Final Version

Identification

Department
Commune

Urban/rural

Name of head of household
Cluster number
Household number
Name and line number of woman

Household selected for men's survey? (1=Yes, 2=No)

Interviewer visits
1 2 3
Date

Interviewer's name
Result*

Final visit
Day
Month
Year 201
Int. number
Result

Next visit
Date
Time

Total no. of visits

* Result codes

Language of questionnaire 01
Language of interview
Native language of respondent

Translator used (yes=1, no=2)

Language of questionnaire: French

Language codes:

Supervisor
Name
Date

Editor
Name
Number

Introduction and consent

Hello. My name is ___. I am working with the National Institute of Statistics and Economic Analysis (INSAE). We are conducting a survey about health all over Benin. 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 to 30 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?

Signature of interviewer Date
Respondent agrees to be interviewed 1
Respondent does not agree to be interviewed 2-End

Section 1. Respondent's background

No.
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101) Record the time

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

103) Just before you moved here, did you live in a city, in a town, or in a rural area?

104) Before you moved here, which (province/region/state) did you live in?

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.

106b) Check 106:

106c) During this interview I would like to measure your blood pressure. I will do this three times during the interview. There is no danger to the procedure. We do it to know if a person has high blood pressure. If it isn't treated, high blood pressure can seriously hurt the heart.

I will give you the results of the blood pressure measurement after the interview and explain to you the meaning of the results. If you have high blood pressure, we recommend that you consult a health care facility or see a doctor because we cannot offer any treatment as part of the survey.

Do you have any questions to ask me about blood pressure measurement?

106d) Before measuring your blood pressure, I would like to ask you some questions on things that could affect the measurements. Did you do any of the following things in the last 30 minutes:

106e) Look at the respondent's arm and take the appropriate armband to take blood pressure

106f) Take the blood pressure
Record the systolic and diastolic pressure

If you can't measure the respondent's blood pressure, record the reason.

107) Have you ever attended school?

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

109) What is the highest grade 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?

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?

123) What is your ethnicity?

123b) Check 106:

123c) Can I measure your blood pressure now?

123d) Take blood pressure.
Record systolic and diastolic pressure.
If you cannot measure the respondent's blood pressure, record the reason.

Codes for Q 108 and 109: Education
Level attainted
Class successfully achieved

Section 2. Reproduction

No.
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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 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, recode '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:

Has had only one child:

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.
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.

Section 4. Marriage and sexual activity

No.
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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:

More than one wife/partner:

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) Ask 408 for each person.
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?

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.

Last sexual partner

Second-to-last sexual partner

Third-to-last sexual partner

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

417) The last time you had sexual intercourse this 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 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 420 (all columns):

426) Check 419 and 417 (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):

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
(Name of 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
No.
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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:

Has not fathered children:

514) Check 203 and 205:
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 it not matter if it's a boy or a girl?

Section 6. Employment and gender roles

No.
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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 vacation, illness, maternity, 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
No.
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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.

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
(Name of 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?

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- Apart from HIV, have you heard about other infections that can be transmitted through sexual contact?

Not heard about HIV or AIDS- Have you heard about infections that can be transmitted through sexual contact?

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?

732) 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
(Name of place(s))

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 a woman other than his wives?

Section 8. Other health issues

No.
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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 daily for 3 months or more, 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."

All skip to 813

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."

All skip 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 report using the product but not every week, record "888." If the product is not used at all, record "000."

816) Are you covered by any health insurance?

817) What type of health insurance are you covered by?
Record all mentioned

817a) Is there are charge for the caring of children under 5 with malaria in Benin?

817b) Do women have to pay for a cesarean in Benin?

817b) Check 106

817c) Can I measure your blood pressure now?

817d) Take blood pressure
Record systolic and diastolic pressure
If you cannot measure the respondent's blood pressure, record the reason

Section 9. Non-communicable diseases for women's questionnaire

No.
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901) Has a doctor or other health care professional taken your blood pressure?

902) Has a doctor or other health care professional told you that you have elevated or high blood pressures?

903) In the last 12 months, has a doctor or other health care professional that you have elevated or high blood pressure?

904) Has a doctor or other health care professional prescribed drugs to control your blood pressure?

905) Are you currently taking drugs to control your blood pressure?

906) Has a doctor or other health care professional measured the level of sugar in your blood?

907) Has a doctor or other health care professional told you that you have high levels of sugar in your blood, or that you have diabetes?

908) In the last 12 months, has a doctor or other health care professional told you that you have high levels of sugar in your blood, or that you have diabetes?

909) Has a doctor or other health care professional prescribed drugs to control the levels of sugar in your blood or to control diabetes?

910) Are you currently taking drugs to control the level of sugar in your blood or to control diabetes?

911) Has a doctor or other health care professional told you that you have heart disease or a chronic heart problem?

912) Are you currently in treatment for heart disease or a chronic heart problem?

913) Has a doctor or other health care professional told you that you have a pulmonary illness or a chronic pulmonary problem like asthma?

914) Are you currently undergoing treatment for a pulmonary illness or a chronic pulmonary problem?

915) Has a doctor or other health care professional told you that you have cancer or a tumor?

916) Are you currently undergoing treatment for cancer or a tumor?

917) Has a doctor or other health care professional told you have depression?

918) Are you currently undergoing treatment for depression?

919) Has a doctor or other health care professional told you that have arthritis?

920) Are you currently undergoing treatment for arthritis?

921) Has a doctor or other health care professional told you that you have another chronic illness, meaning an illness that lasts a long time?

922) Are you currently undergoing treatment for (chronic illness from 921)?

931) Check Q123D and 817D:

932) Record and calculate the average systolic and diastolic blood pressure from Q123D and 817D.

933) Blood pressure measurement from Q123D

934) Blood pressure measurement form 817D

935) Total of Q933 + Q934

936) Divide Q935 by 2

937) Check 123d

938) Check 817D

939) Check 106f

940) Record the systolic and diastolic blood pressure

941) Use the table below to determine the correct code to record the report on blood pressure and the reference form.

Circle the line where you find the value of the systolic pressure from Q936 or Q940.

Next, circle the column with the value of the diastolic pressure from Q936 or Q940.

The value found at the intersection of the line and the column circled in the table should be used to compete Q942.

942) In the table below, record the number that you circled in Q941. Next use the instructions to the right of this number to complete the report on blood pressure and the reference form for the respondent. Give the respondent the formula and answer any questions.

Category of blood pressure for respondent/Consult a health care professional to check blood pressure in:

###) 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