QUESTIONNAIRE
Introduction
My name is ____________. I am working in research team of ________________. I am here to
study about
______________________________________________________________________________
_____________________________________and you are chosen to participate in this study.
You are selected and included in the study as part of the sample population to complete the
questionnaire designed by the researcher. The information obtained in this study will be used
only for research purposes to generate important information and to achieve changes in the
service utilization.
The study will involve various personal and sensitive issues of individuals. In order to attain
study objectives your good will and kindly participation is needed. Confidentiality is strictly
protected and none of your response will be reported separately. Therefore, there is no need to
tell or write your names or House ID numbers on these questionnaires. It is your right to
participate or to refuse in this study. And you can drop any individual question or the whole
questionnaire. But your participation and contribution in the study is very important to come up
with important findings which may help local health planners to intervene the problem locally.
So please take a few minutes to answer to the questions. Questionnaire code number
_____________________
Do you agree to participate in this study? Yes, continue No, thank you!
Name of the data collector______________________________ Sign__________ Date________
Time started _____________ Time finished ____________
PART I. Socio-demographic and Personal Information
S.N Questions Responses and coding Skip to
Q101 Age _______years
2. Don’t know
Q102 Permanent address 1. Hargeisa town
2. Out of Hargeisa
Q103 Current Marital Status 1. Married
2. Widowed
3. Separated
4. Divorced
Q104 Number of Children you have? _______ children
Q105 Age of first marriage? ________ years
Q106 Educational status 1. No formal education
2. Elementary(1-8 grade)
3. Secondary (9-12 grade)
4. Higher education
Q107 Educational status of your 1. No formal education
Spouse. 2. Elementary(1-8 grade)
3. Secondary (9-12 grade)
4. Higher education
Q108 Occupation 1. Employed
2. Merchant
3. Daily laborer
4. Have no job
5. Others, specify__________________
Q109 Occupation of your spouse? 1. Employed
2. Merchant
3. Daily laborer
4. Have no job
5. Others, specify_______________
Q110 Estimated Monthly income _________________ USD
Q111 Are you any substance user? 1. Yes
2. No
Q113
Q112 If yes, what? 1. Khat
2. Alcohol
( Multiple responses possible) 3. Smoking
4. Drugs
5. Other, specify________________
Q113 Are you in polygamous marriage? 1. Yes
2. No
Q114 Do you have access to mainstream 1. Yes
or social media? 2. No
Part II: - HIV Test related questions
S.N Questions Responses and coding Skip to
Q201 Do you know any place of HIV testing? 1. Yes
2. No
Q202 Is there any discriminatory attitude in 1. Yes
community regarding HIV test? 2. No
Q203 Have you ever done HIV test? 1. Yes
2. No
Q212
Q204 When did you do HIV test? ( __________year)
88. Don’t remember
Q205 When have you made HIV test? 1. Just before marriage (marriage preparation)
2. Long before marriage
3. After marriage
Q206 Why have you made HIV test? 1. Premarital preparation
2. Voluntary counselling and testing (VCT)
3. Provider initiated counseling and testing
4. Because of Sickness (For diagnosis)
5. Blood donation
6. Travel/Visa
7. Other, specify__________________
Q207 Have you been influenced by anyone to 1. Yes
undergo HIV test? 2. No
Q208 If yes, by whom? 1. Spouse
( Multiple responses possible)
2. Family member
3. Friend
4. Health professional
5. Relative
6. Other, specify____________________
Q209 Have you made prior discussion with 1. Yes
anyone to undergo HIV test? 2. No
Q210 If yes, with whom? 1. Spouse
( Multiple responses possible)
2. Family member
3. Friend
4. Health professional
5. Relative
6. Other, specify___________________
Q211 If yes, what was the response? 1. They encouraged you
2. They object you
3. Neutral (No response)
Q212 What was the reason that you didn’t do _________________________________________
HIV test? _________________________________________
_________________________________________
_________________________________________
Q213 Do you think people face discrimination if 1. Yes
they undergo HIV test before marriage? 2. No
Q214 Do you think it is important to undergo 1. Yes
HIV test before marriage? 2. No
Q215 Do you recommend people to have 1. Yes
premarital HIV test? 2. No
Q216 What are reasons for couples not to have _________________________________________
premarital HIV test? _________________________________________
_________________________________________
_________________________________________
Q217 Do you know any person who had HIV test 1. Yes
just before marriage? 2. No
Q218 Does the community encourage or 1. Encourage
discourage premarital HIV test? 2. Discourage
Q219 Does your current partner had ever had 1. Yes
HIV test? 2. No
3. I don’t know
Q220 Have you ever witnessed discriminatory 1. Yes
attitude to People living with HIV? 2. No
Q221 Do you feel confident to ask your spouse to 1. Yes
undergo HIV test? 2. No
Q222 Do you think Health professionals who 1. Yes
made test keep the result confidential? 2. No
Q223 Do you think HIV has treatment? 1. Yes
2. No
Q224 Is it available in Somaliland? 1. Yes
2. No
Part III: - Questions related to HIV knowledge
S.N Questions Responses and coding Skip to
Q301 Consistent use of condoms during sexual intercourse can 1. Yes
reduce the chance of getting HIV 2. No
Q302 Having just one uninfected faithful partner can reduce 1. Yes
the chance of getting HIV 2. No
Q303 Healthy-looking person can have HIV; 1. Yes
2. No
Q304 HIV can be transmitted by mosquito bites 1. Yes
2. No
Q304 A person can become infected by sharing food with a 1. Yes
person who has HIV. 2. No
Q305 Coughing and sneezing do not spread HIV 1. Yes
2. No
Q306 Would not buy fresh vegetables from a shopkeeper or 1. Yes
vendor if they knew that person had HIV? 2. No
Q307 Children living with HIV should not be allowed to 1. Yes
attend school with children who do not have HIV. 2. No