1-Form Number
2-Date of Survey
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Identification of the School:
3-Name of the District
1. Gnidjazoun
2. Avogbana
3. Sodohomè
4. Saclo
5. Ouassaho
6. Agongointo
7. Lissèzoun
8. Bohicon I
9. Bohicon II
10. Passagnon
4-Name of the School
1-CEG1
2-CEG2
3-CEG3
4-CEG4
5-CEG5
6-CEG6
7-CEG Avogbanan
8-CEG Gnidjazoun
9-CEG Saclo
10-LYTEB
11-Hélios
12-St thomas d’Acquin
13-Trinité
14-JJ Rousseau
15-Triomphe du Roi
16-Providence IKM
17-CEG Passagon
5-Respondent
1-Case
2-Control
Sociodemographic Characteristics
6-How old are you?
Years
7-What type of family do you live in?
1. Monogamous (father + one wife)
2. Polygamous (father with multiple wives)
3. Blended (one biological parent + one guardian)
4. Single-parent (only one parent)
5-Other, please specify...
………….
8-What is your birth order in your siblings?
1. First
2. Second
3. Third
4. Other, please specify …………….
9-What is your marital status?
1. Single
2. Common-law (living together without marriage)
3. Traditional marriage
10-What is your father's level of education?
1. No education
2. Primary level
3. Secondary level
4. Higher education
11-What is your mother's level of education?
1. No education
2. Primary level
3. Secondary level
4. Higher education
12-What is your current level of education?
1. 6th grade
2. 5th grade
3. 4th grade
4. 3rd grade
5. 2nd grade
6. 1st grade
7. Senior year (Tle)
13-In which area do you reside?
1- Bohicon I
2- Bohicon II
3- Gnidjazoun
4- Avogbana
5- Sodohomè
6- Saclo
7- Ouassaho
8- Agongointo
9- Lissèzoun
10- Passagnon
11- Other, please specify...
14-Who do you live with?
1. Father only
2. Mother only
3. Both parents
4. Guardians
5. Alone
15-Which of your parents is still alive?
1. Father
2. Mother
3. Both parents
4. None
Sociocultural Characteristics
16-What is your ethnicity?
1. Fon
2. Yoruba
3. Adja
4. Other, please specify...
17-What is your religion?
1. Christianity
2. Islam
3. Indigenous religions
4. Other, please specify...
Biological Characteristics
18-Have you already had your first menstruation?
1. Yes
2. No
19-At what age did you have your first menstruation?
ans
20-What is the date of your last menstruation?
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Socioeconomic Characteristics
21-What is your father's occupation?
1. Farmer
2. Artisan
3. Driver
4. Civil servant
5. Vendor
6. Teacher
7. Other, please specify...
22-What is your mother's occupation?
1. Farmer
2. Craftswoman
3. Vendor
4. Civil servant
5. Teacher
6. Unemployed
7. Other, please specify...
23-How much is your monthly allowance?
FCFA
24-Is this amount sufficient for you?
1. Yes
2. No
25-Who provides you with this money?
1. Parents
2. Your boyfriend
3. Your teachers
4. Other, please specify
26-Do you have another source of income?
1. Yes
2. No
27-If yes, please specify.
1. Parents
2. Your boyfriend
3. Your teachers
4. Income-generating activities
5. Other, please specify...
………….
28-Do you own a personal mobile phone?
1. Yes
2. No
29-If yes, who gave it to you?
1- Your boyfriend
2- Your parents (Father and Mother)
3- Yourself
4- Other, please specify...
30-Socioeconomic well-being assessment scale of the household to which the adolescent belongs:
a. Are you a tenant or a homeowner of the house?
0 = Tenant
1 = Owner
b. Do you have land or a property?
0 = No
1 = Yes
c. What is your source of lighting?
0 = Oil lamp
1 = Battery-powered lamp
2 = Electric power
d. What is your source of cooking energy?
0 = Wood
1 = Charcoal
2 = Kerosene stove
3 = Gas
4 = Electricity
e. What is your means of information?
0 = None
1 = Radio
2 = Television
3 = Both
f. What is your means of communication?
0 = None
1 = Landline phone
2 = Mobile phone
3 = Internet
g. What is your means of transportation?
0 = None
1 = Bicycle
2 = Motorcycle
3 = Car
h. What is your source of water supply?
0 = Well and others (including ponds...)
1 = Pump (Soneb or drilled)
i. How is the floor material of your house?
0 = Sand
1 = Cement
2 = Tiles
j. What type of toilet do you use?
0 = None
1 = Shared
2 = Private traditional
3 = Indoor sanitation
k. What is the roof material of your house?
1 = Straw
2 = Sheet metal
3 = Tile
4 = Slab
l. What materials is your house constructed from?
1 = Bamboo
2 = Adobe (terracotta)
3 = Cement
Total
Characteristics Related to the Adolescent’s Social Environment
31-What is the distance between your home and your school (approximately in kilometers)? Km
Km
32-How do you find this distance?
1 = Close
2 = Average
3 = Far
33-Who takes you to school?
1 = Parents
2 = Yourself
3 = Others
34-By what means?
1 = On foot
2 = Bicycle
3 = Car
4 = Motorcycle taxi
35-Who do you most often receive advice on sexuality from?
1 = Siblings
2 = Guardians
3 = Friends/classmates
4 = Teachers
5 = Boyfriend
6 = Other, please specify...
7 = No one
36-If yes, what kind of advice do they give you?
1 = The importance of preserving virginity until marriage
2 = The benefits of sex for health
3 = The necessity of having a boyfriend
4 = Other, please specify
37-Does anyone in your surroundings advise you to get pregnant?
1 = Yes
2 = No
38-If yes, who?
1 = Biological parents
2 = Siblings
3 = Guardians
4 = Friends/classmates
5 = Teachers
6 = Boyfriend
7 = Other, please specify...
8 = No one
39-Parent-Child Communication Assessment Scale
a. Does your mother, father, or guardian take the time to talk to you alone?
1 = Not at all
2= Sometimes
3= Often
4= Always
b. Do you talk to your mother, father, or guardian about things that are important to you?
1 = Not at all
2= Sometimes
3= Often
4= Always
c. Do you talk to your mother, father, or guardian about your feelings and romantic relationships without fear or embarrassment?
1 = Not at all
2= Sometimes
3= Often
4= Always
d. Do you discuss issues related to sexuality with your mother, father, or guardian?
1 = Not at all
2= Sometimes
3= Often
4= Always
e. When you have difficulties or emotional/financial problems, do you receive support from your parents?
1 = Not at all
2= Sometimes
3= Often
4= Always
Total
40-Parental Control Quality Assessment Scale
a. Does your mother/father or guardian set rules and expect you to follow them?
1 = Not at all
2= Sometimes
3= Often
4= Always
b. Does your mother/father or guardian know how you behave at school?
1 = Not at all
2= Sometimes
3= Often
4= Always
c. Does your mother/father or guardian want you to do your schoolwork every day?
1 = Not at all
2= Sometimes
3= Often
4= Always
d. Do you need permission from your mother/father to go out in the evening during school days?
1 = Not at all
2= Sometimes
3= Often
4= Always
e. When you go out late, do you have to tell your mother/father with whom you are going?
1 = Not at all
2= Sometimes
3= Often
4= Always
f. Do you need to ask your mother/father for permission before planning to go out with your friends on weekends?
1 = Not at all
2= Sometimes
3= Often
4= Always
g. When you stay out late, does your mother/father want you to call?
1 = Not at all
2= Sometimes
3= Often
4= Always
Total
Behavioral Characteristics
41-Have you ever had sexual intercourse at least once in your life?
1 = Yes
2 = No
If no, proceed to question 49 and continue with question 53.
42-At what age did you have your first sexual intercourse?
years
43-Do you have a boyfriend (sexual partner)?
1 = Yes
2 = No
44-If yes, how many?
45-If yes, please indicate their age.
P1 : P2 : P3 :
(Years)
46-What is their profession?
P1
1-Student
2-Student
3-Teacher
4-Craftsman
5-Shopkeeper
6-Unemployed
7-Other to specify
P2
1-Student
2-Student
3-Teacher
4-Craftsman
5-Shopkeeper
6-Unemployed
7-Other to specify
P3
1-Student
2-Student
3-Teacher
4-Craftsman
5-Shopkeeper
6-Unemployed
7-Other to specify
47-How would you describe your relationship with your partner(s)?
P1
1-Transient
2-Serious with no intention of marriage
3-Serious with intention of marriage
P2
1-Passing
2-Serious with no intention of marriage
3-Important with intention of marriage
P3
1-Passing
2-Serious with no intention of marriage
3-Important with intention of marriage
48-In your opinion, what could be the consequences of a pregnancy that occurs in a student under 19 years old?
1 = Sexually transmitted infections
2 = Depression
3 = School dropout
4 = Marginalization
5 = Maternal mortality related to pregnancy
6 = Other, please specify...
49-Do you use contraception?
1 = Yes
2 = No
If no, proceed to question 52.
50-If yes, which method do you use?
1 = Condom
2 = Birth control pills
3 = Intrauterine device (IUD)
4 = Jadelle (forearm implants)
5 = Injectable contraceptives (every 3 months)
6 = Vasectomy
7 = Spermicide
8 = Other
9 = Traditional methods
51-If no, please explain why.
1 = Lack of financial means
2 = Belief that contraceptives cause infertility
3 = Belief that contraceptives cause obesity
4 = Parental prohibition
5 = Partner’s prohibition
6 = Religious prohibition
7 = Lack of knowledge of where to obtain contraceptives
8 = Other, please specify...
52-Do you receive sex education at school?
1-Yes
2-No
53-Do your parents/guardians educate you about sexuality at home?
1-Yes
2-No