Questionnaire on Sexually Transmitted Infections (STI) and other Reproductive Tract Infections (RTI)

At the age of 15-60 in Male and 15-55 in Female

Welcome.We are research team from Hanoi Medical University, Dermatology Central Hospital and local Family Planning Clinic. This research is conducted to discover the syndrome of Sexually Transmitted Infections and other Reproductive Tract Infections. Thank you so much for spending your time. Please answer exactly our questions, do not hesitate to say right or wrong answer. The Information will be kept confidential and under no circunstances be used by anyone other than for research. Your participation is voluntary and you may refuse or stop at any questions.

Do you have any questions? Do you agree to enter the interview?

Yes
Interviewee Signature

No
Witness Signature (Illiteracy situation)

Province :.............................. District:.............................Commune.................................... Date of interview./............/............Name of interviewer................................................. Comments of interviewer on respondents cooperation .. ........................................................................... ............... I. General Information: Cluster number:.......................................Household code..................................................... Name:..............................................ID number: ...............................................................

CONTENTS
STT QUESTIONS ANSWERS

PART A. GENERAL INFORMATION A1. A2. A3. How old are you? Sex Ethnic group 1. Male 2. Female 1. Kinh 2. Ty 3. Nng 4. Kh me 5. Hoa 6. Ohers( please specify) 1. No religion 2. Christian 3. Buddhism 4. Protestant 5. Others (please specify) 1. Farmer 2. Governement staff 3. Worker 4. Trader 5. Student 6. Housewife 7. Unemployed 8. Driver 9. Fishery 10. Others ( please specify) 1. Illiterate 2. Primary 3. Secondary school 4. High school 5. College or University 6. Post Graduate 1. Unmarried 2. Married, living with partner 3. Separated

A4.

Your religion

A5.

Your occupation

A6.

Your education

A7.

Your marital status at present

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4. Divorced 5. Widowed A8. A9. A10. Year of your first marriage Have you had any children? If yes, How many? Which of the following events have you ever experienced? ( can be many)

How many times Induced abortion Miscarriage Still birth Premature birth Neonatal death 1. Intrauterine device 2. Condom 3. Contraceptive pill 4. Calendar/ mucus method 5. Sterilization 6. Other ( please specify) 7. None 1. Shallow wells 2. Deep tube well 3. Piped water 4. Rain water 5. Pond/ Lake/ River/Stream water 6. Others ( please specify)

A11.

What contraceptive methods are you currently using? ( can be many)

A12.

What source of water do you use? (can be more than one)

PART B: QUESTIONS ABOUT KNOWLEDGE

(NO SUGGESTION)

A13.

What are the sexually transmitted infections diseases? (can be many)

1. 2. 3. 4. 5. 6. 7. 8. 9.

Gonorrhoea Syphilis Hepatitis B Genital herpes Trichomonas Pubic lice Bacterial vaginosis Genital warts HIV/AIDS

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A14.

What are considered suspected symptoms of STI? ( can be many)

10. candidiasis 11. Chlamydia 12. Dont know 13. No answer 1. Abnormal vaginal discharge (female) 2. Urethral discharge (male) 3. Ulcers in the genital, anus 4. Warts in the genital 5. Genital itching 6. Dysuria 7. Lower abdominal pain ( female) 8. Pain during sexual intercourse 9. Bleeding after sexual intercourse 10. Fever 11. Other (please specify) 12. Dont know 13. No answer 1. Bacterial 2. Virus 3. Fungus 4. Other ( please specify) 5. Dont know 6. No answer 1. Bad hygiene 2. Having multiple sex partners 3. Changing sex partners frequently 4. Having sex with prostitute 5. Homosexual 6. Having sex without condom 7. Blood transfusion 8. STI history 9. Having alcohol, drug before sex 10. Other ( please specify) 11. Dont know

A15.

What are possible causes of STI? (can be many)

A16.

What are risk factors of STI? (can be many)

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12. No answer A17. What are routes of transmission? (can be many) 1. Sexual intercourse 2. Blood transfusion 3. Sharing needle 4. Mother to child 5. Sharing clothes, things 6. Oral sex 7. Anal sex 8. Others ( please specify) 9. Dont know 10. No answer 1. Yes 2. No 3. Dont know 4. No answer 1. Infertility 2. Ectopic pregnancy 3. Uterus cancer 4. Premature birth 5. Still birth 6. Miscarriage 7. Neonatal death 8. Neonatal Conjunctivitis 9. Others ( please specify) 10. Dont know 11. No answer 1. Yes 2. No 3. Dont know 4. No answer 1. Safe sex 2. Using condom 3. Being faithful 4. Keep hygiene 5. Others ( please specify)

A18.

Is it necessary to treat the husband/wife/partner of STI patientss? What are the consequences of untreated STI? ( can be many)

A19.

A20.

Can STI be prevented?

A21.

How to prevent?

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A22.

Have you had any gynaecological or social disease during your life? If yes, which disease/ symptoms

A23.

A24. A25.

If yes, how many times? If yes, when was the last episode? Do you have sexual intercourse while having abnormal vaginal discharge? (married female only) Do you have sexual intercourse while having menses? (married female only) Do you use regular vaginal douching as part of your daily ablutions? (married female only) Do you have any other sexual partner except your wife/husband/partner? How many sexual partner do you have? Have you had any abnormal symptoms on Reproductive Tract during the last 6 months? Have you had nay of the following symptoms during the last 6 months?

A26.

A27.

A28. A29. A30.

1. Yes 2. No 3. Dont know .. ...... time(s) ...month(s) 1. Never 2. Sometimes 3. Often 1. Never 2. Sometimes 3. Often 1. Never 2. Sometimes 3. Often 1. Yes 2. No .. 1. No ( go to 42) 2. Yes 1. Abnormal vaginal discharge (female) 2. Urethral discharge (male) 3. Ulcers in the genital and anus 4. Warts in the genital and anus 5. Genital itching 6. Dysuria ( pain during urination) 7. Lower abdominal pain (female) 8. Pain during sexual intercourse 9. Bleeding after sexual intercourse 10. Fever 11. Others ( please specify)

A31.

If No in all options GO TO 42

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A32. A33.

If Yes please continue Did you seek care from any health provider / health facility ? If not, what is ( are) reason(s)? (can be many)

A34.

Where was the first place that you looked for examination or treatment? (choose one only)

A35.

Why did you choose that place as the first one for treatment? (can be many)

A36. A37.

Duration between the first symptom and the first treatment? What was the main symptom(s) that made you seek heathcare? (can be many)

1. No 2. Yes ( Go to 34) 3. It is normal 4. It is shameful 5. Mild, unworthy of medical attention 6. Living far away the health facilities 7. Fear of RTI/STI diagnosis 8. Fear of conflict with husband/wife 9. Others (please specify) 1. Private provider 2. Pharmacy / drug store 3. Commune Health Station 4. District hospital 5. Provincial hospital 6. Central hospital 7. Traditional healer 8. Others (please specify) 1. Confidentiality 2. Convenient 3. Skilled provider /Good equipment 4. Friendly provider 5. Others (please specify) .day(s) 1. Abnormal vaginal discharge (female) 2. Urethral discharge (male) 3. Ulcers in the genital and anus 4. Warts in the genital and anus 5. Genital itching 6. Dysuria ( pain during urination) 7. Lower abdominal pain (female) 8. Pain during sexual intercourse 9. Bleeding after sexual intercourse 10. Fever 11. Others ( please specify)

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QUESTIONS

ANSWERS

A38.

A39.

A40.

A41.

A42.

A43.

A44.

12. Dont know What did you do when the symptoms 1. Stop using drug and retreatment by werent prevented the last provider 2. keep using drug in few days 3. keep using drug with stronger dose 4. Changing drug 5. Changing provider (please specify) 1. No Did you tell anyone about your symptom? (can be many) 2. Friends 3. Parents, sisters, brothers, relatives 4. Husband, partner 5. Others (please specify) If yes, please specify the reasons (can 1. To get sympathy/help be many) 2. To share experiences 3. Others (please specify) 1. Hesitated, ashamed If no, please specify the reason (can be many) 2. Afraid of conflict, divorce 3. Others (please specify) Do you have any following symptoms 1. Abnormal vaginal discharge (female) at present? (can be many) 2. Urethral discharge (male) 3. Ulcers in the genital and anus 4. Warts in the genital and anus 5. Genital itching 6. Dysuria ( pain during urination) 7. Lower abdominal pain (female) 8. Pain during sexual intercourse 9. Bleeding after sexual intercourse 10. Fever 11. Others ( please specify) 12. Dont know How do you think about your health at 1. Good present? 2. Normal 3. Weak 1. Good How do you think about your health during the last 6 months? 2. Normal 3. Weak

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After the interview completed, the surveyor will give the invitation leter to people who have symptoms in 31 & 37 for treatment at health center If they are married, the invitation letter will be given to both them and partner.

Thank you !