Afghanistan - Multiple Indicator Cluster Survey - 2011

Publication date: 2011

ii Afghanistan Multiple Indicator Cluster Survey 2010-2011 Central Statistics Organisation (CSO) UNICEF (United Nations Children s Fund) January 2013 The Afghanistan Multiple Indicator Cluster Survey (AMICS) was carried out in 2010-2011 by the Central Statistics Organisation (CSO) of the Government of the Islamic Republic of Afghanistan in collaboration with United Nations Children s Fund (UNICEF). Financial and technical support was provided by UNICEF. MICS is an international household survey programme developed by UNICEF. The Afghanistan MICS was conducted as part of the fourth global round of MICS surveys (MICS4). MICS provides up-to-date information on the situation of children and women, and measures key indicators to monitor progress towards the Millennium Development Goals (MDGs), the Afghanistan National Development Strategy (ANDS) and other internationally agreed upon commitments. Suggested citation: Central Statistics Organisation (CSO) and UNICEF (2012). Afghanistan Multiple Indicator Cluster Survey 2010-2011: Final Report. Kabul: Central Statistics Organisation (CSO) and UNICEF. Photos Copyright: Chapter 1: © UNICEF/NYHQ2007-1196/Noorani Report Cover Photos: Chapter 2: © UNICEF/NYHQ2000-0859/LeMoyne © UNICEF/AFGA2007-00819/Noorani Chapter 3: © UNICEF/AFGA2011-00116/Aziz Froutan © UNICEF/AFGA2009-00802/Shehzad Noorani Chapter 4: © UNICEF/AFGA2009-00654/Noorani © UNICEF/AFGA2010-01134/Noorani Chapter 5: © UNICEF/NYHQ2001-0491/Noorani Chapter 6: © UNICEF/AFGA2011-00010/Jalali Chapter 7: © UNICEF/AFGA2009-00546/Noorani Chapter 8: © UNICEF/NYHQ1992-0344/Isaac Chapter 9: © UNICEF/NYHQ2001-0486/Noorani Chapter 10: © UNICEF/NYHQ2007-1106/Noorani Chapter 11: © UNICEF/AFGA2010-00211/Noorani Chapter 12: © UNICEF/AFGA2007-00043/Khemka Report Copyright © Central Statistics Organization, 2012 iii Foreword After over three decades of armed conflict, Afghanistan has made great strides in overcoming some of the legacies of the past, amidst ongoing challenges and hope for the future. The Government of Afghanistan has worked closely with the international community to lead in progress achieved in a number of key social and economic indicators since 2002. Article 54 of the Afghanistan Constitution (2004) stipulates that the family is the fundamental pillar of society, and that the Government shall adopt all necessary measures to attain the physical and spiritual health of the family, especially that of children and mothers. Article 22 declares non- discrimination and equality in rights and duties between men and women, while Article 49 prohibits the forced labour of children. Several government ministries such as the Ministry of Women s Affairs (MoWA), the Ministry of Education (MoE), the Ministry of Labour, Social Affairs, Martyrs and Disabled (MoLSAMD), and organizations as well as departments within other ministries have been tasked with addressing the needs of children, women, and families. The Afghanistan Independent Human Rights Commission (AIHRC) came into being in 2002, and includes a Child s Rights Desk focused on protecting the basic human rights of children. Based on the global commitment to meeting the Millenium Development Goals (MDGs), several national policies and strategies aimed at improving the wellbeing of children and women have been adopted. These include the National Action Plan for the Women of Afghanistan, 2007-2017 (NAPWA), the National Child and Adolescent Health Policy, 2009-2013, the National Strategy for Street Working Children, the National Strategy for the Protection of Children at Risk, the National Education Strategic Plan of Afghanistan (NESP), the National Social Protection policy, among others. Afghanistan is also considering the development of a comprehensive Child Act. The Child Protection Action Plan (CPAN) was adopted in 2003 by MoLSAMD, and has the goal of protecting children against all forms of exploitation, violence and abuse. CPAN promotes and disseminates the principles embodied in the Convention on the Rights of the Child (CRC) in Afghanistan. However, the 2011 concluding observations of the CRC Committee urged the Government to apply to a much greater extent the provisions of the CRC in our domestic legal framework. As the main poverty reduction strategy policy, the Afghanistan National Development Strategy (ANDS) 2008-2013 was developed to identify national development priorities and to outline a plan of action for achieving Afghanistan s MDGs, through the enhanced delivery of health services, expanded access to education, improved water and sanitation facilities, and the entrenchment of the rule of law. To protect the legal rights of children in conflict, ANDS calls upon the Government to enhance the legal and policy framework related to the juvenile offenders and children in conflict, and also calls for improved access to the formal legal system for women and children. Recognizing the plight of children in Afghanistan, ANDS underlines the commitments made by the Government to focus on supporting the most vulnerable and the poorest of the poor. This includes in particular, children at risk, chronically poor women, and poor and disabled people; and the obligation to develop social protection programmes to meet the needs of these most vulnerable groups. iv Further, the Government and the donor community affirmed their commitment to realizing identified national priorities through the National Priority Programmes (NPP). These commitments were reaffirmed at the Bonn Conference in November 2011 where pledges were made to support Afghanistan beyond 2014. The Afghanistan MICS for 2010-2011 contributes greatly towards our efforts to monitor the progress of the Afghan MDGs for 2020, as well as other national priorities defined in the ANDS and NPPs. The present report highlights the status of children and women in Afghanistan, and will prove to be of great value to planners, administrators, policy makers, researchers, and to all of our development partners. The data here will serve to develop and prescribe appropriate programmes and to develop responsive policies for the development and welfare of children and women in Afghanistan, which is ultimately aimed at helping us achieve important national goals. I am grateful to all the team members who provided various forms of technical assistance that allowed for the publication of this report. And last but not least, I would like to extend my sincere thanks to UNICEF for extending their financial and technical support towards the realization of the report. Abdul Rahman Ghafoori President General Central Statistics Organization Government of the Islamic Republic of Afghanistan Kabul v Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Afghanistan, 2010-2011 Topic MICS4 Indicator Number MDG Indicator Number Indicator Value Unit CHILD MORTALITY Child mortality 1.1 4.1 Under-five mortality rate 102 per thousand 1.2 4.2 Infant mortality rate 74 per thousand NUTRITION Nutritional status 1.8 Underweight prevalence 2.1a Moderate and Severe (- 2 SD) 25.0 percent 2.1b Severe (- 3 SD) 10.6 percent Stunting prevalence 2.2a Moderate and Severe (- 2 SD) 51.6 percent 2.2b Severe (- 3 SD) 34.1 percent Wasting prevalence 2.3a Moderate and Severe (- 2 SD) 13.9 percent 2.3b Severe (- 3 SD) 7.2 percent Breastfeeding and infant feeding 2.4 Children ever breastfed 93.4 percent 2.5 Early initiation of breastfeeding 53.6 percent 2.6 Exclusive breastfeeding under 6 months 54.3 percent 2.7 Continued breastfeeding at 1 year 87.8 percent 2.8 Continued breastfeeding at 2 years 69.4 percent 2.9 Predominant breastfeeding under 6 months 69.2 percent 2.10 Duration of breastfeeding 23.7 percent 2.11 Bottle feeding 28.2 percent 2.12 Introduction of solid, semi-solid or soft foods 20.1 percent 2.13 Minimum meal frequency 17.8 percent 2.14 Age-appropriate breastfeeding 36.7 percent 2.15 Milk feeding frequency for non-breastfed children 59.5 percent Salt iodization 2.16 Iodized salt consumption 20.4 percent Vitamin A 2.17 Vitamin A supplementation (children under age 5) 50.6 percent Anaemia Child Anaemia prevalence 33.7 percent Non-pregnant women anaemia prevalence 21.4 percent Pregnant women anaemia prevalence 16.3 percent CHILD HEALTH Vaccinations 3.1 Tuberculosis immunization coverage 64.2 percent 3.2 Polio immunization coverage 48.0 percent 3.3 Immunization coverage for diphtheria, pertussis and tetanus (DPT) 40.2 percent 3.4 4.3 Measles immunization coverage 55.5 percent vi Tetanus toxoid 3.7 Neonatal tetanus protection 40.8 percent Care of illness 3.8 Oral rehydration therapy with continued feeding 47.5 percent 3.9 Care seeking for suspected pneumonia 60.5 percent 3.10 Antibiotic treatment of suspected pneumonia 63.9 percent Solid fuel use 3.11 Solid fuels 84.2 percent WATER AND SANITATION Water and sanitation 4.1 7.8 Use of improved drinking water sources 56.7 percent 4.2 Water treatment 14.9 percent 4.3 7.9 Use of improved sanitation facilities 28.5 percent 4.4 Safe disposal of child's faeces 45.8 percent Hand washing 4.5 Place for hand washing 70.8 percent 4.6 Availability of soap 74.4 percent REPRODUCTIVE HEALTH Early childbearing and contraception 5.2 Early childbearing 25.6 percent 5.3 5.3 Contraceptive prevalence rate 21.2 percent Maternal and newborn health 5.5 Antenatal care coverage 5.5a At least once by skilled personnel 47.9 percent 5.5b At least four times by any provider 14.6 percent 5.6 Content of antenatal care 12.1 percent 5.7 5.2 Skilled attendant at delivery 38.6 percent 5.8 Institutional deliveries 32.9 percent 5.9 Caesarean section 3.6 percent CHILD DEVELOPMENT Child development 6.1 Support for learning 73.1 percent 6.2 Father's support for learning 61.8 percent 6.3 Learning materials: children s books 2.2 percent 6.4 Learning materials: playthings 52.6 percent 6.5 Inadequate care 40.2 percent 6.7 Attendance to early childhood education 1.0 percent EDUCATION Literacy and education 7.1 2.3 Literacy rate among young women 22.2 percent 7.2 School readiness 12.7 percent 7.3 Net intake rate in primary education 29.0 percent 7.4 2.1 Primary school net attendance ratio (adjusted) 55.2 percent 7.5 Secondary school net attendance ratio (adjusted) 32.4 percent 7.6 2.2 Children reaching last grade of primary 84.1 percent 7.7 Primary completion rate 30.7 percent 7.8 Transition rate to secondary school 92.9 percent 7.9 Gender parity index (primary school) 0.74 ratio 7.10 Gender parity index (secondary school) 0.49 ratio CHILD PROTECTION Birth registration 8.1 Birth registration 37.4 percent Child labour 8.2 Child labour 25.3 percent 8.3 School attendance among child labourers 50.9 percent 8.4 Child labour among students 30.9 percent Child discipline 8.5 Violent discipline 74.4 percent vii Early marriage and polygamy 8.6 Marriage before age 15 15.2 percent 8.7 Marriage before age 18 46.3 percent 8.8 Young women age 15-19 currently married 19.8 percent 8.9 Polygamy 7.1 percent Spousal age difference 8.10a Women age 15-19 11.0 percent 8.10b Women age 20-24 14.0 percent Domestic violence 8.14 Attitudes towards domestic violence 91.5 percent Orphaned children 9.17 Children s living arrangements 1.7 percent 9.18 Prevalence of children with at least one parent dead 4.7 percent 9.19 6.4 School attendance of orphans 34.4 percent 9.2 6.4 School attendance of non-orphans 57.4 percent HIV & AIDS HIV and AIDS knowledge and attitudes 9.1 Comprehensive knowledge about HIV prevention 1.5 percent 9.2 6.3 Comprehensive knowledge about HIV prevention among young people 1.8 percent 9.3 Knowledge of mother-to-child transmission of HIV 8.4 percent 9.4 Accepting attitude towards people living with HIV 16.0 percent viii Table of Contents Foreword . iii Summary Table of Findings . v Table of Contents . viii List of Tables . xi List of Figures . xiv List of Abbreviations . xv Acknowledgements . xvii Executive Summary . xviii 1. Introduction . 1 Background . 2 Survey Objectives . 4 2. Sample and Survey Methodology . 5 Sample Design . 6 Sample Coverage . 7 Contents of Questionnaires . 8 Training and Fieldwork . 9 Data Processing . 10 3. Household and Population Characteristics . 11 Characteristics of Households . 12 Characteristics of the Population . 13 Characteristics of Female Respondents 15-49 Years of Age . 14 Characteristics of Children Under Age 5 . 16 4. Child Mortality . 18 Introduction: Child Mortality . 19 Child Mortality Estimates for Afghanistan . 19 Progress on Child Mortality in Afghanistan . 22 5. Nutrition . 24 Introduction: Nutrition . 25 Nutritional Status . 26 Breastfeeding, Infant and Young Child Feeding . 26 Salt Iodization . 35 Children s Vitamin A Supplementation . 37 Children s Anaemia Prevalence . 39 Women s Anaemia Prevalence . 40 A Profile of Women s and Children s Nutrition in Afghanistan . 41 6. Child Health . 43 Introduction: Child Health . 44 Vaccinations . 44 Neonatal Tetanus Protection . 48 ix Oral Rehydration Treatment . 50 Care Seeking and Antibiotic Treatment of Pneumonia . 57 Solid Fuel Use . 61 Assessing Children s Health in Afghanistan . 64 7. Water and Sanitation . 65 Safe Drinking Water . 66 Use of Improved Water Sources . 66 Use of Adequate Water Treatment Methods . 69 Time to Source of Drinking Water . 71 Person Collecting Drinking Water . 72 Use of Improved Sanitation Facilities . 73 Use and Sharing of Sanitation Facilities . 75 Disposal of Child s Faeces . 77 Drinking Water and Sanitation Ladders . 79 Hand Washing . 81 Water and Sanitation Practices in Afghanistan . 84 8. Reproductive Health . 85 Early Childbearing . 86 Contraception . 88 Antenatal Care . 91 Assistance at Delivery . 94 Place of Delivery . 98 The State of Reproductive Health in Afghanistan . 99 9. Child Development . 100 Early Childhood Education and Learning . 101 Adults Engaging in Activities with Children . 102 Children s Exposure to Reading Material and Play Items . 103 Care of Children. 105 Assessing Early Child Development in Afghanistan . 106 10. Literacy and Education . 108 Literacy Among Young Women . 109 School Readiness . 110 Primary and Secondary School Participation . 111 The School Experience of Children in Afghanistan . 119 11. Child Protection . 120 Birth Registration . 121 Child Labour . 122 Child Discipline . 126 Orphans . 128 Early Marriage and Polygamy . 131 Spousal Age Difference . 134 Attitudes toward Domestic Violence . 136 Protecting Children s Interests in Afghanistan . 137 12. HIV and AIDS. 139 x Knowledge about HIV Transmission and Misconceptions about HIV/AIDS . 140 Accepting Attitudes toward People Living with HIV and AIDS . 146 Measuring HIV/AIDS Awareness Among Afghan Women. 147 Appendix A. Sample Design . 148 Appendix B. List of Personnel Involved in the Survey . 153 Appendix C. Estimates of Sampling Errors . 162 Appendix D. Data Quality Tables . 177 Appendix E. AMICS4 Indicators: Numerators and Denominators . 192 Appendix F. Questionnaires . 198 xi List of Tables Table 2.1: Results of household, women, and under-5 interviews . 7 Table 3.1: Household composition . 12 Table 3.2: Population distribution by age and sex . 13 Table 3.3: Women's background characteristics . 15 Table 3.4: Under-5s background characteristics. 16 Table 4.1: Children ever born, children surviving and proportion dead . 19 Table 4.2: Child mortality . 20 Table 4.3: Reduction in U5MR and IMR in South Asia . 22 Table 5.1: Initial breastfeeding . 27 Table 5.2: Breastfeeding . 29 Table 5.3: Duration of breastfeeding . 30 Table 5.4: Age-appropriate breastfeeding . 31 Table 5.5: Introduction of solid, semi-solid or soft foods . 33 Table 5.6: Minimum meal frequency . 33 Table 5.7: Bottle-feeding . 34 Table 5.8: Iodized salt consumption . 36 Table 5.9: Children's Vitamin A supplementation . 38 Table 5.10: Anaemia status of children . 40 Table 5.11: Anaemia status of women . 41 Table 6.1: Routine immunization schedule in Afghanistan . 44 Table 6.2: Vaccinations in first year of life . 45 Table 6.3: Vaccinations by background characteristics . 46 Table 6.4: Neonatal tetanus protection . 48 Table 6.5: Oral rehydration solutions and recommended homemade fluids . 51 Table 6.6: Feeding practices during diarrhoea . 53 Table 6.7: Oral rehydration therapy with continued feeding and other treatments . 55 Table 6.8: Care seeking for suspected pneumonia and antibiotic use during suspected pneumonia . 58 Table 6.9: Knowledge of the two danger signs of pneumonia . 60 Table 6.10: Solid fuel use . 62 Table 6.11: Solid fuel use by place of cooking . 64 Table 7.1: Use of improved water sources . 67 Table 7.2: Household water treatment . 70 Table 7.3: Time to source of drinking water . 71 Table 7.4: Person collecting water . 72 Table 7.5: Types of sanitation facilities . 74 Table 7.6: Use and sharing of sanitation facilities . 76 Table 7.7: Disposal of child's faeces . 77 Table 7.8: Drinking water and sanitation ladders . 80 Table 7.9: Water and soap at place for hand washing . 82 xii Table 7.10: Availability of soap . 83 Table 8.1: Early childbearing . 86 Table 8.2: Trends in early childbearing . 87 Table 8.3: Use of contraception . 89 Table 8.4: Antenatal care coverage . 91 Table 8.5: Number of antenatal care visits. 93 Table 8.6: Content of antenatal care . 94 Table 8.7: Assistance during delivery . 96 Table 8.8: Place of delivery . 98 Table 9.1: Early childhood education . 101 Table 9.2: Support for learning . 102 Table 9.3: Learning materials . 104 Table 9.4: Inadequate care . 105 Table 10.1: Literacy among young women . 109 Table 10.2: School readiness . 110 Table 10.3: Primary school entry . 111 Table 10.4: Primary school attendance . 112 Table 10.5: Secondary school attendance . 114 Table 10.6: Children reaching last grade of primary school . 116 Table 10.7: Primary school completion and transition to secondary school . 117 Table 10.8: Education gender parity . 118 Table 11.1: Birth registration . 121 Table 11.2: Child labour, Ages 5-11 . 123 Table 11.3: Child labour, Ages 12-14 and Ages 5-14 . 124 Table 11.4: Child labour and school attendance . 125 Table 11.5: Child discipline . 126 Table 11.6: Children's living arrangements and orphanhood . 129 Table 11.7: School attendance of orphans and non-orphans . 130 Table 11.8: Early marriage and polygamy . 132 Table 11.9: Trends in Early Marriage . 134 Table 11.10: Spousal age difference . 135 Table 11.11: Attitudes toward domestic violence . 136 Table 12.1: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission . 140 Table 12.2: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission among young women . 142 Table 12.3: Knowledge of mother-to-child HIV transmission . 144 Table 12.4: Accepting attitudes toward people living with HIV/AIDS . 146 Table A.1: Allocation of Sample Clusters (Primary Sampling Units) and Households by Region, Urban and Rural Strata . 149 Table A.2: Subsample selection for a Hemoglobin Test . 152 xiii Table C.1: Sampling Errors Total Sample . 162 Table C.2: Sampling Errors - Urban Areas . 163 Table C.3: Sampling Errors - Rural Areas . 164 Table C.4: Sampling Errors Central Region . 166 Table C.5: Sampling Errors Central Highlands Region . 167 Table C.6: Sampling Errors East Region . 168 Table C.7: Sampling Errors North Region . 170 Table C.8: Sampling Errors North East Region . 171 Table C.9: Sampling Errors South Region . 172 Table C.10: Sampling Errors South East Region . 174 Table C.11: Sampling Errors West Region . 175 Table D.1: Age distribution of household population . 177 Table D.2: Age distribution of eligible and interviewed women . 179 Table D.3: Age distribution of under-5s in household and under-5 questionnaires . 180 Table D.4: Women's completion rates by socio-economic characteristics of households . 180 Table D.5: Completion rates for under-5 questionnaires by socio-economic characteristics of households . 180 Table D.6: Completeness of reporting . 181 Table D.7: Completeness of information for anthropometric indicators . 183 Table D.8: Heaping in anthropometric measurements . 185 Table D.9: Observation of places for hand washing. 186 Table D.10: Observation of under-5s birth certificates . 186 Table D.11: Observation of women s health cards . 187 Table D.12: Observation of vaccination cards . 188 Table D.13: Presence of mother in the household and the person interviewed for the under-5 questionnaire. 189 Table D.14: Selection of children age 2-14 years for the child discipline module . 189 Table D.15: School attendance by single age . 190 Table D.16: Sex ratio at birth among children ever born and living . 191 xiv List of Figures Figure 2.1: Map Showing Regions Sampled . 6 Figure 3.1: Age and sex distribution of household population . 14 Figure 4.1: Under-5 mortality rates by background characteristics . 21 Figure 5.1: Percentage of mothers who started breastfeeding within one hour and within one day of birth . 28 Figure 5.2: Percent distribution of children under age 2 by feeding pattern . 30 Figure 5.3: Percentage of households consuming adequately iodized salt . 37 Figure 6.1: Percentage of children aged 12-23 months who received the recommended vaccinations by 12 months . 46 Figure 6.2: Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus . 50 Figure 6.3: Percentage of children under age 5 with diarrhoea who received oral rehydration treatment . 52 Figure 6.4: Percentage of children under age 5 with diarrhoea who received ORT Or increased fluids, and continued feeding Afghanistan, 2010-2011 . 57 Figure 7.1: Percent distribution of household members by source of drinking water . 68 Figure 12.1: Percentage of women who have comprehensive knowledge of HIV/AIDS transmission . 144 xv List of Abbreviations AIHRC Afghanistan Independent Human Rights Commission AIDS Acquired Immune Deficiency Syndrome AMICS Afghanistan s Multiple Indicator Survey ANDS Afghanistan National Development Strategy BCG Bacillis-Cereus-Geuerin (Tuberculosis) CEDAW Convention on the Elimination of All Forms of Discrimination Against Women CO Carbon Monoxide CPAN Child Protection Action Network CSPro Census and Survey Processing System CSO Central Statistics Organization CRC Convention on the Rights of the Child DPT Diphteria Pertussis Tetanus EA Enumeration Area EPI Expanded Programme on Immunization g/dl gram per decilitre GDP Gross Domestic Product GPI Gender Parity Index HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders IMR Infant Mortality Rate ITN Insecticide Treated Net IUD Intrauterine Device JMP Joint Monitoring Programme LAM Lactational Amenorrhea Method MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MoE Ministry of Education MoLSAMD Ministry of Labour, Social Affairs, Martyrs and Disabled MoWA Ministry of Women s Affairs MoPH Ministry of Public Health NAPWA National Action Plan for the Women of Afghanistan, 2007-2017 NAR Net Attendance Rate NESP National Education Strategic Plan NGO Non-Governmental Organization NPP National Priority Programs NRVA National Risk and Vulnerability Assessment OHCHR Office of the High Commissioner for Human Rights ORS Oral Rehydration Salts ORT Oral rehydration treatment PPS Probability proportional to size ppm Parts Per Million RHF Recommended Home Fluid RME Relative Margin of Error PSU Primary Sampling Units SPSS Statistical Package for Social Sciences STI Sexually Transmitted Infection xvi U5MR Under-five Mortality Rate UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children s Fund USI Universal Salt Iodization VIP Ventilated improved pit latrine WFFC World Fit For Children WHO World Health Organization xvii Acknowledgements The Government of the Islamic Republic of Afghanistan has mandated the Central Statistics Organization (CSO) to collect data in order to provide strong evidence for equity-based planning and programming, as well as to monitor progress on the implementation of international conventions. The CSO, in collaboration with UNICEF, conducted the Afghanistan Multiple Indicator Survey (AMICS), which began in October 2010 and concluded in May 2011. The CSO collaborated with the Ministry of Public Health, the Ministry of Education, and other government stakeholders to successfully complete the survey. Staff from the CSO and UNICEF, as well as many others from various government agencies, UN programs and other partners took part in conducting this AMICS. We greatly appreciate the support demonstrated by the relevant ministries, agencies and individuals, and we want to thank everyone involved in the survey, the subsequent data analysis, and all those involved in preparing the final report. The Global MICS Team of UNICEF defined the MICS protocols and methodology, and in consultation with the CSO s staff, the survey tools were customized to Afghanistan s context. The standardized MICS questionnaires, sample selection procedures and software used for tabulations (provided by UNICEF) were indispensable for carrying out the survey and data analysis. The CSO, with the collaboration of UNICEF consultants, trained their staff and others for the fieldwork required to undertake the survey s sampling, data processing, analysis and report writing. UNICEF also supported training abroad for the AMICS team members. In particular, we sincerely thank UNICEF for their technical and financial support, which made this survey and the resulting report possible. xviii Executive Summary The Afghanistan Multiple Indicator Cluster Survey (AMICS) is a nationally representative sample survey that presents data on the social, health, and educational status of women and children in Afghanistan. It was conducted in 2010-2011 by the Central Statistics Organisation (CSO) of the Government of the Islamic Republic of Afghanistan, with the technical and financial support of UNICEF. The survey is based on the need to monitor progress towards goals and targets emanating from recent international agreements such as the Millennium Declaration and the Plan of Action of A World Fit For Children. It further helps track progress towards the Afghan Government s policy commitments to reduce poverty and support the wellbeing of women and children, such as the commitments made through the Afghanistan National Development Strategy (ANDS). The findings of the AMICS reveal the story of a country in transition, where many significant improvements have occurred in the last decade, as Afghanistan emerged from decades of war, poor governance, and widespread human rights abuses. Many Afghans have improved access to drinking water, school attendance is up for both boys and girls, and child mortality is relatively down, if still unacceptably high when compared with global estimates. Yet, progress has come more slowly in many areas, such as women s literacy, and Afghanistan faces new threats on the horizon, such as HIV/AIDS. Across all sectors covered in AMICS, major disparities exist by the background characteristics of respondents. There are often dramatic differences in indicators between urban and rural areas, by household socio-economic status, and by region. Consistently, the education level of women emerges as a reliable predictor of almost all indicators for women and children. This finding is compelling evidence that investments in the status and wellbeing of women are investments in children, and in communities at large. Below follows major findings highlighted from each chapter of the report. Survey Coverage In the AMICS, there were 13,314 households visited, across eight regions of Afghanistan, with a household response rate of 98.5%. In the interviewed households, 22,053 women (age 15-49 years) were identified. Of these, 21,290 were successfully interviewed, yielding a response rate of 96.5% within interviewed households. In addition, 15,327 children under age five were listed in the household questionnaire. Questionnaires were completed for 14,872 of these children, which corresponds to a response rate of 97.0% within interviewed households. Overall response rates are 95.1% for women and 95.6% for children under-5. Characteristics of Households and Population Of the 21,290 female respondents aged 15-49 years who were surveyed, 81% live in rural areas. Most of the women interviewed were married (69%), while 29% had never been married, 1.5% were widowed, and 0.1% were divorced or separated. The majority of the women (64%) had given birth at least once in their lifetime, 36% had never given birth at the time of the survey, and 36% had given birth in the previous two years. Most of the women respondents (82%) had no formal education, while 8% had primary level education only, and 11% had attained secondary level education or higher. Of females aged 15-49 years, 22% were in the wealthiest quintile, while 19% were in the poorest quintile. xix Of the children under five years of age included in the sample, 51% were male and 49% were female, with most (84%) residing in rural areas. The vast majority of the mothers of these children have attained no formal education (91%), while 5% had attained primary education and 4% had attained secondary education or higher. The children surveyed are quite evenly distributed across households of different wealth quintiles, with 21% in the poorest quintile, and 17% in the wealthiest quintile. Child Mortality The AMICS estimates Afghanistan s infant mortality rate at 74 per thousand live births, while the probability of dying before the age of five, the under-5 mortality rate (U5MR), is around 102 per thousand live births. The male infant and under-five mortality rates for males are much higher than the female rates, with a 10% difference between the probabilities of dying between males and females. The mortality rates are lower in urban areas as compared to rural areas. There are also differences in mortality in terms of educational levels and wealth. As education and wealth levels rise, infant and under-5 mortality rates lower. While the infant mortality rate is 62 for the wealthiest quintile, it is 75 for the poorest quintile. Infant mortality for mothers with no education is 74, while it is notably lower (55) for mothers with secondary education or higher. Given that for other countries in the region that are comparatively more stable than Afghanistan, such as India and Bangladesh, the speed of reduction in U5MR and IMR is less than 4% per year over the past two decades, the AMICS findings on child mortality should be interpreted with caution. Nutrition One in four children under age five in Afghanistan is moderately and severely underweight (25%), one in two is moderately stunted (52%) and almost one in seven is moderately or severely wasted (14%). Children in the Southern region are more likely to be underweight, stunted and wasted than other children. The same pattern is observed for children living in rural areas, and for children whose mothers have secondary education or higher. Only 54% of babies are breastfed for the first time within one hour of birth, while 84% of newborns in Afghanistan start breastfeeding within one day of birth, with notable differences by region. Women who delivered in a public sector health facility were most likely to have breastfed within the first hour of birth (62%) and within the first day of birth (89%), compared to women who delivered in a private sector health facility, at home, or in another location. Approximately 54% of children aged less than six months are exclusively breastfed. Even at the earliest ages, almost 40% of children are receiving liquids or foods other than breast milk, which puts them at increased risk of consuming contaminated foods and water. By the end of the sixth month, the percentage of children exclusively breastfed is below 30%. Overall, only 37% of children aged 0-23 months are being adequately breastfed, with a radical decrease in appropriate feeding practice observed among infants aged 6-23 months in the Southern and South Eastern regions. Only 20% of households are consuming adequate levels of iodized salt, with use lowest in the Western region (9%) and highest in the Central region (52%), and a considerable gap found in consumption between urban (41%) and rural (16%) areas. Within the six months prior to survey, 51% of children aged 6-59 months received a high dose Vitamin A supplement, with significant variation in coverage by region, with the lowest in the Southern region (19%). The mother s level of education is related to the likelihood of Vitamin A supplementation. Anaemia, which poses an increased risk of child mortality, has prevalence among children aged 6-59 months of 34%. Overall, xx the prevalence of anaemia among pregnant women aged 15-49 is 16%, and among non-pregnant women aged 15-49, it is 21%. Child Health The data present major concerns with the reach of vaccination coverage in Afghanistan. Only 18% of children aged 12-23 months are fully vaccinated, one in four children receive no vaccination before age 1, and only 31% of children had vaccination cards. For vaccines with multiple dosages, coverage declines with the dosage, with the highest coverage at the first dosage. For instance, 66% of children received Polio 1 by the age of 12 months and this declines to 42% by the third dose. The coverage for the measles vaccine by 12 months reaches 44%. The mother s education appears to be a factor significantly influencing children s immunization rates, with higher educational attainment being linked to higher immunization rates. This is also the case for women s protection against tetanus, with her education level and wealth index quintile influencing the likelihood of protection. Only 41% of women with a birth in the last two years are protected against tetanus. Overall, 23% of children under age five had diarrhoea in the two weeks preceding the survey, with prevalence varying by region. Approximately 64% of children with diarrhoea received oral rehydration salt or any recommended home fluid. Less than half of children were given oral rehydration treatment with continued feeding during diarrhoeal episodes. It was found that 19% of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, 61% were taken to an appropriate provider. In Afghanistan, 19% of children were taken to a governmental hospital for treatment of suspected pneumonia, and 64% of children under-5 with suspected pneumonia had received an antibiotic during the two weeks prior to the survey. Overall, only 15% of women know of the two danger signs of pneumonia fast and difficult breathing. Overall, most households (84%) in Afghanistan are using solid fuels for cooking. Use of solid fuels is low in urban areas (33%), but very high in rural areas, where almost all of the households (95%) are using solid fuels. Differentials with respect to household wealth and the educational level of the household head are also significant. In urban areas, 73% of households cook with solid fuel in a separate room used as a kitchen, while 66% of rural households do so. More than half of households cook with solid fuel in a separate room in most regions, except in the Western region where only 44% of households do so. Water and Sanitation Overall, 57% of the Afghan population is using an improved source of drinking water, including 82% who use an improved source in urban areas and 51% who are using an improved source in rural areas, though the source of drinking water for the population varies significantly by region. With high regional, wealth and other variations, overall there exists a wide range of practices in the disposal of human excreta. In Afghanistan, 31% of the population live in households using improved sanitation facilities, including 60% in urban areas and 25% in rural areas. Use of improved sanitation facilities is strongly correlated with wealth, and also differs profoundly between urban and rural areas. Nationally, 29% of households use an improved sanitation facility that is not shared with other households. The percentage using improved and unshared sanitation facilities is significantly higher in urban areas (51%) than in rural areas (24%). xxi Nationally, it was observed that 60% of households use a specific place for hand washing. Of those households where a designated place for hand washing was observed, 71% had both water and soap present at the designated place. Reproductive Health Despite the significant risks of early childbearing to mother and child, 10% of women in Afghanistan aged 15-19 have already had a birth and 4% are pregnant with their first child; therefore, 14% have begun childbearing. Alarmingly, 2% have had a live birth before the age of 15. One in four women age 20-24 years have had already a live birth before reaching age 18. There are strong correlations between early childbearing and mothers education levels. Contraception use is extremely low with almost 80% of women not using any form of contraception. Of those women who do use contraception, the most popular method is use of injectables followed by the pill. The percentage of women using any method of contraception rises from 20% among those with no education to 27% among women with primary education, and to 38% among women with secondary education or higher. Coverage of antenatal care (by a doctor, nurse, or midwife) is low in Afghanistan with 48% of women receiving antenatal care at least once by skilled health personnel during the pregnancy. Overall, recommended antenatal care is inconsistent, with recommended practices applied only in a minority of cases. Among women who have given birth to a child during the two years preceding the survey, only 12% of pregnant women had antenatal care visits where their blood pressure was measured, and urine and blood tested. Doctors assisted with the delivery of 20% of births, nurses or midwives assisted with 16% of births, and auxiliary midwives assisted with 2% of births. More than 60% of births were delivered with the assistance of non-skilled personnel. Almost 33% of births in Afghanistan are delivered in a health facility. More than half of births (65%) occur at home. Women in urban areas (66%) are more than twice as likely to deliver in a health facility as their rural counterparts (25%). Child Development Only 1% of children aged 36-59 months are attending pre-school in Afghanistan. While exceedingly low overall, the attendance figure is still eight times higher in urban areas (4%), compared to rural areas (0.5%), with variances by socioeconomic status. For more than two-thirds (73%) of under- five children, an adult household member engaged in more than four activities that promote learning and school readiness during the three days preceding the survey, such as reading a book, singing a song, or playing, with fathers involvement in such activities accounting for two thirds of instances. Only 2% of children aged 0-59 months are living in households where at least three children s books are present, and the proportion of children with 10 or more books declines to less than 0.5%. Of children aged 0-59 months, 53% had two or more play items in their homes. With regards to inadequate care, it was found that 40% of children had recently either been left alone or in the care of another child. Literacy and Education One in five Afghan women aged 15-24 are literate. The women s literacy rate in rural areas is more than three times lower than in urban areas. Of women who stated that primary school was their highest level of education attained, only 29% were actually literate. Literacy among women living in the poorest households is 10 times lower than their counterparts in the wealthiest quintile. xxii In 2010/2011, 29% of school eligible children were attending the first grade of primary school, with significant regional disparities. In the Southern region, for instance, the school attendance indicator is below 12%, but 45% in the Eastern region. Children s entry into primary school is timelier in urban areas (43%) than in rural areas (26%). Only 55% of children of primary school age are attending school, with disparities between urban and rural areas, and about 68% of secondary school age children are not attending school. The secondary school net attendance rate for girls is more than two times lower than that of boys. Of all children starting Grade 1, nearly four in five will eventually reach the last grade, and the majority of the children who successfully completed the last grade of primary school (93%) were attending the first grade of secondary school. Gender parity for primary school is 0.74, indicating a difference in the attendance of girls and boys in primary school. The indicator drops to 0.49 for secondary education, with a particularly pronounced inequity for girls in the Southern region. Child Protection The births of 63% of children under five years of age in Afghanistan have not been registered. Child labour is very prevalent, with 25% of children aged between 5 and 14 participating in labour activities. Of children aged 2-14 years, 74% have been subjected to at least one form of psychological or physical punishment by their mothers/caretakers or other household members, and 38% of children were subjected to severe physical punishment. The majority (94%) of children aged 0-17 years in Afghanistan live with both of their parents, with around 2% living with neither parent. While still high overall, the data suggests that early marriage is on the decrease in Afghanistan. Still, one in five women aged 15-19 years is already married. Overall, 15% of women surveyed were married before the age of 15, while 46% were married before the age of 18. Early marriage is strongly correlated to education: young women without education are more than three times as likely to be married before the age of 18 than are their counterparts who have secondary education or higher. The survey found that about 7% of women aged 15-49 years are in a polygamous marriage. The AMICS considered spousal age difference and found that 11% of women aged 15-19 and 14% of women aged 20-24 are married to men at least ten years older than them. A finding of great concern was that the majority (92%) of women surveyed feel that their husband is justified in using physical violence against them, for any specific reason. HIV and AIDS Afghanistan is considered to be a country with low HIV prevalence, but at high risk for an outbreak. The survey found that one in four women aged 15-49 (26%) had heard of AIDS. However, only 2% have comprehensive and correct knowledge of HIV prevention and transmission. Numerous disparities were found in HIV/AIDS awareness and knowledge levels. For instance, more than half (55%) of urban dwelling women had heard of AIDS, compared to 21% of rural women. One in five women (21%) knows that HIV can be transmitted from mother to child. The percentage of women who know all three ways of mother-to-child transmission is 8%, while 4% of women did not know of any specific way. 1 2 Background This report is based on the Afghanistan Multiple Indicator Cluster Survey (AMICS), conducted in 2010-2011 by the Central Statistics Organisation (CSO) of the Government of the Islamic Republic of Afghanistan. The survey provides valuable information on the situation of children and women in Afghanistan, and was based in large part on the needs to monitor progress towards goals and targets emanating from recent international agreements such as the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task. A Commitment to Action National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning (A World Fit for Children, paragraph 60). We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions (A World Fit for Children, paragraph 61). The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: As the world s lead agency for children, the United Nations Children s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action. Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action. 3 The Government of Afghanistan ratified the Convention on the Rights of the Child (CRC) in 1994 and the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) was signed in 1980, but ratified only in 2003 (without reservations). Ratification of these conventions are aimed at fulfilling the human rights of women and children as per international law and in accordance with global commitments made towards improving the status of women and children worldwide. Due to political instability under the Taliban regime, which was in power at the time the Millennium Declaration was issued, Afghanistan endorsed the Millenium Development Goals (MDGs) only in 2004, and was granted an extension to meet the MDG targets by 2020 rather than by 2015. A ninth Development Goal was also added for Afghanistan, that of ensuring security as a precondition for development. The Government of Afghanistan has worked with the international community to develop various tools to help measure human development indicators. The most extensive of these tools is the National Risk and Vulnerability Assessment (NRVA) of 2007-2008. The NRVA is Afghanistan s most comprehensive source of statistical information to date, providing a wide range of information on conditions such as poverty and wealth, the labour force, health, the status of women, education, and housing and agriculture, among others. The NRVA was a key step in collecting information that would assist in developing policies and programs that would target the most vulnerable citizens of Afghanistan. While less extensive, the AMICS provides updated, complementary and comparative data to the NRVA, and is an additional data tool that will further help track progress towards the country s development objectives, particularly those aimed at women and children. Since 2004, Afghanistan has made important progress across many human development indicators, as the country has embarked upon an ambitious rebuilding effort. Government services have been reinstated, helping to meet basic needs in many parts of the country, from the expansion of primary education to an increase in access to basic healthcare. Yet, poverty continues to characterize the lives of much of the population. The Central Statistics Organization of Afghanistan estimates that 36% of the population, approximately 10 million people, live in poverty in the country. Food insecurity is an ongoing vulnerability, and many people are still unable to access basic guarantees of human security such as safe drinking water, sanitation, or housing. Social inequalities are widespread and threaten to undermine the economic growth that has been achieved over the last decade. The ongoing violence is another destabilizing factor, which systematically victimizes women and children, and renders poor people even more vulnerable. The Afghan Government is seeking to reduce poverty and raise human development indicators, as reflected in the policy efforts mentioned earlier. Having accurate and reliable data on hand is critical to designing strong evidence-based interventions that will be responsive to the needs of Afghan citizens. This data should also inform the work of all stakeholders to Afghanistan s humanitarian and development assistance efforts, including donor governments, multilateral agencies, international non-governmental organizations (NGOs), and Afghan civil society. Much remains to be done to fulfil the commitments made to better protecting and promoting the basic rights of Afghan children and women. 4 The AMICS was carried out by Afghanistan s Central Statistics Organization (CSO), with the technical and financial assistance of UNICEF. The AMICS is a nationally representative sample of 13,468 selected households. The survey was designed to produce representative estimates of indicators for Afghanistan as a whole, for urban and rural areas, and for each of the country s eight regions (Central, Central Highlands, East, North, North East, South, South East and West). A stratified two-stage cluster sample design was used in the AMICS. Questionnaires for the household, for women, and for children were administered in each sampled household. The methodology is described in further detail in Chapter Two. The results of the AMICS are presented in ten chapters: (3) characteristics of household and population, (4) child mortality, (5) nutrition, (6) child health, (7) water and sanitation, (8) reproductive health, (9) child development, (10) literacy and education, (11) child protection, and (12) HIV and AIDS. The findings chapters share the data in table format, highlight key aspects of the results, and provide relevant methodological information that helps to further illuminate the data. This final report presents the results of the indicators and topics covered in the survey. As a report sharing the findings of a complex survey covering a multitude of indicators across several major sectors, the AMICS report has as its purpose to present the key findings resulting from the collection of data. It is beyond the scope of the report to analyze the findings or speculate on causes for survey results, though it is hoped that the data presented here will serve other stakeholders in better understanding the causes and consequences of these findings. Survey Objectives The primary objectives of the AMICS 2010-2011 include the following: To provide up-to-date information for assessing the situation of children and women in Afghanistan; To generate data on the situation of children and women, including the identification of vulnerable groups and of disparities. To furnish data required for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals; To serve as the evidence basis for future action and programming design, and to inform relevant policies and interventions; To contribute to the improvement of data and monitoring systems in Afghanistan and to strengthen technical expertise in the design, implementation, and analysis of such systems. 5 6 Sample Design The sample for the AMICS was designed to provide estimates for a large number of indicators on the situation of children and women at the national level, for urban and rural areas, in eight regions: Central, Central Highlands, East, North, North East, South, South East, and West. The list of provinces by region is shown below: Name of Region Name of Province Name of Region Name of Province Central Kabul Wardak Kapisa Logar Parwan Panjsher North East Baghlan Takhar Badakhshan Kunduz Central Highlands Bamyan Daikundi South Uruzgan Helmand Zabul Nimroz Kandahar East Nangarhar Kunar Laghman Nooristan South East Ghazni Paktya Paktika Khost North Samangan Sar-e-Pul Balkh Jawzjan Faryab West Ghor Herat Badghis Farah Figure 2.1: Map Showing Regions Sampled 7 A stratified two-stage sample design was used for the AMICS. The primary sampling units (PSUs) are the enumeration areas (EAs), which are segments with well-defined boundaries delineated by the CSO within each administrative unit for the purposes of census enumeration. The EAs have an average of about 185 households each, which is a reasonable size for conducting a new listing of households. The sampling frame has a total of 21,194 EAs covering the territory of Afghanistan. The frame was based on a quick count of the households and population in each EA that the CSO had previously conducted in preparation for the census. For the calculation of the sample size, the key indicator used was the rate of fully immunized children from 12 to 23 months. The urban and rural areas within each region were identified as the main sampling strata and the sample was selected in two stages. Within each stratum, a specified number of EAs were selected systematically with probability proportional to size as the first stage. After a household listing was carried out within the selected EAs, a systematic sample of 30 households was drawn in each sample EA as the second stage. The selection of 30 households per sample EA was based on the consideration of the high costs of transportation, logistics for the fieldwork, and cost-effective cluster size. Sample Coverage Table 2.1 shows the number of households, women, men, and children under five by results of the household, women's, men's and under-5's interviews, and household, women's, men's and under-5's response rates. Table 2.1: Results of household, women's, men's and under-5 interviews Number of households, women, men, and children under 5 by results of the household, women's, men's and under-5's interviews, and household, women's, men's and under-5's response rates, Afghanistan, 2010-2011 Residence Region Total Urban Rural Central Central Highlands East North North East South South East West Households Sampled 3,681 9,787 2,763 1,203 1,591 1,949 1,831 1,352 1,314 1,465 13,468 Visited 3,634 9,680 2,717 1,174 1,586 1,932 1,819 1,340 1,309 1,437 13,314 Interviewed 3,545 9,571 2,626 1,164 1,571 1,922 1,811 1,309 1,280 1,433 13,116 Household response rate 97.6 98.9 96.7 99.1 99.1 99.5 99.6 97.7 97.8 99.7 98.5 Women Eligible 5,962 16,091 4,650 1,907 2,320 2,935 3,265 2,251 2,809 1,916 22,053 Interviewed 5,740 15,550 4,423 1,781 2,276 2,904 3,222 2,228 2,597 1,859 21,290 Women's response rate 96.3 96.6 95.1 93.4 98.1 98.9 98.7 99.0 92.5 97.0 96.5 Women's overall response rate 93.9 95.5 91.9 92.6 97.2 98.4 98.2 96.7 90.4 96.8 95.1 Children under 5 Eligible 3,633 11,694 2,795 1,402 1,834 2,112 2,165 1,469 2,302 1,248 15,327 Mothers/caretakers interviewed 3,529 11,343 2,703 1,321 1,814 2,104 2,134 1,450 2,131 1,215 14,872 Under-5's response rate 97.1 97.0 96.7 94.2 98.9 99.6 98.6 98.7 92.6 97.4 97.0 Under-5's overall response rate 94.8 95.9 93.5 93.4 98.0 99.1 98.1 96.4 90.5 97.1 95.6 8 Of the 13,468 households selected for the sample, 13,314 were visited. Of these, 13,116 were successfully interviewed for a high household response rate of 98.5%. In the interviewed households, 22,053 women (age 15-49 years) were identified. Of these, 21,290 were successfully interviewed, yielding a response rate of 96.5% within interviewed households. In addition, 15,327 children under age five were listed in the household questionnaire. Questionnaires were completed for 14,872 of these children, corresponding to a response rate of 97% within interviewed households. Overall, response rates of 95.6% are calculated for interviews with women and children under age five (Table 2.1). A reserve sample of EAs was also selected within each stratum (using the same type of systematic PPS selection) to be used as possible replacements in extreme cases where the security situation for an original sample EA made it difficult to enumerate. A total of 102 sample EAs were selected as possible replacements. During the MICS fieldwork, 423 of the original 516 sample EAs were enumerated, and 26 replacement EAs were enumerated; while the remaining 67 sample EAs were not replaced. Therefore the final sample in the AMICS data file includes 449 sample EAs; thus there was an overall reduction in the effective sample size. Of the 516 EAs, 67 were not accessible due to high insecurity during the fieldwork period. The sample was stratified by region and by urban/rural divide, and is not self-weighting. For reporting national level results, sample weights are used. For all tables mentioning the background characteristic of mother s educational level, up to a maximum of seven cases out of 14,872 cases, and for all tables mentioning the background characteristic of household head s educational level, up to maximum of eleven cases out of 13,116 cases, are missing. For this reason, the sums for each educational level do not equal the total number of cases shown in the tables where these background characteristics are shown. A subsample was administered to test blood in some households for anaemia. The results of the anaemia test subsample are included in Chapter 5, and a description of how the subsample was selected can be found in Appendix A, along with a more detailed description of the overall sample design. Contents of Questionnaires Three sets of questionnaires were used in the survey: 1) A household questionnaire used to collect information on all de jure household members (usual residents), on the household, and on the dwelling; 2) A women s questionnaire administered in each household to all women aged 15-49; 3) An under-five questionnaire administered to all mothers or caretakers for all children under the age of five living in the household. The Questionnaire for the household included the following modules: o Household Listing Form o Education o Water and Sanitation o Household Characteristics o Child Labour o Child Discipline o Hand washing o Salt Iodization 9 The Questionnaire for individual women included the following modules: o Woman s Background o Child Mortality o Desire for Last Birth o Maternal and Newborn Health o Illness Symptoms o Contraception o Attitudes Towards Domestic Violence o Marriage o Anthropometry1 o HIV/AIDS o Blood Test for Anaemia2 The Questionnaire for Children Under Five3 was normally administered to mothers of children under the age of five; however, in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Age o Birth Registration o Early Childhood Development o Breastfeeding o Care of Illness o Immunization o Anthropometry o Blood Test for Anaemia4 The questionnaires are based on the MICS4 model questionnaire5. From the MICS4 model English version, the questionnaires were translated into Dari and Pashto, and were pre-tested in Kabul province (Kabul city district and Farza district) and Parwan province (Charikar city district and Bagram district) during May 2010. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the AMICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the place and facilities used for hand washing, measured the weights and heights of children aged less than five years, and tested the blood of children aged under five and the blood of women aged between 15 and 49 years. Details and findings of these measurements are provided in the respective sections of the report. Training and Fieldwork Training for the fieldwork was conducted for 21 days in August and September 2010. Training included lectures on interviewing techniques and the contents of the questionnaires, in addition 1 This module is country-specific. 2 This module has been added to the Afghanistan adapted version of MICS. 3 The terms children under 5 , children age 0-4 years , and children aged 0-59 months are used interchangeably in this report. 4 This module has been added to the Afghanistan adapted version of MICS. 5 The model MICS4 questionnaires can be found at www.childinfo.org/mics4_questionnaire.html. 10 to mock interviews between trainees to gain practice in asking questions. Towards the end of the training period, trainees spent three days holding practice interviews in Kabul. For the fieldwork, data were collected by 66 teams. Each team was comprised of six interviewers (three females, three males), two editors (one female editor/measurer) and a supervisor. Fieldwork began in October 2010 and concluded in May 2011. Data Processing Data were entered using the CSPro software. The data were entered onto 24 microcomputers and carried out by 24 data entry operators, two data entry supervisors and one data processing manager. In order to ensure quality control, all questionnaires were double entered and internal consistency checks performed. Procedures and standard programs developed under the global MICS4 programme and adapted to the Afghanistan questionnaire were used throughout the processing. Data processing was completed in August 2011. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 18, and the model syntax and tabulation plans developed by UNICEF were used for this purpose. 11 12 Characteristics of Households Table 3.1 provides basic background information on the households, with both weighted and unweighted numbers. Within households, the sex of the household head, region, residence, number of household members, and education of household head are shown. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report, and provide important details to the interpretation of the data by respondents characteristics. The remaining tables in this report are presented only with weighted numbers. See Appendix A for more details about the weighting. The weighted and unweighted numbers of households are equal, since sample weights were normalized (See Appendix A). The table also shows the proportions of households with at least one child under 18, at least one child under five, and at least one eligible woman aged 15-49. The table also shows the weighted average household size estimated by the survey. Table 3.1: Household composition Percent and frequency distribution of households by selected characteristics, Afghanistan, 2010-2011 Weighted percent Number of households Weighted Unweighted Sex of household head Male 99.1 13,003 12,977 Female 0.9 113 139 Region Central 16.5 2,159 2,626 Central Highlands 3.3 432 1,164 East 11.6 1,520 1,571 North 14.6 1,913 1,922 North East 15.9 2,091 1,811 South 12.1 1,584 1,309 South East 9.6 1,263 1,280 West 16.4 2,155 1,433 Residence Urban 18.5 2,427 3,545 Rural 81.5 10,689 9,571 Number of household members 1 0.2 20 23 2 2.8 373 343 3 4.6 599 567 4 8.1 1,064 1,040 5 10.5 1,375 1,416 6 12.7 1,667 1,716 7 12.7 1,668 1,668 8 12.7 1,664 1,703 9 10.4 1,360 1,339 10+ 25.4 3,326 3,301 Education of household head None 68.0 8,922 8,460 Primary 11.4 1,498 1,567 Secondary + 20.5 2,689 3,078 13 Percent and frequency distribution of households by selected characteristics, Afghanistan, 2010-2011 Weighted percent Number of households Weighted Unweighted Total 100.0 13,116 13,116 Households with at least One child age 0-4 years 69.0 13,116 13,116 One child age 0-17 years 94.2 13,116 13,116 One woman age 15-49 years 96.3 13,116 13,116 Mean household size 7.8 13,116 13,116 Characteristics of the Population The weighted age and sex distribution of the survey population is provided in Table 3.2. The distribution is also used to produce the population pyramid in Figure 3.1. Table 3.2: Population distribution by age and sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Afghanistan, 2010-2011 Males Females Total Number Percent Number Percent Number Percent Age 0-4 7,972 15.0 7,503 15.4 15,475 15.2 5-9 8,928 16.8 8,267 17.0 17,195 16.9 10-14 7,500 14.1 6,899 14.2 14,399 14.2 15-19 6,578 12.4 5,748 11.8 12,326 12.1 20-24 4,750 8.9 4,271 8.8 9,021 8.9 25-29 3,589 6.8 3,673 7.6 7,262 7.1 30-34 2,747 5.2 2,494 5.1 5,241 5.2 35-39 2,238 4.2 2,427 5.0 4,664 4.6 40-44 1,965 3.7 1,846 3.8 3,811 3.7 45-49 1,562 2.9 1,474 3.0 3,036 3.0 50-54 1,385 2.6 1,648 3.4 3,033 3.0 55-59 956 1.8 788 1.6 1,743 1.7 60-64 1,211 2.3 688 1.4 1,899 1.9 65-69 554 1.0 327 0.7 881 0.9 70-74 662 1.2 290 0.6 952 0.9 75-79 215 0.4 92 0.2 307 0.3 80-84 200 0.4 90 0.2 290 0.3 85+ 128 0.2 47 0.1 175 0.2 Dependency age groups 0-14 24,400 45.9 22,668 46.7 47,069 46.3 15-64 26,981 50.8 25,056 51.6 52,037 51.2 65+ 1,759 3.3 846 1.7 2,605 2.6 Child and adult populations Children age 0-17 years 28,304 53.3 25,988 53.5 54,292 53.4 Adults age 18+ years 24,835 46.7 22,583 46.5 47,418 46.6 Total 100.0 100.0 100.0 In the 13,116 households successfully interviewed in the survey, 101,713 household members were listed. Of these, 53,140 were males, and 48,573 were females. 14 Characteristics of Female Respondents 15-49 Years Tables 3.3 and 3.4 provide information on the background characteristics of female respondents aged 15-49 years and of children under age five. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in subsequent tabulations found in this report. Table 3.3 provides background characteristics of female respondents 15-49 years of age. The table includes information on the distribution of women according to region, residence, age, marital status, motherhood status, births in the last two years, education6, and wealth index quintiles. Principal components analysis was performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household s wealth to assign weights (factor scores) to each of the household assets. Each household was then assigned a wealth score based on these weights and the assets owned by that household. The survey household population was then ranked according to the wealth score of the household they are living in, and was finally divided into five equal parts (quintiles) from lowest (poorest) to highest (wealthiest). The assets used in these calculations Unless otherwise stated, throughout this report education refers to educational level attained by the respondent when used as a background variable. 15 were as follows: household water source, sanitation facility, number of persons per sleeping room, type of floor, type of roof, type of wall, type of cooking fuel, TV, radio, refrigerator. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to wealthiest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. Table 3.3: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Afghanistan, 2010-2011 Weighted percent Number of women Weighted Unweighted Region Central 17.4 3,696 4,423 Central Highlands 3.4 714 1,781 East 10.1 2,153 2,276 North 13.5 2,876 2,904 North East 17.6 3,752 3,222 South 12.6 2,672 2,228 South East 12.8 2,731 2,597 West 12.7 2,695 1,859 Residence Urban 18.9 4,031 5,740 Rural 81.1 17,259 15,550 Age 15-19 25.9 5,510 5,579 20-24 19.3 4,110 4,139 25-29 16.8 3,579 3,546 30-34 11.6 2,460 2,434 35-39 11.2 2,389 2,420 40-44 8.5 1,805 1,759 45-49 6.8 1,438 1,413 Marital status Currently married 69.4 14,757 14,521 Widowed 1.5 316 326 Divorced/Separated 0.1 18 21 Never married 29.1 6,185 6,411 Motherhood status Ever gave birth 64.1 13,640 13,468 Never gave birth 35.9 7,650 7,822 Births in last two years Had a birth in last two years 22.9 4,865 4,962 Had no birth in last two years 77.1 8,775 8,506 Education None 81.5 17,359 16,621 Primary 7.5 1,595 1,767 Secondary + 10.9 2,330 2,899 Wealth index quintile Poorest 18.7 3,989 3,513 16 Percent and frequency distribution of women age 15-49 years by selected background characteristics, Afghanistan, 2010-2011 Weighted percent Number of women Weighted Unweighted Second 19.5 4,143 3,869 Middle 19.9 4,227 3,997 Fourth 20.4 4,333 4,250 Richest 21.6 4,598 5,661 Total 100.0 21,290 21,290 Of the 21,290 female respondents aged 15-49 years, 81% live in rural areas, while 19% live in urban areas. The largest age group segment featured in the survey was the ages 15-19 category (26%), followed by the ages 20-24 category (19%). The smallest segment is the ages 45-49 category (7%). A high proportion of the women interviewed were married (69%), while 29% had never been married, less than 2% were widowed, and 0.1% were divorced or separated. The majority of the women (64%) had given birth at least once in their lifetime, 36% had never given birth at the time of the survey, and 23% had given birth in the previous two years. Of note is that most of the women respondents (82%) had no formal education, while 8% had primary level education only, and 11% had attained secondary level education or higher7. This signals continued overall low levels of formal education among women, even more than ten years after the end of the Taliban regime. Women respondents aged 15-49 were fairly evenly distributed among the five wealth quintiles, with 22% were in the wealthiest quintile, and 19% in the poorest quintile. The largest sample of women is represented by the Central region (17%), while the smallest is found in the Central Highlands region (3%). If the unweighted figure is higher than the weighted, it signifies that the women in any domain were oversampled by selection, and vice versa. This means that, for example, women in the Central Highlands region were under-sampled by selection while women living in the West region and in rural areas were over-sampled by selection. Characteristic of Children Under Age 5 Some background characteristics of children under age five are presented in Table 3.4. These include the distribution of children by several attributes: sex, region and residence, age, mother s or caretaker s education, and wealth. Table 3.4: Under-5s background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Afghanistan, 2010-2011 Weighted percent Number of under-5 children Weighted Unweighted Sex Male 51.5 7,653 7,607 Female 48.5 7,218 7,265 Region 7 In the AMICS, secondary education is combined with post-secondary education. 17 Percent and frequency distribution of children under five years of age by selected characteristics, Afghanistan, 2010-2011 Weighted percent Number of under-5 children Weighted Unweighted Central 15.0 2,230 2,703 Central Highlands 3.5 517 1,321 East 11.2 1,667 1,814 North 14.0 2,087 2,104 North East 16.6 2,464 2,134 South 11.9 1,774 1,450 South East 15.5 2,308 2,131 West 12.3 1,825 1,215 Residence Urban 16.1 2,398 3,529 Rural 83.9 12,474 11,343 Age 0-5 months 8.1 1,202 1,270 6-11 months 7.0 1,042 1,100 12-23 months 16.8 2,497 2,535 24-35 months 21.6 3,220 3,185 36-47 months 23.1 3,438 3,379 48-59 months 23.4 3,474 3,403 Mother s education* None 91.0 13,532 13,198 Primary 4.7 698 831 Secondary + 4.3 634 839 Wealth index quintile Poorest 20.9 3,101 2,788 Second 21.4 3,190 2,984 Middle 20.3 3,015 2,882 Fourth 20.1 2,983 2,967 Richest 17.4 2,583 3,251 Total 100.0 14,872 14,872 * Mother's education refers to educational attainment of mothers and caretakers of children under 5. Of the children under five (Table 3.4), 51% were male and 49% were female, with most (84%) residing in rural areas. The largest segment represented are those children aged 48-59 months (23%), while the lowest represented are those aged 0-11 months (15%). The vast majority of the mothers of these children have attained no formal education (91%), while 5% had attained primary education and 4% had attained secondary education or higher. In terms of wealth, the children surveyed are quite evenly distributed across households of different wealth quintiles, with 21% in the poorest quintile, and 17% in the wealthiest quintile. 18 19 Introduction: Child Mortality One of the overarching goals of the MDGs is the reduction of infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two-thirds between 1990 and 2015. The infant mortality rate is the probability of dying before the first birthday. The under-five mortality rate is the probability of dying before the fifth birthday. Monitoring progress towards this goal is an important but challenging objective. Measuring childhood mortality is a complex process. For instance, attempts using direct questions such as Has anyone in this household died in the last year? often give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to the training and supervision of surveyors. Alternatively, indirect methods developed to measure child mortality produce estimates that are comparable with the ones obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing technique. Child Mortality Estimates for Afghanistan In MICS surveys, infant and under five mortality rates are calculated based on an indirect estimation technique known as the Brass method8. The data used in the estimation are: the mean number of children ever born for five year age groups of women from age 15 to 49, and the proportion of these children who are dead, also for five-year age groups of women (Table 4.1). The technique converts the proportions dead among children of women in each age group into probabilities of dying by taking into account the approximate length of exposure of children to the risk of dying, assuming a particular model age pattern of mortality. The West model life table was selected, as it is most appropriate for Afghanistan, based on recommendations in the United Nations Manual X: Indirect Techniques for Demographic Estimation. Table 4.1: Children ever born, children surviving and proportion dead Children ever born Children surviving Proportion dead Number of women Mean Total Mean Total Age 15-19 0.130 716 0.121 664 0.072 5,510 20-24 1.194 4,905 1.094 4,496 0.083 4,110 25-29 3.024 10,823 2.751 9,844 0.090 3,579 30-34 4.714 11,596 4.241 10,433 0.100 2,460 35-39 6.128 14,636 5.440 12,993 0.112 2,389 40-44 6.756 12,197 5.871 10,600 0.131 1,805 45-49 7.173 10,313 6.107 8,781 0.149 1,438 Total 3.062 65,187 2.715 57,810 0.113 21,290 Table 4.2 provides estimates of child mortality. The infant mortality rate is estimated at 74 per thousand live births, while the probability of dying under age 5 (U5MR) is around 102 per 8 United Nations (1983). Manual X: Indirect Techniques for Demographic Estimation (United Nations publication, Sales No. E.83.XIII.2); United Nations (1990a); QFIVE, United Nations Program for Child Mortality Estimation. New York: UN Pop Division; United Nations (1990b). Step-by-step Guide to the Estimation of Child Mortality. New York: UN. 20 thousand live births. These estimates have been calculated by averaging mortality estimates obtained from women age 25-29 and 30-34.9 Table 4.2: Child mortality (Reference year 2005) Infant and under-five mortality rates, West Model, Afghanistan, 2010-2011 Infant mortality rate1 Under-five mortality rate2 Sex Male 78 106 Female 68 97 Region Central 66 90 Central Highlands 86 122 East 50 65 North 86 122 North East 71 99 South 54 71 South East 87 124 West 89 127 Residence Urban 63 85 Rural 76 105 Mother's education None 74 103 Primary 71 98 Secondary + 55 73 Wealth index quintile Poorest 75 104 Second 68 94 Middle 80 112 Fourth 80 113 Richest 62 84 Total 74 102 1 MICS indicator 1.2; MDG indicator 4.2; 2 MICS indicator 1.1; MDG indicator 4.1 As Table 4.2 shows, the infant mortality rate among males is 78, while it is 68 among females. The under-five mortality rate shows 106 among males and 97 among females. The male infant mortality is higher than the female rate because biologically, male infants are more vulnerable than female infants. There are wide regional variations found in infant and under-5 mortality rates. The West region has the highest U5MR and IMR (127 and 89 per thousand live births, respectively) and the East region has the lowest U5MR and IMR (65 and 50 per thousand live births, respectively). The U5MR in the West region is twice as high as in the East region, while the IMR figures for the Central, Central Highlands, North, North East, South East and West regions are all at least 22% higher than those of the East and South regions. In terms of rural-urban differences, the mortality rate is lower in urban areas than in rural areas. 9Note that further analyses are needed to explain the differences between administrative records and survey findings. 21 There are also differences in mortality in terms of mother s educational levels and household wealth. As education and wealth levels rise, infant and under-5 mortality rates lower. While the infant mortality rate is 62 for the wealthiest quintile, it is 75 for the poorest quintile. Infant mortality for the children of mothers with no education is 74, while it is notably lower (55) for the children of mothers with secondary education or higher. Differentials in under-5 mortality rates by selected background characteristics are shown in Figure 4.1. In the 2007-2008 National Risk and Vulnerability Assessment (NRVA), the infant mortality rate (IMR) was 111 (per thousand live births) and the under-five mortality rate (U5MR) was 161. The NRVA applied a similar sampling methodology to that used by AMICS, a provincially representative sample with 20,576 sample households enumerated. Like the AMICS, the NRVA used the indirect method for its child mortality module. 22 The child mortality findings from AMICS indicate that the reduction of the IMR and U5MR would be 11% and 12% annually, respectively. Table 4.3 shows the speed of reduction between 1990 and 2010 in U5MR in the South Asian region overall as well as some specific countries. Countries like Bangladesh, Bhutan and India are stabilized in terms of these indicators, and have seen a steady increase in the social and economic status of their populations. However, their speed of reduction in U5MR is less than 6% per year over the past two decades. Afghanistan experienced violent conflict during the last three decades, a near absence of social services in many areas, and a rapidly deteriorating human security situation in the last few years of the post-Taliban period. Its child immunization coverage is low, and child malnutrition levels are high. Table 4.3: Reduction in U5MR and IMR in South Asia U5MR 1990 2010 Average annual rate of reduction (percent) South Asia 120 67 2.9 Bangladesh 143 48 5.5 Bhutan 139 56 4.5 India 115 63 3.0 Source: Levels and Trends in Child Mortality, Report 2011, UN Inter-Agency Group for Child Mortality Estimation Considering the above noted regional comparisons and characteristics of the situation in Afghanistan, it can be concluded that the U5MR and IMR are under-estimated in the AMICS. The estimation of child mortality is complex, especially in a country such as Afghanistan. The mortality data resulting from any single survey cannot be reflected as a true value, unless a series of data from different surveys are found to be comparable, and thus validated. As UNICEF has previously noted: Generating accurate estimates of child mortality poses a considerable challenge because of the limited available of high-quality data for many developing countries. Complete vital registration systems are the preferred source of data on child mortality because they collect information as events occur and they cover the entire population. However, many developing countries lack fully functioning vital registration systems that accurately record all births and deaths.10 For these reasons, users are advised to interpret the child mortality data from the AMICS with caution. Progress on Child Mortality in Afghanistan To put child mortality in Afghanistan in historical perspective, in 1970 UNICEF reported Afghanistan s U5MR at 314. In 1990, the U5MR was estimated at 209 by UNICEF11 (and the IMR 10 See Child Mortality Methodology, www.childInfo.org. 11 Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation, Levels and Trends in Child Mortality: Report 2011. 23 was estimated at 140), a reduction by more than one third over that 20-year period. The AMICS 2010/11 estimates U5MR at 102. Thus, there has been laudable progress. However, Afghanistan s U5MR is still one of the highest child mortality rates in the world, with more than 1 in 10 children dying before their fifth birthdays. The vast majority of child deaths occurring in Afghanistan are preventable. Research undertaken by UNICEF has found that cost-effective, low-tech interventions such as vaccination programs, antibiotics, micronutrient supplementation, and improved family care and breastfeeding practices can help children survive into adulthood. The extent and impact of access to some of these programs are reported on in the next chapters of this report. 24 25 Introduction: Nutrition Children s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they can reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, they are more likely to have recurring sicknesses and faltering growth. Three-quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished showing no outward signs of their vulnerability. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also greatly assist in the goal of reducing child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on new WHO growth standards12. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for- age is more than two standard deviations below the median of the reference population are considered to be moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and from recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In the AMICS, weights and heights of all children under five years of age were measured using anthropometric equipment recommended by UNICEF13. Findings in this section are based on the results of these measurements. 12 WHO Child Growth Standards, WHO (2007). http://www.who.int/childgrowth/standards/second_set/technical_report_2.pdf 13 See www.childinfo.org. 26 Nutritional Status The prevalence estimates of the three key nutrition indicators are underweight 25%, stunting 52% and wasting 14% in Afghanistan based on anthropometric measurements during the field data collection. A detailed review of the anthropometric data and the three nutrition indicators by experts in UNICEF New York and Centre for Disease Control of United States raised questions around the quality of the data. During the analysis children with incomplete birth date (month and year) and children whose measurements are outside a plausible range are excluded from the estimates. Children are excluded from one or more of the anthropometric indicators when their weights and heights have not been measured, whichever applicable. For example, if a child was weighed but his/her height was not measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. The extent and reasons for these exclusions are shown in the data quality tables (see Appendix D: Tables D.6 and D.7). Based on the findings of the expert review, it was concluded that whilst the data provides a strong indication of a significant problem of malnutrition in children of age under five, the results are likely to be overestimates. It is recommended therefore that the AMICS anthropometric data is to be used with caution and should not be used as the sole evidence to trigger policy and program decisions. Breastfeeding, Infant and Young Child Feeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula. This can contribute to growth faltering and micronutrient malnutrition, and is also unsafe if clean water is not readily available. WHO and UNICEF have the following feeding recommendations: Exclusive breastfeeding for the first six months; Continued breastfeeding for two years or more; Safe, appropriate and adequate complementary foods beginning at six months; Frequency of complementary feeding: twice per day for 6 to 8-month-olds; and three times per day for 9 to 11-month-olds. It is also recommended that breastfeeding be initiated within one hour of birth. The indicators related to recommended child feeding practices are as follows: Early initiation of breastfeeding (within one hour of birth) Exclusive breastfeeding rate (< six months) Predominant breastfeeding (< six months) Continued breastfeeding rate (at one year and at two years) Duration of breastfeeding Age-appropriate breastfeeding (0-23 months) 27 Introduction of solid, semi-solid and soft foods (six-eight months) Minimum meal frequency (six-23 months) Milk feeding frequency for non-breastfeeding children (six-23 months) Bottle feeding (0-23 months) Table 5.1: Initial breastfeeding Percentage of last-born children in the two years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Afghanistan, 2010-2011 Percentage who were ever breastfed1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last- born children in the two years preceding the survey Within one hour of birth2 Within one day of birth Region Central 93.9 57.2 87.4 22.4 824 Central Highlands 96.4 45.5 84.7 22.1 196 East 84.7 52.5 78.1 26.2 491 North 96.6 53.3 87.6 33.9 743 North East 95.7 70.8 91.3 33.9 869 South 91.8 24.1 71.7 50.1 353 South East 93.6 37.4 77.4 28.0 726 West 92.5 63.5 87.6 25.1 662 Residence Urban 94.6 58.5 87.2 30.4 903 Rural 93.2 52.5 83.8 29.6 3,962 Months since last birth 0-11 months 93.6 54.5 84.3 29.5 2,340 12-23 months 93.2 52.7 84.6 30.1 2,525 Assistance at delivery Skilled attendant 94.6 59.1 87.0 29.0 1,880 Traditional birth attendant 95.7 51.9 86.9 34.4 1,463 CHW/Relative/Friend 96.5 52.8 85.9 28.3 1,294 Other 52.0 23.0 39.3 15.3 228 Place of delivery Public sector health facility 95.5 61.6 88.9 27.1 1,363 Private sector health facility 94.9 47.2 79.0 40.0 237 Home 95.4 52.3 85.7 31.1 3,149 Other 12.2 7.1 10.2 5.1 116 Mother s education None 93.1 53.0 83.8 29.8 4,311 Primary 95.5 63.2 89.4 32.0 286 Secondary + 96.1 53.3 88.9 26.9 268 Wealth index quintile Poorest 92.8 52.1 84.2 32.2 933 Second 93.4 55.1 85.8 29.8 1,029 Middle 93.5 54.6 83.9 28.0 993 Fourth 93.2 51.8 83.1 28.0 967 Richest 94.3 54.3 85.3 31.0 944 Total 93.4 53.6 84.5 29.8 4,865 1 MICS indicator 2.4; 2 MICS indicator 2.5 28 Table 5.1 provides the proportion of children born in the last two years who were ever breastfed, those who were first breastfed within one hour and within one day of birth, and those who received a prelacteal feed. Although a very important step in the management of lactation and in the establishment of a physical and emotional relationship between the baby and the mother, only half of babies (54%) are breastfed for the first time within one hour of birth, while 85% of newborns in Afghanistan start breastfeeding within one day of birth. Whereas there is no significant difference in the breastfeeding pattern between urban and rural areas, there is a remarkable difference by region (Figure 5.1). While 71% of newborns in the North Eastern region are initially breastfed within one hour of birth, less than a quarter of babies (24%) in the Southern region receive the initial breastfeeding just after birth. Women who did not deliver with either a skilled birth attendant or a traditional birth attendant present were far less likely to have breastfed within the first hour of delivery (23%) as well as within the first day of delivery (39%), and a remarkable 48% in this group never breastfed at all. Women who delivered in a public sector health facility were most likely to have breastfed within the first hour of birth (62%) and within the first day of birth (89%), compared to women who delivered in a private sector health facility, at home, or in another location. There was some difference found by mother s educational level in breastfeeding pattern, with a difference between mothers with no education at all and with secondary education and above found to be breastfeeding within the first hour of birth (53%), and mothers with primary education (63%). There was little difference by educational level in babies being breastfed within the first day of birth. 29 In Table 5.2, breastfeeding status is based on the reports of mothers/caretakers of children s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table below shows the degree to which there was exclusive breastfeeding of infants during the first six months of life, as well as continued breastfeeding of children at 12-15 months and at 20-23 months of age. Table 5.2: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Afghanistan, 2010-2011 Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent exclusively breastfed1 Percent predominantly breastfed2 Number of children Percent breastfed (Continued breastfeeding at 1 year)3 Number of children Percent breastfed (Continued breastfeeding at 2 years)4 Number of children Sex Male 53.5 66.8 611 90.4 502 71.0 284 Female 55.2 71.7 591 85.2 510 67.7 277 Region Central 54.1 68.0 204 72.5 171 54.0 92 Central Highlands 64.9 77.2 46 94.4 49 (74.2) 17 East 62.3 79.5 113 94.1 89 75.3 52 North 56.5 71.4 186 89.4 172 77.4 86 North East 49.1 70.0 235 93.9 220 59.3 56 South 48.1 48.1 46 95.3 101 89.5 85 South East 57.5 66.0 223 78.3 90 54.4 95 30 Percentage of living children according to breastfeeding status at selected age groups, Afghanistan, 2010-2011 Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent exclusively breastfed1 Percent predominantly breastfed2 Number of children Percent breastfed (Continued breastfeeding at 1 year)3 Number of children Percent breastfed (Continued breastfeeding at 2 years)4 Number of children West 47.8 68.2 150 89.2 120 77.4 77 Residence Urban 50.9 64.4 248 78.3 162 55.8 100 Rural 55.2 70.5 954 89.6 850 72.4 461 Mother s education None 55.4 69.7 1,039 88.8 913 70.2 510 Primary 58.8 76.0 80 70.5 51 (61.3) 26 Secondary + 36.4 57.5 84 87.0 47 (62.8) 25 Wealth index quintile Poorest 57.8 73.1 185 93.9 213 71.5 121 Second 54.2 71.6 257 89.8 230 80.3 121 Middle 54.6 67.8 235 90.7 210 72.6 116 Fourth 51.6 67.6 249 86.8 168 63.2 110 Richest 54.2 67.2 277 76.1 191 56.0 94 Total 54.3 69.2 1,202 87.8 1,012 69.4 561 1 MICS indicator 2.6; 2 MICS indicator 2.9; 3 MICS indicator 2.7; 4 MICS indicator 2.8 Figures in parenthesis indicate that the percentage is based on only 25-49 unweighted cases. Approximately 54% of children aged less than six months are exclusively breastfed. By age 12- 15 months, 88% of children are still being breastfed and by age 20-23 months, 69% are still breastfed. Although there is minimal difference between exclusive breastfeeding in girls (55%) and boys (53%), boys at 12-15 months (90%) and 20-23 months (71%) continue receiving breastfeeding more than girls (85% and 68% respectively). While children in the Western region are least likely to be exclusively breastfed, they are more likely to continue to be breastfed at two years of age compared to children from the South Eastern region and Central region. More interestingly, children living in the households falling in the richest quintile (54%) are slightly less breastfed than their peers in the poorest quintile (58%). In terms of the mother s education, mothers with secondary education or higher exclusively breastfed their children aged 0-5 months less so (36%) than mothers with primary education (59%). Figure 5.2 shows the detailed pattern of breastfeeding by children s ages in months. Even at the earliest ages, almost 40% of children are receiving liquids or foods other than breast milk. By the end of the sixth month, the percentage of children exclusively breastfed is below 30%. Only about 8% of children are receiving breast milk after two years. 31 Table 5.3 shows the median duration of breastfeeding by selected background characteristics. Table 5.3: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Afghanistan, 2010-2011 Median duration (in months) of Number of children age 0-35 months Any breastfeeding1 Exclusive breastfeeding Predominant breastfeeding Sex Male 23.5 3.1 5.9 4,106 Female 23.2 3.4 8.8 3,854 Region Central 21.6 3.2 7.3 1,269 Central Highlands 23.2 4.4 6.1 294 East 24.0 4.1 7.5 846 North 23.4 4.6 8.0 1,138 North East 23.7 2.3 7.0 1,332 South 29.5 2.3 2.3 750 South East 22.0 3.5 5.6 1,290 West 23.1 2.3 8.0 1,041 Residence Urban 21.8 2.7 5.4 1,391 Rural 23.6 3.5 7.8 6,570 Mother s education None 23.3 3.5 7.4 7,126 Primary 22.5 3.5 6.6 429 Secondary + 23.6 .7 5.5 402 Wealth index quintile Poorest 24.1 3.9 8.4 1,567 32 Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Afghanistan, 2010-2011 Median duration (in months) of Number of children age 0-35 months Any breastfeeding1 Exclusive breastfeeding Predominant breastfeeding Second 24.0 3.3 6.8 1,697 Middle 23.3 3.5 9.0 1,587 Fourth 22.6 2.8 8.0 1,608 Richest 21.9 3.2 5.6 1,502 Median 23.3 3.3 7.2 7,961 Mean 23.7 5.4 9.9 7,961 1 MICS indicator 2.10 Among children under age three, the median duration is 23 months for any breastfeeding, 3 months for exclusive breastfeeding, and 7 months for predominant breastfeeding (Table 5.3). There is no gender difference in the duration of any breastfeeding between boys and girls. Infants in rural areas receive a longer duration of any breastfeeding, exclusive breastfeeding and predominant breastfeeding than infants in urban areas. The median duration of exclusive breastfeeding is longer among infants from the Northern region (5 months) and Central Highlands region (4 months) than in other regions. The adequacy of infant feeding in children under 24 months old is provided in Table 5.4. Different criteria for adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as adequate feeding, while infants aged 6-23 months are considered to be adequately fed if they are receiving breast milk and solid, semi-solid or soft food. Table 5.4: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Afghanistan, 2010-2011 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed1 Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed2 Number of children Sex Male 53.5 611 31.6 1,801 37.2 2,412 Female 55.2 591 29.9 1,737 36.3 2,329 Region Central 54.1 204 25.7 595 33.0 798 Central Highlands 64.9 46 47.9 140 52.1 186 East 62.3 113 32.8 362 39.8 475 North 56.5 186 29.1 535 36.2 721 North East 49.1 235 40.2 628 42.6 863 South 48.1 46 18.8 304 22.6 350 South East 57.5 223 18.3 497 30.5 720 West 47.8 150 40.6 477 42.3 627 Residence Urban 50.9 248 32.8 652 37.8 900 Rural 55.2 954 30.3 2,887 36.5 3,841 Mother s education None 55.4 1,039 30.8 3,164 36.9 4,202 33 Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Afghanistan, 2010-2011 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed1 Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed2 Number of children Primary 58.8 80 33.6 201 40.7 281 Secondary + 36.4 84 26.2 174 29.5 258 Wealth index quintile Poorest 57.8 185 30.6 710 36.3 895 Second 54.2 257 33.9 758 39.0 1,014 Middle 54.6 235 26.5 708 33.5 943 Fourth 51.6 249 29.3 695 35.2 944 Richest 54.2 277 33.4 668 39.5 945 Total 54.3 1,202 30.8 3,539 36.7 4,741 1 MICS indicator 2.6; 2 MICS indicator 2.14 Of infants aged 0-5 months, 54% are adequately fed through exclusive breastfeeding, and 31% of infants aged 6-23 months are appropriately breastfed and receiving adequate feeding (Table 5.4). As a result of these feeding patterns, only 37% of children aged 0-23 months are being adequately breastfed. Infants at 0-23 months in the Central Highlands region are receiving the most adequate feeding by the age of two, compared to other regions. In the Southern and South Eastern regions, a radical decrease in appropriate feeding practice is observed among infants aged 6-23 months. Adequate complementary feeding of children from six months to two years of age is particularly important for growth and development and for the prevention of under-nutrition. Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary foods that help meet nutritional requirements when breast milk is no longer sufficient. This requires that for breastfed children, two or more daily meals of solid, semi-solid or soft foods are needed if they are 6-8 months old, and three or more meals daily if they are 9-23 months of age. For children 6-23 months and older who are not breastfed, four or more daily meals of solid, semi-solid or soft foods or milk feeds are needed. Table 5.5 shows the percentage of infants aged 6-8 months who received solid, semi- solid or soft foods during the previous day from the survey date. 34 Table 5.5: Introduction of solid, semi-solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day, Afghanistan, 2010-2011 Currently breastfeeding All Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods1 Number of children age 6-8 months Sex Male 19.8 331 20.6 351 Female 18.0 323 19.6 343 Residence Urban 25.8 133 27.1 139 Rural 17.2 522 18.3 554 Total 18.9 654 20.1 694 1 MICS indicator 2.12 Overall, 20% of infants aged 6-8 months received solid, semi-solid, or soft foods (Table 5.5). Among currently breastfeeding infants this percentage is 19%. Infants living in urban areas (27%) are better fed than those living in rural areas (18%). Table 5.6 presents the proportion of children aged 6-23 months who received semi-solid or soft foods the minimum number of times or more during the previous day according to breastfeeding status (see the note in Table 5.6 for a definition of minimum number of times for different age groups). Table 5.6: Minimum meal frequency Percentage of children age 6-23 months who received solid, semi-solid, or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the previous day, according to breastfeeding status, Afghanistan, 2010-2011 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid and soft foods the minimum number of times Number of children age 6-23 months Percent receiving at least 2 milk feeds1 Percent receiving solid, semi-solid and soft foods or milk feeds 4 times or more Number of children age 6-23 months Percent with minimum meal frequency2 Number of children age 6-23 months Sex Male 11.5 1,541 54.8 51.3 260 17.3 1,801 Female 11.0 1,456 63.7 56.7 281 18.4 1,737 Age 6-8 months 10.6 654 76.1 (59.2) 39 13.4 694 9-11 months 6.8 313 63.4 (62.5) 36 12.5 349 12-17 months 11.2 1,262 62.1 56.6 203 17.5 1,464 18-23 months 13.6 768 54.4 50.3 264 23.0 1,032 Region Central 10.1 443 65.2 60.5 151 22.9 595 Central Highlands 25.5 126 24.9 (21.2) 15 25.1 140 East 9.8 322 67.5 (73.5) 40 16.9 362 35 Percentage of children age 6-23 months who received solid, semi-solid, or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the previous day, according to breastfeeding status, Afghanistan, 2010-2011 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid and soft foods the minimum number of times Number of children age 6-23 months Percent receiving at least 2 milk feeds1 Percent receiving solid, semi-solid and soft foods or milk feeds 4 times or more Number of children age 6-23 months Percent with minimum meal frequency2 Number of children age 6-23 months North 9.3 471 49.6 48.6 64 14.1 535 North East 12.3 558 32.5 40.7 70 15.5 628 South 8.2 275 80.5 (64.2) 29 13.6 304 South East 4.5 383 65.3 41.9 114 13.1 497 West 18.1 420 68.9 (74.1) 57 24.9 477 Residence Urban 15.1 505 62.7 59.3 147 25.0 652 Rural 10.5 2,492 58.3 52.2 395 16.2 2,887 Mother s education None 11.1 2,697 58.4 52.0 466 17.1 3,164 Primary 15.2 160 61.1 (63.2) 41 25.0 201 Secondary + 9.0 140 71.7 (72.5) 34 21.5 174 Wealth index quintile Poorest 11.2 636 51.4 54.5 73 15.7 710 Second 8.9 665 55.8 44.1 92 13.2 758 Middle 10.2 607 67.0 48.6 102 15.7 708 Fourth 10.5 580 52.3 50.2 115 17.1 695 Richest 16.4 509 65.7 66.1 159 28.2 668 Total 11.2 2,997 59.5 54.1 542 17.8 3,539 1 MICS indicator 2.15 Note: Figures in parenthesis indicate that the percentage is based on just 25-49 unweighted cases. Overall, more than one in five children aged 6-23 months (18%) were receiving solid, semi-solid and soft foods the minimum number of times (Table 5.6). Among currently breastfeeding children aged 6-23 months, nearly one in six children (11%) were receiving solid, semi-solid and soft foods the minimum number of times. There is no significant gender difference in this proportion. Among non-breastfeeding children, more than a half of the children were receiving solid, semi-solid and soft foods or milk feeds four times or more (54%). The continued practice of bottle-feeding is a concern because of possible contamination resulting from unsafe water and/or lack of hygiene in preparation. Table 5.7 shows the percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day. Table 5.7: Bottle-feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Afghanistan, 2010-2011 Percentage of children age 0-23 months fed with a bottle with a nipple1 Number of children age 0-23 months Sex Male 28.4 2,412 36 Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Afghanistan, 2010-2011 Percentage of children age 0-23 months fed with a bottle with a nipple1 Number of children age 0-23 months Female 28.1 2,329 Age 0-5 months 22.6 1,202 6-11 months 31.8 1,042 12-23 months 29.5 2,497 Region Central 30.9 798 Central Highlands 17.0 186 East 21.4 475 North 22.8 721 North East 26.0 863 South 53.8 350 South East 26.8 720 West 30.1 627 Residence Urban 31.9 900 Rural 27.4 3,841 Mother s education None 28.0 4,202 Primary 28.2 281 Secondary + 32.5 258 Wealth index quintile Poorest 25.8 895 Second 27.4 1,014 Middle 27.1 943 Fourth 28.2 944 Richest 32.7 945 Total 28.2 4,741 1 MICS indicator 2.11 Table 5.7 shows that bottle-feeding is still prevalent in Afghanistan. More than a quarter of children under six months of age (28%) are fed using a bottle with a nipple. As the mother s education level and wealth index quintile increases, infants are more likely to be fed through a bottle with a nipple. The highest prevalence of bottle-feeding is observed among children age 0- 23 months in the Southern region (54%). Salt Iodization Iodine Deficiency Disorders (IDD) are the world s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The international goal was to achieve sustainable elimination of iodine deficiency by 2005. The indicator used is the percentage of households consuming adequately iodized salt (>15 parts per million). 37 In Afghanistan, the Universal Salt Iodization (USI) program was initiated in 2003 through public and private partnerships. The overall objective of the program is to achieve the elimination of IDD, by ensuring that 90% of households in Afghanistan have access to and consume adequately quality iodized salt by 2015 or sooner. In-country capacity to produce iodized salt, social mobilization and communication to promote the use of iodized salt, the creation of an enabling environment, and the establishment of a surveillance system are the major strategies that have been implemented to increase access and consumption of iodized salt at the household level in Afghanistan. Table 5.8: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Afghanistan, 2010-2011 Percentage of households in which salt was tested Number of households Percent of households with Total Number of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 PPM >0 and <15 PPM 15+ PPM1 Region Central 99.0 2,159 0.4 8.4 39.1 52.2 100.0 2,145 Central Highlands 93.1 432 0.0 29.2 43.7 27.0 100.0 402 East 97.2 1,520 0.8 24.6 50.1 24.6 100.0 1,488 North 99.6 1,913 0.1 64.3 24.6 10.9 100.0 1,907 North East 99.0 2,091 0.4 58.0 26.7 14.9 100.0 2,080 South 97.8 1,584 1.1 48.4 36.5 14.0 100.0 1,566 South East 95.3 1,263 1.8 33.3 54.0 10.9 100.0 1,226 West 98.1 2,155 1.3 69.9 20.2 8.6 100.0 2,141 Residence Urban 98.6 2,427 0.5 21.0 37.3 41.2 100.0 2,404 Rural 97.9 10,689 0.8 49.8 33.7 15.7 100.0 10,552 Wealth index quintile Poorest 97.7 2,809 1.2 66.7 23.2 8.9 100.0 2,777 Second 97.7 2,721 0.7 53.6 30.3 15.5 100.0 2,676 Middle 97.6 2,524 0.8 44.8 38.3 16.1 100.0 2,483 Fourth 99.0 2,419 0.4 33.9 41.7 24.0 100.0 2,404 Richest 98.3 2,643 0.7 20.9 39.8 38.7 100.0 2,617 Total 98.0 13,116 0.8 44.5 34.3 20.4 100.0 12,956 1 MICS indicator 2.16 In about 98% of households, salt used for cooking was tested for iodine content by using salt test kits and by testing for the presence of potassium iodate content. Table 5.8 shows that in a very small proportion of households (less than 1%), there was no salt available. In 20% of households, salt was found to contain 15 parts per million (ppm) or more of iodine, thus only a small portion of households are consuming adequately iodized salt. Use of iodized salt was lowest in the Western region (8.6%) and highest in the Central region (52%). There is a considerable gap in iodized salt consumption between urban and rural areas: 41% of urban households were found to be using adequately iodized salt as compared to only 16% in rural areas (Figure 5.3). 38 Children s Vitamin A Supplementation Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of Vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where Vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, Vitamin A deficiency is quite prevalent in the developing world and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of Vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly's Special Session on Children in 2002. The critical role of Vitamin A for child health and immune function also makes control of deficiency a primary component of child survival efforts, and therefore critical to the achievement of the fourth MDG: a two-thirds reduction in under-five mortality by the year 2015. 39 For countries with Vitamin A deficiency problems, current international recommendations call for high-dose Vitamin A supplementation every four to six months, targeted at all children between the ages of 6-59 months living in affected areas. Providing young children with two high-dose Vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating Vitamin A deficiency and improving child survival. Giving Vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother's stores of Vitamin A, which are depleted during pregnancy and lactation. For countries with Vitamin A supplementation programs, the definition of the indicator is the percentage of children 6-59 months of age receiving at least one high dose Vitamin A supplement in the previous six months period. Based on UNICEF/WHO guidelines, the Afghan Ministry of Health s recommendation is that children aged 6-11 months are given one high dose Vitamin A capsule and children aged 12-59 months are given one high dose Vitamin A capsule every six months. In some parts of the country, Vitamin A capsules are linked to immunization services and are given when the child has contact with these services after six months of age. It is also recommended that mothers take a Vitamin A supplement within eight weeks of giving birth due to mothers increased Vitamin A requirements during pregnancy and lactation. Table 5.9: Children's Vitamin A supplementation Percent distribution of children age 6-59 months by receipt of a high dose Vitamin A supplement in the last 6 months, Afghanistan, 2010-2011 Percentage who received Vitamin A according to: Percentage of children who received Vitamin A during the last 6 months1 Number of children age 6-59 months Child health book/card/vaccination card Mother's report Sex Male 0.6 51.0 51.1 7,043 Female 0.6 50.0 50.1 6,627 Region Central 0.4 75.7 75.8 2,026 Central Highlands 1.2 53.2 53.3 471 East 0.8 48.4 49.0 1,553 North 0.3 54.4 54.5 1,901 North East 1.7 59.1 59.3 2,230 South 0.0 19.3 19.3 1,727 South East 0.2 52.7 52.8 2,085 West 0.3 34.5 34.7 1,676 Residence Urban 0.6 63.7 63.9 2,150 Rural 0.6 48.0 48.1 11,520 Age 6-11 months 1.4 40.3 41.0 1,042 12-23 months 2.1 50.0 50.3 2,497 24-35 months 0.3 51.7 51.8 3,220 36-47 months 0.1 52.2 52.2 3,438 48-59 months 0.1 51.0 51.1 3,474 Mother s education None 0.6 49.4 49.5 12,494 Primary 0.3 60.0 60.3 619 Secondary + 0.6 65.6 65.6 550 40 Percent distribution of children age 6-59 months by receipt of a high dose Vitamin A supplement in the last 6 months, Afghanistan, 2010-2011 Percentage who received Vitamin A according to: Percentage of children who received Vitamin A during the last 6 months1 Number of children age 6-59 months Wealth index quintile Poorest 0.8 43.7 43.9 2,916 Second 0.6 48.3 48.3 2,933 Middle 0.4 49.5 49.5 2,780 Fourth 0.3 51.3 51.5 2,734 Richest 0.8 62.1 62.4 2,306 Total 0.6 50.5 50.6 13,670 1 MICS indicator 2.17 Within the six months prior to the AMICS, 51% of children aged 6-59 months received a high dose Vitamin A supplement, as reported by the mothers (Table 5.9). The prevalence shows a significant variation among regions. For instance, the Central region shows the highest Vitamin A coverage rate (76%), while it is lowest in the Southern region (19%). There is no gender difference found in Vitamin A supplement coverage in Afghanistan. However, it is notable that data for 51% of children aged 6-59 are based on the reports from mothers/caretakers, and fewer than 1% of cases are verified by a child health book or vaccination card. The age pattern of Vitamin A supplementation shows that supplementation in the last six months rises from 41% among children aged 6-11 months to 50% among children aged 12-23 months and reaches the highest prevalence at 36-47 months. Then the rate slightly declines with age to 51% among the oldest children. The mother s level of education is also related to the likelihood of Vitamin A supplementation. The percentage receiving a supplement in the last six months increases from 50% among children whose mothers have no education to 60% of those whose mothers have primary education, and to 66% among children of mothers with secondary education or higher. As the wealth index quintiles increase, the coverage rate is higher: from 44% of children living in the poorest households to 62% of those living in the wealthiest households. Children s Anaemia Prevalence Anaemia in childhood is defined as a haemoglobin (Hb) concentration below established cut-off levels. These levels vary depending on the age of the child, and on the laboratory in which the blood sample is tested. The WHO has suggested levels of Hb below which anaemia is said to be present. Children aged 6-59 months have anaemia if their Hb concentration is less than 11 grams per decilitre (g/dl). Childhood anaemia poses a major public health issue leading to an increased risk of child mortality, as well as to the negative consequences of iron deficiency anaemia on cognitive and physical development. In the AMICS, blood tests were administered for sub-sampled children aged 6-59 months. All children aged 6-59 months in the odd number of clusters were selected for the blood test. Table 5.11 presents the prevalence of anaemia among children 6-59 months. 41 Table 5.10: Anaemia Status of Children Percentage of children 6-59 months who have blood tested and who have anaemia, Afghanistan, 2010-2011 Percentage of children who have anaemia Number of children under 5 who have blood tested Sex Male 32.7 3,058 Female 34.8 2,801 Residence Urban 31.2 929 Rural 34.2 4,931 Region Central 18.5 848 Central Highlands 19.8 172 East 42.9 671 North 50.1 946 North East 38.0 906 South 35.2 617 South East 19.3 897 West 35.6 800 Wealth index quintile Poorest 36.0 1,319 Second 36.6 1,237 Middle 36.9 1,096 Fourth 28.2 1,180 Richest 30.0 1,027 Total 33.7 5,859 Overall, the prevalence of anaemia among children 6-59 months is 34%. Small differentials were found between children living in urban areas (31%) and in rural areas (34%). Significant differences among regions are observed, with the lowest prevalence found in the Central region (19%) and the highest in the Northern region (50%). W omen s Anaemia Prevalence Women often become anaemic during pregnancy because the demand for iron and other vitamins is increased. The mother must increase her production of red blood cells and, in addition, the foetus and placenta need their own supply of iron, which can only be obtained from the mother. Anaemia in women aged 15-49 is defined as Hb concentration less than 12 g/dl for non- pregnant women and 11 g/dl for pregnant women. In the AMICS, the blood test was administered for women aged 15-49. Anaemia testing was done on a sub-sample of women in the survey, whereby all women aged 15-49 in the odd number of clusters were selected for the blood test. The same clusters were selected for both women s and children s anaemia tests. Table 5.11 shows the anaemia prevalence among women aged 15-49 in Afghanistan. 42 Table 5.11: Anaemia Status of Women Percentage of women aged 15-49 years who have blood tested and who are anaemic, Afghanistan, 2010-2011 % of non-pregnant women who have anemia Number of non- pregnant women aged 15-49 who have blood tested % of pregnant women who have anemia Number of pregnant women aged 15-49 who have blood tested Residence Urban 17.5 1,644 11.4 88 Rural 22.4 6,518 16.8 928 Region Central 9.6 1,439 5.0 60 Central Highlands 5.0 279 7.7 13 East 22.2 712 21.4 159 North 27.0 1,249 18.7 75 North East 37.8 1,504 21.3 89 South 16.4 962 8.7 150 South East 20.3 953 19.5 313 West 16.8 1,064 13.4 157 Education None 22.6 6,439 15.9 966 Primary 20.1 673 (27.6) 29 Secondary+ 15.2 1,052 (15.0) 20 Wealth index quintile Poorest 25.0 1,574 17.0 270 Second 23.4 1,502 18.1 171 Middle 24.2 1,528 18.9 222 Fourth 18.9 1,678 12.6 230 Richest 16.7 1,882 13.8 123 Total 21.4 8,164 16.3 1,016 Note: Figures in parenthesis indicate that the percentage is based on just 25-49 unweighted cases Overall, the prevalence of anaemia is 21% among non-pregnant women aged 15-49, and 16% among pregnant women. There is a higher rate of anaemia found among pregnant women living in rural areas (17%) compared to urban areas (11%), as well as among non-pregnant women (18% among urban women, and 22% among rural women). Significant differences are observed by region. Prevalence is lowest among pregnant women in the Central region (5%) and highest in the East and North East regions (21%), and follows the same pattern for non-pregnant women (the lowest prevalence at 5% in the Central Highlands region; and the highest at 38% in the North East region). Non-pregnant women living in the poorest households (25%) are more likely to have anaemia than their counterparts living in the wealthiest households (17%). A Profile of W omen s and Children s Nutrition in Afghanistan Afghanistan has made some progress in improving children s and women s health, such as in the establishment of the Universal Salt Iodization (USI) programme in an effort to achieve the elimination of IDD. However, significant challenges remain. Only 20% of households are consuming adequate levels of iodized salt. Approximately only half of children receive Vitamin A supplementation. Anaemia is common among young children. Almost one in three children 43 under age five are moderately underweight, and 18% are classified as severely underweight. Breastfeeding practices among women vary by region and other factors, but in general, the data demonstrate an acute need for greater awareness of the recommended good practices in breastfeeding, as well as for targeting interventions at women who are giving birth in places other than in public sector facilities. Improving the nutritional practices and status of women and children will help reduce mortality rates. Optimal feeding and supplementation practices are critical for brain development, healthy growth, and energy intake, and ultimately play a major role in the health of the population, and in Afghanistan s prospects for development. 44 45 Introduction: Child Health Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds by 2015. Immunization plays a key part in reaching this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Yet worldwide, there are still 27 million children overlooked by routine immunization. As a result, vaccine-preventable diseases cause more than two million deaths every year. One of the goals of A World Fit for Children is to ensure full immunization of children under one year of age at 90% nationally, with at least 80% coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG (Bacillis-Cereus- Geuerin) vaccination to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine, and a measles vaccination, all by the age of 12 months. The routine immunization schedule in Afghanistan is shown in Table 6.1. Table 6.1: Routine Immunization Schedule in Afghanistan (children under 5) Antigen At Birth 6 weeks 10 weeks 14 weeks 9 months BCG X Polio X X X X X Pentavalent X X X Measles X The Pentavalent vaccine is a combination of five vaccines: diphtheria, pertussis, tetanus, hepatitis B and haemophilus influenza. Although the Pentavalent vaccine was introduced in Afghanistan in 2009, there has been no change to reflect this in the vaccination card. Therefore, interviewers recorded only the DPT vaccination during the field data collection. Vaccinations Information on vaccination coverage was collected for all children under five years of age. All mothers or caretakers were asked to provide vaccination cards. If the vaccination card for a child was available, interviewers copied vaccination information from the cards onto the MICS questionnaire. If no vaccination card was available for the child, the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccinations, and for Polio, DPT and Hepatitis B, how many doses were received. The final vaccination coverage estimates are based on both information obtained from the vaccination card and from the mother s report of vaccinations received by the child. 46 Table 6.2: Vaccinations in first year of life Percentage of children age 12-23 months immunized against childhood diseases at any time before the survey and before the first birthday, Afghanistan, 2010-2011 Vaccinated at any time before the survey according to Vaccinated by 12 months of age Vaccination card Mother's report Either BCG1 31.0 33.1 64.2 61.3 Polio At birth 30.3 17.8 48.1 45.9 1 30.4 41.1 71.4 66.1 2 30.4 32.1 62.5 57.3 32 30.3 17.8 48.0 41.8 DPT 1 31.8 25.6 57.5 53.2 2 31.7 20.2 51.9 47.5 33 31.5 8.7 40.2 35.0 Measles4 29.9 25.6 55.5 43.8 All vaccinations 29.4 0.7 30.0 17.6 No vaccinations 0.1 24.0 24.0 24.7 Number of children age 12-23 months 2,497 2,497 2,497 2,497 MICS Indicators 3.1, 3.2, 3.3, 3.4; MDG 4.3 Overall, 31% of children had vaccination cards. If the child did not have a card, the mother was asked to recall whether or not the child had received each of the vaccinations and, for DPT and polio, how many times. The percentage of children aged 12-23 months who received each of the vaccinations is shown in Table 6.2. The denominator for the table is comprised of children aged 12-23 months so that only children who are old enough to be fully vaccinated are counted. In the top panel, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother s report. In the bottom panel, only those who were vaccinated before their first birthday, as recommended, are included. For children without vaccination cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards. Approximately 61% of children aged 12-23 months received a BCG vaccination by the age of 12 months and the first dose of DPT was given to 53% of children. The percentage declines for subsequent doses of DPT to 48% for the second dose, and 35% for the third dose (Figure 6.1). Similarly, 66% of children received polio 1 by the age of 12 months and this declines to 42% by the third dose. The coverage for the measles vaccine by 12 months reaches 44%. As a result, the percentage of children who had all the recommended vaccinations by their first birthday is low, at only 18%. In Afghanistan, one in four children receive no vaccination before age 1 (25%). 47 Table 6.3 shows vaccination coverage rates among children 12-23 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and from the mothers/caretakers reports. Table 6.3: Vaccinations by background characteristics Percentage of children age 12-23 months currently vaccinated against childhood diseases, Afghanistan, 2010-2011 Percentage of children who received: Percentage with vaccination card seen Number of children age 12- 23 months BCG Polio DPT Measles None All At birth 1 2 3 1 2 3 Sex Male 64.4 49.0 71.1 62.8 48.8 58.0 52.8 41.6 56.4 24.3 30.9 31.6 1,262 Female 63.9 47.2 71.7 62.3 47.2 56.9 51.0 38.9 54.5 23.7 29.2 29.6 1,235 Region Central 79.0 60.7 79.9 67.2 56.5 72.7 63.5 50.0 70.4 14.1 34.8 36.3 405 Central Highlands 57.5 37.2 64.0 59.8 53.3 54.7 50.2 42.6 53.8 34.9 29.6 30.8 104 East 76.5 62.2 79.8 66.6 52.7 71.3 67.2 46.0 69.6 13.5 38.7 39.5 247 North 60.6 43.9 69.7 63.6 47.9 53.5 47.0 33.6 49.9 24.4 23.6 26.6 377 North East 70.8 60.0 81.4 72.6 57.9 61.6 59.5 52.6 62.0 16.0 41.5 41.7 427 South 34.8 13.9 41.4 28.2 8.4 23.9 14.0 4.6 19.4 52.4 1.5 1.5 254 South East 63.2 48.8 64.2 57.2 44.9 59.2 54.1 40.1 57.7 31.8 33.3 33.1 351 West 57.4 40.4 77.2 72.4 53.4 51.0 48.0 41.9 50.2 20.7 28.7 27.1 332 Residence Urban 79.2 64.1 81.1 69.5 58.4 72.3 63.5 53.2 70.0 12.4 37.0 36.4 436 Rural 61.0 44.7 69.4 61.1 45.8 54.3 49.4 37.5 52.4 26.5 28.5 29.4 2,060 48 Percentage of children age 12-23 months currently vaccinated against childhood diseases, Afghanistan, 2010-2011 Percentage of children who received: Percentage with vaccination card seen Number of children age 12- 23 months BCG Polio DPT Measles None All At birth 1 2 3 1 2 3 Mother s education None 62.4 46.1 70.4 61.7 46.6 55.6 50.2 38.3 53.5 25.1 28.7 29.5 2,267 Primary 78.1 65.5 79.2 68.8 60.5 72.2 64.3 54.9 73.6 15.8 41.9 40.7 122 Secondary + 85.9 69.9 83.8 72.1 63.2 78.5 71.9 64.0 75.2 11.2 44.0 43.4 108 Wealth index quintile Poorest 54.4 34.0 68.4 58.4 40.0 47.3 41.6 28.9 43.7 27.6 23.1 23.0 532 Second 63.0 48.6 71.9 63.9 49.2 55.3 52.3 40.1 55.6 24.3 30.0 30.8 549 Middle 59.8 44.2 67.7 60.0 43.4 53.8 47.8 36.4 52.2 28.1 28.2 29.3 495 Fourth 66.8 51.1 70.4 62.0 51.0 59.7 54.2 43.5 59.7 25.8 32.7 33.4 473 Richest 79.3 65.4 79.8 69.1 58.1 73.4 65.2 54.4 68.1 13.0 37.3 37.9 447 Total 64.2 48.1 71.4 62.5 48.0 57.5 51.9 40.2 55.5 24.0 30.0 30.6 2,497 In Afghanistan, 30% of children aged 12-23 months are fully vaccinated (Table 6.3). One in four children are not vaccinated at all against any diseases (24%). There is no significant gender disparity in immunization coverage; however, a disparity between urban (37%) and rural (29%) areas is observed. The situation differs considerably by region: in the North Eastern region, children have the highest rate of vaccination coverage against communicable diseases (42%). However, in the Southern region, fewer than 2% of children are fully vaccinated, an alarming situation that stands in contrast to all other regions. The mother s education appears to be a factor significantly influencing children s immunization rates. The higher the mother s educational level, the more her children tend to be vaccinated. For example, 63% of children whose mothers are educated to the secondary level received the third dose of polio vaccine, while only 47% of children are fully protected against polio if their mothers have no education at all. Overall, 64% of children aged 12-23 are protected against tuberculosis as a result of having received the BCG vaccine. More children living in urban areas (79%) are immunized with the BCG vaccine compared to those living in rural areas (61%). In the Central region, almost four in five children received the BCG vaccine, while in the Southern region, one in three children are immunized. Table 6.3 shows a regressive trend in the immunization coverage of the oral polio vaccine up to the third dose, according to the immunization schedule. Children in the North Eastern region (81%) are protected against polio 1 most frequently, followed by children in the Central and Eastern regions (80%). However, the coverage rate of polio 3 drops to 58% in the North East region, to 57% in the Central region, and to 53% in the East region by the third polio vaccination. Among the eight regions, the Southern region has the lowest coverage from polio 1 to 3. 49 More than one in two children (58%) aged 12-23 months were vaccinated with the first dosage of DPT (DPT 1), with the coverage rate slightly lower by the second dosage (52%), and falling to 40% by the third dosage. The national coverage rate of children protected against measles is 56%. The Central region has the highest coverage rate (70%), while the lowest coverage rate for the measles vaccine is found in the Southern region (19%). Neonatal Tetanus Protection One of the MDGs is to reduce the maternal mortality ratio by three quarters. One strategy to that end is to eliminate maternal tetanus. Another goal is to reduce the incidence of neonatal tetanus to less than one case of neonatal tetanus per 1,000 live births in every district. The goal of A World Fit for Children was to eliminate maternal and neonatal tetanus by 2005. The prevention of maternal and neonatal tetanus requires assuring that all pregnant women receive at least two doses of the tetanus toxoid vaccine. However, if a woman has not received two doses of the vaccine during her pregnancy, she (and her new born) are also considered to be protected if the following conditions are met: Received at least two doses of tetanus toxoid vaccine, the last within the prior three years; Received at least three doses, the last within the prior five years; Received at least four doses, the last within 10 years; Received at least five doses during her lifetime. Table 6.4 shows the tetanus protection status of women aged 15-49 who had had a live birth within the last two years preceding the survey, by major characteristics. Table 6.4: Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus, Afghanistan, 2010-2011 Percentage of women who received at least 2 doses during last pregnancy Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus1 Number of women with a live birth in the last 2 years 2 doses, the last within prior 3 years 3 doses, the last within prior 5 years 4 doses, the last within prior 10 years 5 or more doses during lifetime Region Central 36.3 10.5 2.5 0.9 1.1 51.3 824 Central Highlands 33.2 14.8 0.3 0.0 0.0 48.4 196 East 29.9 10.5 1.3 0.6 0.2 42.5 491 North 29.2 5.2 2.3 0.0 0.1 36.9 743 North East 37.5 10.1 0.8 0.6 0.1 49.2 869 South 17.7 6.0 0.0 0.4 0.0 24.1 353 South East 35.4 6.9 0.0 0.2 0.0 42.5 726 West 18.0 5.7 0.3 0.3 0.2 24.4 662 Residence Urban 33.4 10.9 1.6 1.3 1.1 48.4 903 Rural 30.1 7.7 1.0 0.2 0.1 39.0 3,962 Education None 29.5 7.7 1.0 0.3 0.2 38.6 4,311 50 Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus, Afghanistan, 2010-2011 Percentage of women who received at least 2 doses during Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus1 Number of women with a live birth in the Primary 34.0 15.5 2.1 1.6 0.8 54.0 286 Secondary + 47.1 9.5 2.3 0.5 1.2 60.6 268 Wealth index quintile Poorest 24.6 6.8 1.0 0.0 0.0 32.4 933 Second 28.7 7.9 0.8 0.3 0.0 37.7 1,029 Middle 30.4 8.6 1.0 0.0 0.2 40.2 993 Fourth 34.5 7.9 0.8 0.2 0.3 43.8 967 Richest 35.2 10.2 1.9 1.6 0.8 49.8 944 Total 30.7 8.3 1.1 .4 .3 40.8 4,865 1 MICS indicator 3.7 Only 41% of women with a birth in the last two years are protected against tetanus (Table 6.4). Mother s education level and household wealth were found to have a positive association with neonatal tetanus protection. As mothers are more educated, they tend to be more vaccinated (39% among mothers without education compared to 61% among mothers with secondary education or higher). Almost half of women from the wealthiest households are protected against neonatal tetanus, while only one in three women from the poorest wealth quintile are protected. Figure 6.2 shows the protection of women against neonatal tetanus by major background characteristics. Women living in the Central region are the most protected against tetanus (51%) followed by the North Eastern region (49%). The lowest coverage of neonatal tetanus vaccination is found in the Southern and Western regions, where only one in four women are protected (24%). There is a disparity between urban and rural areas in neonatal tetanus protection (48 % versus 39%). 51 Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea either through oral rehydration salts (ORS) or a recommended home fluid (RHF) can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goal of A World Fit for Children is to reduce by one half death due to diarrhoea among children under age five by 2010 (compared to 2000); and the MDG is to reduce by two thirds the mortality rate among children under five by 2015 (compared to 1990). In addition, A World Fit for Children calls for a reduction in the incidence of diarrhoea by 25% worldwide. The indicators used in the MICS survey include: Prevalence of diarrhoea Oral rehydration therapy (ORT) among children age less than 5 years with diarrhea Home management of diarrhoea among children age less than 5 years with diarrhea 52 ORT with continued feeding among children age less than 5 years with diarrhea In the MICS questionnaire, mothers (or caretakers) were asked to report whether their child had had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Table 6.5: Oral rehydration solutions and recommended homemade fluids Percentage of children age 0-59 months with diarrhoea in the last two weeks, and treatment with oral rehydration solutions and recommended homemade fluids, Afghanistan, 2010-2011 Had diarrhoea in last two weeks Number of children age 0-59 months Children with diarrhoea who received: Number of children age 0-59 months with diarrhoea ORS (Fluid from ORS packet or pre- packaged ORS fluid) Recommended homemade fluids ORS or any recommended homemade fluid Wheat Salt Solution Salt & Sugar Solution Any recommended homemade fluid Sex Male 22.9 7,653 55.1 13.0 18.9 26.4 65.2 1,752 Female 22.9 7,218 51.3 13.6 16.7 24.3 61.6 1,652 Region Central 25.0 2,230 46.0 12.6 17.2 23.1 59.9 557 Central Highlands 33.4 517 36.3 12.4 12.7 19.6 48.2 173 East 21.4 1,667 58.9 15.6 17.5 23.2 70.6 357 North 25.9 2,087 48.3 12.9 12.4 21.6 56.5 541 North East 19.3 2,464 36.5 6.6 7.9 11.8 42.8 477 South 20.0 1,774 74.0 17.8 44.5 49.6 85.0 355 South East 24.3 2,308 60.5 14.8 18.1 29.5 69.4 560 West 21.0 1,825 64.6 15.0 16.0 27.0 75.7 384 Residence Urban 21.2 2,398 48.2 8.7 14.8 19.0 57.2 508 Rural 23.2 12,474 54.2 14.1 18.3 26.5 64.5 2,896 Age 0-11 months 18.6 2,244 44.3 10.0 10.6 17.9 51.9 418 12-23 months 28.2 2,497 55.8 12.7 16.2 23.8 66.1 704 24-35 months 27.6 3,220 55.7 13.4 18.3 25.4 65.6 888 36-47 months 22.5 3,438 51.2 14.1 21.4 28.8 63.0 772 48-59 months 17.9 3,474 55.7 14.9 19.3 27.8 65.9 622 Mother s education None 23.1 13,532 53.7 13.5 18.4 26.0 63.9 3,125 Primary 23.3 698 44.5 13.0 14.3 20.7 56.2 163 Secondary + 17.8 634 55.5 8.3 8.3 14.2 62.0 113 Wealth index quintile Poorest 22.0 3,101 55.6 16.8 18.1 30.1 68.7 683 Second 22.2 3,190 50.8 13.6 21.1 28.9 63.4 707 Middle 25.1 3,015 52.4 13.7 16.9 24.4 61.8 758 Fourth 25.0 2,983 55.6 12.6 17.1 23.2 63.4 744 Richest 19.8 2,583 51.6 8.5 15.3 18.6 59.0 512 Total 22.9 14,872 53.3 13.3 17.8 25.3 63.5 3,403 53 Overall, 23% of children under five had diarrhoea in the two weeks preceding the survey (Table 6.5). Diarrhoea prevalence varies by region. One in three children in the Central Highlands region had diarrhoea in the last two weeks, while one in five children had had diarrhoea in the North Eastern and Southern regions. This high prevalence of diarrhoea in the Central Highlands region is assumed to be due to low coverage in improved sources of drinking water (at 25%; refer to Table 7.1 in the next chapter). The peak of diarrhoea prevalence occurs in the weaning period, among children aged 12-23 months (28%). Table 6.5 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea.14 About 53% received fluids from ORS packets or pre- packaged ORS fluids and 25% received recommended homemade fluids. Interestingly, it was found that the mother s education level does not influence the frequency of ORT use to treat children with diarrhoea in Afghanistan. Mothers without any formal education give ORS or any RHF to the children to treat diarrhoea (64%) at comparable rates to mothers with secondary education or higher (62%). Approximately 63% of children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or any RHF), as shown in Figure 6.3. 14 Since mothers were able to name more than one type of liquid, the percentages do not necessarily add up to 100%. 54 Table 6.6: Feeding practices during diarrhoea Percent distribution of children age 0-59 months with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, Afghanistan, 2010-2011 Had diarrhea in last two weeks Number of children age 0-59 months Drinking practices during diarrhoea: Total Eating practices during diarrhoea: Total Number of children age 0-59 months with diarrhoea in last two weeks Given much less to drink Given somewhat less to drink Given about the same to drink Given more to drink Given nothing to drink Missing/ DK Given much less to eat Given somewhat less to eat Given about the same to eat Given more to eat Stopped food Had never been given food Missing/ DK Sex Male 22.9 7,653 21.0 24.1 25.3 19.0 7.0 3.5 100.0 18.1 23.0 34.2 8.6 8.6 5.7 1.9 100.0 1,752 Female 22.9 7,218 20.9 23.9 26.3 17.3 7.1 4.4 100.0 17.6 21.7 34.9 8.8 8.6 6.3 2.1 100.0 1,652 Region Central 25.0 2,230 20.7 24.5 25.5 21.8 7.2 0.2 100.0 18.1 17.5 32.7 12.2 12.2 6.4 0.7 100.0 557 Central Highlands 33.4 517 26.5 15.1 18.6 31.3 7.4 1.0 100.0 31.0 19.4 22.9 8.0 9.8 8.0 0.7 100.0 173 East 21.4 1,667 20.5 31.6 19.6 7.1 15.0 6.2 100.0 15.8 28.7 27.0 6.4 4.3 14.8 2.9 100.0 357 North 25.9 2,087 28.0 15.3 28.1 18.3 8.5 1.8 100.0 26.5 20.4 32.2 6.3 9.4 4.2 1.0 100.0 541 North East 19.3 2,464 24.7 23.3 25.8 19.5 5.7 0.9 100.0 16.8 21.8 39.1 9.3 8.2 4.2 0.5 100.0 477 South 20.0 1,774 16.9 22.6 34.8 17.9 4.7 3.1 100.0 17.3 20.2 46.2 6.6 5.2 2.8 1.7 100.0 355 South East 24.3 2,308 14.2 25.0 31.6 12.5 4.4 12.4 100.0 6.5 17.7 47.9 8.0 7.7 5.9 6.3 100.0 560 West 21.0 1,825 18.4 33.2 15.4 24.2 5.0 3.7 100.0 19.9 36.9 16.6 11.2 10.7 4.0 0.7 100.0 384 Residence Urban 21.2 2,398 24.2 24.4 24.4 19.4 6.6 0.9 100.0 21.0 21.5 28.1 11.3 9.0 8.3 0.8 100.0 508 Rural 23.2 12,474 20.4 23.9 26.1 18.0 7.1 4.5 100.0 17.3 22.5 35.7 8.2 8.6 5.6 2.2 100.0 2,896 Age 0-11 months 18.6 2,244 19.0 25.4 26.2 13.0 12.5 3.9 100.0 15.1 17.2 30.0 7.0 10.0 17.4 3.3 100.0 418 12-23 months 28.2 2,497 22.4 21.5 27.7 17.7 8.2 2.6 100.0 21.1 19.7 33.4 7.7 9.9 7.1 1.1 100.0 704 24-35 months 27.6 3,220 21.0 24.9 25.6 18.5 6.3 3.7 100.0 18.1 22.9 37.2 7.7 8.4 4.2 1.5 100.0 888 36-47 months 22.5 3,438 22.4 24.6 23.8 19.5 5.9 3.9 100.0 17.5 26.6 32.5 10.4 8.1 3.4 1.6 100.0 772 48-59 months 17.9 3,474 19.0 24.0 26.3 20.2 4.6 5.9 100.0 16.2 22.8 37.6 10.2 7.3 2.8 3.2 100.0 622 Mother s education None 23.1 13,532 21.0 24.5 25.3 18.3 6.8 4.2 100.0 17.8 22.7 34.7 8.8 8.3 5.7 2.0 100.0 3,125 55 Percent distribution of children age 0-59 months with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, Afghanistan, 2010-2011 Had diarrhea in last two weeks Number of children age 0-59 months Drinking practices during diarrhoea: Total Eating practices during diarrhoea: Total Number of children age 0-59 months with diarrhoea in last two weeks Given much less to drink Given somewhat less to drink Given about the same to drink Given more to drink Given nothing to drink Missing/ DK Given much less to eat Given somewhat less to eat Given about the same to eat Given more to eat Stopped food Had never been given food Missing/ DK Primary 23.3 698 24.6 19.3 29.5 16.2 9.9 0.5 100.0 19.2 17.0 34.3 6.3 11.4 10.0 1.8 100.0 163 Secondary + 17.8 634 17.4 18.4 34.9 16.6 10.3 2.4 100.0 19.3 20.9 28.8 7.6 13.1 7.4 2.8 100.0 113 Wealth index quintile Poorest 22.0 3,101 21.1 26.5 22.0 17.2 7.6 5.6 100.0 17.5 28.3 27.8 7.9 9.7 6.6 2.1 100.0 683 Second 22.2 3,190 22.0 23.6 24.0 17.7 9.1 3.6 100.0 21.1 23.1 31.0 7.4 9.8 5.6 2.0 100.0 707 Middle 25.1 3,015 21.4 24.7 27.6 15.2 6.0 5.2 100.0 15.8 20.3 40.4 8.5 7.3 5.2 2.5 100.0 758 Fourth 25.0 2,983 20.0 21.4 27.4 21.5 6.2 3.6 100.0 16.9 18.8 42.3 8.1 7.2 4.9 1.9 100.0 744 Richest 19.8 2,583 20.3 23.9 28.7 19.8 6.3 1.0 100.0 18.3 21.5 28.4 12.5 9.6 8.5 1.1 100.0 512 Total 22.9 14,872 21.0 24.0 25.8 18.2 7.0 3.9 100.0 17.9 22.4 34.5 8.7 8.6 6.0 2.0 100.0 3,403 Feeding practices during incidence of children s diarrhoea are important in the prevention of dehydration as well as further complications resulting from diarrhoea in children. Table 6.6 shows the feeding patterns by mothers or caretakers during a diarrhoeal episode among children. Less than one fifth (18%) of under-five children with diarrhoea drank more than usual while 71% drank the same or less. Nine percent of children are given nothing to drink, and 22% ate somewhat less, the same or more (continued feeding), but 32% ate much less or ate almost nothing. Almost 9% of children had feeding stopped during the episode. Table 6.7 provides the proportion of children aged 0-59 months with diarrhoea in the last two weeks who received ORT with continued feeding, and the percentage of children with diarrhoea who received other treatments. 56 Table 6.7: Oral rehydration therapy with continued feeding and other treatments Percentage of children age 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and percentage of children with diarrhoea who received other treatments, Afghanistan, 2010-2011 Children with diarrhoea who received: Other treatments: Not given any treatment or drug Number of children age 0- 59 months with diarrhoea in last two weeks ORS or increased fluids ORT (ORS or recommended homemade fluids or increased fluids) ORT with continued feeding1 Pill or syrup Injection Intra- venous Home remedy, herbal medicine Other Anti- biotic Anti- motility Zinc Other Unknown Anti- biotic Non- antibiotic Unknown Sex Male 63.3 71.8 48.7 16.9 24.5 5.4 1.3 16.6 5.0 0.6 3.3 1.9 14.6 4.4 9.8 1,752 Female 59.2 68.4 46.3 17.2 24.4 5.1 1.8 17.0 4.6 0.7 3.3 1.6 15.6 4.0 9.7 1,652 Region Central 55.9 67.4 41.9 16.6 20.8 4.7 0.9 17.6 1.7 0.2 2.8 0.4 5.1 4.7 10.3 557 Central Highlands 57.0 65.0 30.6 14.0 13.1 0.4 0.6 21.1 0.1 0.3 2.0 0.7 4.0 2.6 22.0 173 East 62.3 73.7 47.3 28.0 16.6 4.0 2.1 14.7 9.3 0.9 2.7 1.0 21.0 2.8 9.8 357 North 58.7 66.1 39.2 15.8 25.1 3.8 0.2 21.9 4.7 0.0 2.0 3.1 10.0 5.9 11.8 541 North East 46.5 51.6 35.2 13.5 31.7 5.0 1.4 17.7 5.1 0.0 1.8 0.3 15.4 6.0 13.9 477 South 78.1 88.3 67.9 31.8 35.2 10.4 6.6 15.8 9.4 2.3 3.3 0.9 27.6 7.5 2.7 355 South East 64.2 71.4 59.6 12.6 26.1 9.8 0.7 12.7 4.2 1.4 6.7 4.6 19.8 1.9 6.5 560 West 72.8 83.1 54.2 7.8 20.2 0.5 0.8 14.2 4.0 0.0 4.1 1.2 17.5 1.4 6.8 384 Residence Urban 57.0 64.9 39.5 24.8 24.0 4.2 1.7 20.4 5.6 0.6 2.2 1.8 6.1 5.7 8.3 508 Rural 62.1 71.0 48.9 15.7 24.5 5.4 1.5 16.1 4.7 0.6 3.5 1.7 16.7 3.9 10.1 2,896 Age 0-11 months 51.7 57.7 32.3 16.2 22.0 2.5 1.0 16.7 4.1 0.4 2.2 2.5 9.4 4.7 16.5 418 12-23 months 62.7 71.7 45.3 16.1 22.2 3.5 0.8 16.2 5.5 0.6 2.9 2.2 13.5 5.0 8.6 704 24-35 months 64.0 72.8 49.9 17.7 25.7 6.9 2.1 15.0 5.0 0.4 3.2 1.7 14.4 4.1 9.4 888 36-47 months 60.3 70.6 51.4 16.9 26.6 7.4 2.0 18.4 5.2 1.0 3.7 1.8 19.2 3.7 8.2 772 48-59 months 63.7 72.3 52.2 18.0 24.1 4.2 1.5 18.1 3.9 0.5 4.3 0.7 16.5 3.7 9.0 622 Mother s education 57 Percentage of children age 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and percentage of children with diarrhoea who received other treatments, Afghanistan, 2010-2011 Children with diarrhoea who received: Other treatments: Not given any treatment or drug Number of children age 0- 59 months with diarrhoea in last two weeks ORS or increased fluids ORT (ORS or recommended homemade fluids or increased fluids) ORT with continued feeding1 Pill or syrup Injection Intra- venous Home remedy, herbal medicine Other Anti- biotic Anti- motility Zinc Other Unknown Anti- biotic Non- antibiotic Unknown None 61.6 70.4 48.5 16.7 24.4 5.5 1.6 16.8 5.0 0.6 3.4 1.8 15.6 4.1 9.8 3,125 Primary 55.4 66.1 34.5 19.3 30.8 2.3 0.6 15.9 2.4 0.4 1.0 1.6 11.0 3.9 7.5 163 Secondary + 61.7 67.3 40.0 23.8 18.7 3.8 0.0 15.6 4.1 0.6 1.5 0.4 5.7 9.0 12.3 113 Wealth index quintile Poorest 63.4 75.0 50.7 12.1 13.8 3.7 1.3 13.0 4.3 0.6 4.7 2.0 17.8 5.8 10.5 683 Second 58.5 68.8 42.9 15.6 26.5 6.0 0.9 15.2 4.2 1.0 3.9 1.6 16.2 3.9 12.5 707 Middle 58.4 66.7 48.0 19.4 29.1 7.0 1.2 16.3 6.5 0.5 1.8 1.7 15.7 1.9 9.8 758 Fourth 66.2 72.9 52.8 17.2 27.7 5.3 2.5 21.1 3.5 0.7 3.3 1.9 15.8 5.0 6.8 744 Richest 59.6 66.4 41.3 21.9 24.2 3.6 1.8 18.4 5.8 0.3 2.9 1.5 7.9 4.8 9.4 512 Total 61.3 70.1 47.5 17.1 24.5 5.3 1.5 16.8 4.8 0.6 3.3 1.7 15.1 4.2 9.8 3,403 1 MICS indicator 3.8 Observing Table 6.7, overall, 61% of children with diarrhoea received ORS or increased fluids, 70% received ORT (ORS or recommended homemade fluids, or increased fluids). It was observed that 48% of children either received ORT and/or at the same time, feeding was continued, as per the recommendation. There are significant differences in the home management of diarrhoea by background characteristics. In the Central Highlands region, less than one in three children (31%) received ORT and continued feeding, while 68% of children in the Southern region received ORT and continued feeding. Interestingly, better treatment practices during an episode of diarrhoea among children are observed in the Southern region despite otherwise discouraging indicators on child health such as the low vaccination coverage noted earlier: 88% of children with diarrhoea in the Southern region were treated by ORT, while only 52% of children in the North Eastern region were treated with ORT. 58 Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children. The use of antibiotics in children under age five with suspected pneumonia is a key intervention. The goal of A World Fit for Children is to reduce by one-third deaths due to acute respiratory infections. Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were NOT due to a problem in the chest and a blocked nose. The indicators are: Prevalence of suspected pneumonia Care seeking for suspected pneumonia Antibiotic treatment for suspected pneumonia Knowledge of the danger signs of pneumonia 59 Table 6.8: Care seeking for suspected pneumonia and antibiotic use during suspected pneumonia Percentage of children age 0-59 months with suspected pneumonia in the last two weeks who were taken to a health provider and percentage of children who were given antibiotics, Afghanistan, 2010-2011 Had suspected pneumoni a in the last two weeks Number of children age 0-59 months Children with suspected pneumonia who were taken to: Other Any appropriat e provider1 Percentage of children with suspected pneumonia who received antibiotics in the last two weeks2 Number of children age 0-59 months with suspected pneumonia in the last two weeks Public sources Private sources Other source Govt. hospital Govt. health centre Govt. health post Village health worke r Mobile/ outreach clinic Other public Private hospital/ clinic Private physician Private pharmacy Mobile clinic Other private medical Relative or friend Shop Trad. Practi- tioner Sex Male 18.2 7,653 18.2 9.0 3.7 6.5 2.9 0.2 3.2 25.5 6.4 0.6 0.0 3.9 1.5 3.5 0.7 61.9 63.2 1,392 Female 19.0 7,218 19.5 7.8 3.8 6.6 1.8 0.7 3.4 23.1 8.2 0.6 0.2 3.2 2.1 3.9 0.0 59.1 64.6 1,370 Region Central 25.0 2,230 19.1 9.0 0.7 2.1 2.2 0.1 7.2 28.2 7.8 0.2 0.0 2.0 0.2 0.5 0.3 65.3 60.2 558 Central Highlands 30.2 517 17.0 10.5 0.0 2.0 5.9 1.4 .2 5.9 4.9 0.4 0.3 1.8 0.0 0.5 0.4 40.7 37.9 156 East 23.6 1,667 12.4 8.1 13.3 7.0 0.1 0.0 3.3 36.1 9.0 0.6 0.0 0.6 0.8 1.5 0.3 72.2 68.9 394 North 20.3 2,087 18.3 8.8 0.5 9.6 4.8 1.1 2.1 15.6 3.8 1.6 0.4 2.9 2.3 2.6 0.2 54.6 63.2 424 North East 13.0 2,464 18.5 17.0 1.0 4.5 2.9 0.0 1.7 10.1 10.7 0.0 0.0 5.3 3.2 2.9 0.0 52.9 58.2 320 South 10.0 1,774 22.4 6.6 6.7 8.6 2.0 2.0 7.2 39.5 4.0 1.5 0.0 1.7 0.0 24.0 0.0 63.3 83.4 178 South East 18.7 2,308 25.2 1.9 6.7 13.2 0.4 0.3 0.6 32.2 9.0 0.4 0.0 5.3 1.9 2.5 0.0 72.1 74.4 431 West 16.5 1,825 17.6 7.8 0.3 3.6 3.1 0.0 2.3 18.5 6.5 0.0 0.0 9.1 5.5 5.9 1.6 45.0 58.1 301 Residence Urban 19.1 2,398 25.7 4.7 2.3 1.0 2.2 0.3 5.4 36.1 8.1 0.2 0.0 1.4 0.6 1.8 0.4 67.3 70.3 457 Rural 18.5 12,474 17.5 9.2 4.0 7.6 2.4 0.5 2.8 22.0 7.2 0.6 0.1 4.0 2.0 4.1 0.3 59.2 62.6 2,304 Age 0-11 months 19.5 2,244 21.3 9.9 2.3 4.3 2.9 0.3 3.9 28.1 5.5 1.2 0.1 2.2 .4 1.8 0.0 67.6 66.3 439 12-23 months 19.6 2,497 21.0 8.0 2.9 5.4 3.0 0.1 2.3 25.4 9.1 0.5 0.0 3.4 2.7 3.0 0.3 60.4 61.8 489 24-35 months 19.7 3,220 18.1 8.0 4.4 8.3 2.3 0.5 4.4 24.4 6.3 0.4 0.0 3.7 1.4 4.7 0.1 60.8 62.6 633 36-47 months 19.1 3,438 17.0 7.9 4.0 6.7 2.6 0.7 3.4 26.0 7.5 0.5 0.3 4.1 2.0 4.0 0.2 60.9 67.6 655 48-59 months 15.7 3,474 18.0 8.7 4.5 7.2 1.3 0.5 2.2 18.2 8.2 0.4 0.0 4.1 2.2 4.2 1.0 54.2 60.9 547 Mother s education None 18.4 13,532 18.7 8.7 3.7 7.0 2.3 0.4 2.9 23.4 7.3 0.6 0.0 3.5 1.9 4.0 0.3 59.6 63.6 2,496 Primary 22.3 698 25.5 7.2 3.8 2.0 2.8 0.0 4.6 30.0 8.1 0.0 0.0 3.4 1.8 0.4 0.0 68.8 62.7 156 Secondary+ 17.3 634 12.8 3.3 4.8 3.3 3.2 1.6 9.1 37.5 7.4 1.3 1.6 5.5 0.0 1.9 0.9 71.1 72.4 110 60 Percentage of children age 0-59 months with suspected pneumonia in the last two weeks who were taken to a health provider and percentage of children who were given antibiotics, Afghanistan, 2010-2011 Had suspected pneumoni a in the last two weeks Number of children age 0-59 months Children with suspected pneumonia who were taken to: Other Any appropriat e provider1 Percentage of children with suspected pneumonia who received antibiotics in the last two weeks2 Number of children age 0-59 months with suspected pneumonia in the last two weeks Public sources Private sources Other source Govt. hospital Govt. health centre Govt. health post Village health worke r Mobile/ outreach clinic Other public Private hospital/ clinic Private physician Private pharmacy Mobile clinic Other private medical Relative or friend Shop Trad. Practi- tioner Wealth index quintile Poorest 15.7 3,101 10.4 8.5 4.4 6.5 3.1 1.3 1.6 18.6 4.9 0.8 0.5 2.6 2.8 3.3 0.2 46.4 57.0 486 Second 18.7 3,190 18.7 12.0 3.9 8.2 2.4 0.2 1.8 18.3 6.4 0.8 0.0 3.0 1.6 5.4 0.0 59.7 58.6 597 Middle 20.7 3,015 20.7 10.6 5.4 8.9 2.3 0.2 3.2 22.9 7.7 0.2 0.0 3.6 2.9 4.1 0.7 65.6 67.5 625 Fourth 18.6 2,983 21.1 7.2 2.9 6.4 2.7 0.4 4.2 26.0 9.1 1.0 0.0 6.3 1.2 3.6 0.3 63.5 66.2 554 Richest 19.3 2,583 22.3 2.9 1.8 1.8 1.4 0.2 5.7 37.1 8.4 0.2 0.0 2.1 0.2 1.6 0.4 65.7 69.8 500 Total 18.6 14,872 18.8 8.4 3.7 6.5 2.4 0.4 3.3 24.3 7.3 0.6 0.1 3.6 1.8 3.7 0.3 60.5 63.9 2,762 1 MICS indicator 3.9; 2 MICS indicator 3.10 Table 6.8 presents the prevalence of suspected pneumonia, whether care was sought outside the home, and the site of care. It was found that 19% of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, 61% were taken to an appropriate provider, and 64% of children under five with suspected pneumonia had received an antibiotic during the two weeks prior to the survey. There is some difference between urban (70%) and rural areas (63%) in children receiving an antibiotic during suspected pneumonia. Among eight regions in Afghanistan, the Central Highlands and Central regions reported higher prevalence of suspected pneumonia in the last two weeks before the survey (30% and 25% respectively). In the Central Highlands region, only 41% of children were taken to any appropriate health provider and 38% received antibiotics in the last two weeks. In the South region, 63% of children were taken to any appropriate provider, while more than 80% received medication, and 22% of children were taken to a governmental hospital for treatment of suspected pneumonia. Also, good practices in seeking appropriate care for suspected pneumonia among children are observed in the Eastern region, where 72% of children were taken to an appropriate provider (36% of them were taken to a private physician) and 69% of cases were treated with antibiotics. The table also shows that the antibiotic treatment of suspected pneumonia is lower among the poorest households and among children whose mothers/caretakers have no education. The use of antibiotics is not correlated to the age of the child, and children at any age receive medication in case of suspected pneumonia. Overall, around 60-70% of children in each age group with suspected pneumonia received antibiotics. 61 Table 6.9: Knowledge of the two danger signs of pneumonia Percentage of mothers and caretakers of children age 0-59 months by symptoms that would cause them to take the child immediately to a health facility, and percentage of mothers who recognize fast and difficult breathing as signs for seeking care immediately, Afghanistan, 2010-2011 Percentage of mothers/caretakers of children age 0-59 months who think that a child should be taken immediately to a health facility if the child: Mothers/car etakers who recognize the two danger signs of pneumonia Number of mothers/c aretakers of children age 0-59 months Is not able to drink or breastfeed Becomes sicker Develops a fever Has fast breathing Has difficult breathing Has blood in stool Is drinking poorly Has other symptoms Region Central 17.0 19.3 73.5 23.0 43.6 22.0 11.8 34.6 8.7 1,481 Central Highlands 13.6 17.6 75.1 24.2 41.4 12.9 13.9 44.4 8.4 356 East 43.7 56.0 68.8 44.8 35.7 26.3 21.9 13.5 18.9 1,137 North 28.1 32.3 80.0 25.2 48.3 30.8 27.5 46.2 17.2 1,342 North East 22.1 36.3 73.7 31.7 42.9 23.4 22.0 32.9 15.9 1,640 South 57.9 65.6 76.1 54.3 49.7 30.7 56.0 33.4 35.8 1,220 South East 53.7 29.1 60.0 22.3 21.4 21.5 37.4 26.2 5.7 1,444 West 27.4 32.5 71.9 26.2 43.8 29.8 15.3 26.8 9.5 1,274 Residence Urban 22.8 28.8 75.5 27.8 45.0 22.0 16.8 34.5 12.4 1,627 Rural 36.2 38.5 71.4 32.2 39.8 26.3 28.4 30.9 15.8 8,269 Mother's education None 35.2 37.8 72.0 32.1 40.4 26.0 27.6 30.8 15.7 8,925 Primary 23.4 29.7 71.1 23.9 45.8 22.3 14.7 40.4 10.0 489 Secondary + 22.4 26.8 73.9 25.8 40.2 20.7 16.8 34.5 10.6 475 Wealth index quintile Poorest 39.3 42.4 72.4 34.3 43.2 27.8 31.5 25.8 18.6 2,028 Second 33.4 39.8 71.5 31.0 40.2 26.7 26.5 30.8 15.1 2,071 Middle 37.2 37.4 71.2 34.1 40.8 27.3 29.5 33.8 16.9 2,017 Fourth 35.5 33.9 71.7 31.3 38.5 24.9 27.7 32.9 15.1 1,993 Richest 23.6 30.1 73.8 26.0 40.8 20.8 16.0 34.3 9.7 1,786 Total 34.0 36.9 72.1 31.5 40.7 25.6 26.5 31.5 15.2 9,895 Issues related to knowledge of the danger signs of pneumonia are presented in Table 6.9. It is clearly evident that mothers knowledge of the danger signs is an important determinant of care-seeking behaviour. Overall, only 15% of women know of the two danger signs of pneumonia fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility is when a child develops a fever (72%). Of the mothers surveyed, 32% identified fast breathing and nearly 41% of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. Mothers/caretakers living in the poorest households (19%) and who have no education (16%) are more likely to seek care if their children develop the symptoms of pneumonia. Less than 10% of the mothers in the wealthiest quintile know two danger signs of pneumonia in Afghanistan, compared to 18% in the poorest households. Out of eight regions, mothers in the Southern region are more likely to recognize the two danger signs of pneumonia (36%). In the Central Highlands and Central regions, where there is a higher prevalence of suspected pneumonia than in other regions, only 8-9% of mothers recognize the two danger signs of pneumonia. 62 Solid Fuel Use More than three billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, which is a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is products of incomplete combustion, including CO, polyaromatic hydrocarbons, SO2, and other toxic elements. Use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts, and asthma. The primary indicator of solid fuel use is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. Table 6.10 shows the percentage of household members according to the type of cooking fuel used by the household, and the percentage of household members living in households using solid fuels for cooking. 63 Table 6.10: Solid fuel use Percent distribution of household members according to type of cooking fuel used by the household, and percentage of household members living in households using solid fuels for cooking, Afghanistan, 2010-2011 Percentage of household members in households using: Number of household members Electricity Liquefied Petroleum Gas (LPG) Natural Gas Biogas Kerosene Solid fuels No food cooked in the household Other Missing Total Solid fuels for cooking1 Coal, lignite Char- coal Wood Straw, shrubs, grass Animal dung Agricultural crop residue Region Central 0.9 10.4 40.5 0.1 0.0 0.4 1.5 35.7 4.0 6.2 0.4 0.0 0.1 0.0 100.0 48.1 16,232 Central Highlands 0.0 0.1 1.4 0.0 0.0 3.3 0.3 21.0 29.2 43.5 1.1 0.0 0.1 0.0 100.0 98.3 3,449 East 0.1 4.6 0.6 0.0 0.1 0.1 0.1 70.8 11.3 9.8 2.0 0.1 0.1 0.3 100.0 94.2 11,335 North 0.2 0.9 4.6 0.3 0.0 0.2 1.2 39.5 9.4 38.0 4.6 0.0 0.9 0.3 100.0 92.9 14,055 North East 0.4 1.3 9.4 0.0 0.4 0.9 0.4 14.2 26.0 42.0 4.8 0.0 0.1 0.1 100.0 88.3 16,557 South 0.2 5.8 0.4 0.5 0.0 0.1 0.7 38.0 31.7 15.7 6.2 0.0 0.2 0.5 100.0 92.4 13,825 South East 0.2 1.1 0.4 0.0 0.0 0.0 0.8 72.6 15.4 5.9 3.4 0.0 0.1 0.0 100.0 98.2 12,867 West 0.2 2.1 17.7 0.0 0.0 0.0 0.3 21.4 44.2 11.2 2.4 0.1 0.3 0.1 100.0 79.5 13,393 Residence Urban 1.1 14.7 50.9 0.3 0.1 0.8 1.6 22.1 4.0 3.6 0.5 0.0 0.3 0.1 100.0 32.6 18,000 Rural 0.1 1.4 2.6 0.1 0.1 0.3 0.6 42.9 24.0 23.5 3.9 0.0 0.2 0.2 100.0 95.2 83,713 Education of household head None 0.2 2.2 6.6 0.1 0.1 0.3 0.7 38.0 23.8 23.4 4.0 0.0 0.3 0.2 100.0 90.2 69,034 Primary 0.1 3.7 15.4 0.1 0.0 0.7 0.7 41.4 15.7 19.1 3.0 0.0 0.2 0.0 100.0 80.5 11,529 Secondary + 0.6 8.7 23.9 0.1 0.1 0.4 0.8 42.1 12.3 9.6 1.2 0.0 0.2 0.1 100.0 66.4 21,099 Wealth index quintiles Poorest 0.0 0.0 0.0 0.0 0.0 0.0 0.1 29.9 39.0 24.4 6.0 0.1 0.2 0.3 100.0 99.4 20,338 Second 0.0 0.1 0.1 0.2 0.2 0.3 0.3 36.8 26.1 31.4 4.1 0.0 0.2 0.1 100.0 99.1 20,340 Middle 0.0 0.5 0.8 0.2 0.0 0.3 0.4 48.9 19.7 25.2 3.5 0.1 0.3 0.2 100.0 98.0 20,344 64 Percent distribution of household members according to type of cooking fuel used by the household, and percentage of household members living in households using solid fuels for cooking, Afghanistan, 2010-2011 Percentage of household members in households using: Number of household members Electricity Liquefied Petroleum Gas (LPG) Natural Gas Biogas Kerosene Solid fuels No food cooked in the household Other Missing Total Solid fuels for cooking1 Coal, lignite Char- coal Wood Straw, shrubs, grass Animal dung Agricultural crop residue Fourth 0.1 2.9 5.2 0.1 0.0 0.7 1.5 57.0 13.9 15.5 2.6 0.0 0.3 0.2 100.0 91.1 20,345 Richest 1.3 15.2 49.8 0.1 0.0 0.5 1.4 23.6 3.7 3.6 0.4 0.0 0.3 0.0 100.0 33.2 20,347 Total 0.3 3.7 11.2 0.1 0.1 0.4 0.7 39.2 20.5 20.0 3.3 0.0 0.2 0.2 100.0 84.2 101,713 MICS Indicator 3.11 Overall, most households (84%) in Afghanistan are using solid fuels for cooking (Table 6.10). Use of solid fuels is low in urban areas (33%), but very high in rural areas, where almost all households (95%) are using solid fuels. Differentials with respect to household wealth and the educational level of the household head are also significant. The findings show that use of solid fuels is at 90% in households where the head of household has no education, while it is 66% in households where the head of household has secondary education or higher. One in three of the wealthiest households use solid fuel, while 99% of the poorest households use solid fuel, demonstrating striking differentials by household socio-economic status. The table also clearly shows that the overall percentage of use of solid fuels is high due to use of wood for cooking purposes (39%), use of straw/shrubs/grass (21%), and use of animal dung (20%). Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burned in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while open stoves or fires with no chimney or hood means that there is no protection from the harmful effects of solid fuels. Solid fuel use by place of cooking is shown in Table 6.11. 65 Table 6.11: Solid fuel use by place of cooking Percent distribution of household members in households using solid fuels by place of cooking, Afghanistan, 2010-2011 Place of cooking: Number of household members in households using solid fuels for cooking In a separate room used as kitchen Elsewhere in the house In a separate building Outdoors At another place Missing Total Region Central 82.5 10.8 1.2 4.7 0.4 0.5 100.0 7,801 Central Highlands 76.5 17.0 2.0 2.1 2.1 0.3 100.0 3,392 East 57.4 34.5 0.5 6.0 1.2 0.5 100.0 10,672 North 84.1 6.6 0.2 6.4 2.4 0.3 100.0 13,057 North East 69.5 12.8 4.0 12.9 0.2 0.5 100.0 14,621 South 63.7 30.2 0.4 4.2 0.2 1.1 100.0 12,778 South East 62.9 34.2 0.8 1.3 0.1 0.8 100.0 12,637 West 44.4 20.0 2.4 32.0 1.1 0.2 100.0 10,644 Residence Urban 73.2 15.4 0.9 8.8 0.9 0.9 100.0 5,867 Rural 66.2 21.6 1.5 9.3 0.9 0.5 100.0 79,736 Education of household head None 65.3 21.2 1.5 10.6 0.9 0.5 100.0 62,292 Primary 69.5 19.2 1.3 8.7 0.9 0.5 100.0 9,285 Secondary + 71.1 22.2 1.4 3.8 0.8 0.8 100.0 14,000 Wealth index quintiles Poorest 49.0 30.6 1.5 15.5 2.6 0.8 100.0 20,216 Second 66.4 20.8 1.2 10.8 0.4 0.3 100.0 20,151 Middle 71.5 20.0 1.0 6.5 0.3 0.7 100.0 19,945 Fourth 77.3 15.5 1.8 4.9 0.2 0.3 100.0 18,537 Richest 77.3 12.9 2.6 6.0 0.4 0.8 100.0 6,754 Total 66.7 21.2 1.4 9.2 0.9 0.6 100.0 85,602 The table shows that 9% of households that use solid fuels cook outdoors and 1% cook in a separate building, while 67% of households use solid fuel in a separate room used as the kitchen. More than one in five households does the cooking elsewhere in the house (21%). In urban areas, 73% of households that use solid fuels cook with solid fuel in a separate room used as a kitchen, compared to 66% of rural households. More than half of households cook with solid fuel in a separate room in most regions, except the Western region where only 44% of households that use solid fuels do so. Assessing Children s Health in Afghanistan The reach of vaccination coverage in Afghanistan is cause for concern, particularly the low reach of measles coverage, and the inconsistency in ensuring children receive all required dosages of vaccines such as that for polio prevention. For both children s and women s immunization, mothers educational levels are strongly associated to the likelihood of vaccination coverage, suggesting that the more educated a mother, the more likely she is to immunize her children, and herself. While the findings demonstrate awareness of treatment options for diarrhoea in children, there is wide variation found in treatment and feeding practices, pointing to the need for consistent, clear and convincing messaging around diarrhoea treatment targeted at parents. There is also a demonstrated need for better awareness of the danger signs of pneumonia, a significant threat facing Afghan children. 66 67 Safe Drinking Water Safe drinking water is a basic necessity for good health. Access to safe drinking water and to adequate sanitation facilities are fundamental human rights. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid, and schistosomiasis. Drinking water can also be tainted with chemical, physical and radiological contaminants with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children who often bear the primary responsibility for carrying water, especially in rural areas, often over long distances. The MDG goal for improving access to safe drinking water is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and to basic sanitation. The goal of a World Fit for Children with regards to safe drinking water calls for a reduction by at least one-third in the proportion of households without access to hygienic sanitation facilities and to affordable and safe drinking water. The list of indicators used for water and sanitation in the AMICS are as follows: Water Use of improved drinking water sources Use of adequate water treatment method Time to source of drinking water Person collecting drinking water Sanitation Use of improved sanitation facilities Sanitary disposal of child s faeces Use of Improved Water Sources The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, compound, yard or plot, public tap/standpipe), tube well/borehole, protected well, protected spring, rainwater collection, and bottle water. The distribution of the population by source of drinking water is shown in Table 7.1 and Figure 7.1. 68 Table 7.1: Use of Improved Water Sources Percent distribution of household population according to main source of drinking water and percentage of household population using improved drinking water sources, Afghanistan, 2010-2011 Main source of drinking water Total Percentage using improved sources of drinking water1 Number of household members Improved sources Unimproved sources Piped water Tube- well/ bore- hole Pro- tected well/ Kariaz Pro- tected spring Rainwater collection Bottled water Unpro- tected well/ Kariaz Unpro- tected spring Tanker truck Cart with tank/ drum Surface water* Other Into dwell- ing Into yard/ plot To neighbour Public tap/ stand- pipe Region Central 5.1 9.7 1.0 6.0 32.1 13.4 1.8 0.0 0.2 6.3 4.1 2.2 0.3 16.8 0.9 100.0 69.3 16,232 Central Highlands 0.1 0.5 0.0 3.5 3.7 9.5 7.9 0.0 0.0 13.2 35.1 0.0 0.6 25.8 0.0 100.0 25.3 3,449 East 6.5 5.3 4.2 8.9 8.8 26.0 2.8 0.0 0.0 9.1 23.6 0.0 0.2 4.5 0.3 100.0 62.4 11,335 North 0.8 3.0 0.5 17.7 9.6 12.5 1.1 0.1 0.0 15.6 10.8 0.1 0.3 27.2 0.7 100.0 45.3 14,055 North East 0.7 6.7 1.2 1.4 23.1 8.9 2.2 0.0 0.0 15.6 4.0 0.2 2.3 32.8 0.9 100.0 44.2 16,557 South 4.2 1.3 1.3 0.1 32.4 15.5 4.7 0.2 0.0 26.6 3.7 0.5 0.9 7.7 1.0 100.0 59.7 13,825 South East 3.4 4.8 1.3 3.5 26.8 24.0 3.0 0.2 0.0 12.2 6.7 1.2 4.3 5.2 3.4 100.0 67.0 12,867 West 8.0 12.4 1.3 8.9 16.6 8.9 2.0 1.4 0.0 15.8 13.0 0.0 0.0 11.0 0.8 100.0 59.3 13,393 Residence Urban 13.0 18.2 3.8 7.9 29.1 9.7 0.4 0.0 0.2 7.3 1.3 2.3 0.6 5.1 1.1 100.0 82.3 18,000 Rural 1.9 3.4 0.9 6.0 19.6 16.0 3.1 0.3 0.0 15.9 11.5 0.3 1.3 18.7 1.1 100.0 51.2 83,713 Education of household head None 2.6 4.9 1.1 6.3 20.3 14.0 2.9 0.3 0.0 16.1 10.7 0.4 1.4 17.7 1.1 100.0 52.5 69,034 Primary 4.0 6.8 1.4 7.0 19.3 18.1 1.7 0.2 0.0 13.4 8.8 0.5 0.5 17.5 0.7 100.0 58.5 11,529 Secondary + 7.6 9.4 2.2 6.3 25.6 15.9 2.2 0.0 0.2 9.2 6.7 1.3 0.9 11.1 1.3 100.0 69.5 21,099 Wealth index quintile Poorest 0.0 0.2 0.3 6.7 8.3 8.9 5.3 0.6 0.0 17.1 27.2 0.0 0.6 24.0 0.6 100.0 30.5 20,338 Second 0.6 0.8 0.5 6.9 15.6 15.3 3.4 0.4 0.0 18.5 12.8 0.2 1.2 22.8 1.1 100.0 43.5 20,340 Middle 1.5 3.9 0.9 5.7 23.4 18.9 2.1 0.1 0.0 15.8 5.0 0.2 1.6 19.5 1.3 100.0 56.4 20,344 Fourth 3.6 5.3 2.0 6.2 26.9 20.8 1.8 0.1 0.0 14.1 2.9 0.6 1.9 12.4 1.5 100.0 66.6 20,345 Richest 13.4 20.2 3.2 6.3 32.4 10.3 0.6 0.0 0.2 6.5 0.5 2.2 0.6 2.8 1.0 100.0 86.6 20,347 Total 3.8 6.1 1.4 6.4 21.3 14.9 2.6 0.2 0.0 14.4 9.7 0.6 1.2 16.3 1.1 100.0 56.7 101,713 * Surface water includes river, stream, dam, lake, pond, canal, or irrigation channel. MICS Indicator 4.1 69 Overall, 57% of the Afghan population is using an improved source of drinking water (Table 7.1), including 82% in urban areas and 51% in rural areas. The situation in the Central Highlands region is considerably worse than in other regions, with only 25% of the population drinking water from an improved source (Table 7.1). Tube wells or boreholes (improved sources) are the most common water source used for drinking (21%), and surface water (an unimproved source) is the second most common source (16%) in Afghanistan. The population s drinking water source varies strongly by region. The first and second most commonly used source for drinking water are improved sources in the South Eastern region, while they are unimproved sources in the Central Highlands region. In Afghanistan, the second most important source of drinking water is surface water (river, stream, dam, lake, pond, canal, or irrigation channel), considered to be an unimproved source of drinking water. Surface water is used particularly in the North Eastern region, where 33% of the population relies on this source. In the Southern region, 27% of the population uses unprotected wells and/or kariaz for drinking water, as unimproved sources. Unprotected springs, a source that may be responsible for causing water-related diseases, are used by 35% of the population in the Central Highlands Region. In the Western region, 20% of the population uses drinking water that is piped into their dwelling or into their yard or plot. In the Central and Eastern regions, 5% and 7% respectively use water that is piped into their dwellings. In contrast, only about 3% of those residing in the Southern region and less than 1% of those in the Central Highlands, Northern and North Eastern regions have water that is piped into their dwelling. Nationally, there is wide variation in the types of sources used for drinking water (Figure 7.1). 70 Use of Adequate Water Treatment Methods Use of in-house water treatment is presented in Table 7.2. Households were asked of ways they may be treating water at home to make it safer to drink. Boiling, adding bleach or chlorine, using a water filter, and/or using solar disinfection were considered appropriate means for the proper treatment of drinking water.15 The table shows water treatment by all households and the percentage of those living in households using unimproved water sources but using appropriate water treatment methods. 15 WHO and UNICEF (2006), Meeting the MDG Drinking Water and Sanitation Target: The Urban and Rural Challenge of the Decade. 71 Table 7.2: Household water treatment Percentage of household population by drinking water treatment method used in the household, and for household members living in households where an unimproved drinking water source is used, the percentage who are using an appropriate treatment method, Afghanistan, 2010-2011 Water treatment method used in the household Number of household members Percentage of household members in households using unimproved drinking water sources and using an appropriate water treatment method1 Number of household members in households using unimproved drinking water sources None Boil Add bleach/ chlorine Strain through a cloth Use water filter Solar dis- infection Let it stand and settle Other Missing/DK Region Central 74.8 17.8 10.8 0.3 0.6 0.0 0.7 0.4 0.0 16,232 21.4 4,981 Central Highlands 62.6 36.8 1.4 0.3 0.3 0.0 0.1 0.3 0.0 3,449 36.1 2,577 East 93.6 2.5 2.9 1.0 0.2 1.3 1.6 0.3 0.0 11,335 3.9 4,266 North 85.1 11.5 5.1 0.5 0.1 0.7 3.4 0.3 0.0 14,055 8.4 7,689 North East 75.0 23.6 2.7 2.0 0.1 0.2 2.5 0.0 0.1 16,557 26.7 9,242 South 88.8 5.8 3.1 1.4 0.6 3.7 6.6 0.0 0.0 13,825 4.8 5,577 South East 82.6 11.5 6.0 0.9 0.6 4.3 6.2 0.1 0.0 12,867 19.4 4,248 West 91.5 6.4 1.6 1.1 0.0 0.5 0.8 0.1 0.0 13,393 3.5 5,447 Residence Urban 70.0 22.2 12.8 1.8 0.2 1.4 3.1 0.4 0.0 18,000 36.6 3,191 Rural 85.8 10.9 2.8 0.8 0.3 1.4 2.9 0.1 0.0 83,713 13.2 40,837 Education of household head None 85.4 11.3 2.8 0.9 0.2 1.1 2.8 0.1 0.0 69,034 13.4 32,799 Primary 82.4 13.6 4.7 1.0 0.3 1.0 1.9 0.3 0.0 11,529 15.5 4,784 Secondary + 75.6 17.7 10.6 1.3 0.6 2.4 4.1 0.4 0.0 21,099 22.2 6,432 Wealth index quintile Poorest 91.9 5.4 0.5 0.9 0.2 0.7 1.9 0.1 0.0 20,338 6.8 14,140 Second 87.7 9.3 1.1 1.0 0.2 1.3 2.9 0.0 0.0 20,340 12.7 11,502 Middle 83.7 13.3 3.0 0.8 0.3 1.9 3.6 0.1 0.0 20,344 19.5 8,861 Fourth 78.3 17.2 6.5 0.9 0.4 1.7 4.2 0.3 0.0 20,345 23.4 6,789 Richest 73.5 19.1 12.0 1.4 0.4 1.4 2.0 0.4 0.0 20,347 30.3 2,736 Total 83.0 12.9 4.6 1.0 0.3 1.4 2.9 0.2 0.0 101,713 14.9 44,028 1 MICS indicator 4.2 72 In Afghanistan, only 20% of household members are using an appropriate treatment for drinking water. Of those who treat their drinking water, 13% boil the water, 5% add bleach or chlorine, 1% strain the water through a cloth, and 1% use solar disinfection. In urban areas, 30% of household members and 14% of household members in rural areas apply any form of treatment to their drinking water. The proportion of household members using appropriate treatment for drinking water is positively associated with socio-economic background characteristics. Among households using unimproved drinking water sources, only 15% of household members apply an appropriate treatment to drinking water, and significant differences were found across household members background characteristics. A higher percentage of those treating unimproved drinking water sources was found in urban areas, among the educated population, and among the population living in wealthier households. The population in the Central Highlands region has the highest proportion of people who appropriately treat their drinking water collected from unimproved sources (36%), compared to their counterparts in the Western region, where it is only 4%, the lowest among all the regions. Time to Source of Drinking Water The amount of time it takes to obtain water is presented in Table 7.3 and the person from the household who usually collects the water is shown in Table 7.4. Note that these results refer to one round trip from the home to the drinking water source. Information on the number of trips made in one day was not collected. Table 7.3: Time to source of drinking water Percent distribution of household population according to time to go to source of drinking water, get water and return, for users of improved and unimproved drinking water sources, Afghanistan, 2010-2011 Time to source of drinking water Total Users of improved drinking water sources Users of unimproved drinking water sources Number of household members Water on premises Less than 30 minutes 30 minutes or more Missing/DK Water on premises Less than 30 minutes 30 minutes or more Missing/DK Region Central 47.1 17.9 3.9 0.4 6.8 20.0 3.1 0.8 100.0 16,232 Central Highlands 2.9 18.0 4.3 0.1 3.1 47.2 24.2 0.2 100.0 3,449 East 32.0 23.7 6.4 0.3 6.6 16.3 13.5 1.3 100.0 11,335 North 13.2 26.8 5.2 0.1 8.9 32.2 13.5 0.1 100.0 14,055 North East 15.3 19.8 9.0 0.1 9.4 23.2 22.9 0.3 100.0 16,557 South 46.3 7.1 4.2 2.0 25.5 9.3 3.5 2.0 100.0 13,825 South East 49.6 13.7 3.2 0.6 9.2 13.9 5.2 4.7 100.0 12,867 West 33.6 17.4 6.6 1.7 12.5 15.4 10.3 2.6 100.0 13,393 Residence Urban 66.5 11.3 4.2 0.3 7.7 5.6 3.7 0.7 100.0 18,000 Rural 25.2 19.5 5.8 0.8 11.7 22.9 12.4 1.7 100.0 83,713 Education of household head None 27.8 17.9 6.0 0.8 12.2 21.4 12.3 1.5 100.0 69,034 Primary 30.2 21.8 6.1 0.4 8.6 20.8 11.7 0.5 100.0 11,529 Secondary + 49.0 16.2 3.7 0.6 8.2 14.3 5.8 2.2 100.0 21,099 Wealth index quintile Poorest 7.4 13.8 7.9 1.4 10.7 31.8 23.9 3.1 100.0 20,338 73 Percent distribution of household population according to time to go to source of drinking water, get water and return, for users of improved and unimproved drinking water sources, Afghanistan, 2010-2011 Time to source of drinking water Total Users of improved drinking water sources Users of unimproved drinking water sources Number of household members Water on premises Less than 30 minutes 30 minutes or more Missing/DK Water on premises Less than 30 minutes 30 minutes or more Missing/DK Second 14.3 21.6 6.5 1.0 11.7 26.0 16.6 2.2 100.0 20,340 Middle 29.6 21.4 4.8 0.7 13.4 21.5 7.8 0.9 100.0 20,344 Fourth 38.9 22.3 5.1 0.3 12.3 15.7 4.6 0.8 100.0 20,345 Richest 72.2 11.0 3.2 0.2 6.8 4.3 1.7 0.7 100.0 20,347 Total 32.5 18.0 5.5 0.7 11.0 19.9 10.9 1.5 100.0 101,713 Table 7.3 shows that for 32% of household members, the improved drinking water source is located on the premises. Slightly less than 6% of household members spend 30 minutes or longer getting to the improved drinking water source. Among the household members using an unimproved source of drinking water, only 11% have water on their premises. It takes 30 minutes or more to fetch water for 11% of household members. For those household members with improved drinking water sources, the water source is more likely to be located on the household premises when the head of household is educated: 49% of households where the head of household had a secondary education had a source of improved drinking water located on the premises of the home, compared to 28% of households where the household head had no education. Further, the wealthiest quintile of households were the most likely (72%) to have an improved drinking water source on the household premises, while for the poorest quintile only 7% of households had an improved drinking water source on the household premises. Improved drinking water sources are found on the premises of urban households (67%) more often than in rural households (25%). Person Collecting Drinking Water Table 7.4 shows the percentage of households without drinking water on the premises, and the person who usually collects drinking water used in such households. Table 7.4: Person collecting water Percentage of households without drinking water on premises, and percent distribution of households without drinking water on premises according to the person usually collecting drinking water used in the household, Afghanistan, 2010-2011 Percentage of households without drinking water on premises Number of households Person usually collecting drinking water Number of households without drinking water on premises Adult woman Adult man Female child under age 15 Male child under age 15 Missing/DK Total Region Central 46.2 2,159 31.4 34.2 14.3 19.8 0.3 100.0 997 Central Highlands 94.7 432 63.9 13.1 13.7 9.3 0.0 100.0 409 East 60.6 1,520 64.9 12.6 13.5 8.2 0.8 100.0 921 North 80.1 1,913 27.2 43.1 11.0 18.7 0.0 100.0 1,532 North East 75.1 2,091 19.9 59.1 6.7 14.1 0.3 100.0 1,570 South 29.7 1,584 17.5 26.5 15.8 37.5 2.7 100.0 470 74 Percentage of households without drinking water on premises, and percent distribution of households without drinking water on premises according to the person usually collecting drinking water used in the household, Afghanistan, 2010-2011 Percentage of households without drinking water on premises Number of households Person usually collecting drinking water Number of households without drinking water on premises Adult woman Adult man Female child under age 15 Male child under age 15 Missing/DK Total South East 42.8 1,263 63.7 11.8 10.8 10.8 2.9 100.0 541 West 56.0 2,155 56.5 24.7 8.9 9.8 0.1 100.0 1,206 Residence Urban 25.8 2,427 12.8 51.9 10.7 24.0 0.5 100.0 625 Rural 65.7 10,689 41.7 32.2 11.0 14.5 0.6 100.0 7,021 Education of household head None 62.5 8,922 41.1 34.1 10.0 14.2 0.6 100.0 5,573 Primary 60.4 1,498 37.7 31.2 13.8 16.8 0.5 100.0 905 Secondary + 43.3 2,689 32.5 34.3 13.1 19.4 0.7 100.0 1,163 Wealth index quintile Poorest 84.1 2,809 49.8 26.2 11.7 11.8 0.6 100.0 2,363 Second 74.8 2,721 43.5 33.4 9.7 12.9 0.5 100.0 2,036 Middle 58.7 2,524 36.7 35.8 11.3 15.5 0.7 100.0 1,480 Fourth 50.8 2,419 27.4 40.4 10.5 21.2 0.6 100.0 1,229 Richest 20.4 2,643 12.3 48.1 12.7 26.4 0.6 100.0 538 Total 58.3 13,116 39.4 33.8 10.9 15.3 0.6 100.0 7,647 Table 7.4 shows that for 39% of households, an adult female is usually the person collecting the water, when the source of drinking water is not located on the premises. Adult men collect water in 34% of cases, while for the rest of the households, female (11%) or male (15%) children under the age of 15 collect water. However, the distribution of persons who usually collect drinking water among households without drinking water on their premises varies considerably by region. In the Central Highlands, Eastern and South Eastern regions, more than 60% of adult women are the drinking water carriers for their households. In the Central Highlands and Eastern regions, more girls under age 15 collect water than boys. In terms of gender differences, while more men are in charge of collecting water than women in urban areas (52% versus 13%), more adult females over the age of 15 collect drinking water for their households than do adult males in rural areas (42% versus 32%). Use of Improved Sanitation Facilities Inadequate disposal of human excreta and inadequate personal hygiene are associated with a range of diseases including diarrhoeal diseases and polio. An improved sanitation facility is defined as one that hygienically separates human excreta from human contact. Improved sanitation can reduce diarrheal disease by more than a third, and can significantly lessen the adverse health impacts of other disorders responsible for death and disease among millions of children in developing countries. Improved sanitation facilities for excreta disposal include flushing or pouring flush into a piped sewer system, septic tank, or latrine; ventilated improved pit (VIP) latrine, pit latrine with slab, and composting toilet. 75 Table 7.5: Types of sanitation facilities Percent distribution of household population according to type of toilet facility used by the household, Afghanistan, 2010-2011 Type of toilet facility used by household Total Number of household members Improved sanitation facility Unimproved sanitation facility Flush/pour flush to: Ventilated improved pit latrine Pit latrine with slab Compos- ting toilet Flush/ pour flush to somewhere else Unknown place/not sure/DK where Pit latrine without slab/ open pit Bucket Double vault Eco sanitation Single vault Other Missing Open defecation (no facility, bush, field) Piped sewer system Septic tank Pit latrine Region Central 1.2 12.2 2.1 2.8 17.2 0.1 0.4 0.2 31.9 0.0 1.9 2.5 26.5 0.1 0.0 0.9 100.0 16,232 Central Highlands 0.1 0.4 0.1 0.2 5.9 13.8 2.9 0.0 12.6 0.0 2.7 0.1 10.7 0.3 0.1 50.2 100.0 3,449 East 4.4 4.7 4.2 3.8 24.4 0.5 0.6 0.0 15.3 0.4 4.4 0.0 9.0 0.7 0.0 27.5 100.0 11,335 North 0.2 2.8 2.6 0.6 26.9 2.1 0.4 0.0 12.2 1.4 0.5 0.1 31.1 3.6 0.0 15.5 100.0 14,055 North East 0.6 5.9 3.0 0.3 9.1 0.1 0.4 0.0 23.4 0.1 6.2 0.1 47.0 0.6 0.3 3.1 100.0 16,557 South 11.2 4.0 4.0 4.6 6.3 0.0 4.4 0.5 21.0 0.1 10.5 1.0 8.5 0.0 0.2 23.7 100.0 13,825 South East 0.6 0.3 0.7 21.0 7.9 0.5 0.8 0.1 13.1 0.0 22.0 2.4 7.7 0.7 0.1 22.1 100.0 12,867 West 1.5 3.6 6.2 1.4 19.0 1.3 1.1 0.1 18.5 6.7 0.5 0.2 8.1 0.6 0.2 31.1 100.0 13,393 Residence Urban 4.5 22.8 10.3 4.1 18.2 0.5 1.3 0.1 19.2 0.7 0.8 2.7 13.8 0.2 0.0 0.6 100.0 18,000 Rural 2.2 1.0 1.6 4.5 14.6 1.2 1.2 0.1 19.8 1.2 7.4 0.5 22.2 1.0 0.1 21.3 100.0 83,713 Education of household head None 2.4 2.6 2.5 4.0 15.0 1.0 1.3 0.1 19.1 1.4 6.3 0.7 21.1 1.0 0.2 21.3 100.0 69,034 Primary 2.1 4.3 3.6 2.1 15.4 1.2 0.4 0.2 22.8 0.6 6.2 1.2 25.0 0.9 0.0 14.3 100.0 11,529 Secondary + 3.4 12.7 4.7 7.5 15.9 1.2 1.3 0.0 19.7 0.6 6.0 1.6 17.3 0.3 0.0 7.8 100.0 21,099 Wealth index quintile Poorest 0.0 0.0 0.2 1.0 6.6 0.4 1.0 0.3 13.2 2.8 4.8 0.3 11.3 1.0 0.0 57.3 100.0 20,338 Second 0.5 0.1 0.9 2.6 14.5 1.3 1.0 0.1 21.1 1.3 7.8 0.4 27.8 1.6 0.2 18.9 100.0 20,340 Middle 3.8 0.8 1.4 5.6 15.2 1.6 1.9 0.1 21.6 0.8 7.6 0.5 28.2 1.1 0.2 9.6 100.0 20,344 Fourth 4.0 1.0 2.8 8.0 21.1 1.5 1.1 0.0 23.5 0.5 7.8 1.0 24.9 0.3 0.0 2.4 100.0 20,345 Richest 4.8 22.6 10.3 5.2 18.8 0.5 1.0 0.1 18.8 0.3 3.2 2.4 11.4 0.3 0.1 0.2 100.0 20,347 Total 2.6 4.9 3.1 4.5 15.2 1.1 1.2 0.1 19.7 1.1 6.2 0.9 20.7 0.9 0.1 17.7 100.0 101,713 76 In Afghanistan, 31% of the population live in households using improved sanitation facilities (Table 7.5), with a significant divide by residence: 60% in urban areas and 25% in rural areas. In rural areas, the most common type of improved sanitation facility is a pit latrine with slab (14%). Residents of the Central and North Eastern regions are more likely than others to use improved sanitation facilities. The highest proportion of use of piped sewer systems is found in the South region (11%), while 12% of households in the Central region are using a septic tank. In the South Eastern region, more than 20% of the population uses VIP latrines. In urban areas, for those using improved sanitation facilities, the most common facilities are flush toilets with a connection to a septic tank (23%), followed by pit latrine with a slab (18%). Still, both urban and rural populations frequently use open pits or pit latrines without slabs (20%). The distribution of sanitation facilities is markedly correlated to the wealth index quintile. For instance, 62% of households in the wealthiest quintile use improved sanitation facilities, compared to 8% in the poorest households, and 57% in the poorest quintile do not have any sanitation facility. With high regional, wealth and other variations, overall, there is a wide range of practices in the disposal of human excreta in use in Afghanistan. Use and Sharing of Sanitation Facilities Access to safe drinking water and to basic sanitation is measured by the proportion of the population using an improved sanitation facility. The MDGs and the WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation classify households as using an unimproved sanitation facility if they are using otherwise acceptable sanitation facilities but sharing a facility between two or more households or using a public toilet facility. Table 7.6 shows the percentage of households using private and public sanitation facilities, the percentage using shared facilities, and the percentage using improved and unimproved sanitation facilities. 77 Table 7.6: Use and sharing of sanitation facilities Percent distribution of household population by use of private and public sanitation facilities and use of shared facilities, by users of improved and unimproved sanitation facilities, Afghanistan, 2010-2011 Users of improved sanitation facilities Users of unimproved sanitation facilities Open defecation (no facility, bush, field) Total Number of household members Not shared 1 Public facility Shared by Missing/DK Not shared Public facility Shared by Missing/DK 5 households or less More than 5 households 5 households or less More than 5 households Region Central 27.4 1.4 5.5 1.4 0.0 52.4 2.4 7.0 1.6 0.0 0.9 100.0 16,232 Central Highlands 18.1 1.2 0.9 0.1 0.0 24.5 3.9 0.5 0.5 0.0 50.2 100.0 3,449 East 39.6 0.3 2.0 0.2 0.0 27.7 0.5 1.9 0.3 0.0 27.5 100.0 11,335 North 34.6 0.2 0.3 0.2 0.0 46.7 0.5 1.7 0.4 0.0 15.5 100.0 14,055 North East 16.5 0.4 1.5 0.5 0.1 71.0 1.3 4.5 1.0 0.1 3.1 100.0 16,557 South 29.1 0.4 0.3 0.6 0.0 44.7 0.7 0.1 0.3 0.0 23.7 100.0 13,825 South East 29.0 0.7 1.3 0.0 0.0 44.5 0.6 1.2 0.6 0.0 22.1 100.0 12,867 West 30.1 0.2 2.6 0.2 0.0 30.8 0.8 3.9 0.3 0.1 31.1 100.0 13,393 Residence Urban 51.2 1.5 6.1 1.7 0.1 29.5 2.0 5.9 1.4 0.1 0.6 100.0 18,000 Rural 23.6 0.3 1.1 0.2 0.0 49.6 0.9 2.3 0.5 0.0 21.3 100.0 83,713 Education of household head None 25.6 0.4 1.4 0.3 0.0 46.6 1.2 2.7 0.6 0.0 21.3 100.0 69,034 Primary 24.1 0.6 3.2 0.9 0.0 50.5 0.8 4.6 1.0 0.0 14.3 100.0 11,529 Secondary + 40.2 1.0 3.4 0.7 0.1 42.0 0.9 3.1 0.8 0.0 7.8 100.0 21,099 Wealth index quintile Poorest 7.9 0.2 0.3 0.0 0.0 31.6 1.2 1.1 0.3 0.0 57.3 100.0 20,338 Second 18.5 0.3 0.9 0.2 0.0 57.0 1.2 2.6 0.4 0.0 18.9 100.0 20,340 Middle 27.2 0.3 0.9 0.0 0.0 57.6 1.1 2.7 0.7 0.0 9.6 100.0 20,344 Fourth 35.0 0.5 2.3 0.5 0.0 53.7 1.0 3.7 0.9 0.0 2.4 100.0 20,345 Richest 53.6 1.4 5.5 1.6 0.1 30.4 1.2 4.8 1.2 0.1 0.2 100.0 20,347 Total 28.5 0.5 2.0 0.5 0.0 46.1 1.1 3.0 0.7 0.0 17.7 100.0 101,713 1 MICS Indicator 4.3; MDG Indicator 7.9 78 As shown in Table 7.6, 29% of the household population is using an improved sanitation facility that is not shared. Use of a shared facility is more common among households using an unimproved facility. Only 3% of households use an improved toilet facility that is shared with other households, compared with nearly 4% among households using an unimproved facility. Rural households are less likely than urban households to use a shared improved toilet facility (1% and 8%, respectively). In terms of improved sanitation facilities, the percentage for the use of unshared sanitation facilities is significantly higher in urban areas (51%) than in rural areas (24%). As for unimproved sanitation facilities, the results are opposite in that almost 30% of urban households who are using unimproved sanitation facilities do not share their toilets or latrines, compared with those living in rural areas (50%). In the Eastern region, almost 40% of households using improved sanitation facilities do not share their toilets with other households. The use and sharing of sanitation facilities is correlated with wealth index quintiles. The use of improved unshared sanitation facilities is highest among the wealthiest households, at 54% of the wealthiest households, compared with less than 8% of the poorest households using unshared facilities. Instead, open defecation is common among the poorest households (57%), and among only 0.2% of the wealthiest households. A correlation is also found with the education level of the head of household. For instance, the greatest proportion of households with access to an improved water source are those where the head of household has attained secondary level education or higher (40%). Disposal of Child s Faeces Safe disposal of a child s faeces is disposing of the stool produced by the child by using a toilet or by rinsing the stool into a toilet or latrine. Table 7.7 shows the percentage of the distribution of children aged 0-2 years according to the place of disposal of the child's faeces, and the percentage of children aged 0-2 years whose stools were disposed of safely the last time the child passed stools. Table 7.7: Disposal of child's faeces Percent distribution of children age 0-2 years according to place of disposal of child's faeces, and the percentage of children age 0-2 years whose stools were disposed of safely the last time the child passed stools, Afghanistan, 2010-2011 Place of disposal of child's faeces Percen- tage of children whose last stools were disposed of safely1 Number of children age 0-2 years Child used toilet/latrine Put/ rinsed into toilet or latrine Put/ rinsed into drain or ditch Thrown into garbage (Solid waste) Buried Left in the open Other DK Missing Total Type of sanitation facility in dwelling Improved 7.3 45.2 21.3 12.4 3.8 8.0 0.4 0.5 1.0 100.0 52.5 2,454 Unimproved 5.3 47.1 17.1 6.1 6.8 15.4 0.5 0.7 1.0 100.0 52.5 4,050 Open defecation 0.0 0.0 26.7 9.5 6.2 40.2 16.5 0.5 0.4 100.0 15.7 1,445 Region Central 13.4 60.7 7.5 9.9 3.5 4.1 0.2 0.5 0.2 100.0 74.1 1,262 Central Highlands 0.9 9.9 42.9 0.8 5.9 32.9 4.1 1.3 1.3 100.0 10.8 293 East 5.2 23.3 27.0 16.7 1.8 25.0 0.2 0.3 0.6 100.0 28.4 846 North 5.8 47.9 11.0 7.0 6.2 19.6 1.1 0.8 0.5 100.0 53.7 1,133 North East 2.5 64.7 7.7 2.2 8.9 11.6 0.0 0.3 2.1 100.0 67.3 1,331 79 Percent distribution of children age 0-2 years according to place of disposal of child's faeces, and the percentage of children age 0-2 years whose stools were disposed of safely the last time the child passed stools, Afghanistan, 2010-2011 Place of disposal of child's faeces Percen- tage of children whose last stools were disposed of safely1 Number of children age 0-2 years Child used toilet/latrine Put/ rinsed into toilet or latrine Put/ rinsed into drain or ditch Thrown into garbage (Solid waste) Buried Left in the open Other DK Missing Total South 2.3 31.7 15.3 18.8 4.1 25.4 0.6 1.0 0.9 100.0 34.0 752 South East 4.0 17.9 53.4 8.1 0.6 14.2 0.1 0.6 1.0 100.0 21.9 1,292 West 3.4 34.0 11.8 6.3 14.8 28.0 0.8 0.4 0.4 100.0 37.4 1,041 Residence Urban 12.3 61.8 6.0 12.8 3.0 2.2 0.7 0.6 0.6 100.0 74.1 1,387 Rural 3.8 36.0 23.2 7.8 6.4 20.9 0.5 0.6 1.0 100.0 39.8 6,563 Mother s education None 4.5 38.9 21.2 8.5 6.0 18.9 0.5 0.5 1.0 100.0 43.5 7,115 Primary 8.9 52.9 15.4 7.7 4.8 8.8 0.6 0.6 0.3 100.0 61.7 429 Secondary 14.5 55.1 7.3 13.2 3.4 4.3 0.7 1.2 0.1 100.0 69.6 402 Wealth index quintile Poorest 1.3 25.4 22.7 9.8 6.3 33.0 0.5 0.4 0.8 100.0 26.6 1,566 Second 2.2 33.7 22.7 7.4 8.5 22.7 1.0 0.8 1.0 100.0 35.9 1,694 Middle 3.5 38.1 24.8 6.7 7.4 17.2 0.3 0.6 1.4 100.0 41.6 1,590 Fourth 7.2 45.4 22.4 7.8 4.0 11.3 0.4 0.6 0.9 100.0 52.6 1,604 Richest 12.8 61.3 7.3 11.9 2.3 3.0 0.4 0.6 0.3 100.0 74.1 1,496 Total 5.3 40.5 20.2 8.7 5.8 17.6 0.5 0.6 0.9 100.0 45.8 7,950 1 MICS indicator 4.4 Overall, 46% of children 0-2 years of age had their last stools disposed of safely. The table shows that there is no difference in the pattern of disposal of child s faeces between the households who have an improved sanitation facility and those with an unimproved facility (both are at 53%). However, even among the households with an improved sanitation facility, 21% of children had their last stools put into the drain or ditch, and 12% had their last stools thrown into garbage as solid waste. More than 65% of households using the practice of open defecation leave the child s faeces in the open or put them into a drain or ditch. Only 16% of households that practice open defecation practice safe disposal of the child s faeces. At the regional level, the pattern of disposal of a child s faeces varies. In the Central region, almost 74% of children had safe stool disposal. In the Central Highlands region, only 10% of households treat child s faeces in an appropriately hygienic manner. In general, there is a marked disparity between urban and rural areas: 74% of households living in urban areas correctly dispose of the child s faeces, compared to rural areas where only 40% practice correct disposal. The percentage of households who practice appropriate disposal of the child s faeces is highest among households whose mothers have attained secondary edu

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