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DEMOGRAPHIC AND HEALTH SURVEY-BENIN 2001 - HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

DEPARTMENT

SUB-PREFECTURE/URBAN DISTRICT

RURAL/URBAN MUNICIPALITY

URBAN 1
RURAL 2

TOWN/NEIGHBORHOOD

CLUSTER NUMBER

STRUCTURE NUMBER

HOUSEHOLD NUMBER

NAME OF HEAD OF HOUSEHOLD

MEN'S SURVEY:

YES 1
NO 2

ANEMIA SURVEY:

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER'S NAME____
RESULT ____

NEXT VISIT
DATE___
TIME____

FINAL VISIT
DAY____
MONTH____
YEAR 2001
NAME___
RESULT____

RESULT CODES:

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

TOTAL NUMBER OF VISITS__

TOTAL PERSONS IN HOUSEHOLD___

TOTAL ELIGIBLE WOMEN___

TOTAL ELIGIBLE MEN___

NAME AND LINE NUMBER OF RESPONDENT____

QUESTIONNAIRE USED:

FRENCH 1

LANGUAGE OF INTERVIEW:

FRENCH 1
ADJA 2
BARIBA 3
FON 4
DENDI 5
DITAMARI 6
YORUBA 7
OTHER 8

INTERPRETER:

YES 1
NO 2

SUPERVISOR
NAME___
DATE____

FIELD EDITOR
NAME____
DATE____

OFFICE EDITOR____

KEYED BY____

HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.

1) LINE NUMBER

LINE NUMBER___

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.

NAME___________

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

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
CO-SPOUSE 09
OTHER RELATIVE 10
ADOPTED/FOSTER CHILD 11
NOT RELATED 12
DON'T KNOW 98

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)?

IN YEARS_________

ELIGIBILITY:

8) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

9) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-6

9A) CIRCLE LINE NUMBER OF ALL MEN 15-64 IF YES TO MEN'S SURVEY

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD**

**Q. 10 TO Q. 13
THESE QUESTIONS ARE ABOUT THE CHILD'S BIOLOGICAL PARENTS.
FOR Q. 11 AND Q. 13, RECORD '91' IF THE PARENTS DO NOT LIVE IN THE HOUSEHOLD BUT LIVE IN THE SUB-PREFECTURE;
'92' IF THE PARENTS LIVE IN ANOTHER SUB-PREFECTURE IN BENIN AND
'93' IF THE PARENTS LIVE ABROAD
'98' IF DON'T KNOW

10) Is (NAME)'s natural mother alive?

YES 1
NO 2
DON'T KNOW 8

11) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER

LINE NUMBER____

12) Is (NAME)'s natural father alive?

YES 1
NO 2
DON'T KNOW 8

13) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.

LINE NUMBER___

EDUCATION IF AGE 5 YEARS OR OLDER:

14) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

15) What is the highest level of school (NAME) has attended?***What is the highest grade (NAME) completed at that level?***
IF LEVEL=8, LEAVE "GRADE" BLANK

LEVEL_____
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
GRADE _____
LESS THAN ONE YEAR FINISHED 00
DON'T KNOW 98

IF AGE 5-24 YEARS:

17) Did (NAME) attend school at any time during the 2000-2001 school year, which ended in July 2001?

YES 1
NO 2 (GO TO 19)

18) During this school year, what level and grade (is/was) (NAME) attending?***
IF LEVEL=8, LEAVE "GRADE" BLANK

LEVEL _____
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
GRADE _____
DON'T KNOW 98

19) Did (NAME) attend school at any time during the previous 1999-2000 school year, which ended in July 2000?

YES 1
NO 2 (GO TO NEXT LINE)

20) During this previous school year, what level and grade was (name) attending?***
IF LEVEL=8, LEAVE "GRADE" BLANK

LEVEL_____
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
GRADE_____
DON'T KNOW 98

TOTAL NUMBER OF ELIGIBLE WOMEN IN HOUSEHOLD__

TOTAL NUMBER OF ELIGIBLE CHILDREN UNDER 6 YEARS OLD IN HOUSEHOLD___

TOTAL NUMBER OF ELIGIBLE MEN IN HOUSEHOLD___

TICK HERE IF CONTINUATION SHEET USED___

Just to make sure that I have a complete listing:

1) Are there any other persons such as small children or infants that we have not listed?

YES (ENTER EACH IN TABLE)
NO

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

YES (ENTER EACH IN TABLE)
NO

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

YES (ENTER EACH IN TABLE)
NO

21) What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 23)
PIPED ELSEWHERE 12
PUBLIC TAP/STANDPIPE 13
DUG WELL
WELL WITH MANUAL PUMP 21
PROTECTED WELL 22
UNPROTECTED WELL 23
SURFACE WATER
EQUIPPED SPRING 31
RIVER/BACKWATER/POND 32
RAINWATER IN TANK41
OTHER RAINWATER 42 (GO TO 23)
TANKER TRUCK 51
BOTTLED WATER 61
OTHER (SPECIFY) _____ 96

22) How long does it take you to go there, get water, and come back?

MINUTES____
ON PREMISES 996

22B) How far is the source from your house?

ON PREMISES 1
LESS THAN 1 KILOMETER 2
1 KILOMETER OR MORE 3
DON'T KNOW 8

22C) How often do you stock up on drinking water? Per day? Per week? Per month?
RECORD THE NUMBER OF TIMES PER DAY, PER WEEK, OR PER MONTH

NUMBER OF TIMES PER DAY 1 ___
NUMBER OF TIMES PER WEEK 2___
NUMBER OF TIMES PER MONTH 3___

23) What kind of toilet facility do members of your household usually use?

PIT LATRINE
NON-VENTILATED PIT LATRINE 21
VENTILATED PIT LATRINE 22
FLUSH TOILET 23
SEWAGE SYSTEM 24
HANGING TOILET/HANGING LATRINE 25
BUCKET TOILET 26
NO FACILITY/BUSH 31 (GO TO 24A)
OTHER (SPECIFY) ______ 96

24) Do you share this toilet facility with other households?

YES 1
NO 2

24A) What is the main method of evacuation for the household waste?

PUBLIC REFUSE COLLECTION 11
PRIVATE/NGO REFUSE COLLECTION 12
BURIED13
BURNED 14
IN THE YARD 15
OUTDOORS 16
OTHER (SPECIFY) ______ 96

24B) What is the main method of evacuation for the used water in your household?

CLOSED CANAL 11
OPEN CANAL 12
SEPTIC TANKS 13
CESSPOOL 14
SEWER 15
IN THE YARD 16
OUTDOORS 17
OTHER (SPECIFY) ______ 96

25) Does your household have:

Electricity?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2

26) What type of fuel does your household mainly use for cooking?

WOOD 01
CHARCOAL 02
ELECTRICITY 03
GAS 04
PETROLEUM 05
OTHER (SPECIFY) _____ 96

26A) What type of lighting does your household mainly use?

ELECTRICITY 11
PETROLEUM 21
GAS 22
OIL 31
SOLAR ENERGY 41
COMMUNITY GENERATOR 51
PRIVATE GENERATOR 52
OTHER (SPECIFY) _____ 96

27) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD/PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
TILE 32
CEMENT 33
OTHER (SPECIFY) _____ 96

27B) MAIN MATERIAL OF THE WALLS
RECORD OBSERVATION

NATURAL WALLS
EARTH 11
STONE 12
RUDIMENTARY WALLS
WOOD/PLANKS 21
PALM/BAMBOO 22
FINISHED WALLS
BRICKS 31
PARTLY HARD MATERIAL 32
OTHER (SPECIFY) ______ 96

27C) MAIN MATERIAL OF ROOF
RECORD OBSERVATION.

NATURAL ROOFING
EARTH 11
STRAW 12
RUDIMENTARY ROOFING
WOOD/PLANKS 21
PALM/BAMBOO 22
FINISHED ROOFING
SHEET METAL 31
TILE 32
SLAB 33
OTHER (SPECIFY) _____ 96

28) Does any member of your household have:

A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A canoe?
YES 1
NO 2

29) Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 33)

30) CHECK COLUMNS (6) AND (7):
NUMBER OF CHILDREN UNDER AGE 6 WHO SLEPT IN THE HOUSEHOLD LAST NIGHT

NONE (GO TO 33)
ONE (GO TO 31)
TWO OR MORE (GO TO 32)

31) Did (NAME) sleep under a mosquito net last night?

YES 1 (GO TO 33)
NO 2 (GO TO 33)

32) Did all, some, or none of the children under age 6 who slept in the household last night sleep under a mosquito net?

ALL CHILDREN 1
SOME CHILDREN 2
NONE 3

33) Is there a place to wash your hands in your household?

YES 1
NO 2 (GO TO 35)

34) ASK TO SEE THE PLACE AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT:

WATER/TAP
YES 1
NO 2
SOAP, ASH, OR OTHER CLEANSING AGENT
YES 1
NO 2
BASIN
YES 1
NO 2

IODINE TEST:

35) ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE.
RECORD THE PPM (PARTS PER MILLION)

0 PPM (NO IODINE) 1
7 PPM 2
15 PPM 3
30 PPM 4
NO SALT IN HOUSEHOLD 5 (GO TO 36)

35B) TYPE OF SALT?
RECORD OBSERVATION

TABLE SALT 1
GRANULATED SALT (SOFT OR HARD) 2
PIECED/ROCK SALT 3
OTHER (SPECIFY) ______ 6

35C) CHECK TO SEE IF THE CONTAINER THAT HOLDS THE SALT IS CLOSED OR OPEN. RECORD OBSERVATION.

CLOSED CONTAINER 1
OPEN CONTAINER 2
OTHER (SPECIFY) _____ 6

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT

CHECK COLUMNS 8 AND 9: RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN 15-49 AND ALL CHILDREN UNDER AGE 6.

36) LINE NUMBER FROM 8

LINE NUMBER___

37) NAME FROM COLUMN 2

NAME___

38) AGE FROM COLUMN 7

YEARS ______

39) What is (NAME)'s date of birth?*
[ONLY FOR CHILDREN UNDER AGE 6]

DAY___
MONTH___
YEAR___

40) WEIGHT (KILOGRAMS)

WEIGHT___

41) HEIGHT (CENTIMETERS)

HEIGHT___

42) MEASURED LYING DOWN OR STANDING UP?
[ONLY FOR CHILDREN UNDER AGE 6]

LYING 1
STANDING 2

43) RESULT

MEASURED 1
ABSENT 2
REFUSED 3
OTHER 6

TICK HERE IF CONTINUATION SHEET USED____

CHECK COVER PAGE:

YES TO ANEMIA TEST (GO TO 44)
NO TO ANEMIA TEST (END)

HEMOGLOBIN MEASUREMENT IN WOMEN AGE 15-49 AND CHILDREN BORN IN JANUARY 1996 OR LATER:

44) CHECK COLUMN 38:
[ONLY FOR WOMEN AGE 15-49]

AGE 15-17 1
AGE 18-49 (GO TO 46)

45) LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD "00" IF NOT LISTED ON HOUSEHOLD QUESTIONNAIRE:

LINE NO. OF PARENT/RESPONSIBLE ADULT ___

46) READ CONSENT TO WOMAN/PARENT/RESPONSIBLE ADULT*
CIRCLE CODE AND SIGN

AGREED 1 (SIGN) _____
REFUSED 2 (GO TO NEXT LINE)

47) HEMOGLOBIN LEVEL (G/DL)

G/DL___

48) CURRENTLY PREGNANT?
[ONLY FOR WOMEN 15-49]

YES 1
NO/DON'T KNOW 2

49) RESULT

MEASURED 1
ABSENT 2
REFUSED 3
OTHER 6

* CONSENT STATEMENT

As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that you (and your children born since January 1996) participate in this anemia test and give a few drops of blood from your finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right away after the blood is taken. The results will be kept confidential.

50) CHECK 5, 47 AND 48:
NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT* **

ONE OR MORE (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND CONTINUE WITH Q. 51)

NONE (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND END HOUSEHOLD INTERVIEW)

51) We detected a low level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)). This indicates that (you/NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem. We would like to inform the doctor at ____ about (your condition/the condition of NAME OF CHILD(REN)). This will assist you in obtaining appropriate treatment for the condition. Do you agree that the information about the level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)) may be given to the doctor?

AFTER HAVING READ THE ABOVE DECLARATION, I CERTIFY THAT (NAME) ACCEPTS/DOES NOT ACCEPT THAT THE INFORMATION BE TRANSMITTED FOR THE USUAL RESIDENTS WHO ARE BELOW THE CUTOFF POINT.

52) WOMEN AGE 18-49

NAME OF PERSON WITH HEMOGLOBIN BELOW THE CUTOFF POINT____

AGREES TO REFERRAL?

YES 1
NO 2

53) WOMEN AGE 15-17 AND CHILDREN

NAME OF PERSON WITH HEMOGLOBIN BELOW THE CUTOFF POINT____
NAME OF PARENT/RESPONSIBLE ADULT____

AGREES TO REFERRAL?

YES 1
NO 2

*The cutoff point is 9g/dl for pregnant women and 7 g/dl for children and women who are not pregnant (and who don't know if they are pregnant)

**If more than one woman or child is below the cutoff point, read the statement in Q. 51 to each woman who is below the cutoff point and to each woman/parent/responsible adult of a child who is below the cutoff point.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW
(IF THE QUESTIONNAIRE WAS NOT FILLED OUT, EXPLAIN)

OBSERVATIONS______________

NAME OF INTERVIEWER_____
DATE_____

SUPERVISOR'S OBSERVATIONS
TO BE FILLED OUT AFTER HAVING FINISHED VERIFYING THE QUESTIONNAIRE

OBSERVATIONS__________

NAME OF SUPERVISOR____
DATE____

FIELD EDITOR'S OBSERVATIONS
TO BE FILLED OUT AFTER HAVING FINISHED VERIFYING THE QUESTIONNAIRE

OBSERVATIONS____

NAME OF FIELD EDITOR___
DATE___