REPUBLIC OF CAMEROON
PEACE WORK FATHERLAND
NATIONAL INSTITUTE OF STATISTICS

IDENTIFICATION

LOCALITY NAME: ___
NAME OF HEAD OF HOUSEHOLD: ___
REGION: ___
CLUSTER NUMBER: ___
STRUCTURE NUMBER: ___
HOUSEHOLD NUMBER: ___
NAME AND LINE NUMBER OF MAN: ___

CHECK HOUSEHOLD QUESTIONNAIRE:
CHECK 109 OF HOUSEHOLD QUESTIONNAIRE: HAS THIS MAN BEEN SELECTED FOR THE SECTION 'RELATIONS IN THE HOUSEHOLD'?

INTERVIEWER'S VISITS:

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___

RESULTS:

NEXT VISIT:

DATE ___
HOUR ___
NUMBER OF TOTAL VISITS ___

FINAL VISIT:

DAY: ___
MONTH: ___
YEAR: ___
SURVEY NUMBER: ___

RESULTS:

SURVEY LANGUAGE:

LANGUAGE OF INTERVIEW:

INTERPRETER:

FIELD EDITED BY:
NAME ___
DATE ___

SUPERVISOR:
NAME ___
DATE ___

OFFICE EDITED BY:
NAME ___

KEYED BY:
NAME ___

SECTION 1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENT

INTRODUCTION AND CONSENT

INFORMED CONSENT:

Hello. My name is ___ and I am working with the National Institute of Statistics. We are conducting a national survey during which we are asking women and men questions about problems related to health. 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 30 and 60 minutes to complete. Whatever information you provide will be kept strictly confidential, will not be shown to other persons, and will only be used for research purposes.
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?

INTERVIEWER SIGNATURE: ___
DATE: ___

101) RECORD TIME

102) In what month and year were you born?

103) How old were you on your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

IF AGE IS LESS THAN 15 YEARS OR OLDER THAN 59 YEARS, END INTERVIEW.

104) Have you gone to school?

105) What is the highest level of study you have attained: Primary, secondary (1st cycle), secondary (2nd cycle) or higher?

106) What is the last class/year that you finished successfully at this level?

107) CHECK 105:

108) Now, I would like you to read aloud this sentence to me.

SHOW CARD TO RESPONDENT.

IF RESPONDENT CAN NOT READ THE WHOLE SENTENCE, PROBE: Can you read a portion of this sentence?

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

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

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

112) What is your religion?

113) What is your ethnicity?

RECORD THE NAME OF THE ETHNICITY. LEAVE THE CODIFICATION EMPTY.

FOR FOREIGNERS, RECORD 'FOREIGNER'.

114) In the past 12 months, how many times have you traveled outside of your community and slept somewhere other than your household?

115) In the past 12 months, have you been away from home for a month or more?

SECTION 2. REPRODUCTION

201) Now I'd like to ask you some questions about all the children you've have in your life I am interested in all of your biological children, even if they are not legally yours or if they do not have your name.

Do you have or have you had any children?

202) Do you have sons or daughters currently living with you?

203) How many sons live with you?
And how many daughters?

IF NONE, ENTER '00'.

204) Have you fathered any sons or daughters who are still living but do not currently live with you?

205) How many sons are alive but not living with you?
And how many daughters?

IF NONE, ENTER '00'.

206) Have you had a son or daughter who was born alive but later died?

IF NO, PROBE: Any child who cried or showed signs of life but did not survive?

207) How many boys have died?
And how many girls?

IF NONE, ENTER '00'.

208) ADD THE RESPONSES FROM 203, 205, AND 207 AND RECORD THE TOTAL:

IF NONE, RECORD '00'.

209) CHECK 208:

210) Are all of your children from the same biological mother?

211) In all, with how many women have you had children?

212) Is your wife/the woman you live with aware that you have children with other women?

SECTION 3. CONTRACEPTION

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)?

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

402) Have you ever been married or have you ever lived with a woman?

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

404) Does your wife/partner live with you now, or is she elsewhere?

405) Do you live with more than one wife or woman as if married?

406) In all, how many wives/partners do you have?

407) CHECK 405:

ONE WIFE/PARTNER:
Please tell me your wife/(live-in partner)'s name.

MORE THAN ONE WIFE/PARTNER:
Please tell me each of your wives/(live in partner)'s names.

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

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

ASK 408 FOR EACH PERSON.

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

409) CHECK 407:

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

411) In what month and year did you start living with your wife/partner?

411A) Now, I would like to talk about your first wife/partner. 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, DO EVERYTHING YOU CAN TO ENSURE PRIVACY.

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

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

414A) Now I would like to ask you some questions about your recent sexual activity. Let me assure you 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 on to the next question.

419) 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.

(NOTE: QUESTIONS 421-428 IN TABLE FORMAT, ASK FOR EACH SEXUAL PARTNER STARTING WITH MOST RECENT.

421) (SKIP FOR MOST RECENT SEXUAL PARTNER) When did you last have sexual relations with this second (third) person?

422) The last time you had sex with this (second, third) person was a condom used?

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

424) 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'.

425) CHECK 410:

426) CHECK 414:

427) When did you first have sexual relations with this person?

427A) In the last 12 months, how many times did you have sexual relations with this person?

IF THE NUMBER OF TIMES IS GREATER THAN 95, RECORD '95'.

427B) How old is this person?

428) Apart from this person/these people have you had sexual intercourse with any other person in the past 12 months?

429) 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'.

430) CHECK 424 (ALL COLUMNS):

431) CHECK 424 AND 422 (ALL COLUMNS):

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

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

434) In the last 12 months, did you use a condom every time you paid someone in exchange for sexual intercourse?

435) In all, how many different people have you had sexual relations with in your whole life?

IF RESPONSE IS NON NUMERIC, PROBE FOR AN ESTIMATE.

IF THE NUMBER IS GREATER THAN 95, RECORD '95'.

436) Do you know of a place where you can get condoms?

437) Where is that?

Any other place?

PROBE TO DETERMINE EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).

IF YOU CAN NOT DETERMINE IF THE HOSPITAL, HEALTH CENTER OR THE CLINIC IS A PUBLIC OR PRIVATE PROPERTY, WRITE THE NAME OF THE PLACE.

438) If you wanted one, could you yourself get a condom?

SECTION 5. FERTILITY PREFERENCES

501) CHECK 407:

503) Is your wife (partner)/one of your wives/partners currently pregnant?

504) CHECK 503:

NO WIFE/PARTNER PREGNANT OR DOES NOT KNOW:
Now I have some questions about the future. Would you like to have (a/nother) child or would you prefer not have any (more) children?

WIFE/WIVES/PARTNER(S) PREGNANT:
Now I have some questions about the future. After the child(ren) your wife/wives/partner(s) are expecting, would you like to have another child or would you prefer to not have any more children?

505) CHECK 407:

506) CHECK 503:

WIFE/PARTNER NON PREGNANT OR DOES NOT KNOW:
How much longer would you like to wait before you have (a/another) child?

WIFE/PARTNER PREGNANT:
After the birth of your next child, how much longer would you like to wait before you have (a/another) child?

507) How long would you like to wait from now until the birth of another child?

508) 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 the exact number of children to have in your whole life, how many would that be?

PROBE FOR A NUMERIC ANSWER.

509) 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 HOUSEHOLD RELATIONS

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

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

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

609) For this work, are you paid in cash or kind, or are you not paid at all?

610) CHECK 407:

611) CHECK 609:

612) Who normally decides how the money you earn will be used; you, your wife/wives/partner(s), or you and your wife/wives/partner(s) together?

613) In a couple, who, in your opinion, should have the last word about each of the following decisions: the husband, the wife, or both equally?

a) make major purchases for household?
b) make purchases for daily household needs?
c) decide visits to wife's family, friends or relatives?
d) decide how the money the wife earns will be spent?
e) decide how many children to have?

615) 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?

616) In your opinion, if a wife refuses to have sexual relations with her husband he has the right to:

a) Become angry and reprimand her?
b) Refuse to give her money or other financial support?
c) Resort to force and have sexual relations with her even if she does not want to?
d) Go elsewhere and have sexual relations with another woman?

SECTION 7. HIV/AIDS

701) Now I would like to talk to you about something else. 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?

707) Can people get the AIDS virus by witchcraft or other supernatural means?

707B) Is there something (else) a person can do to avoid catching the AIDS virus?

707C) What can be done?

Anything else?

RECORD ALL MENTIONED.

708) Is it possible for a healthy-looking person to, in fact, have the AIDS virus?

709) Can the virus that causes AIDS can be transmitted from mother to child:

During pregnancy?
During childbirth?
During breastfeeding?

710) CHECK 709:

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

712) Have you heard about special antiretroviral drugs (USE LOCAL NAME) that people infected by the AIDS virus can get from a doctor or nurse to allow them to live for longer?

712A) CHECK FOR PRESENCE OF OTHERS BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

713) I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?

714) How many months ago was your most recent HIV test?

715) The last time you had a test, did you ask to take it yourself, was it offered and you accepted, or was it obligatory?

716) I don't want to know the results, but have you gotten the test results?

716A) Did you share your results with your partner(s)?

717) Where was the test done?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, CTV CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

718) Do you know of a place where people can go to get tested for the AIDS virus?

719) Where is that?

Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF F THE HOSPITAL, HEALTH CENTER, CTV CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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

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

722) If someone in your family contracted the virus that causes AIDS, would you be willing to take care of him or her in your own household?

723) If a female teacher has the AIDS virus, but is not sick, should she be allowed to continue teaching at the school?

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

733) CHECK 701:

HAS HEARD ABOUT AIDS:
Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

HAS NOT HEARD ABOUT AIDS:
Have you heard about infections that can be transmitted through sexual contact?

734) CHECK 414:

735) CHECK 733:

HAS HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

736) Now I would like to ask you some questions about your health.
In the last 12 months, have you had a disease which you got through sexual contact?

737) Sometimes men experience an abnormal discharge from their penis.
In the past 12 months, have you had an abnormal discharge from your penis?

738) Sometimes men have a sore or ulcer near their penis.
In the past 12 months, have you had a sore or ulcer near your penis?

739) CHECK 736, 737, AND 738:

740) The last time you had (PROBLEM FROM 736/737/738), did you seek any kind of advice or treatment?

740A) Did you also seek advice or treatment for your partner(s)?

741) Where did you go?

Anywhere else?

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

IF UNABLE TO DETERMINE IF THE HOSPITAL, HEALTH CENTER, CTV CENTER, OR CLINIC IS PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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

745) 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 want to ask you some other questions about relating to health matters.
In the last 12 months, have you had an injection for any reason?

IF YES: How many injections have you had?

IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR IF DAILY FOR 3 MONTHS OR MORE, RECORD '90'.

IF NONNUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

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 GREATER THAN 90, OR IF DAILY FOR 3 MONTHS OR MORE FOR 3 MONTHS OR MORE, RECORD '90'.

IF NONNUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

807) Did the person who gave you the injection take the syringe and needle from a new, unopened package?

810) Do you currently smoke cigarettes?

811) In the last 24 hours, how many cigarettes have you smoked?

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

813) What (other) type of tobacco do you currently smoke or use?

814) Do you have medical insurance?

815) What type of medical insurance?

RECORD ALL MENTIONED.

SECTION 9. HOUSEHOLD RELATIONS

901) CHECK COVER PAGE (MAN SELECTED FOR THIS SECTION):

902) CHECK FOR PRESENCE OF OTHERS:

DO NOT CONTINUE UNTIL IN PRIVATE.

READ TO RESPONDENT:

Now, I would like to ask you some questions about some aspects of relations in a couple. I know that some of these questions are very personal. However, your answers are very important in helping us understand the situation of men in Cameroon. I guarantee that your answers will stay totally confidential and will not be repeated to anyone. I would like to tell you that you are the only person in your household to whom these questions are asked and that no one will know that you were posed these questions. Finally, if anyone comes in during our discussion, we will change the subject.

903) CHECK 401, 402, AND 403:

904) Now I would like to ask you some questions about certain situations that some women experience. Please tell me if the following phrases apply to your relations with your (last) wife/partner?

a) You are/were jealous or angry if she speaks/spoke to others?
b) You accuse/accused her frequently of being unfaithful?
c) You do not/did not allow her to see her female friends?
d) You try/tried to limit her contact with her family?
e) You insist/insisted on knowing where she is/was at all times?
f) You do not/did not trust her with matters concerning money?
e) You threaten/threatened to kick her out, to leave her without a cent, or to reduce/restrict her access to money?

905) Now, if you will allow me, I need to ask you some other questions about your (last) wife/partner.

A. Have you ever:

a) said or done something to humiliate your (last) wife/partner in front of other people?

b) threatened to harm your (last) wife/partner or someone close to her?

c) Insulted or belittled your (last) wife/partner?

CHECK 403: ONLY ASK QUESTION IF RESPONDENT IS NOT A WIDOWER.

B: In the last 12 months, has this happened often, sometimes, or never?

a)

b)

c)

906)

A. Have you ever done any of the following to your (last) wife/partner?

a) Have you ever shoved or shook her or thrown something at her?

b) Have you ever slapped her?

c) Have you ever twisted her arm or pulled her hair?

d) Have you ever hit her with your fist or anything else that might hurt her?

e) Have you ever kicked her, dragged her, or beaten her?

f) Have you ever tried to strangle her or burn her?

g) Have you ever threatened her with a knife, a pistol, or other type of weapon?

h) Have you ever forced her to have sexual relations when she did not want to?

i) Did you force her to perform sexual acts that she did not want to perform?

CHECK 403: ONLY ASK IF RESPONDENT IS NOT A WIDOWER.

B: In the last 12 months, has this happened often, sometimes, or never?

a) Shoved or shook her or thrown something at her?

b) Slapped her?

c) Twisted her arm or pulled her hair?

d) Hit her with your fist or anything else that might hurt her?

e) Kicked her, dragged her, or beaten her?

f) Tried to strangle her or burn her?

g) Threatened her with a knife, a pistol, or other type of weapon?

h) Forced her to have sexual relations when she did not want to?

i) Force her to perform sexual acts that she did not want to perform?

907) CHECK 906A (a-i):

908) Did the following happen to your (last) wife/partner after what you did?

a) Have cuts, hematoma, or bruises?

b) Have hematomas of the eye, sprains dislocations or burns?

c) Have deep wounds, broken bones, broken teeth, or other serious injuries?

909) Has it ever happened that your (last) wife/partner hit, slapped, kicked or did anything else to hurt you physically when you neither hit nor physically harmed her?

910) Did your (last) wife/partner drink alcohol?

911) Does/did she get drunk often, sometimes, or never?

912) CHECK 401 AND 402:

HAS BEEN/IS MARRIED/IN UNION:
From age 15, has anyone else besides your (last) wife/partner beaten, slapped, kicked or did anything else to hurt you physically when you neither hit nor physically harmed them?

NEVER MARRIED/IN UNION:
From age 15, has anyone else beaten, slapped, kicked or did anything else to hurt you physically when you neither his nor physically harmed them?

913) Who physically harmed you in this way?

Anyone else?

RECORD ALL MENTIONED.

914) In the past 12 months, were you often, sometimes, or never beaten, slapped, kicked or harmed by this/these person(s)?

915) Who physically harmed you the last time?

Anyone else?

RECORD ALL MENTIONED.

916) The last time that you were physically harmed, where did this occur?

917) CHECK 208:

918) Have you ever hit, slapped, kicked, or done anything else to harm your wife/partner while she was pregnant?

919) CHECK 414: EVER HAD SEXUAL INTERCOURSE?

920) At any point in your life, whether as a child or as an adult, has anyone ever forced you by whatever means to perform sexual acts that you did not want to perform?

921) How old were you when, for the first time, you were forced to have sex or perform sexual acts?

922) As far as you know, has your father ever beaten your mother?

THANK THE RESPONDENT FOR HIS COOPERATION AND REASSURE HIM THAT HIS ANSWERS WILL REMAIN CONFIDENTIAL. ANSWER THE BELOW QUESTIONS ONLY AS THEY RELATE TO THE HOUSEHOLD RELATIONS QUESTIONNAIRE.

923) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULTS TRIED TO LISTEN OR CAME IN TO THE ROOM OR TRIED TO INTERFERE AT ANY TIME?

924) INTERVIEWER COMMENTS: IF THE SURVEY COULD NOT BE ADMINISTERED, EXPLAIN REASONS

925) RECORD THE TIME:

INTERVIEWER OBSERVATIONS

TO BE FILLED OUT AFTER COMPLETING THE INTERVIEW:

COMMENTS ON THE RESPONDENT: ___

COMMENTS ON SPECIFIC ISSUES: ___

OTHER COMMENTS: ___

SUPERVISOR OBSERVATIONS:

NAME OF SUPERVISOR: ___
DATE: ___

EDITOR'S OBSERVATIONS:

EDITOR NAME: ___
DATE: ___