N˚

Questionnaire item

Answer

Code

1

Questionnaire number

/____________________/

-

2

Date of the survey

Day: /__//__/

Month: /__//__/

Year: /__//__//__//__/

3

Name of the interviewer

/____________________/

/____________________/

/____________________/

4

What is the language of the interview?

/____________________/

Socio-demographic factors

5

How old are you?

Day: /__//__/

Month: /__//__/

Year: /__//__//__//__/

6

what is your profession?

1) Trader /__/

2) Farmer

3) Retailer

4) Housewife

5) Craftman/woman

6) Retired

7) Other (Specify)_______

8) No Response

7

Are you educated?

1) Yes /__/

2) Literate only

3) Illiterate

8

What is your highest level of education?

1) Primary /__/

2) Secondary 1

3) Secondary 2

4) University

9

What ethnic group are you from?

1) Dendi and related /__/

2) Bariba and related

3) Fon and related

4) Yoruba and related

5) Nago and related

6) Peulh and related

7) Other (specify)_______________

8) Don’t know

9) No response

10

What is your religion?

1) Animistic /__/

2) Christian

3) Muslim

4) Atheistic

5) Other (spify)_________

6) No response

11

Seniority in the village?

/__/

1) Before January 2018 to present

2) From January 2018 to present

3) From 2019 to present

12

What is your marital status?

1) Single /__/

2) Maried

3) Divorced

4) Widow (wer)

13

How many children?

/__//__/

14

What is your monthly income?

1) <35,000 f CFA

2) 35,000 f to 50,000 f (CFA)

3) >50,000 f CFA

Behavioural Factors and Lifestyle

15

What water do you drink?

1) Runoff water /__/

2) Backwater

3) Borehole water

16

If water from backwater or runoff, do you treat it before consumption?

1) Yes /__/

2) No

17

If yes, how do you treat water?

1) by Aquatab /__/

2) by boiling

3) Other (Specify)________:

18

Do you usually suffer from the following diseases?

1) stomach ache

Yes /__/

No /__/

2) diarrhea

Yes /__/

No /__/

3) vomiting

Yes /__/

No /__/

19

If drilling water, do you still suffer from these diseases?

stomach ache /__/

1) Yes

2) No

Diarrhea /__/

1) Yes

2) No

Vomiting /__/

1) Yes

2) No

Other response (Specify)________________

20

Are you still going to the hospital for these diseases since the well drilling?

1) Yes /__/

2) No

21

If so, do you have a health record?

1) Yes /__/

2) No

Environmental factors

22

How far is your house from the well drilling?

1) Less than 1 km /__/

2) 2 km

3) More than 2 km

23

What is the waiting time at the well?

1) Less than 1 h /__/

2) 2 h

3) 3 h

4) 4 h

5) 5 h

6) More than 5 h

24

What water do you prefer to drink?

1) Borehole water /__/

2) Backwater

25

If Marigot water, why?

/__/

1) Distance to reach the drilling well

2) Waiting time at the borehole

26

Where do you defecate?

1) In the bush /__/

2) Latrines