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Côte d?Ivoire Phase 3 Household Questionnaire

001a. Your ID:

001b. Enter your ID below.

Please record your ID

Must start with "N11" followed by 3 numbers

002a. Is this date and time correct?

[] Yes
[] No

002b. Record the correct date and time.

The date must be between 2022-07-01 and 2022-12-31.

003a. Region

003b. Department

003c. Sub-prefecture

Enumeration area

004a. Previous Annual Survey Household list

Structure number
Please record the structure number from the household listing form.

Please record the structure number from the household listing form.

Invalid response.

Household number

Please record the household number from the household listing form.

Invalid response.

007a. Are you at the same dwelling unit location from the previous annual survey?

[] Yes
[] No

007b. Do people live in this dwelling unit?

[] Yes
[] No

007c. Is at least one of the members from the previous annual survey still living in the dwelling unit?

[] Yes
[] No

007d. Why are people not living in this dwelling unit?

[] Dwelling vacant
[] Address not a dwelling unit
[] Dwelling unit destroyed
[] Dwelling unit not found

007e. What is the status of the original household from the previous annual survey?
Confirm with the neighbors to know the status

[] Household moved out of the study area
[] Household moved within the study area
[] Household split with some members in the study area and some out of the study area
[] No information

Which woman from the previous annual survey are you following up?

If you do not see any women in this list, double-check your answers to 004a and 007a

Is a member of the household and competent respondent present and available to be interviewed today?

[] Yes
[] No


Find a competent member of the household. Read the greeting on the following screen.

Hello, my name is {your_name} and I work for the Ecole Nationale Supérieure de Statistique et d?Economie Appliquée (ENSEA) in Abidjan. We are conducting a study in the field of health, specifically on family planning in Côte d?Ivoire. To this end, I am going to read you this form in order to explain the main objective of the study and to give you additional information in order to solicit your participation in this study.
Presentation and purpose of the study
In collaboration with the Ministry of Health and Public Hygiene and Universal Health Coverage of Côte d?Ivoire and the Johns Hopkins University School of Public and Reproductive Health in the United States, the Ecole Nationale Supérieure de la Statistique et d?Economie Appliquée (ENSEA) is conducting a study called PMA (Performance Monitoring for Action).
The main objective of this study is to implement a follow-up system for performance in the area of family planning and women?s reproductive health among the population and health facilities in Côte d?Ivoire. In addition, the information we collect will be used to inform social development programs in Côte d?Ivoire.
Why are you being asked to participate?
Your household has been selected for this study. Your participation is important because the information collected will be used to inform the government in order to improve the delivery of health services, particularly for mothers and children in this region. The information you share with us will be confidential and will not be shared with anyone other than our team members. We would like to make it clear that participation in this survey is voluntary and there is no direct personal benefit for your participation in this study. Nevertheless, we rely heavily on your participation as your views are very important. If you do not wish to answer a particular question, please let me know and I will move on to the next question. The survey will take about 1 hour and you may find it tedious. If so, you are free to stop the interview at any time.
Next, we would like to ask a series of questions to women in the household, aged between 15 and 49. You will not receive any financial incentive for your participation, but as a thank you we will offer you a hygiene kit (consisting of soap and washing powder) as compensation for the time that the members of your household have spent answering our different questionnaires.
Protection of data confidentiality Data will be collected on smartphones. All data will be sent electronically to the PMA study cloud server. The use and sharing of information will be subject to strict precautionary principles to ensure security and confidentiality. Once collection is complete, identifying information will be deleted from the database.
Before continuing, do you have any questions about this survey?
Contact person for additional information or concerns If you have any questions or concerns about this study, you can contact the National Principal Investigator of the study, Dr. Rosine Mosso-BOMISSO in Abidjan. If necessary, you can also contact the National Ethics Committee in Abidjan which has given its approval for the study.

011a. Read the verbal consent text.
Then, ask: May I begin the interview now?

[] Yes
[] No

011b. Respondent?s signature

Please ask the respondent to sign or check the box in agreement of their participation.


[] NA

Interviewer?s ID: {your_name}

Mark your ID as a witness to the consent process.

[] NA

Section 1 ? Household Roster
Move forward and select "Add"

Household member

Is this person the respondent?

If yes, check this box.

[] NA

PL_103. What is the status of this member in the household?

Respondent cannot be deceased

[] Resident
[] Resident, temporarily not at home
[] Moved elsewhere in the study area
[] Moved out of the study area
[] Deceased
[] Unknown

PL_103a. Do you know where the panel woman {firstname} moved to so that she can be followed up at her new household?

[] Yes
[] No

PL_103b. Where did {firstname} move to?

PL_104. Household Member
First name: {hq_firstname_auto} Relationship to HH head: {hq_relationship_lab} Gender: {hq_gender_lab} Age: {hq_age_auto} Marital Status: {hq_marital_status_lab}

Do you wish to update any of this information?

[] Yes
[] No

Section 1 ? Household Roster

I am now going to ask a series of questions about each usual member of the household or anyone who slept in the house last night.

Name of household member / visitor

Start with the head of the household.

101a. Is this person the respondent?

If yes, check this box.

[] NA

What is {firstname}?s relationship to the head of household?

[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] House help
[] Other
[] Do not know
[] No response

Is {firstname} male or female?

[] Male
[] Female

How old was {firstname} at their last birthday?

If less than one year old, record 0

Age must be less than 130 and greater than 0.

What is {firstname}?s current marital status?

If not married, probe to determine if they have ever been married and, if so, if they are divorced/separated, or widowed.

A spouse must be married

[] Married
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Never married
[] No response

Does {firstname} usually live here?

[] Yes
[] No
[] No response

Did {firstname} stay here last night?

[] Yes
[] No
[] No response

LCL_101. What is the religion of {firstname}?

Only recorded for the head of the household.

[] Muslim
[] Catholic
[] Methodist
[] Evangelica
[] Other Christian Religion
[] Animast
[] Other religion
[] No religion
[] No response

LCL_102. What is the ethnic group of {firstname}?

Only recorded for the head of the household.

[] Akan
[] Mandé du sud
[] Mandé du nord
[] Gur
[] Krou
[] Other Ivorian
[] Non Ivorian
[] No response

PL-106/PL-108. Are there any other usual members of your household or persons who slept in the house last night that I have not listed here?

[] Yes
[] No

READ THIS CHECK OUT LOUD: There are {num_HH_members} household members who are named {names}. Is this a complete list of the household members?

Remember to include all children in the household.

Go back and update the roster.

[] Yes
[] No

Section 2 ? Household Characteristics

Now I would like to ask you a few questions about the characteristics of your household.

Is this structure/house newly built in the last 12 months?

[] Yes
[] No
[] No response

Please tell me about items that your household owns. Does your household have:

Read out all types and select all that apply. Scroll to bottom to see all choices.
If an item is reported broken but said to be out of use only temporarily, select the item. Otherwise, do not select the item.

Cannot select ?no response? or ?none of the above? with other options.

[] Electricity?
[] A radio?
[] A television?
[] A mobile phone?
[] A landline telephone?
[] A refrigerator?
[] A TV5 Antenna?
[] A cabel subscription?
[] A washing machine?
[] A gas or electric stove?
[] An improved stove?
[] A DVD/CD?
[] An air conditioner?
[] A computer?
[] Home internet?
[] A wall clock?
[] Charruees?
[] A bicycle/tricycle?
[] A motorcycle or motor scooter?
[] Animal-drawn cart?
[] A canoe or fishing nets?
[] A tractor?
[] A car or truck?
[] A boat with a motor?
[] None of the above
[] No response

Check here to acknowledge you considered all options.

[] NA

Does this household own any livestock, herds, other farm animals, or poultry?

These livestock can be kept anywhere, not necessarily on the homestead.

[] Yes
[] No
[] No response

How many of the following animals does this household own?

The household can keep the livestock anywhere, but must own the livestock recorded here.
Zero is a possible answer. Enter -88 for do not know. Enter -99 for no response.

Cows or bulls
Horses, donkeys or mules

Section 3 ? Household Observation

Please observe the floors, roof and exterior walls.

Main material of the floor


[] Earth / sand
[] Cow dung
[] Wooden boards
[] Palm / bamboo
[] Parquet or polished wood
[] Tapes vinyl / asphalt
[] Tiles
[] Cement
[] Carpet
[] Other
[] No answer

Main material of the roof


[] No roof
[] Thatch / palm
[] Earth mottes
[] Mats
[] Palm / bamboo
[] Wooden boards
[] Cardboard
[] Sheet metal
[] Wood
[] Zinc / fiber cement
[] Tile
[] Cement
[] Shingles
[] Other
[] No answer

Main material of the exterior walls


[] No wall
[] Bamboo / cane / palm / trunk
[] Earth
[] Bamboo with mud
[] Stones with mud
[] Adobe not covered
[] Plywood
[] Cardboard
[] Recovered wood
[] Cement
[] Stones with lime / cement
[] Bricks
[] Cement blocks
[] Covered adobe
[] Wood board / shingles
[] Other
[] No answer

Section 4 ? Water Sanitation and Hygiene

Now I would like to ask you a few questions about water, sanitation and hygiene.

We would like to learn about the places that households use to wash their hands. Can you please show me where members of your household most often wash their hands?

[] Fixed facility observed (sink/tap) in dwelling
[] Fixed facility observed (sink/tap) in yard/plot
[] Mobile object (bucket/jug/kettle) observed
[] Not observed, facility in dwelling/yard/plot but no permission to see
[] Not observed, not in dwelling/yard/plot
[] Not observed, other reason
[] No Response

At the place where the household washes their hands, observe availability of water

[] Water is available
[] Water is not available
[] No Response

At the place where the household washes their hands, observe availability of soap or detergent:

[] Soap is available
[] Soap is not available
[] No Response

What is the main source of drinking water for members of your household?

[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from Spring: Unprotected Spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

What is the main toilet facility used by members of your household?

[] Flush/pour flush toilets connected to: Piped sewer system
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Pit Latrine
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: Unknown / Not sure / Do not know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab / open pit
[] Composting toilet
[] Bucket
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

Thank you for the time you have kindly granted us.
Are you willing to provide a phone number for this household where we may reach you in the future to follow up for future research?

[] Yes
[] No
[] No response

What is the phone number?

Enter a 9 or 10-digit number without the country code. Do not include spaces or dashes.

Invalid number of digits.

Can you repeat the number again?

Enter a 9 or 10-digit number without the country code. Do not include spaces or dashes.

Number entered must match previously entered number.

What is the name of the person who normally answers this phone?

Location and Questionnaire result


Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6 m.

096a. Where were you when you recorded the GPS coordinates?

[] In front of the selected structure
[] Away from the structure but within the study area
[] Outside the study area

How many times have you visited this household?

[] 1st time
[] 2nd time
[] 3rd time

In what language was this interview conducted?

[] English
[] French
[] Abbey
[] Abron
[] Adjoukrou
[] Agni
[] Arabic
[] Attie
[] Avikam
[] Bakoué
[] Baoule
[] Bete
[] Dida
[] Dioula
[] Djimini
[] Ebrié
[] Eholié
[] Elomoin
[] Fantin
[] Gnaboua
[] Godié
[] Gouro
[] Guere
[] Koulango
[] Kouzié
[] Kôyaka
[] Kroumen
[] Lobi
[] Mahou
[] Moré
[] N?zima
[] Senoufo
[] Suamlin
[] Wobe
[] Yacouba
[] Other

Questionnaire Result

Record the result of the questionnaire.

Check answer to 009 and the consent.

[] Completed
[] No household member at home or no competent respondent at home at time of visit
[] Postponed
[] Refused
[] Partly completed
[] Dwelling vacant
[] Address not a dwelling
[] Dwelling unit destroyed
[] Dwelling unit not found
[] Entire household absent for extended period