Pathfinder A guide to Monitoring and Evaluating Adolescent Reproductive Heath Programs Part 2

Publication date: 2000

274 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs P H O T O : H ar ve y N el so n 275 Instruments and Questionnaires Adapting Instruments to Meet Your M&E Needs The questions and methods used in the sample data collection instruments have been collected from checklists, tally sheets, questionnaires, surveys, inventories and focus group discussion guides that are used to monitor and evaluate youth programs in a variety of contexts. The questions includ- ed are not necessarily the best questions for every context, nor are they exhaustive. The instruments you choose should be adapted to your objectives before use. For example, Instrument 7 (Observation Guide for Counseling and Clinical Procedures) is designed to assess the quality of service provision in a health facility-based program. However, you could easily adapt it to reflect the counseling and services provid- ed in a school-based program or during outreach effects. You should also adapt instruments to your context before use. For example, you will probably need to add or delete questions from Instrument 12, the Comprehensive Youth Survey, before using it to evaluate your programÕs context-specific outcomes. Pre-testing data collection instruments before you use them will improve your efforts. Table 1 provides an overview of what data collection method each instrument utilizes and how it can be used as a tool for your M&E effort. Developing Surveys Surveys are one of the most commonly used evaluation tools because they are a cost-effective way to gather comparable information from a large group of people. Surveys may be self-administeredÑcom- pleted by the respondent using a pencil and paperÑor administered by an interviewer who completes the form by filling in the respondentÕs answers. When designing surveys, you may choose to use either open-ended or closed ques- tions, depending on your needs. Open- ended questions do not have a pre-deter- mined response, and allow respondents to reply in their own words. Closed questions are accompanied by a list of possible responses from which the respondent selects. Open-ended questions often result in a greater depth of understanding, while responses to closed questions can be more quickly analyzed. Part II: Instruments and Questionnaires Part II at a Glance ä Offers guidance on adapting instruments for your M&E effort ä Provides sample data collection instruments ä Gives tips for collecting data through a variety of methods A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 276 Table 1 Data Collection Instruments No. Title Data Collection Method 1A Program Design Checklist Checklist 1B Checklist of Stakeholder Involvement Checklist 1C Training Course Checklist for ARH Program Staff Checklist 1D Checklist for ÒYouth-FriendlyÓ Service Characteristics Checklist 1E Checklist of Selection Criteria for Peer Educators Checklist 2A Monthly Tally Sheet for Counseling Service statistics 2B Tally Sheet for Communication Products Service statistics 2C Tally Sheet for Stakeholder Involvement Service statistics 2D Tally Sheet on Number and Characteristics of Youth Counseled Service statistics 2E Institutional Infrastructure Tally Sheet Service statistics 3A Reporting Form for Counseling Program report 3B Peer EducatorsÕ Reporting Form Program report 4 ARH Coalition Questionnaire Interview with key informant 5A Index on Quality of Counseling (for individual counseling sessions) Direct observation 5B Policy Environment Score: Adolescents Composite index 6 Inventory of Facilities and Services Inventory and direct observation 7 Observation Guide for Counseling and Clinical Procedures Direct observation 8 Interview Guide for Staff Providing RH Services Staff survey 9 Guide for Client Exit Interview Exit interview with client 10 Questionnaire for Debriefing Mystery Clients Mystery client 11 Community Questionnaire Interview with key informant 12 Comprehensive Youth Survey Population survey 13 Focus Group Discussion Guide for In-School Adolescents Focus group discussion 14 Assessing Coalition Effectiveness Worksheet Survey of key informant 15 Parents of Youth Questionnaire Interview with key informant When developing a survey instrument, keep in mind the following rules: ä Be unambiguous: Try to avoid ques- tions that can be interpreted in differ- ent ways. For example, if you ask a nurse, ÒHow many patients did you see last week?Ó she might respond, ÒWhom do you mean, me or the clin- ic?Ó Focus group discussions can help clarify interpretations of terminology before you finalize your survey instru- ment. ä Use clear language that is not conde- scending: Try to strike a balance between using simple language and seeking complex information. ä Plan the survey well: Only include questions that you are sure you will analyze. Cluster your questions by topic so that respondents donÕt become frustrated, confused or annoyed by repetition. ä Make use of skip questions: For exam- ple, if a respondent reports that she has never been pregnant, the survey should skip over any questions per- taining to experience with pregnancy. ä In providing possible responses, make the lists exhaustive and exclusive: This is especially important when you want respondents to check only one response. Also give respondents the option of answering ÒDonÕt know.Ó ä DonÕt ask two questions at once: For example, asking, ÒWhen did you leave home and go to work on your own for the first time?Ó wrongly assumes that all respondents left home before going to work for the first time, and that they went to work when they left home. To explore these issues, it is better to use a series of questions focusing on each step. ä If translating a survey, back translate to ensure accuracy: First, work closely with a bilingual translator who is a native speaker of the language you are translating into. Next, ask a native speaker of the language to translate the survey back into that language. The two versions should be essentially identical. If not, correct errors in trans- lation. ä Confidentiality is vital: A respondentÕs name should not be written on the survey. Most evaluators assign a code to keep track of respondents. If a survey is used to guide an interview, also keep in mind the following: ä Decide how simple or how complex you want the interview to be: Topics for individual interviews can range from a handful of simple, open-ended questions that take a few minutes to conduct, to a detailed survey that may take an hour or more to conduct. ä Be sensitive to the environment: Be aware of the image you are projecting, and aim to build trust with the respon- dent. For example, if you arrive in a Land Rover with a driver, you may be identified as an ÒofficialÓ person, influ- encing the respondentÕs perception of you. ä Make introductions and explain the purpose of the survey: Explain why you are conducting the survey, and ask permission for the interview to commence. ä Familiarize yourself with the survey instrument: You must be able to read the survey items without stumbling over words and phrases, know how to follow skip patterns and understand the correct procedure for probing and recording responses. 277 Part II: Instruments and Questionnaires A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 278 ä Probe responses and rephrase open- ended questions: Open-ended ques- tions should be presented in a neutral way. If you unknowingly hint at the ÒrightÓ answer, respondents may try to provide it. Probing and rephrasing questions during an interview is help- ful to explore respondentsÕ real feel- ings, especially when they give short answers. Often the best probe is patient silence; verbal probes include ÒIn what ways?Ó or ÒAnything else?Ó Developing and Leading Focus Group Discussions Focus group discussions are a qualitative research technique used to gain an in- depth, but not representative, understand- ing of the attitudes, beliefs and perceptions of a specific group of people in their own language. A focus group is a facilitated, open conver- sation, recorded and observed by a note taker. A facilitator asks questions that stimu- late interaction among participants on sub- jects relevant to the evaluation. Each partici- pant should have the opportunity to speak, ask questions of other participants and respond to the comments of others, includ- ing the facilitator. Generally, it is best to hold several focus groups on the same topic. The first few focus group sessions are often longer because the facilitator is getting all new information. Thereafter, the facilitator is able to move quickly over points that have already been covered with previous groups if similar answers are emerging. The num- ber of focus group discussions you should conduct depends on the project needs and resources and whether different views from separate groups are still emerging. In gener- al, at least two focus group discussions should be conducted among each specific target group. When designing focus groups, keep in mind the following: ä Develop a guide for facilitators: To get the most thorough information, offer tips and guidance to facilitators. If a facilitator is new to a topic, provide a list of possible probe questions that he or she should ask. Suggest that facilita- tors avoid leading questions. For example, they should not ask why participants donÕt eat certain foods; instead, they should ask participants to discuss what kinds of foods they like and dislike, and why. Focus group questions should be different from the questions you would ask in a survey; asking a group about an issue is differ- ent from asking individuals about their own behavior. ä Hold focus groups at a neutral and comfortable venue: For example, the community health center would not be a good place to meet if the topic were attitudes about health services. ä Carefully determine the composition of the focus group: When selecting participants, aim to recruit a homoge- neous group in terms of age, sex, edu- cation, occupation, political status and authority. For example, do not com- bine counselors, nurses and the man- ager of a clinic in one focus group. ä Document the discussion: If possible, tape-record the focus group and tran- scribe it before it is analyzed. Minimally, have an observer present to take notes. ä Be supportive and nonjudgmental: Respondents will disclose more if they believe there are no right or wrong answers and that they are in a confi- dential group with people who are similar to them in terms of back- ground and social characteristics. Using Mystery Clients A mystery client is a person selected from the target population to pose as a partici- pant in a program and report back to the evaluator on his or her experience. Mystery clients are especially useful for collecting information about health facilities and providers. When using mystery clients, keep in mind the following: ä Develop a range of scenarios and per- sonality traits for mystery clients to act out: Have the mystery clients present erroneous information (to determine whether and how the program cor- rects these ideas) and have them say they do not understand what the provider tells them (to determine whether the program ensures compre- hension). ä Mystery clients should select scenarios that best suit them: Explain to partici- pants that they will ÒbecomeÓ the per- son described when participating in the program. Ask them to carefully read over the scenario they have selected. ä Discuss or role-play each scenario: Before participants act as mystery clients, have them discuss what their characters are like and how they would feel about the situation they are in. Be attentive to details such as how the person behaves, what kind of lan- guage he or she uses and body lan- guage. Then role-play the interaction so that each mystery client will be pre- pared for the questions and proce- dures he or she is likely to encounter. ä Prepare participants for what to do once they are in the role of a mystery client: Remind them to be Òin charac- terÓ upon entering the program, and tell them what to do if they see some- one they know. Also ask them to record the amount of time spent wait- ing and participating in the program and to collect educational materials. Mystery clients should not undergo any type of exam or procedure. ä Debrief the mystery client as soon as possible: Using an open-ended sur- vey, interview mystery clients soon after they complete each mystery client assignment. Relate questions on the survey to the specific indicators that the program is interested in assessing. 279 Part II: Instruments and Questionnaires 280 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 281 Part II: Instruments and Questionnaires Instrument 1: Checklists Page 1 of 8 A. Program Design Checklist Indicator Criteria Yes No Comments A Has assessment identified RH issues and needs of youth? B Has assessment identified different types of youth? C Has assessment identified risk and protective factors for youth? Baseline assessment conducted to identify ARH issues, needs and target audience D Has assessment identified the context for risk-taking and health-seeking behaviors among youth? A Has stakeholder and gatekeeper support been assessed? B Has a review of policies and regulations that might affect ARH program activities been conducted? Political feasibility analysis conducted C Has there been an assessment of collaborative arrangements with other ARH programs and activities? A Is there a mission statement? B Is the mission statement consistent with institutional/local/regional policies and priorities regarding RH? C Does the mission statement provide a vision of the future? D Does the mission statement define the program’s services and products? E Does the mission statement define the program’s target audience/clients? Existence of clearly defined mission statement that contributes to the achievement of program goals F Does the mission statement provide a meaningful basis for developing operational plans? A Does the program have goals and objectives? B Is the target audience(s) defined in the goals and objectives? C Do the goals define the ultimate achievement of the program? D Are the objectives specific, time-bound and measurable? Existence of clearly defined goals and objectives E Do staff and volunteers know, understand and accept the goals and objectives of the program? Intervention goals and strategy based on conceptual model of behavior change A Did you develop a logic model linking outcomes, antecedents and activities? A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 282 Instrument 1: Checklists Page 2 of 8 A. Program Design Checklist (continued) Indicator Criteria Yes No Comments A Have youth been involved in program planning? B Have school administrators, teachers and school staff been involved in program planning? C Have parents, relatives, caretakers and/or guardians been involved in program planning? D Have policymakers/local government leaders been involved in program planning? E Have key social-group representatives been involved in program planning? F Have community elders and/or leaders been involved in program planning? Local stakeholders involved in program planning G Have service providers been involved in program planning? A Does the plan identify and recruit local stakeholders and community leaders to participate in program activities? B Does the plan establish a coordinating body (committee) that would support ARH program activities? Existence of plan for community mobilization C Does the plan include a schedule for community activities that would include ARH messages and information? A Has assessment included a history of training for present staff positions? B Has the number of existing staff been assessed? C Has the number of existing staff who are competent and confident in working with youth been assessed? D Has the number of existing staff who are knowledgeable in relevant ARH subjects been assessed? Assessment of staffing needs and related training requirements E Have future training needs and training selection criteria been established? A Have program costs been estimated? B Have potential clients’ ability and willingness to pay been assessed? Financial feasibility analysis conducted C Has there been a review of financial support sources? 283 Part II: Instruments and Questionnaires Instrument 1: Checklists Page 3 of 8 B. Checklist of Stakeholder Involvement DIRECTIONS: For each recommended type of consultation with a stakeholder group, write the date of consultation in the “Actual” column for those consultations that took place. Leave blank if no consultation was held. Stakeholder Groups Youth School Personnel1 Parents/Families2 Service Providers3 Community Leaders Consultation on: Recom- mended Actual Recom- mended Actual Recom- mended Actual Recom- mended Actual Recom- mended Actual Definition of reproductive health X X X X X Goals of ARH program X X X X Structure of ARH program4 X X X Topics to be covered in ARH program X X X Evaluation of ARH program X X X X Desired level of involvement with program5 X X X X X Views of RH education in schools, health centers, media and community programs X X X X Perceived need for ARH services X Knowledge and perception of sexual activity (and/or risk- taking behavior), including age at sexual initiation among youth X X X X Knowledge, attitudes, behaviors about sex, pregnancy, contraception, HIV/AIDS/STIs, abortion, etc. X Extent to which RH topics are discussed in family X X Who initiates family discus- sions on RH and sexual topics (i.e., youth or parents) X X Difficulty in discussing RH and sexual topics with youth X X X Gender differences in discussions on ARH and sex X X X Appropriate ages for address- ing different RH and sexual topics X X X 1 School personnel includes administrators, teachers and staff. 2 Parents/families also includes caretakers and guardians. 3 Service providers includes counselors, physicians, nurses, nurses aides, volunteers, peer promoters and social workers. 4 From the perspective of youth, program structure would include the range of activities, such as family life education, skills training, counseling, peer education, communications and media. From the perspective of school personnel, program structure would cover the curriculum, type of instruction, teacher training, access or referral to health services and coordination of community efforts. From the perspective of service providers, program structure would include youth-only clinics, separate hours for youth and integrated services with adults. 5 “Involvement” can cover the following elements: program design, planning, implementation and evaluation. A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 284 Instrument 1: Checklists Page 4 of 8 B. Checklist of Stakeholder Involvement (continued) Stakeholder Groups Youth School Personnel Parents/Families Service Providers CommunityLeaders Consultation on: Recom- mended Actual Recom- mended Actual Recom- mended Actual Recom- mended Actual Recom- mended Actual Appropriate amount of time to devote to RH and sexual topics X X Context in which to include ARH program (new course or within existing course; if existing course, which one) X Approachable source(s) of ARH counseling and services6 X Where youth go for fun and relaxation and how often X Male involvement in ARH services X X Reaction to various youth behaviors7 X X X X Barriers to youth getting services X X Types of training needed to assist youth X Types of services that can be offered to youth X X Views about working with youth in clinics, pharmacies and other commercial outlets X How youth can be attracted to health centers X X Changes to be made in current system X X X 6 “Approachable source(s)” are where youth feel comfortable going to get information, counseling and/or services. 7 Behaviors include having sex, using contraception for pregnancy and STI/HIV/AIDS prevention, becoming pregnant for girl or causing pregnancy for boy, having an abortion, etc. 285 Part II: Instruments and Questionnaires Instrument 1: Checklists Page 5 of 8 C. Training Course Checklist for ARH Program Staff I. METHODOLOGICAL APPROACH Methodology Criteria Yes No Comments Curriculum has specific learning objectives Methodology is interactive Methodology is competency-based II. COURSE CONTENT Training Topics Yes No Comments Basic RH care Adolescent physical and sexual growth and development Predictors of adolescent sexual behavior Contraceptive methods, including emergency contraception HIV/AIDS Sexually transmitted infections Relationship among risk-taking behaviors (e.g., sexual activity, smoking, drugs, alcohol) Services for adolescent males Partner counseling with adolescent males Youth culture and language (especially related to sex) III. FACILITATOR(S) CAPACITY Facilitator Characteristics Yes No Comments Facilitator trained as trainer Facilitator knowledgeable about ARH topics and course curriculum Facilitator skilled with a variety of training techniques A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 286 Instrument 1: Checklists Page 6 of 8 D. Checklist for “Youth-Friendly” Service Characteristics PROVIDERS AND STAFF Characteristics Yes No Comments Staff is friendly and responsive to youth clients Staff is respectful to and ensures privacy of youth clients Staff is understanding of and knowledgeable about youth concerns and needs Counselors spend adequate time with youth clients Counselors use language that is understandable to youth Counselors are nonjudgmental and approachable Medical providers spend adequate time with youth clients Medical providers use language that is understandable to youth Medical providers are nonjudgmental and approachable Information provided during counseling is clear and helpful Information on need for and timing of follow- up visit(s) is provided and clear Medical providers offer choices, including abstinence, contraception and withdrawal POLICIES AND PROCEDURES Characteristics Yes No Comments Youth drop-ins are welcome and accommodated (for drop-ins only) Services are offered to both male and female youth clients Facility provides informational and/or audiovisual materials on RH services and concerns of youth clients Facility provides contraceptive methods that are most popular among youth clients Facility offers wide range of services Services are linked to other youth service and program networks Cost of RH services is affordable 287 Part II: Instruments and Questionnaires Instrument 1: Checklists Page 7 of 8 D. Checklist for “Youth-Friendly” Service Characteristics (continued) ENVIRONMENT AND FACILITIES Characteristics Yes No Comments ARH services are provided at convenient (and separate) hours for youth clients Décor and surroundings are inviting to youth clients (i.e., non-medical) Counseling and examination rooms ensure privacy for youth clients Separate space is used for youth clients1 Facilities are conveniently located for youth Education materials are displayed and available to youth clients Youth clients report overall satisfaction with ARH services 1 Separate space and separate hours may not always be feasible. A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 288 Instrument 1: Checklists Page 8 of 8 E. Checklist of Selection Criteria for Peer Educators Selection Criteria Yes No Comments Is person committed to good reproductive health? Is person a credible role model? Is person respectful of peers? Is person able to hold confidences? Is person able to interact with both peers and adults? Is person honest? Is person caring? Is person trustworthy? Is person able to speak in public? Is person able to hold public’s interest? Is person understandable when speaking in public? Is person of similar age to youth target population? Does person speak the language of youth target population? Is person from same geographic location as youth target population? How many criteria did the person meet? ______ Should person be selected? q Yes q No 289 Part II: Instruments and Questionnaires Instrument 2: Tally Sheets Page 1 of 7 A. Monthly Tally Sheet for Counseling Month: Name of Provider: Content of Counseling Session A Number of Individual/Couple Sessions for Youth B Number of Group Sessions for Youth Number of Youth Who Attended Each Group Session Total Number of Sessions (A + B) HIV/AIDS Other STIs Contraceptive methods Strategies to avoid unsafe sex Negotiation skills Self-esteem Prenatal care Parenting Postnatal care/breastfeeding Abortion Nutrition Drugs/alcohol Relationships Other: TOTAL A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 290 Instrument 2: Tally Sheets Page 2 of 7 B. Tally Sheet for Communication Products Type of Product # Distributed or Aired in 1s t Quarter # Distributed or Aired in 2nd Quarter # Distributed or Aired in 3rd Quarter # Distributed or Aired in 4t h Quarter # Distributed or Aired for Year RH STIs HIV/AIDS Condoms Other contraception Pamphlets (by topic): Pregnancy/maternal care RH STIs HIV/AIDS Condoms Other contraception Posters (by topic): Pregnancy/maternal care Videos Television programs/spots Radio programs/spots Stories Advertisements Newspapers: Special inserts Stories Advertisements Magazines: Special inserts 291 Part II: Instruments and Questionnaires Instrument 2: Tally Sheets Page 3 of 7 C. Tally Sheet for Stakeholder Involvement Organization Stakeholders/Leaders Type of Involvement Comments 1 2 3 4 q Planning q Service delivery q Evaluation q Financial support q Policy q Other: 1 2 3 4 q Planning q Service delivery q Evaluation q Financial support q Policy q Other: 1 2 3 4 q Planning q Service delivery q Evaluation q Financial support q Policy q Other: 1 2 3 4 q Planning q Service delivery q Evaluation q Financial support q Policy q Other: 1 2 3 4 q Planning q Service delivery q Evaluation q Financial support q Policy q Other: 1 2 3 4 q Planning q Service delivery q Evaluation q Financial support q Policy q Other: 1 2 3 4 q Planning q Service delivery q Evaluation q Financial support q Policy q Other: A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 292 Instrument 2: Tally Sheets Page 4 of 7 D. Tally Sheet on Number and Characteristics of Youth Counseled Characteristics January February March April May June Total Under 14 15–16 17–19 20–24 Age group Total all ages* Females Males Sex Total both sexes* No education Some primary school Completed primary school Some secondary school Completed secondary school University Education level Total all levels* Enrolled in school Not enrolled in school School status Total all statuses* Never married Currently married Unmarried, living with partner Divorced/separated/widowed Marital status Total all statuses* Rural Peri-urban Urban Residence status Total all statuses* * The total of each category should be the same, unless there is missing information on the characteristics of some youth. 293 Part II: Instruments and Questionnaires Instrument 2: Tally Sheets Page 5 of 7 D. Tally Sheet on Number and Characteristics of Youth Counseled (continued) Characteristics January February March April May June Total Lives on street Commercial sex worker Drug or alcohol user School dropout Other risk category: Risk status Total all statuses* Not working Looking for work Working part-time Working full-time Work status Total all statuses* * The total of each category should be the same, unless there is missing information on the characteristics of some youth. A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 294 Instrument 2: Tally Sheets Page 6 of 7 E. Institutional Infrastructure Tally Sheet Type of Institution No. of Locations in Community Title of Institutions, Organizations and Opportunities Service organizations for victims of sexual abuse Youth organizations Schools that provide RH information Economic opportunities for youth Type: Type: Type: Type: Type: 295 Part II: Instruments and Questionnaires Instrument 2: Tally Sheets Page 7 of 7 E. Institutional Infrastructure Tally Sheet (continued) Type of Institution No. of Locations in Community Title of Institutions, Organizations and Opportunities Entertainment venues for youth Venues that serve alcohol to youth 296 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 297 Part II: Instruments and Questionnaires Instrument 3: Reporting Forms Page 1 of 2 A. Reporting Form for Counseling Number and content of reproductive health counseling sessions held for youth. January 2000 February 2000 January to February 2000 Content of Counseling Number of Group Sessions Held Number that Attended Each Group Session Number of Individual/ Couple Sessions Held Number of Group Sessions Held Number that Attended Each Group Session Number of Individual/ Couple Sessions Held Total Number of RH Counseling Sessions HIV/AIDS Other STIs Contraceptive methods Strategies to avoid unsafe sex Negotiation skills Self-esteem Prenatal care Parenting Postnatal care/ breastfeeding Abortion Nutrition Drugs/alcohol Relationships Other: TOTAL A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 298 Instrument 3: Reporting Forms Page 2 of 2 B. Peer Educators’ Reporting Form Name of peer educator: Month: Year: Location: Service to Individuals No. Date Sex Counseling Referred Number of Commodities Contact M F Y N Topic Y N Reason Condom Foam New Follow- up 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Total 299 Part II: Instruments and Questionnaires Instrument 4: ARH Coalition Questionnaire Page 1 of 4 The purpose of this questionnaire is to see how well organizations and various stakeholders are represented in decision making about ARH programming and to assess their ability to work in coalition with ARH programs. 1 Organization you belong to: 2 Job title: Please use the checklist below to describe how involved the following members/sectors of the community are in decision making about your ARH programming. (The coding categories 2 through 5 build on one another; select only one response for each group. If you do not know, circle NR.) RESPONSE CODES: 1 Not involved 2 Observation Involved as observers of meetings and activities, or recipients of information or advice 3 Advice Involved as providers of information or advice 4 Doing Involved in carrying out activities 5 Decision making Involved as participants in program decision making NR No response I do not know A Young adolescents (10–14 years) 1 2 3 4 5 NR B Middle adolescents (15–19 years) 1 2 3 4 5 NR C Older adolescents (20–24 years) 1 2 3 4 5 NR D Parents/guardians 1 2 3 4 5 NR Individuals working in the following sectors: E Religious (churches, mosques, temples, interfaith councils, synagogues, etc.) 1 2 3 4 5 NR F Economic (business persons) 1 2 3 4 5 NR G Educational (teachers, principals, parent- teacher associates, etc.) 1 2 3 4 5 NR H Health care (nurses, doctors, social workers, etc.) 1 2 3 4 5 NR I Arts and cultural organizations 1 2 3 4 5 NR J Media (local radio, news, etc.) 1 2 3 4 5 NR K Recreational (team coaches, sports leagues, etc.) 1 2 3 4 5 NR L Social welfare (human services, mental health, etc.) 1 2 3 4 5 NR M Youth-serving organizations (YMCA, YWCA, youth centers, etc.) 1 2 3 4 5 NR N Other community group leaders (civic and neighborhood associations, etc.) 1 2 3 4 5 NR O Local or district government officials 1 2 3 4 5 NR P Regional/national government officials 1 2 3 4 5 NR 3 Q Other (specify:______________________) 1 2 3 4 5 NR 4 Is there anything else you would like to tell us about the extent to which diverse people and groups are involved in the ARH program? (If so, please describe.) A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 300 Instrument 4: ARH Coalition Questionnaire Page 2 of 4 5 In an average month, about how many hours of time do you spend participating in the ARH coalition? Include time spent in preparing for meetings or activities; in meetings, including travel to and from meetings; participating in ARH coalition-sponsored activities other than meetings; and communicating with members. (Circle one response.) 1 Never participate in any of these activities 2 Less than 1 hour per month 3 1–2 hours per month 4 3–5 hours per month 5 6–10 hours per month 6 11 or more hours per month 6 How are major decisions usually made about ARH coalition activities? (Circle the one primary way you think decisions are made.) 1 Voting, with majority rule 2 Discussion and consensus among ARH coalition members 3 The chair listens to discussion and makes final decisions for the members 4 ARH program staff make the decisions independently 5 Another way (please describe): 7 From your perspective, to what extent has your ARH coalition achieved consensus on its mission and direction? (Circle only one response.) 1 No consensus 2 Very little consensus 3 Some consensus 4 A great deal of consensus In the ARH program coalition, how important or unimportant are each of the following ways of communicating? (Circle one response for each category below.) Very important Somewhat important Not very important Not at all important A Mailed/faxed written materials 1 2 3 4 B Verbal reports at meetings 1 2 3 4 C Group discussions 1 2 3 4 8 D Talking outside of meetings 1 2 3 4 Please rate communication between ARH program staff and coalition members on the scales below. (Circle one number for each pair of adjectives.) A Frequent 1 2 3 4 5 Infrequent 9 B Productive 1 2 3 4 5 Unproductive How much do you agree or disagree with the statements below about the ARH coalition? (Circle one response for each category.) Strongly agree Somewhat agree Somewhat disagree Strongly disagree A There is always a clear agenda for meetings. 1 2 3 4 B The coalition follows its agenda. 1 2 3 4 C Coalition members regularly attend meetings. 1 2 3 4 10 D Coalition members listen to one another. 1 2 3 4 301 Part II: Instruments and Questionnaires Instrument 4: ARH Coalition Questionnaire Page 3 of 4 Participation in a coalition may change relationships among groups or organizations. If you represent an organization in the ARH coalition, rate the extent to which linkages between your organization and others that are represented on the coalition have changed as a result of your participation in the coalition. (Circle one response for each category. If you do not represent an organization in the ARH coalition, skip this question and go to Question 13.) Major increase Slight increase Stayed the same Slight decrease Major decrease A Exchange of information 1 2 3 4 5 B Referrals to or from other groups/ organizations 1 2 3 4 5 C Sharing of resources 1 2 3 4 5 D Sharing of staff 1 2 3 4 5 E Co-sponsoring events 1 2 3 4 5 F Coordinating services 1 2 3 4 5 G Undertaking joint programs 1 2 3 4 5 11 H Obtaining media coverage 1 2 3 4 5 In your opinion, how much of a problem are the health behavior issues listed below for youth in your community? (Check one box in each row.) Problem for youth in your community? Health Behavior Issue No problem Minor problem Somewhat of a problem Major problem Don’t know A Alcohol use/drinking B Cigarette smoking/tobacco use C Illegal drug use D STIs E Unwanted pregnancy F Abortion G HIV/AIDS H Lack of proper nutrition I Sexual assault/Coercion 12 J Other: 13 Look over your responses to the issues listed in Question 12. Of the health concerns you identified as major problems for youth in your community, which is the most important? A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 302 Instrument 4: ARH Coalition Questionnaire Page 4 of 4 In your opinion, how much of a problem are the health or social service issues listed below for youth in your community? (Check one box in each row.) Problem for youth in your community? Health or Social Service Issue No problem Minor problem Somewhat of a problem Major problem Don’t know A Availability of reproductive health services B Availability of adequate and timely care by a health provider C Availability of health education programs (e.g., pregnancy prevention) D Availability of pharmacy services 14 E Availability of counseling and/or mental health services 15 In your opinion, what can be done to address the problems identified in Question 14? Thank you very much for your time and help! 303 Part II: Instruments and Questionnaires Instrument 5: Composite Indices Page 1 of 5 A. Index on Quality of Counseling (for Individual Counseling Sessions) DIRECTIONS: After observing a counseling session, use this index to score the counselor’s performance on each item. Score each sub- item on a scale of 0–2. A score of 0 indicates that no attention was given to this item during the counseling session; a score of 1 indicates moderate attention and a score of 2 indicates good attention. The subtotal is the sum of the scores for each sub-item. In the example below, the maximum total score possible is 28. The total score can be converted to a percentage by dividing total by the maximum total score possible. For example, if the total score using this index is 17, then divide 17 by 28. The result is .61, or 61 percent. Item Score (0–2) Subtotal Counselor covered essential points in ARH service protocol: • Youth’s needs are determined • Information on key youth characteristics is obtained • Information on preventing STIs is provided • Information on contraception is provided Counselor developed rapport with youth (illustrative): • Used youth’s name during session • Treated youth with respect • Encouraged youth to ask questions • Used a kind and inviting tone of voice • Listened to youth Counselor demonstrated appropriate counseling techniques Counselor explained relevant medical procedures (e.g., medical exams) to youth and answered youth’s questions in advance of a medical provider performing the procedures IEC materials are available in the counseling facility Counselor used and/or provided IEC materials during counseling session Counselor provided referral information for obtaining services TOTAL A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 304 Instrument 5: Composite Indices Page 2 of 5 B. Policy Environment Score: Adolescents1 DIRECTIONS: This Policy Environment Score (PES) is meant to assess the current environment as well as year-to-year changes. Many of the items will change little over a one-year period; however, the PES allows the features of the policy environment to be systematically assessed at regular intervals. A scale of 0 to 4 should be assigned to each item. In every case, 4 means a better or more satisfactory rating. Some items may seem to require only a yes or no response, but please adhere to the 0 to 4 rating scale. Enter a “DK” for don’t know when you have little or no information about an item. Do not leave anything blank. Score the two columns separately, to compare this year with last year. Retain the results for reference use next year, when the instrument can be used for a repeat assessment. Normally, scoring will be done by several observers who can assess the policy environment from different vantage points (e.g., youth programs staff, board members, other stakeholders). Their scores can be compared in detail for the insight they provide and be averaged as an overall measure. An alternate approach is to obtain ratings from a small group of experts who meet to seek consensus through discussion. A variation is for each person to complete the form, recording an independent set of ratings prior to the discussion. Either approach may be used in a workshop format to alert officials and donors to policy issues. How to score: Enter a number from 0 to 4 in each box (2 is the midpoint). Calculate the mean score by dividing the sum of the scores by the number of items. The sum of the seven means is the final score, which can range from 0 to 28. It can be converted to a percentage by dividing the final score by 28. Scoring: 0 = weak; 4 = strong I. POLITICAL SUPPORT Status Now Status 1 Year Ago 1 High-level national government support exists for effective policies and programs 2 Public opinion supports effective policies and programs 3 Media campaigns are permitted 4 Political parties support effective policies and programs 5 The issue is recognized by top planning bureaus 6 Major religious organizations support effective policies and programs SUM MEAN 1 Future’s Group International, Research Triangle Institute, and the Centre for Development and Population Activities. 1998. Project Design and Evaluation Guidelines. Washington, DC: The POLICY Project. 305 Part II: Instruments and Questionnaires Instrument 5: Composite Indices Page 3 of 5 Scoring: 0 = weak; 4 = strong II. POLICY FORMULATION Status Now Status 1 Year Ago 1 A favorable national policy exists 2 Formal program goals exist 3 Specific and realistic strategies to meet goals exist 4 Ministries other than Health are involved in policy formulation 5 Policy dialogue and formulation involves NGOs, community leaders and representatives of the private sector and special interest groups 6 Government policy supports family life education and other IEC efforts for youth SUM MEAN III. ORGANIZATIONAL STRUCTURE Status Now Status 1 Year Ago 1 A national coordinating body exists that engages various ministries to assist with appropriate services (if none, enter 0) 2 Ministries other than Health are mandated to help with project implementation 3 NGOs are formally included in policy deliberations 4 The private sector is formally included in policy deliberations SUM MEAN IV. LEGAL AND REGULATORY ENVIRONMENT Status Now Status 1 Year Ago 1 There is a favorable legal and regulatory climate for ensuring that unmarried adolescents of any age may receive reproductive health services 2 Pregnant adolescents are allowed to continue with their education 3 Providers are free from unnecessary legal and regulatory restrictions (e.g., services available to adults are available to adolescents as well) SUM MEAN A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 306 Instrument 5: Composite Indices Page 4 of 5 Scoring: 0 = weak; 4 = strong V. PROGRAM RESOURCES Status Now Status 1 Year Ago 1 Funding from government sources is generally adequate 2 Funding from donor sources is generally adequate 3 Staffing for service provision is generally adequate 4 Enough service points and providers exist for reasonable access by most clients 5 Resources are allocated by explicit priority guidelines SUM MEAN VI. PROGRAM COMPONENTS Status Now Status 1 Year Ago 1 Reproductive health services for single adolescents are offered not only in the usual service delivery points but also elsewhere, such as in schools, youth centers or other places where youth are found 2 STI/AIDS information is an integral part of educational efforts 3 Condoms are easily available to youth through accessible channels 4 Post-abortion counseling is an integral part of the youth program 5 Health staff are trained to counsel youth in sexual and reproductive health matters 6 Community-based distribution systems exist and use youth (male and female) as distributors (if none exist, enter 0) SUM MEAN 307 Part II: Instruments and Questionnaires Instrument 5: Composite Indices Page 5 of 5 Scoring: 0 = weak; 4 = strong VII. EVALUATION AND RESEARCH Status Now Status 1 Year Ago 1 A regular system of service statistics exists and functions adequately 2 A system exists to monitor secondary data sources (e.g., surveys, censuses, local studies) for the benefit of policy guidance 3 A system exists to bring evaluation and research results to management’s attention 4 Special studies are undertaken to address leading policy issues SUM MEAN Comments: 308 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 309 Part II: Instruments and Questionnaires Instrument 6: Inventory of Facilities and Services Page 1 of 18 INSTRUCTIONS TO DATA COLLECTOR: Complete this inventory using observation and discussion with the person in charge of reproductive health services. Verify existence of equipment and supplies and the condition of the facility through observation. If you cannot observe the equipment, supplies or conditions, then indicate this in the margins. Note: The respondent should be the manager of the facility. Background Characteristics 1 Health facility (name and number): 2 District (name and number): 3 Region (name and number): 4 Date of interview: _____ / _____ / _____ 5 Level of facility where observation took place: 1 Referral hospital 2 Hospital 3 Health center 4 Health post 5 Mobile health clinic 6 Pharmacy 7 Clinic in non-permanent facility (e.g., schools, rotating rural health outposts, youth centers, kiosks) 8 Other: _____________________________ 6 Type of facility: 1 Government/Ministry of Health 2 Government/other 3 Family planning association 4 Other NGO 5 Missionary 6 Private 7 Structure of facility: 1 Youth-only facility 2 Youth-only facility hours 3 Integrated services 8 Locality of facility: 1 Rural 2 Urban 3 Peri-urban Name of interviewer: Signature of team leader: A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 310 Instrument 6: Inventory of Facilities and Services Page 2 of 18 1 What time is the clinic scheduled to open? (Observe) _____ _____: _____ ____ 2 What time did staff actually arrive? (Observe) _____ _____: _____ ____ 3 What time (at or after the clinic opened) did the first client arrive? (Observe) _____ _____: _____ ____ 4 What time was the first client seen? (Observe) _____ _____: _____ ____ 5 What is the official closing time for this health facility? (Observe) _____ _____: _____ ____ 6 How many days per week are reproductive health services offered at this health facility? ________ days per week 7 Is there a sign announcing that reproductive health services are available? 1 Outside building 2 Inside building 3 Both inside and outside building 4 No sign visible 8 Is there a sign for youth clients announcing that reproductive health services are available? 1 Outside building 2 Inside building 3 Both inside and outside building 4 No sign visible 9 Are there special hours or days for youth clients? 1 Special hours 2 Special days 3 Special hours and days 4 None 311 Part II: Instruments and Questionnaires Instrument 6: Inventory of Facilities and Services Page 3 of 18 Section 1: Equipment and Commodities Inventory Which contraceptive methods are usually provided at this facility? (Record responses below.) If the method is provided, determine if it is available today. If yes, count the approximate number of non-expired units of each method available either in the facility or the storeroom. For each method provided, ask whether there has been a stockout in the last six months. If yes, determine the duration of the last stockout.) Type of Contraception Usually provides method? Available today? # Available (approx. # of units) Stockout in last 6 months? If yes, duration of last stockout A Combined pills Yes No Yes No Yes No ___ days ___ weeks ___ months B Progesterone-only pill Yes No Yes No Yes No ___ days ___ weeks ___ months C Condoms Yes No Yes No Yes No ___ days ___ weeks ___ months D Spermicides Yes No Yes No Yes No ___ days ___ weeks ___ months E IUD Yes No Yes No Yes No ___ days ___ weeks ___ months F Injectables Yes No Yes No Yes No ___ days ___ weeks ___ months G Diaphragm Yes No Yes No Yes No ___ days ___ weeks ___ months H Emergency contraception Yes No Yes No Yes No ___ days ___ weeks ___ months 10 I Other (specify): Yes No Yes No Yes No ___ days ___ weeks ___ months A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 312 Instrument 6: Inventory of Facilities and Services Page 4 of 18 Section 1: Equipment and Commodities Inventory (continued) Record the types of tests that are provided at this facility: Type of Test Usually provides test? Available today? # Available (approx. # of units) Stockout in last 6 months If yes, duration of last stockout A Pregnancy test Yes No Yes No Yes No ___ days ___ weeks ___ months 11 B Anemia test Yes No Yes No Yes No ___ days ___ weeks ___ months Which services are offered at this facility? (For each service, first record if it is provided, and then record whether the service has been available at all times in the last six months. If the service has not been available at all times in the last six months, mark the reason why it was last not available and record the length of time it was not available.) (Observe and ask) Type of Service Provided? Available at all times in last 6 months? If no, reason last not available Length of time not available (the last time) A Pregnancy testing Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months B Maternity care/delivery services Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months C STI screening and treatment Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months D HIV/AIDS testing Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months 12 E Contraceptive method counseling Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months 313 Part II: Instruments and Questionnaires Instrument 6: Inventory of Facilities and Services Page 5 of 18 Section 1: Equipment and Commodities Inventory (continued) Type of Service Provided? Available at all times in last 6 months? If no, reason last not available Length of time not available (the last time) F Abortion/post-abortion services Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months G Risk-reduction counseling Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months H Infertility consultation Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months I Gynecological exams Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months J Breastfeeding counseling Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months K Anemia testing Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months L Nutrition counseling Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months M Parenting classes Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months 12 N Other (specify): Yes No Yes No 1 Supplies not available 2 Equipment not available 3 Trained staff not available 4 Other: ___ days ___ weeks ___ months A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 314 Instrument 6: Inventory of Facilities and Services Page 6 of 18 Section 1: Equipment and Commodities Inventory (continued) 13 Is any laboratory testing available for STIs? Yes No Is there a test available at this facility, or are clients’ specimens, or the clients themselves, sent elsewhere? STI Test Available at this facility? Clients’ specimens sent elsewhere? A Syphilis Yes No Yes No B Gonorrhea Yes No Yes No C Chlamydia Yes No Yes No D Candida Yes No Yes No E Cervical cancer Yes No Yes No 14 F Other: Yes No Yes No Which of the equipment listed below is available and in working order? (Ask to see each type of equipment. Count how many of each are in working order and put the number available in the corresponding box on the table.) Equipment and Supplies Number Available Flashlight/lamp Scale Blood pressure gauge Stethoscopes Sterile needles and syringes Specula for adults Specula for youth Tenacula Alligator forceps Sponge-holding forceps Uterine sounds Artery forceps Dressing forceps Tissue forceps 15 Mosquito forceps 315 Part II: Instruments and Questionnaires Instrument 6: Inventory of Facilities and Services Page 7 of 18 Section 1: Equipment and Commodities Inventory (continued) Equipment and Supplies Number Available 15 Flashlight/lamp Scale Blood pressure gauge Stethoscopes Sterile needles and syringes Specula for adults Specula for youth Tenacula Alligator forceps Uterine sounds Artery forceps Dressing forceps Tissue forceps Intestinal forceps Babcock forceps NSV ringed forceps Scalpels Sutures Needle holder Tubal hook Sharp trocars Sterilizers Iodine Xylocaine or lignocaine Antiseptic Chlorine solution Sterile gloves Disposal containers for contaminated waste/suplies Sharps containers for used sharps Plastic buckets for containers for decontamination Clean-instrument containers Instrument trays Swab containers with sterile swabs or sterile gauze Examination couch or table Examination table capable of trendelenburg A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 316 Instrument 6: Inventory of Facilities and Services Page 8 of 18 Section 1: Equipment and Commodities Inventory (continued) Equipment and Supplies Number Available Operation theater Recovery room Microscopes Cotton wool Thermometer Dettol 15 Audiovisual equipment for presentations 16 Is there a system for monitoring and maintaining materials, equipment and supplies? 1 Yes 2 No Skip to Q. 18 17 If yes, could I see protocols on how the system works? (Observe) Describe briefly: Are facilities for storing contraceptives adequate in the following respect: (Observe) A Products are protected from the rain 1 Yes 2 No B Products are off the floor and on shelves 1 Yes 2 No 18 C First In First Out (FIFO) procedures are in place and followed 1 Yes 2 No 317 Part II: Instruments and Questionnaires Instrument 6: Inventory of Facilities and Services Page 9 of 18 Section 2: Conditions of Facility 19 Is there a client waiting area with shelter from sun and rain at the clinic? (Note: The waiting area must have some form of seating for at least 10 people. Verify if such an area is available.) (Observe) 1 Yes 2 No 20 Observe where pelvic exams and STI testing (if available) take place. (Choose the response that best describes this area.) (Observe and ask) 1 Separate room, with no ability to see into the room from outside 2 Behind a curtain 3 Other area that ensures privacy (Explain: ___________________________________________________) 4 No privacy 21 Is there a working lamp for use during examinations? (Observe and ask) 1 Yes 2 No 3 No information 22 What is the source of water for this facility? (Observe and ask) 1 Water piped into facility 2 Water piped from public tap 3 Well water on facility premises 4 Well water from public well 5 Other: _____________________ 6 No running water available A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 318 Instrument 6: Inventory of Facilities and Services Page 10 of 18 Section 3: IEC Materials and Activities Which IEC materials are available on the following subjects? (Observe and ask) Subject Flipchart Available? Brochure/Pamphlet Available? Posters Available? Contraception Yes No Yes No Yes No HIV/AIDS Yes No Yes No Yes No STIs Yes No Yes No Yes No Nutrition Yes No Yes No Yes No Pregnancy Yes No Yes No Yes No Abortion Yes No Yes No Yes No 23 Other Yes No Yes No Yes No 24 Are any of these IEC materials targeted toward youth? (Observe and ask) 1 Yes 2 No Skip to Q. 26 98 Don’t know Skip to Q. 26 25 Which topic or topics are targeted toward youth? 1 Contraception 2 HIV/AIDS 3 STIs 4 Nutrition 5 Pregnancy 6 Abortion 7 Other: _____________________________ 26 Was a “health talk” (group lecture or discussion with clients) held today? 1 Yes 2 No Skip to Q. 28 98 Don’t know Skip to Q. 28 319 Part II: Instruments and Questionnaires Instrument 6: Inventory of Facilities and Services Page 11 of 18 Section 3: IEC Materials and Activities (continued) If yes, which topics did the health talk include? Topic Topic Included? Contraception Yes No HIV/AIDS Yes No STIs Yes No Infertility Yes No Treatment of incomplete abortion Yes No Nutrition Yes No Pelvic exams Yes No Pregnancy Yes No 27 Other: Yes No A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 320 Instrument 6: Inventory of Facilities and Services Page 12 of 18 Section 4: Supervision 28 What was the date of the last “outside” supervisory visit that included reproductive health? (Observe and ask) _____ / _____ month year What did the supervisor do? (Do not read, but probe by asking, “Any other actions?”) Actions Mentioned? Observed delivery of different services Yes No Observed only service(s) respondent is responsible for Yes No Inquired about service problems Yes No Examined the records Yes No Made suggestions for improvements Yes No Offered praise for good work Yes No 29 Other: Yes No 321 Part II: Instruments and Questionnaires Instrument 6: Inventory of Facilities and Services Page 13 of 18 Section 5: Protocols and Guidelines 30 Review any written guidelines and protocols for delivering reproductive health services issued in the last five years. (Record “yes” if at least one set of written guidelines is available.) 1 Yes 2 No Skip to Q. 32 98 Don’t know Skip to Q. 32 31 Are youth mentioned in any of these guidelines and protocols? (Observe and ask) 1 Yes 2 No 98 Don’t know 32 Ask to see where informed consent forms are kept at the facility. 1Forms kept at facility 2 No forms kept at facility 3 No procedures performed at facility that would require informed consent 98 Don’t know 33 Ask to see where the confidentiality protocols are kept at this facility. 1 Protocols kept at facility 2 No protocol kept at facility 3 No procedures performed at facility that would require a confidentiality protocol 98 Don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 322 Instrument 6: Inventory of Facilities and Services Page 14 of 18 Section 6: Use of Information in Facility Management 34 What methods do you have for soliciting client opinions? (Mark all that apply.) 1 Client suggestion box 2 Provider asks client 3 Other staff ask client 4 Other: ________________________________ 5 No method available to solicit client opinion 35 In the past year, have any changes been made in the program based on feedback from clients? 1 Yes 2 No 98 No information 36 What changes have taken place? Explain: 37 What methods do you have for soliciting provider opinions? (Mark all that apply.) 1 Staff suggestion box 2 Staff meetings 3 Internal facility evaluations 4 Other: ____________________ 5 No method available to solicit provider opinion 38 In the past year, have any changes been made as a result of provider opinions? 1 Yes 2 No Skip to Q. 40 98 No information Skip to Q. 40 39 What changes have taken place? Explain: 40 In the past year, have any changes been made as a result of new organizational priorities? 1 Yes 2 No Skip to Q. 42 98 No information Skip to Q. 42 41 What changes have taken place? Explain: 323 Part II: Instruments and Questionnaires Instrument 6: Inventory of Facilities and Services Page 15 of 18 Section 7: Service Statistics How many youth clients received the services listed below in the past 12 months? (999 = no data available) (Compile statistics for the number of youth clients [ages 10–24 years] served in a continuous period of 12 months in any of the last 24 months. In those cases where a continuous 12-month period is not available, use the longest continuous period for which there are statistics, and record the number of months in the last column.) Type of Service New Clients Repeat Clients Based on _____ (Number of) Months of Continuous Records A Pregnancy testing B Maternity care/delivery services C STI screening D STI treatment E HIV/AIDS testing F Contraceptive counseling G Abortion services H Post-abortion services I Infertility counseling J Gynecological exams K Breastfeeding counseling L Anemia testing M Nutrition counseling N Parenting classes 42 O Other: What is the total number of clients who received services (of any type) in the past 12 months? (999 = no data available) Clients Number New Clients New Youth Clients Repeat Clients 43 Repeat Youth Clients 44 Indicate the calendar month and year of the most recent month reported in the table above: Month: _________ Year: __________ 45 Do you keep a record for each patient/client? (Observe and ask) 1 Yes 2 No 46 Is client follow-up conducted here? 1 Yes 2 No Skip to Q. 48 47 Do you keep the address of the patient/client for follow-up? (Observe and ask) 1 Yes 2 No A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 324 Instrument 6: Inventory of Facilities and Services Page 16 of 18 Section 8: Staffing How many of the staff positions listed bellow are assigned at this facility? Staff Position # Working Full-time # Working Part-time # On Duty Today A Medical doctor B Nurse C Nurse-midwife D Community-based distributor E MCH assistant F Peer educator G Young adult counselor H Social worker 48 I Other: 325 Part II: Instruments and Questionnaires Instrument 6: Inventory of Facilities and Services Page 17 of 18 Section 9: Fees for Services 49 Is there a fee for services at this facility? 1 Yes 2 No Skip to Q. 51 For the following methods and services, how much are clients (both adult and youth) charged? (Read each method) Service/Method Provided? General Client Fee Youth Client Fee A Oral contraceptive Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ B IUD Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ C Injectable Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ D Condom Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ E Diaphragm Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ F Spermicide Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ G Antenatal care Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ H Maternity care/delivery services Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ I Postnatal care Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ J HIV/AIDS counseling/IEC Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ K HIV/AIDS testing Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ L Other STI counseling/IEC Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ M Other STI diagnosis Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ N Other STI treatment Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ O Infertility consultation Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ P Treatment of incomplete abortion Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ 50 Q Post-abortion counseling/IEC Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 326 Instrument 6: Inventory of Facilities and Services Page 18 of 18 Section 9: Fees for Services (continued) Service/Method Provided? General Client Fee Youth Client Fee R Pregnancy testing Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ S Nutrition counseling Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ T Risk reduction counseling/IEC Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ 50 U Parenting counseling/IEC Yes No $ ___________ Not available: _____ $ ___________ Not available: _____ 51 Is there a consultation fee for new clients? 1 Yes 2 No Skip to Q. 55 98 Don’t know Skip to Q. 55 52 How much is this fee? 53 Is this fee the same for youth clients? 1 Yes Skip to Q. 55 2 No 98 Don’t know Skip to Q. 55 54 If no, how much is the fee for youth clients? 55 Is there anything else you would like to tell me about your services for youth? Thank you very much for your time and help! 327 Part II: Instruments and Questionnaires Instrument 7: Observation Guide for Counseling and Clinical Procedures Page 1 of 8 INSTRUCTIONS TO OBSERVER: Obtain the consent of both the youth client and the provider before proceeding to observe the interaction between them. Make sure that the provider knows you are not there to evaluate her or him and that you are not an “expert” who can be consulted during the session. When observing, be as discreet as possible: Try to sit so that you are behind the client but not directly in view of the provider, and make notes quickly. For each question, check the response that most accurately represents your observation of what happened during the interaction. 1 Health facility (name and number): 2 District (name and number): 3 Region (name and number): 4 Provider ID number: 5 Date of observation: _____/_____/_____ 6 Observer (name and number): 7 Level of facility where observation took place: 1 Referral hospital 2 Hospital 3 Pharmacy 4 Health center 5 Health post 6 Mobile health clinic 7 Clinic in non-permanent facility (e.g., schools, rotating rural health outposts) 8 Other: _______________________________ 8 Type of facility: 1 Government/Ministry of Health 2 Government/other 3 Family planning association 4 Other NGO 5 Missionary 6 Private 9 Structure of facility: 1 Youth-only facility 2 Youth-only facility hours 3 Integrated services 10 Locality of facility: 1 Rural 2 Urban 3 Peri-urban 11 Time observed session began: ___ ___: ___ ___ IF YOUTH CLIENT REFUSES TO BE OBSERVED, CHECK THIS BLANK AND PROCEED TO THE NEXT OBSERVATION. 12 Provider providing most of the counseling session: 1 Nurse 2 Nurse-midwife 3 Doctor 4 Peer educator 5 Health worker 6 Other: ________________________ 13 Sex of provider: 1 Female 2 Male A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 328 Instrument 7: Observation Guide for Counseling and Clinical Procedures Page 2 of 8 Counseling Observation 20 Main reason for visit: 1 New client 2 Contraceptive information and/or counseling 3 Contraceptive resupply 4 Follow-up 5 STI testing 6 STI treatment 7 HIV/AIDS testing 8 Pregnancy testing 9 Nutrition counseling 10 Other: _________________________ 21 Family planning status: 1 Current user 2 Not using now but has used 3 Has never used 4 Not determined Did the provider: Yes No A Greet client in a friendly manner B Ask open-ended questions C Encourage client to ask questions D Treat client with respect E See client in private F Discuss return visit G Ask client about concerns with contraceptive method H Use visual aids I Use client’s records 22 J Explicitly mention that the condom protects against STIs/HIV/AIDS Information provided: Provider Question Client Question Not Determined A Previous contact with provider B Current age C School status D Education level E Marital status F Whether sexually active or abstinent G Number of sexual partners in last year H Whether partner had more than one sexual partner in last year I Pregnancy history J Abortion history K Current pregnancy status 23 L Living children 329 Part II: Instruments and Questionnaires Instrument 7: Observation Guide for Counseling and Clinical Procedures Page 3 of 8 Counseling Observation (continued) Information provided: Provider Question Client Question Not Determined M History of contraceptive use N Current method use O History of pregnancy complications P History of STIs Q Vaginal bleeding R Vaginal discharge S Genital itching T Lower abdominal pain/pelvic pain U Whether discussed contraceptives with partner(s) 23 V Ease of returning to facility A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 330 Instrument 7: Observation Guide for Counseling and Clinical Procedures Page 4 of 8 Contraceptive Methods 24 What methods were discussed during the consultation? (Circle all that apply.) 1 Oral contraceptives 2 Condoms 3 IUD 4 Spermicide 5 Diaphragm 6 Injectable 7 Natural methods (e.g., rhythm) 8 Breastfeeding 25 Was more than one method discussed during the visit? 1 Yes 2 No 26 Which IEC materials were used during the visit? (Circle all that apply.) 1 Flipchart 2 Brochures/handouts 3 Contraceptive samples 4 Posters 5 Anatomical models 6 Other: ____________________________ 27 Did the provider promote or overemphasize one method in particular? 1 Yes 2 No Skip to Q. 29 28 Which method did the provider promote or overemphasize? 1 Oral contraceptives 2 Condoms 3 IUD 4 Spermicide 5 Diaphragm 6 Injectable 7 Natural methods (e.g., rhythm) 8 Breastfeeding 29 Did the provider promote the use of condoms for STI prevention along with the use of another method? 1 Yes 2 No 30 Did the provider mention explicitly that condoms protect against STIs and HIV? 1 Yes 2 No 31 Was the client asked which method she or he would prefer to use? 1 Yes 2 No Skip to Q. 33 32 Did the client receive her or his preferred method? 1 Yes Skip to Q. 35 2 No 33 Did the client decide to use a contraceptive method during the consultation? 1 Yes Skip to Q. 35 2 No 331 Part II: Instruments and Questionnaires Instrument 7: Observation Guide for Counseling and Clinical Procedures Page 5 of 8 Contraceptive Methods (continued) 34 What was the main reason that the client did not choose a method at the consultation? 1 Medical contraindications Skip to Q. 42 2 Changed mind Skip to Q. 42 3 Wanted information only Skip to Q. 42 4 Pregnancy suspected Skip to Q. 42 5 Method not available Skip to Q. 42 6 Not currently sexually active Skip to Q. 42 7 No obvious reason Skip to Q. 42 8 Other: _____________________________ Skip to Q. 42 35 Did the provider give a medical or other explanation for why a particular method was inappropriate for the client? 1 Yes 2 No 36 Which method did the client decide to use? 1 Oral contraceptives 2 Condoms 3 IUD 4 Spermicide 5 Diaphragm 6 Injectable 7 Natural methods (e.g., rhythm) 8 Breastfeeding 9 Other: _____________________________ 37 When the client selected a method, did the provider ask the client to explain why he or she chose this method? 1 Yes 2 No 38 What information did the health service provider offer the client in relation to the chosen method? (Circle all that apply.) 1 How to use the method 2 Advantages/benefits 3 Disadvantages 4 Possible side effects 5 What to do if problems arise 6 Possibility of changing methods 7 Prevention of STIs/HIV 8 Other: ____________________________ 39 Was the client told when to return for resupply or follow-up? 1 Yes 2 No 40 Was the client told where to go for resupply or follow-up? 1 Yes 2 No Skip to Q. 42 41 If yes, where? (Circle all that apply.) 1 This health facility 2 Another health facility 3 Pharmacy/shop/chemist/private doctor 4 Community-based distributor (CBD) 5 Other: ________________________________ A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 332 Instrument 7: Observation Guide for Counseling and Clinical Procedures Page 6 of 8 Discussion of STIs and Other Health Issues 42 Did the provider indicate that the client might have an STI? 1 Yes 2 No Skip to Q. 44 43 What did the provider do? (Circle all that apply.) 1 Requested laboratory tests 2 Treated STI 3 Referred elsewhere 4 Provided counseling 5 Other: _________________________ 77 No actions taken 44 What other health issues were mentioned at any time during the consultation? (Circle all that apply.) 1 HIV/AIDS 2 Other STIs 3 Infertility 4 Abortion 5 Nutrition 6 Breastfeeding 7 Sexual relations 8 Social/economic factors 9 Drugs/alcohol/smoking 10 Pregnancy testing 11 Other: _____________________________ 77 None of these issues 333 Part II: Instruments and Questionnaires Instrument 7: Observation Guide for Counseling and Clinical Procedures Page 7 of 8 Medical Procedures Did the health worker: Yes No A Take blood pressure B Check weight C Check height D Perform a laboratory test for an STI E Refer for an STI lab test F Perform a physical exam G Perform a breast exam H Perform/request a blood test I Perform/request urinalysis 45 J Perform/request a pregnancy test 46 Was a pelvic exam performed? 1 Yes 2 No Skip to Q. 52 47 Was the client given a choice of postponing the pelvic exam? 1 Yes 2 No 48 Were people other than the client, the provider and other necessary medical staff (and interviewer) present during this exam? 1 Yes 2 No Did the provider: Yes No A Explain the procedure to the client B Wash his or her hands before the exam C Perform a Pap smear 49 D Wash his or her hands after the exam 50 Was a speculum used during the exam? 1 Yes 2 No Skip to Q. 52 51 Did the health worker use a sterile speculum? 1 Yes 2 No 98 Don’t know 52 Did the health worker wear gloves during the exam? 1 Yes 2 No Skip to Q. 54 53 Were sterile gloves used? 1 Yes 2 No 98 Don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 334 Instrument 7: Observation Guide for Counseling and Clinical Procedures Page 8 of 8 Interviewer Impressions of Consultation 54 Did the client: Yes No A Ask questions of the provider B Express worry or concern C Volunteer relevant information D Appear anxious, uneasy or worried E Maintain eye contact with the provider (if this is appropriate in cultural setting) 55 Did the provider: Yes No A Use the client’s name when talking to him or her B Treat the client with respect C Use a kind and inviting tone of voice D Listen to the client E Maintain eye contact with the client (if this is appropriate in cultural setting) 56 Characterize the way the provider presented information during the consultation: 1 Standard presentation (like a tape recorder) 2 Standard presentation, but involved client with questions 3 Adjusted presentation based on client information 98 Don’t know 57 Did the provider use a language that the client seemed to understand? 1 Yes 2 No 58 Did the provider seem to genuinely like youth, in general? 1 Yes 2 No 59 Mark the time: ___ ___: ___ ___ 335 Part II: Instruments and Questionnaires Instrument 8: Interview Guide for Staff Providing RH Services Page 1 of 11 INSTRUCTIONS TO INTERVIEWER: All health facility staff who are responsible for providing reproductive health services should be interviewed individually and in private at the end of the working day. It should be made clear that you are seeking their assistance in finding ways to improve the functioning and quality of the services offered by facilities, and are not evaluating the performance of the facility or of themselves individually. For each item, please check the correct response, or describe as appropriate. Background Characteristics 1 Health facility (name and number): 2 District (name and number): 3 Region (name and number): 4 Date of interview: _____ / _____ / _____ 5 Level of facility where interview took place: 1 Referral hospital 2 Hospital 3 Health center 4 Health post 5 Mobile health clinic 6 Pharmacy 7 Clinic in non-permanent facility (e.g., schools, rotating rural health outposts, youth centers) 8 Other: _____________________________ 6 Type of facility: 1 Government/Ministry of Health 2 Government/other 3 Family planning association 4 Other NGO 5 Missionary 6 Private 7 Structure of facility: 1 Youth-only facility 2 Youth-only facility hours 3 Integrated services 8 Locality of facility: 1 Rural 2 Urban 3 Peri-urban 9 Position of person interviewed: 1 Doctor 2 Professional nurse/midwife 3 Auxiliary nurse 4 Clinic officer 5 Peer educator 6 Outreach worker 7 Other: _________________________________ 10 Sex of person interviewed: 1 Female 2 Male 11 Beginning time: ___ ___: ___ ___ A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 336 Instrument 8: Interview Guide for Staff Providing RH Services Page 2 of 11 Name of interviewer: Experience and Training in Reproductive Health Services I would like to ask you about the services you provide to youth clients at this facility. What services do you yourself provide to clients of the age groups below at this health facility? (Check the appropriate boxes for each row.) 10–14 Years 15–19 Years 20–24 Years A Contraceptive counseling B Antenatal care C Maternity care/delivery services D Postnatal care E HIV/AIDS counseling/IEC F HIV/AIDS testing G Other STI counseling/IEC H Other STI diagnosis I Other STI treatment J Treatment of incomplete abortions K Nutrition counseling L Infertility consulting M Gynecological exam N Pregnancy testing 20 O Reproductive health education 21 How many years have you been working in this facility? _________ years 00 Less than one year 98 Don’t know 22 How many years ago did you finish your basic training? _________ years 00 Less than six months 97 No basic training 98 Don’t know 23 Did your basic training cover this? (Read A-J and circle if yes) A Contraceptive counseling B Antenatal care C Maternity care/delivery services D Postnatal care E Treatment of incomplete abortions F Nutrition counseling G Infertility consulting H Gynecological exam I Pregnancy testing J Reproductive health education 337 Part II: Instruments and Questionnaires Instrument 8: Interview Guide for Staff Providing RH Services Page 3 of 11 Experience and Training in Reproductive Health Services (continued) Have you ever had refresher training in these areas? (Read A-J and check if yes. For those areas checked yes, indicate the month of the training.) A Refresher Training? Check if yes B What was the month/year of your last refresher training? A Contraceptive counseling / B Antenatal care / C Maternity care/delivery services / D Postnatal care / E Treatment of incomplete abortions / F Nutrition counseling / G Infertility consulting / H Gynecological exam / I Pregnancy testing / 24 J Reproductive health education / 25 Have you attended any refresher or post-basic training courses specifically on contraceptive clinical skills, program management or HIV/STI counseling diagnosis and treatment? 1 Yes 2 No Skip to Q. 28 98 Don’t know Skip to Q. 28 26 Did that training include the following areas? (Read A–O and circle if yes) A General clinical skills in contraceptive methods B Contraceptive counseling C Natural family planning methods D Management E Supervision F Record keeping G Stock keeping H STI risk assessment/screening I STI counseling J STI laboratory diagnosis K Syndromic approach to diagnosis and treatment L HIV/AIDS counseling M HIV/AIDS testing N Special needs of youth O Counseling youth A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 338 Instrument 8: Interview Guide for Staff Providing RH Services Page 4 of 11 Experience and Training in Reproductive Health Services (continued) How long ago was that training? (If topic was covered) A General clinical skills in contraceptive methods _____ years 0 less than 1 year 98 don’t know B Contraceptive counseling _____ years 0 less than 1 year 98 don’t know C Natural family planning methods _____ years 0 less than 1 year 98 don’t know D Management _____ years 0 less than 1 year 98 don’t know E Supervision _____ years 0 less than 1 year 98 don’t know F Record keeping _____ years 0 less than 1 year 98 don’t know 27 G Stock keeping _____ years 0 less than 1 year 98 don’t know H STI risk assessment/screening _____ years 0 less than 1 year 98 don’t know I STI counseling _____ years 0 less than 1 year 98 don’t know J STI laboratory diagnosis _____ years 0 less than 1 year 98 don’t know K Syndromic approach to diagnosis and treatment _____ years 0 less than 1 year 98 don’t know L HIV/AIDS counseling _____ years 0 less than 1 year 98 don’t know 339 Part II: Instruments and Questionnaires Instrument 8: Interview Guide for Staff Providing RH Services Page 5 of 11 Experience and Training in Reproductive Health Services (continued) How long ago was that training? (If topic was covered) M HIV/AIDS testing _____ years 0 less than 1 year 98 don’t know N Special needs of youth _____ years 0 less than 1 year 98 don’t know 27 O Counseling youth _____ years 0 less than 1 year 98 don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 340 Instrument 8: Interview Guide for Staff Providing RH Services Page 6 of 11 Contraceptives 28 In the last three months, have you yourself actually provided contraceptive counseling to youth clients? 1 Yes 2 No Skip to Q. 30 98 Don’t know Skip to Q. 30 29 If yes, which methods have you yourself actually provided to youth clients in the last three months? (Circle all that apply.) 1 Oral contraceptives 2 IUD 3 Injectable 4 Norplant 5 Condom 6 Diaphragm 7 Spermicide 8 Female sterilization 9 Vasectomy 10 Natural family planning 11 Emergency contraceptives 12 Other: ________________________________________ 30 Is there a minimum age below which you yourself will not prescribe (Read A–E), in the absence of medical contraindications? (Circle if yes.) A Pill B Condom C IUD D Injectable E Sterilization If yes, what is that minimum age? A Pill B Condom C IUD D Injectable 31 E Sterilization 32 Is there a minimum number of children a young woman must have before you yourself will prescribe (Read A-E), in the absence of medical contraindications? (Circle if yes.) A Pill B Condom C IUD D Injectable E Sterilization 341 Part II: Instruments and Questionnaires Instrument 8: Interview Guide for Staff Providing RH Services Page 7 of 11 Contraceptives (continued) If yes, what is that minimum number of children? A Pill B Condom C IUD D Injectable 33 E Sterilization 34 Would you yourself prescribe (Read A-E) to an unmarried youth, in the absence of medical contraindications? (Circle if yes.) A Pill B Condom C IUD D Injectable E Sterilization 35 Do you require parental consent before you will provide (Read A-E) to a youth client? (Circle if yes.) A Pill B Condom C IUD D Injectable E Sterilization 36 In the past month, have you advised any youth clients to use contraception specifically for preventing pregnancy? 1 Yes 2 No 98 Don’t remember/don’t know 37 If a youth client comes to you for contraception and is breastfeeding an infant under six months old, what advice would you give her? 1 You treat her like any other client 2 You advise her to stop breastfeeding and use a contraceptive method 3 You advise her to continue breastfeeding and also begin a contraceptive method 4 You advise her to continue full breastfeeding and not use any contraception until her menses begin 98 Don’t know 38 If a 14-year-old client who admits to being sexually active comes to you for contraception, what advice would you give her or him? 1 You ask the client what type of method he or she prefers and prescribe that method for the client 2 You advise the client to abstain from having sex and do not prescribe any contraception 3 You advise the client to abstain from having sex, but give the client some condoms, just in case 4 Other: ___________________________________________________ 98 Don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 342 Instrument 8: Interview Guide for Staff Providing RH Services Page 8 of 11 Contraceptives (continued) 39 If a youth client visiting for resupply of contraceptive pills appears to be at high risk of infection by STIs or HIV/AIDS, what advice would you offer? 1 To continue to use only the pill 2 To continue with the pill but also use condoms 3 To change from the pill to condoms 4 To stop using any type of contraceptive method 5 To not have sex 98 Don’t know 40 What methods would you NOT recommend for youth clients with an STI? (Circle all that apply.) 1 Pill 2 Condom 3 Spermicide 4 IUD 5 Injectable 6 Norplant 7 Natural family planning 8 Diaphragm 9 None 10 Other: _________________________________ 41 Are there any methods you would never recommend under any circumstances? 1 Yes 2 No Skip to Q. 43 3 Depends on client’s health Skip to Q. 43 4 Depends on client’s preference Skip to Q. 43 98 Don’t know Skip to Q. 43 42 What are those methods? (Circle all that apply.) 1 Pill 2 Condom 3 Spermicide 4 IUD 5 Injectable 6 Norplant 7 Natural family planning 8 Diaphragm 9 Other: ___________________________________ 43 Are you aware of any institutional policies on providing contraceptives to youth? 1 Yes 2 No Skip to Q. 47 44 If so, please describe these policies: 45 Do you agree with the above policies? 1 Yes Skip to Q. 47 2 No 46 If not, which policies do you think should be changed? 343 Part II: Instruments and Questionnaires Instrument 8: Interview Guide for Staff Providing RH Services Page 9 of 11 Other Reproductive Health Practices 47 How do you determine the pregnancy status of a client who comes to the facility and is not having her menses? (Circle all that apply.) 1 Don’t determine pregnancy status 2 Tell her to return at menses 3 Ask if no sex since last menses 4 Ask if less than six weeks since delivery 5 Ask if less than six months since delivery, with no supplemental feeding 6 Perform pregnancy test 7 Perform physical exam 8 Other: __________________________ 48 If you think that a youth client has an STI, what do you do for your client? (Circle all that apply.) 1 Request laboratory test 2 Diagnose STI 3 Treat STI 4 Refer for diagnosis 5 Refer for treatment 6 Provide counseling 7 Refer for counseling 8 Issue a contact or partner notification slip 9 Other: _________________________________ 49 Consider the following case: A 16-year-old girl is quite sick when she comes to your clinic. She has a fever (39.5), a genital discharge and lower abdominal pain. It is very difficult to examine her, as her adnexa seem very painful. She had her period two weeks ago and does not use contraception. There is no other health facility in the community. How will you treat her? 1 Admit her 2 Tell her to wait until the lab is open 3 Prescribe or give: A Ciprofloxin B Kanamycin C Gentamycin D Spectinomycin E Tetracycline F Erythromycin G Metronidazole H Clotrimazole I Nystatinin J Injections of benzathine penicillin K GV paint L Painkillers M Other medication: _________________________ 4 Other: ______________________ 50 What advice will you give her? (Circle all that apply.) 1 Abstain from sex 2 Notify and bring her partner 3 Other: __________________________ A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 344 Instrument 8: Interview Guide for Staff Providing RH Services Page 10 of 11 Other Reproductive Health Practices (continued) 51 What do you do for a youth client who presents to you with complaints suggesting that he or she may be HIV positive or have AIDS? (Circle all that apply.) 1 Counsel client 2 Refer for counseling 3 Make a diagnosis 4 Treat the condition in clinic 5 Refer for treatment 6 Provide follow-up after treatment 7 Refer for follow-up after treatment 8 Refer for testing 9 Other: _______________________ 98 Don’t know 52 In the past month, have you advised any youth clients to use condoms specifically for preventing STIs or HIV infection? 1 Yes 2 No 98 Don’t remember/don’t know 53 Would you provide reproductive health services to a client who has HIV or AIDS? 1 Yes 2 No 98 Don’t know 54 How comfortable are you discussing sexual behavior related to STIs/HIV with youth clients? Would you say you are very uncomfortable, somewhat uncomfortable, comfortable, or very comfortable? 1 Very uncomfortable 2 Somewhat uncomfortable 3 Comfortable 4 Very comfortable 55 As far as you know, do female youth come to this facility for advice on termination of pregnancies? 1 Yes 2 No 98 Don’t know 56 As far as you know, do female youth come to this facility for medical treatment as a consequence of incomplete induced abortion? 1 Yes 2 No 98 Don’t know 345 Part II: Instruments and Questionnaires Instrument 8: Interview Guide for Staff Providing RH Services Page 11 of 11 Socio-Demographic Characteristics 57 To end this interview, I would like to ask you a few questions about yourself. How old are you? __________ years old 98 Don’t know 58 What is your current marital status? 1 Married/monogamous 2 Married/polygamous 3 Cohabiting/living together 4 Single, never married 5 Divorced/separated 6 Widowed 59 How many living children of your own do you have? _______ children 99 No response 60 Do you take care of anyone else’s children? 1 Yes 2 No Skip to Q. 62 61 If yes, how many children? _________ children 62 What is your religion? 1 Protestant 2 Catholic 3 Moslem 4 Hindu 5 Buddhist 6 Traditional 7 None 8 Other: _________________________ 98 Don’t know 63 Are you and/or your partner currently using contraceptives? 1 Yes 2 No Skip to end 64 What contraceptive methods are you or your partner currently using? (Circle all that apply.) 1 Pill 2 Condom 3 Spermicide 4 IUD 5 Injectable 6 Norplant 7 Natural family planning 8 Diaphragm 9 Male and/or female sterilization 10 Other: ___________________________________ Thank you very much for having spent so much time with me. 346 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 347 Part II: Instruments and Questionnaires Instrument 9: Guide for Client Exit Interview Page 1 of 9 METHODOLOGY: To identify clients, either ask a staff person for contact information for youth (ages 10–24 years) who have used the facility, or simply wait at the facility and ask youth clients for an interview after they have finished seeing a provider. Select a private place away from the facility and explain to clients that their names will not be recorded and that all the information they provide will be completely confidential. You should also explain why you need the information from them (see “Greeting” below for further details). Finally, tell them the interview should only take about 30–45 minutes of their time. Background Characteristics 1 Health facility (name and number): 2 District (name and number): 3 Region (name and number): 4 Date of interview: _____ / _____ / _____ 5 Level of facility where observation took place: 1 Referral hospital 2 Hospital 3 Health center 4 Health post 5 Mobile health clinic 6 Pharmacy 7 Clinic in non-permanent facility (e.g., schools, rotating rural health outposts, youth centers) 8 Other: _____________________________ 6 Type of facility: 1 Government/Ministry of Health 2 Government/other 3 Family planning association 4 Other NGO 5 Missionary 6 Private 7 Structure of facility: 1 Youth-only facility 2 Youth-only facility hours 3 Integrated services 8 Locality of facility: 1 Rural 2 Urban 3 Peri-urban Name of interviewer: ____________________________________________________________ INSTRUCTIONS TO INTERVIEWER: When a youth client (i.e., between the ages of 10 and 24) has finished his or her consultation with the clinic staff, ask the client if he or she is willing to answer a few questions about the service the client received. It is essential that you gain the client’s informed consent before beginning the interview, so the following introduction should be given. GREETING “Hello, my name is ____________________________. I am from ______________________ (name of organization). We are interested in what youth clients think about the reproductive health services provided at this facility and would like to find out your feelings about the service you received. I would like to ask you a few questions about the meeting you just had with the clinic staff and would be very grateful if you would spend a little time talking with me. I will not write down your name, and everything you tell me will be kept strictly confidential. Your participation is voluntary, and you are not obliged to answer any questions you do not want to answer. Do I have your permission to continue?” If yes, continue; if no, stop and wait for another client. If client refuses to be interviewed, please check this box: r A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 348 Instrument 9: Guide for Client Exit Interview Page 2 of 9 Section 1: Basic Features 1 Sex of client (do not ask): 1 Female 2 Male 2 How old were you at your last birthday? Age in years: ______ 3 Are you currently going to school? 1 Yes 2 No 4 What was your last year of completed studies? 1 None/preschool 2 Primary 3 Secondary 4 Higher/university 98 Don’t know 5 Are you currently married or living with a boyfriend/girlfriend? 1 Married 2 Living with boyfriend/girlfriend 3 Neither 6 Have you ever had a child? 1 Yes 2 No 349 Part II: Instruments and Questionnaires Instrument 9: Guide for Client Exit Interview Page 3 of 9 Section 2: Information About Services 20 Why did you come to this health facility today? (Circle all that apply.) 1 Contraceptive counseling 2 Contraceptive purchasing 3 Prenatal care 4 Postpartum care 5 Counseling about nutrition 6 Pregnancy test 7 STI screening 8 STI treatment 9 HIV/AIDS test 10 Gynecological exam 11 Peer counseling 12 Abortion-related services 13 Infertility consultation 14 General health service (non-RH oriented) 15 Other: ______________________________ 21 How did you hear about this facility? 1 Radio 2 Television 3 Newspaper 4 Friend 5 Relative 6 Poster 7 Pamphlet/brochure 8 Other: _______________________________ 22 Did the health service provider physically examine you during your visit? 1 Yes 2 No Skip to Q. 25 23 Did the service provider take you to a private examination room? 1 Yes 2 No 24 Did the service provider explain the results of the health exam? 1 Yes 2 No 25 Did you receive or did you take any brochure(s) or educational material to read at home? 1 Yes 2 No Skip to Q. 27 26 What subject(s) is/are covered in this material? (Circle all that apply.) 1 Maternal health 2 Contraception 3 STIs 4 HIV/AIDS 5 Abortion 6 Drugs/alcohol 7 Other: _________________________________ A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 350 Instrument 9: Guide for Client Exit Interview Page 4 of 9 Section 2: Information About Services (continued) 27 Did any service provider tell you when you should return for another visit? 1 Yes 2 No Skip to Q. 29 98 Don’t know Skip to Q. 29 28 Did the service provider tell you where you should return for another visit? 1 Yes 2 No 29 Is this your first visit for reproductive health services? 1 Yes Skip to Q. 31 2 No 30 Are you here today for a follow-up? 1 Yes 2 No 31 Overall, would you say you were satisfied with your visit to the facility today, or were you dissatisfied with your visit today? 1 Satisfied Skip to Q. 33 2 Dissatisfied 3 Other: ____________________________________ Skip to Q. 33 32 Why were you dissatisfied with your visit today? 33 If you could suggest one improvement to the services provided, what would it be? 34 Did you receive the information and services that you wanted today? 1 Yes 2 No 3 Partially 98 Don’t know 35 Was your consultation with the health providers too short, too long or about the right amount of time? 1 Too short 2 Too long 3 About right 98 Don’t know 36 During this visit, did you have any concerns about family planning or other health issues that you wanted to discuss with the provider? 1 Yes 2 No Skip to Q. 38 37 If yes, did the provider listen to your concerns to your satisfaction? 1 Yes 2 No 38 During this visit, did you have any questions you wanted to ask? 1 Yes 2 No Skip to Q. 41 39 If yes, did the provider let you ask the questions? 1 Yes 2 No Skip to Q. 41 40 If yes, did the provider respond to your questions to your satisfaction? 1 Yes 2 No 41 In your opinion, did you have enough privacy during your consultation with the service provider? 1 Yes 2 No 42 Do you believe that the information you shared about yourself with the provider will be kept confidential? 1 Yes 2 No 98 Don’t know 351 Part II: Instruments and Questionnaires Instrument 9: Guide for Client Exit Interview Page 5 of 9 Section 2: Information About Services (continued) 43 During your visit, how were you treated by the provider? 1 Very well 2 Well 3 Not very well/poorly 44 During your visit, how were you treated by the other staff? 1 Very well 2 Well 3 Not very well/poorly 45 During your visit, was the provider easy to understand when explaining things to you, or was the provider difficult to understand? 1 Easy to understand 2 Difficult to understand 98 Don’t know 46 About how long did you wait between the time you first arrived at this facility and the time you saw a staff person for a consultation? (Record exactly what client says.) 98 Don’t know 47 In your opinion, was waiting time reasonable or too long? 1 No waiting time 2 Reasonable/short 3 Too long 98 Don’t know 48 Did you attend a group talk(s) at this facility today? 1 Yes 2 No Skip to Q. 50 49 If yes, what topics were covered in the group talk(s)? (Do not read list, but probe by asking, Any other topics?” Then, circle all that apply.) 1 Contraception 2 Antenatal care 3 Maternity care/delivery services 4 Postnatal care 5 HIV/AIDS 6 Other STIs 7 Infertility 8 Treatment of incomplete abortions 9 Nutrition counseling 10 Drugs/alcohol 11 Risk reduction 12 Other: ___________________________________ 98 Don’t know 50 Are the hours this facility is open convenient for you? 1 Yes Skip to Q. 52 2 No 98 Don’t know Skip to Q. 52 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 352 Instrument 9: Guide for Client Exit Interview Page 6 of 9 Section 2: Information About Services (continued) 51 If no, what time would be the most convenient for you? (Circle one.) 1 Earlier in the morning 2 Over lunch hour 3 Afternoon 4 Evening/night 5 Weekends 6 Holidays 7 Other: ____________________________ 98 Don’t know 52 Have you ever been turned away from this facility during official working hours? 1 Yes 2 No 3 No previous experience with facility 98 Don’t know 53 How long did it take you to come here today? ______ minutes 98 Don’t know 54 What was the main means of transport you used to get here? (Circle one.) 1 Car/truck 2 Bus/minivan/taxi 3 Motorcycle/bicycle 4 Animal 5 Walked 6 Other: __________________________ 55 As far as you know, what types of services are provided at this facility for youth clients? (Circle all that apply.) 1 Contraceptive counseling 2 Contraceptive purchasing 3 Prenatal care 4 Postpartum care 5 Nutrition counseling 6 Pregnancy testing 7 STI screening 8 STI treatment 9 HIV/AIDS testing 10 Gynecological exams 11 Abortion-related services 12 Peer counseling 13 Infertility consultation 14 Other: ______________________________ 56 Apart from this facility, is there any other place in your neighborhood/community where you can go for reproductive health services? 1 Yes 2 No Skip to Q. 58 98 Don’t know Skip to Q. 58 353 Part II: Instruments and Questionnaires Instrument 9: Guide for Client Exit Interview Page 7 of 9 Section 2: Information About Services (continued) 57 If yes, what type of facility is it? (If more than one, choose the one closest to home.) 1 CBD 2 Pharmacy/chemist shop 3 Health post 4 Health center 5 Hospital 6 Private service provider, such as doctor, nurse or midwife 7 Traditional healer 8 Other: ______________________ 98 Don’t know 58 What would you say is the main reason you did not go there today for reproductive health services? (Circle one.) 1 Inconvenient opening times 2 Takes too long to get there 3 Poor-quality services 4 Fewer services available 5 Want to be anonymous 6 Have other reasons to come here (e.g., immunizations, health talks) 7 More expensive there 8 Prefer provider here 9 Other: ______________________________ 98 Don’t know 59 Now I would like to ask you about the cost of travel and the services you received from this facility. How much did you pay for your consultation? ___________ (local currency units) 1 No costs 98 Don’t know 60 How much did you pay for contraceptives? ___________ (local currency units)/unit of contraceptive 1 Did not buy contraceptives 98 Don’t know 61 How much did you pay for registration card/membership? ____________(local currency units) 1 Did not buy card/membership 98 Don’t know 62 How much did you pay for travel? ____________(local currency units) 1 Did not pay for transport 98 Don’t know 63 How much did you pay for any other services or fees? ____________ (local currency units) 1 Did not pay for other fees or services 98 Don’t know 64 Overall, do you think that the total cost of obtaining services is much too expensive, a little too expensive or acceptable to you? 1 Much too expensive 2 A little too expensive 3 Acceptable 98 Don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 354 Instrument 9: Guide for Client Exit Interview Page 8 of 9 Section 2: Information About Services (continued) 65 To end this interview, I would like to ask you some questions about reproductive health. I would like to remind you that the information you provide will remain strictly confidential, and that you do not have to answer any question you do not want to answer. Do you know people your age who are not married and are sexually active? 1 Yes 2 No 98 Don’t know 66 What are the ways you know of to prevent pregnancy? (Circle all that apply.) 1 Contraceptives Which contraceptives?: __________________________ 2 Withdrawal 3 Rhythm 4 Traditional methods 5 Abstinence 6 Other: ______________________________ 98 Don’t know 67 As far as you know, are there any diseases that can be transmitted through sexual intercourse? 1 Yes 2 No Skip to Q. 69 98 Don’t know Skip to Q. 69 68 From what you’ve heard or read, what are some common signs and symptoms of sexually transmitted infections? (Do not read list, but probe by asking, "Any other ways?" Then, check all that apply.) 1 Abnormal vaginal discharge 2 Abnormal vaginal bleeding 3 Genital itching 4 Lesions/sores 5 Lower abdominal pain 6 Pain during intercourse 7 Painful urination 8 Abnormal growth in genital area (i.e., warts) 9 Penile/urethral discharge 10 Loss of weight 11 Diarrhea of long duration 12 Other: ______________________________ 98 Don’t know 69 Have you heard of HIV or AIDS? 1 Yes 2 No Skip to Q. 71 98 Don’t know Skip to Q. 71 70 As far as you know, what are the ways to get HIV/AIDS? (Do not read list, but probe by asking, “Any other ways?” Then, circle all that apply.) 1 Sexual intercourse 2 Blood transfusion 3 Sharing items like razor blades or needles 4 Mother to baby 5 Other: _______________________ 98 Don’t know 355 Part II: Instruments and Questionnaires Instrument 9: Guide for Client Exit Interview Page 9 of 9 Section 2: Information About Services (continued) 71 Do you know of any ways you can protect yourself from sexually transmitted infections, including HIV/AIDS? 1 Yes 2 No Skip to end 72 If yes, what are the ways of protecting yourself? (Do not read list, but probe by asking, “Any other ways?” Then, circle all that apply.) 1 Stay faithful to one partner 2 Encourage partner to remain faithful 3 Use condoms 4 Avoid sharing needles, razors, etc. 5 Other: ______________________________ Thank you very much for your time and help! 356 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 357 Part II: Instruments and Questionnaires Instrument 10: Questionnaire for Debriefing Mystery Clients Page 1 of 6 Interviewer code: _____________________________ Mystery client code: _____________________________ Scenario enacted: _____ A Unwanted pregnancy B Information regarding contraceptives C Information regarding STIs D Counseling regarding premarital intercourse E Other (please specify): __________________________________ Background Characteristics 1 Health facility (name and number): 2 District (name and number): 3 Region (name and number): 4 Date of interview: Date: _____ /_____ /_____ 5 Level of facility where mystery client went: 1Referral hospital 2 Hospital 3 Pharmacy 4 Health center 5 Health post 6 Mobile health clinic 7 Clinic in non-permanent facility (e.g., schools, rotating rural health outposts, youth centers, etc.) 8 Other: _____________________________ 6 Type of facility: 1 Government/Ministry of Health 2 Government/other 3 Family planning association 4 Other NGO 5 Missionary 6 Private 7 Structure of facility: 1 Youth-only facility 2 Youth-only facility hours 3 Integrated services 8 Locality of facility: 1 Rural 2 Urban 3 Peri-urban 9 Age of mystery client: ________ years 10 Sex of mystery client: 1 Male 2 Female 11 Name of interviewer: 12 Time client arrived at clinic: A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 358 Instrument 10: Questionnaire for Debriefing Mystery Clients Page 2 of 6 Questions for Mystery Client 20 Were you able to speak to a counselor? 1 Yes Skip to Q. 23 2 No 21 If no, why not: 1 Clinic was closed 2 Provider was not at clinic 3 Provider had no available appointments 4 Provider refused to see client 5 Other: ____________________________ 98 Don’t know If you were not able to see counselor, were you given an appointment for a later date? 1 Yes 2 No 98 Don’t know 22 (If unable to see a counselor, end interview here.) 23 What formalities did you have to go through before seeing a provider? 24 A About how long did you wait between the time you first arrived at this facility and the time you saw a provider? 24 B Do you think that your waiting time was reasonable, or too long? 1 No waiting time 2 Reasonable/short 3 Too long 4 Don’t know 25 Time counseling session started (approximately): Time counseling session ended (approximately): _____:_____ _____:_____ 26 Length of counseling session: _________ hours 27 Sex of provider visited: 1 Woman 2 Man 28 Was the person who counseled you a: 1 Doctor 2 Nurse 3 Midwife 4 Health aide 5 Peer educator 6 Pharmacist 7 Other: _____________________________________________ 98 Don’t know 29 Did the provider greet you in a friendly fashion? 1 Yes 2 No 359 Part II: Instruments and Questionnaires Instrument 10: Questionnaire for Debriefing Mystery Clients Page 3 of 6 Questions for Mystery Client (continued) 30 Did the provider ask you the reason for your visit? 1 Yes 2 No 98 Don’t know 31 How did the provider react (i.e., what did he or she say) when you told the provider the reason for your visit? (Probe for more information.) RESPONSE CODES: (Coded by analyst) 1 Reaction acceptable/appropriate 2 Reaction was unacceptable/inappropriate 32 What advice did the provider give you? RESPONSE CODES: (Rated by analyst on following) 1 Provider tells client what to do 2 Provider helps client identify options 3 Provider allows client to determine own course of action 33 Could anyone overhear the conversation you had with the provider? 1 Yes 2 No 98 Don’t know 34 Did you discuss any of the following topics with the provider? (Circle all that apply.) 1 Your sexual history 2 Your current sexual status 3 The nature of your relationship with your current partner 4 Your current and/or past contraceptive use 35 Do you feel like the provider took your concerns seriously? 1 Yes 2 No 3 Not sure 36 Did anything occur to interrupt your discussion with the provider? 1 Yes 2 No If yes, what? 37 Did the provider ask you questions about yourself? 1 Yes 2 No If yes, what kinds of questions did the provider ask? Did the provider give you information about any of the following: 0 None 1 Minimum 2 Moderate 3 Extensive A Contraceptive methods B HIV/AIDS C Other STIs 38 D Treatment of unwanted pregnancies A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 360 Instrument 10: Questionnaire for Debriefing Mystery Clients Page 4 of 6 Questions for Mystery Client (continued) 39 Did the provider ask if you knew about these topics before giving you information? 1 Yes 2 No 98 Don’t know Did the provider: Yes No A Require you to get parental consent for any service B Require you to get spousal consent for any service C Inform you that you were too young to receive any of the services D Require you to have a blood test before giving you contraceptives E Require you to have a pelvic exam before giving you contraceptives 40 F Require you to make another appointment before receiving a service Did the provider use any of the following visual aids during the session? 1 Yes 2 No 3 Don’t Know A Posters B Drawings C Booklets 41 D Videos 42 Did the provider give you his or her personal opinion on what you should do? 1 Yes 2 No If yes, what was his or her opinion regarding your situation? 43 Did you discuss with the provider how your life would be affected by your behaviors? 1 Yes 2 No Did you discuss how your life would be affected if you were to: 1 Yes 2 No A Become sexually active B Become pregnant C Continue a pregnancy D Become infected with HIV 44 E Become infected with an STI 361 Part II: Instruments and Questionnaires Instrument 10: Questionnaire for Debriefing Mystery Clients Page 5 of 6 Questions for Mystery Client (continued) 45 Did the provider ask you if you had any questions? 1 Yes 2 No 46 Did the provider respond to your questions? 1 Yes 2 No 3 Partially 47 Did you feel comfortable asking the provider questions? 1 Yes 2 No If no, why not? 48 Was the information given by the provider clear and simple? 1 Yes 2 No 49 Was anything the provider said confusing or unclear? 1 Yes 2 No 98 Don’t know 50 Did the provider check to make sure you understood the information properly? 1 Yes 2 No 98 Don’t know 51 When you pretended not to understand, did the provider make an effort to explain the matter in a clearer fashion? 1 Yes 2 No 98 Don’t know 52 Do you feel like enough time was spent with the provider? 1 Yes 2 No If no, why not? 53 Did the provider do or say anything that made you feel uncomfortable? 1 Yes 2 No 98 Don’t know If yes, what? 54 Did the provider do or say anything during your visit that led you to believe he or she did not approve of something you said? 1 Yes 2 No 98 Don’t know 55 Did the provider ask you to return for another visit? 1 Yes 2 No 56 Did you set a date for your next appointment? 1 Yes 2 No A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 362 Instrument 10: Questionnaire for Debriefing Mystery Clients Page 6 of 6 Questions for Mystery Client (continued) 57 Overall, were you satisfied with the counseling session? 1 Yes 2 No 58 Would you recommend this provider to a friend? 1 Yes 2 No 59 Is there anything else you would like to add regarding your visit? Thank you very much for your time and help! 363 Part II: Instruments and Questionnaires Instrument 11: Community Questionnaire Page 1 of 10 DIRECTIONS: Complete this questionnaire by using a panel of key informants (e.g., health care providers, managers of health facilities, teachers). Instruct them to guess or approximate the distance of the various types of health facilities to the best of their knowledge. 1 District (name and number): 2 Location (name and number): 3 Name of place: 4 Cluster number: 5 Urban/rural: 1 Urban 2 Rural 3 Peri-urban 6 Date of visit: _____ / _____ / _____ 7 Name of interviewer: Name Job or Position8 Name and job or position of persons interviewed: 9 Beginning time: ___ ___: ___ ___ A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 364 Instrument 11: Community Questionnaire Page 2 of 10 Section 1: Community Information 1 Type of locality: 1 Large city (500,000 or Skip to Q. 9 more people) 2 Small city Skip to Q. 9 3 Town Skip to Q. 6 4 Rural 2 Cluster description: 1 Compact 2 Dispersed 3 What is the name of the closest town? 4 How far (in minutes) is the nearest town? ___________ minutes 5 Which is the most common type of transportation used to go to the nearest town? 1 Car/truck 2 Bus/minivan/taxi 3 Motorcycle/bicycle 4 Animal 5 Walking 6 Other: (specify) _____________________ 6 What is the main access route to this community? 1 All-year road 2 Seasonal road 3 Waterway 4 Path 5 Other: (specify) _____________________ 7 What are the main economic activities in this community? (Circle all that apply.) 1 Agriculture 2 Livestock 3 Fishing 4 Commerce 5 Manufacturing 6 Other: (specify) _____________________ 8 Is telephone service available here? 1 Yes 2 No 9 What is the primary source of water for this community? 1 Piped 2 Public tap 3 Well 4 River/stream/lake 5 Rainwater 6 Other: (specify) ________________________ 10 Is this water supply maintained by the community? 1 Yes 2 No 365 Part II: Instruments and Questionnaires Instrument 11: Community Questionnaire Page 3 of 10 Section 1: Community Information (continued) Minutes: A Elementary/primary school B Secondary/high school C University/technical school D Local market E Post office F Recreation center G Public transportation H Movie theater/video center I Health center J Hospital K Youth center 11 How long (in minutes) does it take to travel from (name of community) to the closest area listed below? (If not available in the cluster, write 00. If not known, write 98.) L Sports playing field A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 366 Instrument 11: Community Questionnaire Page 4 of 10 Section 2: Reproductive Health Services in the Community 20 Is there at least one traditional healer in (name of community)? 1 Yes 2 No 21 How many traditional healers are there in this area? Number: _____________ 98 Don’t know 22 Why do the people in this community go to traditional healers? (Circle all that apply.) 1 Illness 2 Trust 3 They are inexpensive 4 They understand better 5 Acceptable 6 Other: (specify) _______________________ 98 Don’t know 23 Does this community have a health promoter/outreach worker? 1 Yes 2 No Skip to Q. 26 24 How often does this health promoter/ outreach worker have contact in this community, either through visits to a central point or to households? 1 Weekly 2 Monthly 3 Quarterly 4 Semi-annually 5 Annually 6 Other: (specify) _________________________ 98 Don’t know 25 Does this health promoter/outreach worker provide: Type of service Yes No A Basic medications B Vitamins C Counseling D Contraceptives E Pregnancy testing F STI screening G STI treatment H Education classes on reproductive health issues 26 Does this community have a community- based distributor (CBD)? 1 Yes 2 No Skip to Q. 31 27 How many CBDs work in this community? Number: _____________ 98 Don’t know 367 Part II: Instruments and Questionnaires Instrument 11: Community Questionnaire Page 5 of 10 Section 2: Reproductive Health Services in the Community (continued) 28 How often does a CBD visit households in the community? 1 Weekly 2 Monthly 3 Quarterly 4 Semi-annually 5 Annually 6 Other: (specify) _________________________ 98 Don’t know 29 What is (are) the name(s) of the CBD(s) that work in this community? 1: _____________________________________________ 2: _____________________________________________ 3: _____________________________________________ 98 Don’t know 30 Do the CBDs working in this community provide: Type of service Yes No A Birth control pills B Condoms C Other modern contraceptive methods (e.g., foaming tablets, spermicide) D Contraceptive counseling E Counseling on other reproductive health issues A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 368 Instrument 11: Community Questionnaire Page 6 of 10 Section 3: Identification of the Facility 31 What is the name of the hospital nearest to this community? Name: ______________________________________ 98 Don’t know Skip to Q. 35 32 What is the distance between here and (name of hospital)? Kilometers: ______________ 98 Don’t know 33 What type of transportation is most commonly used to go from here to (name of hospital)? 1 Car/truck 2 Bus/minivan/taxi 3 Motorcycle/bicycle 4 Animal 5 Walking 6 Other: (specify) _______________________ 34 How many minutes does it take to go from here to (name of hospital), using the most common form of transport? Minutes:____________ 98 Don’t know 35 What is the name of the health center nearest to this community? Name: _______________________ 98 Don’t know Skip to Q. 39 36 What is the distance between here and (name of health center)? Kilometers: ______________ 98 Don’t know 37 What type of transportation is most commonly used to go from here to (name of health center)? 1 Car/truck 2 Bus/minivan/taxi 3 Motorcycle/bicycle 4 Animal 5 Walking 6 Other: (specify) _______________________ 38 How many minutes does it take to go from here to (name of health center), using the most common form of transport? Minutes: ___________ 98 Don’t know 39 What is the name of the dispensary nearest to this community? Name:___________________________________ 98 Don’t know Skip to Q. 43 40 What is the distance from here to (name of dispensary)? Kilometers: ______________ 98 Don’t know 41 What type of transportation is most commonly used to go from here to (name of dispensary)? 1 Car/truck 2 Bus/minivan/taxi 3 Motorcycle/bicycle 4 Animal 5 Walking 6 Other: (specify) _______________________ 42 How many minutes does it take to go from here to (name of dispensary), using the most common form of transport? Minutes: ___________ 98 Don’t know 43 What is the name of the clinic nearest to this community? Name: _________________________________________ 98 Don’t know Skip to Q. 47 369 Part II: Instruments and Questionnaires Instrument 11: Community Questionnaire Page 7 of 10 Section 3: Identification of the Facility (continued) 44 What is the distance from here to (name of clinic)? Kilometers: ______________ 98 Don’t know 45 What type of transportation is most commonly used to go from here to (name of clinic)? 1 Car/truck 2 Bus/minivan/taxi 3 Motorcycle/bicycle 4 Animal 5 Walking 6 Other: (specify) _______________________ 46 How many minutes does it take to go from here to (name of clinic), using the most common form of transport? Minutes: ___________ 98 Don’t know 47 What is the name of the pharmacy nearest to this community? Name: _________________________________________ 98 Don’t know Skip to Q. 51 48 What is the distance from here to (name of pharmacy)? Kilometers: ______________ 98 Don’t know 49 What type of transportation is most commonly used to go from here to (name of pharmacy)? 1 Car/truck 2 Bus/minivan/taxi 3 Motorcycle/bicycle 4 Animal 5 Walking 6 Other: (specify) _______________________ 50 How many minutes does it take to go from here to (name of pharmacy), using the most common form of transport? Minutes: ___________ 98 Don’t know For health facilities that were not yet mentioned, ask key informants the following questions about other facilities in the district or community: 51 Have you ever heard of (Facility 1 in district)? 1 Yes 2 No Skip to Q. 56 52 How have you heard of (Facility 1 in district)? (Circle all that apply.) 1 Radio 2 Television 3 Newspaper 4 Pamphlet/brochure 5 Poster 6 Friend 7 Relative 8 Other: (specify) ________________________________ 53 How far is it from here? Kilometers: ______________ 98 Don’t know 54 Do people in this community use this facility? 1 Yes 2 No Skip to Q. 56 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 370 Instrument 11: Community Questionnaire Page 8 of 10 Section 3: Identification of the Facility (continued) 55 For what services? (Circle all that apply.) 1 Illnesses 2 Vaccination 3 Prenatal care OR ANTENATAL? 4 Delivery 5 Family planning 6 HIV/AIDS testing 7 STI diagnosis 8 STI treatment 9 Abortion-related services 10 Other: (specify) _______________________ 56 Have you ever heard of (Facility 2 in district)? 1 Yes 2 No Skip to Q. 61 57 How have you heard of (Facility 2 in district)? (Circle all that apply.) 1 Radio 2 Television 3 Newspaper 4 Pamphlet/brochure 5 Poster 6 Friend 7 Relative 8 Other: (specify) ________________________________ 58 How far is it from here? Kilometers: ______________ 98 Don’t know 59 Do people in this community use this facility? 1 Yes 2 No Skip to Q. 61 60 For what services? (Circle all that apply.) 1 Illnesses 2 Vaccination 3 Prenatal care or Antenatal? 4 Delivery 5 Family planning 6 HIV/AIDS testing 7 STI diagnosis 8 STI treatment 9 Abortion-related services 10 Other: (specify) _______________________ 61 Have you ever heard of (Facility 3 in district)? 1 Yes 2 No Skip to Q. 66 371 Part II: Instruments and Questionnaires Instrument 11: Community Questionnaire Page 9 of 10 Section 3: Identification of the Facility (continued) 62 How have you heard of (Facility 3 in district)? (Circle all that apply.) 1 Radio 2 Television 3 Newspaper 4 Pamphlet/brochure 5 Poster 6 Friend 7 Relative 8 Other: (specify) ________________________________ 63 How far is it from here? Kilometers: ______________ 98 Don’t know 64 Do people in this community use this facility? 1 Yes 2 No Skip to Q. 66 65 For what services? (Circle all that apply.) 1 Illnesses 2 Vaccination 3 Prenatal care or Antenatal? 4 Delivery 5 Family planning 6 HIV/AIDS testing 7 STI diagnosis 8 STI treatment 9 Abortion-related services 10 Other: (specify) _______________________ 66 Have you ever heard of (Facility 4 in district)? 1 Yes 2 No Skip to Q. 71 67 How have you heard of (Facility 4 in district)? (Circle all that apply.) 1 Radio 2 Television 3 Newspaper 4 Pamphlet/brochure 5 Poster 6 Friend 7 Relative 8 Other: (specify) ________________________________ 68 How far is it from here? Kilometers: ______________ 98 Don’t know 69 Do people in this community use this facility? 1 Yes 2 No Skip to Q. 71 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 372 Instrument 11: Community Questionnaire Page 10 of 10 Section 3: Identification of the Facility (continued) 70 For what services? (Circle all that apply.) 1 Illnesses 2 Vaccination 3 Prenatal care or Antenatal? 4 Delivery 5 Family planning 6 HIV/AIDS testing 7 STI diagnosis 8 STI treatment 9 Abortion-related services 10 Other: (specify) _______________________ 71 How far is it from here to the nearest place that provides: Type of service Kilometers Don’t know A Prenatal care B Delivery care C Pregnancy testing D Parenting classes E Child immunizations F Nutrition counseling G Condoms H Birth control pills I IUDs J Injectables K STI screening L STI treatment M HIV/AIDS testing N Contraceptive counseling O Abortion-related services 72 Register the time: ___ ___: ___ ___ Comments: 373 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 1 of 71 Table of Contents Module Title of Module Page Introduction. 2 1 Background and Related Information . 3 2 Reproductive Health Knowledge. 7 3 STI/HIV/AIDS . 13 4 Attitudes, Beliefs and Values . 19 5 Social Influences. 27 6 Sexual Activity, Contraception and Pregnancy. 36 7 Skills and Self-Efficacy. 51 8 Leisure Activities and Concerns . 55 9 Media Influence . 62 10 Drugs and Alcohol. 66 11 Health-Seeking Behaviors . 68 References. 71 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 374 Instrument 12: Comprehensive Youth Survey Page 2 of 71 Introduction Good morning/afternoon, my name is __________ and I represent (name of organization). We are conducting a survey within (name of geographic area). The purpose of this survey is to learn what young people understand about reproduction, contraception, sexually transmitted infections, HIV and AIDS. This information will help us understand the health needs of youth in (name of geographic area). Regarding this, I would like to ask you some questions. Some of the questions are personal, but the answers you give will not be shown to anyone. They will only assist us in learning more about the behavior, beliefs and practices of young people. We especially want your answers because if everyone who is selected participates, our information will be more useful. Do I have your permission to continue? (Circle one.) 1 = Yes 2 = No (End the interview) (Interviewer arranges for a private setting to conduct interview) Time Start: __________________ Time End: ____________________ 375 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 3 of 71 Module 1: Background and Related Information 101 Sex of respondent (Circle the sex of the respondent. Please do not ask.) 1 Male 2 Female 102 How old were you on your last birthday? Age: _________ years 98 Don’t know 103 When were you born? Date: ____ / ____ / ____ 98 Don’t know 104 What is your religious denomination? 1 None 2 Catholic 3 Protestant 4 Moslem 5 Buddhist 6 Hindu 7 Spiritual 8 Traditional 9 Other (Specify): _____________ 105 Can you read and write in any language? 1 Yes 2 No 106 Have you ever attended formal school? 1 Yes 2 No Skip to Q. 111 107 Are you currently attending school? 1 Yes Skip to Q. 109 2 No 108 Why is that you are not currently attending a school or university? 1 Never went 2 Already completed all studies 3 Got married 4 Quit due to pregnancy 5 Have to provide child care 6 Family problems 88 Other (specify): _____________ 109 What is the highest level of school you have completed? 1 Primary 2 Secondary 3 Technical/vocational school 4 University/college 5 Post-university/graduate school 98 Don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 376 Instrument 12: Comprehensive Youth Survey Page 4 of 71 Module 1: Background and Related Information (continued) 110 Do you intend to complete any additional years of school or university at any time in the future? 1 Yes 2 Probably yes 3 Probably not 4 Definitely not 111 What is the highest level of education you hope to complete? 1 Primary 2 Secondary 3 Technical/vocational school 4 University/college 5 Post-university/graduate school 98 Don’t know 112 How important is it to you that you get a good education? 1 Not important at all 2 Not very important 3 Somewhat important 4 Quite important 5 Very important 113 Are you involved in any extra-curricular activities at school? 1 Yes 2 No Skip to Q. 115 114 If so, what are they? 1 Sports clubs/teams 2 Drama club 3 Debate club 4 Academic club 5 Religious club 6 Other (specify): ______________________ 115 What have you done in the last month to earn money for yourself? (If more than one activity, ask which is the main activity, and circle that response.) 1 Nothing Skip to Q. 201 2 Employed 3 Selling goods/small-scale business 4 Casual labor 5 Farming 6 Other (specify): _______________________ 377 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 5 of 71 Module 1: Background and Related Information (continued) 116 Who controls the money that you earn? 1 Myself 2 My brother/sister 3 My mother 4 My father 5 My boyfriend/girlfriend 6 My spouse 7 My grandmother 8 My grandfather 9 Other relative (specify): _________________ 10 Other (specify): _______________________ 117 Have you ever thought of migrating to an urban area to find work? 1 Yes 2 No 118 If so, have you ever acted on this thought? 1 Never 2 Once 3 Twice 4 Three times or more 119 Have you ever had a boyfriend/girlfriend/partner? 1 Yes 2 No Skip to Q. 125 120 Do you currently have a boyfriend/girlfriend/partner? 1 Yes 2 No Skip to Q. 122 121 How committed are you to your current boyfriend/girlfriend/partner? 1 Very committed/want to get married or live together 2 Somewhat committed/no plans yet to get married or live together 3 Not committed at all/casual relationship 122 How old were you when you first had a boyfriend/girlfriend/partner? 1 Less than 15 years old 2 15 years old 3 16 years old 4 17 years old 5 18 years or older 123 Have you ever lived with a boyfriend/girlfriend/partner? 1 Yes 2 No Skip to Q. 125 124 How old were you when you started living with a boyfriend/girlfriend/partner? Age: _____________ years 98 Don’t know/don’t remember 125 Have you ever been married? 1 Yes 2 No Skip to Q. 127 126 How old were you when you got married? Age: _____________ years 98 Don’t know/don’t remember A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 378 Instrument 12: Comprehensive Youth Survey Page 6 of 71 Module 1: Background and Related Information (continued) 127 Are you currently: 1 Married, living with spouse 2 Married, spouse lives elsewhere 3 Not married, but living with a partner 4 Not married 5 Divorced/separated 6 Widowed 379 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 7 of 71 Module 2: Reproductive Health Knowledge (Read to respondent) Now I’m going to ask you some questions about pregnancy and having children. 201 During which part of the monthly cycle does a woman have the greatest chance of becoming pregnant? 1 During her period 2 In the middle of her cycle 3 Right after her period has ended 4 Just before her period begins 88 Other (specify): _____________ 98 Don’t know/don’t remember 202 Can a girl get pregnant the first time she has sex? 1 Yes 2 No 98 Don’t know/don’t remember 203 Can a girl get pregnant if she has sex only once? 1 Yes 2 No 98 Don’t know/don’t remember 204 Can a girl get pregnant if she has sex standing up? 1 Yes 2 No 98 Don’t know/don’t remember 205 How old does a boy need to be to be able to physically make a girl pregnant? Age: ____ 1 After puberty 98 Don’t know/don’t remember 206 How old does a girl need to be to be pregnant? Age: ____ 1 After puberty 98 Don’t know/don’t remember 207 Is it possible for a girl to get pregnant if the boy withdraws before ejaculation? 1 Yes 2 No 98 Don’t know/don’t remember 208 Do you know any ways to avoid getting pregnant? 1 Yes 2 No Skip to Q. 211 98 Don’t know/don’t remember Skip to Q. 211 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 380 Instrument 12: Comprehensive Youth Survey Page 8 of 71 Module 2: Reproductive Health Knowledge (continued) 209 What are the ways to avoid getting pregnant? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Pill 1 2 IUD 1 2 Injectable/Depo-Provera 1 2 Diaphragm/foam tablets/jelly/cream 1 2 Condom 1 2 Norplant 1 2 Contraceptive (unspecified) 1 2 Traditional method (specify): ______________ 1 2 Non-penetrative sex 1 2 Herbs 1 2 Male sterilization 1 2 Female sterilization 1 2 Safe days/abstinence 1 2 Emergency contraception 1 2 Nat. family planning/billing method 1 2 Withdrawal 1 2 Douching 1 2 Other (specify):________________________ 88 Don’t know/don’t remember 98 210 Which contraceptive method is the least effective? 1 A condom with foam 2 A diaphragm with jelly 3 A condom only 4 Withdrawal 5 The pill 6 Abstinence (not having sex) 7 Rhythm 98 Don’t know/don’t remember 381 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 9 of 71 Module 2: Reproductive Health Knowledge (continued) 211 If you wanted to find out more about ways to avoid pregnancy, whom would you talk to? (Probe by asking, “Anyone else?” and circle all that apply.) Yes No Brother 1 2 Sister 1 2 Aunt 1 2 Uncle 1 2 Female adult 1 2 Male adult 1 2 Female friend 1 2 Wife 1 2 Husband 1 2 Male friend 1 2 Female peer educator at clinic 1 2 Male peer educator at clinic 1 2 Boyfriend 1 2 Girlfriend 1 2 Doctor 1 2 Religious leader 1 2 Male adult counselor at clinic 1 2 Female adult counselor at clinic 1 2 Male adult counselor 1 2 Female adult counselor 1 2 Male peer educator 1 2 Female peer educator 1 2 Teacher 1 2 Grandmother 1 2 Grandfather 1 2 Nurse 1 2 Pharmacist 1 2 Shopkeeper 1 2 CBD agent 1 2 Other (specify): _____________ 88 212 Are there any good things about having a child while you are a teenager? 1 Yes 2 No Skip to Q. 214 98 Don’t know/don’t remember Skip to Q. 214 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 382 Instrument 12: Comprehensive Youth Survey Page 10 of 71 Module 2: Reproductive Health Knowledge (continued) 213 What are the good things about having a child while you are a teenager? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Having a baby to love 1 2 Having a child’s love 1 2 Moving out of parent’s house 1 2 Getting married early 1 2 Proving your fertility 1 2 Showing your maturity 1 2 Enjoying them growing up 1 2 Having a partner to love 1 2 Having security during old age 1 2 Proving you are a man/woman 1 2 Other (specify): _____________ 88 Don’t know 98 214 Are there any reasons why pregnancy/ childbirth should be avoided when you are a teenager? 1 Yes 2 No Skip to Q. 216 98 Don’t know/don’t remember Skip to Q. 216 215 What are the reasons? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Mother could die 1 2 Baby could be unhealthy 1 2 Children are too costly 1 2 Father could be thrown 1 2 out of family Mother could be thrown 1 2 out of family Affects mother’s educational 1 2 chances Child could die 1 2 Mother alone cannot 1 2 take care of child Mother and father together 1 2 cannot take care of child Other (specify): _____________ 88 216 What would be the ideal number of children for you? 1 None 2 One 3 Two 4 Three 5 Four or more 98 Don’t know 383 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 11 of 71 Module 2: Reproductive Health Knowledge (continued) 217 What does “safe sex” mean to you? (Do not read. Probe by asking “Anything else?” and circle all responses.) Yes No Abstaining from sex 1 2 Using condom 1 2 Avoiding multiple sex partners 1 2 Avoiding sex with prostitutes 1 2 Avoiding anal sex 1 2 Other (specify): _____________ 88 Don’t know 98 218 If you had a reproductive health problem or question, where would you go for help? (Probe by asking, “Anyplace else?” and circle all that apply.) (Note for interviewers: Reproductive health problems are problems associated with the reproductive health organs, such as pregnancy, contraceptive concerns, HIV/AIDS, STIs, abortion, etc.) 1 Clinic/hospital 2 Health worker 3 Peer counselor 4 Youth center 5 Friend 6 Parent 7 Relative 8 Teacher 9 Other (specify): _____________ 98 Don’t know 219 If you wanted to buy contraceptives, do you know where you would go? (Probe by asking, “Anyplace else?” and circle all that apply.) 1 Clinic/hospital 2 Health worker 3 Peer counselor 4 Youth center 5 Friend 6 Health worker 7 Relative 8 Teacher 9 Bar 10 Movie theater/video center 11 Place were sporting events are held 12 Pharmacy 13 CBD agent 88 Other (specify): _____________ 98 Don’t know (Read to respondent) Now I am going to read some statements. After I read each statement, please tell me if you agree or disagree. 220 A woman must use the pill every day for it to be effective. 1 Agree 2 Disagree 98 Don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 384 Instrument 12: Comprehensive Youth Survey Page 12 of 71 Module 2: Reproductive Health Knowledge (continued) 221 Side effects from the pill, such as nausea, go away a few months after a girl starts using it. 1 Agree 2 Disagree 98 Don’t know 222 The pill can cause infertility. 1 Agree 2 Disagree 98 Don’t know 223 Taking the pill is riskier than getting pregnant. 1 Agree 2 Disagree 98 Don’t know 224 A person can always tell by looking that another person has a sexually transmitted infection. 1 Agree 2 Disagree 98 Don’t know 225 If signs of a sexually transmitted infection disappear, it means that the person no longer has the disease. 1 Agree 2 Disagree 98 Don’t know 226 A healthy-looking person can be infected with HIV. 1 Agree 2 Disagree 98 Don’t know 227 A person can get HIV/AIDS the first time he or she has sex. 1 Agree 2 Disagree 98 Don’t know 228 A woman who has HIV can give birth to a child with HIV. 1 Agree 2 Disagree 98 Don’t know 229 AIDS is curable in some cases. 1 Agree 2 Disagree 98 Don’t know 230 HIV infection could be passed through sharing eating utensils with someone who has AIDS. 1 Agree 2 Disagree 98 Don’t know 231 A person can get AIDS through circumcision. 1 Agree 2 Disagree 98 Don’t know 232 A person can get AIDS through mosquito, flea or bedbug bites. 1 Agree 2 Disagree 98 Don’t know 385 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 13 of 71 Module 3: STI/HIV/AIDS I. Sexually Transmitted Infections 301 Do you know of any infections a person can get through sexual intercourse? 1 Yes 2 No Skip to Q. 316 302 Which infections do you know about? (Probe by asking, “Any others?” and circle all that apply.) Yes No HIV/AIDS 1 2 Gonorrhea 1 2 Syphilis 1 2 Chancroid 1 2 Chlamydia 1 2 Genital warts 1 2 Genital herpes 1 2 Hepatitis B 1 2 Vaginitis 1 2 Cervical cancer 1 2 Other (specify): _____________ 88 Don’t know/don’t remember 98 303 What signs or symptoms suggest that a person has a sexually transmitted infection (STI)? (Probe by asking, “Any others?” and circle all that apply.) Yes No Discharge from penis/vagina 1 2 Burning pain or itching 1 2 in penis/vagina Abnormal vaginal bleeding 1 2 Loss of weight 1 2 Sores or warts on penis/vagina 1 2 Painful urination 1 2 Swelling in groin region 1 2 Other (specify): _____________ 88 Don’t know/don’t remember 98 Skip to Q. 305 304 Have you had any of these symptoms in the last 12 months? 1 Yes 2 No 98 Don’t know/don’t remember 305 Have you ever had any sexually transmitted infections (STIs)? 1 Yes 2 No Skip to Q. 315 98 Don’t know/don’t remember Skip to Q. 315 306 How did you know you had a sexually transmitted infection (STI)? 1 Was diagnosed 2 Thought by myself 3 Friend/relative told me 88 Other (specify): _____________ 98 Don’t know/don’t remember A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 386 Instrument 12: Comprehensive Youth Survey Page 14 of 71 Module 3: STI/HIV/AIDS (continued) I. Sexually Transmitted Infections (continued) 307 Did you receive treatment for the STI? 1 Yes 2 No 98 Don’t know/don’t remember 308 Have you had another STI since then? 1 Yes 2 No 98 Don’t know/don’t remember 309 Have you had any STIs in the past 12 months? 1 Yes 2 No Skip to Q. 315 98 Don’t know/don’t remember Skip to Q. 315 310 How many times have you had an STI in the past 12 months? 1 None 2 One 3 Two 4 Three 5 Four or more 98 Don’t know/don’t remember 311 Whom did you discuss this problem with? (Probe by asking, “Anyone else?” and circle all that apply.) Yes No No one 1 2 Spouse 1 2 Boyfriend/girlfriend 1 2 Peer educator/counselor 1 2 Adult counselor 1 2 Grandfather 1 2 Grandmother 1 2 Traditional healer 1 2 Friend 1 2 Mother 1 2 Father 1 2 Sister 1 2 Brother 1 2 Aunt 1 2 Uncle 1 2 Cousin 1 2 Nurse 1 2 Doctor 1 2 Other (specify): _____________ 88 387 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 15 of 71 Module 3: STI/HIV/AIDS (continued) I. Sexually Transmitted Infections (continued) 312 Where did you seek advice or treatment? (Probe by asking, “Anyplace else?” and circle all that apply.) Yes No Did not go for treatment 1 2 Treated myself 1 2 Youth center 1 2 Drug store 1 2 Hospital/clinic 1 2 Traditional healer 1 2 Friends/relatives 1 2 Other (specify): _____________ 88 313 When you had the STI, did you advise your sexual partner to seek treatment? 1 Yes 2 No 98 Don’t know/don’t remember 314 When you had the STI, what did you do to prevent infecting your partner? 1 Did not have sex 2 Used condoms 3 Got treated 4 Nothing 88 Other (specify): _____________ 315 Is there anything a person can do to avoid getting STIs? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Non-penetrative sex 1 2 Use of condom 1 2 Washing/douching 1 2 Avoiding casual partners 1 2 Abstinence 1 2 Avoiding commercial 1 2 sex workers Using herbs 1 2 Other (specify): _____________ 88 II. HIV/AIDS 316 Have you heard of an illness called AIDS? 1 Yes 2 No Skip to Q. 401 317 Do you believe that AIDS exists? 1 Yes 2 No Skip to Q. 401 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 388 Instrument 12: Comprehensive Youth Survey Page 16 of 71 Module 3: STI/HIV/AIDS (continued) II. HIV/AIDS (continued) 318 Please mention all the ways in which you believe a person can get AIDS. (Probe by asking, “Anything else?” and circle all that apply.) Yes No Sexual intercourse 1 2 Sharing needles/unclean 1 2 medical equipment Blood transfusions 1 2 During pregnancy 1 2 Mother to child during birth 1 2 Mosquito or other insect bites 1 2 Through breast milk 1 2 Casual contact with infected 1 2 person (e.g., sharing food, shaving equipment, cup or glass; handshake, cough or sneeze) Other (specify): _____________ 88 Don’t know 98 319 Is there anything a person can do to avoid getting AIDS? 1 Yes 2 No Skip to Q. 321 98 Don’t know Skip to Q. 321 320 What can a person do? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Avoid sex completely/ 1 2 abstinence Stay faithful to partner 1 2 Encourage partner to 1 2 stay faithful Avoid contaminated blood 1 2 Use condoms for every act 1 2 of sexual intercourse Avoid sharing needles 1 2 Avoid commercial sex workers 1 2 Avoid casual sex 1 2 Avoid circumcision at 1 2 unauthorized places Other (specify): _____________ 88 321 Does the use of a condom during sexual intercourse reduce the risk of HIV/AIDS? 1 Yes Skip to Q. 323 2 No 98 Don’t know/don’t remember 389 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 17 of 71 Module 3: STI/HIV/AIDS (continued) II. HIV/AIDS (continued) 322 If no, why not? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Might be holes in condom 1 2 It can burst 1 2 It can come off inside 1 2 the woman It can leak 1 2 Other (specify): _____________ 88 Don’t know 98 323 How long does it usually take somebody to get sick with AIDS after being infected with HIV (the virus that causes AIDS)? 1 A few weeks 2 A few months 3 One or two years 4 Several years 88 Other (specify): _____________ 98 Don’t know/don’t remember 324 Do you think you are at risk of getting the AIDS virus in the next 12 months 1 Yes 2 No 98 Don’t know 325 Do you worry about getting infected with the virus that causes AIDS? 1 Yes 2 No 326 Do you think you have done anything that may have put you at risk of getting the AIDS virus? 1 Yes (specify): _____________ 2 No 98 Don’t know/don’t remember 327 Do you think most of your friends are at risk of getting the AIDS virus? 1 Yes 2 No 98 Don’t know 328 Have you ever known anyone who has had AIDS? 1 Yes 2 No Skip to Q. 401 329 How many people do you know who have had AIDS? No. of people with AIDS: __________ A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 390 Instrument 12: Comprehensive Youth Survey Page 18 of 71 Module 3: STI/HIV/AIDS (continued) II. HIV/AIDS (continued) 330 What were your relationships to these people? (Circle all that apply.) Yes No Mother 1 2 Father 1 2 Brother 1 2 Sister 1 2 Aunt 1 2 Uncle 1 2 Female friend 1 2 Male friend 1 2 Girlfriend 1 2 Boyfriend 1 2 Teacher 1 2 Grandmother 1 2 Grandfather 1 2 Husband 1 2 Wife 1 2 Other (specify): _____________ 88 331 How many people do you know who have died of AIDS? No. of people who have died of AIDS: _____ 332 What were your relationships to these people? (Circle all that apply.) Yes No Mother 1 2 Father 1 2 Brother 1 2 Sister 1 2 Aunt 1 2 Uncle 1 2 Female friend 1 2 Male friend 1 2 Girlfriend 1 2 Boyfriend 1 2 Teacher 1 2 Grandmother 1 2 Grandfather 1 2 Husband 1 2 Wife 1 2 Other (specify): _____________ 88 391 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 19 of 71 Module 4: Attitudes, Beliefs and Values 401 During the next year, how likely or unlikely do you think it is that someone will force you to have sexual intercourse? 1 I’m sure this won’t happen 2 This probably won’t happen 3 I’m not sure whether this will happen or not 4 This probably will happen 5 I’m sure this will happen 402 If someone did try to force you to have sexual intercourse during the next year, what would you do? 1 I definitely would not do it 2 I probably would not do it 3 I’m not sure whether I would do it or not 4 I probably would do it 5 I definitely would do it 403 What are the advantages to using condoms? (Probe by asking, “Anything else?” and circle all that apply.) Yes No No advantages 1 2 Pregnancy prevention only 1 2 Less worry 1 2 STI and pregnancy prevention 1 2 AIDS and pregnancy prevention 1 2 AIDS prevention only 1 2 Less mess/clean/neat 1 2 Feel safer/protected 1 2 Other (specify): _____________ 88 Don’t know 98 404 What are the disadvantages of using condoms? (Probe by asking, “Anything else?” and circle all that apply.) Yes No There are no disadvantages 1 2 Reduces pleasure 1 2 Can come off inside the woman 1 2 Can burst 1 2 Shows lack of trust in 1 2 your partner Unsafe/not 100 percent 1 2 effective Causes itchiness/discomfort 1 2 Ruins mood 1 2 Other (specify): _____________ 88 Don’t know/don’t remember 98 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 392 Instrument 12: Comprehensive Youth Survey Page 20 of 71 Module 4: Attitudes, Beliefs and Values (continued) 405 What important steps do you know on how to use a condom? (Probe by asking, “Anything else?” and circle all that apply) Yes No Use new one every time 1 2 Check expiration date 1 2 Open wrapper carefully 1 2 Hold base of condom when 1 2 withdrawing after ejaculation Squeeze end 1 2 Unroll on erect penis 1 2 Other (specify): _____________ 88 Don’t know/don’t remember 98 406 When do you think you would use a condom? (Probe by asking, “Any other time?” and circle all that apply.) Yes No Never 1 2 For casual sex 1 2 In a stable boy-girl relationship 1 2 When having sex with 1 2 prostitutes For protection against STIs 1 2 To avoid pregnancy 1 2 In a husband-wife relationship 1 2 When one has multiple 1 2 sexual partners If partner has STI 1 2 Other (specify): _____________ 88 Don’t know 98 407 When do you think most boys your age would use condoms? (Probe by asking, “Any other time?” and circle all that apply.) Yes No Never 1 2 For casual sex 1 2 In a stable boy-girl relationship 1 2 When having sex with 1 2 prostitutes For protection against STIs 1 2 To avoid pregnancy 1 2 In a husband-wife relationship 1 2 When one has multiple 1 2 sexual partners If partner has STI 1 2 Other (specify): _____________ 88 Don’t know 98 393 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 21 of 71 Module 4: Attitudes, Beliefs and Values (continued) 408 When do you think most girls your age would use condoms? (Probe by asking, “Any other time?” and circle all that apply.) Yes No Never 1 2 For casual sex 1 2 In a stable boy-girl relationship 1 2 When having sex with prostitutes 1 2 For protection against STIs 1 2 To avoid pregnancy 1 2 In a husband-wife relationship 1 2 When one has multiple sexual partners 1 2 If partner has STI 1 2 Other (specify): _____________ 88 Don’t know 98 409 In your opinion, what is the ideal age for a girl to have sex for the first time? Age: ____ years 1 After marriage 2 Other (specify): _____________ 98 Don’t know 410 In your opinion, what is the ideal age for a boy to have sex for the first time? Age: ____ years 1 After marriage 2 Other (specify): _____________ 98 Don’t know 411 In your opinion, what is the ideal age for a girl to marry? Age: ____ years 98 Don’t know 412 In your opinion, what is the ideal age for a boy to marry? Age: ____ years 98 Don’t know 413 Do you feel like you are ready to cause a pregnancy (be pregnant) right now? 1 Yes Skip to Q. 415 2 No 414 If not, why not? 1 Still young 2 Want to study further 3 Want to build a career 4 Cannot afford to have children 5 Not mentally ready yet 6 Still want to be free 7 Still live with parents/family 8 Other (specify): _____________ 415 How many years after marriage do you want to have the first baby? ____ years 416 When you get married, how many children do you want to have? ____ children A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 394 Instrument 12: Comprehensive Youth Survey Page 22 of 71 Module 4: Attitudes, Beliefs and Values (continued) 417 At what intervals would you like to have these children? ____ (# of) years between children 418 What do you think is the best age, if any, for you to have your first child? ____ years 419 After you get married, do you want (or want your wife) to conceive immediately? 1 Yes 2 No Skip to Q. 421 420 Why do you want (or want your wife) to conceive immediately after you get married? 1 Family demand 2 To have a baby as soon as possible 3 Feel old enough 4 To have children while still young 5 In order to have many children 6 To ensure an everlasting marriage 7 Other (specify): _____________ 421 Do you think that it is easy or difficult for unmarried boys to obtain contraceptive methods? 1 Easy Skip to Q. 423 2 Difficult 98 Don’t know Skip to Q. 423 422 Why is it difficult for unmarried boys to obtain contraceptive methods? (Circle all that apply.) Yes No Money 1 2 Difficult to find 1 2 Provider/seller disapproves 1 2 Parents/elders disapprove 1 2 Other (specify): _____________ 88 Don’t know 98 423 Do you think that it is easy or difficult for unmarried girls to obtain contraceptive methods? 1 Easy 2 Difficult Skip to Q. 425 98 Don’t know Skip to Q. 425 424 Why is it difficult for unmarried girls to obtain contraceptive methods? (Circle all that apply.) Yes No Money 1 2 Difficult to find 1 2 Provider/seller disapproves 1 2 Parents/elders disapprove 1 2 Other (specify): _____________ 88 Don’t know 98 395 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 23 of 71 Module 4: Attitudes, Beliefs and Values (continued) 425 Can anything be done to make it less difficult for unmarried boys and girls to obtain contraceptive methods other than condoms? For boys: For girls: 426 Do you believe that discussing contraceptives with young people promotes promiscuity? 1 Yes 2 No 98 Don’t know 427 Which of the following attitudes best describes your expectations about sexual partners during the rest of your adolescent years? (Read out loud.) 1 I don’t expect to have any sexual partners. 2 I expect to have only one partner. 3 I expect to have two or three sexual partners, but only one at a time. 4 I expect to have several sexual partners at the same time. 428 Which of the following attitudes best describes your plans about having sexual intercourse in the future? (Read out loud.) 1 I plan to wait until marriage before having sex. 2 I plan to wait until I am engaged before having sex. 3 I plan to wait until I find someone I love before having sex. 4 I plan to wait until I’m at least 19 before having sex. 5 I plan to wait until I’m at least 17 before having sex. 6 I plan to have sex as soon as possible. 7 I plan to have sex whenever an opportunity comes along. 8 Having sex isn’t something you can plan; it just happens. 9 I plan to have sex whenever my partner wants to have sex. 429 Which of the following attitudes best describes your plans about using a contraceptive the first/next time you have sexual intercourse? (Read out loud.) 1 I plan to use a contraceptive and will not have sex without using one. 2 I plan to use a contraceptive, as long as it’s convenient. 3 I plan to use a contraceptive, as long as my partner doesn’t object. 4 I plan to use a contraceptive only if my partner insists on it. 5 I do not plan to use a contraceptive. 430 Which of the following attitudes best describes your plans about going to see a reproductive health provider for information, advice and/or services? (Read out loud.) 1 I do not plan to see a provider at all. 2 I may see a provider for some information. 3 I may see a provider for services. 4 I definitely plan to see a provider for information. 5 I definitely plan to see a provider for services. 6 I definitely plan to see a provider for services and information. A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 396 Instrument 12: Comprehensive Youth Survey Page 24 of 71 Module 4: Attitudes, Beliefs and Values (continued) 431 I am going to read you a list of many contraceptive methods that people use to avoid pregnancy or sexually transmitted infections. Which of these methods do you intend to use in the next year? (Read out loud and circle all that apply.) 1 None, I don’t intend to be sexually active 2 None, even though I expect to be sexually active 3 Pills 4 Injections (Depo-Provera) 5 IUD/loop 6 Condom 7 Diaphragm/sponge/foam 8 Rhythm 9 Withdrawal 10 Traditional methods 88 Other (specify): _____________ 98 Don’t know (Read to respondent) Now I would like to read some statements to you, and I would like you to tell me whether you agree or disagree with each statement. 432 A girl should have sex before she gets married. 1 Agree 2 Disagree 98 Don’t know 433 A boy should have sex before he gets married. 1 Agree 2 Disagree 98 Don’t know 434 It is necessary for a girl to get pregnant shortly before marriage. 1 Agree 2 Disagree 98 Don’t know 435 Unmarried young people who are having sex should use a contraceptive method to avoid pregnancy. 1 Agree 2 Disagree 98 Don’t know 436 If a young person is desperate for school fees or to learn a trade, it is OK to have an adult pay for the education in exchange for sex from the young person (i.e., a “sugar daddy” or “sugar mommy”). 1 Agree 2 Disagree 98 Don’t know 437 Young people’s knowledge of contraception encourages them to have sex with many people. 1 Agree 2 Disagree 98 Don’t know 438 When a girl uses contraceptives, it will probably be more difficult for her to have children later on. 1 Agree 2 Disagree 98 Don’t know 397 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 25 of 71 Module 4: Attitudes, Beliefs and Values (continued) 439 A girl who carries condoms in her purse cares about herself. 1 Agree 2 Disagree 98 Don’t know 440 Carrying condoms is difficult because it makes it look as if a person plans to have sex. 1 Agree 2 Disagree 98 Don’t know 441 You can easily afford to buy condoms anytime you want to. 1 Agree 2 Disagree 98 Don’t know 442 When a relationship moves from casual to serious, it is no longer necessary to use a condom. 1 Agree 2 Disagree 98 Don’t know 443 A woman would lose a man’s respect if she requested that he use a condom. 1 Agree 2 Disagree 98 Don’t know 444 It is embarrassing to purchase a condom. 1 Agree 2 Disagree 98 Don’t know 445 Using condoms is a sign of not trusting your partner. 1 Agree 2 Disagree 98 Don’t know 446 Using condoms is a sign of mutual respect. 1 Agree 2 Disagree 98 Don’t know 447 Condoms are easy to use. 1 Agree 2 Disagree 98 Don’t know 448 It is sometimes okay to pressure my partner to have sex with me in certain circumstances. 1 Agree 2 Disagree 98 Don’t know 449 I believe that I am responsible for my own welfare and well-being. 1 Agree 2 Disagree 98 Don’t know 450 I feel responsible for all of my actions to others. 1 Agree 2 Disagree 98 Don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 398 Instrument 12: Comprehensive Youth Survey Page 26 of 71 Module 4: Attitudes, Beliefs and Values (continued) (Read to respondent) Now I would like to discuss what young people, such as yourself and your friends, talk about. Young people may talk to different people about different things that concern them. They may talk to family members, friends, teachers or counselors. I am going to read a list of topics that young people may talk about. I would like you to tell me whether you have discussed this topic in the last six months and, if so, with whom you have discussed it. 451 In the last six months, have you discussed (read each topic): Yes No Body changes during puberty 1 2 Whether you can have fun in a 1 2 relationship without having sexual intercourse Sexual urges 1 2 How to avoid getting pregnant 1 2 Relationships with the opposite sex 1 2 Whether or not to have sex 1 2 Unwanted pregnancy 1 2 Abortion 1 2 Job availability 1 2 STIs or HIV/AIDS 1 2 How to use condoms 1 2 Where to get condoms 1 2 Drugs and alcohol 1 2 Sexual abuse/coercion 1 2 Negotiating sex 1 2 452 (If yes) With whom did you discuss this topic? (Probe by asking, “Anyone else?” Use codes below and circle all that apply.) CODES: 1 = Mother 2 = Father 3 = Brother 4 = Sister 5 = Aunt 6 = Uncle 7 = Female friend 8 = Male friend 9 = Husband 10 = Wife 11 = Boyfriend 12 = Girlfriend 13 = Teacher 14 = Nurse 15 = Doctor 16 = Religious leader 17 = Male adult counselor at clinic 18 = Female adult counselor at clinic 19 = Male adult counselor at other site 20 = Female adult counselor at other site 21 = Male peer educator at clinic 22 = Female peer educator at clinic 23 = Male peer educator at other site 24 = Female peer educator at other site 25 = Grandmother 26 = Grandfather 27 = Respected adult 28 = Pharmacist 29 = Other (specify): ___________ 453 With whom do you most prefer to discuss sexual matters? (Use code list above.) _____ 399 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 27 of 71 Module 5: Social Influences 501 Do you think that any of your friends have drunk alcohol? 1 Yes 2 No 98 Don’t know 502 About how many of your friends have drunk alcohol? 1 None of them 2 A few of them 3 About half of them 4 Most of them 5 All of them 503 Do you think that any of your friends have taken drugs? 1 Yes 2 No 98 Don’t know 504 About how many of your friends have taken drugs? 1 None of them 2 A few of them 3 About half of them 4 Most of them 5 All of them 505 Do you think that any of your friends have smoked? 1 Yes 2 No 98 Don’t know 506 About how many of your friends have smoked? 1 None of them 2 A few of them 3 About half of them 4 Most of them 5 All of them 507 Do unmarried girls in this community encourage other girls to have sex with boys or older men? 1 Yes 2 No 98 Don’t know 508 Do unmarried boys in this community encourage other boys to have sex with girls or older women? 1 Yes 2 No 98 Don’t know 509 Have you ever been encouraged to do this? 1 Yes 2 No 3 Respondent is male 98 Don’t know 510 Do you think that any of your friends have frequented a commercial sex worker? 1 Yes 2 No Skip to Q. 512 98 Don’t know Skip to Q. 512 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 400 Instrument 12: Comprehensive Youth Survey Page 28 of 71 Module 5: Social Influences (continued) 511 If yes, about how many of your friends have frequented a commercial sex worker? 1 None of them 2 A few of them 3 About half of them 4 Most of them 5 All of them 512 Is there support among your friends for you to wait until marriage before having sexual intercourse? 1 No support at all 2 A little support 3 A moderate amount of support 4 A lot of support 513 Is there pressure from your friends for you to have sexual intercourse? 1 No pressure at all 2 A little pressure 3 A moderate amount of pressure 4 A lot of pressure 514 About how many of your friends have had sexual intercourse? 1 None of them 2 A few of them 3 About half of them 4 Most of them 5 All of them 515 Among friends your age, is it common to use condoms? 1 Yes 2 No 98 Don’t know 516 Is it common among your friends who have sex to use a contraceptive method? 1 Yes 2 No 98 Don’t know 517 Which contraceptive methods are most commonly used? (Circle all that apply.) 1 Pill 2 IUD 3 Condom (male) 4 Diaphragm 5 Natural family planning 6 Sterilization 7 Injection (Depo-Provera) 8 Norplant 9 Condom (female) 10 Spermicide/foaming tablets 11 Abortion 12 Abstinence 13 Other (specify): ____________ 518 Do you think most people in your age group have a boyfriend or girlfriend? 1 Yes 2 No 98 Don’t know 519 Do you think most couples in your age group have sexual relations before marriage? 1 Yes 2 No 98 Don’t know 401 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 29 of 71 Module 5: Social Influences (continued) Family Dynamics 520 With whom do you live with most of the time? 1 Both parents 2 Mother only 3 Father only 4 Guardian/non-relative 5 Brother or sister 6 Friends 7 On my own 8 Girlfriend/boyfriend 9 Uncle 10 Aunt 11 Grandmother 12 Grandfather 13 Boarding school 14 Mother and stepfather 15 Father and stepmother 16 Wife/husband 88 Other (specify): _____________ 521 Is your father alive? 1 Yes Skip to Q. 523 2 No 522 How old were you when your father died? ____ years Skip to Q. 524 523 Does your father usually live here with you? 1 Always 2 Usually 3 Sometimes 4 Not usually 5 Never 524 What is (was) the highest level of education your father completed? 0 No education 1 Less than primary 2 Primary 3 Secondary 4 Vocational/technical college 5 University/college 98 Don’t know 525 Is your mother alive? 1 Yes Skip to Q. 527 2 No 526 How old were you when your mother died? ____ years Skip to Q. 528 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 402 Instrument 12: Comprehensive Youth Survey Page 30 of 71 Module 5: Social Influences (continued) Family Dynamics (continued) 527 Does your mother usually live here with you? 1 Always 2 Usually 3 Sometimes 4 Not usually 5 Never 528 What is (was) the highest level of education your mother completed? 0 No education 1 Less than primary 2 Primary 3 Secondary 4 Vocational/technical college 5 University/college 98 Don’t know If you asked your father, mother or other adult family member sex-related questions (e.g., nocturnal emission, menstruation, contraception, masturbation, sexual intercourse), what would be his or her response? (Check one.) 1 Would answer helpfully 2 Would turn me away without giving an answer 3 Would scold me 4 Response would vary with type of question 5 Not competent enough to give an answer 529 Father/male adult family member 530 Mother/female adult family member 531 How often have you talked about each of the topic listed below with a parent or adult family member in the last three months? (Read each topic and fill in the appropriate response code.) RESPONSE CODES: 1 Once a week 2 2–3 times/month 3 Once a month 4 Haven’t talked A Birth control ____ B What is right and wrong in sexual behavior ___ C What my parents think about unmarried youth having sex ___ D What my friends think about sex ___ E My questions about sex ___ F Reasons why I shouldn’t have sex at my age ___ G How my life would change if I became a father or a mother while I’m a teenager ___ H Sexually transmitted infections ___ 403 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 31 of 71 Module 5: Social Influences (continued) Family Dynamics (continued) 532 Have you ever talked with one or both of your parents or an adult family member about: 1 Yes 2 No A The female menstrual cycle? B How pregnancy occurs? C Sexually transmitted infections? D How to say no to sex? E Contraceptives? F How to prevent AIDS? G Using safe sex practices? 533 Who started these conversations? 1 I always started them 2 I usually started them 3 My parent/adult family member and I each started them 4 My parent/adult family member usually started them 5 My parent/adult family member always started them 6 We had no conversations 534 How did you feel about your talks with a parent or adult family member on these topics? (Read each topic and fill in the appropriate response code. If no discussion on the topic occurred in the last three months, put 0.) RESPONSE CODE: 1 Very good 2 Good 3 Neutral 4 Bad 5 Very bad 0 Have not talked A. Birth control ____ B. What is right and wrong in sexual behavior ____ C. What my parents think about unmarried youth having sex ____ D. What my friends think about sex ____ E. My questions about sex ____ F. Reasons why I shouldn’t have sex at my age ____ G. How my life would change if I became a father or a mother while I’m a teenager ____ H. Sexually transmitted infections ____ A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 404 Instrument 12: Comprehensive Youth Survey Page 32 of 71 Module 5: Social Influences (continued) Family Dynamics (continued) 535 There are different types of families. I would like you to tell me, in your opinion, to which category your family belongs. A Religious 1 2 3 4 5 Not religious B Traditional 1 2 3 4 5 Modern C Liberal 1 2 3 4 5 Conservative D Peaceful 1 2 3 4 5 Violent E Open/lots of communication 1 2 3 4 5 Closed/no communication F Without problems 1 2 3 4 5 With problems G Trustful 1 2 3 4 5 Distrustful 536 Would you seek approval from/notify your parents or another adult family member beforehand if you were going to do the following? A Go to a disco 1 Yes, notify 2 No 3 Yes, seek approval 98 Don’t know B Have a late-night outing with friends 1 Yes, notify 2 No 3 Yes, seek approval 98 Don’t know C Choose a religion 1 Yes, notify 2 No 3 Yes, seek approval 98 Don’t know D Get married 1 Yes, notify 2 No 3 Yes, seek approval 98 Don’t know E Go to a health facility 1 Yes, notify 2 No 3 Yes, seek approval 98 Don’t know 405 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 33 of 71 Module 5: Social Influences (continued) Family Dynamics (continued) How does your father or other male adult family members feel about you doing the following? (Ask entire list of possibilities, then ask:) How does your mother or other female adult family members feel about you doing the following? Father (or other adult male family member) Mother (or other adult female member) 1 Approve 2 Disapprove 88 No adult male in family 98 Don’t know 1 Approve 2 Disapprove 88 No adult female in family 98 Don’t know 537 / 545 Premarital sex 538 / 546 Buying contraceptives 539 / 547 Drinking beer and other alcoholic beverages 540 / 548 Smoking 541 / 549 Joining clubs or organizations, either in school or in the community 542 / 550 Living with someone of the opposite sex 543 / 551 Watching violent films/videos 544 / 552 Watching pornographic films/videos of reading pornographic magazines 553 How would you describe your family in general? 1 Sweet and warm 2 Good 3 Fair 4 Not very good, but tolerable 5 Intolerable and would like to leave 98 Don’t know 554 Are your parents supportive of your decisions? 1 Not at all 2 No 3 Yes 4 Yes, very much 98 Don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 406 Instrument 12: Comprehensive Youth Survey Page 34 of 71 Module 5: Social Influences (continued) Family Dynamics (continued) For the next four questions, indicate whether you agree or disagree with the statement and the extent to which you agree or disagree. 555 It is against my parents’(guardians’) values for me to have sexual intercourse while I am an unmarried teenager. 1 Strongly disagree 2 Disagree 3 Not sure 4 Agree 5 Strongly agree 556 I have a lot of respect for my parents’(guardians’) ideals and opinions about sex. 1 Strongly disagree 2 Disagree 3 Not sure 4 Agree 5 Strongly agree 557 My values and beliefs about sex match those of my parents (guardians). 1 Strongly disagree 2 Disagree 3 Not sure 4 Agree 5 Strongly agree 558 I feel like I can go to my parents (guardians) with questions about sex. 1 Strongly disagree 2 Disagree 3 Not sure 4 Agree 5 Strongly agree How does your father or other male adult family members feel about you doing the following? (Ask entire list of possibilities, then ask:) How does your mother or other female adult family members feel about you doing the following? Father (or other adult male family member) Mother (or other adult female member) 1 Yes 2 No 88 No adult male in family 98 Don’t know 1 Yes 2 No 88 No adult female in family 98 Don’t know 559 / 565 Too traditional/ conservative 560 / 566 Too ignorant/stupid 561 / 567 Reasonable 562 / 568 Doesn’t understand me 563 / 569 Spends too little time with me 407 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 35 of 71 Module 5: Social Influences (continued) Family Dynamics (continued) Right now, what kind of terms are you on with your father? with your mother? 1 Very good 2 Good 3 Fair 4 Bad 5 Very bad 98 Don’t know 571 Father 572 Mother How often do you quarrel with your father? with your mother? 1 A lot 2 Occasionally 3 Rarely 4 Never 98 Don’t know 573 Father 574 Mother 575 How important is it to your family that you continue your education after high school? 1 Not important at all 2 Not too important 3 Somewhat important 4 Quite important 5 Very important Siblings 576 How many brothers and sisters do you have? No. of brothers: _________ No. of sisters: ____________ 0 None Skip to Q. 601 577 What number child are you (e.g., first born, second born)? No. child: ____________ 578 Do you get along well with your brothers and/or sisters? 1 All the time 2 Usually 3 Sometimes 4 Not usually 5 Never 579 Have you ever confided in your brothers and/or sisters when in trouble? 1 Yes 2 No A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 408 Instrument 12: Comprehensive Youth Survey Page 36 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (Read to respondent) Now I would like to ask you about your sexual experiences. Please answer truthfully, as your answers will not be revealed to anyone. A Have you ever heard of: B Do you know anyone who has practiced: C Have you practiced: 601 Holding hands? 1 Yes 2 No 98 Don’t know 1 Yes 2 No 98 Don’t know 1 Yes 2 No 98 Don’t know 602 Kissing? 1 Yes 2 No 98 Don’t know 1 Yes 2 No 98 Don’t know 1 Yes 2 No 98 Don’t know 603 Hugging? 1 Yes 2 No 98 Don’t know 1 Yes 2 No 98 Don’t know 1 Yes 2 No 98 Don’t know 604 Fondling (i.e., caressing a woman’s breast or a man’s penis)? 1 Yes 2 No 98 Don’t know 1 Yes 2 No 98 Don’t know 1 Yes 2 No 98 Don’t know 605 Sexual intercourse (i.e., putting the penis inside the vagina)? 1 Yes 2 No 98 Don’t know 1 Yes 2 No 98 Don’t know 1 Yes 2 No Skip to Q. 641 98 Don’t know 606 During the past 30 days, have you had sexual intercourse? 1 Yes 2 No Skip to Q. 608 98 Don’t know/don’t remember 607 During the past 30 days, how often have you had sexual intercourse? 1 3–5 days per week 2 1–2 days per week 3 Less than once per week 4 Only once per week 98 Don’t know/don’t remember 608 During the past three months, have you had sexual intercourse? 1 Yes 2 No 98 Don’t know/don’t remember 609 During the past 12 months, have you had sexual intercourse? 1 Yes 2 No Skip to Q. 613 98 Don’t know/don’t remember 409 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 37 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 610 During the past 12 months, how often have you had sexual intercourse? 1 None 2 Once 3 Two to three 4 Four to five 5 Six to eight 6 Nine or more 98 Don’t know/don’t remember 611 How many partners have you had sexual intercourse with in the last three months? No. sexual partners: ____________ 98 Don’t know/don’t remember 612 How many partners have you had sexual intercourse with in the last 12 months? No. sexual partners: ____________ 98 Don’t know/don’t remember 613 How many different partners have you ever had sexual intercourse with in your lifetime? No. sexual partners: ____________ 98 Don’t know/don’t remember 614 How old were you when you first had sexual intercourse? Age: __________ years 98 Don’t know/don’t remember 615 What was your relationship with your partner the first time you had sexual intercourse? 1 Husband/wife 2 Fiancé/engaged 3 Boyfriend/girlfriend 4 Friend 5 School friend/classmate 6 Teacher 7 Acquaintance 8 Just met 9 Cousin 10 Brother 11 Sister 12 Other relative (specify): _____________ 13 Commercial sex worker 14 Forced intercourse/rape 88 Other (specify): _____________ 98 Don’t remember 616 How long did you know your partner before having sex? 1 Did not know him/her _____ days _____ months _____ weeks _____ years 98 Don’t know/don’t remember A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 410 Instrument 12: Comprehensive Youth Survey Page 38 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 617 About how old was the person you had intercourse with the first time? Age: ________ years 98 Don’t know/don’t remember 618 Why did you decide to have sex the first time? Yes No To get a boyfriend/girlfriend 1 2 Aroused 1 2 Curious 1 2 Needed food/money/school fees 1 2 In love 1 2 Fun/enjoyment/pleasure 1 2 Encouraged by parent 1 2 Wanted to get married 1 2 Forced 1 2 Skip to Q. 623 Friends doing it 1 2 Other (specify): _____________ 1 2 Don’t know/don’t remember 1 2 619 Did you talk about contraceptive methods the first time you had sex? 1 Yes 2 No 98 Don’t know/don’t remember 620 Did you or your partner use a method to prevent pregnancy the first time you had sex? 1 Yes 2 No 98 Don’t know/don’t remember 411 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 39 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 621 Which method did you or your partner use? Yes No Pill 1 2 IUD 1 2 Injectable/Depo-Provera 1 2 Diaphragm/foam tablets/jelly/cream 1 2 Condom 1 2 Norplant 1 2 Contraceptive (unspecified) 1 2 Traditional method 1 2 (specify): _________________ Non-penetrative sex 1 2 Herbs 1 2 Male sterilization 1 2 Female sterilization 1 2 Safe days/abstinence 1 2 Emergency contraception 1 2 Nat. contraceptive/billing method 1 2 Withdrawal 1 2 Don’t know/don’t remember 98 622 Where did you go to get the contraceptive(s)? 1 Hospital 2 Clinic/dispensary 3 Health post 4 Traditional healer 5 CBD 6 Pharmacy 7 Private doctor 88 Other(specify): _____________ 98 Don’t know/don’t remember 623 The last time you had sexual intercourse, did you or your partner use any contraceptive method? 1 Yes 2 No Skip to Q. 626 98 Don’t know/don’t remember Skip to Q. 626 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 412 Instrument 12: Comprehensive Youth Survey Page 40 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 624 Which method did you or your partner use? Yes No Pill 1 2 IUD 1 2 Injectable/Depo-Provera 1 2 Diaphragm/foam tablets/ 1 2 jelly/cream Condom 1 2 Norplant 1 2 Contraceptive (unspecified) 1 2 Traditional method 1 2 (specify): _______ Non-penetrative sex 1 2 Herbs 1 2 Male sterilization 1 2 Female sterilization 1 2 Safe days/abstinence 1 2 Emergency contraception 1 2 Nat. contraceptive/ 1 2 billing method Withdrawal 1 2 Don’t know/don’t remember 98 625 Where did you go to get the contraceptive(s)? 1 Hospital 2 Clinic/dispensary 3 Health post 4 Traditional healer 5 CBD 6 Pharmacy 7 Private doctor 88 Other(specify): _____________ 98 Don’t know/don’t remember 626 How did you feel about the first time you had sexual intercourse? (Read the entire list first and then circle one response.) 1 Very unhappy 2 Unhappy 3 Neutral 4 Very happy 5 Happy 98 Don’t know/don’t remember 413 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 41 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 627 The first time you had sexual intercourse, did you want to have sex, did it just happen or were you tricked, threatened or forced to have sex? 1 Wanted 2 Just happened 3 Tricked 4 Threatened 5 Forced Skip to Q. 629 6 Other (specify): _____________ 98 Don’t know/don’t remember 628 Have you ever been forced against your will to have sexual intercourse? 1 Yes 2 No 98 Don’t know/don’t remember 629 Have you ever received anything in exchange for sex? 1 Yes 2 No Skip to Q. 632 98 Don’t know/don’t remember Skip to Q. 632 630 What did you receive? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Money 1 2 Gifts (specify): 1 2 _____________________ Food 1 2 School fees 1 2 Drugs 1 2 Alcohol 1 2 Shelter/rent 1 2 Clothes 1 2 Other (specify): _____________________ 88 631 (Ask only if response in 630 is “money”) What did you use the money for? 632 Have you ever given anything to someone to get that person to have sex with you? 1 Yes 2 No Skip to Q. 634 98 Don’t know/don’t remember Skip to Q. 634 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 414 Instrument 12: Comprehensive Youth Survey Page 42 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 633 What did you give? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Money 1 2 Food 1 2 School fees 1 2 Drugs 1 2 Alcohol 1 2 Shelter/rent 1 2 Clothes 1 2 Other gifts (specify): _____________ 88 634 Have you or your partner ever used a condom? 1 Yes 2 No 98 Don’t know/don’t remember 635 Do you currently have a condom with you? 1 Yes 2 No 00 No response 636 Are you currently using any contraceptive methods? 1 Yes 2 No Skip to Q. 638 00 No response Skip to Q. 638 637 If yes, which method are you using? Yes No Pill 1 2 IUD 1 2 Injectable/Depo-Provera 1 2 Diaphragm/foam tablets/ 1 2 jelly/cream Condom 1 2 Norplant 1 2 Contraceptive (unspecified) 1 2 Traditional method 1 2 (specify): _______ Non-penetrative sex 1 2 Herbs 1 2 Male sterilization 1 2 Female sterilization 1 2 Safe days/abstinence 1 2 Emergency contraception 1 2 Nat. contraceptive/ 1 2 billing method Withdrawal 1 2 Don’t know/don’t remember 98 415 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 43 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 638 In the last 30 days, did you and your partner ever use a type of contraception? 1 Yes 2 No 98 Don’t know/don’t remember 639 In the last 30 days, did you or your partner use a contraceptive method every time you had sexual intercourse? 1 Yes 2 No 98 Don’t know/don’t remember 640 Have any of your female friends ever been pregnant? 1 Yes 2 No Skip to Q. 642 98 Don’t know/ Skip to Q. 642 don’t remember 641 About how many? No. friends pregnant: _____________ 98 Don’t know/don’t remember (QUESTIONS 642–660 ARE TO BE ASKED OF GIRLS ONLY) 642 Do you think you are physically able to get pregnant at the present time? 1 Yes Skip to Q. 644 2 No 98 Don’t know Skip to Q. 644 643 What is the main reason you think you cannot get pregnant? 1 Too young 2 Ovarian cysts 3 Currently breastfeeding/postpartum 4 Sexually transmitted infection/PID 5 Partner had a medical operation 6 Partner is infertile 7 (Respondent) Had a medical operation that makes pregnancy impossible 8 Uses birth control 9 Is not sexually active 10 Has tried to get pregnant in the past two years and did not succeed 88 Other (specify): ______________ 98 Don’t know 644 Have you ever been pregnant? 1 Yes 2 No Skip to Q. 660 98 Don’t know/don’t remember Skip to Q. 660 645 How many times have you been pregnant? 1 One 2 Two 3 Three 4 Four 5 Five 6 Six or more A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 416 Instrument 12: Comprehensive Youth Survey Page 44 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 646 Are you currently pregnant? 1 Yes 2 No 98 Don’t know 647 Have you ever had any live-born children? 1 Yes 2 No Skip to Q. 649 648 How many living children do you have, including those who do not live with you? No: _____ children 649 How old were you when you first became pregnant? Age: _____ years 98 Don’t know/don’t remember 650 How old was the boy or man who made you pregnant? (If more than one pregnancy, probe for the first one.) Age: _____ years 98 Don’t know/don’t remember 651 At the time you became pregnant, did you want to be pregnant? 1 Yes 2 No 98 Don’t know/don’t remember 652 Did you have one or more prenatal care visits? 1 Yes 2 No 98 Don’t know/don’t remember 653 At the time you became pregnant, were you using any contraceptives to avoid or delay getting pregnant? 1 Yes 2 No Skip to Q. 655 98 Don’t know/don’t remember Skip to Q. 655 417 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 45 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 654 What were you or your partner using? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Pill 1 2 IUD 1 2 Injectable/Depo-Provera 1 2 Diaphragm/foam tablets/jelly/cream 1 2 Condom 1 2 Norplant 1 2 Contraceptive (unspecified) 1 2 Traditional method 1 2 (specify): _______ Non-penetrative sex 1 2 Herbs 1 2 Male sterilization 1 2 Female sterilization 1 2 Safe days/abstinence 1 2 Emergency contraception 1 2 Nat. contraceptive/billing method 1 2 Withdrawal 1 2 Don’t know/don’t remember 98 655 Have you ever tried to abort a pregnancy? 1 Yes 2 No Skip to Q. 660 98 Don’t know/don’t remember Skip to Q. 660 656 Was the abortion successful? 1 Yes 2 No 98 Don’t know/don’t remember 657 How did you abort the pregnancy? Yes No At health center/hospital 1 2 Herbal drink 1 2 Chloroquine tablets 1 2 Washing powder solution 1 2 Ash solution 1 2 Soaked blue gum leaf 1 2 Red and black capsules 1 2 Other (specify): _____________ 88 658 Did either of your parents or an adult family member know about the abortion? 1 Yes 2 No 98 Don’t know/don’t remember A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 418 Instrument 12: Comprehensive Youth Survey Page 46 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 659 How many times have you tried to abort a pregnancy? No. __________ 660 Has anyone you know ever tried to abort a pregnancy? 1 Yes 2 No Skip to Q. 664 98 Don’t know/don’t remember Skip to Q. 664 661 How did she try to abort her last pregnancy? (Write in.) ____________________ 662 Has anyone you know died trying to abort a pregnancy? 1 Yes 2 No Skip to Q. 664 98 Don’t know/don’t remember Skip to Q. 664 663 How many? Number died: __________ 664 In your opinion, how common is abortion in your area among teenage girls that get pregnant? 1 Not common 2 Somewhat common 3 Very common 98 Don’t know (Read to respondent) Now I would like to ask you some questions about your last sexual partner. By partner, I mean someone whom you consider a boyfriend or girlfriend, or husband or wife, or someone with whom you had sexual intercourse, even if only once. I do not need to know this person’s name, but please tell me the person’s initials, or you can make up some initials if you like. 665 What are the initials of your last partner? Most recent partner’s initials: __ __ 666 When did you start your relationship with __? Month/year: __ __ /__ __ 667 Is __ __ still your partner? 1 Yes Skip to Q. 669 2 No 668 When did the relationship end? Month/year: __ __ /__ __ 669 Where did you meet __ __? (Write in.) ____________________ 670 What is/was your relationship to ___ ___? 1 Fiancé 2 Boyfriend/girlfriend 3 Family member 4 Teacher 5 Friend 6 Employer 7 Stranger 8 Other (specify): _____________ 419 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 47 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 671 Why are/were you with ___ ___? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Companionship 1 2 Love 1 2 Sex/pleasure 1 2 Money 1 2 Gifts/food 1 2 Security 1 2 Children 1 2 Hope to marry/married 1 2 Other (specify): _____________ 88 672 Why do you think ___ ___ is/was with you? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Companionship 1 2 Love 1 2 Sex/pleasure 1 2 Money 1 2 Gifts/food 1 2 Security 1 2 Children 1 2 Hope to marry/married 1 2 Other (specify): _____________ 88 673 Have you had sexual intercourse with ___ ___? 1 Yes 2 No Skip to Q. 683 674 How long had you known ___ ___ before you two had sexual intercourse? No: ______________ days or ______________ months or ________ years 98 Don’t know/don’t remember 675 How confident are you that you could convince ____ ___ to use or let you use a condom? 1 Very confident 2 Fairly confident 3 Not confident 98 Don’t know 676 The last time you had sexual intercourse with ___ ___, did either of you use a contraceptive method? 1 Yes 2 No Skip to Q. 679 98 Don’t know/don’t remember Skip to Q. 679 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 420 Instrument 12: Comprehensive Youth Survey Page 48 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 677 What method(s) did you or your partner use? Yes No Pill 1 2 IUD 1 2 Injectable/Depo-Provera 1 2 Diaphragm/foam tablets/ 1 2 jelly/cream Condom 1 2 Norplant 1 2 Contraceptive (unspecified) 1 2 Traditional method 1 2 (specify): ________ Non-penetrative sex 1 2 Herbs 1 2 Male sterilization 1 2 Female sterilization 1 2 Safe days/abstinence 1 2 Emergency contraception 1 2 Nat. contraceptive/ 1 2 billing method Withdrawal 1 2 Don’t know/don’t remember 98 678 (If a condom was used) What are the reasons you used a condom? (Circle all that apply.) Yes No HIV/AIDS prevention 1 2 STI prevention 1 2 Partner wanted to use it 1 2 Prevent pregnancy 1 2 Don’t know/don’t remember 98 Other (specify): _____________ 88 679 Have you ever used a condom with __ __ ? 1 Yes 2 No Skip to Q. 681 680 How frequently do/did you use a condom with ___ __? 1 Never 2 Once/twice 3 Sometimes 4 Almost every time 5 Every time 421 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 49 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) 681 The last time you had sex, who made the decision to use a contraceptive, you or ___ ___ 1 Self 2 Partner 3 Both 4 Other(specify): _____________ 98 Don’t know/don’t remember 682 The first time you had sex with ___ ___ did you want to have sex, did it just happen, or were you forced? 1 Wanted 2 Just happened 3 Forced 88 Other (specify): _____________ 98 Don’t know/don’t remember 683 What are/were your future intentions with ___ ___? 0 None 1 Marriage 2 Cohabitation without marriage 98 Don’t know 4 Other(specify): __________________ 684 How confident are/were you that you could ask ___ ___ about his/her other sexual partners? 1 Very confident 2 Fairly confident 3 Not confident 98 Don’t know 685 How confident are/were you that you could ask ___ ___ if he/she is/was faithful to you? 1 Very confident 2 Fairly confident 3 Not confident 98 Don’t know 686 Have/had you ever talked to ___ ___ about (read list): Yes No Avoiding/delaying sex 1 2 Being faithful 1 2 Ways to avoid pregnancy 1 2 Use of condoms to avoid AIDS 1 2 Use of condoms to avoid 1 2 other STIs 687 Have you ever encountered any resistance from your partner in negotiating contraceptive/condom use? 1 Yes 2 No 98 Don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 422 Instrument 12: Comprehensive Youth Survey Page 50 of 71 Module 6: Sexual Activity, Contraception and Pregnancy (continued) Same-Sex Partners (QUESTIONS 688–694 ARE TO BE ASKED OF MALES ONLY) 688 Have you ever had sexual contact with another male? 1 Yes 2 No Skip to Q. 701 98 Don’t know/don’t remember 689 Have you ever had anal intercourse with another male? 1 Yes 2 No Skip to Q. 693 98 Don’t know/don’t remember 690 If so, did you or your partner use a condom? 1 Yes 2 No 98 Don’t know/don’t remember 691 Have you had anal intercourse with another male within the last month? 1 Yes 2 No Skip to Q. 693 98 Don’t know/don’t remember Skip to Q. 693 692 If so, did you or your partner use a condom? 1 Yes 2 No 98 Don’t know/don’t remember 693 Are you currently in a same-sex relationship? 1 Yes 2 No Skip to Q. 701 98 Don’t know Skip to Q. 701 694 If so, how often do you or your partner use a condom? 1 Always 2 Almost always 3 Not very often 4 Almost never 5 Never 423 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 51 of 71 Module 7: Skills and Self-Efficacy (Read to respondent) Now I want to ask you how confident you are that you could do certain things. As I read each question, tell me if you think you definitely could, probably could, probably could not or definitely could not do each of the things listed below. If you did not want to have sex, how confident are you that you would be able to refuse sexual intercourse: 701 With a person you have known for a few days? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 702 With a person you have known for more than three months? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 703 With a person who offers you gifts? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 704 With a person you care about deeply? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 705 With a person who has paid for your school or training fees and who demands sex? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 706 With someone who has power over you, like a teacher or employer? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 424 Instrument 12: Comprehensive Youth Survey Page 52 of 71 Module 7: Skills and Self-Efficacy (continued) How confident are you that you would be able to: 707 Have a sexual relationship with only one person for six months? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know How confident are you that you would be able to: 708 Choose with whom to have sex? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 709 Avoid sex any time you didn’t want it? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know How confident are you that you can: 710 Use a condom correctly? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 711 Use a condom every time you had sexual intercourse? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 712 Use a condom during sex after you had been drinking/taking drugs? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 425 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 53 of 71 Module 7: Skills and Self-Efficacy (continued) 713 Insist on condom use during sex even if your boyfriend or girlfriend does not want to use one? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 714 Refuse to have sex if your boyfriend or girlfriend will not use a condom? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know How confident are you that you can: 715 Get the money to buy condoms any time you want? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 716 Buy condoms in a store? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 717 Discuss contraceptives with a reproductive health provider? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 718 Discuss STIs/HIV/AIDS with a reproductive health provider? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 719 Discuss pregnancy and related problems with a reproductive health provider? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 426 Instrument 12: Comprehensive Youth Survey Page 54 of 71 Module 7: Skills and Self-Efficacy (continued) 720 Discuss abortion with a reproductive health provider? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 721 Discuss menstruation/wet dreams with a reproductive health provider? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know How confident are you that you can: 722 Visit a reproductive health clinic? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 723 Attend a sex education class? 0 Definitely could not 1 Probably could not 2 Probably could 3 Definitely could 98 Unsure/don’t know 427 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 55 of 71 Module 8: Leisure Activities and Concerns 801 Do you attend a church, temple, mosque or other religious site? 1 Yes 2 No 802 How often do you attend a church, temple, mosque or other religious site? 1 More than once per week 2 Once per week 3 Once per month 4 Other (specify): _____________ 98 Don’t know/don’t remember 803 Do you consider yourself a religious person? 1 Yes 2 No 98 Don’t know 804 Have you ever been to a youth event or program at a church, temple, mosque or other religious site? 1 Yes 2 No Skip to Q. 806 98 Don’t know/don’t remember Skip to Q. 806 805 What was the name of the event and the religious site? Event/program: ________________________________ Name of religious site: _______________________________ 806 During the past six months, did you and a friend(s) talk about (read each topic): Yes No Don’t know Nutrition 1 2 98 Ways to prevent pregnancy 1 2 98 Condoms 1 2 98 Not having sex 1 2 98 HIV/AIDS 1 2 98 STIs 1 2 98 807 Has a peer educator ever talked to you? 1 Yes 2 No Skip to Q. 815 98 Don’t know/don’t remember Skip to Q. 815 808 Where did the peer educator talk to you? (Circle all that apply.) Yes No Market 1 2 Bus stop 1 2 School 1 2 College/university 1 2 Club 1 2 Clinic 1 2 Neighborhood 1 2 Home 1 2 Friend’s home 1 2 Shop 1 2 Other (specify): _____________ 88 A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 428 Instrument 12: Comprehensive Youth Survey Page 56 of 71 Module 8: Leisure Activities and Concerns (continued) 809 What topics did you discuss? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Contraception 1 2 Body changes/anatomy 1 2 HIV/AIDS 1 2 Sexually transmitted infections 1 2 Health center/clinic services 1 2 Relationship with 1 2 boyfriend/girlfriend Other (specify): _____________ 88 810 Was the peer educator (read each topic): Yes No Don’t know Knowledgeable 1 2 98 Polite 1 2 98 Patient 1 2 98 Someone who can keep secrets 1 2 98 Respectful 1 2 98 Friendly 1 2 98 A good listener 1 2 98 Understanding 1 2 98 Able to give advice 1 2 98 Able to solve problems 1 2 98 811 Did the peer educator refer you to any other services? 1 Yes 2 No Skip to Q. 813 98 Don’t know/don’t remember Skip to Q. 813 812 Where were you referred to? 813 Would you talk with a peer educator again? 1 Yes Skip to Q. 815 2 No 98 Don’t know/don’t remember Skip to Q. 815 814 Why not? (Circle all that apply.) Yes No Made me feel unwelcome 1 2 Scolded me 1 2 Made me feel ashamed 1 2 Did not provide me with 1 2 necessary treatment Did not seem knowledgeable 1 2 Did not seem interested in 1 2 working with me Did not provide me with 1 2 needed information Other (specify): _____________ 88 429 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 57 of 71 Module 8: Leisure Activities and Concerns (continued) 815 What services or information do peer educators provide that you think are most useful? (Probe by asking, “Anything else?” and circle all that apply.) Yes No Contraceptive information 1 2 Counseling 1 2 Pregnancy/prenatal care 1 2 information STI/HIV prevention 1 2 information Supply condoms 1 2 (specify brand): __________ Supply local newspaper 1 2 Other (specify): _____________ 88 Don’t know 98 816 Now I am going to read a list of activities. Please tell me which of these you have ever done. Who did you do each activity with? Female friends Male friends Fiancée/ girlfriend/ boyfriend Family members A Go to the beach Y N B Go to the gardens Y N C Go to the disco Y N D Go shopping Y N E Go to the bungalows Y N F Rent a hotel room Y N G Go to restaurants Y N H Go to snack bars Y N I Attend parties Y N J Attend religious ceremonies Y N K Go to the cinema Y N L Go to community centers/clubs/ youth centers Y N M Go to video centers Y N N Go to massage parlors Y N O Spend the night out with your friends Y N P Go to strip shows/night clubs Y N Q Go to beer houses/bars Y N R Attend sports events Y N S Spend time with family Y N T Help with household chores Y N U Go to live drama/concert parties Y N A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programs 430 Instrument 12: Comprehensive Youth Survey Page 58 of 71 Module 8: Leisure Activities and Concerns (continued) 817 Which person in your immediate environment would you consider to be a role model? 1 Parent/parent figure 2 Other adult relative 3 Sibling 4 Teacher 5 Same-sex friend 6 Opposite-sex friend 7 Older friend/senior 8 Other: ___________ 818 Do you believe that religion shapes your attitudes about sexuality? 1 Definitely 2 Very much 3 Pretty much 4 Not very much 5 Definitely not In the past three months, how often have the following been true for you? RESPONSE CODES: 1 Never 2 One to three times 3 Four to six times 4 More than six times Response code 819 Feeling lonely, depressed _______ 820 Feeling worried, not sleeping well or at all _______ 821 Feeling mentally incoherent and over-stressed _______ 822 Being bored with life and the world around you _______ 823 Feeling befuddled; having a headache with no obvious cause _______ 824 Being absent-minded _______ 825 Wanting to run away from home _______ 431 Part II: Instruments and Questionnaires Instrument 12: Comprehensive Youth Survey Page 59 of 71 Module 8: Leisure Activities and Concerns (continued) How well do each of the following statements describe your feeling about yourself? 1 Not well at all 2 Somewhat well 3 Fairly well 4 Extremely well 826 You feel like you have a number of good things 827 You feel like you are as important to your family as other members 828 You ever feel like you are capable of doing as many things as other people 829 You hardly ever feel proud of yourself 830 Whatever you do and wherever you are, you can make yourself happy 831 You are not satisfied with the relationships you have with the people surrounding you 832 You always know your own strengths and weaknesses 833 You feel like many things you do are not very personally meaningful 834 You feel

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