Protocol - Water Access and Sanitation

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Specific items from AHS have been selected to assess key concepts of water access and sanitation at the household level. The survey is administered via computer. 

Specific Instructions

Assuming that information on current address (see PhenX Demographics domain, Current Address measure) has been collected for a study respondent, then it is possible to fill in the ^address_unit variable. The address of a study participant may be linked to their source of water at the county level from publicly available databases, such as the American Community Survey (ACS) 5-year estimates and the Environmental Protection Agency (EPA).

From the AHS 2019 Definitions document to assist in clarification of wastewater disposal systems:

Type of sewage system. Types of systems used for wastewater disposal are as follows:

Public sewer. A public sewer is connected to a city, county, sanitary district, neighborhood, or subdivision sewer. It includes systems run by a government body or by a private organization sewage treatment system that is serving six or more units or units connected to small sewage treatment plants or neighborhood septic tanks.

Septic tank. A septic tank is an underground tank used for disposal of sewage (serving five or fewer units.) Includes units where the septic tank is connected to a public sewer, which catches overflow. It may empty either by gravity to a drain field, or be pumped to a mound system. Mound systems are a type of raised drain field for us in areas where groundwater would be contaminated by a conventional septic field.

Cesspool. A cesspool is an underground reservoir for sewage disposal serving 5 or fewer units. A cesspool is a covered hole or tank that receives household drainage or sewage. Unlike septic tanks, cesspools are closed systems and are not connected to a septic field. When full, cesspools must be pumped out and the material disposed of at another site.

Other (type of sewage system). Housing units for which sewage is disposed of in some other way, such as chemical toilets (uses chemicals to break down or dissolve sewage), are included in the other category.

Examples of septic tank or cesspool systems:

  • Standard septic tank and subsurface leach field. Considered a conventional system, the primary components are a standard septic tank and subsurface leach field. This type of system relies on gravity for flow of wastewater throughout the system. If a pump is used, it is only to move wastewater to the gravity-based leach field. This is the most common type of on-site wastewater disposal system.
  • Pump used to distribute wastewater. Often called a pressurized system, an on-site wastewater system uses a pump to distribute wastewater throughout a shallow leach field under pressure. It is often referred to as a low-pressure pipe system.
  • Elevated above natural soil surface. A “mound” pressurized wastewater system that is elevated above the natural soil surface using a mound of suitable fill material, such as quality sand media.
  • Applied treated Wastewater. Often referred to as an irrigation system, this type of system applies treated wastewater slowly and uniformly (by dripping) from a network of narrow plastic tubing placed at shallow depths of six to 12 inches in the plant root zone.
  • Other (septic tank or cesspool). Any type of septic tank or cesspool system not listed above. This would include systems such as, aerobic treatment units, sand filters, peat filters and constructed wetlands.

1. Is [answer from Current Address] a house, an apartment, a manufactured/mobile home, or some other type of residence?
 [ ] 1 House
 [ ] 2 Apartment, flat
 [ ] 3 Manufactured/mobile home
 [ ] 5 HU in nontransient hotel, motel, etc
 [ ] 6 HU, permanent in transient hotel, motel
 [ ] 7 HU in rooming house or boarding house
 [ ] 8 Boat or recreational vehicle
 [ ] 9 Tent, cave, or railroad car
 [ ] 10 HU not specified above, specify
 [ ] 11 Unoccupied site for manufactured/mobile home, trailer, or tent
 [ ] 12 Group Quarters

2. Specify other type of home _______________

3. Does your/the/that [Question 1 answer] have a toilet?
 [ ] 1 Yes
 [ ] 2 No

4. Does your/the/that [Question 1 answer] have a bathtub or shower?
 [ ] 1 Yes
 [ ] 2 No

5. What means of sewage disposal does your/the/that [Question 1 answer] have?
 [ ] 1 Septic tank
 [ ] 2 Cesspool
 [ ] 3 Chemical toilet
 [ ] 4 Outhouse or privy
 [ ] 5 Other; specify
 [ ] 6 None

6. Specify other type of sewage disposal _______________

7. Is there both hot and cold water anywhere in your/the/that home?
 [ ] 1 Yes
 [ ] 2 No



Personnel and Training Required

The interviewer must be trained to conduct computer interviews with individuals from the general population. The interviewer must be trained and found to be competent (i.e., tested by an expert) at the completion of computer interviews. The interviewer should be trained to prompt respondents further if a “don’t know” response is provided.

Equipment Needs

Computer software is necessary to develop computer-assisted instruments. The interviewer will require a laptop computer/handheld computer to administer a computer-assisted questionnaire.

Requirement CategoryRequired
Major equipment No
Specialized training No
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Interviewer-administered questionnaire





Selection Rationale

AHS is a national survey that is well established and validated for surveying the quality of housing stock in the United States. This questionnaire measures several characteristics of housing adequacy at the household level, including water access and sanitation.


English, Spanish

caDSR Common Data Elements (CDE) Water Access and Sanitation 12114279 CDE Browser
Derived Variables


Process and Review

Not Applicable

Protocol Name from Source

American Housing Survey (AHS), 2019


Department of Housing and Urban Development. American Housing Survey (AHS) 2019. Questions HTYPE, HTYPESP, HOTPIPP, TUB2, TOILET2, SEWDISQ and SEWDISQS

Department of Housing and Urban Development. American Housing Survey (AHS) 2019 Subject Definitions Document.

General References

Capone, D., Cumming, O., Nichols, D., & Brown, J. (2020). Water and Sanitation in Urban America, 2017-2019. American Journal of Public Health, 110(10), 1567–1572. https://doi.org/10.2105/AJPH.2020.305833

Mueller, J. T., & Gasteyer, S. (2021). The widespread and unjust drinking water and clean water crisis in the United States. Nature Communications, 12(1), 3544. https://doi.org/10.1038/s41467-021-23898-z

Protocol ID


Export Variables
Variable Name Variable IDVariable DescriptiondbGaP Mapping
Structural Social Determinants of Health
Measure Name

Water Access and Sanitation

Release Date

December 14, 2022


Water access is defined as consistent access to a sufficient amount of safe and clean water for an active and healthy lifestyle. Sanitation is defined as access to complete plumbing facilities, which include running water, a facility for washing, and a toilet or other safe means of sewage disposal.


Lack of access to adequate water causes physical ailments such as dehydration; contributes to water-related illnesses like cholera; exposure to lead and high levels of fecal matter; and impedes basic hygiene practices like hand-washing. Lack of access to sanitation increases the likelihood of water-related illnesses such as cholera, and impedes basic hygiene practices. Measuring water access and sanitation at the household level allows for assessment of its prevalence, identifying inequities or heterogeneity within populations, and contributes to the understanding of the relationship between water access or sanitation and other phenomena, including the impact of public health interventions and the health, economic, and psychosocial burdens associated with lack of consistent access to quality water and sanitation.


water access and sanitation, Water, insecurity, Access, sanitation, washing, household, plumbing, toilet, American Housing Survey (AHS), neighborhood built environment

Measure Protocols
Protocol ID Protocol Name
291101 Water Access and Sanitation

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