Ministry of Planning and of Territory Construction
Confidential
Individual Man's questionnaire
Republic of Togo
REGION __________
PREFECTURE __________
CITY/ADMINISTRATIVE DISTRICT __________
RURAL 2
VILLAGE/NEIGHBORHOOD __________
CLUSTER NUMBER __________
PLOT NUMBER __________
HOUSEHOLD NUMBER __________
NAME OF HEAD OF HOUSEHOLD __________
MAN'S NAME AND LINE NUMBER __________ ____
DATE __________
INTERVIEWER'S NAME __________
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) __________ 7
TIME __________
FINAL VISIT:
MONTH ____
YEAR 1998
NAME __________
RESULT __________
LANGUAGE OF INTERVIEW
EWE 2
COTOKOLI 3
KABYE 4
MOBA 5
OTHER 6
NO 2
DATE __________
FIELD EDITOR
DATE __________
OFFICE EDITOR ____
KEYED BY ____
SECTION 1. RESPONDENT'S BACKGROUND
101) RECORD THE TIME
MINUTE _____
102) First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in Lome, another city, in the countryside or abroad?
(NAME OF PLACE "PREFECTURE")_________
MAIN REGIONAL LOCATION/KPALIME 2
OTHER CITY 3
COUNTRYSIDE 4
ABROAD 5
103) How long have you been continuously live in (NAME OF CURRENT PLACE OF RESIDENCE)?
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)
104) Just before you moved to (NAME OF CURRENT PLACE OF RESIDENCE), did you live in Lome, main regional location/Kpalime, in another city, in the countryside or abroad?
(NAME OF PLACE "PREFECTURE")_____________
MAIN REGIONAL LOCATION/KPALIME 2
OTHER CITY 3
COUNTRYSIDE 4
ABROAD 5
105) In what month and what year were you born?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
106) How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCORRECT
107) Have you ever attended school?
NO 2 (GO TO 110B)
108) What is the highest level of school you attended: primary, 2Nd degree, 3rd degree, or higher?
2ND DEGREE 2
3RD DEGREE 3
HIGHER 4
109) What is the highest grade you completed at this level?
(CONVERT IN NUMBERS OF YEARS COMPLETED)
SECONDARY OR HIGHER (GO TO 111A)
110B) Do you understand French easily, with difficulty, or not at all?
WITH DIFFICULTY 2
NOT AT ALL 3
111) Can you read and understand a letter, a newspaper, or any type of document easily, with difficulty, or not at all in French or in another language?
WITH DIFFICULTY 2
NOT AT ALL 3 (GO TO 113)
111A) Do you usually read a newspaper, magazine, or any type of document at least once a month?
NO 2 (GO TO 113)
112) Do you usually read a newspaper, magazine, or any type of document at least once a week?
NO 2
113) Do you usually listen to the radio often, sometimes, or never?
SOMETIMES 2
NEVER 3 (GO TO 114)
113A) What days of the week do you normally listen to the radio?
RECORD ALL RESPONSES GIVEN
IF THE RESPONSE IS "IT DEPENDS," "IT DOESN'T MATTER," OR "DON'T KNOW," YOU ONLY NEED TO RECORD ONE CODE.
TUESDAY B
WEDNESDAY D
THURSDAY E
FRIDAY F
SATURDAY G
SUNDAY H
IT DEPENDS/DOESN'T MATTER X
DON'T KNOW Z
113B) What time do you normally listen to the radio?
RECORD ALL RESPONSES GIVEN
IF THE RESPONSE IS "ALL DAY", "IT DEPENDS," "IT DOESN'T MATTER," OR "DK", YOU ONLY NEED TO RECORD ONE CODE.
FROM 8 TO 12 O'CLOCK B
FROM 12 TO 14 O'CLOCK C
FROM 14 TO 18 O'CLOCK D
FROM 18 TO 20 O'CLOCK E
AFTER 20 O'CLOCK F
ALL DAY LONG G
IT DEPENDS/DOESN'T MATTER X
DON'T KNOW Z
113C) What time of radio program do you normally listen to?
PROBE TO OBTAIN THE TYPE OF PROGRAM.
RECORD ALL THE PROGRAMS
SPORTS B
SPOKEN NEWS C
REPORTING D
SHOW ON HEALTH E
OTHER (SPECIFY) __________ X
113D) Have you had a chance to listen to the radio serial "Yamba Songo"?
NO 2 (GO TO 114)
113E) According to you, is this serial educational, or for entertainment?
ENTERTAINMENT 2 (GO TO 114)
BOTH 3
DON'T KNOW 4 (GO TO 114)
113F) According to you, what problems does "Yamba Songo" talk about?"
RECORD ALL OF THE RESPONSES GIVEN
IF THE RESPONSE IS 'DON'T KNOW,' YOU ONLY HAVE TO CIRCLE THAT CODE.
AIDS/HIV B
SEXUALLY TRANSMITTED DISEASES C
TREATMENT OF DIARRHEA/ORS D
HEALTH PROBLEMS E
OTHER (SPECIFY) __________ X
DON'T KNOW Z
114) Do you usually watch television often, sometimes, or never?
SOMETIMES 2
NEVER 3 (GO TO 115)
114A) What days of the week do you normally watch television?
RECORD ALL THE RESPONSES GIVEN
IF THE RESPONSE IS "EVERY DAY", 'IT DEPENDS,' 'DOESN'T MATTER,' OR 'DON'T KNOW,' YOU ONLY HAVE TO RECORD ONE CODE.
TUESDAY B
WEDNESDAY C
THURSDAY D
FRIDAY E
SATURDAY F
SUNDAY G
EVERY DAY H
IT DEPENDS/DOESN'T MATTER X
DON'T KNOW Z
114B) What time do you normally watch television?
RECORD ALL THE RESPONSES GIVEN
IF THE RESPONSE IS 'ALL DAY,' 'IT DEPENDS,' 'DOESN'T MATTER,' OR 'DON'T KNOW,' YOU ONLY HAVE TO RECORD ONE CODE.
FROM 12 TO 14 O'CLOCK B
FROM 14 TO 18 O'CLOCK C
FROM 18 TO 20 O'CLOCK D
AFTER 20 O'CLOCK E
ALL DAY LONG F
IT DEPENDS/DOESN'T MATTER X
DON'T KNOW Z
114C) What type of television show do you normally watch?
PROBE TO OBTAIN THE TYPE OF SHOW.
RECORD ALL OF THE SHOWS WATCHED
SPORTS B
MOVIES/SERIALS C
SPOKEN NEWS D
REPORTING E
SHOW ON HEALTH F
OTHER (SPECIFY) __________ X
115) What religion do you practice?
ISLAM 2
CATHOLIC 3
PRESBYTERIAN/METHODIST PROTESTANT 4
OTHER CHRISTIAN 5
OTHER (SPECIFY) __________ 6
NONE 7
116) What is your nationality?
OTHER (SPECIFY) __________ 2 (GO TO 118)
(NAME OF ETHNICITY) __________
AKPOSSO/AKEBOU 2
ANA-IFE 3
KABYE/TEM 4
PARA-GOURMA/AKAN 5
OTHER (SPECIFY) __________ 6
118) Are you currently working?
NO
119) Have you done any type of work in the last 12 months?
NO 2 (GO TO 201)
120) What is your occupation, that is, what kind of work do you mainly do?
____________________
____________________
DOES NOT WORK IN AGRICULTURE (GO TO 123)
122) 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?
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
123) Do you do this work for a family member, for someone else, or are you self-employed?
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3
124) Do you usually work throughout the year, or do you work seasonally, or only once in a while?
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3 (GO TO 127)
125) During the last 12 months, how many months did you work?
126) During the last 12 months, how many days a week did you usually work (in the months that you worked)?
127) During the last 12 months, approximately how many days did you work?
128) Do you earn cash for your work?
PROBE: Do you make money for working?
NO 2 (GO TO 201)
129) How much do you usually earn for this work?
PROBE: Is this by the day, by the week, by the month, or by the year?
PER DAY 2______________
PER WEEK 3______________
PER MONTH 4______________
PER YEAR 5______________
OTHER (SPECIFY) __________ 99999996
201) Now I would like to ask you about your children. I'm only interested in your biological children. Do you have or have you had children?
NO 2 (GO TO 206)
202) Do you have children who are now living with you?
NO 2 (GO TO 204)
203) How many sons live with you?
And how many daughters live with you?
IF NONE, RECORD '00'
DAUGHTERS AT HOME ____
204) Do you have any children who are alive but do not live with you?
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, RECODE '00'
DAUGHTERS ELSEWHERE ____
206) Have you ever had any children who were born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life at birth but did not survive?
NO 2 (GO TO 208)
207) How many boys have died?
And how many girls have died?
IF NONE, RECORD '00'
GIRLS DEAD ____
208) SUM ANSWERS TO Q. 203, 205, AND 207 AND ENTER TOTAL.
IF NONE, RECORD 00
209) CHECK 208:
Just to makes sure that I have this right: you have had in TOTAL ____children during your life. Is that correct?
NO (PROBE AND CORRECT 201-208 AS NECESSARY)
NEVER HAD CHILDREN (GO TO 301)
210A) In what month and year was your last child born?
YEAR 19____
BEFORE JANUARY 1995 (GO TO 301)
211) At the time you expecting this last child, did you want a child then, did you want to wait until later, or did you not want to have any (more) children?
LATER 2
NOT AT ALL 3
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. THEN PROCEED DOWN COLUMN 302, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 2 IF METHOD IS RECOGNIZED, AND CODE 3 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 301 OR 302, ASK 303.
301) Which ways or methods have you heard about?
302) Have you heard of (METHOD)?
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
NO 3
303) Have you ever used (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
AT LEAST ONE 'YES' (EVER USED) (GO TO 307)
305) Have you or any of your partners ever used anything or tried in any way to delay or avoid getting pregnant?
NO 2 (GO TO 309)
306) What have you done or used?
CORRECT 303 AND 304 (AND 302 IF NECESSARY)
307) Are you or your partner currently doing something or using any method to delay or avoid getting pregnant?
NO 2 (GO TO 309)
308) Which method are you using?
(CHECK THAT METHOD LISTED IS KNOWN AND ALREADY USED)
(CIRCLE 08 FOR MALE STERILIZATION)
IUD 02
INJECTABLES 03
NORPLANT 04
DIAPHRAGM/FOAM/GEL 05
CONDOM 06
FEMALE STERILIZATION 07
MALE STERILIZATION 08
PERIODIC ABSTINENCE 09
WITHDRAWAL 10
PROLONGED ABSTINENCE 11
OTHER (SPECIFY) __________ 96
308b) Why do you use this method over another method?
MORE AVAILABLE 02 (GO TO 401)
WAS PRESCRIBED 03 (GO TO 401)
MORE EFFECTIVE 04 (GO TO 401)
NO SIDE EFFECTS 05 (GO TO 401)
IT SUITS ME 06 (GO TO 401)
ONLY KNOWN METHOD 07 (GO TO 401)
REVERSIBLE METHOD 08 (GO TO 401)
OTHER (SPECIFY) __________ 96 (GO TO 401)
309) What is the main reason that you do not use a contraceptive method?
INFREQUENT SEX 22
WIFE MENOPAUSAL/HYSTERECTOMY 23
WIFE SUBFECUND/INFECUND 24
WIFE POST-PARTUM/BREASTFEEDING 25
WANTS (MORE) CHILDREN 26
WIFE PREGNANT 27
SPOUSE/PARTNER OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
KNOWS NO SOURCE 42
FEAR OF SIDE EFFECTS 52
LACK OF ACCESS/TOO FAR 53
COSTS TOO MUCH 54
INCONVENIENT TO USE 55
INTERFERES WITH BODY'S NORMAL PROCESSES 56
401) Are you currently married or living with a woman?
LIVING WITH A WOMAN 2 (GO TO 402A)
NO, NOT IN UNION 4 (GO TO 404)
402) How many wives do you have?
402A) How many women do you live with as husband and wife?
403) WRITE THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE OF HIS WIFE/WIVES.
IF ONE WIFE DOES NOT LIVE IN THE HOUSEHOLD, RECORD '00'.
THE NUMBER OF SPACES FILLED SHOULD BE EQUAL TO THE NUMBER OF WOMEN
404) Do you currently have a regular sexual partner, an occasional sexual partner, or no sexual partner at all?
OCCASIONAL SEXUAL PARTNER 2
NO SEXUAL PARTNER 3
405) Have you ever been married or lived with a woman?
YES, LIVED WITH A WOMAN 2 (GO TO 407)
NO 3 (GO TO 410F)
406) What is your current marital status: are you widowed, divorced, or separated?
DIVORCED 2
SEPARATED 3
407) Have you been married or have you lived with a woman only once or more than once (including current union)?
MORE THAN ONCE 2
MARRIED/LIVED WITH WOMAN ONLY ONCE: In what month and year did you start living with your wife/partner?
MARRIED/LIVED WITH WOMAN MORE THAN ONCE: Now we will talk about your first wife/partner. In what month and year did you start living with her?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
409) How old were you when you started living with her?
NOT IN A UNION (GO TO 410F)
410) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family planning issues.
When was the last time you had sexual intercourse with (your spouse/the woman with whom you live)?
NUMBER OF WEEKS 2____
NUMBER OF MONTHS 3____
NUMBER OF YEARS 4____
KNOWS CONDOM: The last time you had sex with (your spouse/the woman with whom you live), was a condom used?
DOES NOT KNOW CONDOM: Some men used a condom, which means they put a rubber sheath on their penis during sexual intercourse. The last time you had sex with (your spouse/the woman with whom you live), was a condom used?
NO 2 (GO TO 410B)
DON'T KNOW 8 (GO TO 410B)
410AA) During this last sexual relation, who suggested using the condom?
SPOUSE/WOMAN 2
BOTH 3
410B) Have you had sexual relations with someone other than (your spouse/the woman with whom you live) in the last 12 months?
NO 2 (GO TO 410J)
410C) When was the last time you had sexual relations with someone other than (your spouse/the woman with whom you live)
NUMBER OF WEEKS 2____
NUMBER OF MONTHS 3____
NUMBER OF YEARS 4____
410D) Was a condom used on this occasion?
NO 2 (GO TO 410E)
DON'T KNOW 8 (GO TO 410E)
410DA) During this last sexual relation, who suggested using the condom?
PARTNER 2
BOTH 3
410E) During the last 12 months, how many different people other than (your spouse/the woman with whom you live) did you have sexual relations with?
DON'T KNOW 98 (GO TO 410J)
410F) Now I would like to ask you some questions about sexual activity in order to gain a better understanding of some family planning issues.
When was the last time you had sexual intercourse (if ever)?
NUMBER OF DAYS 1____
NUMBER OF WEEKS 2____
NUMBER OF MONTHS 3____
NUMBER OF YEARS 4____
KNOWS CONDOM: The last time you had sex, was a condom used?
DOES NOT KNOW CONDOM: Some men used a condom, which means they put a rubber sheath on their penis during sexual intercourse. The last time you had sex, was a condom used?
NO 2 (GO TO 410H)
DON'T KNOW 8 (GO TO 410H)
410GA) During this last sexual relation, who suggested using the condom?
PARTNER 2
BOTH 3
12 MONTHS OR MORE SINCE LAST SEXUAL RELATIONS (GO TO 410J)
410I) In total, with how many different people have you had sex in the last 12 months?
DON'T KNOW 98
CURRENTLY MARRIED OR LIVES WITH WOMAN: The last time you had sexual relations, was it with your spouse/the woman with whom you live, a regular partner, an acquaintance, someone who you paid, or someone else?
NOT CURRENTLY MARRIED/NOT LIVING WITH A WOMAN: The last time you had sexual relations, was it a regular partner, an acquaintance, someone who you paid, or someone else?
REGULAR PARTNER 2
ACQUAINTANCE 3
SOME PAID 4
SOMEONE ELSE 5
413) Do you know of a place where you can get condoms?
NO 2 (GO TO 414A)
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.
MEDICAL-SOCIAL CENTER 12
NURSE 13
M.C.H. 14
HEALTH POST 15
STATE PHARMACY 16
OTHER PUBLIC (SPECIFY) __________ 17
PHARMACY 22
TOGOLESE ASSOCIATION FOR FAMILIAL WELL-BEING 23
DOCTOR'S OFFICE 24
FIELDWORKER 25
OTHER PRIVATE MEDICAL (SPECIFY) __________ 26
CHURCH 32
FRIENDS/RELATIVES 33
GAS STATION 34
NO YES (GO TO 415)
415b) Where did you get the condoms 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.
(NAME OF PLACE)_________
MEDICAL-SOCIAL CENTER 12
DISPENSARY/INFIRMARY 13
M.C.H. 14
HEALTH POST 15
STATE PHARMACY 16
OTHER PUBLIC (SPECIFY) __________ 17
PHARMACY 22
TOGOLESE ASSOCIATION FOR FAMILIAL WELL-BEING 23
DOCTOR'S OFFICE 24
FIELDWORKER 25
OTHER PRIVATE MEDICAL (SPECIFY) __________ 26
BAR/NIGHTCLUB 32
KIOSK 33
INFORMAL COMMERCIAL DISTRIBUTION 34
CHURCH 35
ACQUAINTANCES/RELATIVES 36
OTHER (SPECIFY) __________ 96
414C) Do you know the brand name of the condoms that you used last time?
RECORD NAME OF BRAND
PRUDENCE PLUS 02
SUPRATEX 03
PROTECTOR 04
GOLD CIRCLE 05
COOL 06
OTHER (SPECIFY) __________ 96
DON'T KNOW 98
414d) The last time you bought condoms (or the last time someone else bought them for you), how many did you buy?
DETERMINE THE NUMBER AND RECORD.
DON'T KNOW 998
FREE 9996
DON'T KNOW 9998
415) How old were you when you first had sexual intercourse?
FIRST TIME WHEN MARRIED 96
SECTION 5. FERTILITY PREFERENCES
501) CHECK 401:
CURRENTLY MARRIED OR LIVING WITH A WOMAN (GO TO 503)
HAS OCCASIONAL SEX PARTNER (CONTINUE)
DOES NOT HAVE SEX PARTNER (GO TO 505A)
503) Is your spouse (or one of your spouses/partners) currently pregnant?
NO 2 (GO TO 505A)
UNSURE 8 (GO TO 505A)
504) When she became pregnant did you want her to get pregnant then, did you want to wait until later, or did you not want her to get pregnant?
LATER 2 (GO TO 505B)
NOT AT ALL 3 (GO TO 505B)
A) SPOUSE/PARTNER NOT PREGNANT OR UNSURE OR NO SPOUSE/PARTNER: Now I have some questions about the future. Would you like to have (another) child, or would you prefer not have any (more) children?
B) SPOUSE/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 have any more children?
NO (MORE) 2 (GO TO 507)
SAYS WIFE CANNOT GET PREGNANT 3 (GO TO 507)
SAYS HE CANNOT HAVE ANY CHILDREN 4 (GO TO 507)
UNDECIDED/DON'T KNOW 8 (GO TO 507)
SPOUSE/PARTNER NOT PREGNANT OR UNSURE OR NO SPOUSE/PARTNER: How long would you like to wait from now before the birth of (a/another) child?
SPOUSE/PARTNER PREGNANT: After the birth of this child your spouse/partner is expecting now, how long would you like to wait before the birth of another child?
YEARS 2____
SOON/NOW 993
SAYS WIFE CAN'T GET PREGNANT 994
AFTER MARRIAGE 995
OTHER (SPECIFY) __________ 996
DON'T KNOW 998
507) CHECK 308: USES A METHOD?
NOT CURRENTLY USING (CONTINUE)
CURRENTLY USING (GO TO 512)
508) Do you think you will use a contraceptive method to delay or avoid pregnancy in the next 12 months?
NO 2
DON'T KNOW 8
509) Do you think you will use a contraceptive method at any time in the future?
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)
510) Which contraceptive method would you prefer to use?
IUD 02 (GO TO 512)
INJECTABLES 03 (GO TO 512)
NORPLANT 04 (GO TO 512)
DIAPHRAGM/FOAM/GEL 05 (GO TO 512)
CONDOM 06 (GO TO 512)
FEMALE STERILIZATION 07 (GO TO 512)
MALE STERILIZATION 08 (GO TO 512)
PERIODIC ABSTINENCE 09 (GO TO 512)
WITHDRAWAL 10 (GO TO 512)
PROLONGED ABSTINENCE 11 (GO TO 512)
OTHER (SPECIFY) __________ 96 (GO TO 512)
DON'T KNOW 98 (GO TO 512)
511) What is the main reason that you think you would never use a method of contraception to avoid pregnancy?
WIFE MENOPAUSAL/HYSTERECTOMY 23
WIFE SUBFECUND/INFECUND 24
WANTS CHILDREN 26
HUSBAND/PARTNER OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
KNOWS NO SOURCE 42
FEAR OF SIDE EFFECTS 52
LACK OF ACCESS/TOO FAR 53
COSTS TOO MUCH 54
INCONVENIENT TO USE 55
INTERFERES WITH BODY'S NORMAL PROCESSES 56
DON'T KNOW 98
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?
PROBE FOR A NUMERIC RESPONSE.
OTHER (SPECIFY) __________ 96 (GO TO 514)
513) 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?
OTHER (SPECIFY) __________ 96
OTHER (SPECIFY) __________ 96
OTHER (SPECIFY) __________ 96
514) Would you say that you approve or disapprove of couples using a contraceptive method to avoid getting pregnant?
DISAPPROVE 2
DON'T KNOW/UNSURE 3
515) Is it acceptable or not acceptable to you for information on family planning to be provided:
NOT ACCEPTABLE 2
DON'T KNOW 8
NOT ACCEPTABLE 2
DON'T KNOW 8
516) In the last few months have you heard about family planning:
NO 2
NO 2
NO 2
NO 2
NO 2
516a) What is your main source of information on family planning?
PUBLIC HEALTH WORKER 02
PRIVATE HEALTH WORKER 03
COMMUNITY HEALTH WORKER 04
FAMILY PLANNING CLINIC 05
SPOUSE/PARTNER 06
OTHER RELATIVES 07
FRIENDS/RELATIVES 08
RADIO 09
TELEVISION 10
NEWSPAPERS/POSTERS 11
SCHOOL/LIBRARY 12
COMMUNITY MEETINGS 13
OTHER (SPECIFY) __________ 96
DON'T KNOW 98
518) In the last few months, have you discussed the practice of family planning with your friends, neighbors, or relatives?
NO 2 (GO TO 520)
RECORD ALL PERSONS MENTIONED
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTERS(S) F
SON(S) G
MOTHER-IN-LAW H
FATHER-IN-LAW I
FRIENDS/NEIGHBORS J
OTHER (SPECIFY) __________ X
YES, LIVING WITH A WOMAN (CONTINUE)
NO, NOT IN A UNION (GO TO 601A)
521) Spouses/partners do not always agree on everything. Now I want to ask you about your spouse/partner's views on family planning.
Do you think your spouse/partner approves or disapproves of couples using a contraceptive method to avoid pregnancy?
DISAPPROVES 2
NO OPINION 3
DON'T KNOW 8
522) How often have you talked to your spouse/partner about family planning in the last twelve months?
ONCE OR TWICE 2
MORE OFTEN 3
522A) In general, who initiates the discussion about family planning: you, your spouse/partner, or both?
SPOUSE/PARTNER 2
BOTH 3
522B) CHECK 307: USING A METHOD?
NO, NOT CURRENTLY USING A METHOD OR QUESTION NOT ASKED (GO TO 523)
522C) Before starting to use (CURRENT METHOD), did you discuss which method you would use with your spouse/partner?
NO 2
DON'T RECALL 8
522D) After having started using (CURRENT METHOD), did you discuss this method with your spouse/partner?
NO 2
DON'T RECALL 8
522E) CHECK 308:
CIRCLE CODE OF METHOD
IUD 02
INJECTABLES 03
NORPLANT 04
DIAPHRAGM/FOAM/GEL 05
CONDOM 06
FEMALE STERILIZATION 07
MALE STERILIZATION 08
PERIODIC ABSTINENCE 09
WITHDRAWAL 10
PERIODIC ABSTINENCE 11
OTHER METHOD 96
522F) Did your spouse/partner encourage you or discourage you from using (current method)?
DISCOURAGE 2
NEITHER/NEUTRAL 3
DON'T KNOW 8
522G) According to you, who should make the decision to use a contraceptive method, the man or the woman?
WOMAN 2
BOTH 3
SOMEONE ELSE 4
522H) According to you, who generally makes the decision to use a contraceptive method, the man or the woman?
WOMAN 2
BOTH 3
SOMEONE ELSE 4
522I) Do you think your mother approves or disapproves of couples using a method to avoid or delay pregnancy?
IF THE MOTHER IS DEAD, ASK: "If your mother were alive, do you think?"
DISAPPROVE 2
NO OPINION
DON'T KNOW 8
522J) Do you think your father approves or disapproves of couples using a method to avoid or delay pregnancy?
IF THE FATHER IS DEAD, ASK: "If your father were alive, do you think?"
DISAPPROVE 2
NO OPINION 3
DON'T KNOW 8
522K) Do you think that the use of contraceptives goes against or does not go against your religion?
IS NOT AGAINST 2
HIS RELIGION HAS NO POSITION ON THE SUBJECT 3
RESPONDENT DOES NOT HAVE A RELIGION 4
DON'T KNOW 8
522L) Do you think that it is better to have small family or a large family to improve the quality of life?
LARGE FAMILY 2
NOT IMPORTANT/EITHER 3
DEPENDS 4
DON'T KNOW/NO OPINION 8
522M) Have you encouraged a friend or relative to use family planning?
NO 2
523) Do you think your spouse/woman with whom you live wants the same number of children that you want, or does she want more or fewer than you want?
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8
SECTION 6. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS
601A) Have you ever heard of an illnesses that you can get from having sex?
NO 2 (GO TO 601F)
601B) What illnesses have you heard of?
RECORD ALL RESPONSES
GONORRHEA B
AIDS C
TRICHOMONAS VAGINALIS D
CHANCROID E
OTHER (SPECIFY) __________ X
DON'T KNOW Z
HAS NEVER HAD SEXUAL INTERCOURSE (GO TO 601F)
601D) Over the last 12 months, have you had any of these illnesses?
NO 2 (GO TO 601F)
DON'T KNOW 8 (GO TO 601F)
601E) Which illnesses did you have?
RECORD ALL RESPONSES
GONORRHEA B
AIDS C
TRICHOMONAS VAGINALIS D
CHANCROID E
OTHER (SPECIFY) __________ X
DON'T KNOW Z
601F) Have you had any discharge from your penis in the last 12 months?
NO 2
DON'T KNOW 8
601G) During the last 12 months, have you had a sore or ulcer near your penis?
NO 2
DON'T KNOW 8
HAS NOT HAD ANY INFECTION (GO TO 601N)
601I) The last time you had (INFECTION FROM 601E/DISCHARGE/SORE), did you seek any kind of advice or treatment?
NO 2 (GO TO 601JA)
Any other place?
RECORD ALL MENTIONED.
MEDICAL-SOCIAL CENTER B
DISPENSARY/INFIRMARY C
M.C.H. D
HEALTH POST E
STATE PHARMACY F
OTHER PUBLIC (SPECIFY) __________ G
PHARMACY I
TOGOLESE ASSOCIATION FOR FAMILIAL WELL-BEING J
DOCTOR'S OFFICE K
FIELDWORKER L
OTHER PRIVATE MEDICAL (SPECIFY) __________ M
FRIENDS/RELATIVES O
TRADITIONAL PRACTITIONER P
DON'T KNOW Z
HAS NOT HAD SEXUAL RELATIONS (GO TO 601N)
601K) When you had (INFECTION FROM 601E/DISCHARGE/SORE), did you inform the people were you having sexual intercourse with?
NO 2
601L) When you had (INFECTION FROM 601E/DISCHARGE/SORE), did you do something to avoid infecting your sexual partners?
NO 2 (GO TO 601N)
PARTNER(S) ALREADY INFECTED 3 (GO TO 601N)
RECORD ALL MENTIONED.
USED CONDOM B
TOOK DRUGS C
OTHER (SPECIFY) __________ X
MENTIONED AIDS (GO TO 602)
601O) Have you ever heard of an illness called AIDS?
NO 2 (GO TO 611C)
602) From which sources of information have you learned most about AIDS?
Any other sources?
RECORD ALL MENTIONED.
TV B
NEWSPAPERS/MAGAZINES C
PAMPHLETS/POSTERS D
HEALTH WORKERS E
MOSQUES/CHURCHES F
SCHOOLS/TEACHERS G
COMMUNITY MEETINGS H
FRIENDS/RELATIVES I
WORKPLACE J
OTHER (SPECIFY) __________ X
602A) If you wanted more information on AIDS, where (from whom) would you like to get this information?
TV 02
NEWSPAPERS/MAGAZINES 03
PAMPHLETS/POSTERS 04
HEALTH WORKERS/CENTERS 05
MOSQUES/CHURCHES 06
SCHOOLS/TEACHERS 07
COMMUNITY MEETINGS 08
THEATER 09
FRIENDS/RELATIVES 10
WORKPLACE 11
ENOUGH INFORMATION 12
OTHER (SPECIFY) __________ 96
602B) How can you get AIDS?
Any other way?
RECORD ALL MENTIONED
SEX WITH SEVERAL PARTNERS B
SEX WITH PROSTITUTES C
NOT USING A CONDOM D
SEX WITH HOMOSEXUALS E
BLOOD TRANSFUSIONS F
INJECTIONS G
KISSING H
MOSQUITO BITES I
CONTAMINATED OBJECTS K
OTHER (SPECIFY) __________ X
DON'T KNOW Z
603) Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?
NO 2 (GO TO 607)
DON'T KNOW 8 (GO TO 607)
604) What can a person do?
Anything else?
RECORD ALL WAYS MENTIONED.
USE CONDOMS C
AVOID MULTIPLE PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH HOMOSEXUALS F
AVOID BLOOD TRANSFUSIONS G
AVOID INJECTIONS H
AVOID KISSING I
AVOID MOSQUITO BITES J
SEEK PROTECTION FROM TRADITIONAL PRACTITIONER K
OTHER (SPECIFY) __________ X
DON'T KNOW Z
607) Is it possible for a healthy-looking person to have the AIDS virus?
NO 2
DON'T KNOW 8
608) Do you think that persons with AIDS almost never die from the disease, sometimes die, or almost always die from the disease?
SOMETIMES 2
ALMOST ALWAYS 3
DON'T KNOW 8
NO 2
DON'T KNOW 8
608b) Can AIDS be transmitted from a mother to a child she is breastfeeding?
NO 2
DON'T KNOW 8
608c) Do you know someone personally who has AIDS or someone who died of AIDS?
NO 2
609) Do you think your chances of getting AIDS are small, moderate, great, or no risk at all?
MODERATE 2 (GO TO 609C)
GREAT 3 (GO TO 609C)
NO RISK AT ALL 4
HAS AIDS 5 (GO TO 611A)
609B) Why do you think that you (have no risk/have small risk) for getting AIDS?
Any other reason?
RECORD ALL MENTIONED
USES CONDOMS C (GO TO 611A)
ONLY HAS ONE SEXUAL PARTNER D (GO TO 611A)
HAS A LIMITED NUMBER OF SEXUAL PARTNERS E (GO TO 611A)
AVOIDS PROSTITUTES F (GO TO 611A)
PARTNER DOESN'T HAVE ANOTHER PARTNERS G (GO TO 611A)
DOESN'T HOMOSEXUAL RELATIONSHIPS H (GO TO 611A)
DOESN'T GET BLOOD TRANSFUSIONS I (GO TO 611A)
DOESN'T GET INJECTIONS I (GO TO 611A)
OTHER (SPECIFY) __________ X (GO TO 611A)
609C) Why do you think you have (moderate/great) risk of getting AIDS?
Any other reason?
RECORD ALL MENTIONED
HAS MORE THAN 1 SEXUAL PARTNER D
HAS SEVERAL SEXUAL PARTNERS E
GOES TO PROSTITUTES F
PARTNER HAS OTHER PARTNER(S) G
HAS HOMOSEXUAL RELATIONSHIPS H
BLOOD TRANSFUSIONS I
INJECTIONS J
OTHER (SPECIFY) __________ X
611A) Since you have heard of AIDS, have you changed your behavior to avoid getting AIDS?
IF YES: What have you done?
Anything else?
RECORD ALL MENTIONED.
STOP HAVING SEX B-(GO TO 611C)
START USING CONDOMS C-(GO TO 611C)
RESTRICT SEX TO ONE PARTNER D-(GO TO 611C)
REDUCES NUMBER OF SEXUAL PARTNERS E-(GO TO 611C)
AVOIDS PROSTITUTES F-(GO TO 611C)
ASK PARTNER TO BE FAITHFUL G -(GO TO 611C)
STOPS HOMOSEXUAL RELATIONSHIPS H-(GO TO 611C)
STOPS INJECTIONS J
OTHER (SPECIFY) __________ X
NO CHANGE Y
611B) Has your knowledge of AIDS influenced or changed your decisions about having sex or sexual behavior?
IF YES, PROBE: In what way?
RECORD ALL MENTIONED.
STOPPED ALL SEX B
STARTED USING CONDOMS C
RESTRICTED SEX TO ONE PARTNER D
REDUCED NUMBER OF PARTNERS E
AVOID PROSTITUTES F
STOP HOMOSEXUAL RELATIONS G
STOPPED INJECTIONS H
OTHER (SPECIFY) __________ X
NO CHANGE IN SEXUAL BEHAVIOR Y
DON'T KNOW Z
611C) Some people use condoms during sex to avoid getting AIDS or other sexually transmitted illnesses. Have you ever heard of condoms?
NO 2 (GO TO 611F)
HAS NOT HAD SEX (GO TO 613)
611E) We may have already discussed this. Have you ever used a condom during sexual relations to avoid getting AIDS or transmitting illnesses, like AIDS?
NO 2 (GO TO 611F)
611EA) Do you use a condom from time to time, often, or with each sexual encounter?
OFTEN 2
EACH ENCOUNTER 3
611F) Have you given or received money, gifts, or favors in exchange for sexual relations in the last 12 months?
NO 2
MINUTES ____
INTERVIEWER'S OBSERVATIONS
TO BE FILLED OUT 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: ______