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CONFIDENTIAL


CENTRAL BUREAU OF STATISTICS
KENYA DEMOGRAPHIC AND HEALTH SURVEY 2003
HOUSEHOLD QUESTIONNAIRE

Questionnaire Number:____
FINAL COPY 22 MARCH 2003

IDENTIFICATION

PROVINCE* _________________

NAIROBI 1
CENTRAL 2
COAST 3
EASTERN 4
NYANZA 5
R.VALLEY 6
WESTERN 7
NORTHEASTERN 8

DISTRICT _____________________
LOCATION/TOWN ____________________
SUBLOCATION/WARD _________________
NASSEP CLUSTER NUMBER _______________
KDHS CLUSTER NUMBER __________________
HOUSEHOLD NUMBER _______________________

LOCATION

NAIROBI/MOMBASA/KISUMU 1
NAKURU/ELDORET/THIKA/NYERI 2
SMALL TOWN 3
RURAL 4

NAME OF HOUSEHOLD HEAD _______________

IS HOUSEHOLD SELECTED FOR MAN'S SURVEY ______

YES 1
NO 2

INTERVIEWER VISITS

INTERVIEWER VISIT 1
DATE ______________
INTERVIEWER'S NAME _______________
RESULT** ______________

NEXT VISIT:
DATE ______
TIME _____

INTERVIEWER VISIT 2
DATE ______________
INTERVIEWER'S NAME _______________
RESULT** ______________

NEXT VISIT:
DATE ______
TIME _____

INTERVIEWER VISIT 3
DATE ______________
INTERVIEWER'S NAME _______________
RESULT** ______________

FINAL VISIT
DAY ____
MONTH ____
YEAR (2003) ___
INT. CODE ___
RESULT ____

TOTAL NO. OF VISITS __

TOTAL PERSONS IN HOUSEHOLD __

TOTAL ELIGIBLE WOMEN__

TOTAL ELIGIBLE MEN __

LINE NO. OF RESP. TO HOUSEHOLD QUESTION __

RESULT___
**RESULT CODES:

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

LANGUAGE: ENGLISH

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 NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

__

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.

__________________

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

* CODES FOR Q.3
RELATIONSHIP TO HEAD OF HOUSEHOLD:

__
01 = HEAD
02 = WIFE/HUSBAND/PARTNER
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 = CO-WIFE
10 = OTHER RELATIVE
11 = ADOPTED/FOSTER/ STEPCHILD
12 = NOT RELATED
98 = DOES NOT KNOW

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

M 1
F 2

RESIDENCE

5. 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 AGE 15-49.
STAR * LINE NO. OF THE WOMAN SELECTED FOR Qs. ON VIOLENCE.

9. CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6

9A. CIRCLE LINE NUMBER OF ALL MEN AGE 15-54.
IF HOUSEHOLD NOT SELECTED FOR MAN'S SURVEY, LEAVE BLANK.

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


** Q.10 THROUGH Q.13
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
IN Q.11 AND Q.13, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE

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

YES 1
NO 2 (go to 12)
DK 8 (go to 12)

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

___

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

YES 1
NO 2 (go to 14)
DK 8 (go to 14)

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

___

EDUCATION

IF AGE 4 YEARS OR OLDER

14. Has (NAME) ever attended school?

YES 1
NO 2 (next line)

***CODES FOR Qs.15, 18 AND 20
EDUCATION LEVEL:

0 = NURSERY, KINDERGARDEN
1 = PRIMARY
2 = POST-PRIMARY, VOCATIONAL
3 = SECONDARY, A LEVEL
4 = COLLEGE (MIDDLE LEVEL)
5 = UNIVERSITY
8 = DOES NOT KNOW

EDUCATION GRADE:

00 = LESS THAN 1 YEAR COMPLETED
98 = DOES NOT KNOW

15. What is the highest level of school (NAME) has attended?***
What is the highest grade (NAME) completed at that level? ***

LEVEL ____
GRADE ____

IF AGE 4-24 YEARS

16. Is (NAME) currently attending school?

YES 1 (go to 18)
NO 2

17. During the current school year, did (NAME) attend school at any time?

YES 1
NO 2 (go to 19)

18. During the current school year, what level and grade [is/was] (NAME) attending?

LEVEL ____
GRADE ____

19. During the previous school year, did (NAME) attend school at any time?

YES 1
NO 2 (next line)

20. During that school year, what level and grade did (NAME) attend?

LEVEL ____
GRADE ____

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, lodgers 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 slept 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?

IF VARIES BY SEASON, ASK ABOUT THE CURRENT TIME

PIPED WATER
PIPED INTO DWELLING 11 (skip to 22A)
PIPED INTO COMPOUND/PLOT 12 (skip to 22A)
PUBLIC TAP 13
WATER FROM OPEN WELL
OPEN WELL IN COMPOUND/PLOT 21 (skip to 22A)
OPEN PUBLIC WELL 22
COVERED WELL/BOREHOLE
COVERED WELL IN COMP./PLOT 31 (skip to 22A)
COVERED PUBLIC WELL 32
SURFACE WATER
SPRING 41
RIVER/STREAM 42
POND/LAKE 43
DAM 44
RAINWATER 51 (skip to 22A)
BOTTLED WATER 71 (skip to 23)
OTHER (SPECIFY)_______ 96

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

MINUTES ___
ON PREMISES 996

22A. How frequently is water available from this source?

USUALLY ALWAYS AVAILABLE 1
SEVERAL HOURS PER DAY 2
ONCE OR TWICE A WEEK 3
INFREQUENTLY 4

23. What kind of toilet facility does your household have?

FLUSH TOILET 11
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/BUSH/FIELD 31 (skip to 25)
OTHER (SPECIFY) ____ 96

24. Do you share this toilet with other households?

YES 1
NO 2 (skip to 25)

24A. How many other households use this toilet?

LESS THAN 5 1
5-9 2
10 OR MORE 3

25. Does your household have:

Electricity?
Solar power?
A radio?
A television?
A telephone or mobile phone?
A refrigerator?

ELECTRICITY
YES 1
NO 2
SOLAR
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE/MOBILE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2

25A. How many rooms in your household are used for sleeping?

ROOMS ___

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

ELECTRICITY 01
LPG/NATURAL GAS 02
BIOGAS 03
PARAFFIN/KEROSENE 04
COAL, LIGNITE 05
CHARCOAL FROM WOOD 06
FIREWOOD/STRAW 07
DUNG 08
OTHER (SPECIFY) ______ 96

27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

EARTH/MUD/DUNG/SAND 11
WOOD PLANKS 21
PALM, BAMBOO 22
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) ______ 96

27A. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

GRASS/THATCH/MAKUTI 11
TIN CANS 12
CORRUGATED IRON (MABATI) 21
ASBESTOS SHEETS 22
CONCRETE 31
TILES 32
OTHER (SPECIFY) _____ 96

27B. STATE OF REPAIR OF THE DWELLING.
RECORD OBSERVATION.

COMPLETELY DILAPIDATED, SHACK 1
NEEDS MAJOR REPAIRS 2
NEEDS NO OR MINOR REPAIRS 3
BEING REPAIRED NOW 4
UNDER CONSTRUCTION 5

28. Does any member of your household own:

A bicycle?
A motorcycle or motor scooter?
A car or truck?

BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2

28A Does your household own this structure (house, flat, shack), do you rent it, or do you live here without paying?

OWNS 1
PAYS RENT/LEASE 2
NO RENT, W. CONSENT OF OWNER 3
NO RENT, SQUATTING 4

28B. Does your household own the land on which the structure (house, flat, shack) sits?

OWNS 1
PAYS RENT/LEASE 2
NO RENT, W. CONSENT OF OWNER 3
NO RENT, SQUATTING 4

28C. How does this household dispose of kitchen waste and trash?

REGULAR COLLECTION BY GOV'T 01
INFREQUENT COLLECTION BY GOV'T 02
PAYS FOR PRIVATE COLLECTION 03
COMPOSTED 04
DUMP, BURY, BURN IN COMPOUND 05
DUMP IN STREET/EMPTY PLOT 06
OTHER (SPECIFY) _______ 96

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

YES 1
NO 2 (skip to p.9)

30. How many mosquito nets does your household own?

NUMBER OF NETS ___

31. ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD.

NET SEEN 1
NET NOT SEEN 2

32. How long ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, WRITE '00'

MONTHS AGO __
MORE THAN 3 YRS AGO 96
DK 98

32A. How did your household obtain the net, was it bought or was it given free of charge?
IF FREE, ASK: Was it from a non-governmental organisation or from the government?

BOUGHT 1
FREE FR. NGO 2
FREE FR. GOV 3
NOT SURE 8

33. OBSERVE OR ASK THE SHAPE OF THE NET

CONICAL 1
RECTANGULAR 2
OTHER 3
NOT SURE 8

33A. OBSERVE OR ASK THE COLOR OF THE NET

WHITE 1
BLUE 2
GREEN 3
OTHER 6
NOT SURE 8

34. Since you got the mosquito net, was it ever soaked or dipped in dawa or a chemical to repel mosquitoes or insects?

YES 1
NO 2 (GO TO 34B)
NOT SURE 8 (GO TO 34B)

34A. How long ago was the net last soaked or dipped?
IF LESS THAN 1 MONTH AGO, WRITE '00'.

MONTHS AGO __
MORE THAN 3 YRS AGO 96

34B. Who slept under this mosquito net last night? Anyone else?

WRITE THE LINE NUMBERS FROM THE HOUSEHOLD SCHEDULE.
IF NO ONE SLEPT UNDER THE NET, WRITE '00'.

LINE NO. __

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE NUMBER OF THE ROW YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. THIS IS THE NUMBER OF THE COLUMN YOU SHOULD GO TO. FIND THE BOX WHERE THE ROW AND THE COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE NUMBER OF THE WOMAN WHO WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS. THEN, GO TO COLUMN 8 IN THE HOUSEHOLD SCHEDULE AND PUT A STAR * NEXT TO THE LINE NUMBER OF THE ELIGIBLE WOMAN.

FOR EXAMPLE, IF THE QUESTIONNAIRE NUMBER IS '36716', GO TO ROW '6'. IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE BOX ('2'). SUPPOSE THE LINE NUMBERS OF THE THREE WOMEN ARE '02', '03', AND '07', THEN THE ELIGIBLE WOMAN FOR DOMESTIC VIOLENCE QUESTIONS IS THE SECOND ONE, I.E., THE ONE ON LINE '03'.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)
TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD (COLUMN)

1 2 3 4 5 6 7 8
0 1 2 2 4 3 6 5 4
1 1 1 3 1 4 1 6 5
2 1 2 1 2 5 2 7 6
3 1 1 2 3 1 3 1 7
4 1 2 3 4 2 4 2 8
5 1 1 1 1 3 5 3 1
6 1 2 2 2 4 6 4 2
7 1 1 3 3 5 1 5 3
8 1 2 1 4 1 2 6 4
9 1 1 2 1 2 3 7 5

WEIGHT AND HEIGHT MEASUREMENT-WOMEN AND CHILDREN

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

WOMEN 15-49

36. LINE NO. FROM COL.(8)

_____

37. NAME FROM COL.(2)

_____

38. AGE FROM COL.(7)

YEARS
_____

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49

40. WEIGHT (KILOGRAMS)

_____.__

41. HEIGHT (CENTIMETRES)

_____.__

43. RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

CHILDREN UNDER AGE 6

36. LINE NO. FROM COL.(9)

_____

37. NAME FROM COL.(2)

_____

38. AGE FROM COL.(7)

YEARS ____

39. What is (NAME)'s date of birth?

DAY __
MONTH__
YEAR____

WEIGHT AND HEIGHT OF CHILDREN BORN IN 1998 OR LATER

40. WEIGHT (KILOGRAMS)

____.__

41. HEIGHT (CENTIMETRES)

____._

42. MEASURED LYING DOWN OR STANDING UP

LYING 1
STAND. 2

43. RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

TICK HERE IF CONTINUATION SHEET USED __

HIV TESTING--WOMEN AND MEN

Total Number of Samples___

CHECK COLUMNS (8) AND (9A): WRITE LINE NUMBER, NAME, SEX, AND AGE OF WOMEN 15-49 AND MEN 15-54. THIS PAGE TO BE DESTROYED IN OFFICE BEFORE TEST RESULTS ARE ADDED TO DATA FILE.

44. LINE NO. FROM COL (8) OR (9A)

__

45. NAME FROM COL.(2)

______

46. SEX FROM COL.(4)

M 1
F 2

47. AGE FROM COL.(7)

YEARS ____

48. CHECK AGE IN COL.(47):

15-17 1
18+ 2 (GO TO 51)

49. LINE NO. OF PARENT/RESPONSIBLE ADULT

__

50. READ THE CONSENT STATEMENT TO THE PARENT OR RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN).

AGREES 1
SIGN _____
REFUSES 2
NOT READ 3

51. READ THE CONSENT STATEMENT TO THE WOMAN OR MAN OR YOUTH.
CIRCLE CODE (AND SIGN).

AGREES 1
SIGN _____
REFUSES 2
NOT READ 3

52. SAMPLE RESULT

1 SAMPLE TAKEN
2 REFUSED
3 NOT PRESENT
4 TECH. PROBLEM
6 OTHER (SPECIFY)

53. SAMPLE BAR CODE

PASTE FIRST LABEL HERE
PASTE SECOND LABEL ON FILTER PAPER AND THIRD LABEL ON BLOOD SAMPLE TRANSMITTAL FORM

CONSENT STATEMENT

Hello, my name is _______ . I'm from the Ministry of Health and collaborating with Central Bureau of Statistics. As part of this survey, we are studying HIV among women and men. As you know, HIV is the virus that causes AIDS. The government is trying to find out how common HIV and other sexually transmitted diseases are, so that they can develop programs to prevent HIV and care for those who have it.

We request that you participate in this test by giving a few drops of blood from a finger. For this test, I will use clean, sterile instruments that are completely safe. Blood will be tested later in the laboratory.

To ensure the confidentiality of this test result, no individual names will be attached to the blood sample; therefore, we will not be able to give you the result of your test and no one will be able to trace the test back to you. If you want to know whether you have HIV, I can tell you where you can go to get tested.

Do you have any questions?

I hope you will agree to participate in the HIV/STD testing. But if you decide not to have the test done, it is your right and I will respect your decision.

Will you accept to participate in the HIV/STD test? GO BACK TO COLUMN (51). CIRCLE THE APPROPRIATE CODE AND SIGN.

IF RESPONDENT IS AGE 15-17, ASK PARENT/GUARDIAN:
Now, will you tell me if you accept for (NAME OF YOUTH) to participate in the HIV/STD test? GO TO COLUMN (50). CIRCLE THE APPROPRIATE CODE AND SIGN.
IF PARENT AGREES, READ THE PRECEDING PARAGRAPHS TO YOUTH FOR HIS/HER CONSENT AND RECORD IN COL.(51).

NOTE FOR THE INTERVIEWER:
THE RESPONDENT HAS THE RIGHT TO REFUSE THE HIV TEST, AND THEREFORE SHOULD NOT BE FORCED.