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DEMOGRAPHIC AND HEALTH SURVEY-ETHIOPIA 2005-
MAN’S QUESTIONNAIRE

IDENTIFICATION

LOCALITY NAME ____________________

NAME OF HOUSEHOLD HEAD _____________________

CLUSTER NUMBER ___ ___ ___

HOUSEHOLD NUMBER ___ ___ ___

REGION ___ ___

LARGE CITY/SMALL CITY/TOWN/RURAL:

LARGE CITY 1
SMALL CITY 2
TOWN 3
RURAL 4

NAME AND LINE NUMBER OF MAN _____________________ ___ ___

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________________
INTERVIEWER’S NAME __________________
RESULT_____________________

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

NEXT VISIT:
DATE ____________________
TIME __________________

FINAL VISIT
DAY ___ ___
MONTH ___ ___
YEAR ___ ___ ___ ___
INTERVIEWER NUMBER ___ ___ ___
RESULT ___

TOTAL NUMBER OF VISITS ___

LANGUAGE OF QUESTIONNAIRE:

AMARIGNA 1
OROMIGNA 2
TIGRIGNA 3
OTHER 6

LANGUAGE OF INTERVIEW:

AMARIGNA 1
OROMIGNA 2
TIGRIGNA 3
OTHER 6

LANGUAGE OF RESPONDENT:

AMARIGNA 1
OROMIGNA 2
TIGRIGNA 3
OTHER 6

TRANSLATOR USED:

YES 1
NO 2

SUPERVISOR
NAME __________
DATE __________ ___ ___

FIELD EDITOR
NAME __________
DATE __________ ___ ___

OFFICE EDITOR ___ ___

KEYED BY___ ___

SECTION 1. RESPONDENT’S BACKGROUND AND WORK STATUS

Hello. My name is ________________________ and I am working with the Population and Housing Census Commission Office (PHCCO). We are conducting a national survey about the health of women, men and children. We would very much appreciate your participation in this survey. I would like to ask you about your health. This information will help the government to plan health services. The survey usually takes about 30 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

101. RECORD THE TIME.

MORNING/EVENING__
MORNING 1
EVENING 2
HOUR ___ ___
MINUTES ___ ___

102. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD ‘00’ YEARS.

YEARS __ ___

ALWAYS 95 (GO TO 104)
VISITOR 96 (GO TO 104)

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

CITY 1
TOWN 2
COUNTRYSIDE 3

104. In what month and year were you born?

MONTH ___ ___
DON’T KNOW MONTH 98
YEAR ___ ___ ___ ___
DON’T KNOW YEAR 9998

105. How old were you at your last birthday?
COMPARE AND CORRECT 104 AND/OR 105 IF INCONSISTENT.

AGE IN COMPLETE YEARS ___ ___

106. Have you ever attended school?

YES 1
NO 2 (GO TO 110)

108. What is the highest grade you completed?

GRADE ___ ___

TECHNICAL/VOCATIONAL CERTIFICATE 13
UNIVERSITY/COLLEGE DIPLOMA 14
UNIVERSITY/COLLEGE DEGREE OR HIGHER 15

109. CHECK 108:

GRADE 00-06 (GO TO 110)
GRADE 07 AND ABOVE (GO TO 113)

110. 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?

CANNOT READ AT ALL 1
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE)___________4
BLIND/VISUALLY IMPAIRED 5

111. Have you ever participated in a Basic Education Program or any other program that involves learning to read or write (not including primary school)?

YES 1
NO 2

112. CHECK 110:

CODE ‘2’,’3’ OR ‘4’ CIRCLED (GO TO 113)
CODE ‘1’ OR ‘5’ CIRCLED (GO TO 114)

113. Do you read a newspaper or magazine almost every day, at least once a week or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

114. Do you listen to the radio almost every day, at least once a week or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

115. Do you watch television almost every day, at least once a week or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

116. In the last 12 months, on how many separate occasions have you traveled away from your home community and slept away?

NUMBER OF TRIPS ___ ___
NONE 00 (GO TO 118)

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

YES 1
NO 2

118. What is your religion?

ORTHODOX 1
CATHOLIC 2
PROTESTANT 3
MOSLEM 4
TRADITIONAL 5
OTHER (SPECIFY)__________ 6

119. What is your ethnicity?
RECORD THE MAJOR ETHNIC GROUP.

ETHNICITY _____________ ___ ___

120. Are you currently working?

YES 1 (GO TO 123)
NO 2

121. Have you done any work in the last 12 months?

YES 1 (GO TO 123)
NO 2

122. What have you been doing for most of the time over the last 12 months?

GOING TO SCHOOL/STUDYING 01 (GO TO 201)
LOOKING FOR WORK 02 (GO TO 201)
RETIRED 03 (GO TO 201)
TOO ILL TO WORK 04 (GO TO 201)
HANDICAPPED, CANNOT WORK 05 (GO TO 201)
HOUSEWORK/CHILD CARE 06 (GO TO 201)
OTHER (SPECIFY) ______________ 96 (GO TO 201)

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

OCCUPATION _____________________________

124. CHECK 123:

WORKS IN AGRICULTURE (GO TO 125)
DOES NOT WORK IN AGRICULTURE (GO TO 126)

125. Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else’s land?

OWN LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE’S LAND 4
DOESN’T WORK ON LAND 5

126. Are you paid in cash or kind for this work or are you not paid at all?

CASH ONLY 1
CASH AND KIND 2
IN KIND ONLY 3
NOT PAID 4

SECTION 2. REPRODUCTION

201. Now I would like to ask about any children you have had. I am interested only in the children that are biologically yours. Have you ever fathered any children with any woman?

YES 1
NO 2 (GO TO 206)
DON’T KNOW 8 (GO TO 206)

202. Do you have any sons or daughters that you have fathered who are now living with you?

YES 1
NO 2 (GO TO 204)

203. How many sons live with you? And how many daughters live with you?
IF NONE, RECORD ‘00’.

SONS AT HOME ___ ___
DAUGHTERS AT HOME ___ ___

204. Do you have any sons or daughters you have fathered who are alive but do not live with you?

YES 1
NO 2 (GO TO 206)

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’

SONS ELSEWHERE ___ ___
DAUGHTERS ELSEWHERE ___ ___

206. Have you ever fathered a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

YES 1
NO 2 (GO TO 208)

207. How many boys have died? And how many girls have died?
IF NONE, RECORD ‘00’.

BOYS DEAD ___ ___
GIRLS DEAD ___ ___

208. (In addition to the children that you have just told me about), do you have any other living sons or daughters who died who are biologically your children but who are not legally yours or do not have your name?

NO (GO TO 209)
YES (PROBE AND CORRECT 201-207 AS NECESSARY.)

209. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
IF NONE RECORD ‘00’

TOTAL ___ ___

210. CHECK 209:

HAS HAD MORE THAN ONE CHILD (GO TO 211)
HAS HAD ONLY ONE CHILD (GO TO 213)
HAS NOT HAD ANY CHILDREN (GO TO 214)

211. Do the children you have fathered all have the same biological mother?

YES 1 (GO TO 213)
NO 2

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

NUMBER OF WOMEN ___ ___

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

AGE IN YEARS ___ ___

214. Are you the primary care giver for any children?

YES 1
NO 2 (GO TO 301)

215. Are any of these children for whom you are the primary caregiver under the age of 18?

YES 1
NO 2 (GO TO 301)

216. Now I would like to ask you about the children who are under the age of 18 and for whom you are the primary caregiver. Have you made arrangements for someone to care for these children in the event that you fall sick or are unable to care for them?

YES 1
NO 2
UNSURE 8

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. Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?
CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302

01) FEMALE STERILIZATION: Women can have an operation to avoid having any more children.
YES 1
NO 2
02) MALE STERILIZATION: Men can have an operation to avoid having any more children.
YES 1
NO 2
03) PILL: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
04) IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
05) INJECTABLES: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2
06) IMPLANTS (or NORPLANTS): Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for five or more years.
YES 1
NO 2
07) CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
08) DIAPHRAGM/FOAM/JELLY: Women can place a sheath and/or a suppository/tablet/jelly/cream in their vagina before intercourse.
YES 1
NO 2
09) STANDARD DAYS METHOD: Women can use a cycle of beads to count the days they are most likely to get pregnant and avoid sexual intercourse during those days.
YES 1
NO 2
10) LACTATIONAL AMENORRHEA METHOD (LAM)
YES 1
NO 2
11) RHYTHM METHOD: Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is not likely to get pregnant.
YES 1
NO 2
12) WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2
13) Have you heard of any other ways or methods that women or men can use to avoid pregnancy? LIST UP TO TWO DIFFERENT METHODS.
SPECIFY_____
YES 1
NO 2

302. Have you ever used (METHOD)?

02) MALE STERILIZATION: Men can have an operation to avoid having any more children: Have you ever had an operation to avoid having any more children?
YES 1
NO 2
07) CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
11) RHYTHM METHOD: Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is not likely to get pregnant.
YES 1
NO 2
12) WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2

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

YES 1
NO 2

304. Now I would like to ask you about when a woman is most likely to get pregnant. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations?

YES 1
NO 2 (GO TO 306)
DON’T KNOW 8 (GO TO 306)

305. Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods?

JUST BEFORE HER PERIOD BEGINS 1
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) ______ 6
DON’T KNOW 8

306. Do you think that a woman who is breastfeeding her baby can get pregnant?

YES 1
NO 2
DEPENDS 3
DON’T KNOW 8

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

Contraception is women’s business and a man should not have to worry about it.
AGREE 1
DISAGREE 2
DON’T KNOW 8
Women who use contraception may become promiscuous.
AGREE 1
DISAGREE 2
DON’T KNOW 8
A woman is the one who gets pregnant so she should be then one to get sterilized.
AGREE 1
DISAGREE 2
DON’T KNOW 8

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401. Are you currently married or living together with a woman as if married?

YES, CURRENTLY MARRIED 1
YES, LIVING WITH A WOMAN 2 (GO TO 404)
NO, NOT IN UNION 3 (GO TO 407)

402. Do you currently have one wife or more than one wife?
IF ONLY ONE WIFE, ENTER ‘01’. IF MORE THAN ONE, ASK: How many wives do you currently have?

NUMBER OF WIVES ___ ___

403. In addition to your wife (wives), are you currently living with any other women as if married?

YES 1
NO 2 (GO TO 405)

404. Are you living with one woman or more than one woman as if married?
IF ONE LIVE-IN PARTNER, ENTER ‘01’. IF MORE THAN ONE, ASK: How many women are you living with as if you were married?

NUMBER OF LIVE-IN PARTNERS ___ ___

405. CHECK Q.402 AND Q.404

SUM OF Q.402 AND Q.404=01: Please tell me the name of your wife/partner.
(RECORD THE WIFE’S/PARTNER’S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF SHE IS NOT LISTED IN THE HOUSEHOLD, RECORD ‘00’.)

SUM OF Q.402 AND Q.404>01: Please tell me the name of each wife/partner that you live with as if married, starting with the one you lived with first.
(RECORD EACH WIFE’S/PARTNER’S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE SEPARATELY. IF A WIFE/PARTNER IS NOT LISTED IN THE HOUSEHOLD, RECORD ‘00’. CIRCLE THE APPROPRIATE CODE FOR WIFE OR PARTNER.)

WIFE/PARTNER NAME ___________
LINE NUMBER IN HOUSEHOLD QUESTIONNAIRE______

STATUS

WIFE 1
PARTNER 2

405A. How old was your wife/partner on her last birthday?

AGE ________

406. CHECK 405:

ONLY ONE WIFE/PARTNER: Have you ever been married to or lived together as if married with any other woman than your current wife/partner?

MORE THAN ONE WIFE/PARTNER: Have you ever been married to or lived together as if married with any other woman in addition to those you have just mentioned?

YES 1 (GO TO 409)
NO 2 (GO TO 410)

407. Have you ever been married or lived together with a woman as if married?

YES 1
NO 2 (GO TO 412)

408. What is your marital status now: are you widowed, divorced, or separated?

WIDOWED 1
DIVORCED 2
SEPARATED 3

409. In total, how many women have you been married to or lived together with as if married in your whole life?

NUMBER ___ ___

409A. CHECK 405 AND 409:

ONLY ONE WIFE/PARTNER TOTAL IN 405 AND 409 (GO TO 410)
MORE THAN ONE WIFE/PARTNER IN 405 AND/OR 409 (GO TO 410A)

410. In what month and year did you start living with your wife/partner?
410A. Now I would like to ask about when you started living with your first wife/partner. In what month and year was that?

MONTH ___ ___
DON’T KNOW MONTH 98
YEAR ___ ___ ___ ___ (GO TO 412)
DON’T KNOW YEAR 9998

411. How old were you when you first started living with her?

AGE ___ ___

412. Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family life issues. How old were you when you had sexual intercourse for the very first time (if ever)?

NEVER 00
AGE IN YEARS ___ ___ (GO TO 414)
FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE/PARTNER 95 (GO TO 414)

413. Do you intend to wait until you get married to have sexual intercourse for the first time?

YES 1 (GO TO 443)
NO 2 (GO TO 443)
DON’T KNOW/UNSURE 8 (GO TO 443)

414. CHECK 105:

15-24 YEARS OLD (GO TO 415)
25-49 YEARS OLD (GO TO 419)

415. The first time you had sexual intercourse, was a condom used?

YES 1
NO 2
DON’T KNOW/DON’T REMEMBER 8

419. When was the last time you had sexual intercourse?
RECORD ‘YEARS AGO’ ONLY IF LAST INTERCOURSE WAS ONE OR MORE YEARS AGO. IF 12 MONTHS OR MORE, ANSWER MUST BE RECORDED IN YEARS.

DAYS AGO 1 ___ ___
WEEKS AGO 2 ___ ___
MONTHS AGO 3 ___ ___
YEARS AGO 4 ___ ___ (GO TO 428)

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

YES 1
NO 2 (GO TO 422)

421. Did you see a condom every time you had sexual intercourse with this person in the last 12 months?

YES 1
NO 2

422. What was your relationship to this person with whom you had sexual intercourse?
IF BOYFRIEND/GIRLFRIEND: Were you living together as if married?
IF YES, CIRCLE ‘02’. IF NO, CIRCLE ‘03’

SPOUSE 01 (GO TO 424)
LIVE-IN PARTNER 02 (GO TO 424)
BOYFRIEND/GIRLFRIEND NOT LIVING WITH RESPONDENT 03
CASUAL ACQUAINTANCE 04
COMMERCIAL SEX WORKER 05
OTHER (SPECIFY)___________ 96

423. For how long (have you had/did you have) a sexual relationship with this person?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD ‘01’ DAYS.

DAYS 1 ___ ____
MONTHS 2 ___ ____
YEARS 3 ___ ___

424. The last time you had sexual intercourse with this (second) person, did you or this person drink alcohol?

YES 1
NO 2 (GO TO 426)

425. Were you or your partner drunk at that time?
IF YES: Who was drunk?

RESPONDENT ONLY 1
PARTNER ONLY 2
RESPONDENT AND PARTNER BOTH 3
NEITHER 4

426. Apart from [this person/these two people], have you had sexual intercourse with any other person in the last 12 months?

YES 1 (GO BACK TO 420 IN THE NEXT COLUMN)
NO 2 (GO TO 428)

427. In total, with how many different people have you had sexual intercourse in the last 12 months?
IF NON-NUMERICAL ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE ‘95’.

NUMBER OF PARTNERS LAST 12 MONTHS ___ ___
DON’T KNOW 98

428. In total, with how many different people have you had sexual intercourse in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE ‘95’

NUMBER OF PARTNERS IN LIFETIME ___ ___
DON’T KNOW 98

429. CHECK 422 ALL COLUMNS:

NO PARTNERS ARE COMMERCIAL SEX WORKERS (GO TO 430)
AT LEAST ONE PARTNER A COMMERCIAL SEX WORKER (GO TO 431)
Q. 422 NOT ASKED (GO TO 443)

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

YES 1
NO 2 (GO TO 433)

431. The last time you paid someone in exchange for sex, was a condom used?

YES 1
NO 2 (GO TO 433)

432. Was a condom used every time you paid someone in exchange for sex in the last 12 months?

YES 1
NO 2
DON’T KNOW 8

433. CHECK 420 COLUMN 1:
(CONDOM USE WITH LAST SEXUAL PARTNER)

YES (GO TO 434)
NO/NOT ASKED (GO TO 439)

434. The last time you had intercourse you told me you used a condom. Did you or your partner obtain the condom?

MAN HIMSELF 1
PARTNER 2
SOMEONE ELSE 3

435. What brand did you use?

BRAND NAME (SPECIFY) __________ ___ ___
DON’T KNOW 98

436. How much did you (your partner) pay when getting the condom?

COST ___ ___ ___ . __ ___

FREE 995
DON’T KNOW 998

437. How many condoms did you (your partner) get the last time?

NUMBER ___ ___
DON’T KNOW 98

438. From where did you (your partner) obtain the condom the last time? Any other place?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
RECORD ALL PLACES MENTIONED.

NAME OF THE PLACE____________
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
GOVERNMENT HEALTH STATION/CLINIC D
CBD E
OTHER PUBLIC (SPECIFY) ________F
NON-GOVERNMENT (NGO)
NGO HEALTH FACILITY G
CBD/CBRHA H
OTHER NGO ______ I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR J
PHARMACY K
OTHER PRIVATE MEDICAL (SPECIFY) ___________________ L
OTHER SOURCE
DRUG VENDOR M
SHOP N
FRIEND/RELATIVE O
OTHER (SPECIFY) _____________ X

439. CHECK 302(02):
USING MALE STERILIZATION

YES (GO TO 442)
NO (GO TO 440)

440. The last time you had sex did you (or your partner) use any method (other than the condom) to avoid or prevent a pregnancy?

YES 1
NO 2 (GO TO 442)
DON’T KNOW 8 (GO TO 442)

441. What method did you (your partner) use?
PROBE: Did you use any other method to prevent pregnancy?

FEMALE STERILIZATION A
MALE STERILIZATION B
PILL C
IUD D
INJECTABLES E
IMPLANTS F
CONDOM G
DIAPHRAGM/FOAM/JELLY H
STANDARD DAYS METHOD I
LACTATIONAL AMENORRHEA METHOD J
RHYTHM METHOD K
WITHDRAWAL L
OTHER (SPECIFY)___________ X

442. CHECK 420 COLUMN 1:
(CONDOM USE WITH LAST SEXUAL PARTNER)

NO/NOT ASKED (GO TO 443)
YES (GO TO 447)

443. CHECK 301 (07):
KNOWS MALE CONDOM

YES (GO TO NEXT)
NO (GO TO 447)

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

YES 1
NO 2 (GO TO 447)

445. Where is that? Any other place?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
RECORD ALL PLACES MENTIONED.

NAME OF PLACE_______
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
GOVERNMENT HEALTH STATION/CLINIC D
CBD E
OTHER PUBLIC (SPECIFY) ________F
NON-GOVERNMENT (NGO)
NGO HEALTH FACILITY G
CBD/CBRHA H
OTHER NGO ______ I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR J
PHARMACY K
OTHER PRIVATE MEDICAL (SPECIFY) ___________________ L
OTHER SOURCE
DRUG VENDOR M
SHOP N
FRIEND/RELATIVE O
OTHER (SPECIFY) _____________ X

446. If you wanted to, could you yourself get a condom?

YES 1
NO 2
DON’T KNOW/UNSURE 8

447. I will now read you some statements about the male condom.
Please tell me if you agree or disagree with each statement.

Condoms diminish a man’s sexual pleasure.
YES 1
NO 2
DON’T KNOW 8
Condoms diminish a woman’s pleasure
YES 1
NO 2
DON’T KNOW 8
A condom is very inconvenient to use.
YES 1
NO 2
DON’T KNOW 8
A condom can be reused.
YES 1
NO 2
DON’T KNOW 8
Buying condoms is embarrassing.
YES 1
NO 2
DON’T KNOW 8

448. Some men are circumcised. Are you circumcised?

YES 1
NO 2

SECTION 5. FERTILITY PREFERENCES

501. CHECK 401 AND 405:

IN Q. 405 MARRIED TO OR LIVING WITH ONE WOMAN (GO TO 502)
IN Q. 405 MARRIED TO AND/OR LIVING WITH MORE THAN ONE WOMAN (GO TO 502A)
Q. 401: NOT IN UNION (GO TO 505)

502. Is your wife/partner currently pregnant?
502A. IF MORE THAN ONE WIFE/PARTNER, ASK:
Are you any of your wives/partners currently pregnant?

YES 1
NO 2
UNSURE 8

503. CHECK 502:

WIFE NOT PREGNANT OR UNSURE: Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

WIFE PREGNANT: Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?

HAVE (A/ANOTHER ) CHILD 1
NO MORE/NONE 2 (GO TO 505)
SAYS WIFE/WIVES CAN’T GET PREGNANT 3 (GO TO 505)
UNDECIDED/DON’T KNOW 8 (GO TO 505)

504. CHECK 502:

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

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

MONTHS 1 ___ ___
YEARS 2 ___ ___

SOON/NOW 993
AFTER MARRIAGE 995
OTHER (SPECIFY) _________ 996
DON’T KNOW 998

505. CHECK 202 AND 204:

HAS LIVING CHILDREN: If you could go back to the time you did not have 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.

NONE 00 (GO TO 507)
NUMBER ___ ___
OTHER (SPECIFY) ________ 96 (GO TO 507)

506. 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?

NUMBER OF BOYS____
OTHER (SPECIFY)____ 96
NUMBER OF GIRLS____
OTHER (SPECIFY)_____ 96
NUMBER OF EITHER SEX____
OTHER (SPECIFY)_____ 96

507. In the last few months have you heard about family planning:

On the radio?
YES 1
NO 2
On the television?
YES 1
NO 2
In a newspaper or magazine?
YES 1
NO 2
In a pamphlet/poster/leaflets/booklets?
YES 1
NO 2
At a community event?
YES 1
NO 2

508. CHECK 401 AND 405:

IN Q.405 MARRIED TO OR LIVING WITH ONE WOMAN (GO TO 509)
IN Q.405 MARRIED TO AND/OR LIVING WITH MORE THAN ONE WOMAN (GO TO 509A)
Q.401: NOT IN UNION (GO TO 514)

509. Is your wife/partner currently using a method of family planning?
509A. IF MORE THAN ONE WIFE/PARTNER, ASK:
Are any of your wives/partners currently using a method of family planning?

YES 1
NO 2 (GO TO 511)
DON’T KNOW 8 (GO TO 511)

510. Would you say that using contraception is mainly your decision, mainly your wife’s decision, or did you both decide together?

MAINLY RESPONDENT 1
MAINLY WIFE/PARTNER 2
JOINT DECISION 3
OTHER (SPECIFY) __________ 6

511. Do you think your wife/partner wants the same number of children that you want, or does she want more or fewer than you want?

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DON’T KNOW 8

512. Who decides how the money you earn will be used: mainly you, mainly your wife/partner, or you and your wife/partner jointly?

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER JOINTLY 3
RESPONDENT DOESN’T BRING IN ANY MONEY 4
OTHER 6

513. Would you say that the money that you bring into the household is more than what your wife/partner brings in, less than what she brings in, or about the same?

MORE THAN HER 1
LESS THAN HER 2
ABOUT THE SAME 3
WIFE/PARTNER DOESN’T BRING IN ANY MONEY 4
DON’T KNOW 8

514. Now I would like to ask you a few questions regarding relationships between men and women. In a couple, who do you think should have the greater say in each of the following decisions: the husband, the wife or both equally:

making large household purchases?
HUSBAND 1
WIFE 2
BOTH EQUALLY 3
DON’T KNOW, DEPENDS 8
making small daily household purchases?
HUSBAND 1
WIFE 2
BOTH EQUALLY 3
DON’T KNOW, DEPENDS 8
deciding when to visit family, friends or relatives?
HUSBAND 1
WIFE 2
BOTH EQUALLY 3
DON’T KNOW, DEPENDS 8
deciding what to do with the money she earns for her work?
HUSBAND 1
WIFE 2
BOTH EQUALLY 3
DON’T KNOW, DEPENDS 8
deciding how many children to have and when to have them?
HUSBAND 1
WIFE 2
BOTH EQUALLY 3
DON’T KNOW, DEPENDS 8

515. Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

If she goes out without telling him?
YES 1
NO 2
DON’T KNOW 8
If she neglects the children?
YES 1
NO 2
DON’T KNOW 8
If she argues with him?
YES 1
NO 2
DON’T KNOW 8
If she refuses to have sex with him?
YES 1
NO 2
DON’T KNOW 8
If she burns the food?
YES 1
NO 2
DON’T KNOW 8

516. Husbands and wives do not always agree on everything. Please tell me if you think a wife is justified in refusing to have sex with her husband when:

She knows her husband has a sexually transmitted disease?
YES 1
NO 2
DON’T KNOW 8
She knows her husband has sex with other women?
YES 1
NO 2
DON’T KNOW 8
She is tired or not in the mood?
YES 1
NO 2
DON’T KNOW 8

517. Do you think that if a woman refuses to have sex with her husband when he wants her to, he has the right to...

Get angry and reprimand her?
YES 1
NO 2
DON’T KNOW, DEPENDS 8
Refuse to give her money or other means of financial support?
YES 1
NO 2
DON’T KNOW, DEPENDS 8
Use force and have sex with her even if she doesn’t want to?
YES 1
NO 2
DON’T KNOW, DEPENDS 8
Go and have sex with another woman?
YES 1
NO 2
DON’T KNOW, DEPENDS 8

518. When a wife knows her husband has a disease that can be transmitted through sexual contact, is she justified in asking that they use a condom when they have sex?

YES 1
NO 2
DON’T KNOW 8

519. Now I would like to ask you some questions about any injections you have had in the last 12 months. 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 GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD ‘90’. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS ___ ___
NONE 00 (GO TO 523)

520. 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 DAILY FOR 3 MONTHS OR MORE, RECORD ‘90’. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS ___ ___
NONE 00 (GO TO 523)

521. The last time you had an injection given to you by a health worker, where did you go to get the injection?

PUBLIC SECTOR
GOVERNMENT HOSPITAL/CLINIC 11
GOVERNMENT HEALTH CENTER 12
GOVERNMENT HEALTH POST 13
COMMUNITY HEALTH AGENT 14
OTHER PUBLIC (SPECIFY) ________16
NON-GOVERNMENT (NGO) HEALTH FACILITY 21
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR 31
DENTAL CLINIC/OFFICE 32
PHARMACY 33
OFFICE OR HOME OF NURSE/HEALTH WORKER 34
OTHER PRIVATE MEDICAL (SPECIFY) ___________________ 36
OTHER PLACE
AT HOME 41
OTHER (SPECIFY) _____________ 96

522. Did the person who gave you that injection take the syringe and needle from a new, unopened package?

YES 1
NO 2
DON’T KNOW 8

523. Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 525)

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

CIGARETTES ___ ___

525. Do you currently smoke or use any other type of tobacco like gaya, shisha or suret?

YES 1
NO 2 (GO TO 527)

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

PIPE A
CHEWING TOBACCO B
SNUFF/SURET C
SHISHA D
GAYA E
OTHER (SPECIFY) ____ X

527. Have you ever heard of an illness called tuberculosis or TB?

YES 1
NO 2 (GO TO 601)

528. How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORD ALL MENTIONED.

THROUGH THE AIR WHEN COUGHING OR SNEEZING A
THROUGH SHARING UTENSILS B
THROUGH TOUCHING A PERSON WITH TB C
THROUGH FOOD D
THROUGH SEXUAL CONTACT E
THROUGH MOSQUITO BITES F
OTHER (SPECIFY) ___________ X
DON’T KNOW Z

529. Can tuberculosis be cured?

YES 1
NO 2
DON’T KNOW 8

530. If a member of your family got tuberculosis, would you want it to remain a secret or not?

YES, REMAIN A SECRET 1
NO 2
DON’T KNOW/NOT SURE/DEPENDS 8

SECTION 6. HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

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

YES 1
NO 2 (GO TO 634)

602. Can people reduce their chances of getting the AIDS virus by having just one sex partner who is not infected and who has no other partners?

YES 1
NO 2
DON’T KNOW 8

603. Can people get the AIDS virus from mosquito bites?

YES 1
NO 2
DON’T KNOW 8

604. Can people reduce their chances of getting the AIDS virus by using a condom every time they have sex?

YES 1
NO 2
DON’T KNOW 8

605. Can people get the AIDS virus by sharing food with a person who had AIDS?

YES 1
NO 2
DON’T KNOW 8

606. Can people reduce their chance of getting the AIDS virus by abstaining from sexual intercourse?

YES 1
NO 2
DON’T KNOW 8

607. Can people get the AIDS virus because of the curse of God or other supernatural means?

YES 1
NO 2
DON’T KNOW 8

608. Is there anything else a person can do to avoid or reduce the chances of getting the AIDS virus?

YES 1
NO 2 (GO TO 610)
DON’T KNOW 8 (GO TO 610)

609. What can a person do? Anything else?
RECORD ALL WAYS MENTIONED.

ABSTAIN FROM SEX A
USE CONDOMS B
LIMIT SEX TO ONE PARTNER/STAY FAITHFUL TO ONE PARTNER C
LIMIT NUMBER OF SEXUAL PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS F
AVOID SEX WITH HOMOSEXUALS G
AVOID SEX WITH PERSONS WHO INJECT DRUGS H
AVOID BLOOD TRANSFUSIONS I
AVOID INJECTIONS J
AVOID SHARING RAZORS/BLADES K
AVOID KISSING L
AVOID MOSQUITO BITES M
SEEK PROTECTION FROM TRADITIONAL PRACTITIONER N
OTHER (SPECIFY) _____________W
OTHER (SPECIFY) _____________ X
DON’T KNOW __________________ Z

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

YES 1
NO 2
DON’T KNOW 8

611. Can the virus that causes AIDS be transmitted from a mother to her baby:

During pregnancy?
YES 1
NO 2
DON’T KNOW 8
During delivery?
YES 1
NO 2
DON’T KNOW 8
By breastfeeding?
YES 1
NO 2
DON’T KNOW 8

612. CHECK 611:

AT LEAST ONE ‘YES’ (GO TO 613)
OTHER (GO TO 614)

613. Are there any special medications 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?

YES 1
NO 2
DON’T KNOW 8

614. Is there any special medication that people infected with the AIDS virus can get from a doctor or a nurse?

YES 1
NO 2
DON’T KNOW 8

615. I don’t want to know the results, but have you ever been tested to see if you have the AIDS virus?

YES 1
NO 2 (GO TO 620)

616. When was the last time you were tested?

LESS THAN 12 MONTHS AGO 1
12-23 MONTHS AGO 2
2 OR MORE YEARS AGO 3

617. The last time you had the test, did you yourself ask for the test, was it offered to you and you accepted, or was it required?

ASKED FOR THE TEST 1
OFFERED AND ACCEPTED 2
REQUIRED 3

618. I don’t want to know the results, but did you get the results of the test?

YES 1
NO 2

619. Where was the test done?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE____
PUBLIC SECTOR
GOVERNMENT HOSPITAL/CLINIC 11 (GO TO 622)
GOVERNMENT HEALTH CENTER 12 (GO TO 622)
VCT CENTER 13 (GO TO 622)
GOVERNMENT HEALTH POST 14 (GO TO 622)
FAMILY PLANNING CLINIC 15 (GO TO 622)
STAND ALONE VCT CENTER 16 (GO TO 622)
OTHER PUBLIC (SPECIFY) ________17 (GO TO 622)
NON-GOVERNMENT (NGO) HEALTH FACILITY 21 (GO TO 622)
STAND ALONE VCT CENTER 22 (GO TO 622)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR 31 (GO TO 622)
STAND ALONE VCT CENTER 32 (GO TO 622)
OTHER PRIVATE MEDICAL (SPECIFY) ___________________ 36 (GO TO 622)
OTHER (SPECIFY) _____________ 96 (GO TO 622)

620. Do you know of a place where people can go to get tested for the virus that causes AIDS?

YES 1
NO 2 (GO TO 622)

621. Where is that? Any other place?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
RECORD ALL SOURCES MENTIONED.

NAME OF PLACE_____________
PUBLIC SECTOR
GOVERNMENT HOSPITAL/CLINIC A
GOVERNMENT HEALTH CENTER B
VCT CENTER C
GOVERNMENT HEALTH POST D
FAMILY PLANNING CLINIC E
STAND ALONE VCT CENTER F
OTHER PUBLIC (SPECIFY) ________G
NON-GOVERNMENT (NGO) NGO HEALTH FACILITY H
STAND ALONE VCT CENTER I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR J
STAND ALONE VCT CENTER K
OTHER PRIVATE MEDICAL (SPECIFY) ___________________ L
OTHER (SPECIFY) _____________ M

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

YES 1
NO 2
DON’T KNOW 8

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

YES, REMAIN A SECRET 1
NO 2
DON’T KNOW/NOT SURE/DEPENDS 8

624. If a relative of yours became sick with the virus that causes AIDS, would you be willing to care for her or him in your own household?

YES 1
NO 2
DON’T KNOW/NOT SURE/DEPENDS 8

625. 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?

SHOULD BE ALLOWED 1
SHOULD NOT BE ALLOWED 2
DON’T KNOW/NOT SURE/DEPENDS 8

626. Do you personally know someone who is suspected to have the AIDS virus or who has the AIDS virus?

YES 1
NO 2 (GO TO 630)

627. Do you personally know someone who has been denied health services in the last 12 months because he or she is suspected to have the AIDS virus or has the AIDS virus?

YES 1
NO 2

628. Do you personally know someone who has been denied involvement in social events, religious services, or community events in the last 12 months because he or she is suspected to have the AIDS virus or has the AIDS virus?

YES 1
NO 2

629. Do you personally know someone who has been verbally abused or teased in the last 12 months because he or she is suspected to have the AIDS virus or has the AIDS virus?

YES 1
NO 2

630. Do you agree or disagree with the following statement:
People with the AIDS virus should be ashamed of themselves.

AGREE 1
DISAGREE 2
DON’T KNOW/NO OPINION 8

631. Do you agree or disagree with the following statement:
People with the AIDS virus should be blamed for bringing the disease into the community.

AGREE 1
DISAGREE 2
DON’T KNOW/NO OPINION 8

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

YES 1
NO 2
DON’T KNOW/NOT SURE/DEPENDS 8

633. Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid AIDS?

YES 1
NO 2
DON’T KNOW/NOT SURE/DEPENDS 8

634. CHECK 601:

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?

YES 1
NO 2

635. CHECK 412:

HAD SEXUAL INTERCOURSE (GO TO 636)
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 643)

636. CHECK 634:

HEARD ABOUT INFECTION TRANSMITTED THROUGH SEXUAL CONTACT (GO TO 637)
HAS NOT HEARD ABOUT INFECTION TRANSMITTED THROUGH SEXUAL CONTACT (GO TO 638)

637. 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?

YES 1
NO 2
DON’T KNOW 8

638. Sometimes men experience a bad smelling abnormal genital discharge. During the last 12 months, have you had a bad smelling abnormal genital discharge?

YES 1
NO 2
DON’T KNOW 8

639. Sometimes men have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?

YES 1
NO 2
DON’T KNOW 8

640. CHECK 637, 638, AND 639:

HAS HAD AN INFECTION (ANY ‘YES’) (GO TO 641)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 643)

641. The last time you had (PROBLEM FROM 637/638/639) did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 643)

642. Where did you go? Any other place?
RECORD ALL SOURCES MENTIONED.

PUBLIC SECTOR
GOVERNMENT HOSPITAL/CLINIC A
GOVERNMENT HEALTH CENTER B
VCT CENTER C
GOVERNMENT HEALTH POST D
FAMILY PLANNING CLINIC E
STAND ALONE VCT CENTER F
OTHER PUBLIC (SPECIFY) ________G
NON-GOVERNMENT (NGO) HEALTH FACILITY H
STAND ALONE VCT CENTER I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR J
STAND ALONE VCT CENTER K
PHARMACY L
OTHER PRIVATE MEDICAL (SPECIFY) ___________________ L
OTHER SOURCE
DRUG VENDOR N
SHOP O
TRADITIONAL HEALER P
OTHER (SPECIFY) _____________ X

643. RECORD THE TIME.

MORNING/EVENING__
MORNING 1
EVENING 2
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 THE SUPERVISOR: _______________________________ DATE:_____________________________

EDITOR’S OBSERVATIONS:_____________________________________________

NAME OF THE EDITOR: _______________________________ DATE:_____________________________