Health Education To Villages




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Safe Water System Manual


ANNEX A:


COLLECTING BACKGROUND DATA:
SAMPLE QUESTIONNAIRE ON KNOWLEDGE AND PRACTICES

 

Date of interview _____/_____/200_
Index subject study no. _______
Household no. _______
Interviewer's name _________________________________________

Demographic data
1. Name of principal respondent __________________________
2. Relationship of respondent to the head of household
         a = Husband b = Wife c = Son
         d = Daughter e = Other (specify) ____________
3. Name of the village _________________________________

I WOULD LIKE TO ASK YOU ABOUT THE SOURCES OF INCOME FOR YOUR HOUSEHOLD
4. What are the main sources of income for the household?
         a. Professional technical or managerial job
         b. Large scale agriculture
         c. Small scale agriculture
         d. Sales or services
         e. Skilled manual labor
         f. Unskilled manual labor
         g. Other _______________________________________

5. What is the type of the house (Look at the house and circle the appropriate choice below)
         a. The walls are made of mud and the roof is grass-thatched.
         b. The walls made of mud and the roof is of iron sheets.
         c. The walls are made of bricks and the roof is grass-thatched.
         d. The walls are made of bricks and the roof is made of iron sheets.
         e. The walls are made of bricks and the roof is made of tiles.

6. Which of the following things do you have in your house?
         a. Beds Yes No Don't know
         [If yes] how many? _____
         b. Bicycle Yes No Don't know
         c. Car Yes No Don't know
         d. Truck Yes No Don't know
         e. Radio Yes No Don't know
         f. TV Yes No Don't know
         g. Refrigerator Yes No Don't know
         h. Electricity Yes No Don't know
         i. Stove Yes No Don't know
         [if yes] Is it electric kerosene gas

7. Do you keep any animals or birds in your household?
  (If yes) record the type and number of animals/birds kept in the table below. (If no go to question 8)

Type of animal/bird1 = Yes 2 = NoNumber of animals/birds kept
Cows1          2  
Goats1          2  
Sheep1          2  
Pigs1          2  
Chicken / Ducks1          2  
Other1          2  

 

I WOULD LIKE TO ASK YOU ABOUT THE SOURCE AND HANDLING OF HOUSEHOLD WATER

8. From where do you usually collect the water you use in the house? Do not read the options to the respondent.          Mark all the sources that apply
         a. Pond or dam
         b. Lake
         c. Stream or river
         d. Well
         e. Borehole
         f. Spring
         g. Rainwater
         h. Water-tap
         i. Other_____________________________________

9. With what container do you collect the water you use in the household? (Ask to see the vessel that is usually used to collect water)
         a. No container
         b. Bucket
         c. Jerrycan
         d. Barrel / drum
         e. Clay pot
         f. Sauce -pan
         g. Directly from the tap
         h. Other (specify)__________________

10. Do you think this water is safe to drink without any treatment?
         1 = Yes 2 = No 3 = I do not know

11. What type of container do you use to store water for drinking in the house? (Look at the vessel usually used to store drinking water) (Do not read, circle all that apply)
         a. No container
         b. Bucket
         c. Jerrycan
         d. Barrel/drum
         e. Clay-pot
         f. Saucepan
         g. Jug
         h. Kettle
         i. Bottles
         j. Other (Specify)

12. What type of water storage vessel does the household use?
See if it is
         a. Wide mouthed
         b. Narrow mouthed
         c. Other. (Describe)__________________

13. Is the water in the storage vessel covered?
         1 = Yes 2 = No

14. Do you process this water in any way to make it safer to drink?
         1 = Yes 2 = No 3 = Don't know

15. If yes what do you do to the water to make it safer to drink? (Circle all that apply)
         a. Boil
         b. Add bleach
         c. Sieve it through cloth
         d. Other (Specify)________________________

16. What do you use to get/pour drinking water out of the storage container (Look and circle all that applies)
         a. Nothing
         b. Cup
         c. Ladle
         d. Pitcher
         e. Bowl
         f. Bucket
         g. Pour water directly from container
         h. Other (Specify)______________________

I WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT THE TOILET HABITS OF THE PEOPLE IN YOUR HOUSEHOLD

17. What toilet facility do you use? (Do not read the options. Circle all that apply.)
         a. In the bushes or on the ground?
         b. In a latrine?
         c. Other (specify)_________________________________

18. Can I see the type of soap that you use? (Look at the soap and comment whether)
         1 = Soap available 2 = Soap not available

Observations to be made by the interviewer

Ask to look at the toilet facility and record

19. What toilet facility does this household use?
         a. No facilities
         b. Pit latrine
         c. Other______________________________

20. Is there water for hand washing near or at the toilet?
         1 = Yes 2 = No

Inspect the compound and observe for

21. Are there any visible excreta in the yard? (If no go to 22)
         a. Human feces 1 = Yes 2 = No
         b. Animal feces 1 = Yes 2 = No
         c. Unknown excreta 1 = Yes 2 = No

22. If yes how many stools are observed?
         a. Small amount (1-2 feces)
         b. Moderate amount (3-4 feces)
         c. Large amount (>5 feces)


23. Record the names and age of all people who currently live in the household.

NoNamesID No.AgeSex
1 = M
2 = F
Relationship to head of household
a = Husband
b = Child
c = Grandchild
d = Other relative
e = Not related
    1 2a b c d e
    1 2a b c d e
    1 2a b c d e
    1 2a b c d e
    1 2a b c d e
    1 2a b c d e
    1 2a b c d e
    1 2a b c d e
    1 2a b c d e
    1 2a b c d e
    1 2a b c d e
    1 2a b c d e


Check form at the end of the visit
        · Water vessel inspected [__]
        · Water from the household storage vessel sampled [__]
        · Water source inspected [__]
        · Water from the source sampled [__]
        · Toilet facility inspected [__]
        · The compound inspected [__]

Say goodbye to the family after going through the check form above

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Centers for Disease Control and Prevention
National Center for Infectious Diseases
Division of Bacterial and Mycotic Diseases
Foodborne and Diarrheal Diseases Branch

 

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