Republic of Senegal
Ministry of the Economy, Finance, and Planning
Ministry of Health and Social Action

ICF International

IDENTIFICATION

PLACE NAME

NAME OF HEAD OF HOUSEHOLD NUMBER HOUSEHOLD

PLOT NUMBER

CLUSTER NUMBER CLUSTER

REGION

DEPARTMENT

SANITATION DISTRICT

MILIEU

URBAN/RURAL

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

MAN'S NAME AND LINE NUMBER _________

Household selected for men's survey (DV)?

INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE

INTERVIEWER'S NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR 201
INT. NUMBER
RESULT

NEXT VISIT
DATE
TIME

TOTAL NO. OF VISITS

LANGUAGE OF QUESTIONNAIRE

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

LANGUAGE OF QUESTIONNAIRE: FRENCH

LANGUAGE CODES:

SUPERVISOR
NAME
NUMBER
DATE

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Agency for Statistics and Demography in collaboration with the Ministry of Health and Social Action. We are conducting a survey about health all over Senegal. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.

Do you have any questions?
May I begin the interview?

Signature of interviewer
Date

SECTION 1. RESPONDENT'S BACKGROUND

101) RECORD THE TIME

105) In what month and year were you born?

106) How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT

107) Have you ever attended school?

108) What is the highest level of school you attended: primary, secondary 1, secondary 2, or higher?

109) What is the highest (grade/form/year) you completed at this level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 00

110) Check 108

111) 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?

111a) Have you ever participated in a literacy program or any other program that included learning how to read and right (not including primary school)?

111b) In what languages were these literacy programs?
PROBE: ANY OTHER?
RECORD ALL MENTIONED

112) CHECK 111:

113) Do you read a newspaper or magazine at least once a week, less than once a week or not at all?

114) Do you listen to the radio at least once a week, less than once a week or not at all?

115) Do you watch television at least once a week, less than once a week, or not at all?

116) Do you own a mobile telephone?

117) Do you use your mobile phone for any financial transactions?

118) Do you have an account in a bank or other financial institution that you yourself use?

119) Have you ever used the internet?

120) In the last 12 months, have you used the internet?
If necessary, probe for use from any location, with any device.

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

122) What is your religion?

122a) Are you Senegalese?

123) What is your ethnicity?

SECTION 2. REPRODUCTION

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, even if they are not legally yours or do not have your last name.

Have you ever fathered any children with any woman?

202) Do you have any sons or daughters that you have fathered who are now living with you?

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 that you have fathered who are not alive but do not live with you?

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 fathered a son or a daughter who was born alive but later died?
IF NO, PROBE: Any baby who cried, who made any movement, sound or effort to breathe, or who showed any other signs of life even if for a very short time?

207) How many boys have died?
And how many girls have died?
IF NONE, RECORD '00'

208) SUM ANSWERS TO 203, 205, AND 207 AND ENTER TOTAL.
IF NONE, RECORD 00

209) CHECK 208:

210) Did all of the children you have fathered have the same biological mother?

211) CHECK 208:

HAS HAD MORE THAN ONE CHILD

How old were you when your child was born?

212) CHECK 203 AND 205:

213) CHECK 203 AND 205:

MORE THAN ONE LIVING CHILD

ONLY ONE LIVING CHILD

214) CHECK 213:

215) CHECK 203 AND 205:

MORE THAN ONE LIVING CHILD

ONLY ONE LIVING CHILD

216) When (name)'s mother was pregnant with (name), did she have any antenatal check-ups?

217) Were you ever present during any of those antenatal check-ups?

218) Was (name) born in a hospital or a health facility?

219) When a child has diarrhea, how much should he or she be given to drink: more than usual, about the same as usual, less than usual or nothing to drink at all?

SECTION 3. CONTRACEPTION

301) 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.

Have you ever heard of (method)?

302) In the last few months have you

303) In the last few months, have you discussed family planning with a health worker or health professional?

304) 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 when she has sexual relations?

305) Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods?

306) After the birth of a child, can a woman become pregnant before her menstrual period has returned?

307) I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.

308) CHECK 301 (07): Know male condom

309) Do you know a place where a person can get condoms?

310) Where is that?
Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

311) If you wanted, could you yourself get a condom?

312) CHECK 301 (08): Knows female condom

313) Do you know of a place where a person can get female condoms?

314) Where is that?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

315) If you wanted, could you yourself get a female condom?

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401) Are you currently married or living with a woman as if married?

402) Have you ever been married or lived together with a woman as if married?

403) What is your marital status now: are you widowed, divorced, or separated?

404) Is your (wife/partner) living with you now or is she staying elsewhere?

405) Do you have other wives or do you live with other women as if married?

406) Altogether, how many wives or live-in partners do you have?

407) CHECK 405:

ONE WIFE/PARTNER

Please tell me the name of (your wife/the woman you are living with as if married).

MORE THAN ONE WIFE/PARTNER

Please tell me the name of each of your wives or each woman you are living with as if married.

RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIFE-IN PARTNER.

IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD 00.

ASK 408 FOR EACH PERSON

408) How old was (name) on her last birthday?

409) CHECK 407:

410) Have you been married or lived with a woman only once or more than once?

411) CHECK 405 AND 410:

BOTH ARE CODE 2

OTHER

412) How old were you when you started living with her?

413) CHECK FOR THE PRESENCE OF OTHERS.
BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

414) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues. 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. How old were you when you had sexual intercourse for the very first time?

How old were you when you had sexual intercourse for the very first time?

415) Now I would like to ask you some questions about your recent sexual activity. When was the last time you had sexual intercourse?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

416) When was the last time you had sexual intercourse with this person?

417) The last time you had sexual intercourse (with this second/third) person, was a condom used?

418) Was a condom used every time you had sexual intercourse with this person in the last 12 months?

419) 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 2, IF NO, CIRCLE 3.

420) How long ago did you first have sexual intercourse with this (second/third) person?

421) How many times during the last 12 months did you have sexual intercourse with this person?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNER IS 95 OR MORE, RECORD 95.

422) How old is this person?

423) Apart from this person, have you had sexual intercourse with any other person in the last 12 months?

424) In total, with how many different people have you had sexual intercourse in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE 95

425) CHECK 419 (ALL COLUMNS):

426) CHECK 420 AND 418 (ALL COLUMNS)

427) In the last 12 months, did you pay anyone in exchange for having sexual intercourse?

428) Have you ever paid anyone in exchange for having sexual intercourse?

429) The last time you paid someone in exchange for having sexual intercourse, was a condom used?

430) Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse in the last 12 months?

431) In the past 12 months have you given any gifts or other goods in order to have sex or to become sexually involved with anyone?

432) Have you ever given any gift or other goods in order to have sex or to become sexually involved with anyone?

433) In total, with how many different people have you had sexual intercourse in your life?
IF NON-NUMERIC NUMBER, PROBE TO GET AN ESTIMATE
IF THE NUMBER IF MORE THAN 95, WRITE '95'

434) CHECK 417, MOST RECENT PARTNER (FIRST COLUMN): Condom used

435) You told me that a condom was used the last time you had sex. What is the brand name of the condom you used at that time?
IF BRAND NOT KNOWN, ASK TO SEE THE PACKAGE.

436) From where did you obtain the condom the last time?

PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

437) The last time you had sex did you or your partner use any method (other than a condom) to avoid or prevent a pregnancy?

438) The last time you had sex did you or your partner use any method to avoid or prevent a pregnancy?

439) What method did you or your partner use?
PROBE: Did you or your partner use any other method to prevent pregnancy?
RECORD ALL MENTIONED

440) Do you know of a place where you can obtain a method of family planning?

SECTION 5. FERTILITY PREFERENCES

501) CHECK 401:

502) CHECK 439:

503) CHECK 407:

504) Is your (wife/partner) currently pregnant?

505) 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 have any more children?

506) After the birth of the child you are expecting now, how long would you wait before the birth of another child?

507) CHECK 208:

HAS FATHERED CHILDREN

HAS NOT FATHERED CHILDREN

508) CHECK 208:

HAS FATHERED CHILDREN

HAS NOT FATHERED CHILDREN

509) Are any of your (wives/partners) currently pregnant?

510) Now I have some questions about the future. After the (child/children) you and your (wives/partners) are expecting now, would you like to have another child, or would you prefer not have any more children?

511) After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?

512) CHECK 208:

HAS FATHERED CHILDREN

HAS NOT FATHERED CHILDREN

513) CHECK 208:

HAS FATHERED CHILDREN

How long would you wait before the birth of another child?

HAS NOT FATHERED CHILDREN

How long would you wait before the birth of a child?

514) CHECK 203 AND 205:
PROBE FOR A NUMERIC RESPONSE.

HAS LIVING CHILDREN

NO LIVING CHILDREN

515) 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?

SECTION 6. EMPLOYMENT AND GENDER ROLES

601) Have you done any work in the last seven days?

602) Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, or any other such reason?

603) Have you done any work in the last 12 months?

604) What is your occupation, that is, what kind of work do you mainly do?

605) Do you usually work throughout the year, or do you work seasonally, or only once in a while?

606) Are you paid in cash or kind for this work or are you not paid at all?

607) CHECK 401:

608) CHECK 606:

609) Who usually decides how the money you earn will be used: you, your (wife/partner), or you and your (wife/partner) jointly?

610) Who usually makes decisions about health care for yourself: you, your (wife/partner), you and your (wife/partner) jointly, or someone else?

611) Who usually makes decisions about making major household purchases?

612) Do you own this or any other house either alone or jointly with someone else?

613) Do you have a title deed for any house you own?

614) Is your name on the title deed?

615) Do you own any agricultural or non-agricultural land either alone or jointly with someone else?

616) Do you have a title deed for any land you own?

617) Is your name on the title deed?

618) In your opinion, is a husband justified in hitting or beating his wife in the following situations:

SECTION 7. HIV/AIDS

701) Now I would like to talk about something else.
Have you ever heard of an HIV or AIDS?

702) HIV is the virus that can lead to AIDS. Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

703) Can people get the AIDS virus from mosquito bites?

704) Can people reduce their chance of getting HIV by using a condom every time they have sex?

705) Can people get HIV by sharing food with a person who has AIDS?

706) Can people get HIV because of witchcraft or other supernatural means?

707) Is it possible for a healthy-looking person to have HIV?

708) Can the virus that causes HIV be transmitted from a mother to a child?

709) CHECK 708:

710) Are there any special drugs that a doctor or a nurse can give to a woman infected with HIV to reduce the risk of transmission to the baby?

711) CHECK FOR THE PRESENCE OF OTHERS.
BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

712) I don't want to know the results, but have you ever been tested for HIV?

713) How many months ago was your most recent HIV text?

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

715) Where was the test done?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

716) Do you know of a place where people can go to get an HIV test?

717) Where is that?
Any other place?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

718) Have you ever heard of test kits people can use to test themselves for HIV?

719) Have you ever tested yourself for HIV using a self-testing kit?

720) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?

720a) If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?

720b) If a member of your family became sick with the virus that causes AIDS, would you be willing to care for her or him in your own household?

721) Do you think children living with HIV should be allowed to attend school with children who do not have HIV?

722) Do you think people hesitate to take an HIV test because they are afraid of how other people will react if the test results is positive for HIV?

723) Do people talk badly about people living with HIV, or who are thought to be living with HIV?

724) Do people living with HIV, or thought to be living with HIV, lose the respect of other people?

725) Do you agree or disagree with the following statement: I would be ashamed if someone in my family had HIV.

726) Do you fear that you could get HIV if you come into contact with the saliva of a person living with HIV?

727) CHECK 701:

HEARD ABOUT HIV OR AIDS

NOT HEARD ABOUT HIV OR AIDS

728) CHECK 414:

729) CHECK 727: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

730) 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?

731) Sometimes men experience an abnormal discharge from their penis. During the last 12 months, have you had an abnormal discharge from your penis?

731) 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?

733) CHECK 730, 731, AND 732:

734) The last time you had (infection from 730/731/732), did you seek any kind of advice or treatment?

735) Where did you go?
Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

736) If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

737) Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women?

SECTION 8. OTHER HEALTH ISSUES

805) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD 90
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

806) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or another healthcare worker?
IF THE NUMBER OF INJECTIONS IS OVER 90 OR IF THERE WERE DAILY INJECTIONS IN THE LAST 3 MONTHS OR LONGER, RECORD 90.
IF THE RESPONSE IS NOT NUMERIC, PROBE TO OBTAIN AN ESTIMATE.

807) The last time you got an injection from a health worker, did he/she take the syringe and needle form a new, unopened package?

808) Do you currently smoke tobacco every day, some days, or not at all?

809) In the past, have you smoked tobacco every day?

810) In the past, have you ever smoked tobacco every day, some days, or not at all?

811) On average, how many of the following products do you currently smoke each day? Also, let me know if you use the product, but not every day.

IF RESPONDENT REPORT USING THE PRODUCT BUT NOT EVERY DAY, RECORD "888." IF THE PRODUCT IS NOT USED AT ALL, RECORD "000."

812) On average, how many of the following products do you currently smoke each week? Also, let me know if you use the product, but not every week.

IF RESPONDENT REPORT USING THE PRODUCT BUT NOT EVERY WEEK, RECORD "888." IF THE PRODUCT IS NOT USED AT ALL, RECORD "000."

813) Do you currently use smokeless tobacco every day, some days, or not at all?

814) On average, how many of the following products do you currently use each day? Also, let me know if you use the product, but not every day.

IF RESPONDENT REPORT USING THE PRODUCT BUT NOT EVERY DAY, RECORD "888." IF THE PRODUCT IS NOT USED AT ALL, RECORD "000."

815) On average, how many of the following products do you currently use each week? Also, let me know if you use the product, but not every week.

IF RESPONDENT REPORT USING THE PRODUCT BUT NOT EVERY WEEK, RECORD "888." IF THE PRODUCT IS NOT USED AT ALL, RECORD "000."

SECTION 9. FEMALE CIRCUMCISION

901) Have you ever heard of female circumcision?

902) In some countries, there is a practice in which a girl may have part of her genitals cut. Have you ever heard about this practice?

903) Do you believe that female circumcision is required by your religion?

904) Do you think that female circumcision should be continued, or should it be stopped?

905) RECORD THE TIME

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

Comments about respondent:

Comments on specific questions:

Any other comments:

SUPERVISOR'S OBSERVATIONS

EDITOR'S OBSERVATIONS