LESOTHO DEMOGRAPHIC AND HEALTH SURVEY 2004
HOUSEHOLD QUESTIONNAIRE
PLACE NAME ___________________
NAME OF HOUSEHOLD HEAD ______________
EA NUMBER
HOUSEHOLD NUMBER
FOOTHILLS 2
MOUNTAINS 3
SENQU RIVER VALLEY 4
LERIBE 02
BEREA 03
MASERU 04
MAFETENG 05
MOHALE'S HOEK 06
QUTHING 07
QASHA'S NEK 08
MOKHOTLONG 09
THABA-TSEKA 10
RURAL 2
HOUSEHOLD SELECTED FOR MALE SURVEY
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER'S NAME __________
RESULT* ________
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
NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE _______
TIME _______
FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER ______
RESULT _____
TOTAL PERSONS IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____
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.
(2) USUAL RESIDENT 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?
SPOUSE 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
OTHER RELATIVE 09
DOMESTIC EMPLOYEE 10
HERDBOY 11
ADOPTED/FOSTER/STEPCHILD 12
NOT RELATED 13
DON'T KNOW 98
(4) RESIDENCE: Does (NAME) usually live here or elsewhere in Lesotho outside Lesotho?
ELSEWHERE IN LESOTHO 2 (GO TO 7)
OUTSIDE LESOTHO 3
(5) In which country outside Lesotho does (NAME) lived in (COUNTRY)? ***
SWAZILAND 02
BOTSWANA 03
NAMIBIA 04
ZIMBABWE 05
ZAMBIA 06
MOZAMBIQUE 07
ANGOLA 08
TANZANIA 09
MALAWI 10
OTHER AFRICA 11
UNITED STATES OF AMERICA 12
ASIA 13
EUROPE 14
OTHER 96
DON'T KNOW 98
(6) How long has (NAME) lived in (CONTRY)?
IF LESS THAN 1 YEAR, RECORD 00' RECORD 98' FOR DON'T KNOW.
(7) Did (NAME) stay here last night?
NO 2
(8) SEX: Is (NAME) male or female?
FEMALE 2
ELIGIBILITY
(10) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 WHO ARE USUAL RESIDENTS (COL 5) AND/OR SLEPT THERE LAST NIGHT (COL 8)
01-20
(11) CIRCLE LINE NUMBER OF ALL MEN AGE 15-49 WHO ARE USUAL RESIDENTS (COL 5) AND/OR SLEPT THERE LAST NIGHT (COL 8)
01-20
(12) CIRCLE LINE NUMBER OF ALL CHILREN 0-5 WHO ARE USUAL RESIDENTS (COL 5) AND/OR SLEPT THERE LAST NIGHT(COL 8)
01-20
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS OLD***
(13) Is (NAME)'s natural mother alive?
NO 2 (GO TO 15)
DON'T KNOW 8 (GO TO 15)
(14) IF ALIVE: Does (NAME)'s natural mother live in this household?
If yes: What is her name?
RECORD MOTHER'S LINE NUMBER
(15) Is (NAME)'s natural father alive?
NO 2 (GO TO 17)
DON'T KNOW 8 (GO TO 17)
(16)IF ALIVE: Does (NAME)'s natural father live in this household?
If yes: What is her name?
RECORD FATHER'S LINE NUMBER
(17) Has (NAME) ever attended school?
NO 2 (GO TO NEXT LINE)
(18) What is the highest level of school (NAME) has attended? *****
What is the highest standard/form/year (NAME) completed at that level? ****
LEVEL 2 = VOCATIONAL/TECHNICAL TRAINING AFTER PRIMARY .
LEVEL 3 = SECONDARY/HIGH
LEVEL 4 = VOCATIONAL/TECHNICAL TRAINING AFTER SECONDARY
LEVEL 5 = COLLEGE
LEVEL 6 = GRADUATE/POST GRADUATE
8 = DON'T KNOW 98
STANDARD 01-07 = LEVEL 1 (PRIMARY) .
YEAR 01-06 = LEVEL 2 (VOC/TECHN. AFTER PRIMARY)
FORM 01-05 = LEVEL 3 (SECONDARY/HIGH) .
YEAR 01-06 = LEVEL 4 (VOC/TECHN. AFTER SECONDARY)
YEAR 01-03 = LEVEL 5 (COLLEGE) .
YEAR 01-06 = LEVEL 6 (GRADUATE/POST GRADUATE) .
98= DON'T KNOW
CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS
(19) Is (NAME) currently attending school?
NO 2
(20) During the current school year, did (NAME) attend school at any time?
NO 2 (GO TO 22)
(21) During the school year, what level and standard/form/year is (NAME) attending? ******
LEVEL 2 = VOCATIONAL/TECHNICAL TRAINING AFTER PRIMARY .
LEVEL 3 = SECONDARY/HIGH
LEVEL 4 = VOCATIONAL/TECHNICAL TRAINING AFTER SECONDARY
LEVEL 5 = COLLEGE
LEVEL 6 = GRADUATE/POST GRADUATE
8 = DON'T KNOW 98
(22) During the previous school year, did (NAME) attend school at any time?
NO 2 (GO TO NEXT LINE)
(23) During that school year, what level and standard/form/year did (NAME) attend? ******
LEVEL 2 = VOCATIONAL/TECHNICAL TRAINING AFTER PRIMARY .
LEVEL 3 = SECONDARY/HIGH
LEVEL 4 = VOCATIONAL/TECHNICAL TRAINING AFTER SECONDARY
LEVEL 5 = COLLEGE
LEVEL 6 = GRADUATE/POST GRADUATE
8 = DON'T KNOW 98
YEAR 01-06 = LEVEL 2 (VOC/TECHN. AFTER PRIMARY)
FORM 01-05 = LEVEL 3 (SECONDARY/HIGH) .
YEAR 01-06 = LEVEL 4 (VOC/TECHN. AFTER SECONDARY)
YEAR 01-03 = LEVEL 5 (COLLEGE) .
YEAR 01-06 = LEVEL 6 (GRADUATE/POST GRADUATE) .
98= DON'T KNOW
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?
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?
NO
3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?
NO
24 What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 26)
PIPED INTO SOMEONE ELSE'S YARD/PLOT 13
PUBLIC TAP 14
OPEN WELL IN YARD/PLOT 22 (GO TO 26)
OPEN PUBLIC WELL 23
PROTECTED WELL/BOREHOLE IN YARD/PLOT 32 (GO TO 26)
PROTECTED WELL/BOREHOLE IN SOMEONE ELSE'S YARD/PLOT 33
PROTECTED PUBLIC WELL/BOREHOLE 34
RIVER/STREAM 42
DAM 43
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 26)
OTHER (SPECIFY) _______ 96
25 How long does it take you to go there, get water, and come back?
ON PREMISES 996
26 What kind of main toilet facilities does your household have?
PIT TOILET/LATRINE
VENTILATED IMPROVED PIT (VIP) LATRINE 22
OTHER _______________(SPECIFY) 96
27 Do you share these facilities with other households?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
29 What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02
PARAFFIN 03
COAL, LIGNITE 04
CHARCOAL 05
FIREWOOD, STRAW 06
DUNG 07
CROP WASTE 08
OTHER _____________(SPECIFY) 96
30 MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
BRICK TILES 32
TILES 33
CEMENT 34
CARPET 35
VINYL/LINOLEUM 36
32 Does any member of your household own:
NO 2
NO 2
NO 2
NO 2
NO 2
33 ASK RESPONDENT FOR A TEASPOONFUL OF SALT.
TEST SALT FOR IODINE:
RECORD PPM (PARTS PER MILLION).
BELOW 15 PPM 2
ABOVE 15 PPM (STRONG COLOR) 3
NO SALT IN HH 4
SALT NOT TESTED ________________ (SPECIFY REASON) 5
34 What is the name of the nearest health facility that provides health services to this community?
DON'T KNOW 99998 (GO TO 37)
35 How do you get from here to (HEALTH FACILITY NAME)?
MOTORCYCLE/SCOOTER 02
BICYCLE 03
HORSE/DONKEY/MULE 04
SCOTCH CART 05
WALKING 06
OTHER _____________(SPECIFY) 96
36 How long does it take you to get from here to (HEALTH FACILITY NAME)?
MINUTES ___ ___
HEIGHT, WEIGHT, AND HEMOGLOBIN MEASUREMENT
CHECK COLUMNS (10) AND (11): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
WOMEN 15-49
(37)LINE NO. FROM COL. (10)
WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49
(41) WEIGHT (KILOGRAMS)
NOT PRESENT 2
REFUSED 3
TECHN PROB 4
OTHER 6
(37)LINE NO. FROM COL. (10)
(40) What is (NAME)'s date of birth?*
MONTH ___ ___
YEAR ___ ___ ___ ___
WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1999 OR LATER
(41) WEIGHT (KILOGRAMS)
(43) MEAUSRED LYING DOWN OR STANDING UP
STAND 2
NOT PRESENT 2
REFUSED 3
TECHN PROB 4
OTHER 6
TICK HERE IF CONTINUATION SHEET IS USED:
* FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY (SECTION 2), SUCH AS ORPHANS, ADOPTED CHILDREN, ETC.), ASK
DAY, MONTH AND YEAR OF BIRTH. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM Q.215 IN MOTHER'S BIRTH
HISTORY (SECTION 2) AND ASK DAY OF BIRTH.
HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN 1999 OR LATER
(45) LINE NO. FROM COL. (11)
(47) LINE NO. OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUEHOLD SCHEDULE
(48) READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT*
REFUSED 2 (GO TO NEXT LINE)
NOT PRESENT 2
REFUSED 3
TECHN PROB 4
OTHER 6
* INFORMED CONSENT STATEMENT FOR ANEMIA TESTING FOR CHILDREN
As part of this survey, we are studying anemia among women, men and children under age 6 years. 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 request that all children born since 1999 participate in the anemia testing part of this survey by giving a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be taken with new equipment and the results of the test will be given to you immediately after. These results will be kept confidential.
Now I would like to ask that you (and NAME OF CHILD[REN]) agree to participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test done.
(GO TO COLUMN (48), CIRCLE THE APPROPRIATE CODE (AND SIGN).
Consent Statement for Anemia and HIV for Adults
** INTRODUCTION
Hello, my name is_______________. I'm from the Ministry of Health and Social Welfare. As part of this survey, we are studying anemia among women, men and children under age 6 years. 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 are also studying HIV. HIV is the virus that causes AIDS. The government of Lesotho is trying to find out how common HIV is, so that they can develop programs to prevent AIDS and care for those who have it.
REQUEST FOR CONSENT FOR ANEMIA TEST
We are asking if you will participate in the anemia testing part of this survey by giving a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be taken with new equipment and the results of the test will be given to you immediately after. These results will be kept confidential.
Do you have any questions?
May I now ask that you participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test done.
(GO TO COLUMN (58) AND CIRCLE THE APPROPRIATE CODE (AND SIGN).
IF RESPONDENT IS AGE 15-17: ASK PARENT/GUARDIAN: Now, will you tell me if you accept that (NAME OF YOUTH) to participate in the anemia test? (GO TO COLUMN (56) AND WRITE THE LINE NUMBER OF THE PARENT/GUARDIAN, ASK FOR THEIR CONSENT AND CIRCLE THE APPROPRIATE CODE (AND SIGN) IN COLUMN (57). IF PARENT/GUARDIAN AGREES, READ THE PRECEDING
PARAGRAPHS TO YOUTH FOR HIS/HER CONSENT AND RECORD THE APPROPRIATE CODE IN COLUMN (58).
REQUEST FOR CONSENT FOR HIV TEST
We would also ask you to participate in the HIV test by allowing us to collect a few drops of blood from the finger at the same time.
This 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.
However, 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 testing. However, if you decide not to have the test done, it is your right and we will respect your decision.
Will you accept to participate in the HIV test?
(GO TO COLUMN (58) AND CIRCLE THE APPROPRIATE CODE (AND SIGN).
IF RESPONDENT IS AGE 15-17: ASK PARENT/GUARDIAN: Now, will you tell me if you accept that (NAME OF YOUTH) to participate in the HIV test? (GO TO COLUMN (56) AND WRITE THE LINE NUMBER OF THE PARENT/GUARDIAN, ASK FOR THEIR CONSENT AND CIRCLE THE APPROPRIATE CODE (AND SIGN) IN COLUMN (57). IF PARENT/GUARDIAN AGREES, READ THE PRECEDING PARAGRAPHS TO
YOUTH FOR HIS/HER CONSENT AND RECORD THE APPROPRIATE CODE IN COLUMN (58).
* DON'T FORGET TO GIVE EACH ELIGIBLE PERSON A LIST OF THE NEAREST VCT SERVICES.
HEMOGLOBIN AND HIV TESTING -- WOMEN AND MEN Number of blood samples: _____
CHECK COLUMNS (10) AND (12) FROM HOUSEHOLD SCHEDULE: RECORDTHE LINE NUMBER, NAME, SEX AND AGE OF ALL WOMEN AGE 15-49 AND ALL MEN AGE 15-59 YEARS. THIS
FORM MUST BE DESTROYED BEFORE THE RESULTS OF THE TEST ARE LINKED TO THE LDHS DATABASE.
(51)LINE NUMBER FROM COLUMN (10) OR COLUMN (12)
FEMALE 2
AGE 18+ 2 (GO TO 58)
(56) LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE
(57)READ THE CONSENT TO THE PARENT OR RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)
REFUSED 2
NOT READ 3
CONSENT FOR HIV TESTING 1 (INTERVIEWER SIGNS _______)
REFUSED 2
NOT READ 3
(58)READ THE CONSENT TO PARENT OR RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)
REFUSED 2
NOT READ 3
CONSENT FOR HIV TESTING 1 (INTERVIEWER SIGNS _______)
REFUSED 2
NOT READ 3
(60) FOR WOMEN: CURRENTLY PREGNANT
NO 2
DON'T KNOW 3
ABSENT 2
REFUSED 3
TECHNICAL PROBLEMS 4
OTHER (SPECIFY) __________________ 6
ABSENT 2
REFUSED 3
TECHNICAL PROBLEMS 4
OTHER (SPECIFY) _____________________ 6
(63)PLACE BAR CODES
[1st DROP IS WIPED AWAY; 3 DROPS ARE COLLECTED FOR HIV; 1 (LAST) DROP IS COLLECTED FOR ANEMIA]
PUT 1ST BAR CODE HERE
PUT THE 2ND BAR CODE ON THE RESPONSENT'S FILTER PAPER , AND THE 3RD ON THE BLOOD SAMPLE TRANSMITTAL FORM
TICK HERE IS ANOTHER SHEET IS USED : ____
64 CHECK COLUMNS (49) FOR CHILDREN, (59) FOR ADULTS AND (60) FOR WHETHER THE WOMAN IS CURRENTLY PREGNANT:
NUMBER OF HOUSEHOLD MEMBERS FOR WHICH THE LEVEL OF HEMOGLOBIN IS BELOW THE CUT-OFF POINTS :
LESS THAN 7G/DL FOR CHILDREN, FOR MEN, AND FOR WOMEN WHO ARE NOT PREGNANT (OR WHO DO NOT KNOW IF THEY ARE PREGNANT); LESS THAN 9G/DL FOR PREGNANT WOMEN.
ONE OR MORE
GIVE EACH WOMAN, MAN OR RESPONSIBLE ADULT THE RESULTS OF THE HEMOGLOBIN TEST. READ THE DECLARATION BELOW (Q.65) TO THESE PERSONS WITH HEMOGLOBIN LEVELS BELOW CUT-OFF POINTS.
NONE
GIVE EACH WOMAN, MAN OR RESPONSIBLE ADULT THE RESULTS OF THE HEMOGLOBIN TEST AND THE ANEMIA BROCHURE.
65 The results of the test show that (YOUR BLOOD/THE BLOOD OF NAME OF CHILD/CHILDREN) has a very low level of hemoglobin. This indicates that (YOU/NAME OF CHILD/CHILDREN) are severely anemic, which is a serious health problem. We recommend that you visit a health facility as soon as possible to be examined and obtain the proper treatment. GIVE THE ADULT THE HEMOGLOBIN TEST RESULTS AND THE ANEMIA BROCHURE.