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29 MAY 2013
MINISTRY OF HEALTH AND SOCIAL SERVICES
2013 NAMIBIA DEMOGRAPHIC AND HEALTH SURVEY
MAN'S QUESTIONNAIRE

IDENTIFICATION

NAME AND CODE OF REGION __________
PLACE (LOCALITY) NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____

MAN SELECTED FOR SECTION 9?

YES 1
NO 2

NAME AND LINE NUMBER OF MAN __________

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISIT)
DATES _____
INTERVIEWER'S NAME __________

RESULT __________

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

NEXT VISIT (REPEAT FOR SECOND AND THIRD VISIT)
DATE _____
TIME _____

LANGUAGE OF QUESTIONNAIRE _____

1 AFRIKAANS
2 DAMARA/NAMA
3 ENGLISH
4 OTJIHERERO
5 RUKWANGALI
6 SILOZI
7 OSHIWAMBO
8 OTHER

LANGUAGE OF INTERVIEW _____

1 AFRIKAANS
2 DAMARA/NAMA
3 ENGLISH
4 OTJIHERERO
5 RUKWANGALI
6 SILOZI
7 OSHIWAMBO
8 OTHER

LANGUAGE OF RESPONDENT _____

1 AFRIKAANS
2 DAMARA/NAMA
3 ENGLISH
4 OTJIHERERO
5 RUKWANGALI
6 SILOZI
7 OSHIWAMBO
8 OTHER

TRANSLATOR USED

YES 1
NO 2

SUPERVISOR
NAME __________
DATE _____

FIELD EDITOR
NAME __________
DATE _____

OFFICE EDITOR _____

KEYED BY _____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT
INFORMED CONSENT
Hello. My name is __________. I am working with the Ministry of Health and Social Services. We are conducting a survey about health all over Namibia. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any questions you don't want to answer, just let me know and I will go on to the next questions or you can stop the interview at any time.
In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.
Do you have any questions? May I begin the interview now?
SIGNATURE OF INTERVIEWER __________
DATE _____

RESPONDENT AGREES TO BE INTERVIEW 1 (GO TO 101A)
RESPONDENT DOES NOT AGREE TO BE INTERVIEW 2 (END)

101A) COLLECT ANY RELEVANT DOCUMENTS THAT MAY HAVE INFORMATION ON THE RESPONDENT AND HIS CHILDREN'S AGE.

101) RECORD THE TIME.

HOUR _____
MINUTES _____

102) In what month and year were you born?

MONTH _____
DON'T KNOW MONTH 98

YEAR _____
DON'T KNOW YEAR 9998

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

AGE IN COMPLETED YEARS _____

104) Have you ever attended school?

YES 1
NO 2 (GO TO 108)

105) What is the highest level of school you attended: primary, secondary, or higher?

PRIMARY 1
SECONDARY 2
HIGHER 3

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

GRADE/YEAR _____

107) CHECK 105:

PRIMARY (GO TO 108)
SECONDARY OR HIGHER (GO TO 110)

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

SHOW CARD TO RESPONDENT

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

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

108A) Have you ever participated in a literacy program or any other program that involved learning to read or write (not including primary school)?

YES 1
NO 2

109) CHECK 108:
CODE '2', '3', OR '4' CIRCLED (GO TO 110)
CODE '1', OR '5' CIRCLED (GO TO 111)

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

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEE 2
NOT AT ALL 3

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

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

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

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

113) What is your religion?

ROMAN CATHOLIC 1
PROTESTANT/ANGLICAN 2
ELCIN 3
SEVENTH-DAY ADVENTIST 4
NO RELIGION 5
OTHER (SPECIFY) __________ 6

114) What is the main language spoken in your home?

AFRIKAANS 01
DAMARA/NAMA 02
ENGLISH 03
HERERO 04
KWANGALI 05
LOZI 06
OSHIWAMBO 07
SAN 08
OTHER (SPECIFY __________) 96

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

NUMBER OF TIMES _____
NONE 00 (GO TO 201A)

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

YES 1
NO 2

SECTION 2. REPRODUCTION

201A) CHECK 103:
MAN AGE 15-49 (GO TO 201)
MAN AGE 50-64 (GO TO 401)

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?

YES 1
NO 2 (GO TO 206)
DON'T KNOW 3 (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 that 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 son or daughter who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of live but did not survive?

YES 1
NO 2 (GO TO 208)
DON'T KNOW (GO TO 208)

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

TOTAL CHIDLREN _____

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

TOTAL CHILDREN _____

209) CHECK 208:

HAS HAD MORE THAN ONE CHILD (GO TO 210)
HAS HAD ONLY ONE CHILD (GO TO 212)
HAS NOT HAD ANY CHILDREN (GO TO 301)

210) Did all of the children you have fathered have the same biological mother?

YES 1 (GO TO 212)
NO 2

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

NUMBER OF WOMEN _____

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

AGE IN YEARS _____

213) CHECK 203 AND 205:

AT LEAST ONE LIVING CHILD (GO TO 214)
NO LIVING CHILDREN (GO TO 301)

214) How old is your (youngest) child?

AGE IN YEARS _____

215) CHECK 214:

(YOUNGEST) CHILD IS AGE 0-2 YEARS (GO TO 216)
OTHER (GO TO 301)

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

NAME__________

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

YES 1
NO 2 (GO TO 219)
DON'T KNOW 8 (GO TO 219)

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

PRESENT 1
NOT PRESENT 2 (GO TO 219)

218A) Were you tested for HIV in any of the antenatal check-ups you attended when our wife was pregnant with (NAME)?

YES 1
NO 2 (GO TO 219)

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

HOSPITAL/HEALTH FACILITY 1 (GO TO 220)
OTHER 1

219A) What was the main reason why (NAME)'s mother did not deliver in a hospital or health facility?

COST TOO MUCH 01
FACILITY CLOSED 02
TOO FAR/NO TRANSPORTATION 03
DON'T TRUST FACILITY/ POOR QUALITY SERVICE 04
NO FEMALE PROVIDER 05
NOT THE FIRST CHILD 06
CHILD'S MOTHER DID NOT THINK IT WAS NECESSARY 07
HE DID NOT THINK IT WAS NECESSARY 08
FAMILY DID NOT THINK IT WAS NECESSARY 09
OTHER (SPECIFY __________) 96
DON'T KNOW 98

220) When a child has diarrhea, how much should he or she be given to drink: more than usual, about the same as usual, less than usual, or nothing to drink at all?

MORE THAN USUAL 1
ABOUT THE SAME 2
LESS THAN USUAL 3
NOTHING TO DRINK 4
DON'T KNOW 8

SECTION 3. CONTRACEPTION

301) Now I would like to talk about family planning- the various ways or methods that a couple can use or delay or avoid a pregnancy. Have you ever heard of (METHOD)?

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 chidlren.
YES 1
NO 2
03) IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
04) 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
05) IMPLANTS: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2
06) PILL: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
07) CONTRACEPTIVE PATCH (EVRA): Women can have a transdermal patch applied to their skin that releases synthetic estrogen and progestin hormones to prevent pregnancy.
YES 1
NO 2
08) CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
09) FEMALE CONDOM: Women can place a sheath in their vagine before sexual intercourse.
YES 1
NO 2
10) LACTATIONAL AMENORRHEA METHOD (LAM).
YES 1
NO 2
11) RHYTHM METHOD: To avoid pregnancy, women do not have sexual intercourse on the days of the month they think they can get pregnant.
YES 1
NO 2
12) WITHDRAWL: Men can be careful and pull out before climax or ejaculation.
YES 1
NO 2
13) EMERGENCY CONTRACEPTION: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
YES 1
NO 2
14) Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
SPECIFY __________
YES 1
NO 2

302) In the last few months have you:

Heard about family planning on the RADIO?
YES 1
NO 2
Seen anything about family planning on the TELEVISION?
YES 1
NO 2
Read about family planning in a NEWSPAPER or MAGAZINE?
YES 1
NO 2

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

YES 1
NO 2

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

From on menstrual period to the next, are there certain days when a woman is more likely to become pregnant when she has sexual relations?

YES 1
NO 2 (GO TO 306)
DON'T KNOW (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 __________) 5
DON'T KNOW 8

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

a) Contraception is a woman's business and a man should not have to worry about it.
AGREE 1
DISAGREE 2
DON'T KNOW 3
b) Women who use contraception may become promiscuous.
AGREE 1
DISAGREE 2
DON'T KNOW 3

307) CHECK 301 (08):
KNOWS MALE CONDOM

YES (GO TO 308)
NO (GO TO 311)

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

YES 1
NO 2 (GO TO 311)

309) Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTIOR, WRITE THE NAME OF THE PLACE.

NAME OF PLACE __________
PUBLIC SECTOR
GOVT. HOSPITAL A
GOVT. HEALTH CENTER B
GVT. PRIMARY HEALTH CARE CLINIC C
OUTREACH POINT D
MOBILE CLINIC E
FIELDWORKER/COMMUNITY HEALTH CARE PROVIDER F
OTHER PUBLIC SECTOR (SPECIFY __________) G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL H
PRIVATE CLINIC I
PHARMACY J
PRIVATE DOCTOR K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) L
OTHER SOURCE
SHOP M
CHURCH N
FRIEND/RELATIVE O
SCHOOL P
OTHER (SPECIFY __________) X

310) If you wanted to, could you yourself get a condom?

YES 1
NO 2

311) CHECK 301 (09):
KNOWS FEMALE CONDOM

YES (GO TO 312)
NO (GO TO 401)

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

YES 1
NO 2 (GO TO 401)

313) Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTIOR, WRITE THE NAME OF THE PLACE.

NAME OF PLACE __________
PUBLIC SECTOR
GOVT. HOSPITAL A
GOVT. HEALTH CENTER B
GVT. PRIMARY HEALTH CARE CLINIC C
OUTREACH POINT D
MOBILE CLINIC E
FIELDWORKER/COMMUNITY HEALTH CARE PROVIDER F
OTHER PUBLIC SECTOR (SPECIFY __________) G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL H
PRIVATE CLINIC I
PHARMACY J
PRIVATE DOCTOR K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) L
OTHER SOURCE
SHOP M
CHURCH N
FRIEND/RELATIVE O
SCHOOL P
OTHER (SPECIFY __________) X

314) If you wanted to, could you yourself get a female condom?

YES 1
NO 2

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401) Are you currently married or living together with a women as if married?

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

402) Have you ever been married or live together with a woman as if married?

YES, FORMERLY MARRIED 1
YES, LIVED WITH A WOMAN 2
NO 3 (GO TO 413)

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

WIDOWED 1 ( GO TO 410)
DIVORCED 2 (GO TO 410)
SEPARATED 3 (GO TO 410)

404) Is your (wife/partner) living with you now or is she staying elsewhere?

LIVING WITH HIM 1
STAYING ELSEWHERE 2

405) Do you have other wives or do you live with other women as if married?

YES (MORE THAN ONE) 1
NO (ONLY ONE) 2 (GO TO 407)

406) Altogether, how many wives or live-in partners do you have?

TOTAL NUMBER OF WIVES AND LIVE-IN PARTNERS _____

407) CHECK 405:
RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER.
IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

ONE WIFE/PARTNER:
Please tell me the name of (your wife/the woman you are living with as if married).

NAME __________
LINE NUMBER _____

MORE THAN ONE WIFE/PARTNER:
Please tell me the name of each of your wives or each woman you are living with as if married.

NAME __________
LINE NUMBER _____

408) How old was (NAME) on her last birthday? ASK 408 FOR EACH PERSON

NAME __________
LINE NUMBER _____
AGE _____

409) CHECK 407:

ONE WIFE/PARTNER (GO TO 410)
MORE THAN ONE WIFE/ PARTNER (GO TO 411A)

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

ONLY ONCE 1
MORE THAN ONCE 2 (GO TO 411A)

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

MONTH _____
DON'T KNOW MONTH 98

411A) Now I would like to ask about your first (wife/partner). In what month and year did you start living with her?

MONTH _____
DON'T KNOW MONTH 98

YEAR _____
DON'T KNOW YEAR 9998

412) How old were you when you first started living with her?

AGE _____

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

414) Now I would like to ask some questions about sexual activities in order to gain a better understanding of some important life issues.
How old were you when you had sexual intercourse for the very first time?

AGE IN YEARS _____
NEVER HAD SEXUAL INTERCOURSE 00 (GO TO 501A)
FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE/PARTNER 95

415) Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question.

416) When was the last time you had sexual intercourse?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

DAYS AGO 1 _____
WEEKS AGO 2 _____
MONTHS AGO 3 _____
YEARS AGO 4 _____ (GO TO 430)

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

DAYS AGO 1 _____
WEEKS AGO 2 _____
MONTHS AGO 3 _____

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

YES 1
NO 2 (GO TO 420)

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

YES 1
NO 2 (GO TO 420)

420) What was your relationship to this person with whom you had sexual intercourse?
IF YES, CIRCLE '2'
If NO, CIRLCE '3'

IF GIRLFRIEND: Were you living together as if married?

WIFE 1
LIVE IN PARTNER 2
GIRLFRIEND NO LIVING WITH RESPONDENT 3 (GO TO 423)
CASUAL ACQUAINTANCE 4 (GO TO 423)
CLIENT/ PROSTITUTE 5 (GO TO 423)
OTHER (SPECIFY) __________ 6 (GO TO 423)

421) CHECK 410:

MARRIED ONLY ONCE (CONTINUE)
MARRIED MORE THAN ONCE OR BLANK (GO TO 423)

422) CHECK 414:

FIRST TIME WHEN STARTED LIVING WITH FIRST WIFE (GO TO 424)
OTHER (GO TO 423))

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

DAYS AGO 1 _____
WEEKS AGO 2 _____
MONTHS AGO 3 _____
YEARS AGO 4 _____

424) 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 TIMES IS 95 OR MORE, WRITE '95'

NUMBER OF TIMES _____

425) How old is this person?

AGE OF PARTNER _____
DON'T KNOW 98

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 417 IN NEXT COLUMN)
NO (GO TO 428)

427) In total, with how many different people have you had sexual intercourse in the last 12 months?
IF NON NUMBERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95"

NUMBER OF PARTNERS LAST 12 MONTHS _____
DON'T KNOW 98

428) CHECK 420 (ALL COLUMNS):

AT LEAST ONE PARTNER IS PROSTITUTE (GO TO 429)
NO PARTNERS ARE PROSTITUES (GO TO 430)

429) CHECK 420 AND 418 (ALL COLUMNS):

CONDOM USED WITH PROSTITUE (GO TO 433)
OTHER (GO TO 434)

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

YES 1 (434)
NO 2

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

YES 1 (GO TO 434)
NO 2 (GO TO 434)

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

YES 1
NO 2 (GO TO 434)

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

YES 1
NO 2
DON'T KNOW 8

434) In total, with how many different people have you had sexual intercourse in your lifetime?
IF NON-NUMBERIC ANSWER, PROBE TO GET ESTIMATE.
IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95'.

NUMBER OF PARTNERS IN LIFETIME _____
DON'T KNOW 98

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

CONDOM USED (GO TO 436)
NOT ASKED (GO TO 438)
NO CONDOM USED (GO TO 438)

436) You told me that a condom was used the last time you had sex. What is the brand name of the condom used at that time?
IF BRAND IS NOT KNOWN, ASK TO SEE THE PACKAGE.

SMILE 01
COOL RIDER 02
SENSE 03
FEMIDOM 04
OTHER (SPECIFY) _________ 96
DON'T KNOW 98

437) From where did you obtain the condom the last time?
PROBE TO IDENTIFY TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) __________
PUBLIC SECTOR
GOVT. HOSPITAL 11
GOVT. HEALTH CENTER 12
GVT. PRIMARY HEALTH CARE CLINIC 13
OUTREACH POINT 14
FIELDWORKER/COMMUNITY HEATLH CARE PROVIDER 15
OTHER PUBLIC SECTOR (SPECIFY) __________ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
PRIVATE CLINIC 22
PHARMACY 23
PRIVATE DOCTOR 24
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) __________ 26
OTHER SOURCE
SHOP 31
CHURCH 32
FRIEND/RELATIVE 33
SCHOOL 34
OTHER (SPECIFY) __________ 96

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

YES 1
NO 2 (GO TO 501A)
DON'T KNOW 8 (GO TO 501A)

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.

FEMALE STERILIZATION A
MALE STERILIZATION B
IUD C
INJECTABLES D
IMPLANTS E
PILL F
CONTRACEPTIVE PATCH G
CONDOM H
FEMALE CONDOM I
DIAPHRAGM J
FOAM/JELLY K
LACTATIONAL AMEN. METHOD L
RHYTHM METHOD M
WITHDRAWAL N
OTHER MODERN METHOD X
OTHER TRADITIONAL METHOD Y

SECTION 5. FERTILITY PREFERENCES

501A) CHECK 103:
MAN AGE 15-49 (GO TO 501)
MAN AGE 50-64 (GO TO 601)

501) CHECK 401:
CURRENTLY MARRIED OR LIVING WITH A PARTNER (GO TO 502)
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 509)

502) CHECK 439:
MAN NO STERILIZED (GO TO 503)
MAN STERILIZED (GO TO 509)

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

YES 1
NO 2 (GO TO 505)
DON'T KNOW 8 (GO TO 505)

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

HAVE ANOTHER CHILD (GO TO 506)
NO MORE (GO TO 509)
UNDECIDED/DON'T KNOW (GO TO 509)

505) 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?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 509)
SAYS COUPLE CAN'T GET PREGNANT 3 (GO TO 509)
WIFE (WIVES)/PARTNER(S) STERLIZED 4 (GO TO 509)
UNDECIDED/DON'T KNOW (GO TO 509)

506) CHECK 407:

ONE WIFE/PARTNER (CONTINUE)
MORE THAN ONE WIFE/PARTNER (GO TO 508)

507) CHECK 503:

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

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

MONTHS___ 1 (GO TO 509)
YEARS_____ 2 (GO TO 509) (GO TO 509)
SOON/NOW 993 (GO TO 509)
COUPLE INFECUND 994 (GO TO 509)
OTHER (SPECIFY)_____ 996 (GO TO 509)
DON'T KNOW 998 (ALL GO TO 509)

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

MONTHS 1 ____
YEARS 2 ____

SOON/NOW 993
HE/ALL HIS WIVES/PARTNERS ARE INFECUND 994
OTHER (SPECIFY) ____ 996
DON'T KNOW 998

509) CHECK 203 AND 205:

HAS LIVING CHILDREN:
If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?

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

NONE 00 (GO TO 601)
NUMBER____
OTHER (SPECIFY)_______ 96 (GO TO 601)

510) How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter if it's a boy or girl?

BOYS _____
GIRLS _____
EITHER _____
OTHER (SPECIFY __________) 96

SECTION 6. EMPLOYMENT AND GENDER ROLES

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

YES 1 (GO TO 604)
NO 2

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

YES 1 (GO TO 604)
NO 2

603) Have you done any work in the last 12 months?

YES 1
NO 2 (GO TO 607)

604) What is your occupation, that is, what kind of work do you mainly do?

OCCUPATION __________

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

THROUGHOUT THE YEAR 1
SEASONALLY/ PART OF THE YEAR 2
ONCE IN A WHILE 3

606) 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

607) CHECK 401:

CURRENTLY MARRIED OR LIVING WITH A PARTNER (GO TO 608)
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 612)

608) CHECK 606:

CODE 1 OR 2 CIRCLED (CONTINUE)
OTHER (GO TO 610)

609) Who usually decides how the money you earn will be used: you, your (wife/partner), or you and your (wife/partner) jointly?

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/ PARTNER JOINTLY 3
OTHER (SPECIFY __________) 4

610) Who usually makes decisions about health care for yourself: you, your (wife/partner), you and your (wife/partner) jointly or someone else?

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/ PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY __________) 6

611) Who usually makes decisions about making major household purchases?

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/ PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY __________) 6

612) Do you own this or any other house either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

613) Do you own any land either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

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

If she goes out without telling him?
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
If she is friendly with other men?
YES 1
NO 2
DON'T KNOW

SECTION 7. HIV/AIDS

701) Now I would like to talk about something else. Have you ever heard of HIV/AIDS?

YES 1
NO 2 (GO TO 723)

702) Can people reduce their chances of getting HIV by having just one uninfected sex partner who has no other sex partners?

YES 1
NO 2
DON'T KNOW 8

703) Can people get HIV from mosquito bites?

YES 1
NO 2
DON'T KNOW 8

704) Can people reduce their chance of getting HIV by using a condom everything they have sex?

YES 1
NO 2
DON'T KNOW 8

705) Can people get HIV by sharing food with a person who has AIDS?

YES 1
NO 2
DON'T KNOW 8

706) Can people get HIV because of witchcraft or other supernatural means?

YES 1
NO 2
DON'T KNOW 8

707) Is it possible for a health-looking person to have HIV?

YES 1
NO 2
DON'T KNOW 8

708) Can HIV be transmitted from her 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

709) CHECK 708:

AT LEAST 1 YES (CONTINUE)
OTHER (GO TO 711)

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?

YES 1
NO 2
DON'T KNOW 3

711) CHECK FOR PRESENCE OF OTHERS BEFORE CONTINUING, MAKE EFFORT TO ENSURE PRIVACY.

712) Have you ever been tested to see if you have HIV?

YES 1
NO 2 (GO TO 716)

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

MONTHS AGO _____
TWO OR MORE YEARS AGO 95

714) Did you get the results of the test?

YES 1
NO 2 (GO TO 715)

714A) Will you be willing to share the results with me?

YES 1
NO 2 (GO TO 714C)

714B) What was your HIV test result?

POSITIVE 1
NEGATIVE 2

714C) All men are supposed to receive counseling before and after being tested. Before and after you were tested, did you receive counseling?

YES 1
NO 2

714D) Have you disclosed your result to your partner?

YES 1
NO 2
NO PARTNER 3

715) Where was the test done?
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) __________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVT. HEALTH CENTER 12
STAND-ALONE VCT CENTER 13
GVT PRIMARY HEALTH CARE CLINIC 14
OUTREACH PROINT 15
MOBILE CLINIC 16
SCHOOL BASED CLINIC 17
OTHER PUBLIC SECTOR 18 (SPECIFY __________)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR 21
STAND ALONG VCT CENTER 22
PHARMACY 23
MOBILE CLINIC 24
FIELDWORKER 25
SCHOOL BASED CLNIC 26
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) 27
OTHER SOURCE
HOME 31
CORRECTIONAL FACILITY 32
OTHER (SPECIFY __________) 96

715A) Did you receive HIV counseling and testing individually or as a couple?

INDIVIDUALLY 1
COUPLE 2 (GO TO 715D)

715B) Would you consider HIV counseling and testing as a couple in the future?

YES 1 (GO TO 715D)
NO 2

715C) What is the main reason you would not consider HIV counseling as a couple in the future?

PARTNER REFUSES 1
DISTANCE TO SERVICE DELIVERY 2
NO TIME 3
SERVICE DELIVERY HOURS 4
OTHER (SPECIFY __________) 6

715D) CHECK 714B: HIV TEST RESULT

POSITIVE TEST RESULT (CONTINUE)
NEGATIVE OR BLANK (GO TO 718)

715E) Are you currently taking ARV's daily?

YES 1 (GO TO 718)
NO 2

715F) What is the main reason for not taking ARV's daily?

TRANSPORTATION COST 1 (GO TO 718)
RELIGCIOUS REASONS 2 (GO TO 718)
FOOD/NUTRITIONAL ISSUES 3 (GO TO 718)
SIDE EFFECTS 4 (GO TO 718)
FEAR OF BEING SEEN AT ARV CLINIC 5 (GO TO 718)
OTHER (SPECIFY __________) 6 (GO TO 718)

716) Do you know of a place where people can go to get tested for HIV?

YES 1
NO 2 (GO TO 718)

717) Where is that? Any other places?
PROBE TO IDENITFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE) __________
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVT. HEALTH CENTER B
STAND-ALONE VCT CENTER C
GVT PRIMARY HEALTH CARE CLINIC D
OUTREACH PROINT E
MOBILE CLINIC F
SCHOOL BASED CLINIC G
OTHER PUBLIC SECTOR H (SPECIFY __________)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR I
STAND ALONG VCT CENTER J
PHARMACY K
MOBILE CLINIC L
FIELDWORKER M
SCHOOL BASED CLNIC M
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) O
OTHER SOURCE
HOME P
CORRECTIONAL FACILITY Q
OTHER (SPECIFY __________) X

718) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?

YES 1
NO 2
DON'T KNOW 3

719) If a member of your family got infected with HIV, would you want it to remain a secret or not?

YES, REMAIN A SECRET 1
NO 2
DK/NOT SURE/DEPENDS 8

720) If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?

YES 1
NO 2
DK/NOT SURE/DEPENDS 8

721) In your opinion, if a female teacher has HIV but is not sick, should she be allowed to continue teaching in the school?

SHOULD BE ALLOWED 1
SHOULD NOT BE ALLOWED 2
DK/NOT SURE/DEPENDS 8

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

YES 1
NO 2
DK/NOT SURE/DEPENDS 3

723) CHECK 701:

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

YES 1
NO 2

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

YES 1
NO 2

724) CHECK 414:

HAS HAD SEXUAL INTERCOURSE (GO TO 725)
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 732)

725) CHECK 723: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTION?

YES (CONTINUE)
NO (GO TO 727)

726) 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

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

YES 1
NO 2
DON'T KNOW 8

728) Sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer near your penis?

YES 1
NO 2
DON'T KNOW 8

729) CHECK 726, 727, AND 728:

HAS HAD AN INFECTION (ANY 'YES') (GO TO 730)
HAS NOT HAD AN INFECTION OR DONT NOT KNOW (GO TO 732)

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

YES 1
NO 2 (GO TO 732)

731) Where did you go? Any other place?
PROVE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) __________
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVT. HEALTH CENTER B
STAND-ALONE VCT CENTER C
GVT PRIMARY HEALTH CARE CLINIC D
OUTREACH PROINT E
MOBILE CLINIC F
SCHOOL BASED CLINIC G
OTHER PUBLIC SECTOR H (SPECIFY __________)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR I
STAND ALONG VCT CENTER J
PHARMACY K
MOBILE CLINIC L
FIELDWORKER M
SCHOOL BASED CLNIC N
OTHER PRIVATE MEDICAL SECTOR (SPECIFY __________) L
OTHER SOURCE
HOME O
CORRECTIONAL FACILITY P
OTHER (SPECIFY __________) X

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

YES 1
NO 2
DON'T KNOW 8

733) Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women?

YES 1
NO 2
DON'T KNOW 8.

SECTION 8. HEALTH ISSUES

801) Now I would like to ask you some other questions relating to health matters. Some men are circumcised, that is, the foreskin is completely removed from your penis. Are you circumcised?

YES 1
NO 2 (GO TO 804A)
DON'T KNOW 8 (GO TO 804A)

802) How old were you when you got circumcised?

AGE IN COMPLETED YEARS _____
DURING CHILDHOOD (LESS THAN 5 YEARS) 95
DON'T KNOW 98

803) Who did the circumcision?

TRADITIONAL/PRACTIONIONER/FAMILY/FRIEND 1
HEALTH WORKER/PROFESSIONAL 2
OTHER 3
DON'T KNOW 8

804) Where was it done?

HEALTH FACILITY 1
HOME OF A HEALTH WORKER/ PROFESSIONAL 2
CICUMCISION DONE AT HOME 3
RITUAL SITE 4
OTHER HOME/PLACE 5
DON'T KNOW 8

804A) If you had a baby boy, would you have him circumcised?

YES 1
NO 2
DON'T KNOW 8

804B) Are there any benefits to male circumcision?

YES 1
NO 2 (GO TO 804D)
DON'T KNOW 8 (GO TO 804D)

804C) What are the benefits of male circumcision? RECORD ALL MENTIONED.

RECOMMENDED BY TRADITION/RELIGION A
GOOD FOR HEALTH/HYGIENE B
PROTECTS AGAINST GETTING HIV C
PROTECTS AGAINST GETTING STDS D
INCREASE SEXUAL SATISFACTION E
EASIER TO PUT ON CONDOM F
OTHER (SPECIFY __________) X
DON'T KNOW Z

804D) Have you ever heard of an illness called tuberculosis or TB?

YES 1
NO 2 (GO TO 805)

804E) 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

804F) What symptoms will a person with tuberculosis or TB have? Anything else?
RECORD ALL MENTIONED.

PERSISTENT COUGH (GREATER THAN TWO WEEKS) A
WEIGHT LOSS B
POOR APPETITE C
NIGHT SWEATING D
CHEST PAIN E
FEVER F
OTHER (SPECIFY __________) X
DON'T KNOW Z

804G) Can tuberculosis be cured?

YES 1
NO 2
DON'T KNOW 8

804H) 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

805) 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.

NUMBER OF INJECTIONS _____
NONE 00 (GO TO 808)

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 90 OR MORE, 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 808)

807) The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

YES 1
NO 2
DON'T KNOW 8

808) Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 810)

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

NUMBER OF CIGARETTES _____

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

YES 1
NO 2 (GO TO 811C)

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

PIPE A
CHEWING TOBACCO B
BETEL C
SNUFF D
HUBBLY BUBBLY E
MARIJUANA F
OTHER (SPECIFY __________) X

811A) Do you use or smoke tobacco products daily?

YES 1
NO 2 (GO TO 811C)

811B) How old were you when first started using any tobacco products daily?

AGE IN YEARS _____

811C) Have you ever consumed an alcoholic drink, such as beer, wine, spirits, or other home-brewed liquor?

YES 1
NO 2 (GO TO 812)

811F) Have you consumed an alcoholic drink during the past two weeks?

YES 1
NO 2 (GO TO 812)

811G) During the past two weeks, on how many days did you have at least one alcoholic drink?

NUMBER OF DAYS _____
DON'T KNOW/NOT SURE 98

811H) During the past two weeks, when you consumed alcohol, on average, how many bottles/glasses/tots or alcohol did you have per day?

NUMBER OF DRINKS _____
DON'T KNOW/NOT SURE 98

812) Are you covered by any health insurance?

YES 1
NO 2 (GO TO 812A)

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

HEALTH INSURANT THROUGH EMPLOYER A
SOCIAL SECURITY B
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE C
OTHER (SPECIFY __________) X

813A) Are you involved in exercise that causes an increase in your heart rate for at least 10 minutes continuously? IF YES, ASK: At work?

During other physical activities?

NO 1 (GO TO 813E)
YES AT WORK 2 (GO TO 813E)
YES OTHER PHYSICAL ACTIVITY 3

813B) In the last 7 days, on how many days did you do exercise that lasted for at least 10 minutes each time? IF 'NONE' RECORD '0'

NUMBER OF DAYS _____
DON'T KNOW/NOT SURE 8

813E) Now I would like to ask you about liquids and foods that you consume. How many glasses of water do you drink in one day on average? IF 'NONE' RECORD '00'.

NUMBER OF GLASSES _____

813F) In a typical week, on how many days do you eat fruits, such as apples, pears, oranges, bananas, mangoes, etc? IF 'NONE' RECORD '0'

NUMBER OF DAYS _____
DON'T KNOW/NOT SURE 8 (GO TO 313H)

813G) On a day when you eat fruits, how many times do you eat on average? IF 'NONE' RECORD '0'

NUMBER OF TIMES _____
DON'T KNOW/NOT SURE _____

813H) In the past 30 days, when you were seated in a vehicle either as a driver or passenger, have you used a seatbelt always, sometimes or never?

ALL THE TIME 1
SOMETIME 2
NEVER 3
HAVE NOT BEEN IN VEHICLE IN PAST 30 DAYS 4
NO SEATBELT IN CAR 5
DON'T KNOW/NOT SURE 8

813N) CHECK 103:

MAN AGE 40-64 (CONTINUE)
MAN AGE 15-39 (GO TO 813Q)

813O) Have you ever heard of prostate cancer?

YES 1
NO 2 (813Q)

813P) Have you ever had a test or exam to see if you have prostate cancer?

YES 1
NO 2
DON'T KNOW 8

813Q) Now I would like to ask some questiosn about mental health. Are there times when you see or hear things that are actually not there?

YES 1
NO 2

813R) In the past 12 months, have you ever felt seriously worthless, hopeless, or wished you were dead?

YES 1
NO 2

813S) In the past two weeks, have you felt that you had little interest or pleasure in doing things?
IF YES, ASK: How many days did you feel this way?

NUMBER OF DAYS _____
YES 1
NO 2
DON'T KNOW/NOT SURE 8

813T) In the past two weeks, have you felt very low in energy, been in a bad mood, or been sad all the time?
IF YES, ASK: How many days did you feel this way?

NUMBER OF DAYS 1 _____
YES 1
NO 2
DON'T KNOW/NOT SURE 8

813U) CHECK 813Q, 813R, 813S, AND 813T:

YES TO ANY (CONTINUE)
NO/DK/NOT SURE TO ALL (GO TO 901A)

813V) Did you seek any medical care?

YES 1
NO 2

SECTION 9. DOMESTIC VIOLENCE

901A) CHECK HOUSEHOLD QUESTIONNAIRE.

MAN 15-49 SELECTED FOR THIS SECTION (CONTINUE)
MAN NOT SELECTED (GO TO 933)

901B) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

PRIVACY OBTAINED 1 (CONTINUE)
PRIVACY NOT POSSIBLE 2 (GO TO 932)

READ TO THE RESPONDENT:
Now I would like to ask you questions about some other important aspects of a man's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition or men in Namibia. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions.

902) CHECK 401 AND 402:

CURRENTLY MARRIED/ LIVING WITH A WOMAN (CONTINUE)
FORMERLY MARRIED/ LIVED WITH A WOMAN (READ IN PAST TENSE AND USE 'LAST' WITH WIFE/PARTNER)

903) First, I am going to ask you about some situations which happen to some men. Please tell me if these apply to your relationship with your (last) (wife/partner)?

a) She (is/was) jealous or angry if you (talk/talked) to other women?
YES 1
NO 2
DON'T KNOW 8
b) She frequently (accuses/accused) you of being unfaithful?
YES 1
NO 2
DON'T KNOW 8
c) She (does/did) not permit you to meet your male friends?
YES 1
NO 2
DON'T KNOW 8
d) She (tries/tried) to limit your contact with your family?
YES 1
NO 2
DON'T KNOW 8
e) She (insists/insisted) on knowing where you (are/were) at all times?
YES 1
NO 2
DON'T KNOW 8
f) She doesn't trust you with money/finances?
YES 1
NO 2
DON'T KNOW 8

904) Now I need to ask you some more questions about your relationship with your (last) (wife/partner):

A) Did your (last) (wife/partner) ever:

a) say or do something to humiliate you in front of others?
YES 1
NO
b) threaten to hurt or harm you or someone you care about?
YES 1
NO 2
c) insult you or make you feel bad about yourself?
YES 1
NO 2

B) How did this happen during the last 12 months: often, only sometimes, or not at all?

a) say or do something to humiliate you in front of others?
OFTEN 1
SOMETIMES 2
NOT IN THE LAST 12 MONTHS
b) threaten to hurt or harm you or someone you care about?
OFTEN 1
SOMETIMES 2
NOT IN THE LAST 12 MONTHS 3
c) insult you or make you feel bad about yourself?
OFTEN 1
SOMETIMES 2
NOT IN THE LAST 12 MONTHS 3

905) A) Did your (last) (wife/partner) ever do any of the following things to you?

a) push you, shake you, or throw something at you?
YES 1
NO 2
b) slap you?
YES 1
NO 2
c) twist your arm or pull your hair?
YES 1
NO 2
d) punch you with her fist or with something that could hurt you?
YES 1
NO 2
e) kick you, drag you, or beat you up?
YES 1
NO 2
f) try to choke you or burn you on purpose?
YES 1
NO 2
g) threaten or attack you with a knife, gun, or other weapon?
YES 1
NO 2
h) physically for you to have sexual intercourse with her when you did not want to?
YES 1
NO 2
i) physically force you to perform any other sexual acts you did not want to?
YES 1
NO 2
j) force you with threats or in any other way to perform sexual acts you did not want to?
YES 1
NO 2

B) How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) push you, shake you, or throw something at you?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) slap you?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) twist your arm or pull your hair?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
d) punch you with her first or with something that could hurt you?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
e) kick you, drag you, or beat you up?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
f) try to choke you or burn you on purpose?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
g) threaten or attack you with a knife, gun, or other weapon?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
h) physically force you to have sexual intercourse with her when you did not want to?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
i) physically force you to perform any other sexual acts you did not want to?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
j) force you with threats or in any other way to perform sexual acts you did not want to?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

906) CHECK 905A (a-j):

AT LEAST ONE 'YES' (CONTINUE)
NOT A SINGLE 'YES' (GO TO 909)

907) How long after you first (got married/started living together) with your (last) (wife/partner) did (this/any of these things) first happen?
IF LESS THAN ONE YEAR, RECORD '00'.

NUMBER OF YEARS _____
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95

908) Did the following ever happen as a result of what your (last) (wife/partner) did to you:

a) You had cuts, bruises, or aches?

YES 1
NO 2

b) You had eye injuries, sprains, dislocations, or burns?

YES 1
NO 2

c) You had deep wounds, broken bones, broken teeth, or any other serious injury?

YES 1
NO 2

909) Have you ever hit, slapped, kicked, or done anything else to physically hurt your (last) (wife/partner) at times when she was not already beating or physically hurting you?

YES 1
NO 2 (GO TO 911)

910) In the last 12 months, how often have you dont this to your (last) (wife/partner): often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

911) Does (did) your (last) (wife/partner) drink alcohol?

YES 1
NO 2 (GO TO 913)

912) How often does (did) she get drunk: often, only sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

913) Are (were) you afraid of your (last) (wife/partner): most of the time, sometimes, or never?

MOST OF THE TIME AFRAID 1
SOMETIMES AFRAID 2
NEVER AFRAID 3

914) CHECK 410:

MARRIED MORE THAN ONCE (CONTINUE)
MARRIED ONLY ONCE (GO TO 916)

915) A) So far we have been talking about the behavior of your (current/last) (wife/partner). Now I want to ask you about the behavior of any previous (wife/partner).

a) Did any previous (wife/partner) ever hit, slap, or kick, or do anything else to hurt you physically?
YES 1
NO 2
b) Did any previous (wife/partner) physically force you to have intercourse or perform any other sexual acts against your will?
YES 1
NO 2

B) How long ago did this last happen?

a) Did any previous (wife/partner) ever hit, slap, kick, or do anything else to hurt you physically?
0-9 MONTHS AGO 1
12+ MONTHS AGO 2
DON'T REMEMBER 3
b) Did any previous (wife/partner) physically force you to have intercourse or perform any other sexual acts against your will?
0-9 MONTHS AGO 1
12+ MONTHS AGO 2
DON'T REMEMBER 3

916) CHECK 401 AND 402:

EVER MARRIED/EVER LIVED WITH A WOMAN:
From the time you were 15 years old has anyone other than (your/any) (wife/partner) hit you, slapped you, kicked you, or done anything else to hurt you physically?

YES 1
NO 2 (GO TO 922)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 922)

NEVER MARRIED/NEVER LIVED WITH A WOMAN:
From the time you were 15 years old has anyone hit you, slapped you, kicked you, or done anything else to hurt you physically?

YES 1
NO 2 (GO TO 922)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 922)

917) Who has hurt you in this way? Anyone else?
RECORD ALL MENTIONED.

MOTHER/STEP-MOTHER A
FATHER/STEP-FATHER B
SISTER/BROTHER C
DAUGHTER/SON D
OTHER RELATIVE E
CURRENT GIRLFRIEND F
FORMER GIRLFRIEND G
MOTHER-IN-LAW H
FATHER-IN-LAW I
OTHER IN-LAW J
TEACHER K
EMPLOYER/SOMEONE AT WORK L
POLICE/SOLDIER M
OTHER (SPECIFY __________) X

918) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

922) CHECK 401 AND 402:

EVER MARRIED/EVER LIVED WITH A WOMAN (CONTINUE)
NEVER MARRIED/EVER LIVED WITH A WOMAN (GO TO 922B)

922A) Now I want to ask you about things that may have been done to you by someone other than (your/any) (wife/partner).

At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?

YES 1 (GO TO 923)
NO 2 (GO TO 924A)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 924A)

922B) At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?

YES 1
NO 2 (GO TO 926)
REFUSED TO ANSWER/ NO ANSWER (GO TO 926)

923) Who was the person who was forcing you the first time this happened?

CURRENT WIFE/PARTNER 01
FORMER WIFE/PARTNER 02
CURRENT/ FORMER GIRLFRIEND 03
FATHER/STEP-FATHER 04
BROTHER/ STEP-BROTHER 05
OTHER RELATIVE 06
IN-LAW 07
OWN FRIEND/ACQUAINTANCE 08
FAMILY FRIEND 09
TEACHER 10
EMPLOYER/SOMEONE AT WORK 11
POLICE/SOLDIER 12
PRIEST/RELIGIOUS LEADER 13
STRANGER 14
OTHER (SPECIFY __________) 96

924) CHECK 401 AND 402:

EVER MARRIED/EVER LIVED WITH A WOMAN:
In the last 12 months, has anyone other than (your/any) (wife/partner) physically forced you to have sexual intercourse when you did not want to?

YES 1 (GO TO 925)
NO 2 (GO TO 925)

NEVER MARRIED/ NEVER LIVED WITH A WOMAN:
In the last 12 months has anyone physically forced you to have sexual intercourse when you did not want to?

YES 1 (GO TO 925)
NO 2 (GO TO 925)

924A) CHECK 905A (h-j) and 915(b)

AT LEAST ONE 'YES' (CONTINUE)
NOT A SINGLE 'YES' (GO TO 926)

925) CHECK 401 AND 402:

EVER MARRIED/ EVER LIVED WITH A WOMAN
How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts by anyone, including (your/any) wife/partner?

AGE IN COMPLETED YEARS _____
DON'T KNOW 98

NEVER MARRIED/ NEVER LIVED WITH A WOMAN
How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?

AGE IN COMPLETED YEARS _____
DON'T KNOW 98

926) CHECK 905A (a-j), 915A (a,b), AND 922B:

AT LEAST ONE 'YES' (CONTINUE)
NOT A SINGLE 'YES' (GO TO 930)

927) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?

YES 1
NO 2 (GO TO 929)

928) From whom have you sough help? Anyone else?
RECORD ALL MENTIONED.

OWNS FAMILY A
HUSBAND'S/PARTNER'S FAMILY B
CURRENT/FORMER WIFE/PARTNER C
CURRENT/FORMER GIRLFRIEND D
FRIEND E
NEIGHBOR F
RELIGIOUS LEADER G
DOCTOR/MEDICAL PERSONNEL H
POLICE I
LAWYER J
SOCIAL SERVICE ORGANIZATION K
OTHER (SPECIFY __________) X

929) Have you ever told anyone about this?

YES 1
NO 2

930) As far as you know, did your father ever beat your mother?

YES 1
NO 2
DON'T KNOW 8

THANK THE RESPONDENT FOR HIS COOPERATION AND REASSURE HIME ABOUT THE CONFIDENTIALITY OF HIS ANSWERS. FILL OUT THE QUESTIONS BELOW THE REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

PROVIDE LIST OF REFERRAL PLACES TO RESPONDENT.

931) DID YOU HAVE THE INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

WIFE
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3
OTHER FEMALE ADULT
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3
MALE ADULT
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3

932) INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE __________

933) RECORD THE TIME

HOURS _____
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 SUPERVISOR: __________
DATE: __________

EDITOR'S OBSERVATIONS: __________

NAME OF EDITOR: __________
DATE: __________