SECTION A: DEMORGRAPHIC INFORMATION
1. Names of household members, age, sex and relationship
Names of household Age sex R/ship
members
i
Ii
Iii
Iv
V
Vi
Vii
Viii
ix
2. What is the religion
a. Muslim
b. Christian
c. Other ………………………….
3. What is the level of education of household heads?
a. Primary
b. Secondary
c. Tertiary
d. None
4. Are under five children immunized
a. Yes
b. No
5. What is the nutritional status of under five children
a. Well nourished
b. Malnourished
6. What are the disabilities in the family?
a) Physical
b) Mental
c) visual
d) hearing
e) none
possible cause of the condition
a) birth
b) severe illness
c) any other……………………………………………..
7. Ethnicity /race ……………………………….
8. Health status
a) Chronic illness
b) Recent hospitalization
c) None
9. Health insurance cover
a) Yes
b) No
10. Migration status
a) Migrants
b) Native born
If migrants specify…………………….
11. Empl0yment status of the house hold head
a) Employed
b) Self employed
c) None
d) Other…………………………………………
SECTION B: HOUSING SURVEY (Obunga, Kisumu County)
[Link] Distribution (Observe and Record)
☑ Clustered
☑ Sparse
Type of House (Observe and Record)
☑ Permanent (Brick/Stone/Concrete)
☑ Semi-Permanent (Iron Sheet/Mud Walls)
☑ Temporary (Mud/Thatched)
[Link] of the House (Observe)
☑ Adequate (Good airflow, multiple windows)
☑ Inadequate (Few/no windows, poor airflow)
[Link] Area (Observe and Record)
☑ Inside the main house (Specify: Separate kitchen space / Same living space)
☑ Outside the main house (Open space / Designated kitchen structure)
[Link] Type of Cooking Fuel Used
☑ Firewood
☑ Charcoal
☑ Kerosene
☑ Liquefied Petroleum Gas (LPG)
☑ Electricity
☑ Others (Specify) ____________________________________________
[Link] of Floor (Observe and Record)
☑ Cemented
☑ Earthen
☑ Tiled
[Link] of House with Domesticated Animals (Observe)
☑ Yes (Specify: Cows / Goats / Chicken / Others: _______________
☑ No
[Link] Disposal System (Observe and Ask)
☑ Properly managed (Designated pit / Collection services)
☑ Poorly managed (Scattered waste, open dumping)
[Link] of Drinking Water
☑ Piped water
☑ Borehole
☑ River/Lake
☑ Rainwater harvesting
☑ Others (Specify) ____________________________________________
[Link] Facilities (Observe and Ask)
☑ Private toilet (Flush / Pit latrine)
☑ Shared toilet (Community / Rental block)
☑ No toilet (Open defecation)
SECTION C: SAFE WATER SUPPLY
I) Water Sources and Availability
1. What is your primary source of drinking water? (Select one)
☐ Piped water
☐ Borehole
☐ River/Lake
☐ Rainwater
☐ Purchased bottled water
☐ Other (Specify): ___________
2. How far is the nearest water source?
☐ Less than 500m
☐ 500m - 1km
☐ More than 1km
3. Is there enough water supply throughout the year?
☐ Yes
☐ No
4. Do you experience water shortages?
☐ Yes
☐ No
If yes, how often?
☐ Daily
☐ Weekly
☐ Monthly
☐ Seasonally
II) Water Quality and Treatment
1. Do you consider your drinking water safe?
☐ Yes
☐ No
☐ Not sure
2. How do you treat your drinking water? (Select all that apply)
☐ Boiling
☐ Filtering
☐ Chlorination
☐ No treatment
☐ Other (Specify): ___________
3. Have there been cases of waterborne diseases (e.g., diarrhea, typhoid) in your household?
☐ Yes
☐ No
4. Are there visible signs of contamination in your water?
☐ Yes
☐ No
5. Have water tests been conducted in your community? ☐ Yes ☐ No ☐ Don’t know
Iii) Water Storage and Distribution
1. How do you store drinking water at home?
☐ Covered container
☐ Open container
☐ Water tank
☐ Other (Specify): ___________
2. Do you clean your water storage container regularly?
☐ Yes
☐ No
3. Is the water supply system well-maintained?
☐ Yes
☐ No
iv) Accessibility and Affordability
1. Is piped water available in all households?
☐ Yes
☐ No
2. Do you pay for water?
☐ Yes
☐ No
If yes, is the cost affordable?
☐ Yes
☐ No
3. What are the main challenges in accessing safe water in your community?
SECTION D: ENVIRONMENTAL SANITATION
ii) Waste Disposal
1. How do you dispose of household waste?
☐ Community collection service
☐ Open dumping
☐ Burning
☐ Composting
☐ Other (Specify): ___________
2. Is there a designated waste collection service in your area?
☐ Yes
☐ No
4. How often is waste collected?
☐ Daily
☐ Weekly
☐ Monthly
☐ Not collected
5. Are there areas with illegal dumping in your community?
☐ Yes
☐ No
ii) Sanitation Facilities
1. What type of toilet facility does your household use?
☐ Flush toilet
☐ Pit latrine with slab
☐ Open pit latrine
☐ No toilet (open defecation)
2. Do all household members have access to a toilet?
☐ Yes
☐ No
3. Are public/shared toilets available in your community?
☐ Yes
☐ No
4. How often are sanitation facilities cleaned?
☐ Daily
☐ Weekly
☐ Monthly
☐ Rarely
iii) Drainage and Wastewater Management
1. How is wastewater managed in your household?
☐ Proper drainage system
☐ Open ditches
☐ No drainage system
2. Does your community have proper drainage systems?
☐ Yes
☐ No
3. Does flooding occur in your area due to poor drainage?
☐ Yes
☐ No
4. Are there efforts to prevent water stagnation (to control mosquito breeding)?
☐ Yes
☐ No
iv) Community Awareness and Practices
1. Have you received any education on hygiene and sanitation?
☐ Yes
☐ No
2. Do you practice regular handwashing with soap?
☐ Yes
☐ No
3. Are there government policies promoting sanitation in your community?
☐ Yes
☐ No
4. Who is responsible for maintaining cleanliness in your community?
☐ Local government
☐ Community members
☐ Private companies
☐ Other (Specify): ___________
5. What sanitation challenges do you face in your community?
6. What suggestions do you have for improving water supply and sanitation?
SECTION E: CULTURAL PRACTICE
1. General Cultural Practices
What is the most important cultural practice in your community?
a) Traditional ceremonies
b) Family structures
c) Community gatherings
d) Others (please specify)
2. Gender Roles and Practices
How are gender roles perceived in your community?
a) Clear distinctions between male and female roles
b) Equal roles for men and women
c) No strong cultural emphasis on gender roles
d) Others (please specify)
Are there cultural practices that impact women's rights?
a) Yes, negatively
b) Yes, positively
c) No impact
d) Not sure
3. Health-Related Cultural Practices
Are traditional medicines used in the community?
a) Yes, frequently
b) Occasionally
c) No, not at all
d) Not sure
Are there health-related cultural practices for pregnancy or childbirth?
a) Yes, specific rituals
b) Yes, general beliefs
c) No, not practiced
d) Not sure
4. Education and Learning
How does the community view girls’ education?
a) Highly valued
b) Less valued than boys' education
c) Equal value for boys and girls
d) Not sure
Are there traditional methods of passing knowledge?
a) Yes, through elders
b) Yes, through formal education
c) No, no traditional methods
d) Not sure
5. Marriage and Family Practices
Are arranged marriages common in the community?
a) Yes, common
b) Yes, but rare
c) No, not common
d) Not sure
Is polygamy practiced in your community?
a) Yes, commonly
b) Yes, rarely
c) No, not at all
d) Not sure
6. Cultural Practices and Conflict Resolution
What is the common way to resolve conflicts in your community?
a) Traditional mediation (elders)
b) Formal legal systems
c) Family-based resolution
d) Not sure
How are issues like domestic violence addressed culturally?
a) Through community support
b) Through legal intervention
c) Not addressed
d) Not sure
7. Impact of Cultural Practices on Community Development
Do cultural practices help or hinder community development?
a) Help
b) Hinder
c) No effect
d) Not sure
Are cultural practices changing due to external influences (media, globalization)?
a) Yes, significantly
b) Yes, but slowly
c) No, not at all
d) Not sure
8. Cultural Beliefs and Social Norms
What is the community's view on social equality?
a) Equal opportunities for all
b) Unequal opportunities based on gender or status
c) No clear stance
d) Not sure
How does the community treat outsiders or those who don’t follow cultural practices?
a) Accept them fully
b) Tolerate but exclude from certain activities
c) Reject or isolate them
d) Not sure
9. Cultural Practices and Vulnerable Groups
Are there cultural practices that affect vulnerable groups (e.g., children, elderly)?
a) Yes, negatively
b) Yes, positively
c) No effect
d) Not sure
How does the community view disabilities or aging?
a) With respect and care
b) With neglect or stigma
c) No strong opinion
d) Not sure
SECTION G: GENERAL HEALTH-SEEKING BEHAVIOUR
1. Where do you usually go when you or a family member is sick?
a)hospital
b)clinic
c)pharmacy
d)traditional healer
2. What factors influence your choice of healthcare provider?
a)cost
b)distance
c) quality of care
3. How often do you visit a health facility for check-ups or preventive care?
a) daily
b)weekly
c) monthly
d) never
4. Have you ever delayed or avoided seeking healthcare?
a) Yes
b) No
If so, why?....................................................
5. What major challenges do you face in accessing healthcare services?
a)transportation
b)cost
c)long waiting times
6. Do you feel that healthcare services in this community are affordable and accessible?
a) Yes
b) No
Why or why not?............................................................................
7. Do you use traditional or herbal medicine when sick?
a) Yes
b) No
If yes, what conditions do you treat with them?....................................................................
7.. How do you usually get health-related information?
a) radio
b)TV
c) social media
d) community health workers
8. What are some cultural beliefs that influence how people seek healthcare in this
community?..............................................................
9. Do you have health insurance?
a) Yes
b) No
If not, why?................................................
10. How do you usually pay for healthcare services?
a) out of pocket
b)insurance
c)community-based health schemes
SECTION H: MCH
[Link] is the nutritional status of under-5 year old children in that household (observe,
measure and weight)
Malnourished[ ]
Well-nourished [ ]
Others (specify)----------------------------------------------------------------------------------
(ASK FOR THE ANC BOOKLET in case it is available)
[Link] is the source of the information?
ANC booklet..
Client
Other specify .
[Link] is the age recorded on the card-----------(Enter age in months)
[Link] many visits made ( observe).
Investigations done (observe)
PMTCT
HIV
HB
VDRL
Other
[Link] ITN issued ___________________
6. Was IPT issued? _____________________
7. What was the mode of previous deliveries? SVD____________ C/S__________
8. Where was the delivery conducted? Hospital ______________- Home ________________
9. How many deliveries has she undergone? ____________
[Link] are the out comes
Foetal outcome .......Dead or alive _________________________________
Maternal outcome....Dead or alive __________________________________
Other specify ____________________________________________
11. Does she prefer hospital or home delivery? ________________________________
Explain Why....................................................................................................
12. What do you consider as danger signs in pregnancy, delivery and post natally?
______________________________________________________________________________
____________________________________________
14. Check CWC card if child is <5yrs
15. Age received how many doses
Birth polio
BCG
PCV10
Pentavalent
Measles __________
ROTA 1 __________ __________
ROTA II __________ __________
Vitamin A ____________ __________
IPV ______________ __________
OPV_____________________
16. Check if child is fully immunized or not (check for BCG scar) Yes _______ No _______
17. If card shows she has lost a child, please probe for cause?--------------------------------------------
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