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close this bookLooking Deeper into the HIV Epidemic: A questionnaire for Tracing Sexual Networks (Joint United Nations Programme on HIV/AIDS, 1998, 24 p.)
close this folderAppendix - Multi-site study : questionnaire I - Men and Women
View the document(introduction...)
View the documentPart A: Household form
View the documentPart B: Individual questionnaire (for adults aged 15-49 who slept in the household)

(introduction...)

Multi-site study : questionnaire I - Men and Women

Part A: Household form

HOUSEHOLD IDENTIFICATION

001

City name

________________________________

002

Cluster Number

________________________________

003

Household/Dwelling number

________________________________

004

INTERVIEW VISITS




Visit 1

Visit 2

Visit 3


Date

________

_________

________


Interviewer

________

_________

________


Result*

________

_________

________


Result codes*





Completed

1




No one at home

2




Refused

3




Household away for duration of survey

4




Dwelling vacant or address not a household

5




Dwelling not found

6




Postponed

7




Other (Specify)

8

--------------------------------

005

ID NO.

________________________________


Facilities Available in the Cluster





All -Weather Road


Yes

No


Health centre/hospital


Yes

No


Trading centre (market)


Yes

No


Electricity


Yes

No


Running Water


Yes

No


Hotel/Bar/Boarding house


Yes

No

HOUSEHOLD MEMBERS FORM

Enquire about anyone else aged 15 years or over (including non-family members) who slept in the household last day or night (e.g. servants, lodgers).

"Now I would like some information about the persons aged 15 years or over who usually live in this household. First what is the given name of the head of household?" [Record in line 01]

Initials of first name

Relationship

From line __ & line __

Sex

Age

Slept here last day or night

Eligibility Aged (15-49 who slept there)




M

F


Y

N


Usual household members

01 Head

___________

____&____



____



_________

02 ______

___________

____&____



____



_________

03 ______

___________

____&____



____



_________

04 ______

___________

____&____



____



_________

05 ______

___________

____&____



____



_________

06 ______

___________

____&____



____



_________

07 ______

___________

____&____



____



_________

08 ______

___________

____&____



____



_________

09 ______

___________

____&____



____



_________

10 ______

___________

____&____



____



_________

11 ______

___________

____&____



____



_________

12 ______

___________

____&____



____



_________



























































































All others









21 ______

___________

____&____



____



_________

22 ______

___________

____&____



____



_________

23 ______

___________

____&____



____



_________



















Part B: Individual questionnaire (for adults aged 15-49 who slept in the household)

SECTION 1: HOUSEHOLD IDENTIFICATION

101

City name

___________________________________

102

Cluster number

___________________________________

103

Household/Dwelling number

___________________________________

104

Respondent’s initial and line number

___________________________________

105

Interviewer code

________________________________

106

INTERVIEW VISITS (INDIVIDUALS)






Visit 1

Visit 2

Visit 3


Date





Interviewer





Result*





Result codes*





Completed

1




Not at home

2




Refused

3




Partially completed

4




Other (specify)

8 ________



107

Checked by supervisor

ID No.

__________




Signature

__________




Date

__________


SECTION 2: BACKGROUND CHARACTERISTICS

Questions and filters

Coding categories

Skip to

Q201

Record sex of respondent

Male

1




Female

2


Q202

How old are you? [PROBE FOR BEST ESTIMATE]

Age ___



Q203

Have you ever attended school? If Yes: What was the highest level that you have completed?

Primary

1

® Q205



Secondary

2

® Q205



Higher

3

® Q205



Primary not completed

4




Never

5


Q204

Can you read a newspaper or letter?

YES

1




NO

2


Q205

What is your Religion?

Protestant

1




Catholic

2




Muslim

3




Traditional

4




No religion

5




Other

6


Q206

Which ethnic group you belong to? ____________________________

________



Q207

Where were you born? (write down the district/country)

Same city

1




Other urban area

2




Rural area

3




Other countries

4


Q208

How long have you stayed in this city?

Years ___




Since birth, enter 98 and skip to Q210

Months ___




If less than 1 month ENTER 00




Q209

Where were you before? (location) ____________________________

Same city

1




Other urban

2




Rural

3




Other country

4


Q209B

Why did you move? (main reason) ___________________________

Marriage

1




Family move

2




Work

3




Visit

4




School

5




Other

6


Q210

How many years or months you intend to live in this city?

Years ___





Months ___




Forever, ENTER 97





Do not know, ENTER 96




Q211

In the last 12 months, that is since last ____, how many trips more than one night did you have outside this city? [PROBE]

Number ___




If less than 1 year in the city, ENTER 98




Q212

Altogether how many days, or weeks, or months, were you away from home in last 12 months?

Days___





Weeks___





Months___



Q213

What is your usual occupation?

Fishing

0



[PROBE: What kind of work do you do most of your time? record verbatim and then the code]

Farmer, works in agriculture, forestry, fishing

1




Soldier, Policeman

2




Driver

3




Manual worker

4




Sales, service workers

5




Clerical

6




Professional managerial

7




No employment (housework, student, unemployed)

8




Other

9


Q214

Are you now? [READ OUT]

Regularly employed full time

1




Employed seasonally or on a day to day basis

2




Self employed

3




Unemployed/looking for Work

4




A homemaker with some part-time work outside

5




A homemaker with no other work outside

6




A student

7




Retired or disabled

8




Other

9


Q215

Did you have drinks containing alcohol in last four weeks?

YES

1

® Q301



NO

2


Q216

How often did you have drinks containing alcohol in last four weeks? Would you say? [READ OUT]

At least once a day

1




At least once a Week

2




Less than once a Week

3


SECTION 3: MARRIAGE

Marriage may involve a legal arrangement, a religious ceremony or customary celebration. It may also be an informal union in which a man and woman live together and regard themselves as married. Thus by spouse, we mean married or living as married.

Questions and filters

Coding categories

Skip to

Q301

Have you ever been Married or lived as Married?

YES

1

® Q303



NO

2


Q302

Have you ever had penetrative sexual intercourse? [PROBE]

YES

1

® Q321



NO

2

® Q515

Q303

Are you now married, or living as married, single, separated, divorced, or widowed?

Married

1

® Q317



Single

2

® Q317



Separated/Divorced

3

® Q317



Widowed

4


Q304

[MEN] Do you have more than one spouse? [WOMEN] Does your have other spouses?

YES

1

® Q306



NO

2


Q305

If YES: How many spouses in total now?

Number ____



For each current spouse, ask Q306 to Q316

Now I am going to ask you more details about your current spouse(s): Firstly, what are the initials of your current spouse? (see below)



Spouse(s)



1

2

3

4


Questions





First name initials

----

----

----

----

Q306

Is it a customary, civil, religious, or consensual union?

1

1

1

1


Customary






Civil

2

2

2

2


Religious

3

3

3

3


Consensual

4

4

4

4

Q307

How long have you been married or living as married with this spouse? Years

___

___

___

___


IF LESS THAN 1 YEAR, ENTER 00





Q308

How old is he/she? [PROBE] YEARS

___

___

___

___

Q309

Do you usually live together in the same house/compound?






If YES:, SKIP to 311






YES

1

1

1

1


NO

2

2

2

2

Q310

If NO, where does he/she usually live?






Same city

1

1

1

1


Other city

2

2

2

2


Rural

3

3

3

3


Abroad

4

4

4

4

Q311

Do you have children with this spouse?






If NO, SKIP to 314






YES

1

1

1

1


NO

2

2

2

2

Q312

How old is your youngest one?






YEARS

___

___

___

___


MONTHS

___

___

___

___


If YEARS, SKIP to Q314





Q313

If child is less than 12 MONTHS, have you resumed sex with the spouse since the birth of the child?






YES 1

___

___

___

___


NO 2





Q314

How many days since you had last sexual act with this spouse?

___

___

___

___


Within last 30 days, ENTER 0-30






More than 30 days, but within last year, ENTER 95 and SKIP to Q316






More than one year, ENTER 96 and SKIP to Q306 for next spouse





Q315

IF WITHIN THE LAST 30 DAYS, how many times did you have sex with this spouse in the last week?

___

___

___

___

Q316

Did you use a condom with him/her in the past 12 months? If YES, how often?

1

1

1

1


Always

2

2

2

2


Often

3

3

3

3


Half of the time

4

4

4

4


Rarely

5

5

5

5


Never






IF MORE THAN ONE SPOUSE, GO BACK TO Q306


Q317

(Now think back to the past). Apart from this/these spouse(s), how many persons have you been married to you in your whole life time?

__________________

Q318

How old were you when you got first married?

__________________

Q319

How old was your first spouse at that time?

__________________

Q320

How many different sexual partners did you have penetrative sex with (before you first got married)?

__________________

Q321

How old were you when you had penetrative intercourse for the first time?

__________________

Q322

How many different sexual partners did you have penetrative sex up to now? [PROBE]

__________________

SECTION 4 SEXUAL RELATIONS WITH OTHER PARTNERS THAN SPOUSES

“Now I would like to ask you a few questions about other partners that you may have had in the last 12 months that is since....”

Questions

Coding categories

SKIP to

Q401

Have you had sexual intercourse with anyone else in the last 12 months? (other than a spouse)? [PROBE: Please include the following people that you might have sex with: mistresses, girlfriends, casual partners, prostitutes, somebody else that you may have met in bars, during special events such as wedding etc.]

YES

1

® Q502 [MEN]



NO

2

® Q517 [WOMEN]

Q402

With how many different people have you had sexual intercourse with in last 12 months (apart from spouse(s)

Number

___


“I would like to know more about these sexual partners, beginning with the most recent one you had sex with. What was his/her initials?” (For each sex partner, ask Q403 to Q421)

Questions

Sexual Partner(s)

No

Initial’s or Don’t know (DK)

1

2

3

4

5

6

7

8

Q403

How would you describe your relationship in local terms?

___

___

___

___

___

___

___

___

Q404

What educational level has he/she completed?










Primary

1

1

1

1






Secondary

2

2

2

2






Higher

3

3

3

3






Primary not completed

4

4

4

4






None

5

5

5

5






DK

6

6

6

6





Q405

How old is he/she? [PROBE]

___

___

___

___

___

___

___

___

Q406

Is he/she married, divorced, widowed, separated, single?










Married

1

1

1

1

1

1

1

1


D/S/W

2

2

2

2

2

2

2

2


Single

3

3

3

3

3

3

3

3


DK

4

4

4

4

4

4

4

4

Q407

Which ethnic group does he/she belong to?

___

___

___

___

___

___

___

___

Q408

Where did you have sex first time with her? [SKIP TO Q411]

1

1

1

1

1

1

1

1


Same city

2

2

2

2

2

2

2

2


Other urban area

3

3

3

3

3

3

3

3


Rural Area









Q409

[IF OUTSIDE THIS CITY] Why were you there? Was It for [READ OUT]










Professional Reasons

1

1

1

1

1

1

1

1


Family Reasons

2

2

2

2

2

2

2

2


Economic Reasons

3

3

3

3

3

3

3

3


Others (Specify)

4

4

4

4

4

4

4

4

Q410

[IF OUTSIDE THE CITY] How long did you have stayed in that place?










Days

___

___

___

___

___

___

___

___

Q411

How long did you know him/her before having sexual relation?










Months

___

___

___

___

___

___

___

___


Days

___

___

___

___

___

___

___

___


· If more than 5 years ENTER 99










· If less than one year ENTER 00









Q412

Are these sexual relations currently going on or has sexual relations ended?










Relationship going on

1

1

1

1

1

1

1

1


Relationship Ended

2

2

2

2

2

2

2

2


Do not Know

3

3

3

3

3

3

3

3

Q413

[IF CURRENT RELATION] How many times in the last month did you have sex with this person?

___

___

___

___

___

___

___

___

Q414

[IF ENDED OR DK] How many times did you have sex with him/her in the last year ?

___

___

___

___

___

___

___

___

Q415

[IF ENDED] How many months ago did it finish?










Months

___

___

___

___

___

___

___

___

Q416

How long did the relationship Last? (I mean how long was it between the first time you had sex and the last time?) [IF Less Than I Day, ENTER 00]










Days

___

___

___

___

___

___

___

___


Months

___

___

___

___

___

___

___

___

Q417

In your last intercourse with him/her did you use a condom?

1

1

1

1

1

1

1

1


YES

2

2

2

2

2

2

2

2


NO









Q418

Usually did you use a condom with him/her? [READ OUT]










Always

1

1

1

1

1

1

1

1


Most of the time

2

2

2

2

2

2

2

2


Rarely

3

3

3

3

3

3

3

3


Never

4

4

4

4

4

4

4

4

Q419

Did you receive/give money in exchange for sex with him/her?










YES always

1

1

1

1

1

1

1

1


YES often

2

2

2

2

2

2

2

2


Never

3

3

3

3

3

3

3

3

Q420

Do you think that over the last year, apart from you, he/she has sex with [READ OUT]










Steady partner: Yes: 1 No: 2 Dk:3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3


Casual partner Yes: 1 No: 2 Dk: 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3


Others with exchange of money Yes: 1 No: 2 Dk: 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

1 2 3

Q421

If you took a guess how many Partners do you think he/she had in the past 12 months? (apart from you)?

___

___

___

___

___

___

___

___

Please go back to Q403 for other partners

SECTION 5: STDs AND HEALTH ISSUES

Questions and filters

Coding categories

Skip to

Q501

MEN ONLY

WOMEN SKIP TO


® Q517

Q502

Now I would like to ask you Some question about your health in the last 12 months. Some men experience pain during urination or have a discharge from the penis. During the last 12 months have you noticed any pain or discharge?

Number____




If YES: How many episodes started in the last 12 months?





If NONE, ENTER 00




Q503

At present do you have any pain when passing urine?

YES

1

® Q505



NO

2


Q504

For how long do you have this pain?

DAYS___



Q505

In the last 24 hours did you have any discharge from the penis?

YES

1

® Q507



NO

2


Q506

For how long did you have this discharge?

DAYS___



Q507

Some men experience sores in the genital area. During the last 12 months have you noticed any such sores?

Number___




If YES, how many episodes started in the last 12 months?





If none Enter 00




Q508

At present do you have any sores on the genital area? Are they painful?

YES without pain

1

® Q510



YES painful

2




NO

3


Q509

For how long do you have these sores?

Days___



Q510

Filter: SEE Q502 TO Q508 ONE OR MORE EPISODES

NO EPISODE SKIP To


® Q515

Q511

Which of the following did you do for the last episode? [READ OUT]





Sought advice from friend or relative

YES

1




NO

2



Used medicine that you had at home

YES

1




NO

2



Sought advice from a traditional healer

YES

1




NO

2



Sought advice from a clinic, hospital, or a health worker

YES

1




NO

2



Obtained free drugs from a clinic, hospital, or a health worker

YES

1




NO

2



Bought medicines from a clinic, a hospital, or a health worker

YES

1




NO

2



Bought medicine from traditional healer

YES

1




NO

2



Bought medicine from a pharmacy or shop

YES

1




NO

2



Nothing

YES

1




NO

2



Other (specify)




Q512

Did you tell (any of) your spouse(s) or partner(s) about this last episode?

YES

1




NO

2


Q513

While you had the symptoms, did you do anything to prevent passing the infection to(any of) your spouse(s) or partner(s)? (Seeking treatment excluded)

YES

1

® Q515



NO

2


Q514

If yes, what did you do?

Abstain from sex

1




Use a condom

2




Other

3


Q515

Are you circumcised? (use local terms for operation)

YES

1

® Q600



NO

2


Q516

How old were you when you circumcised?

Years

___


Q600

Eventually, would you accept to be asked 5 or 10 questions for further clarification? Comments

YES

1




NO

2


Women Only

Q517

In the last 12 months did you have sex during menstruation (with any of your partners)?

YES

1




NO

2


Q518

Are you currently doing something or using any method to delay or avoid pregnancy?

YES

1

® Q520



NO

2

® Q520



Pregnant

3


Q519

If yes, which method you are using?

Pill

1




IUD

2




Injections

3




Diaphragm/Foam/Jelly

4




Condom

5




Calendar/safe period

6




Withdrawal

7




Sterilization

8




Other

9


Q520

Do you actually use something to tighten or dry your vagina before sexual intercourse?

Always


® Q600



Often





Rarely





Never



Q521

If YES, what do you use? ----------------------