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AFGHANISTAN DEMOGRAPHIC AND HEALTH SURVEY 2015 HOUSEHOLD QUESTIONNAIRE

CENTRAL STATISTICS ORGANIZATION AND MINISTRY OF PUBLIC HEALTH

IDENTIFICATION

PROVINCE

DISTRICT

VILLAGE/NAHIA

CONTROLLER AREA

CLUSTER NUMBER

TYPE OF LOCATION

URBAN=1
RURAL=2

STRUCTURE/BUILDING NUMBER/GATE NUMBER

HOUSEHOLD NUMBER

NAME OF HOUSEHOLD HEAD

HOUSEHOLD SELECTED FOR MALE SURVEY?

YES=1
NO=2

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER’S NAME
RESULT

RESULT CODING:

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NO A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER_________

NEXT VISIT
DATE
TIME

SECOND VISIT
DATE
INTERVIEWER’S NAME
RESULT

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER’S NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NO.
RESULT

TOTAL NUMBER OF VISITS

TOTAL PERSONS IN HOUSEHOLD

TOTAL ELIGIBLE WOMEN

TOTAL ELIGIBLE MEN

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

LANGUAGE OF INTERVIEW

DARI 1
PASHTO 2
OTHER________6

NATIVE LANGUAGE OF RESPONDENT

DARI 1
PASHTO 2
OTHER________6

TRANSLATOR USED?

YES 1
NO 2

SUPERVISOR
NAME

FIELD EDITOR
NAME

OFFICE EDITOR
NAME

KEYED BY
NAME

INTRODUCTION AND CONSENT

As-salamu alaykum. My name is _______________________________________. I am working with Central Statistics Organization. We are conducting a survey about health all over Afghanistan, which is conducted with the joint effort of the Ministry of Public Health and Central Statistics Organization. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don’t have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don’t want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

Do you have any questions?
May I begin with the interview now?

SIGNATURE OF INTERVIEWER:__________________________
DATE:____________

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 1A)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED (END)

1A. RECORD THE TIME.

HOUR____
MINUTES____

1. LINE NO. ____

2. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

2A) Just to make sure that I have the complete listing: are there any other persons such as small children or infants that we have not listed?

YES (ADD TO TABLE)
NO

2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?

YES (ADD TO TABLE)
NO

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

YES (ADD TO TABLE)
NO

3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

RELATIONSHIP___

CODING:
01 HEAD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED/FOSTER/STEPCHILD
11 NOT RELATED
98 DON’T KNOW

4. SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

5. RESIDENCE: Does name usually live here?

YES 1
NO 2

6. Did (NAME) stay here last night?

YES 1
NO 2

7. AGE: How old is (NAME)? IF 95 OR OLDER, RECORD ‘95’.

IN YEARS____

8. IF AGE 15 OR OLDER: MARITAL STATUS: What is (NAME)’s current marital status?

STATUS__

CODING:
1 MARRIED
2 DIVORCED/SEPARATED
3 WIDOWED
4 NEVER-MARRIED

9. ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49, MARRIED, WIDOWED, OR DIVORCED/SEPARATED.

10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-49, MARRIED, WIDOWED, OR DIVORCED/SEPARATED.

11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.

IF AGE 0-17 YEARS
12. SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS: Is (NAME)’s natural mother alive?

YES 1
NO 2 (GO TO 14)
DON’T KNOW 8 (GO TO 14)

13. Does (NAME)’s natural mother usually live in this household or was she a guest last night?

IF YES: What is her name? RECORD MOTHER’S LINE NUMBER.
IF NO, RECORD ‘00’.

LINE NUMBER___

14. Is (NAME)’s natural father alive?

YES 1
NO 2 (GO TO 16)
DON’T KNOW 8 (GO TO 16)

15. Does (NAME)’s natural father usually live in this household or was he a guest last night?

IF YES: What is his name? RECORD FATHER’S LINE NUMBER.
IF NO, RECORD ‘00’.

LINE NUMBER___

IF AGE 5 YEARS OR OLDER
16. EVER ATTENDED SCHOOL: Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 17A)

17. What is the highest grade (NAME) completed at school?

GRADE___

CODING:
00 LESS THAN GRADE 1 COMPLETED
01 to 12 GRADE 1-GRADE 12
13 BACHELOR’S AND ABOVE
98 DON’T KNOW

(GO TO 18)

17A. Why did (NAME) never attend school?

REASON__

CODING:
1 TOO EXPENSIVE
2 SCHOOL TOO FAR
3 INSECURE
4 NEED TO HELP AT HOME
5 PARENTS DID NOT SEND
6 GOT MARRIED
7 SCHOOL LACKED BASIC FACILITIES
8 NEED TO WORK/EARN
9 OTHER

(GO TO NEXT LINE)

IF AGE 5-24 YEARS
18. CURRENT/RECENT SCHOOL ATTENDANCE: Did (NAME) attend school at any time during the (1394) school year?

YES 1
NO 2 (GO TO 19A)

19. During this/that school year, what grade [is/was] (NAME) attending?

GRADE___

CODING:
00 LESS THAN GRADE 1 COMPLETED
01 TO 12 GRADE 1-GRADE 12
13 BACHELOR’S AND ABOVE
98 DON’T KNOW

(GO TO NEXT LINE)

19A. Why did (NAME) not attend school in 1394 school year?

REASON__

CODING:
1 TOO EXPENSIVE
2 SCHOOL TOO FAR
3 INSECURE
4 NEED TO HELP AT HOME
5 PARENTS DID NOT SEND
6 GOT MARRIED
7 SCHOOL LACKED BASIC FACILITIES
8 NEED TO WORK/EARN
9 OTHER

(GO TO NEXT LINE)

IF AGE 0 TO 4 YEARS
20. BIRTH REGISTRATION: Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)’s birth ever been registered with the civil authority?

RESPONSE__

CODING:
1 HAS CERTIFICATE
2 REGISTERED
3 NEITHER
8 DON’T KNOW

HOUSEHOLD CHARACTERISTICS
101. How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5

102. What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STAND PIPE 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 105)
TANKER TRUCK 61
CART WITH SMALL TANK/DRUM 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER______96

103. Where is that water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

104. How long does it take to go there, get water, and come back?

MINUTES____
DON’T KNOW 998

105. Do you do anything to the water to make it safer to drink?

YES 1
NO 2 (GO TO 107)
DON’T KNOW (GO TO 107)

106. What do you usually do to make the water safer to drink? Anything else? RECORD ALL MENTIONED.

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER________X
DON’T KNOW Z

107. What kind of toilet facility do members of your household usually use?

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON’T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
TRADITIONAL DRY VAULT TOILET
SINGLE VAULT 51
DOUBLE VAULT 52
ECO SANITATION 61
NO FACILITY/BUSH/FIELD 71 (GO TO 110)
OTHER________96

108. Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 110)

109. How many households in total use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10____
10 OR MORE HOUSEHOLDS 95
DON’T KNOW 98

110. Does your household have:

Electricity?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A mobile telephone?
YES 1
NO 2
A landline telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
A table?
YES 1
NO 2
A chair?
YES 1
NO 2
A sofa?
YES 1
NO 2
A bed?
YES 1
NO 2
A cupboard?
YES 1
NO 2
A stand fan?
YES 1
NO 2
A generator?
YES 1
NO 2
A sewing machine?
YES 1
NO 2
A computer?
YES 1
NO 2

111. What type of fuel/energy does your household mainly use for cooking?

ELECTRICITY 01
LPG/CYLINDER 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11

NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER__________96

112. Is the cooking usually done in the house, in a separate building, or outdoors?

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 114)
OUTDOORS 3 (GO TO 114)
OTHER________6 (GO TO 114)

113. Do you have a separate room which is used as a kitchen?

YES 1
NO 2

114. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
MUD AND HAY 13
RUDIMENTARY FLOOR
WOOD PLANKS 21
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 33
RUGS/MAT 35
CARPET 36
OTHER________96

115. MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/BUSHES/GRASS 12
SOD/MUD WITH GRASS 13
RUDIMENTARY ROOFING
RUSTIC MAT 21
MUD AND HAY 22
WOOD PLANKS 23
CARDBOARD/CLOTH/TENT 24
FINISHED ROOFING
METAL 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
OTHER______96

116. MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
PREPARED MUD 12
DIRT 13
RUDIMENTARY WALLS
HAY WITH MUD 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD/CLOTH/TENT 25
REUSED WOOD 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER__________96

117. How many rooms in this household are used for sleeping?

ROOMS____

118. Does any member of this household own:

A watch?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or moto scooter?
YES 1
NO 2
An animal drawn cart?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A tractor?
YES 1
NO 2
A rickshaw?
YES 1
NO 2

119. Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 121)

120. How many jerib of agricultural land do members of this household own?
IF LESS THAN 1, RECORD ‘000’.
IF 950 OR MORE, WRITE ‘950.

JERIB_____
DON’T KNOW 998

121. Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
NO 2 (GO TO 123)

122. How many of the following animals does this household own?

IF NONE, ENTER ‘00’.
IF 95 OR MORE, ENTER ‘95’.
IF UNKNOWN, ENTER ‘98’.

Milk cows or bulls?
COWS/BULLS____
Cattle?
CATTLE____
Horses, donkeys, or mules?
HORSES/DONKEYS/MULES____
Goats?
GOATS____
Sheep?
SHEEP____
Camels?
CAMEL____
Chickens?
CHICKENS____
Ducks?
DUCKS____

123. Does any member of this household have a bank account?

YES 1
NO 2

123A. Has any member of this household been diagnosed with cancer?

YES 1
NO 2 (GO TO 126)

123B. What type of cancer has been diagnosed?

BREAST CANCER A
LUNG CANCER B
LIVER CANCER C
DUODENAL CANCER D
CERVICAL CANCER E
OTHER________X
DON’T KNOW Z

123C. Has any member of this household died due to cancer in the last 3 years?

YES 1
NO 2 (GO TO 126)

123D. What type of cancer caused the death of your household member(s) in the last 3 years?

BREAST CANCER A
LUNG CANCER B
LIVER CANCER C
DUODENAL CANCER D
CERVICAL CANCER E
OTHER________X
DON’T KNOW Z

126. Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 137)

127. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD ‘7’.

NUMBER OF NETS___

128. ASK RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2

129. How many months ago did your household get the mosquito net?
IF LESS THAN A MONTH AGO, RECORD ‘00’.

MONTHS AGO___
MORE THAN 36 MONTHS AGO 95
NOT SURE 98

130. TYPE OF MOSQUITO NET. IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

INSECTICIDE-TREATED NET (LLIN)
PERMANET 11 (GO TO 134)
OLYSET NET 12 (GO TO 134)
OTHER/DON’T KNOW BRAND 16 (GO TO 134)
PRETREATED NET 21 (GO TO 132)
OTHER BRAND 96
DON’T KNOW BRAND 98

131. When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

YES 1
NO 2
NOT SURE 8

132. Since you got the net, was it ever soaked or dipped in a liqued (insecticide) to kill or repel mosquitoes?

YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)

133. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD ‘00’.

MONTHS AGO___
MORE THAN 24 MONTHS AGO 95
NOT SURE 98

134. Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 136)
NOT SURE 8 (GO TO 136)

135. Who slept under this mosquito net last night?
RECORD THE PERSON’S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME_______________
LINE NO.____

136. GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

137. Please show me where members of your household most often wash their hands.

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 140)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 140)
NOT OBSERVED, OTHER REASON 4 (GO TO 140)

138. OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE PLACE FOR HAND WASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

139. OBSERVATION ONLY: OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

SOAP OR DETERGENT (BAR, LIQUID, POWDER, PASTE) A
ASH, MUD, SAND B
NONE C

140. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE.

IODINE PRESENT 1
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON)____________6

141. TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.

NAME OF SELECTED WOMAN______________________
HH LINE NUMBER OF SELECTED WOMAN___

141A. RECORD THE TIME.

HOUR___
MINUTES____