IDENTIFICATION

EA NAME

NAME OF HOUSEHOLD HEAD

HOUSEHOLD NUMBER

SAMPLED HOUSEHOLD NUMBER

NAME AND LINE NUMBER OF MAN

MAN SELECTED FOR VIOLENCE MODULE

INTERVIEWER VISITS

FIRST VISIT

DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT

DATE
TIME

SECOND VISIT

DATE
INTERVIEWER'S NAME
RESULT

NEXT VISIT

DATE
TIME

THIRD VISIT

DATE
INTERVIEWER'S NAME
RESULT

FINAL VISIT

DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NUMBER __ __ __
RESULT __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

LANGUAGE OF THE QUESTIONNAIRE __ __

LANGUAGE USED IN THE INTERVIEW __ __

NATIVE LANGUAGE OF RESPONDENT __ __

TRANSLATOR USED

LANGUAGE USED:

SUPERVISOR

NAME ___________ __ __ __

FIELD EDITOR

NAME ___________ __ __ __

OFFICE EDITOR__ __

KEYED BY __ __

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is _______________________________________. I am working with UGANDA BUREAU OF STATISTICS. We are conducting a survey about health all over UGANDA. 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 question 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.

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: ___________

101) RECORD THE TIME

102) In what month and year were you born?

103) How old were you at your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT

104) Have you ever attended school?

105) What is the highest level of school you attended: primary, '0' level, 'A' level, or university or tertiary?

106) What is the highest (class/year) you completed at that level?

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'

107) CHECK 105:

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?

109) CHECK 108:

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

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

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

113) What is your religion?

114) What is your tribe?

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

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

SECTION 2. REPRODUCTION

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?

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 that you have fathered 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 fathered a son or a daughter who was born alive but later died?

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

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

IF NONE, RECORD '00'

208) SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.

IF NONE, RECORD '00'.

209) CHECK 208:

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

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

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

213) CHECK 203 AND 205:

214) How old is your (youngest) child?

215) CHECK 214:

216) What is the name of your (youngest) child?

WRITE NAME OF (YOUNGEST) CHILD

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

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

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

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?

SECTION 3. CONTRACEPTION

301) Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy.

Have you ever heard of (METHOD)?

302) In the last few months have you:

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

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

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

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

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

307) CHECK 301 (07): KNOWS MALE CONDOM

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

309) Where is that?
Any other place?

PROBE 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)) ____________________

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

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

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

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

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

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

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

407) CHECK 405:

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

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.

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'

ASK 408 FOR EACH PERSON.

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

409) CHECK 407:

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

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

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

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

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 activity 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?

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.

417) When was the last time you had sexual intercourse with this person?
[FOR SECOND-TO-LAST AND THIRD-TO-LAST SEXUAL PARTNERS]

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

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

420) What was your relationship to this person with whom you had sexual intercourse?

IF GIRLFRIEND: Were you living together as if married?

IF YES, CIRCLE '2'
IF NO, CIRCLE '3'

421) CHECK 410:

422) CHECK 414:

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

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'.

425) How old is this person?

426) Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?
[FOR LAST AND SECOND-TO-LAST SEXUAL PARTNERS]

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

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95'.

428) CHECK 420 (ALL COLUMNS):

429) CHECK 420 AND 418 (ALL COLUMNS):

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

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

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

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

434) In total, with how many different people have you had sexual intercourse in your lifetime?

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

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

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 NOT KNOWN, ASK TO SEE THE PACKAGE.

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) _________________________

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?

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.

SECTION 5. FERTILITY PREFERENCES

501) CHECK 401:

502) CHECK 439:

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

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 have any more children?

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?

506) CHECK 407:

507) CHECK 503:

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

509) CHECK 203 AND 205:

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 a girl?

SECTION 6. EMPLOYMENT AND GENDER ROLES

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

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?

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

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

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

606) Are you paid in cash or kind for this work or are you not paid at all?

607) CHECK 401:

608) CHECK 606:

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

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

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

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

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

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

SECTION 7. HIV/AIDS

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

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

703) Can people get the AIDS virus from mosquito bites?

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

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

706) Can people get the AIDS virus because of witchcraft or other supernatural means?

707) Is it possible for a healthy-looking person to have the AIDS virus?

708) Can the virus that causes AIDS be transmitted from a mother to her baby:

709) CHECK 708:

710) 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?

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

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

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

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

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) _______________________

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

717) Where is that?
Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) _______________________

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

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

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?

721) 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?

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

723) CHECK 701:

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?

724) CHECK 414:

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

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?

727) Sometimes men experience an abnormal discharge from their penis.

During the last 12 months, have you had an abnormal discharge from your penis?

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?

729) CHECK 726, 727, AND 728:

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

731) Where did you go?
Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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?

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

SECTION 8. OTHER HEALTH ISSUES

801) Some men are circumcised, that is, the foreskin is completely removed from the penis Are you circumcised?

802) How old were you when you got circumcised?

803) Who did the circumcision?

804) Where was it done?

805) Now I would like to ask you some other questions relating to health matters. 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.

805A) Who administered the last injection you got?

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?

807A) Did you develop any complications as a result of an injection?

808) Do you currently smoke cigarettes?

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

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

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

RECORD ALL MENTIONED.

812) Are you covered by any health insurance?

813) What type of health insurance are you covered by?

RECORD ALL MENTIONED.

SECTION 9: DOMESTIC VIOLENCE

900) CHECK FRONT COVER: MAN SELECTED FOR THIS SECTION?

901) CHECK FOR PRESENCE OF OTHERS:

DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

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 of men in Uganda. 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:

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?

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

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

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

906) CHECK 905A (a-j):

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'.

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

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?

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

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

912) How often does (did) your wife/partner get drunk: often, only sometimes, or never?

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

914) CHECK 410:

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 .

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?

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?

917) Who has hurt you in this way?
Anyone else?

RECORD ALL MENTIONED

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

922) CHECK 401 AND 402

923) How old were you the first first time you were forced to have sexual intercourse or perform any other sexual acts?

924) Who was the person who was forcing you at that time?

925) CHECK 401 AND 402

926) CHECK 905A (a-j),915, 916 922, AND 925

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

928) From whom have you sought help?
Anyone else?

RECORD ALL MENTIONED.

929) Have you ever told any one about this?

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

931) CHECK IF CODE 1 IS CIRCLED IN 922

931A) After being forced to have sexual intercourse or to perform a sexual act, have you ever sought help from a doctor or medical personnel?

931B) How long after you were forced to have a sexual intercourse did you seek help?

931C) Were you offered drugs to prevent you from getting the AIDS virus?

931D) Were you offered a test for the AIDS virus after the violence?

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

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

933) INTERVIEWER'S COMMENTS / EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE
__________________________________________________

END TIME

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: ______________