IDENTIFICATION

PLACE NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
REGION _____

URBAN/RURAL:

CONAKRY/CAPITAL NATURAL REGION/OTHER CITY/RURAL:

NAME OF MAN _____

LINE NO. 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 2005
NAME _____
RESULT _____

TOTAL NUMBER OF VISITS _____

LANGUAGE OF QUESTIONNAIRE: FRENCH

LANGUAGE OF INTERVIEW:

INTERPRETER:

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____

KEYED BY _____

SECTION 1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENT

INTRODUCTION AND CONSENT:

CONSENT AFTER INFORMATION:
Hello. My name is ____ and I work with the National Institute of Statistics. We are conducting a national survey that asks men, women, and children about various health issues. We would very much appreciate your participation in this survey. I would like to ask you some questions about your health (and the health of your children). This information will help the government to plan health services. The survey usually takes about 20 to 45 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Participation in this survey is voluntary, and if we should come to any questions 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. 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 being the interview now?

SIGNATURE OF INTERVIEWER _____
DATE _____

101. RECORD THE TIME:

First I would like to ask some questions about you and your household

102. For most of the time until you were 12 years old, did you live in a big city, a city, or a rural location? IF A CITY, PLEASE ASK THE NAME OF THE CITY.

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

104. Just before you moved here, did you live in a big city, a city, or a rural location?
IF A CITY, ASK THE NAME OF THE CITY.

105. In the past twelve months, how many times have you traveled out of your home location and slept somewhere other than your home?

106. Have you been outside of your home location for more than one continuous month in the last 12 months?

107. In what month and what year were you born?

108. How old were you at your last birthday?
COMPARE AND CORRECT 107 AND/OR 108 IF INCONSISTENT.

109. Have you ever attended school?

110. What is the highest level of school you attended: primary, secondary 1, secondary 2, professional A, professional B, or superior?

111. What is the highest (grade/form/year) you completed at this level?

112. CHECK 110:

113. 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?

114. Have you ever participated in a literacy program or any other program that involved learning to read or write (not including primary school)?

115. CHECK 113:

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

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

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

119. Do you currently have a job of any kind, for which you earn money?

120. Have you had any kind of job in the last 12 months for which you earned money?

121. What have you done most of the time in the last 12 months?

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

123. CHECK 122:

124. 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?

125. How many months have you worked in the last 12 months?

126. Are you paid or do you earn cash of any kind for this work, or are you not paid at all?

127. Who mainly decides how the money you earn will be used?

128. On average, how much of your household's expenditures do your earnings pay for: almost none, less than half, about half, more than half, or all?

129. What is your religion?

130. What is your nationality?

131. What is your ethnicity?

132. What language do you mainly speak at home?

SECTION 2. REPRODUCTION

Now I would like to ask about any children you have had during your life. I am only interested in the children that are biologically yours.

201. Have you fathered any children?

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 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, RECORD '00'.

206. Have you ever had any sons or daughters who were born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life at birth but only survive a few hours or days?

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

208. (Other than the children you just listed), did you have any:

a) Other boys or girls who are still alive, of who you are the biological father, but who you didn't recognize and who don't have your name?

b) Other boys or girls who were born alive but later died, of who you are the biological father, but who you didn't recognize and who don't have your name?

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

210. CHECK 209:

211. Do all of your children have the same biological mother?

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

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

SECTION 3. FAMILY PLANNING

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.

CIRCLE CODE '1' IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. 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. FOR EACH METHOD WITH CODE '1' OR '2' CIRCLED IN 301, ASK 302.

301.Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?

302. Have you ever used (METHOD)?

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

303. 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?

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

305. Do you think that a woman who is breastfeeding her baby can become pregnant?

306. Now I would like to read you some statements about contraception. Please tell me if you agree or disagree with each one:

a) Contraception is a women's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous.
c) Women are the ones who get pregnant; as such she is the one who should use contraception.

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

402. How many spouses/wives live with you total?
IF ONLY ONE SPOUSE, RECORD '01'

403. Are there other women with whom you live with as if you were married?

404. Altogether, how many wives do you have/partners do you live with as if married?
IF ONLY ONE SPOUSE/PARTNER, RECORD '01'.

405. Other than the wives/partners that you just mentioned, are there currently any other women with whom you have regular or occasional sexual intercourse?

406. Do you currently have a regular or occasional sexual partner, or no sexual partner at all?

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

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

409. BASED ON THE HOUSEHOLD QUESTIONNAIRE, RECORD THE NAME AND LINE NUMBER OF EACH WIFE/PARTNER PROVIDED IN QUESTIONS 402 AND 404 ONLY. IF A WIFE/PARTNER DOESN'T LIVE IN THE HOUSEHOLD, RECORD '00' IN THE SPACE CORRESPONDING TO THAT WIFE/PARTNER. THE NUMBER OF SPACES FILLED OUT SHOULD BE EQUAL TO THE NUMBER OF WIVES AND PARTNERS.

410. CHECK 402 AND 404:

IF THE SUM OF 402 AND 404 EQUALS 1: Please tell me the name of your wife/partner.

IF THE SUM OF 402 AND 404 EQUALS 2 OR MORE: Please tell me the name of each of your current wives (and/or of each woman you are living with as if married). Start with the one who is the first you lived with. FILL OUT THE RESPONSES FOR EACH WIFE/PARTNER.

410A. How old was your wife/partner at her last birthday?
FILL OUT THE RESPONSES FOR EACH WIFE/PARTNER.

410B. CHECK 410:

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

414. CHECK 410 AND 411:

WAS MARRIED/LIVED WITH 1 WOMAN ONLY ONCE (411 CODE IS '1'): In what month and year did you start living with your wife/partner?

Q. 411 CODE IS '2' OR OTHER: I would like to ask a question about your first wife/partner. In what month and year did you start living with your first wife/partner?

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

Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family life issues.

416. How old were you when you first had sexual intercourse (if ever)?

416A. Do you intend to wait until you get married to have sexual intercourse for the first time?

416B. CHECK 108:

416C. Was a condom used the first time you had sexual intercourse?

416D. How old was the person you first had sexual intercourse with?

416E. Was this person older than you, younger than you, or about the same age as you?

416F. Would you say this person was ten or more years older than you, or less than ten years older than you?

417. When was the last time you had sexual intercourse?
IF 12 MONTHS OR MORE, ANSWER MUST BE RECORDED IN YEARS

[ASK QUESTIONS 418-434 FOR THE LAST (THREE) SEXUAL PARTNER(S)]

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

419. What is the main reason you used the condom this time?

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

421. CHECK 302 (02):

422. Check 419:

CONDOM WAS USED TO AVOID PREGNANCY ('2' OR '3' CIRCLED): The last time you had sexual intercourse with this woman, did you or your partner do something or use a method other than the condom to avoid pregnancy?

OTHER ('1', '4', '5', '6' OR '8') CIRCLED, OR QUESTION NOT ASKED: The last time you had sexual intercourse with this woman, did you or your partner do something or use a method to avoid pregnancy?

423. What method was used?
IF MORE THAN ONE METHOD USED, CIRCLE THE HIGHEST LISTED METHOD.

423A. GO TO 426.

424. CHECK 419:

425. What is the main reason you did not use a contraceptive method to avoid pregnancy?

426. The last time you had sexual intercourse with this (second, third) person, did either you or your partner drink alcohol?

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

428. 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 '02'. IF NO, CIRCLE '03'.

429. For how long (have you had/did you have) a sexual relationship with this person?
IF YOU ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAY.

434. 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 PARTNER]

435. In total, with how many different people have you had sexual intercourse with in the last 12 months?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.

436. CHECK 428 ALL COLUMNS:

436A. In the last 12 months, did you pay anyone in exchange for having sexual intercourse?

436B. The last time you paid someone in exchange for having sexual intercourse, was a condom used?

436C. Was a condom used during sexual intercourse every time you paid someone in exchange for sexual intercourse in the last 12 months?

438. In total, with how many different men have you had sex in your life?

IF NON-NUMERIC NUMBER, PROBE TO GET AN ESTIMATE.
IF THE NUMBER IF MORE THAN 95, WRITE '95'.

438B. CHECK FOR PRESENCE OF OTHER PEOPLE. DO NOT CONTINUE UNTIL YOU ARE COMPLETELY ALONE WITH RESPONDENT.

438C. The first time you had sexual intercourse, did you want to have sexual intercourse, or were you forced against your will?

438D. Did anyone make you have sexual intercourse against your will in the last 12 months?

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

440. Where is this source?
Any other place?
RECORD ALL MENTIONED.

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.

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

442. CHECK 418 ALL COLUMNS:

443. Where did you get the condom last time?

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.

444. Do you know the brand name of the condoms that you used last time?
RECORD NAME OF BRAND.

445. The last time you bought condoms, how many did you buy?

446. How much did you pay?

SECTION 5. FERTILITY PREFERENCES

501. CHECK 410:

502. Is your wife/partner (are any of your wives/partners) currently pregnant?

503. CHECK 502:

NO, WIFE/PARTNER PREGNANT OR DOESN'T KNOW: 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?

YES, WIFE/PARTNER PREGNANT: Now I have some questions about the future. After the child your wife/partner is expecting now, would you like to have another child, or would you prefer not to have any more children?

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

505. 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 throughout your whole life, how many would that be?

NO LIVING CHILDREN: If you could choose exactly the number of children to have throughout your whole life, how many would that be?

PROBE FOR A NUMERIC RESPONSE.

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?

507. Would you say that you approve or disapprove of couples using a contraceptive method to avoid getting pregnant?

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

On the radio?
On the television?
In a newspaper or a magazine?

510. In the last few months, have you discussed the practice of family planning with your friends, neighbors, or relatives?

511. With whom?
Anyone else?

RECORD ALL PERSONS MENTIONED.

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

SECTION 6. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

Now I would like to talk about something else.

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

602. Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

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

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

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

606. Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

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

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

609. What can a person do?
Anything else?

RECORD ALL WAYS MENTIONED.

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

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

During pregnancy?
During delivery?
During breastfeeding?

612. CHECK 611:

613. 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?

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

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

616. When was the last time you were tested?

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

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

619. Where was the test done?

IF SOURCE IS HOSPITAL OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

621. Where is that?
Any other place?

RECORD ALL PLACES MENTIONED.

IF SOURCE IS HOSPITAL OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

623. If a member of your family contracted the AIDS virus, would you like this to remain a secret or no?

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?

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?

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

627. 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 has (or is suspected to have) the AIDS virus?

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

629. CHECK 626, 627 AND 628:

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

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

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

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

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

635. Do you think that young men should wait until marriage to have sexual intercourse?

636. Do you think that young women should wait until marriage to have sexual intercourse?

637. Do you think that married men should avoid having sexual intercourse with people other than their spouses?

638. Do most of the men you know only have sexual intercourse with their spouses?

639. Do you think that married women should avoid having sexual intercourse with people other than their spouses?

640. Do most of the women you know only have sexual intercourse with their spouses?

641. 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?

642. If a man has a sexually transmitted disease, what symptoms might he have?
Any other sign or symptom? RECORD ALL SYMPTOMS MENTIONED.

643. If a woman has a sexually transmitted disease, what symptoms might she have?
Any other sign or symptom?
RECORD ALL SYMPTOMS MENTIONED.

644. CHECK 416:

645. CHECK 641:

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

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

647. Sometimes men have abnormal discharge from their penis. Have you had any abnormal discharge from your penis in the last 12 months?

648. 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?

649. CHECK 646, 647, AND 648:

650. The last time you had (PROBLEM FROM 646/647/648), did you seek any kind of advice or treatment?

651. Where did you go?
Any other place?

CIRCLE ALL MENTIONED.

652. The last time you had (PROBLEM FROM 646/647/648), did your partner seek any kind of advice or treatment?

653. Where did she go?
Any other place?

CIRCLE ALL MENTIONED.

654. Some men are circumcised. Are you circumcised?

SECTION 7. FEMALE CIRCUMCISION

701. Have you ever heard of female circumcision?

702. In a number of countries, there is a practice in which a girl may have part of her genitals cut. Have you ever heard of this practice?

703. What benefits do girls get if they undergo this genital cutting?
PROBE: Are there any other advantages?
RECORD ALL MENTIONED.

704. What benefits do girls get if they do not undergo this genital cutting?
PROBE: Anything else?
RECORD ALL MENTIONED.

705. CHECK 703:

706. Would you say that this practice is a way to prevent a girl from having sex before marriage or does it have no effect on premarital sex?

707. CHECK 703 AND 704:

708. Do you believe that this practice is required by your religion?

709. Do you think that this practice should be continued or should it be discontinued?

710. Do you think that women want this practice to be continued or discontinued?

711. RECORD TIME:

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW.

COMMENTS ABOUT RESPONDENT _____

COMMENTS ON SPECIFIC QUESTIONS _____

ANY OTHER COMMENTS _____

FIELD EDITOR'S OBSERVATIONS _____
NAME _____
DATE _____