO 2 ___
MONTHS AGO 3 ___
YEARS AGO 4 ___ (GO TO 436A)
417A) Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question.
418) The last time you had sexual intercourse (with this second/third) person, was a condom used?
NO 2 (GO TO 421)
419) What is the main reason you used the condom this time?
RESPONDENT WANTED TO AVOID PREGNANCY 2
RESPONDENT WANTED TO AVOID BOTH STD/AIDS AND PREGNANCY 3
DIDN'T TRUST PARTNER/SUSPECTS PARTNER HAS OTHER PARTNERS 4
PARTNER INSISTED 5
OTHER (SPECIFY) ____ 6
DON'T KNOW 8
420) Did you use a condom every time you had sexual intercourse with this person in the last 12 months?
NO 2
RESPONDENT STERILIZED (GO TO 426)
CONDOM USED TO AVOID PREGNANCY ('2' OR '3' CIRCLED): The last time you had sexual intercourse with this woman, did you or your partner do something or use a method other than the condom to avoid pregnancy?
OTHER ('1', '4', '5', '6', OR '8' CIRCLED, OR QUESTION NOT ASKED): The last time you had sexual intercourse with this woman, did you or your partner do something or use a method to avoid pregnancy?
NO 2 (GO TO 424)
DON'T KNOW 8 (GO TO 426)
423) What method was used?
IF MORE THAN ONE METHOD USED, CIRCLE THE METHOD CODE THAT COMES FIRST IN THE SCHEDULE.
PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
PERIODIC ABSTINENCE 12
WITHDRAWAL 13
OTHER (SPECIFY) _____ 96
DON'T KNOW 98
OTHER (GO TO 425)
425) What is the main reason you did not use a contraceptive method to avoid pregnancy?
CONTRACEPTION IS A WOMAN'S BUSINESS 12
NO NEED, A CONDOM WAS USED TO AVOID STD/AIDS 13
COUPLE SUBFECUND/INFECUND 24
WIFE/PARTNER PREGNANT 25
WIFE/PARTNER POSTPARTUM LACTATIONAL AMENORRHEA 26
WIFE/PARTNER BREASTFEEDING 27
WANTS (OTHER) CHILDREN 26
WIFE/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
426) The last time you had sexual intercourse with this (second, third) person, did either you or your partner drink alcohol?
NO 2 (GO TO 428)
427) Were you or your partner drunk at that time?
IF YES: who was drunk?
PARTNER ONLY 2
RESPONDENT AND PARTNER BOTH 3
NEITHER 4
428) What was your relationship to this person with whom you had sexual intercourse?
IF GIRLFRIEND: Were you living together as if married?
IF YES, CIRCLE '02'
IF NO, CIRCLE '03'
LIVE-IN PARTNER 02 (GO TO 434)
GIRLFRIEND NOT LIVING WITH RESPONDENT 03
CASUAL ACQUAINTANCE 04
PROSTITUTE 05
OTHER (SPECIFY) ____ 96
429) For how long (have you had/did you have) a sexual relationship with this person?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.
MONTHS 2 ___
YEARS 3 ___
434) Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?
NO 2 (GO TO 436)
435) In total, with how many different people have you had sexual intercourse with in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.
DON'T KNOW 98
AT LEAST ONE PARTNER IS PROSTITUTE (AT LEAST ONE '05' CIRCLED) (GO TO 438)
436A) In the last 12 months, did you pay anyone in exchange for having sexual intercourse?
NO 2 (GO TO 438)
436B) The last time you paid someone in exchange for having sexual intercourse, was a condom used?
NO 2 (GO TO 438)
436C) Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse in the last 12 months?
NO 2
DON'T KNOW/UNSURE 8
438) In total, with how many different people have you had sex in your life?
IF NON-NUMERIC NUMBER, PROBE TO GET AN ESTIMATE.
IF THE NUMBER IS MORE THAN 95, WRITE '95'.
DON'T KNOW 98
15-17 YEARS OLD (GO TO 439)
438B) CHECK FOR PRESENCE OF OTHER PEOPLE.
DO NOT CONTINUE UNTIL YOU ARE COMPLETELY ALONE WITH RESPONDENT.
PRIVACY IMPOSSIBLE 2 (GO TO 439)
438C) Have you even been forced to have sexual intercourse against your will?
NO 2 (GO TO 439)
438D) The first time you had sexual intercourse, did you want to have sexual intercourse, or were you forced against your will?
WAS FORCED 2
REFUSED TO RESPOND/NO RESPONSE 3
438E) Did anyone make you have sexual intercourse against your will in the last 12 months?
NO 2
439) Do you know of a place where a person can get condoms?
NO 2 (GO TO 501)
440) Where is that?
Any other place?
RECORD ALL PLACES MENTIONED.
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.
HEALTH CENTER B
HEALTH OUTPOST C
FAMILY PLANNING CLINIC D
COMMUNITY AGENT E
OTHER PUBLIC (SPECIFY) _____ F
PHARMACY H
AMO-CONGO I
FIELDWORKER J
OTHER PRIVATE MEDICAL (SPECIFY) _____ K
BAR/NIGHTCLUB M
KIOSK N
TABLIER O
FRIENDS/ACQUAINTANCES/RELATIVES P
441) If you wanted to, could you yourself get a condom?
NO 2
DON'T KNOW/UNSURE 8
OTHER (GO TO 501)
443) Where did you get the condom last time?
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.
HEALTH CENTER 12
HEALTH OUTPOST 13
FAMILY PLANNING CLINIC 14
COMMUNITY WORKER 15
OTHER PUBLIC (SPECIFY) _____ 16
PHARMACY 22
AMO-CONGO 23
HEALTH AGENT 24
OTHER PRIVATE MEDICAL (SPECIFY) ____ 26
BAR/NIGHTCLUB 32
KIOSK 33
TABLIER 34
FRIENDS/ACQUAINTANCES/RELATIVES 35
HOTEL/MOTEL 36
OTHER (SPECIFY) _____ 96
DON'T KNOW 98
SECTION 5. FERTILITY PREFERENCES
501) CHECK 410:
HAS 2 OR MORE WIVES/PARTNERS (GO TO 502)
NOT ASKED (GO TO 505)
502) (Is your wife (partner)/Are any of your wives (partners)) currently pregnant?
NO 2
DON'T KNOW 8
503) CHECK 502:
NO WIFE/PARTNER OR DON'T KNOW: Now I have some question about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?
YES, WIFE/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 to have any more children?
NO MORE/NONE 2 (GO TO 505)
WIFE/PARTNER CAN'T GET PREGNANT/STERILIZED 3 (GO TO 505)
UNDECIDED/DON'T KNOW 8 (GO TO 505)
504) How long would you like to wait from now before the birth of (a/another) child?
YEARS 2 ___
SOON/NOW 993
AFTER MARRIAGE 995
OTHER (SPECIFY) ____ 996
DON'T KNOW 998
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.
NUMBER _____
OTHER (SPECIFY) _____ 96 (GO TO 507)
506) 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?
507) Would you say that you approve or disapprove of couples using a contraceptive method to avoid getting pregnant?
DISAPPROVE 2
DON'T KNOW/UNSURE 3
508) In the last few months have you heard about family planning:
On the radio?
On the television?
In a newspaper or magazine?
NO 2
NO 2
NO 2
510) In the last few months, have you discussed the practice of family planning with your friends, neighbors, or relatives?
NO 2 (GO TO 512)
511) With whom?
Anyone else?
RECORD ALL PERSONS MENTIONED.
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER(S) F
SON(S) G
MOTHER(S)-IN-LAW H
FRIEND(S)/NEIGHBOR(S) I
OTHER (SPECIFY) _____ X
512) In the last few months, have you discussed the practice of family planning with a health worker or health care professional?
NO 2
SECTION 6. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS
601) Now I would like to talk about something else.
Have you ever heard of an illness called AIDS?
NO 2 (GO TO 635)
602) Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?
NO 2
DON'T KNOW 8
603) Can people get the AIDS virus from mosquito bites?
NO 2
DON'T KNOW 8
604) Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?
NO 2
DON'T KNOW 8
605) Can people get the AIDS virus by sharing food with a person who has AIDS?
NO 2
DON'T KNOW 8
606) Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?
NO 2
DON'T KNOW 8
607) Can people get the AIDS virus because of witchcraft or other supernatural means?
NO 2
DON'T KNOW 8
608) Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?
NO 2 (GO TO 610)
DON'T KNOW 8 (GO TO 610)
609) What can a person do?
Anything else?
RECORD ALL WAYS MENTIONED.
USE CONDOMS B
LIMIT SEX TO ONE PARTNER/STAY FAITHFUL TO ONE PARTNER C
LIMIT NUMBER OF SEXUAL PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS F
AVOID SEX WITH HOMOSEXUALS G
AVOID SEX WITH PERSONS WHO INJECT DRUGS INTRAVENOUSLY H
AVOID BLOOD TRANSFUSIONS I
AVOID INJECTIONS J
AVOID SHARING RAZORS/BLADES K
AVOID KISSING L
AVOID MOSQUITO BITES M
SEEK PROTECTION FROM TRADITIONAL PRACTITIONER N
OTHER (SPECIFY) _____ W
OTHER (SPECIFY) _____ X
DON'T KNOW Z
610) Is it possible for a healthy-looking person to have the AIDS virus?
NO 2
DON'T KNOW 8
611) Can the virus that causes AIDS be transmitted from a mother to a child:
During pregnancy?
During delivery?
By breastfeeding?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NOT ONE 'YES' (GO TO 614)
613) Are there any special drugs that a doctor or a nurse can give to a woman infected with the AIDS virus to reduce the risk of transmission to the baby?
NO 2
DON'T KNOW 8
614) Are there any special drugs that people infected with the AIDS virus can get from a doctor or a nurse?
NO 2
DON'T KNOW 8
615) I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?
NO 2 (GO TO 620)
616) When was the last time you were tested?
12-23 MONTHS AGO 2
2 OR MORE YEARS AGO 3
617) the last time you had the test, did you yourself ask for the test, was if offered to you and you accepted, or was it required?
OFFERED AND ACCEPTED 2
REQUIRED 3
618) I don't want to know the results, but did you get the results of the test?
NO 2
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.
HEALTH CENTER 12 (GO TO 622)
ANONYMOUS VOLUNTEER SCREENING CENTER 13 (GO TO 622)
FAMILY PLANNING CLINIC 14 (GO TO 622)
MOBILE VOLUNTEER SCREENING CENTER 15 (GO TO 622)
TRAVELING TREATMENT CENTER 16 (GO TO 622)
OTHER PUBLIC (SPECIFY) _____ 17 (GO TO 622)
MOBILE VOLUNTEER SCREENING CENTER 22 (GO TO 622)
TRAVELING TREATMENT CENTER 23 (GO TO 622)
YOUTH SUPERVISING CENTER 24 (GO TO 622)
OTHER PRIVATE MEDICAL (SPECIFY) _____ 26 (GO TO 622)
620) Do you know of a place where people can go to get tested for the AIDS virus?
NO 2 (GO TO 622)
621) Where is that?
Any other place?
RECORD ALL PLACES MENTIONED.
IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME FO THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
HEALTH CENTER B
ANONYMOUS VOLUNTEER SCREENING CENTER C
FAMILY PLANNING CLINIC D
MOBILE VOLUNTEER SCREENING CENTER E
TRAVELING TREATMENT CENTER F
OTHER PUBLIC (SPECIFY) _____ G
MOBILE VOLUNTEER SCREENING CENTER I
TRAVELING TREATMENT CENTER J
YOUTH SUPERVISING CENTER K
OTHER PRIVATE MEDICAL (SPECIFY) _____ L
622) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?
NO 2
DON'T KNOW 8
623) If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?
NO 2
DON'T KNOW/DEPENDS 8
624) If a relative of yours became sick with the virus that causes AIDS, would you be willing to care for her or him in your own household?
NO 2
DON'T KNOW/DEPENDS 8
625) In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?
SHOULD NOT BE ALLOWED 2
DON'T KNOW/DEPENDS 8
626) Do you personally know someone who has been denied health services in the last 12 months because he or she has or is suspected to have the AIDS virus?
NO 2
DON'T KNOW ANYONE WITH AIDS (GO TO 631)
627) Do you personally know someone who has been denied involvement in social events, religious services, or community events in the last 12 months because he or she has or is suspected to have the AIDS virus?
NO 2
628) Do you personally know someone who has been verbally abused or teased in the last 12 months because he or she has or is suspected to have the AIDS virus?
NO 2
AT LEAST ONE 'YES' (GO TO 631)
630) Do you personally know someone who has or is suspected to have the AIDS virus?
NO 2
631) Do you agree or disagree with the following statement:
People with the AIDS virus should be ashamed of themselves.
DISAGREE 2
DON'T KNOW/NO OPINION 8
632) Do you agree or disagree with the following statement:
People with the AIDS virus should be blamed for bringing the disease into the community.
DISAGREE 2
DON'T KNOW/NO OPINION 8
633) Should children age 12-14 be taught about using a condom to avoid getting AIDS?
NO 2
DON'T KNOW/DEPENDS 8
634) Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid getting AIDS?
NO 2
DON'T KNOW/DEPENDS 8
HEARD ABOUT AIDS: Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?
NOT HEARD ABOUT AIDS: Have you heard about infections that can be transmitted through sexual contact?
NO 2 (GO TO 644)
642) If a man has a sexually transmitted disease, what symptoms might he have?
Any other sign or symptom? RECORD ALL SYMPTOMS MENTIONED.
GENITAL DISCHARGE B
FOUL SMELLING DISCHARGE C
BURNING PAIN WHEN URINATING D
REDNESS/INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
LOSS OF WEIGHT K
IMPOTENCE L
OTHER (SPECIFY) _____ W
OTHER (SPECIFY) _____ X
NO SYMPTOMS Y
DON'T KNOW Z
643) If a woman has a sexually transmitted disease, what symptoms might she have?
Any other sign or symptom? RECORD ALL SYMPTOMS MENTIONED.
GENITAL DISCHARGE B
FOUL SMELLING DISCHARGE C
BURNING PAIN WHEN URINATING D
REDNESS/INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
LOSS OF WEIGHT K
HARD TO GET PREGNANT/HAVE A CHILD L
OTHER (SPECIFY) ____ W
OTHER (SPECIFY) ____ X
NO SYMPTOMS Y
DON'T KNOW Z
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 654)
HAS NOT HEARD OF SEXUALLY TRANSMITTED INFECTIONS (GO TO 647)
646) Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact?
NO 2
DON'T KNOW 8
647) Sometimes men have abnormal discharge from their penis. Have you had any abnormal discharge from your penis in the last 12 months?
NO 2
DON'T KNOW 8
648) Sometimes men have a sore or ulcer near their penis.
During the last 12 months, have you had a sore or ulcer near your penis?
NO 2
DON'T KNOW 8
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 654)
650) The last time you had (PROBLEM FROM 646/647/648), did you seek any kind of advice or treatment?
NO 2 (GO TO 652)
651) Where did you go?
Any other place?
RECORD ALL MENTIONED.
HEALTH CENTER/OUTPOST B
ANONYMOUS VOLUNTEER SCREENING CENTER C
CENTER FOR SEXUALLY TRANSMITTED INFECTIONS D
FAMILY PLANNING CLINIC E
COMMUNITY AGENT F
MATERNITY CENTER G
OTHER PUBLIC (SPECIFY) _____ H
MATERNITY J
PHARMACY K
ANONYMOUS VOLUNTEER SCREENING CENTER L
HEALTH AGENT M
OTHER PRIVATE MEDICAL (SPECIFY) _____ N
SHOP R
652) The last time you had (PROBLEM FROM 646/647/648), did your partner seek any kind of advice or treatment?
NO 2 (GO TO 654)
PARTNER NOT INFORMED 3 (GO TO 654)
DON'T KNOW 8 (GO TO 654)
653) Where did she go?
Any other place?
RECORD ALL MENTIONED.
HEALTH CENTER/OUTPOST B
ANONYMOUS VOLUNTEER SCREENING CENTER C
CENTER FOR SEXUALLY TRANSMITTED INFECTIONS D
FAMILY PLANNING CLINIC E
COMMUNITY AGENT F
MATERNITY CENTER G
OTHER PUBLIC (SPECIFY) _____ H
MATERNITY J
PHARMACY K
ANONYMOUS VOLUNTEER SCREENING CENTER L
HEALTH AGENT M
OTHER PRIVATE MEDICAL (SPECIFY) _____ N
SHOP R
654) Some men are circumcised. Are you circumcised?
NO 2
TO BE FILLED IN 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: _________