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Table 5 Survey items, HIV/AIDS and condom use survey, Toffo county, Benin (June – July 2002).

From: Towards an understanding of barriers to condom use in rural Benin using the Health Belief Model: A cross sectional survey

SURVEY ITEMS RESPONSE CATEGORIES
General knowledge on HIV/AIDS  
1. Have you ever heard about HIV/AIDS Yes/No
2. In your knowledge how severe is HIV/AIDS Deadly, don't know, imaginary, other
3. How could someone get infected by HIV? At least 2, one or no correct answer(s),
4. Who you think are at risk of getting HIV? Everyone/specific groups/Don't know
5. In your knowledge, what are the prevention methods of getting HIV? Abstinence, Fidelity, Condom, Other, Don't know
6. How could you recognize a HIV-infected person? Could not, Cachexia, Other symptoms, Don't know
Beliefs on HIV/AIDS  
7. Do you believe HIV really exists? Yes/No/Don't know
8. Do you think you are at risk of getting HIV? Yes/No/Don't know
9. If no to 8) why? Fidelity/Condom use/Other/Don't know
10. Where you believe HIV originates from? God/Bewitchment/Other/Don't know
11. Do you think one can completely cure from HIV/AIDS? Yes/No/Don't know
12. If yes to 11) how? Medicine/Herbs/Prayers/Other/Don't know
13. How would you rate the protective effect provided by condoms? Complete/Incomplete/Useless/Don't know
14. Does your religion believe HIV exists? Yes/No/Don't know
15. What is the position of your religion towards condom use? Favorable/Unfavorable/Indifferent/Don't know
Behaviors and attitudes  
16. Would you mind taking a HIV screening test if you were asked? Yes / No / Don't know
17. Do you use condoms? Yes / No / No answer
18. If No or No answer to 17) why? Don't like / Only God save / Other
19. How often do you use condoms? Always / Sometimes / Never
20. Did you use condom during the last occasional intercourse? Yes / No
21. Do you encounter any problem using condoms? Yes / No
22. If yes to 21) what type of problems Less lubrificated / Less pleasure / break easily / Other
23. Numbers of sexual partners during the last 12 months  
Socio demographic characteristics  
24. Age Full years
25. Sex Male / Female
26. Marital status Married monogamous / Married polygamous/ Single / Divorced / Widowed / Separated
27. Education (Ability to read) Fluent / With difficulty / Not able to read at all
28. Occupation Student / Farmer /
29. Religion Christianity / Islam / Animist / Other
30. Place (please give the name of your village) Village name
  1. Adapted from the World Health Organization / Global AIDS Program's questionnaire