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DEMOGRAPHIC AND HEALTH SURVEY - 2004 BANGLADESH - MAN?S QUESTIONNAIRE (ENGLISH)

BANGLADESH

IDENTIFICATION

DIVISION:

DISTRICT:

UPAZILA:

UNION OR WARD:

VILLAGE OR MOHALLA OR BLOCK:

CLUSTER NUMBER:

HOUSEHOLD HUMBER:

RURAL OR MUNICIPALITY OR OTHER URBAN OR SMA?

RURAL 1
MUNICIPALITY 2
OTHER URBAN 3
SMA 4

NAME OF HOUSEHOLD HEAD:

NAME AND LINE NUMBER OF MAN:

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER?S NAME
RESULT*

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 RESPONDENT INCAPACITATED
7 OTHER (SPECIFY)

SECOND VISIT
DATE
INTERVIEWER?S NAME
RESULT*

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER?S NAME
RESULT*

FINAL VISIT
DAY
MONTH

01 JANUARY
02 FEBRUARY
03 MARCH
04 APRIL
05 MAY
06 JUNE
07 JULY
08 AUGUST
09 SEPTEMBER
10 OCTOBER
11 NOVEMBER
12 DECEMBER

YEAR
CODE
RESULT*

TOTAL NUMBER OF VISITS

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 ___. We came from the Mitra and Associated, a private research organization, is located at Dhaka. To assist in the implementation of socio-development programs in the country, we conduct different types of surveys. We are now conducting a national survey about man and the health of women and children under the authority of NIPORT of ministry of health and family Welfare. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes between 20 and 45 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be show to other persons.

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 AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (GO TO END)

101. RECORD THE TIME STARTED.

HOUR ___
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 a city, in a town, or in the countryside?

DHAKA OR CHITTAGONG OR KHULNA OR RAJSHAHI 1
SMALL CITY 2
TOWN 3
VILLAGE 4

103A. Do you usually live in (THE CURRENT PLACE OF RESIDENCE)?

YES 1
NO 2 (GO TO 106)

103B. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?

IF LESS THAN ONCE YEAR, RECORD ?00? YEAR.

NUMBER OF YEARS ___
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)

104. Just before you moved here, did you live in a city, a town, or in the countryside?

DHAKA OR CHITTAGONG OR KHULNA OR RAJSHAHI 1
SMALL CITY 2
TOWN 3
VILLAGE 4

105. In the last 1 year, have you ever lived away from your home community?

YES 1
NO 2 (GO TO 108)

106. In the last 1 year, on how many occasions have you lived away from your home community?

NUMBER OF OCCASION ___

107. How many days altogether (mentioned in 106) did you spend away from you home community?

NUMBER OF TIMES ___

108. In what month and year were you born?

MONTH ___
DON?T KNOW MONTH 98
YEAR ___
DON?T NOW YEAR 9998

109. How old were you at your last birthday?

COMPARE AND CORRECT 108 AND/OR 109 IN INCONSISTENT.

AGE IN COMPLETED YEARS ___
IF AGE IS NOT BETWEEN 15 AND 59 (GO TO END)

110. Have you ever attended school or madrasha?

YES, SCHOOL 1 (GO TO 11B)
YES, MADRASHA 2 (GO TO 11B)
YES, BOTH 3
NO 4 (GO TO 113)

111A. What type of schooling did you last attend?

SCHOOL 1
MADRASHA 2

111B. What level of school have you last attended? What is the highest grade you completed at that schooling?

LEVEL ___
CLASS ___

112. CHECK 111B:

CLASS IS LESS THAN 6 (GO TO 113)
CLASS IS 6 OR MORE THAN 6 (GO TO 114)

113. Can you read and write a letter in any language easily, with difficulty, or not at all?

EASILY 1
WITH DIFFICULTY 2
NOT AT ALL 3 (GO TO 115)

114. Do you usually read a newspaper or magazine?

YES 1
NO 2 (GO TO 115)

114A. How often do you read newspaper or magazine: every day, at least once a week, or less than once a week?

EVERY DAY 1
AT LEAST ONCE WEEK 2
LESS THAN ONCE A WEEK 3

115. Do you listen to the radio?

YES 1
NO 2 (GO TO 116)

115A. How often do you listen to the radio: every day, at least once a week, less than once a week?

EVERY DAY 1
AT LEAST ONCE WEEK 2
LESS THAN ONCE A WEEK 3

116. Do you watch television?

YES 1
NO 2 (GO TO 117)

116A. How often do you watch television: every day, at least once a week, less than once a week?

EVERY DAY 1
AT LEAST ONCE WEEK 2
LESS THAN ONCE A WEEK 3

117. What is your religion?

ISLAM 1
HINDUISM 2
BUDDHISM 3
CHRISTIANITY 4
OTHER (SPECIFY) 6

119. Are you currently working?

YES 1
NO 2 (GO TO 128)

120. What is your occupation, that is, what kind of work do you mainly do?

___

121. CHECK 120:

WORKS IN AGRICULTURE (GO TO 122)
WORKS IN OTHER SECTORS (GO TO 123)

122. Do you work mainly on your own land or on family land, or do you rent land or work on someone else?s land?

OWN LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE?S LAND 4

123. Do you do this work for a member of your family, for someone else, or are you self-employed?

FOR FAMILY MEMBER 1
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3

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

THROUGHOUT THE YEAR 1 (GO TO 126)
SEASONALLY OR PART OF THE YEAR 2
ONCE IN A WHILE 3

125. During the last 1 year, how many months did you work?

NUMBER OF MONTHS ___

126. Do you think that your earning is sufficient, moderately sufficient or not sufficient to provide for your family?s basic needs?

SUFFICIENT 1(GO TO 201)
MODERATELY SUFFICIENT 2 (GO TO 201)
NOT SUFFICIENT 3 (GO TO 201)

128. Have you done any work in the last 1 year?

YES 1 (GO TO 201)
NO 2

129. What have you been doing over the last 1 year?

GOING TO SCHOOL OR STUDYING 1
LOOKING FOR WORK 2
INACTIVE 3
COULD NOT WORK OR HANDICAPPED 4
OTHER (SPECIFY) 6

SECTION 2. HEALTH AND LIFE STYLE

201. At any time during the last 3 months, for any health problem(s) or injury, did you have difficulty in doing your normal work, or in doing regular activities?

YES, ILLNESS A
YES, INJURY B
NONE Y (GO TO 207A)

202. For how many days in the last 3 months were you unable to do your normal work or regular activities due to this (these) health problem(s) and/or injuries?

NUMBER OF DAYS ___

203. CHECK 201:

CIRCLED ?A? (ILLNESS) (GO TO 204)
DID NOT CIRCLE ?A? (GO TO 207A)

204. What type of illness prevents you from doing your work or other regular activities?

TUBERCULOSIS A
ASTHMA B
DIABETES C
HIGH BLOOD PRESSURE D
HEART PROBLEM E
MALARIA OR FEBER F
JAUNDICE OR HEPATITIS G
OTHER (SPECIFY) Z

207A. Do you smoke? Such as:

1. Cigarette?
YES 1 (GO TO 207B)
NO 2 (GO TO 207C)
2. Bidi?
YES 1 (GO TO 207B)
NO 2 (GO TO 207C)
3. Hukka?
YES 1 (GO TO 207B)
NO 2 (GO TO 207C)
4. Pipe?
YES 1 (GO TO 207B)
NO 2 (GO TO 207C)
5. Anything else? (SPECIFY)
YES 1 (GO TO 207B)
NO 2 (GO TO 207C)
6. Do you currently eat tobacco leaves or sada pata or gul?
YES 1 (GO TO 207B)
NO 2 (GO TO 207C)
7. Do you currently eat pan with tobacco or zarda?
YES 1 (GO TO 207B)
NO 2 (GO TO 207C)

207B. In 24 hours usually how many times do you smoke or eat (NAME OF THE ITEM)?

1. Cigarette?
TIMES ___
GO TO NEXT ITEM
2. Bidi?
TIMES ___
GO TO NEXT ITEM
3. Hukka?
TIMES ___
GO TO NEXT ITEM
4. Pipe?
TIMES ___
GO TO NEXT ITEM
5. Anything else? (SPECIFY)
TIMES ___
GO TO NEXT ITEM
6. Do you currently eat tobacco leaves or sada pata or gul?
TIMES ___
GO TO NEXT ITEM
7. Do you currently eat pan with tobacco or zarda?
TIMES ___
GO TO NEXT ITEM

207C. Have you ever smoked or eaten (NAME OF THE ITEM)?

1. Cigarette?
YES 1
NO 2
2. Bidi?
YES 1
NO 2
3. Hukka?
YES 1
NO 2
4. Pipe?
YES 1
NO 2
5. Anything else? (SPECIFY)
YES 1
NO 2
6. Do you currently eat tobacco leaves or sada pata or gul?
YES 1
NO 2
7. Do you currently eat pan with tobacco or zarda?
YES 1
NO 2

SECTION 3. MARRIAGE AND SEXUAL ACTIVITY

301. Are you currently married, widowed, divorced or separated?

MARRIED 1
WIDOWED 2 (GO TO 306)
DIVORCED 3 (GO TO 306)
SEPARATED 4 (GO TO 306)
NEVER MARRIED 5 (GO TO 316A)

305. Is your wife living with you now or is she staying elsewhere?

LIVING WITH HIM 1
STAYING ELSEWHERE 2

306. Have you been married only once, or more than once?

ONCE 1
MORE THAN ONCE 2

307A: CHECK 301:

CURRENTLY MARRIED (GO TO 307B)
NOT CURRENTLY MARRIED (GO TO 308)

307B. RECORD THE WIFE?S NAME AND LINE UMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF SHE IS NOT LISTED IN THE HOUSEHOLD, RECORD ?00?.

IF THERE ARE TWO WIVES IN THE HOUSEHOLD, RECORD THE NAME AND LINE UMBERS OF BOTH.

NAME ___
LINE NUMBER ___

308. CHECK 306:

MARRIED ONLY ONCE: In what month and year did you start living with your wife?

MARRIED MORE THAN ONCE: Now, we will talk about your first wife. In what month and year did you start living with her?

MONTH ___
DON?T KNOW MONTH 98
YEAR ___ (GO TO 310)
DON?T NOW YEAR 9998

309. How old were you when you started living with her?

AGE ___

310. Did you have sex before (first) marriage?

YES 1
NO 2 (GO TO 311)

310A. How old were you when you first had sexual intercourse?

AGE IN YEARS ___

311. Now I would like to talk about sexual relationship after marriage. Sometimes, a man may seek for sexual relationship with women other than his wife. After marriage, have you ever had sex with any woman other than your wife?

YES 1
NO 2 (GO TO 317)

312. Beside you wife, with whom did you have sexual relationship? Any other?

GIRLFRIEND OR FIANCEE A
OTHER FRIEND B
CASUAL ACQUAINTANCE C
COMMERCIAL SEX WORKER D
RELATIVE E
OTHER (SPECIFY) X

313A. In the last 1 year, did you have sexual intercourse with any women other than your wife?

YES 1
NO 2 (GO TO 317)

313B. Beside you wife, with whom did you have sexual intercourse? Any other?

GIRLFRIEND OR FIANCEE A
OTHER FRIEND B
CASUAL ACQUAINTANCE C
COMMERCIAL SEX WORKER D
RELATIVE E
OTHER (SPECIFY) X

313C. In the last 1 year, with how many women did you have sexual intercourse other than your wife?

NUMBER ___

313D. CHECK 313B:

MULTIPLE CODES CIRCLED (GO TO 314A)
ONLY ONE CODE CIRCLED (GO TO 315)

314A. Beside your wife, with whom (among those mentioned in question 313B) did you have last sexual intercourse?

GIRLFRIEND OR FIANCEE A
OTHER FRIEND B
CASUAL ACQUAINTANCE C
COMMERCIAL SEX WORKER D
RELATIVE E
OTHER (SPECIFY) X

314B. The last time you had sexual intercourse with (mentioned in 314A), did you use a condom?

YES 1 (GO TO 315A)
NO 2 (GO TO 315B)

315. The last time you had sexual intercourse with (mentioned in 313B), did you use a condom?

YES 1
NO 2 (GO TO 315B)

315A. Why did you use a condom?

TO PREVENT STD A
TO PREVENT PREGNANCY B
OTHER (SPECIFY) X

315B. CHECK 106:

RESPONSE GIVE (LIVED OUTSIDE IN LAST 1 YEAR) (GO TO 315C)
DID NOT GIVE ANY ANSWER (DID NOT LIVE OUTSIDE IN LAST 1 YEAR) (GO TO 317)

315C. In the last 1 year, did you have sexual intercourse with any woman other than your wife while traveling outside your home community?

YES 1
NO 2 (GO TO 317)

315D. Did you have this sexual intercourse inside Bangladesh or outside Bangladesh?

INSIDE BANGLADESH A
OUTSIDE BANGLADESH B

315E. INTERVIEWER: CHECK 315D IF CODE ?A? CIRCLED THEN ASK, OTHERWISE SKIP TO 315F.

In the last 1 year with whom did you have sexual intercourse other than your wife while traveling inside Bangladesh? Any other?

GIRLFRIEND OR FIANCEE A
OTHER FRIEND B
CASUAL ACQUAINTANCE C
COMMERCIAL SEX WORKER D
RELATIVE E
OTHER (SPECIFY) X

315EA. Beside you wife, with how many women did you have sexual intercourse in the last 1 year?

NUMBER ___

315EB. The last time you had sexual intercourse with (among those mentioned in 315EA), did you use a condom?

YES 1
NO 2 (GO TO 315F)

315EC. Why did you use a condom?

TO PREVENT STD A
TO PREVENT PREGNANCY B
OTHER (SPECIFY) X

315F. INTERVIEWER: CHECK 315 D IF CODE ?B? CIRCLED THAN ASK, OTHERWISE SKIP TO 317.

In the last 1 year, with whom did you have sexual intercourse other than your wife while traveling outside Bangladesh? Any other?

GIRLFRIEND OR FIANCEE A
OTHER FRIEND B
CASUAL ACQUAINTANCE C
COMMERCIAL SEX WORKER D
RELATIVE E
OTHER (SPECIFY) X

315FA. Beside you wife, with how many women did you have sexual intercourse in the last 1 year?

NUMBER ___

315FB. The last time you had sexual intercourse with (among those mentioned in 315FA), did you use a condom?

YES 1
NO 2 (GO TO 317)

315EC. Why did you use a condom?

TO PREVENT STD A (GO TO 317)
TO PREVENT PREGNANCY B (GO TO 317)
OTHER (SPECIFY) X (GO TO 317)

316A. Sometimes men have sexual urge and have sex before marriage. Have you ever had sex with any woman?

YES 1
NO 2 (GO TO 317)

316B. How old were you when you first had sexual intercourse?

AGE IN YEARS ___

316C. With whom did you have sexual intercourse? Any other?

GIRLFRIEND OR FIANCEE A
OTHER FRIEND B
CASUAL ACQUAINTANCE C
COMMERCIAL SEX WORKER D
RELATIVE E
OTHER (SPECIFY) X

316D. In the last 1 year, did you have sexual intercourse with any women?

YES 1
NO 2 (GO TO 317)

316E. With whom did you have sexual intercourse? Any other?

GIRLFRIEND OR FIANCEE A
OTHER FRIEND B
CASUAL ACQUAINTANCE C
COMMERCIAL SEX WORKER D
RELATIVE E
OTHER (SPECIFY) X

316EA. With how many women did you have sexual intercourse in the last 1 year?

NUMBER ___

316EB. CHECK 316E:

MULTIPLE CODES CIRCLED (GO TO 316F)
ONLY ONCE CODE CIRCLED (GO TO 316H)

316F. With whom (among those mentioned in question 316E) did you last have sexual intercourse?

GIRLFRIEND OR FIANCEE A
OTHER FRIEND B
CASUAL ACQUAINTANCE C
COMMERCIAL SEX WORKER D
RELATIVE E
OTHER (SPECIFY) X

316G. The last time you had sexual intercourse with (mentioned in 316F), did you use a condom?

YES 1 (GO TO 316I)
NO 2 (GO TO 316IA)

316H. The last time you had sexual intercourse with (mentioned in 316E), did you use a condom?

YES 1
NO 2 (GO TO 316IA)

316I. Why did you use a condom?

TO PREVENT STD A
TO PREVENT PREGNANCY B
OTHER (SPECIFY) X

316IA. CHECK 106:

RESPONSE GIVEN (LIVED OUTSIDE IN THE LAST 1 YEAR) (GO TO 316J)
DID NOT GIVE ANY RESPONSE (DID NOT LIVE OUTSIDE IN THE LAST 1 YEAR) (GO TO 317)

316J. In the last 1 year, did you have sexual intercourse with any women while traveling outside your home community?

YES 1
NO 2 (GO TO 317)

316K. Was this sexual intercourse inside Bangladesh or outside Bangladesh?

INSIDE BANGLADESH A
OUTSIDE BANGLADESH B

316L. INTERVIEWER: CHECK 316K: IF CODE ?A? CIRCLED THEN ASK, OTHERWISE SKIP TO 317.

With whom did you have sexual intercourse? Any other?

GIRLFRIEND OR FIANCEE A
OTHER FRIEND B
CASUAL ACQUAINTANCE C
COMMERCIAL SEX WORKER D
RELATIVE E
OTHER (SPECIFY) X

316LA. With how many women did you have sexual intercourse in the last 1 year?

NUMBER ___

316LB. The last time you had sexual intercourse with (among those mentioned in 316LA), did you use a condom?

YES 1
NO 2 (GO TO 316M)

316LC. Why did you use a condom?

TO PREVENT STD A
TO PREVENT PREGNANCY B
OTHER (SPECIFY) X

316M. INTERVIEWER: CHECK 316K: IF CODE ?B? CIRCLED THEN ASK, OTHERWISE SKIP TO 317

With whom did you have sexual intercourse? Any other?

GIRLFRIEND OR FIANCEE A
OTHER FRIEND B
CASUAL ACQUAINTANCE C
COMMERCIAL SEX WORKER D
RELATIVE E
OTHER (SPECIFY) X

316MA. INTERVIEWER: CHECK 316K: IF CODE ?B? CIRCLED THEN ASK, OTHERWISE SKIP TO 317

With how many women did you have sexual intercourse in the last 1 year?

NUMBER ___

316MB. The last time you had sexual intercourse with (among those mentioned in 316MA), did you use a condom?

YES 1
NO 2 (GO TO 317)

316MC. Why did you use a condom?

TO PREVENT STD A
TO PREVENT PREGNANCY B
OTHER (SPECIFY) X

317. Sometimes, some men desire sexual pleasure from persons other than women. Have you ever had sex with any boys or men or transgender (hizra)?

YES, WITH MAN OR BOYS 1
YES, WITH A TRANSGENDER 2
YES, BOTH 3
NONE 4 (GO TO 321)

318. In the last 1 year, did you have such sex?

YES, WITH MAN OR BOYS 1
YES, WITH A TRANSGENDER 2
YES, BOTH 3
NONE 4

319. The last time you had such sexual intercourse, did you or your partner use a condom?

YES 1
NO 2 (GO TO 321)

320. Why did you use condom?

TO PREVENT STD A
OTHER (SPECIFY) X

321. Do you know of a place where you can obtain a condom?

YES 1
NO 2 (GO TO 401)

322. Where is that?

IF MAN SAYS MORE THAN ONCE PLACE ASK FOR THE PLACE HE WOULD MOST LIKELY USE.

PUBLIC SECTOR
HOSPITAL OR MEDICAL COLLEGE 11
FAMILY WELFARE CENTRE 12
UPAZILA HEALTH COMPLEX 13
SATELLITE CLINIC OR EPI OUTREACH SITE 14
MATERNAL CHILD WELFARE CENTER (MCWC) 15
GOVERNMENT FIELD WORKER (FWA) 16
COMMUNITY CLINIC 17
NGO SECTOR
NGO STATIC CLINIC 21
NGO SATELLITE CLINIC 22
NGO DEPOT HOLDER 23
NGO FIELDWORKER 24
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL OR CLINIC 31
QUALIFIED DOCTOR 32
TRADITIONAL DOCTOR 33
PHARMACY 34
OTHER PRIVATE SECTOR
SHOP 41
FRIEND OR RELATIVES 42
OTHER (SPECIFY) 96
DON?T KNOW 98

SECTION 4. PARTICIPATION IN HEALTH CARE

Now, I would like to ask you some questions about the participation in healthcare.

401. ASK QUESTIONS SEPARATELY FOR PREGNANCY, DELIVERY AND AFTER DELIVERY BUT RECORD RESPONSES IN SAME CODING CATEGORY.

What are the problems at the time of pregnancy that may cause death to the mother? Any other?

What are the problems at the time of delivery that may cause death to the mother? Any other?

What are the problems after the delivery that may cause death to the mother? Any other?

RECORD ALL MENTIONED.

SEVERE HEADACHE A
BLURRY VISION B
HIGH BLOOD PRESSURE C
PRE-ECLAMSIA D
CONVULSION OR ECLAMSIA E
EXCESSIVE VAGINAL BLEEDING F
FOUL-SMELLING DISCHARGE WITH HIGH FEVER G
JAUNDICE H
TETANUS I
BABY?S HAND OR FEE COME OR BABY IN BAD POSITION J
PROLONG LABOR K
OBSTRUCTED LABOR L
RETAINED PLACENTA M
TORNED UTEROUS N
OTHER (SPECIFY) X
DON?T KNOW Z

402. Do you think that women should have a medical checkup when they are pregnant even if they are not sick?

YES 1
NO 2 (GO TO 404)
DON?T KNOW 8 (GO TO 404)

403. At what months of pregnancy di you think that women should have first checkup for pregnancy?

MONTH ___
DON?T KNOW 98

404. During the pregnancy do you think women should eat more, same or less?

MORE 1
SAME 2
LESS 3
DON?T KNOW 8

405A. In what year was your last child born?

YEAR ___
UNMARRIED OR NO CHILDREN BORN 9996 (GO TO 419B)

405B. CHECK 405A:

CHILD BORN 1998 OR LATER (GO TO 406)
CHILD BORN 1997 OR EARLIER (GO TO 418B)

406. What is the name of your last born child?

NAME OF LAST CHILD ___

407. Did your wife go to a health facility to receive antenatal care when she was pregnant with (NAME OF LAST BORN CHILD)?

YES 1 (GO TO 409)
NO 2
DON?T KNOW 8

408. Did any health professional such as doctor, nurse, FWV or other come for your wife?s antenatal care when she was pregnant with (NAME OF LAST BORN CHILD)?

YES 1
NO 2 (GO TO 412)

409. Were you present anytime during the antenatal care visit?

YES 1
NO 2

410. At any time while she was pregnant with (NAME OF LAST BORN CHILD), did any health professional such as doctor, nurse, or FWV talk to you about this particular pregnancy?

YES 1
NO 2

411. During this pregnancy, did you ever talk with your wife about what the health professional such as doctor, nurse, or FWV told her about her own health or the baby?s health?

YES 1
NO 2

412. Where did you wife give birth to (NAME OF LAST BORN CHILD)?

HOME
OWN HOME 11
OTHER HOME 12
PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
UPAZILA HEALTH COMPLEX 22
MATERNAL AND CHILD WELFARE CENTER (MCWC) 23
NGO SECTOR
NGO STATIC CLINIC 31
PRIVATE SECTOR
PRIVATE HOSPITAL OR CLINIC 41
OTHER (SPECIFY) 96

413. When she gave birth to (NAME OF LAST BORN CHILD), were you present (NAM OF THE PLACE IN 412) at that time?

YES 1
NO 2

414. In the first two months after (NAME OF LAST BORN CHILD) was born, did your wife visit a health facility to have her own health or the child?s health check or did someone such as doctor, nurse or FWV from the health facility come to your place to check your wife?s or child?s health?

YES, VISITED 1
YES, CAME TO THEIR PLACE 2
NO 8 (GO TO 416)

415. Were you present at that time?

YES 1
NO 2

416. Where is your last child (alive or dead)?

ALIVE 1
DEAD 2 (GO TO 418B)

417. Did (NAME OF LAST BORN CHILD) ever receive any vaccinations to prevent him or her from getting diseases?

YES 1
NO 2 (GO TO 418B)
DON?T KNOW 8 (GO TO 418B)

418A. When (NAME OF LAST BORN CHILD) was vaccinated in a health facility, did you take him or her anytime to the health facility?

YES 1
NO 2

418B. How many living children do you have?

NUMBER ___

419A. CHECK 418B: 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 any would that be?

419B. 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 501)

420. 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?

NUMBER OF BOYS ___
NUMBER OF GIRLS ___
EITHER ___
OTHER (SPECIFY) 96

SECTION 5. AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES

501. Now I would like to talk about something else. Have you ever heard of an illness called AIDS?

YES 1
NO 2 (GO TO 509A)

502. From which sources of information have you learned most about AIDS? Any other sources?

RECORD ALL MENTIONED.

RADIO A
TV B
NEWSPAPER OR MAGAZINES C
PAMPHLETS OR POSTERS D
HEALTH WORKERS E
MOSQUES OR TEMPLES OR CHURCHES F
SCHOOLS OR TEACHERS G
COMMUNITY MEETINGS H
FRIENDS OR RELATIVES I
WORK PLACE J
BILL BOARD OR SIGN BOARD K
OTHER (SPECIFY) X

503. Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?

YES 1
NO 2 (GO TO 505)
DON?T KNOW 8 (GO TO 505)

504. What can a person do? Anything else?

RECORD ALL MENTIONED.

ABSTAIN FROM SEX A
USE CONDOMS B
LIMIT SEX WITHIN MARRIAGE C
LIMIT SEX WITH TRUSTED PARTNER D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS F
AVOID SEX WIT HOMOSEXUALS G
AVOID SEX WITH PERSONS WHO INJECT DRUGS INTRAVENOUSLY H
AVOID UNSAFE BLOOD TRANSFUSIONS I
AVOID UNSTERILIZED NEEDLE OR SYRINGE J
AVOID KISSING K
AVOID MOSQUITO BITES L
SEEK PROTECTION FROM TRADITIONAL HEALER M
AVOID SHARING RAZORS OR BLADES N
AVOID SEX WITH OTHER WOMEN O
OTHER (SPECIFY) W
OTHER (SPECIFY) X
DON?T KNOW Z

505. Is it possible for a healthy-looking person to have the AIDS virus?

YES 1
NO 2
DON?T KNOW 8

506. Can the virus that causes AIDS be transmitted from a mother to a child?

YES 1
NO 2
DON?T KNOW 8

507. CHECK 301:

YES CURRENTLY MARRIED (GO TO 508)
NOT CURRENTLY MARRIED (GO TO 509A)

508. Have you ever talked with your wife about ways to prevent getting the virus that causes AIDS?

YES 1
NO 2

509A. (Apart from AIDS), have you heard about (other) infection or disease that can be transmitted through sexual contact?

YES 1 (GO TO 510)
NO 2

509B. Have you heard about ___?

A. Syphilis?
YES 1
NO 2
B. Gonorrhea?
YES 1
NO 2

509C. CHECK 509B:

AT LEAST ONE ?YES? (GO TO 510)
NOT A SINGLE ?YES? (GO TO 514)

510. In a man, what signs and symptoms would lead you to think that he has diseases such as STD or syphilis or gonorrhea? Any others?

RECORD ALL MENTIONED.

LOWER ABDOMINAL PAIN A
DISCHARGE FROM PENIS OR DRIPPING B
FOUL SMELLING DISCHARGE C
BURNING PAIN ON URINATION D
REDNESS OR INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES OR ULCERS G
GENITAL WARTS H
BLOOD IN URINE I
LOS OF WEIGHT J
IMPOTENCE K
NO SYMPTOMS L
OTHER (SPECIFY) W
OTHER (SPECIFY X
DON?T KNOW Z

511. In a woman, what signs and symptoms would lead you to think that she has such a disease STD or syphilis or gonorrhea? Any others?

RECORD ALL MENTIONED.

LOWER ABDOMINAL PAIN A
GENITAL DISCHARGE B
FOUL SMELLING DISCHARGE C
BURNING PAIN ON URINATION D
REDNESS OR INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES OR ULCERS G
GENITAL WARTS H
BLOOD IN URINE I
LOS OF WEIGHT J
INABILITY TO GIVE BIRTH K
NO SYMPTOMS L
OTHER (SPECIFY) W
OTHER (SPECIFY X
DON?T KNOW Z

513. Now I would like to ask you some questions about your health in the last 1 year. During the last 1 year, have you had a sexually transmitted disease?

YES 1
NO 2
DON?T KNOW 8

514. During the last 1 year, have you had a discharge from your penis?

YES 1
NO 2
DON?T KNOW 8

515. Sometimes, men experience a sore or ulcer on or near their penis. During the last 1 year, have you had a sore or ulcer on or near your penis?

YES 1
NO 2
DON?T KNOW 8

516. During the last 1 year, have you had pain or burning sensation during urination?

YES 1
NO 2
DON?T KNOW 8

517. CHECK 513, 514, 515, OR 516:

AT LEAST ONE ?YES? (GO TO 518)
NOT A SINGLE ?YES? (GO TO 521)

518. The last time you had (INFECTION OR DISEASE FROM 513, 514, 515, OR 516), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 520)

519. The last time you had (INFECTION OR DISEASE FROM 513, 514, 515, OR 516), did you do any of the following? Did you

Seek advice from a health professional such as doctor, nurse in a clinic or hospital?
YES 1
NO 2
Seek advice or medicine from a traditional healer?
YES 1
NO 2
Seek advice or buy medicines in a shop or pharmacy?
YES 1
NO 2
Seek treatment from a homeopath doctor?
YES 1
NO 2
Ask for advice from friends or relatives?
YES 1
NO 2

520. CHECK 301:

CURRENTLY MARRIED (GO TO 320A)
CURRENTLY NOT MARRIED (GO TO 520B)

520A. The last time when you had (INFECTION OR DISEASE FROM 513, 514, 515, OR 516), did you inform your wife?

YES 1
NO 2
SOME OR NOT ALL 3

520B. The last time when you had (INFECTION OR DISEASE FROM 513, 514, 515, OR 516), did you have sex with anyone?

YES 1
NO 2 (GO TO 521)

520C. The last time when you had infection and had sexual intercourse with someone, did you use condom?

YES 1
NO 2 (GO TO 521)

520D. As long as you had the infection, did you use condom every time you had sexual intercourse or did you use condom occasionally?

AS LONG AS INFECTION 1
OCCASIONALLY 2

520E. The last time why did you use condom?

PREVENT STD A (GO TO 601)
TO PREVENT PREGNANCY B (GO TO 601)
OTHER (SPECIFY) (GO TO 601)

521. If a woman?s husband has a sexually transmitted disease, would it be acceptable for her to ask him to use a condom?

YES 1
NO 2
DOES NOT KNOW 8

521A. If a woman?s husband has a sexually transmitted disease, would it be acceptable for her to refuse to have sex with him?

YES 1
NO 2
DOES NOT KNOW 8

SECTION 6. ATTITUDES TOWARD WOMEN AND DOMESTIC VIOLENCE

Now I would like to ask you a few questions regarding men and women in couples. People have many different opinions on this subject and we would like to know what it is that you think about it.

601. If the husband is making enough money, do you believe that it is acceptable for married women to work outside the home to earn and income?

YES 1
NO 2
DON?T KNOW 8

602. If for some reason the husband cannot make enough money for the family, do you believe that it is acceptable for married women to work outside the home to earn an income?

YES 1
NO 2
DON?T KNOW 8

603. CHECK 301:

YES CURRENTLY MARRIED (GO TO 606)
NOT CURRENTLY MARRIED (GO TO 612)

606. Do you take your wife?s opinion on:

A. Large household expenses, that require a lot of money?
YES 1
NO 2
NO OPINION 8
B. Minor daily household expenses?
YES 1
NO 2
NO OPINION 8
C. When you wish to visit family, friends, or relatives?
YES 1
NO 2
NO OPINION 8

606A. Does your wife own cash in her work?

YES 1
NO 2 (GO TO 607)

606B. Who mainly decides how to spend the money that your own wife earn?

RESPONDENT 1
WIFE 2
HUSBAND AND WIFE TOGETHER 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE 5

607. It is normal to have quarrels and disagreements. During those quarrels some husbands occasionally severely reprimand or even beat their wives. In your opinion, do you think a man would be justified to beat his wife:

If she neglects the children?
YES 1
NO 2
NO OPINION 8
If she argues with her husband?
YES 1
NO 2
NO OPINION 8
If she fails to provide food on time?
YES 1
NO 2
NO OPINION 8
If she visits family or friend without her husband?s permission?
YES 1
NO 2
NO OPINION 8

610. Anytime, were there any circumstances or family disagreement which caused you to do?

A. Pushing or shaking your wife, or throwing something at her?
YES 1
NO 2
B. Slap her or twisting her arm?
YES 1
NO 2
C. Punching her with your fist or with something that could hurt her?
YES 1
NO 2
D. Kicking her or dragging her?
YES 1
NO 2
E. Trying to strangle her or kill her or by burning her?
YES 1
NO 2
H. Physically forcing her to have sexual intercourse with her even when she did not want to?
YES 1
NO 2

611. In the last 1 year, were there any circumstances or family disagreement which caused you to do any of the following?

A. Pushing or shaking your wife, or throwing something at her?
YES 1
NO 2
B. Slap her or twisting her arm?
YES 1
NO 2
C. Punching her with your fist or with something that could hurt her?
YES 1
NO 2
D. Kicking her or dragging her?
YES 1
NO 2
E. Trying to strangle her or kill her or by burning her?
YES 1
NO 2
H. Physically forcing her to have sexual intercourse with her even when she did not want to?
YES 1
NO 2

612. Now I would like to ask you a very personal question. Some people take such things as Ganja, Charas, Phensidle, Pethedine, Heroin, Morphine etc. I would like to know if you have any such habits. The information you provide shall be kept confidential and be used only for research purposes like the other information.

In the last 3 months, have you taken:

Ganja?
YES 1
NO 2
Charas?
YES 1
NO 2
Phensidle?
YES 1
NO 2
Pethedine?
YES 1
NO 2
Heroin?
YES 1
NO 2
Morphine?
YES 1
NO 2
Any injectable drug?
YES 1
NO 2
Other (specify)?
YES 1
NO 2

613. RECORD THE TIME.

HOUR ___
MINUTES ___

INTERVIEWER?S OBSERVATIONS

(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