IDENTIFICATION

PLACE NAME _____
CLUSTER NUMBER _____
PLOT NUMBER _____
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD ______
HOUSEHOLD NUMBER ______
REGION _____

URBAN/RURAL:

MILIEU:

NAME AND LINE NUMBER OF MAN ______

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ____
INTERVIEWER'S NAME _____

RESULT _____

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR 2010
INTERVIEWER CODE _____
RESULT _____

TOTAL NUMBER OF VISITS _____

LANGUAGE OF QUESTIONNAIRE: FRENCH 01

LANGUAGE OF INTERVIEW:

INTERPRETER:

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____

KEYED BY _____

SECTION 1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENT

INTRODUCTION AND CONSENT:

INFORMED CONSENT:

Hello. My name is _____. I am working with the National Institute of Statistics and Demography (INSD). We are conducting a survey about health all over Burkina Faso. 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 participate 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 _____

101. RECORD THE TIME:

102. In what month and year were you born?

103. How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

104. Have you ever attended school?

105. What is the highest level of school you attended: primary, secondary 1 (1st cycle), secondary 2 (2nd cycle), or higher?

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

107. CHECK 105:

108. 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?

109. CHECK 108:

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

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

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

113. What is your religion?

114. What is your ethnicity (for Burkinabés)/ your nationality (for foreigners)?

115. In the last 12 months, how many times have you been away from home for one or more nights?

116. In the last 12 months, have you been away from home for more than one month at a time?

SECTION 2. REPRODUCTION

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.

201. Have you ever fathered any children with any woman?

202. Do you have any sons or daughters that you have fathered and 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 or showed signs of life but did not survive?

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. In all, how many women have you fathered children with?

212. How old were you when your (first) child was born?

213. CHECK 203 AND 205:

214. How old is your (youngest) child?

215. CHECK 214:

216. What is the name of your (youngest) child?
WRITE NAME OF (YOUNGEST) CHILD.

217. When (NAME)'s mother was pregnant with (NAME), did she have any antenatal check-ups?

218. Were you ever present during any of those antenatal check-ups?

219. Was (NAME) born in a hospital or a health facility?

220. 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

Heard about family planning on the radio?
Heard about family planning on the television?
Read about family planning in a newspaper or magazine?

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

Now I would like to ask you about a woman's risk of pregnancy.

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

a) Contraception is a woman's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous.

307. CHECK 301 (07):
KNOWS MALE CONDOM?

308. Do you know a place where a person can get condoms?

309. 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.

310. If you wanted, could you yourself get a condom?

311. CHECK 301 (08):
KNOWS FEMALE CONDOM?

312. Do you know of a place where a person can get female condoms?

313. 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.

314. 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'.

408. How old was (NAME) on her last birthday?
[ASK FOR ALL OF RESPONDENT'S WIVES/LIVE-IN PARTNERS]

409. CHECK 407:

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

411. In what month and year did you start living with your (wife/partner)?
411A. Now we are going to talk about your first (wife/partner). In what month and year did you start living with her?

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.

Now I would like to ask some questions about sexual activity in order to gain a better understanding of some important life issues.

414. 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. 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.

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.

[ASK QUESTIONS 417-427 FOR THE LAST (THREE) SEXUAL PARTNER(S) OF RESPONDENT]

417. When was the last time you had sexual intercourse with this person?
[DO NOT ASK FOR MOST RECENT SEXUAL PARTNER]

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

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

420. 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'.

421. CHECK 410:

422. CHECK 414:

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

424. How many times during the last 12 months did you have sexual intercourse with this person?

425. How old is this person?

426. Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?
[DO NOT ASK FOR THIRD-TO-LAST SEXUAL PARTNER]

427. 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'.
[ASK ONLY FOR THIRD-TO-LAST PARTNER]

428. CHECK 420 (ALL COLUMNS):

429. CHECK 420 AND 418 (ALL COLUMNS):

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

431. Have you ever paid anyone in exchange for having sexual intercourse?

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

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

434. 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, RECORD '95'.

435. CHECK 418:
MOST RECENT PARTNER (FIRST COLUMN):

436. 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.

437. 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.

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?

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.

SECTION 5. FERTILITY PREFERENCES

501. CHECK 401:

502. CHECK 439:

503. Is your (wife/partner)/Are any of your (wives/partners) currently pregnant?

Now I have some questions about the future.

504. After the (child/children) you and your (wife(wives)/partner(s)) are expecting now, would you like to have another child, or would you prefer not to have any more children?

505. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

506. CHECK 407:

507. CHECK 503:

WIFE/PARTNER NOT PREGNANT OR DOESN'T KNOW: How long would you like to wait from now before the birth of (a/another) child?

WIFE/PARTNER PREGNANT: After the birth of the child you are expecting now, how long would you wait before the birth of another child?

508. How long would you like to wait from now before the birth of (a/another) child?

509. CHECK 203 AND 205:

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.

510. 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, maternity leave, 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 own any land either alone or jointly with someone else?

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

If she goes out without telling him?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

SECTION 7. HIV/AIDS

Now I would like to talk about something else.

701. Have you ever heard of an illness called AIDS?

702. 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 the AIDS virus by using a condom every time they have sex?

705. Can people get the AIDS virus by sharing food with a person who has AIDS?

706. Can people get the AIDS virus because of witchcraft or other supernatural means?

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

708. Can the virus that causes AIDS be transmitted from a mother to a child:

During pregnancy?
During delivery?
By breastfeeding?

709. CHECK 708:

710. 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?

711. CHECK FOR 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 to see if you have the AIDS virus?

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 tested for the AIDS virus?

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. Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?

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

720. 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. 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?

722. Should children age 12-14 be taught about using a condom to avoid getting AIDS?

723. CHECK 701:

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?

724. CHECK 414:

725. CHECK 723:
HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

Now I would like to ask you some questions about your health in the last 12 months.

726. During the last 12 months, have you had a disease which you got through sexual contact?

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

728. 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?

729. CHECK 726, 727, AND 728:

730. The last time you had (INFECTION FROM 726/727/728), did you seek any kind of advice or treatment?

731. 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.

732. 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?

733. 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

801. Some men are circumcised, that is, the foreskin is completely removed from the penis. Are you circumcised?

802. How old were you when you got circumcised?

803. Who did the circumcision?

804. Where was it done?

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 cigarettes?

809. In the last 24 hours, how many cigarettes did you smoke?

810. Do you currently smoke or use any (other) type of tobacco?

811. What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.

812. Are you covered by any health insurance?

813. What type of health insurance are you covered by?
RECORD ALL MENTIONED.

814. Have you ever heard of female circumcision?

815. 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?

816. Do you believe that female circumcision is required by your religion?

817. Do you think that female circumcision should be continued, or should it be stopped?

818. 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 _____
NAME _____
DATE _____

EDITOR'S OBSERVATIONS _____
NAME _____
DATE _____