MODEL MAN'S QUESTIONNAIRE
[NAME OF COUNTRY]
[NAME OF ORGANIZATION]
NAME OF HOUSEHOLD HEAD _________________________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF MAN __ __
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
SECOND VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
THIRD VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
NEXT VISIT:
DATE __________
TIME ____________
FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __
RESULT* __
TOTAL NUMBER OF VISITS __
1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)_______________
LANGUAGE OF QUESTIONNAIRE ** 01
LANGUAGE OF QUESTIONNAIRE ** ENGLISH
LANGUAGE OF INTERVIEW ** __ __
NATIVE LANGUAGE OF RESPONDENT ** __ __
TRANSLATOR USED (YES=1, NO =2)
** LANGUAGE CODES:
01 ENGLISH
02 LANGUAGE 2
03 LANGUAGE 3
04 LANGUAGE 4
05 LANGUAGE 5
06 LANGUAGE 6
SUPERVISOR
NUMBER __ __ __
FIELD EDITOR
NUMBER __ __ __
OFFICE EDITOR
KEYED BY
INTRODUCTION AND CONSENT
Hello. My name is _____________________. I am working with [NAME OF ORGANIZATION]. We are conducting a survey about health all over [NAME OF COUNTRY]. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 20 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 question 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 now?
DATE___________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
SECTION 1. RESPONDENT'S BACKGROUND
101. RECORD THE TIME
MINUTES __ __
102. How long have you been living continuously in (NAME OF CURRENT CITY, TOWN OR VILLAGE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS.
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)
103. Just before you moved here, did you live in a city, in a town, or in a rural area?
TOWN 2
RURAL AREA 3
104. Before you moved here, which [PROVINCE/REGION/STATE] did you live in?
[PROVINCE/REGION/STATE] 02
[PROVINCE/REGION/STATE] 03
OUTSIDE OF [COUNTRY] 96
105. In what month and year were you born?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
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. (2) What is the highest level of school you attended: primary, secondary, or higher?
SECONDARY 2
HIGHER 3
109. (2) What is the highest [GRADE/FORM/YEAR] you completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.
HIGHER (GO TO 113)
111. (3) 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 THE SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE)______________4
BLIND/VISUALLY IMPAIRED 5
CODE '1' OR '5' CIRCLED (GO TO 114)
113. Do you read a newspaper or magazine at least once a week, less than once a week or not at all?
LESS THAN ONCE A WEEK 2
NOT AT ALL 3
114. Do you listen to the radio at least once a week, less than once a week or not at all?
LESS THAN ONCE A WEEK 2
NOT AT ALL 3
115. Do you watch television at least once a week, less than once a week or not at all?
LESS THAN ONCE A WEEK 2
NOT AT ALL 3
116. Do you own a mobile telephone?
NO 2 (GO TO 118)
117. Do you use your mobile phone for any financial transactions?
NO 2
118. Do you have an account in a bank or other financial institution that you yourself use?
NO 2
119. Have you ever used the internet?
NO 2 (GO TO 122)
120. In the last 12 months, have you used the internet?
IF NECESSARY, PROBE FOR USE FROM ANY LOCATION, WITH ANY DEVICE.
NO 2 (GO TO 122)
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?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
122. COUNTRY-SPECIFIC QUESTION ON RELIGION, IF APPROPRIATE.
123. COUNTRY-SPECIFIC QUESTION ON ETHNICITY, IF APPROPRIATE
124. (4) In the last 12 months, how many times have you been away from home for one or more nights?
NONE 00 (GO TO 201)
125. (4) In the last 12 months, have you been away from home for more than one month at a time?
NO 2
(1) Increase the time reported to the respondent if modules are added to the questionnaire.
(2) Revise according to the local education system.
(3) Each card should have four simple sentences appropriate to the country (e.g., "Parents love their children." "Farming is hard work.", "The child is reading a book." "Children work hard at school."). Cards should be prepared for every language in which respondents are likely to be literate.
(4) The question may be considered for deletion in countries with a very low HIV prevalence.
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?
NO 2 (GO TO 206)
DON'T KNOW 8 (GO TO 206)
202. Do you have any sons or daughters that you have fathered who are living with you?
NO 2 (GO TO 204)
203.
a) How many sons live with you?
b) And how many daughters live with you?
IF NONE, RECORD '00'.
DAUGHTERS AT HOME __ __
204. Do you have any sons or daughters that you have fathered who are alive but do not live with you?
NO 2 (GO TO 206)
205. a) How many sons are alive but do not live with you?
b) And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'.
DAUGHTERS ELSEWHERE __ __
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?
NO 2 (GO TO 208)
DON'T KNOW 8 (GO TO 208)
207. a) How many boys have died?
b) An how many girls have died?
IF NONE, RECORD '00'.
GIRLS DEAD __ __
208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'.
HAS HAD ONLY ONE CHILD (GO TO 211)
HAS NOT HAD ANY CHILDREN (GO TO 301)
210. Did all of the children you have fathered have the same biological mother?
NO 2
211. CHECK 208:
HAS HAD MORE THAN CHILD ((a)How old were you when your first child was born)
HAS HAD ONLY CHILD ((b) How old were you when your child was born?)
NO LIVING CHILDREN (GO TO 301)
MORE THAN ONE CHILD ((a) How old is your youngest child?)
ONLY ONE LIVING CHILD ((b) How old is your child?)
(YOUNGEST) CHILD IS AGE 3 YEARS OR OLDER (GO TO 301)
MORE THAN ONE LIVING CHILD ((a) What is the name of your youngest child?)
ONLY ONE LIVING CHILD ((b) What is the name of your child?)
216. When (NAME)s mother was pregnant with (NAME), did she have any antenatal check-ups?
NO 2 (GO TO 218)
DON'T KNOW (GO TO 218)
217. Were you ever present during any of those antenatal check-ups?
NOT PRESENT 2
218. Was (NAME) born in a hospital or health facility?
OTHER 2
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?
ABOUT THE SAME 2
LESS THAN USUAL 3
NOTHING TO DRINK 4
DON'T KNOW 8
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)?
PROBE: Women can have an operation to avoid having any more children.
NO 2
PROBE: Men can have an operation to avoid having any more children.
NO 2
PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse which can prevent pregnancy for one or more years.
NO 2
PROBE: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
NO 2
PROBE: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
NO 2
PROBE: Women can take a pill every day to avoid becoming pregnant.
NO 2
PROBE: Men can put a rubber sheath on their penis before sexual intercourse.
NO 2
PROBE: Women can place a sheath in their vagina before sexual intercourse.
NO 2
PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
NO 2
PROBE: A woman uses a string of colored beads to know the days she can get pregnant. On the days she can get pregnant, she uses a condom or does not have sexual intercourse.
NO 2
PROBE: Up to six months after childbirth, before the menstrual period has returned, women uses a method requiring frequent breastfeeding day and night.
NO 2
PROBE: To avoid pregnancy, women do not have sexual intercourse on the days of the month they think they can get pregnant.
NO 2
PROBE: Men can be careful and pull out before climax.
NO 2
YES, TRADITIONAL METHOD (SPECIFY)___________________2
NO 3
302. In the last few months have you:
NO 2
NO 2
NO 2
NO 2
303. In the last few months, have you discussed family planning with a health worker or health professional?
NO 2
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?
NO 2 (GO TO 306)
DON'T KNOW 8 (GO TO 306)
305. Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods?
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY)______________6
DON'T KNOW 8
306. After the birth of a child, can a woman become pregnant before her menstrual period has returned?
NO 2
DON'T KNOW 8
307. I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.
DISAGREE 2
DON'T NOW 8
DISAGREE 2
DON'T KNOW 8
(1) Studies have indicated emergency contraception can be effective up to five days. Verify country program recommendations and modify wording if appropriate.
(2) The Standard Days Method (SDM) should be deleted in countries that do not have a SDM program. In these countries, SDM should also be deleted as a coding category in Q. 440.
(3) The LAM method should be deleted in countries that do not have a LAM program. In these countries, LAM should also be deleted as a coding category in Q. 440.
SECTION 4. MARRIAGE AND SEXUAL ACTIVITY
401. Are you currently married or living together with a woman as if married?
YES, LIVING WITH A WOMAN 2 (GO TO 404)
NO, NOT IN UNION 3
402. Have you ever been married or lived together with a woman as if married?
YES, LIVED WITH A WOMAN 2
NO 3 (GO TO 413)
403. What is your marital status now: are you widowed, divorced, or separated?
DIVORCED 2 (GO TO 410)
SEPARATED 3 (GO TO 410)
404. Is your (wife/partner) living with you now or is she staying elsewhere?
STAYING ELSEWHERE 2
405. (1) Do you have other wives or do you live with other women as if married?
NO (ONLY ONE WIFE) 2 (GO TO 407)
406. (1) Altogether, how many wives or live-in partners do you have?
407. CHECK 405: RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER.
IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.
ONE WIFE/PARTNER ((a) Please tell me the name of (your wife/the woman you are living with as if married).
MORE THAN ONE WIFE/PARTNER ((b) Please tell me the name of each of your wives or each woman you are living with as if married.)
LINE NUMBER __ __
NAME______________________
LINE NUMBER __ __
NAME______________________
LINE NUMBER __ __
NAME______________________
LINE NUMBER __ __
408. (1) ASK 408 FOR EACH PERSON. How old was (NAME) on her last birthday?
AGE __ __
AGE __ __
AGE __ __
MORE THAN ONE WIFE/PARTNER (GO TO 411)
410. Have you been married or lived with a woman only once or more than once?
ONLY ONCE 2
BOTH ARE CODE '2' ((a) In what month and year did you start living with your (wife/partner)?
OTHER ((b) Now I would like to ask 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 9998
412. How old were you when you first started living with her?
413. CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.
414. I would like to ask some questions about sexual activity in order to gain a better understanding of some important life issues. How old were you when you had sexual intercourse for the very first time?
AGE IN YEARS __ __
415. Now I would like to ask you 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 the next question.
416. 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.
WEEKS AGO 2 __ __ (GO TO 418)
MONTHS AGO 3 __ __ (GO TO 418)
YEARS AGO 4 __ __ (GO TO 428)
417. When was the last time you had sexual intercourse with this person?
WEEKS AGO 2 __ __
MONTHS AGO 3 __ __
418. (2) The last time you had sexual intercourse with this person, was a condom used?
NO 2 (GO TO 420)
419. Was a condom used every time you had sexual intercourse with this person in the last 12 months?
NO 2
420. (3) What was your relationship to this person with whom you had sexual intercourse?
IF GIRLFRIEND: Were you living together as if married?
IF YES, RECORD '2'.
IF NO, RECORD '3'.
LIVE-IN PARTNER 2
GIRLFRIEND NOT LIVING WITH RESPONDENT 3
CASUAL ACQUAINTANCE 4
CLIENT/SEX WORKER 5
OTHER (SPECIFY)____________6
421. How long ago did first have sexual intercourse with this person?
WEEKS AGO 2 __ __
MONTHS AGO 3 __ __
YEARS AGO 4 __ __
422. 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 TIMES IS 95 OR MORE, RECORD '95'.
DON'T KNOW 98
424. Apart from this person, have you had sexual intercourse with any other person in the last 12 months?
NO 2 (GO TO 426)
425. 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, RECORD '95'.
DON'T KNOW 98
NO PARTNERS ARE SEX WORKERS (GO TO 428)
427. CHECK 420 AND 418 (ALL COLUMNS):
OTHER (GO TO 432)
428. In the last 12 months, did you pay anyone in exchange for having sexual intercourse?
NO 2
429. Have you ever paid anyone in exchange for having sexual intercourse?
NO 2 (GO TO 432)
430. (2) The last time you paid someone in exchange for having sexual intercourse, was a condom used?
NO 2 (GO TO 432)
431. 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 8
432. 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?
NO 2
433. Have you ever given any gifts or other goods in order to have sex or to become sexually involved with anyone?
NO 2
434. In total, with how many different people have you had sexual intercourse in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS 95 OR MORE, RECORD '95'.
DON'T KNOW 98
435. (2) CHECK 418: MOST RECENT PARTNER (FIRST COLUMN)
NOT ASKED (GO TO 439)
NO CONDOM USED (GO TO 439)
436. (2) You told me that a condom was used the last time you had sex. What is the brand name of the condom used at that time?
IF BRAND NOT KNOWN, ASK TO SEE THE PACKAGE.
BRAND B 02
BRAND C 03
OTHER (SPECIFY)___________96
DON'T KNOW 98
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.
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
FIELDWORKER 15
OTHER PUBLIC SECTOR (SPECIFY)________________16
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
FIELDWORKER 25
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)___________________26
CHURCH 32
FRIEND/RELATIVE 33
DON'T KNOW 98
438. The last time you had sex did you or your partner use any method other than a condom to avoid or prevent a pregnancy?
NO 2 (GO TO 441)
DON'T KNOW 8 (GO TO 441)
439. The last time you had sex did you or your partner use any method to avoid or prevent a pregnancy?
NO 2 (GO TO 441)
DON'T KNOW 8 (GO TO 441)
440. (5)(6) What method did you or your partner use?
PROBE: Did you or your partner use any other method to prevent pregnancy?
RECORD ALL MENTIONED.
(ALL RESPONSES GO TO 501)
MALE STERILIZATION B
IUD C
INJECTABLES D
IMPLANTS E
PILL F
CONDOM G
FEMALE CONDOM H
EMERGENCY CONTRACEPTION I
STANDARD DAYS METHOD J
LACTATIONAL AMEN. METHOD K
RHYTHM METHOD L
WITHDRAWAL M
OTHER MODERN METHOD X
OTHER TRADITIONAL METHOD Y
441. Do you know of a place where you can obtain a method of family planning?
NO 2
(1) Delete Qs. 405-409 in countries where polygyny is not practiced and replace with Q. 705 from the Woman's Questionnaire with the word 'HUSBAND'S' replaced with 'WIFE'S' and 'HE' replaced with 'SHE'.
(2) In countries with an active female condom program, the wording of the question should be modified to include reference to both the male and female condom.
(3) High polygyny, high HIV prevalence countries may want to add line number of wife from Q. 407 here in the response category.
(4) Coding categories to be developed locally; however, the broad categories must be maintained. Additions to the codes under the private medical sector heading may include religious affiliated sources and NGO sources.
(5) The LAM method coding category should be deleted in countries that do not have a LAM program.
(6) The Standard Days Method (SDM) should be deleted in countries that do not have a SDM program.
SECTION 5. FERTILITY PREFERENCES
501. CHECK 401:
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 514)
MAN STERILIZED (GO TO 514)
MORE THAN ONE WIFE/PARTNER (GO TO 509)
504. Is your (wife/partner) currently pregnant?
NO 2 (GO TO 507)
DON'T KNOW 8 (GO TO 507)
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?
NO MORE 2 (GO TO 514)
UNDECIDED/DON'T KNOW 8 (GO TO 514)
506. After the birth of the child you are expecting now, how long would you like to wait before of another child?
YEARS 2 __ __ (GO TO 514)
SOON/NOW 993 (GO TO 514)
OTHER (SPECIFY)______________996 (GO TO 514)
DON'T KNOW 998 (GO TO 514)
HAS FATHERED CHILD ((a) Now I have some questions about the future. Would you like to have another child, or would you prefer not to have any more children?)
HAS NOT FATHERED CHILDREN ((b) Now I have some questions about the future. Would you like to have a child, or would you prefer not to have any children?)
NO MORE/NONE 2 (GO TO 514)
SAYS COUPLE CAN'T GET PREGNANT 3 (GO TO 514)
WIFE/PARTNER STERILIZED 4 (GO TO 514)
UNDECIDED/DON'T KNOW 8 (GO TO 514)
HAS FATHERED CHILDREN ((a) How long would you like to wait from now before the birth of another child?)
HAS NOT FATHERED CHILDREN ((b) How long would you like to wait from now before the birth of a child?)
YEARS 2 __ __ (GO TO 514)
SOON/NOW 993(GO TO 514)
SAYS COUPLE CAN'T GET PREGNANT 994 (GO TO 514)
OTHER (SPECIFY)______________996 (GO TO 514)
DON'T KNOW 998 (GO TO 514)
509. (1) Are any of your (wives/partners) currently pregnant?
NO 2 (GO TO 512)
DON'T KNOW 8 (GO TO 512)
510. (1) 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 to have any children?
NO MORE 2 (GO TO 514)
UNDECIDED/DON'T KNOW 8 (GO TO 514)
511. (1) 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 __ __ (GO TO 514)
SOON/NOW 993 (GO TO 514)
OTHER (SPECIFY)_____________ (GO TO 514)
DON'T KNOW 998 (GO TO 514)
HAS FATHERED CHILDREN ((a) Now I have some questions about the future. Would you like to have another child, or would you prefer not to have any more children?)
HAS NOT FATHERED CHILDREN ((b) Now I have some questions about the future. Would you like to have a child, or would you prefer not to have any children?)
NO MORE/NONE 2 (GO TO 514)
SAYS COUPLE CAN'T GET PREGNANT 3 (GO TO 514)
WIFE (WIVES)/PARTNER(S) STERILIZED 4 (GO TO 514)
UNDECIDED/DON'T KNOW 8 (GO TO 514)
HAS FATHERED CHILDREN ((a) How long would you like to wait from now before the birth of another child?)
HAS NOT FATHERED CHILDREN ((b) How long would you like to wait from now before the birth of a child?)
YEARS 2 __ __
SOON/NOW 993
SAYS COUPLE CAN'T GET PREGNANT 994
OTHER (SPECIFY)__________________996
DON'T KNOW 998
HAS LIVING CHILDREN ((a) 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 ((b) 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 601)
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 it not matter if it's a boy or girl?
NUMBER OF GIRLS __ __
EITHER __ __
OTHER (SPECIFY)______________________96
(1) This question should be deleted in countries where polygyny is not practiced.
SECTION 6. EMPLOYMENT AND GENDER ROLES
601. Have you done any work in the last seven days?
NO 2
602. Although you did not work in the last seven days, do you have any job or business from which you were absent for leaves, illness, vacation, or any other such reason?
NO 2
603. Have you done any work in the last 12 months?
NO 2 (GO TO 607)
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?
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3
606. Are you paid in cash or kind for this work or are you not paid at all?
CASH AND KIND 2
IN KIND ONLY 3
NOT PAID 4
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 612)
OTHER (GO TO 610)
609. Who usually decides how the money you earn will be used: you, your (wife/partner), or you and your (wife/partner) jointly?
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
OTHER (SPECIFY)_________________6
610. Who usually makes decisions about health care for yourself: you, your (wife/partner), you and your (wife/partner) jointly, or someone else?
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_______________6
611. Who usually makes decisions about making major household purchases?
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_________________6
612. Do you own this or any other house either alone or jointly with someone else?
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4 (GO TO 615)
613. Do you have a title deed for any house you own?
NO 2 (GO TO 615)
DON'T KNOW (GO TO 615)
614. Is your name on the title deed?
NO 2
DON'T KNOW 8
615. Do you own any agricultural or non-agricultural land either alone or jointly with someone else?
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4 (GO TO 618)
616. Do you have a title deed for any land you own?
NO 2 (GO TO 618)
DON'T KNOW 8 (GO TO 618)
617. Is your name on the title deed?
NO 2
DON'T KNOW 8
618. In your opinion, is a husband justified in hitting or beating his wife in the following situations?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
701. Now I would like to talk about something else. Have you ever heard of HIV or AIDS?
NO 2 (GO TO 727)
702. HIV is the virus that can lead to AIDS. Can people reduce their chance of getting HIV by having just one uninfected sex partner who has no other sex partners?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
704. Can people reduce their chance of getting HIV by using a condom every time they have sex?
NO 2
DON'T KNOW 8
705. (1) Can people get HIV by sharing food with a person who has HIV?
NO 2
DON'T KNOW 8
706. (1) Can people get HIV because of witchcraft or other supernatural means?
NO 2
DON'T KNOW 8
707. Is it possible for a healthy-looking person to have HIV?
NO 2
DON'T KNOW 8
708. Can HIV be transmitted from a mother to her baby:
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
OTHER (GO TO 711)
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?
NO 2
DON'T' KNOW 8
712. I don't want to know the results, but have you ever been tested for HIV?
NO 2 (GO TO 716)
713. How many months ago was your most recent HIV test?
TWO OR MORE YEARS 95
714. I don't want to know the results, but did you get the results of the test?
NO 2
715. (2) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE
GOVERNMENT HEALTH CENTER 12 (GO TO 718)
STAND-ALONE HTC CENTER 13(GO TO 718)
FAMILY PLANNING CLINIC 14 (GO TO 718)
MOBILE HTC SERVICES 15 (GO TO 718)
OTHER PUBLIC SECTOR (SPECIFY)__________________ 16(GO TO 718)
STAND-ALONE HTC CENTER 22 (GO TO 718)
PHARMACY 23 (GO TO 718)
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)__________________ 26 (GO TO 718)
WORKPLACE 32 (GO TO 718)
CORRECTIONAL FACILITY 33 (GO TO 718)
716. Do you know of a place where people can go to get an HIV test?
NO 2 (GO TO 718)
717. (2) Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
GOVERNMENT HEALTH CENTER B
STAND-ALONE HTC CENTER C
FAMILY PLANNING CLINIC D
MOBILE HTC SERVICES E
OTHER PUBLIC SECTOR (SPECIFY)_______________F
STAND-ALONE HTC CENTER H
PHARMACY I
MOBILE HTC SERVICES J
OTHER PRIVATE MEDICAL SERVICES (SPECIFY)______________K
718. Have you heard of test kits people can use to test themselves for HIV?
NO 2 (GO TO 720)
719. Have you ever tested yourself for HIV using a self-test kit?
NO 2
720. Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
721. Do you think children living with HIV should be allowed to attend school with children who do not have HIV?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
722. Do you think people hesitate to take an HIV test because they are afraid of how other people will react if the test result is positive for HIV?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
723. Do you think people talk badly about people living with HIV, or who are thought to be living with HIV?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
724. Do people living with HIV, or thought to be living with HIV, lose the respect of other people?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
725. Do you agree or disagree with the following statement: I would be ashamed if someone in my family had HIV.
DISAGREE 2
DON'T KNOW/NOT SURE/DEPENDS 8
726. Do you fear that you could get HIV if you come into contact with the saliva of a person living with HIV?
NO 2
SAYS HE HAS HIV 3
DON'T KNOW/NOT SURE/DEPENDS 8
HEARD ABOUT HIV OR AIDS ((a) Apart from HIV, have you heard about other infections that can be transmitted through sexual contact?)
NOT HEARD ABOUT HIV OR AIDS ((b) Have you heard about infections that can be transmitted through sexual contact?)
NO 2
NEVER HAD SEXUAL INTERCOURSE (GO TO 736)
729. CHECK 727: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?
NO (GO TO 731)
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?
NO 2
DON'T KNOW 8
731. Sometimes men experience an abnormal discharge from their penis. During the last 12 months, have you had an abnormal discharge from your penis?
NO 2
DON'T KNOW 8
732. Sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer on or near your penis?
NO 2
DON'T KNOW 8
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 736)
734. The last time you had (PROBLEM FROM 730/731/732), did you seek any kind of advice or treatment?
NO 2 (GO TO 736)
735. (2) Where did you go? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
GOVERNMENT HEALTH CENTER B
STAND-ALONE HTC CENTER C
FAMILY PLANNING CLINIC D
MOBILE HTC SERVICES E
OTHER PUBLIC SECTOR (SPECIFY)______________F
STAND-ALONE HTC CENTER H
PHARMACY I
MOBILE HTC SERVICES J
OTHER PRIVATE MEDICAL SECTOR (SPECIFY)______________K
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?
NO 2
DON'T KNOW 8
737. (3) Is a wife justified in refusing to have sex with her husband when she knows he has sex with other women?
NO 2
DON'T KNOW 8
(1) If Qs. 703, 705 and/or 706 do not apply to the local context, replace the question using a specific local misconception. At least two questions related to the misconceptions are needed.
(2) Coding categories to be developed locally; however, the broad categories must be maintained. Additions to the codes under the private medical sector heading may include religious affiliated sources and NGO sources.
(3) In polygynous societies, the phrase 'other women' should be replaced by the phrase 'women other than his wives.'
SECTION 8. OTHER HEALTH ISSUES
801. (1) Some men are circumcised, that is, the foreskin is completely removed from the penis. Are you circumcised?
NO 2 (GO TO 805)
DON'T KNOW (GO TO 805)
802. (1) How old were you when you got circumcised?
DURING CHILDHOOD (LESS THAN 5 YEARS) 95
DON'T KNOW 98
803. (1) Who did the circumcision?
HEALTH WORKER/PROFESSIONAL 2
OTHER 3
DON'T KNOW 8
HOME OF A HEALTH WORKER/PROFESSIONAL 2
CIRCUMCISION DONE AT HOME 3
RITUAL SITE 4
OTHER HOME/PLACE 5
DON'T KNOW 8
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.
NONE 00 (GO TO 808)
806. Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?
IF NUMBER OF INJECTIONS IS 90 ORE MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
NONE 00 (GO TO 808)
807. The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?
NO 2
DON'T KNOW 8
808. Do you currently smoke tobacco every day, some days, or not at all?
SOME DAYS 2
NOT AT ALL (GO TO 810)
809. In the past, have you smoked tobacco every day?
NO 2 (GO TO 812)
810. In the past, have you ever smoked tobacco every day, some days, or not at all?
SOME DAYS 2 (GO TO 813)
NOT AT ALL 3 (GO TO 813)
811. (2) 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 REPORTS USING THE PRODUCT BUT NOT EVERY DAY, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.
NUMBER DAILY __ __ __ (GO TO 813)
812. (2) On average, how many of the following products do you currently smoke each week? Also, let me know if you use the products, but not every week.
IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY WEEK, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.
NUMBER WEEKLY __ __ __
813. Do you currently use smokeless tobacco every day, some days, or not at all?
SOME DAY 2 (GO TO 815)
NOT AT ALL 3 (GO TO 816)
814. (2) 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 REPORTS USING THE PRODUCT BUT NOT EVERY DAY, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.
NUMBER DAILY __ __ __ (GO TO 816)
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 REPORTS USING THE PRODUCT BUT NOT EVERY WEEK, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.
NUMBER WEEKLY __ __ __
816. (3) Are you covered by any health insurance?
NO 2 (GO TO 818)
817. (3) What type of health insurance are you covered by?
RECORD ALL MENTIONED.
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
OTHER (SPECIFY)____________X
MINUTES __ __
(1) Question may be omitted depending on the practice of male circumcision in specific countries. Translation of circumcision should indicate removal of the foreskin and not merely coming of age ceremonies.
(2) Add local terms.
(3) If a health service prepayment plan or other types of plans are available in the country, add those types of plans to the question.
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW:
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COMMENTS ON SPECIFIC QUESTIONS:
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ANY OTHER COMMENTS:
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