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2014 LESOTHO DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION:

PLACE NAME ____

NAME OF HOUSEHOLD HEAD ____

EA NUMBER ____

HOUSEHOLD NUMBER ____

LESOTHO ECOLOGICAL ZONE:

LOWLANDS 1
FOOTHILLS 2
MOUNTAINS 3
SENQU RIVER VALLEY 4

DISTRICT CODE* ____

*DISTRICT CODES:

01 BUTHA-BUTHE
02 LERIBE
03 BEREA
04 MASERU
05 MAFETENG
06 MOHALE'S HOEK
07 QUITHING
08 QACHA'S NEK
09 MOKHOTLONG
10 THABA-TSEKA

URBAN/RURAL:

URBAN 1
RURAL 2

HOUSEHOLD SELECTED FOR MALE SURVEY AND BIOMARKER COLLECTION?

YES 1
NO 2

INTERVIEWER VISITS:

FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT CODE**

NEXT VISIT:
DATE ____
TIME ____

SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT CODE**

NEXT VISIT:
DATE____
TIME____

THIRD VISIT
DATE____
INTERVIEWER'S NAME____
RESULT CODE**

FINAL VISIT
DAY____
MONTH____
YEAR 2014
INT. NUMBER____
RESULT CODE**

TOTAL NUMBER OF VISITS____

**RESULT CODES:

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLD 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) _______

TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE____

LANGUAGE OF QUESTIONNAIRE*** 2

LANGUAGE OF QUESTIONNAIRE*** ENGLISH

LANGUAGE OF INTERVIEW***

***LANGUAGE CODES:

1 SESOTHO
2 ENGLISH

TRANSLATOR USED

YES 1
NO 2

SUPERVISOR
NAME____
DATE____

INTRODUCTION AND CONSENT

Hello. My name is ________________________. I am working with the Ministry of Health. We are conducting a survey about health all over Lesotho. 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 the interview now?

SIGNATURE OF INTERVIEWER: __________________ DATE: ________

RESPONDENT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

HOUSEHOLD SCHEDULE

1) LINE NUMBER:

LINE NO. _____

2) USUAL RESIDENTS AND VISITORS:

Please give me the names of the persons who 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?
SEE CODES BELOW.

CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD

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 DOMESTIC EMPLOYEE
12 HERDBOY
13 OTHER NON RELATIVE
98 DON'T KNOW

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

MALE 1
FEMALE 2

RESIDENCE:

5) Does (NAME) usually live here, or somewhere else in Lesotho, or outside Lesotho?

HERE 1 (GO TO 8)
ELSE 2 (GO TO 8)
OUT 3

6) Does (NAME) live in South Africa or some other country?

RSA 1
OTHER 2

7) How long has (NAME) lived in (COUNTRY)?
IF LESS THAN 1 YEAR, RECORD '00'.
RECORD '98' FOR DON'T KNOW.

YEARS____

8) Did (NAME) stay here last night?

YES 1
NO 2

8A) Just to make sure that I have a complete listing: are there any other persons such as small children that we have not listed?

YES (ADD TO TABLE)
NO

8B) 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

8C) 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

9) AGE:
How old is (NAME)?
IF 95 OR MORE, RECORD '95'.

AGE IN YEARS____

IF AGE 15 OR OLDER:

10) MARITAL STATUS:
What is (NAME)'s current marital status?

MARRIED OR LIVING TOGETHER 1
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER-MARRIED AND NEVER LIVED TOGETHER 4

ELIGIBILITY:

11) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 WHO ARE USUAL RESIDENTS (COL. 5-1) AND/OR WHO SLEPT IN HH LAST NIGHT (COL. 8-1)

IF HH IS SELECTED FOR MALE SURVEY AND BIOMARKER COLLECTIONS:

12) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 WHO ARE USUAL RESIDENTS (COL. 5-1) AND/OR WHO SLEPT IN HH LAST NIGHT (COL. 8-1)

13) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5 WHO ARE USUAL RESIDENTS (COL. 5-1) AND/OR WHO SLEPT IN HH LAST NIGHT (COL. 8-1)

IF AGE 0-17 YEARS:

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS:

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

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

15) 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___

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

YES 1
NO 2 (GO TO 18)
DON'T KNOW 8 (GO TO 18)

17) 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:

EVER ATTENDED SCHOOL:

18) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

19) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
SEE CODES BELOW.

LEVEL ____
0 PRE-PRIMARY/PRESCHOOL
1 PRIMARY
2 VOC./TECH. TRAINING AFTER PRIMARY
3 SECONDARY/HIGH
4 VOC./TECH. TRAINING AFTER SECONDARY/HIGH
5 COLLEGE
6 GRADUATE/POST GRADUATE
8 DON'T KNOW
GRADE ____
00 = LESS THAN 1 YEAR COMPLETED (NOT ALLOWED FOR Q. 21)
STANDARD 01-07 = LEVEL 1 (PRIMARY SCHOOL)
YEAR 01-06 = LEVEL 2 (VOC./TECH. AFTER PRIMARY)
FORM 01-05 = LEVEL 3 (SECONDARY/HIGH)
YEAR 01-06 = LEVEL 4 (VOC./TECH. AFTER SECONDARY)
YEAR 01-03 = LEVEL 5 (COLLEGE)
YEAR 01-06 = LEVEL 6 (GRAD./POST GRAD).
98 = DON'T KNOW

IF AGE 5-24 YEARS:

CURRENT/RECENT SCHOOL ATTENDANCE:

20) Did (NAME) attend school at any time during the 2014 school year?

YES 1
NO 2 (GO TO NEXT LINE)

21) During this/that school year, what level and grade [is/was] (NAME) attending? SEE CODES.

LEVEL ____
0 PRE-PRIMARY/PRESCHOOL
1 PRIMARY
2 VOC./TECH. TRAINING AFTER PRIMARY
3 SECONDARY/HIGH
4 VOC./TECH. TRAINING AFTER SECONDARY/HIGH
5 COLLEGE
6 GRADUATE/POST GRADUATE
8 DON'T KNOW
GRADE ____
STANDARD 01-07 = LEVEL 1 (PRIMARY SCHOOL)
YEAR 01-06 = LEVEL 2 (VOC./TECH. AFTER PRIMARY)
FORM 01-05 = LEVEL 3 (SECONDARY/HIGH)
YEAR 01-06 = LEVEL 4 (VOC./TECH. AFTER SECONDARY)
YEAR 01-03 = LEVEL 5 (COLLEGE)
YEAR 01-06 = LEVEL 6 (GRAD./POST GRAD).
98= DON'T KNOW

IF AGE 0-4 YEARS:

22) BIRTH REGISTRATION:
Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

HAS CERTIFICATE 1
REGISTERED 2
NEITHER 3
DON'T KNOW 8

TICK HERE IF CONTINUATION SHEET USED___

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)
NEIGHBOR'S TAP 13
PUBLIC TAP/STANDPIPE 14
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 105)
TANKER TRUCK/CART WITH SMALL TANK 61
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 71
BOTTLED WATER 81
OTHER (SPECIFY)_______96

103) Where is the 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 8 (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 (SPECIFY) _______ 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
NO FACILITY/BUSH/FIELD 61 (GO TO 110)
OTHER (SPECIFY)_______ 96

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

YES 1
NO 2 (GO TO 110)

109) How many households use this facility?

NO. OF HOUSEHOLDS IF LESS THAN 10___
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

110) Does you household have:

a) Electricity that is connected?
b) A battery or generator for power?
c) A solar panel in working condition?
d) A radio in working condition?
e) A television in working condition?
f) A mobile telephone in working condition?
g) A non-mobile telephone in working condition?
h) A refrigerator in working condition?
i) A bed/mattress?
j) A computer?
k) Internet access?

A) ELECTRICITY
YES 1
NO 2
B) BATTERY/GENERATOR
YES 1
NO 2
C) SOLAR PANEL
YES 1
NO 2
D) RADIO
YES 1
NO 2
E) TELEVISION
YES 1
NO 2
F) MOBILE TELEPHONE
YES 1
NO 2
G) NON-MOBILE TELEPHONE
YES 1
NO 2
H) REFRIGERATOR
YES 1
NO 2
I) BED/MATTRESS
YES 1
NO 2
J) COMPUTER
YES 1
NO 2
K) INTERNET ACCESS
YES 1
NO 2

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

ELECTRICITY 01
LPG 02
BIOGAS 03
PARAFFIN 04
COAL 05
WOOD 06
STRAW/SHRUBS/GRASS 07
AGRICULTURAL CROP 08
ANIMAL DUNG 09
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER (SPECIFY)_________ 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 (SPECIFY)_________ 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/MUD/DUNG 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL TILE/VINYL CARPET 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY)________ 96

115) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

NATURAL ROOFING
THATCH/GRASS 11
SOD 13
RUDIMENTARY ROOFING
WOOD PLANKS 21
CARDBOARD 22
FINISHED ROOFING
METAL/CORRUGATED 31
WOOD 32
ASBESTOS/CEMENT FIBER 33
CERAMIC/CLAY TILES 34
CEMENT 35
ROOFING SHINGLES 36
OTHER (SPECIFY)_________ 96

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

NATURAL WALLS
CANE/TREE TRUNKS 11
SOD 12
RUDIMENTARY WALLS
STONE WITH MUD 21
PLYWOOD 22
CARDBOARD 23
REUSED WOOD 24
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS/SHINGLES 35
METAL/CORRUGATED 37
OTHER (SPECIFY)___________ 96

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

ROOMS____

118) Does any member of this household own:

a) A watch?
b) A bicycle?
c) A motorcycle or motor scooter?
d) A scotch cart?
e) A car or truck?

A) WATCH
YES 1
NO 2
B) BICYCLE
YES 1
NO 2
C) MOTORCYCLE OR MOTOR SCOOTER
YES 1
NO 2
D) SCOTCH CART
YES 1
NO 2
E) CAR OR TRUCK
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 hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '950'.

HECTARES _____
95 OR MORE HECTARES 950
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'.

a) Cattle?
b) Milk cows?
c) Bulls?
d) Horses, donkeys, or mules?
e) Goats?
f) Sheep?
g) Ordinary free range chickens?
h) Improved chickens?
i) Ordinary pigs?
j) Improved pigs?
k) Rabbits?

A) CATTLE
YES 1
NO 2
B) COWS
YES 1
NO 2
C) BULL
YES 1
NO 2
D) HORSES/DONKEYS/MULES
YES 1
NO 2
E) GOATS
YES 1
NO 2
F) SHEEP
YES 1
NO 2
G) ORDINARY CHICKENS
YES 1
NO 2
H) IMPROVED CHICKENS
YES 1
NO 2
I) ORDINARY PIGS
YES 1
NO 2
J) IMPROVED PIGS
YES 1
NO 2
K) RABBITS
YES 1
NO 2

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

YES 1
NO 2

124) What is the name of the nearest health facility that provides health services to this community?

(NAME OF HEALTH FACILITY)___________________________
DON'T KNOW 99998 (GO TO 127)

125) How do you get from here to (HEALTH FACILITY NAME)?

CAR/TRUCK/BUS/TAXI 01
MOTORCYCLE/SCOOTER 02
BICYCLE 03
HORSE/DONKEY/MULE 04
SCOTCH CART 05
WALKING 06
COMBINATION WALKING AND BUS/TAXI 07
HOUSEHOLD DOESN'T USE NEAREST HEALTH FACILITY 95 (GO TO 127)
OTHER 96

126) How long does it take you to get from here to (HEALTH FACILITY NAME)?

HOURS_____
MINUTES_____

127) 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 130)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 130)
NOT OBSERVED, NO SPECIFIC PLACE 4 (GO TO 130)
NOT OBSERVED, OTHER REASON 5 (GO TO 130)

128) OBSERVATION ONLY: SEE IF THERE IS WATER AT PLACE FOR HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

129) 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

130) Can you please provide me with a teaspoon of cooking salt? I will conduct a test to determine the presence of iodine. Iodine prevents goiter.

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