Belize Multiple Indicator Cluster Survey 2011

Publication date: 2012

Belize Multiple indicator cluster survey 2011 Final report The Belize Multiple Indicator Cluster Survey (MICS) was carried out in 2011 by Statistical Institute of Belize (SIB). Financial and technical support was provided by the United Nations Children’s Fund (UNICEF). MICS is an international household survey programme developed by UNICEF. The Belize 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 that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. Additional information on the global MICS project may be obtained from www.childinfo.org. Belize Multiple Indicator Cluster Survey 2011 The Statistical Institute of Belize UNICEF United Nations Children’s Fund November, 2012 4 mics f inal report suMMary taBle oF Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Belize, 2011 Topic MICS4 Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY Child mortality 1.1 4.1 Under-five mortality rate 17 per 1,000 1.2 4.2 Infant mortality rate 14 per 1,000 NUTRITION Nutritional status 2.1a 2.1b 1.8 Underweight prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 6.2 percent 1.3 percent 2.2a 2.2b Stunting prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 19.3 percent 5.4 percent 2.3a 2.3b Wasting prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 3.3 percent 1.2 percent Breastfeeding and infant feeding 2.4 Children ever breastfed 91.9 percent 2.5 Early initiation of breastfeeding 61.5 percent 2.6 Exclusive breastfeeding under 6 months 14.7 percent 2.7 Continued breastfeeding at 1 year 62.1 percent 2.8 Continued breastfeeding at 2 years 34.9 percent 2.9 Predominant breastfeeding under 6 months 34.3 percent 2.10 Duration of breastfeeding 16.1 months 2.11 Bottle feeding 57.8 percent 2.12 Introduction of solid, semi-solid or soft foods 67.4 percent 2.13 Minimum meal frequency 67.6 percent 2.14 Age-appropriate breastfeeding 38.2 percent 2.15 At least 2 milk feeds 84.4 percent Vitamin A 2.17 Vitamin A supplementation (children under age 5) 65.1 percent Low birth weight 2.18 Low-birth weight infants 11.1 percent 2.19 Infants weighed at birth 95.0 percent CHILD HEALTH Vaccinations 3.1 Tuberculosis immunization coverage 97.5 percent 3.2 Polio immunization coverage 75.2 percent 3.3 Immunization coverage for diphtheria, pertussis and tetanus (DPT) 67.8 percent 3.4 4.3 Measles immunization coverage 84.9 percent 3.5 Hepatitis B immunization coverage 73.7 percent Tetanus toxoid 3.7 Neonatal tetanus protection 52.4 percent Care of illness 3.8 Oral rehydration therapy with continued feeding 42.5 percent 3.9 Care seeking for suspected pneumonia 82.2 percent 3.10 Antibiotic treatment of suspected pneumonia 70.7 percent Solid fuel use 3.11 Solid fuels 17.7 percent Child Disability 3.21 Child disability 36.4 percent WATER AND SANITATION Water and sanitation 4.1 7.8 Use of improved drinking water sources 97.7 percent 4.2 Water treatment 31.2 percent 4.3 7.9 Use of improved sanitation facilities 89.2 percent 4.4 Safe disposal of child’s faeces 25.6 percent 4.5 Water and soap available 94.4 percent 4.6 Soap anywhere in dwelling 93.2 percent REPRODUCTIVE HEALTH Contraception and unmet need 5.1 5.4 Adolescent fertility rate 64 per 1,000 5.2 Early childbearing 16.9 percent 5.3 5.3 Contraceptive prevalence rate 55.2 percent 5.4 5.6 Unmet need 15.9 percent Maternal and newborn health 5.5a 5.5b 5.5 Antenatal care coverage At least once by skilled personnel At least four times by any provider 96.2 percent 83.1 percent 5.6 Content of antenatal care 96.6 percent 5.7 5.2 Skilled attendant at delivery 96.2 percent 5.8 Institutional deliveries 93.8 percent 5.9 Caesarean section 28.1 percent mics f inal report 5 Topic MICS4 Indicator Number MDG Indicator Number Indicator Value Post-natal health checks 5.10 Post-partum stay in health facility 92.3 percent 5.11 Post-natal health check for the newborn 97.3 percent 5.12 Post-natal health check for the mother 94.6 percent CHILD DEVELOPMENT Child development 6.1 Support for learning 85.6 percent 6.2 Father’s support for learning 50.0 percent 6.3 Learning materials: children’s books 39.6 percent 6.4 Learning materials: playthings 57.3 percent 6.5 Inadequate care 2.4 percent 6.6 Early child development index 87.5 percent 6.7 Attendance to early childhood education 31.7 percent EDUCATION Literacy and education 7.1 2.3 Literacy rate among young women 91.1 percent 7.2 School readiness 32.9 percent 7.3 Net intake rate in primary education 85.3 percent 7.4 2.1 Primary school net attendance rate (adjusted) 94.4 percent 7.5 Secondary school net attendance rate (adjusted) 55.4 percent 7.6 2.2 Children reaching last grade of primary 96.5 percent 7.7 Primary completion rate 92.9 percent 7.8 Transition rate to secondary school 90.9 percent 7.9 Gender parity index (primary school) 1.00 ratio 7.10 Gender parity index (secondary school) 1.23 ratio CHILD PROTECTION Birth registration 8.1 Birth registration 95.2 percent Child labour 8.2 Child labour 10.0 percent 8.3 School attendance among child labourers 90.4 percent 8.4 Child labour among students 9.7 percent Child discipline 8.5 Violent discipline 70.5 percent Early marriage and polygyny 8.6 Marriage before age 15 4.8 percent 8.7 Marriage before age 18 29.4 percent 8.8 Young women age 15-19 currently married or in union 15.2 percent 8.9 Polygyny 3.4 percent 8.10a Spousal age difference - 10+ years older (women age 15 – 19) 17.0 percent 8.10b Spousal age difference - 10+ years older (women age 20 – 24) 15.4 percent Domestic violence 8.14 Attitudes towards domestic violence 8.6 percent HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN HIV/AIDS knowledge and attitudes 9.1 Comprehensive knowledge about HIV prevention 44.5 percent 9.2 6.3 Comprehensive knowledge about HIV prevention among young people 42.9 percent 9.3 Knowledge of mother- to-child transmission of HIV 55.7 percent 9.4 Accepting attitude towards people with HIV 19.3 percent 9.5 Women who know where to be tested for HIV 86.6 percent 9.6 Women who have been tested for HIV and know the results 28.4 percent 9.7 Sexually active young women who have been tested for HIV and know the results 40.8 percent 9.8 HIV counselling during antenatal care 59.4 percent 9.9 HIV testing during antenatal care 71.8 percent Sexual behaviour 9.10 Young women who have never had sex 68.7 percent 9.11 Sex before age 15 among young women 5.3 percent 9.12 Age-mixing among sexual partners 15.9 percent 9.13 Sex with multiple partners 2.1 percent 9.14 Condom use during sex with multiple partners 28.6 percent 9.15 Sex with non-regular partners 41.6 percent 9.16 6.2 Condom use with non-regular partners 64.6 percent 9.18 Prevalence of children with at least one parent dead 3.8 percent SUBJECTIVE WELL-BEING Subjective well- being SW.1 Life satisfaction - women age 15-24 73.7 percent SW.2 Happiness - women age 15-24 91.3 percent SW.3 Perception of a better life - women age 15-24 65.5 percent 6 mics f inal report Table of ConTenTs Summary Table of Findings . 4 Table of Contents . 6 List of Tables . 8 List of Figures .11 List of Abbreviations . 12 Acknowledgements . 15 Executive Summary . 16 I. Introduction . 22 Background . 22 Survey Objectives . 23 II. Sample and Survey Methodology . 24 Sample Design . 24 Questionnaires . 24 Training and Fieldwork . 26 Data Processing . 26 III. Sample Coverage and the Characteristics of Households and Respondents . 27 Sample Coverage. 27 Characteristics of Households . 28 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 . 32 IV. Child Mortality . 35 V. Nutrition Nutritional Status . 37 Breastfeeding and Infant and Young Child Feeding . 41 Children’s Vitamin A Supplementation . 52 Low Birth Weight . 55 VI. Child Health . 58 Vaccinations . 58 Neonatal Tetanus Protection . 61 Oral Rehydration Treatment . 62 Care Seeking and Antibiotic Treatment of Pneumonia . 66 Solid Fuel Use . 69 Child Disability . 72 VII. Water and Sanitation . 75 Use of Improved Water Sources . 75 Use of Improved Sanitation Facilities . 83 Handwashing . 88 VIII. Reproductive Health . 91 Fertility . 91 Contraception . 93 Unmet Need . 96 Antenatal Care .101 Assistance at Delivery .105 Place of Delivery .107 Post-natal Health Checks .109 mics f inal report 7 IX. Child Development .118 Early Childhood Education and Learning .118 Early Childhood Development . 123 X. Literacy and Education . 126 Literacy among Young Women . 126 School Readiness . 127 Primary and Secondary School Participation . 127 XI. Child Protection .141 Birth Registration .141 Child Labour .143 Child Discipline .148 Early Marriage and Polygyny .149 Attitudes toward Domestic Violence . 155 XII. HIV/AIDS, Sexual Behaviour, and Orphans . 157 Knowledge about HIV Transmission and Misconceptions about HIV/AIDS . 157 Attitudes toward People Living with HIV/AIDS . 164 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care 165 Sexual Behaviour Related to HIV Transmission . 169 Orphanhood .174 XIII. Subjective Well-being . 177 Appendix A. Sample Design . 183 Appendix B. Budget . 188 Appendix C. Sensitization Campaign .191 Appendix D. List of Personnel Involved in the Survey .194 Appendix E. Estimates of Sampling Errors .196 Appendix F. Data Quality Tables .210 Appendix G. MICS4 Indicators: Numerators and Denominators . 221 Appendix H. Household Questionnaire . 228 Appendix I. Questionnaire For Individual Women . 244 Appendix J. Questionnaire For Children Under Five . 270 Appendix K. Questionnaire Form For Child Disability . 287 8 mics f inal report lisT of Tables Characteristics of Households Table HH.1: Results of household, women’s, and under-5 interviews. Table HH.2: Household age distribution by sex. Table HH.3: Household composition. Table HH.4: Women’s background characteristics. Table HH.5: Under-5’s background characteristics. Child Mortality Table CM.1: Children ever born, children surviving and proportion dead. Table CM.2: Child mortality. Nutrition Table NU.1: Nutritional status of children. Table NU.2: Initial breastfeeding. Table NU.3: Breastfeeding. Table NU.4: Duration of breastfeeding. Table NU.5: Age-appropriate breastfeeding. Table NU.6: Introduction of solid, semi-solid or soft food. Table NU.7: Minimum meal frequency. Table NU.8: Bottle feeding. Table NU.10: Children’s vitamin A supplementation. Table NU.11: Low birth weight infants. Child Health Table CH.1: Vaccinations in first year of life. Table CH.2: Vaccinations by background characteristics. Table CH.3: Neonatal tetanus protection. Table CH.4: Oral rehydration solutions and recommended homemade fluids. Table CH.5. Feeding practices during diarrhoea. Table CH.6: Oral rehydration therapy with continued feeding and other treatments. Table CH.7: Care seeking for suspected pneumonia and antibiotic use during suspected pneumonia Table CH.8: Knowledge of the two danger signs of pneumonia. Table CH.9: Solid fuel use. Table CH.10: Solid fuel use by place of cooking. Table CH.11: Children at increased risk of disability. Water and Sanitation Table WS.1: Use of improved water sources. Table WS.2: Household water treatment. mics f inal report 9 Table WS.3: Time to source of drinking water. Table WS.4: Person collecting water. Table WS.5: Types of sanitation facilities. Table WS.6: Use and sharing of sanitation facilities. Table WS.7: Disposal of child’s faeces. Table WS.8: Drinking water and sanitation ladders. Table WS.9: Water and soap at place for hand washing. Table WS.10: Availability of soap. Reproductive Health Table RH.1: Adolescent birth rate and total fertility rate. Table RH.2: Early childbearing. Table RH.3: Trends in early childbearing. Table RH.4: Use of contraception. Table RH.5: Unmet need for contraception. Table RH.6: Antenatal care provider. Table RH.7: Number of antenatal care visits. Table RH.8: Content of antenatal care. Table RH.9: Assistance during delivery. Table RH.10: Place of delivery. Table RH.11: Post-partum stay in health facility. Table RH.12: Post-natal health checks for newborns. Table RH.13: Post-natal care (PNC) visits for newborns within one week of birth Table RH.14: Post-natal health checks for mothers Table RH.15: Post-natal care (PNC) visits for mothers within one week of birth Table RH.16: Post-natal health checks for mothers and newborns Child Development Table CD.1: Early childhood education. Table CD.2: Support for learning. Table CD.3: Learning materials. Table CD.4: Inadequate care. Table CD.5: Early child development index Education Table ED.1: Literacy among young women. Table ED.2: School readiness. Table ED.3: Primary school entry. Table ED.4A: Primary school attendance. Table ED.4B: Primary school attendance (ISCED). Table ED.5A: Secondary school attendance. Table ED.5B: Secondary school attendance (ISCED). Table ED.6: Children reaching last grade of primary school. 10 mics f inal report Table ED.7A: Primary school completion and transition to secondary school. Table ED.7B: Primary school completion and transition to secondary school (ISCED). Table ED.8A: Education gender parity. Table ED.8B: Education gender parity (ISCED). Child Protection Table CP.1: Birth registration. Table CP.2: Child labour. Table CP.3: Child labour and school attendance. Table CP.4: Child discipline. Table CP.5: Early marriage and polygyny Table CP.6: Trends in early marriage. Table CP.7: Spousal age difference. Table CP.11: Attitudes toward domestic violence. HIV/AIDS Table HA.1: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission. Table HA.2: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission among young women. Table HA.3: Knowledge of mother-to-child HIV transmission . Table HA.4: Accepting attitudes toward people living with HIV/AIDS. Table HA.5: Knowledge of a place for HIV testing. Table HA.6: Knowledge of a place for HIV testing among sexually active young women. Table HA.7: HIV counselling and testing during antenatal care. Table HA.8: Sexual behaviour that increases the risk of HIV infection. Table HA.9: Sex with multiple partners. Table HA.10: Sex with multiple partners among young women. Table HA.11: Sex with non-regular partners. Table HA.12: Children’s living arrangements and orphanhood. Table HA.13: School attendance of orphans and non-orphans. Life Satisfaction Table SW.1: Domains of life satisfaction. Table SW.2: Life satisfaction and happiness. Table SW.3: Perception of a better life. Sampling Errors Table SE.1: Indicators selected for sampling error calculations Table SE.2: Sampling errors: Total sample Table SE.3: Sampling errors: Urban areas Table SE.4: Sampling errors: Rural areas mics f inal report 11 Table SE.5: Sampling errors: Corozal Table SE.6: Sampling errors: Orange Walk Table SE.7: Sampling errors: Belize Excluding Belize City South Side Table SE.8: Sampling errors: Belize City South Side Table SE.9: Sampling errors: Belize District Table SE.10: Sampling errors: Cayo Table SE.11: Sampling errors: Stann Creek Table SE.12: Sampling errors: Toledo Data Quality Table DQ.1: Age distribution of household population Table DQ.2: Age distribution of eligible and interviewed women Table DQ.3: Age distribution of under-5s in household and under-5 questionnaires Table DQ.4: Women’s completion rates by socio-economic characteristics of households Table DQ.5: Completion rates for under-5 questionnaires by socio-economic characteristics of households Table DQ.6: Completeness of reporting Table DQ.7: Completeness of information for anthropometric indicators Table DQ.8: Heaping in anthropometric measurements Table DQ.9: Observation of women’s health cards Table DQ.10: Observation of under-5s birth certificates Table DQ.11: Observation of vaccination cards Table DQ.12: Presence of mother in the household and the person interviewed for the under-5 questionnaire Table DQ.13: Selection of children age 2-14 years for the child discipline module Table DQ.14: School attendance by single age Table DQ.15: Sex ratio at birth among children ever born and living lisT of figures Figure HH.1. Population pyramid, MICS, Belize 2011 Figure HH.2. Population pyramid, Belize Census 2011 Figure CM.1. Under-5 mortality rates by sex, region and ethnicity, Belize, 2011 Figure CM.1. Trend in under-5 mortality rates, Belize, 2011 Figure NU.1. Anthropometric indicators by wealth, Belize, 2011 Figure NU.2. Anthropometric indicators by region, Belize, 2011 Figure NU.3. Anthropometric indicators by ethnicity, Belize, 2011 Figure NU.4. Breastfeeding by wealth, Belize, 2011 Figure NU.5. Breastfeeding by ethnicity, Belize, 2011 Figure NU.6. Breastfeeding by place of delivery, Belize, 2011 Figure NU.7. Breastfeeding by region, Belize, 2011 Figure NU.8. Age-appropriate breastfeeding by wealth and education, Belize, 2011 Figure NU.9. Fed with a bottle with nipple by wealth and education, Belize, 2011 Figure NU.10. Infants below 2500 grams at birth by wealth, Belize, 2011 12 mics f inal report Figure CH.1. Polio and DPT vaccinations, Belize, 2011 Figure RH.1. Trends in early childbearing by age and area, Belize, 2011 Figure RH.2. Unmet need for contraception by age and wealth, Belize, 2011 Figure RH.3. Met need for contraception by age and wealth, Belize, 2011 Figure RH.4. Met need for spacing and limiting by age, Belize, 2011 Figure RH.5. Demand for contraception satisfied by wealth, education, age and area, Belize, 2011 Figure ED.1. Primary net attendance ratio by education of mother and sex, Belize, 2011 Figure ED.2. Primary net attendance ratio by wealth and sex, Belize, 2011 Figure ED.3 Secondary net attendance ratio by mother’s education and wealth, Belize, 2011 Figure ED.4. Children reaching last grade of primary school by wealth index, Belize, 2011 Figure CP.1. Child labour by wealth index and education, Belize, 2011 Figure CP.2. Labour force participation by ethnicity, Belize, 2011 Figure CP.3. Child discipline by education, Belize, 2011 Figure CP.4. Trends in early marriage by age and area, Belize, 2011 Figure CP.5. Domestic violence justified by area, age of respondent, education and wealth index, Belize, 2011 Figure HA.1. Percentage of women with comprehensive knowledge of HIV by education and wealth index, Belize 2011 Figure HA.2. Accepting attitudes towards people living with AIDS by education and wealth index, Belize 2011 Figure HA.3. Sexual behavior that increases the risk of HIV infection, Belize 2011 Figure HA.4. Never married women age 14-24 who have never had sex by wealth, Belize, 2011 Figure HA.5. Sex with non-cohabiting partner by wealth index and area, Belize, 2011 Figure HA.6. Children’s living arrangements by ethnicity, Belize, 2011 Figure SW.1. Percentage of women age 15-24 years who are very or somewhat satisfied by age, area and education, Belize, 2011 Figure SW.2. Life improved last year and will get better next year by wealth index, Belize, 2011 lisT of abbreviaTions AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care BCG Bacillis-Cereus-Geuerin (Tuberculosis) CDC Center for Disease Control CRC Convention on the Right of the Child CSPro Census and Survey Processing System deff Design Effect DHS Demographic Health Surveys DPT Diphteria, Pertussis, Tetanus ECDI Early Child Development Index ED Enumeration District EPI Expanded Programme on Immunization mics f inal report 13 FHS Family Health Survey GPI Gender Parity Index HepB Hepetitis HIB Haemophilus Influenzae B HIV Human Immunodeficiency Virus IMR Infant Mortality Rate ISCED International Standard Classification of Education IUD Intrauterine Device JMP Joint Monitoring Programme LAM Lactational Amenorrhea Method MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS4 Fourth global round of Multiple Indicator Cluster Survey Programme MoH Ministry of Health NAR Net Attendance Rate NCFC National Committee for Families and Children NCHS National Centre for Health Statistics PNHC Post Natal Health Check NPA National Plan of Action nq0 Probability of Dying Before Year n ORS Oral Rehydration Solution ORT Oral Rehydration Treatment PNC Post Natal Care pps Probability Proportional to Size PSU Primary Sampling Unit RHF Recommended Home Fluid SIB Statistical Institute of Belize STIs Sexually Transmitted Infections SPSS Statistical Package for Social Sciences TSFB Time Since First Birth U5MR Under-5 Mortality Rate UN United Nations UNAIDS United Nations Programme on HIV/AIDS UNCT United Nations Country Team UNDAF United Nations Development Framework UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit For Children WHO World Health Organization 14 mics f inal report foreword The Belize Multiple Indicator Cluster Survey (MICS 4) 2011 conducted is part of the UNICEF- GOB Programme of Cooperation to monitor the progress of boys and girls development in Belize. MICS provides updated statistically sound and internationally comparable estimates of a range of indicators in the areas of health, education, child protection (including disabilities), water and sanitation and HIV and AIDS. The survey provides information on the prevalence of child mortality, stunting, wasting, underweight, and obesity; breastfeeding and supplementary feeding practices, including the immunization status of children. Information is also provided on the prevalence of diarrhea and pneumonia among young children and treatment sought. Valuable data on health practices, including access to improved drinking water sources and sanitation, and knowledge about HIV and Aids are made available. Belize would also have data on child development, child protection and life satisfaction. The findings from the MICS are one of the most important sources of data used as a basis for policy decisions and programme interventions, and for influencing public opinion on the situation of children and women. mics f inal report 15 aCknowledgemenT The Multiple Indicator Cluster Survey 2011 is another land mark achievement of Belize and it is with great pride that the Government of Belize and it’s Statistical Institute and UNICEF make public this report. The report provides vital information on a wide range of social indicators related to the situation of children and women of Belize. The Statistical Institute of Belize and the MICS team, head by Director General Glenn Avilez merit special appreciation for their professionalism, dedication, and effort in undertaking this enormous task. We acknowledge the hard work done by the data collection and enumeration teams whose work in the field was vital to the success of this survey. We are indebted to the women of Belize who participated in this initiate and to the men who provided the support when requested. We would also like to convey special gratitude to the Steering Committee who played an instrumental role in the successful completion of the survey and report. We remain thankful for the technical support of Dr.Nathalia Largaespada Beer (Ministry of Health), Ms.Yuvone Flowers ( Ministry of Education, Youth and Sport), Mr. John Flowers, Mark Antrobus ( Ministry of Human Development, Social Transformation and Poverty Alleviation), Ms. Ann Marie Williams (National Aids Commission), Mr. Dylan Williams ( National Committee for Families and Children), Mariana Mansur (UNDP Belize), Joe Hendrix (University of Belize, Policy Observatory) . Special attention goes to the UNICEF MICS Global (Head Quarters, New York) and Regional (TACRO) teams for the technical and financial support. We are highly indebted to Dr. Shane Khan (MICS Regional Coordinator), Dr Attila Hancioglu (Senior Advisor/Global MICS Coordinator), Dr Ivana Bjelic (Statistics Specialist), and Dr. Claudia Cappa (Statistics and Monitoring Specialist) for their unflagging support and guidance to the entire process. Similarly the technical group at UNICEF Belize, Ms Christine Norton (Representative), Ms Paulette Wade (Planning Monitoring and Evaluation Specialist) and Dr. Leopold Perriott (MICS Belize Coordinator) for their untiring support throughout the survey process. Finally to Mr. Peter Wingfield-Digby and Mr. Martin Wulfe who provided technical support and training to SIB for the sample design and data processing phases of the survey. 16 mics f inal report exeCuTive summary MICS is an international household survey programme developed by UNICEF. The Belize 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 that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. The Belize Multiple Indicator Cluster Survey (MICS) was conducted in 2011 by The Statistical Institute of Belize. Fieldwork was carried out between July, 2011 and August, 2011. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF). Findings Child Mortality • MICS 2011 estimated that the infant mortality rate was 14 per thousand, and the under-5 mortality rate (U5MR) was 17 per thousand. Nutritional Status • The key indicators for monitoring the nutritional status of a child under the age of five are underweight (weight-for-age), stunting (height-for- age) and wasting (weight-for-height). In Belize 6.2 percent of children under age five are underweight, 19.3 percent are stunted and 3.3 percent are wasted. • 7.9 percent of children under age five are overweight. Breastfeeding • About 15 percent of 0-1 month old children are exclusively breastfed. • Continued breastfeeding at one year is 62 percent and declines to 34 percent in the second year of life. Vitamin A Supplements • 65.1 percent of children aged 6-59 months received a high dose Vitamin A supplement in the six months prior to the MICS4. Low Birth Weight • 11.1 percent of children who were weighed had a birth weight of less than 2,500 grams at birth. Immunization • 97.5 percent of children have received BCG vaccinations. • Diphteria, Whooping Cough and Tetanus (DPT) immunization are obtained through the Pentavalent and the DTaP – P vaccines: 68.7 percent have received three doses of DPT. mics f inal report 17 • Immunization against Polio is obtained through the Polio and the DTaP – P vaccines: 75.2 percent have received three doses of polio vaccine. • By 18 months of age 84.9 percent of children were immunized against measles. Tetanus Toxoid • Overall, 52.4 percent of the women in Belize received vaccines against tetanus during pregnancy. • 34.5 percent of the women received at least two doses during their last pregnancy. Oral Rehydration Treatment (ORT) • 7.9 percent of the children under age five had diarrhoea in the two weeks preceding the survey. • The recommended treatment for diarrhoea in children is oral rehydration therapy (ORS packet or recommended homemade fluid or increased fluids) with continued feeding: 42.5 percent of children with diarrhoea received this treatment. Care Seeking and Antibiotic Treatment of Pneumonia • About three percent of children under age five had symptoms consistent with pneumonia during the two weeks preceding the survey. • Overall, 70.7 percent of children with suspected pneumonia received antibiotics. • Antibiotic treatment of suspected pneumonia is lower in rural areas than in urban areas, only 63.7 percent, compared to 90.1 percent in urban areas, received antibiotic treatment. • Solid Fuel Use • 17.7 percent of all households in Belize are using solid fuels for cooking. Water and Sanitation • Most of the population of Belize (97.7 %) use an improved source of drinking water. • Both the urban (99.5 percent) and rural (96.2 percent) areas display a high access to improved sources of drinking water. • The main improved source of drinking water in Belize is bottled water (47.8 percent) followed by water piped into dwelling (17.9 percent). • One in ten households (9.7 percent ) in the Toledo District have no sanitary facility but use the bush or field to dispose of excreta. Fertility • Adolescent birth rate is 64 per thousand and twice as high in rural areas (85 per thousand) than in urban areas (39 per thousand). • The percentage of women age 20-24 years who have had a live birth before age 18 is 16.9. Contraception 18 mics f inal report • Use of contraception was reported by 55.2 percent of women currently married or in a union. • The most popular method is female sterilization which is used by 20.7 percent of married women in Belize. The next most popular method is the pill (12.5 percent). • Contraceptive use in urban and rural married women age 15-49 years was 57.7 percent (urban) and 53.3 percent (rural). • Contraceptive prevalence is highest in Corozal District at 61.8 percent. • In the Cayo District, contraceptive use is relatively rare; only 28.3 percent of married women reported using any method. Unmet Need • The unmet need for contraception is 15.9 percent (spacing 8.4% and limiting 7.5%). • Antenatal Care • 96.2 percent of women age 15-49 years with a live birth in the two years preceding the survey received antenatal care (ANC) at least once by skilled personnel and 83.1 percent received ANC at least 4 times by any provider. • The lowest level of antenatal care is found in the Toledo District (91.5 percent) and in the Belize District (91.7 percent). • In the Belize District the lowest level of antenatal care is in the Belize (Excluding Belize City South Side) (86.9 percent). In Belize City South Side the rate is 96.4 percent. Assistance at Delivery • About 96.2 percent of births occurring in the two years preceding the MICS survey were delivered by skilled personnel. • This percentage is highest in Orange Walk at 99.3 percent and lowest in Toledo at 87.8 percent. • Delivery by C-section occurred in 28.1 percent of births. • Doctors delivered almost twice as many babies in private sector health facilities than in public sector health facilities (47.1 percent to 79.2 percent) and were most active in urban areas (urban 56.9 percent, rural 45.3 percent). • Nurses or midwives delivered most frequently in rural areas (urban 41.3 percent to rural 47.9 percent), in public health facilities (public 52.5 percent to private 17.1 percent) and in poorer families (poorest 55.4 percent, richest 33.9 percent). • Both mother and newborn had post natal health checks within 2 days of birth at a rate of 92.7 percent. Child Development • 31.7 percent of children aged 36-59 months are attending pre-school. Urban-rural and regional differentials are observed – the figure is as high as 40.4 percent in urban areas, compared to 26.4 percent in rural areas. • For 85.6 percent of under-five children, an adult household member engaged in more than four activities that promote learning and school readiness during the 3 days preceding the survey. mics f inal report 19 • The average number of activities in the 3 days preceding the survey that adults engaged with children was 5.1. • Father’s involvement with one or more activities was 50.0 percent. • In Belize, 39.6 percent of children 0-59 months old live in households where at least 3 children’s books are present. The percentage of children with 10 or more books declines to 19.5percent. • 57.3 percent of children aged 0-59 months had 2 or more playthings to play with in their homes. • 2.4 percent of children were left with inadequate care during the week preceding the survey, either by being left alone or in the care of another child. • Physical growth, literacy and numeracy skills, socio-emotional development and readiness to learn are vital domains of a child’s overall development. In Belize, 87.5 percent of children aged 36-59 months are developmentally on track. Pre-School Attendance and School Readiness • Overall, 32.9 percent of children who are currently attending the infant 1 of primary school were attending pre-school the previous year. Primary and Secondary School Participation by National Educational Levels • The majority of children of primary school age are attending school (94.4 percent). • In urban areas 98.0 percent of children attend primary school while in rural areas attendance is only 92.2 percent. • The majority of all children starting infant one in primary school (97.6 percent) will eventually reach the last grade (standard 6). • Only half of the children of secondary school age are attending secondary school (55.4 percent). • Gender parity index (GPI) for primary school is 1.00. • Gender parity increases to 1.21 for secondary education. • The disadvantage of boys is particularly pronounced in urban areas and Garifuna headed households. Adult Literacy • Over ninety percent (91.1 percent) of women in Belize are literate and that literacy status varied considerably by place of residence. The most literate women are found in Belize District (98.5 percent) and the least literate in the Orange Walk District (82.0 percent). Birth Registration • The births of 95.2 percent of children under-five years in Belize have been registered. • Only 87.3 percent of children 0 to 11 months have been registered as compared to older children who have been registered at rates in the mid ninety percentages. • Children in the Corozal (93.3 percent) and Cayo (94.8 percent) Districts are somewhat less likely to have their births registered than other children and children from Garifuna households are registered at slightly less rates (91.9 percent) than children from other ethnic backgrounds. 20 mics f inal report Child Labour • In Belize, 10 percent of children age 5 – 14 are involved in child labour. • 12.1 percent of children 5 to 11 years and 4.8 percent of children 12 to 14 years are engaged in child labour. • For the 5 to 11 years group child labour rates are males 14.6 percent and females 9.7 percent while for the 12 to 14 years group 7.0 percent of males and 2.8 percent of females engage in child labour. • Most of the child labour occurs in rural areas. The rates are 4.1 percent urban and 13.8 percent rural. • Of the 93.4 percent of the children 5-14 years of age attending school, 9.7 percent are also involved in child labour activities. • On the other hand, out of the children who are involved in child labour, the majority of them are also attending school (90.4 percent). Child Discipline • In Belize, 70.5 percent of children age 2-14 years were subjected to at least one form of psychological or physical punishment by their mothers/caretakers or other household members. • 5.2 percent of children were subjected to severe physical punishment. • 26.2 percent of mothers/caretakers believed that children should be physically punished. Domestic Violence • Overall, 8.6 percent of women in Belize feel that their husband/partner has a right to hit or beat them for at least one of a variety of reasons. • 6.8 percent of women justify violence in instances when they neglect the children. • Acceptance is more present among rural dwellers. • Women living in poorest households, less educated and Mayan households are more accepting of domestic violence. Child Disability • In Belize, 2011 more than a third (36.4 percent) of children 2 to 9 years was at risk for one or more disabilities as reported by the mother or primary caretaker. • The Cayo District recorded the highest at risk percentage (59.3 percent) and the Belize City South Side the lowest (23.0 percent). • Rural children are at higher risk for disabilities than urban children (urban 28.3 percent, rural 41.5 percent). Knowledge of HIV Transmission and Condom Use • 94.7 percent of women in Belize had heard of AIDS. • About eighty percent (77.9 percent) of women know of having one faithful uninfected sex partner, 72.9 percent know of using a condom every time, and 64.4 percent know both main ways of preventing HIV mics f inal report 21 transmission. • Comprehensive knowledge about HIV among women age 15 to 49 years is low at only 44.5. • Only 42.9 percent of women aged 15 to 24 years have comprehensive knowledge of HIV. • Urban women have a higher rate of knowledge (56.4 percent) than rural women (34.0 Percent). • Overall, 90.2 percent of women know that HIV can be transmitted from mother to child. • The percentage of women who know all three ways of mother-to-child transmission is 55.7 percent, while 4.5 percent of women did not know of any specific means of mother-to-child transmission. • In Belize 96.5 percent of women who have heard of AIDS agree with at least one accepting statement. • The most common accepting attitude is willingness to care for a family member with the AIDS virus in their own home (85.0 percent). • Women in rural areas tend to be less accepting of people with the AIDS virus. In urban areas, 23.4 percent express accepting attitudes on all four indicators while the rate is 15.4 percent in rural areas. • 86.6 percent of women 15 to 49 years knew where to be tested for HIV, while 62.9 percent had actually been tested ever, and only 29.9 percent had been tested in the last year. Sexual Behaviour Related to HIV Transmission • 68.7 percent of women 15 to 24 years had never had sex while 5.3 percent had sex before age 15. • 15.9 percent had sex with a man 10 years or older in the last 12 months. • 2.1 percent of women 15-49 years of age report having sex with more than one partner. Of those women, only 28.6 percent report using a condom the last time they had sex (this is sex in the last 12 months). Orphaned Children • 65.4 percent of children aged 0-17 years in Belize live with both the parents. • About one in fifteen children (6.9 percent) is living with neither parent. • In Belize, 0.4 percent of children aged 10-14 have lost both parents. • Among the children age 10-14 who have not lost a parent and who live with at least one parent, 95.0 percent are attending school. 22 mics f inal report i. inTroduCTion Background This report is based on the Belize Multiple Indicator Cluster Survey (MICS), conducted in 2011 by the Statistical Institute of Belize. The survey provides valuable information on the situation of children and women in Belize, and was based, in large part, on the needs to monitor progress towards goals and targets emanating from recent international agreements: 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 (see table below). 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 sub-national 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.” mics f inal report 23 The National Plan of Action (NPA) for children and adolescents in Belize 2004 – 2015 was adopted by the Government of Belize to ensure the wellbeing of Belize’s children. This plan was conceptualized within the framework of national development agencies, the International Convention on the Rights of the Child (CRC) and the Millennium Development goals (MDG). Promoting, monitoring and evaluation of the implementation of the Convention on the Rights of the Child (CRC) are responsibilities assigned to the National Committee for Families and Children (NCFC). The NCFC advocates on behalf of children and adolescents with the Government to meet its obligations as signatory to the Convention and also with local agencies which provide services to families and children. Six main areas are addressed in the NPA: Education, Health, Child Protection, HIV & AIDS, Families and Culture. The Multiple Indicator Cluster Survey (MICS) captures information on many of the MDG indicators and also provides information in many additional areas. The MICS programme is designed to review and monitor targets defined in the NPA and to evaluate the extent to which targets are being realized to achieve compliance with the Convention on the Rights of the Child and with the Millennium Development Goals. This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The 2011 Belize Multiple Indicator Cluster Survey has as its primary objectives: • To provide up-to-date information for assessing the situation of children and women in Belize; • To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action; • To contribute to the improvement of data and monitoring systems in Belize and to strengthen technical expertise in the design, implementation, and analysis of such systems. • To generate data on the situation of children and women, including the identification of vulnerable groups and of disparities, to inform policies and interventions. 24 mics f inal report ii. sample and survey meThodology Sample Design The sample for the Belize Multiple Indicator Cluster Survey (MICS) 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, and for seven regions: Corozal District, Orange Walk District, Belize District (excluding Belize City South Side), Belize City South Side, Cayo District, Stann Creek District and Toledo District. The tables present figures for all seven regions and a combined figure for Belize District, composed of Belize District (excluding Belize City South Side) and Belize City South Side. 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, twenty eight census enumeration districts (ED) were selected systematically with probability proportional to size. After a household listing was carried out within the selected enumeration areas, a systematic sample of twenty five households was drawn in each sample enumeration district. Each ED was visited during the fieldwork period. The sample was stratified by region, urban and rural areas, and is not self-weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect information on all de jure household members (usual residents), the household, and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15-49 years; and 3) an under-5 questionnaire, administered to mothers or caretakers for all children under 5 living in the household. The questionnaires included the following modules: The Household Questionnaire included the following modules: o Household Information Panel o Household Listing Form o Education o Water and Sanitation o Household Characteristics o Insecticide Treated Nets o Child Labour o Child Discipline o Hand washing The Questionnaire for Individual Women was administered to all women aged 15-49 years living in the households, and included the following modules: o Women Information Panel o Women’s Background mics f inal report 25 o Child Mortality o Desire for Last Birth o Maternal and Newborn Health o Post Natal Health Checks o Illness Symptoms o Contraception o Unmet Need o Attitudes Towards Domestic Violence o Marriage/Union o Sexual Behaviour o HIV/AIDS o Life Satisfaction The Questionnaire for Children Under-Five was administered to mothers or caretakers of children under 5 years of age1 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; 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 Under Five Information Panel o Age o Birth Registration o Early Childhood Development o Breastfeeding o Care of Illness o Immunization o Anthropometry A Questionnaire for Child Disability was also administered to mothers or primary caretakers of children between the ages of 2 and 9 years. This questionnaire contained two modules. o Child Disability Questionnaire Form o Child Disability Questionnaires are based on the MICS4 model questionnaire2. The MICS4 model English versions of the questionnaires were pre-tested in the Orange Walk District in the rural villages of Shipyard, August Pine Ridge and Trinidad and in the urban areas of San Jose Palmar and Orange Walk Town on Wednesday 26th January 2011 and Thursday 27th January 2011. Based on the results of the pre- test, modifications were made to the wording of the questionnaires. A copy of the Belize MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams observed the place for handwashing and measured the weights and heights of children age under 5 years. Details and findings of these measurements are provided in the respective sections of the report. 1 The terms “children under 5”, “children age 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 2 The model MICS4 questionnaires can be found at www.childinfo.org 26 mics f inal report Training and Fieldwork Training for the fieldwork was conducted in two phases. The training of trainers was conducted from 30th May to 8th June, 2011 in Belmopan City and the ten day main training of field staff was conducted from 13th June to 24th June, 2011 in Belize City at a centralized location. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Time was spent becoming familiar with the various vaccination cards in use and all field staff were trained in the use of the anthropomorphic measuring tools. Towards the end of the training period, trainees spent one day in practice interviewing in several enumeration districts in Belize City. The data were collected by seven teams; each was comprised of four interviewers, one driver, one editor and one field supervisor. Even though the MICS programme requires the use of a dedicated Measurer as part of each data collection team, in Belize MICS 2011 measuring was done by the field supervisor with assistance as needed from the editor. One standby interviewer was provided for each team in the event that an interviewer was unable to continue working. Fieldwork began on 13th June, 2011 and concluded on 5th August, 2011. Data Processing Data were entered using the CSPro software. The data were entered on six microcomputers and carried out by six data entry operators and two data entry supervisors. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS4 programme and adapted to the Belize questionnaire were used throughout. Data processing began simultaneously with data collection in June, 2011 and was completed in September, 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. mics f inal report 27 iii. sample Coverage and The CharaCTerisTiCs of households and respondenTs Sample Coverage Of the 4,900 households selected for the sample, 4,608 were found to be occupied. Of these, 4,424 were successfully interviewed for a household response rate of 96.0 percent. In the interviewed households, 4,485 women (age 15-49 years) were identified. Of these, 4,096 were successfully interviewed, yielding a response rate of 91.3 percent within interviewed households. In addition, 1,982 children under age five were listed in the household questionnaire. Questionnaires were completed for 1,946 of these children, which corresponds to a response rate of 98.2 percent within interviewed households. A total of 3,287 children between the ages of 2 and 11 years were identified and Disability Questionnaires were completed for 3,234 of these children yielding a response rate of 98.4 percent. Overall response rates of 87.8 percent and 94.3 percent are calculated for the women’s and under-5’s interviews respectively (Table HH.1). Table HH.1: Results of household, women’s and under-5 interviews Number of households, womenand children under 5 by results of the household, women’s and under-5’s interviews, and household, women’s and under-5’s response rates, Belize, 2011 AreA region Total Urban rural Corozal orange Walk Belize (excluding Belize City South Side) Cayo Stann Creek Toledo Belize City South Side Belize District Households Sampled 2245 2655 700 699 700 701 700 700 700 1400 4900 Households occupied 2101 2507 655 673 635 651 646 686 662 1297 4608 Households interviewed 2004 2420 642 662 581 626 605 670 638 1219 4424 Household response rate 95.4 96.5 98.0 98.4 91.5 96.2 93.7 97.7 96.4 94.0 96.0 Women eligible 1950 2535 722 738 511 702 547 613 652 1163 4485 Women interviewed 1772 2324 648 688 448 605 493 602 612 1060 4096 Women’s response rate 90.9 91.7 89.8 93.2 87.7 86.2 90.1 98.2 93.9 91.1 91.3 Women’s overall response rate 86.7 88.5 88.0 91.7 80.2 82.9 84.4 95.9 90.5 85.7 87.7 Children under 5 eligible 698 1284 318 329 161 299 256 362 257 418 1982 Children under 5 Mother/Caretaker interviewed 681 1265 314 320 153 295 251 361 252 405 1946 Under-5’s response rate 97.6 98.5 98.7 97.3 95.0 98.7 98.0 99.7 98.1 96.9 98.2 Under-5’s overall response rate 93.1 95.1 96.8 95.7 86.9 94.9 91.8 97.4 94.5 91.1 94.3 Children aged 2-9 eligible for Disability Questionnaire 1147 2140 494 528 293 481 438 647 406 699 3287 Children aged 2-9 Mother/Caretaker interviewed 1121 2113 488 513 281 478 432 643 399 680 3234 Aged 2-9 for Disability Questionnaire response rate 97.7 98.7 98.8 97.2 95.9 99.4 98.6 99.4 98.3 97.3 98.4 Aged 2-9 for Disability Questionnaire overall response rate 93.2 95.3 96.8 95.6 87.7 95.6 92.4 97.1 94.7 91.4 94.5 28 mics f inal report Lowest household response rate occurred in Belize (Excluding Belize City South Side) (91.5 percent) but this is within the design specification of 10 percent non-response allowed by the sample. Non-response rates for the women questionnaire were more than 10 percent for Corozal (10.2 percent), Belize (Excluding Belize City South Side) (12.3 percent) and Cayo (13.8 percent). The response rates for these regions are not excessively higher than the targets set and it is expected that results obtained for these regions should be reliable. Urban and rural response rates are above 90 percent for all questionnaires. Characteristics of Households The age and sex distribution of survey population is provided in Table HH.2. The distribution is also used to produce the population pyramids in Figure HH.1 and Figure HH.2. In the 4,424 households successfully interviewed in the survey, 17,288 household members were listed. Of these, 8,582 were males, and 8,705 were females. The average household size of 3.9 obtained from this MICS is precisely that obtained from the Belize 2010 Census. Table HH.2: Household age distribution by 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, Belize, 2011 Males FeMales ToTal Number Percent Number Percent Number Percent age 0-4 961 11.2 941 10.8 1902 11.0 5-9 1016 11.8 988 11.3 2004 11.6 10-14 1002 11.7 1066 12.2 2068 12.0 15-19 919 10.7 939 10.8 1858 10.7 20-24 765 8.9 801 9.2 1565 9.1 25-29 615 7.2 714 8.2 1329 7.7 30-34 604 7.0 587 6.7 1191 6.9 35-39 537 6.3 587 6.7 1125 6.5 40-44 488 5.7 475 5.5 963 5.6 45-49 399 4.6 379 4.4 778 4.5 50-54 348 4.1 376 4.3 724 4.2 55-59 265 3.1 243 2.8 508 2.9 60-64 203 2.4 217 2.5 419 2.4 65-69 143 1.7 121 1.4 264 1.5 70-74 120 1.4 111 1.3 231 1.3 75-79 75 0.9 58 0.7 132 0.8 80-84 62 0.7 46 0.5 108 0.6 85+ 32 0.4 39 0.4 71 0.4 Missing/DK 29 0.3 19 0.2 47 0.3 Dependency age groups 0-14 2979 34.7 2995 34.4 5974 34.6 15-64 5143 59.9 5317 61.1 10460 60.5 65+ 432 5.0 375 4.3 807 4.7 Missing/DK 29 0.3 19 0.2 47 0.3 Children and adult populations Children age 0-17 years 3532 41.2 3561 40.9 7094 41.0 adults age 18+ years 5021 58.5 5125 58.9 10147 58.7 Missing/DK 29 0.3 19 0.2 47 0.3 Total 8582 100.0 8705 100.0 17288 100.0 mics f inal report 29 The population trends obtained from MICS clearly follow the trends as obtained from the Belize Census 2010 (Figure HH.1 and Figure HH.2). In general rates for MICS in the 0 to 14 age group is lower for both males and females than the rates obtained from the census. However, differences are small: for MICS 34.7 percent of the males are 0 – 14 years old while 34.4 percent of the females lie in this age group. Corresponding rates from the 2010 census are males 36 percent and females 35.3 percent. Rates for the 15 to 49 years age group agree well between the MICS and the Belize Census 2010. For the MICS, 50.4 percent of males are 15 to 49 years old while 51.5 percent of females are 15 to 49 years old. 30 mics f inal report Table HH.3 provides basic background information on the households. Within households, the sex of the household head, region, area, number of household members, education of household head, religion and ethnicity of the household head are shown in the table. 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. There are about three times as many male heads of households as female heads (73.5 percent to 26.5 percent). MICS indicates that there are almost equal numbers of urban and rural households (urban 49.0 percent and rural 51.0 percent). Cayo is the region with the largest number of households (20.7 percent) while the regions with the second largest numbers of households are the Orange Walk and Belize City South Side regions at 13.7 and 13.9 percent respectively. If the two regions of Belize (excluding Belize City South Side) and Belize City South Side are combined then this district, the Belize District, far outstrip the other districts with 33.3 percent of the households. Most household heads are Mestizo (46.5 percent) followed by the Creole at 26.7 percent. The Belize Census 2010 puts the rates of Mestizo and Creole heads at 48.8 percent and 21.1 percent respectively. Most household heads have at least a primary school education (90.5 percent). On average households have about 3.9 members with 17.8 percent of households having 4 members. mics f inal report 31 Table HH.3: Household composition Percent distribution of households by selected characteristics, Belize, 2011 Weighted percent NuMber oF householDs Weighted un-weighted sex of household head Male 73.5 3250 3291 Female 26.5 1174 1133 region Corozal 11.7 519 642 orange Walk 13.7 607 662 belize (excluding belize City south side) 19.4 860 581 belize City south side 13.9 614 638 belize District 33.3 1474 1219 Cayo 20.7 918 626 stann Creek 11.0 488 605 Toledo 9.4 417 670 area urban 49.0 2170 2004 rural 51.0 2254 2420 Number of household members 1 15.1 666 677 2 15.8 699 667 3 16.9 747 737 4 17.8 789 770 5 13.3 589 593 6 8.9 393 410 7 5.2 229 233 8 2.6 117 124 9 2.0 88 92 10+ 2.4 106 121 Education of household head None 7.0 311 349 Primary/Infant 47.6 2104 2201 secondary + 41.8 1851 1722 CeT/ITVeT/VoTeC 1.1 47 41 Missing/DK 1.3 58 50 other 1.2 52 61 ethnicity of household head Creole 26.7 1182 1083 Mestizo 46.5 2058 2010 Garifuna 6.5 286 308 Maya 9.0 399 528 other 9.2 409 409 Missing/DK 2.0 91 86 Total 100.0 4424 4424 Households with at least one child age 0-4 years 31.6 4424 4424 one child age 0-17 years 63.7 4424 4424 one woman age 15-49 years 72.4 4424 4424 Mean household size 3.9 4424 4424 In Table HH.3 the weighted and un-weighted 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 5, and at least one eligible woman age 15-49 along with the weighted average household size estimated by the survey. 32 mics f inal report Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 Tables HH.4 and HH5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. 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 the subsequent tabulations of this report. Table HH.4: Women’s background characteristics Percent and frequency distribution of women age 15-49 years by selected characteristics, Belize, 2011 Weighted percent NUMBER OF WOMEN Weighted Un-weighted Region Corozal 13.0 534 648 Orange Walk 15.1 618 688 Belize (Excluding Belize City South Side) 16.8 687 448 Belize City South Side 14.0 573 612 Belize District 30.8 1260 1060 Cayo 22.8 933 605 Stann Creek 9.9 404 493 Toledo 8.5 347 602 Area Urban 47.0 1926 1772 Rural 53.0 2170 2324 Age 15-19 20.6 844 852 20-24 17.6 720 729 25-29 15.9 651 655 30-34 13.3 544 554 35-39 13.1 537 516 40-44 10.8 442 431 45-49 8.8 359 359 Marital/Union status Currently married/in union 58.3 2386 2394 Widowed 1.1 44 43 Divorced 0.8 35 29 Separated 10.0 410 410 Never married/in union 29.8 1219 1219 Missing 0.0 1 1 Motherhood status Ever gave birth 66.6 2728 2735 Never gave birth 33.4 1368 1361 Births in last two years Had a birth in last two years 16.7 685 702 Had no birth in last two years 83.3 3411 3394 Education None 3.6 148 156 Primary/Infant 39.3 1608 1704 Secondary + 55.2 2259 2148 CET/ITVET/VOTEC 0.6 26 22 Other 1.3 55 66 Wealth index quintiles Poorest 15.7 644 799 Second 19.9 815 821 Middle 21.4 877 860 Fourth 21.0 862 824 Richest 21.9 898 792 Ethnicity of household head Creole 24.0 985 900 Mestizo 50.0 2046 1976 Garifuna 6.2 253 267 Maya 9.9 407 550 Other 8.2 335 335 Missing/DK 1.7 70 68 Total 100.0 4096 4096 mics f inal report 33 Table HH.4 provides background characteristics of female respondents 15-49 years of age. The table includes information on the distribution of women according to region, area, age, marital status, motherhood status, births in last two years, education1, wealth index quintiles2, and ethnicity of the household head. Some background characteristics of children under 5 years are presented in Table HH.5. These include the distribution of children by several attributes: sex, region and area, age, mother’s or caretaker’s education, wealth, and ethnicity of household head. Male and female under-five children occur in equal numbers in the sample (male 50.6 percent, female 49.4 percent). About twice as many (61.8 percent) of the under-five children are rural dwellers compared with the urban percentage (38.2). Rates for Mestizo children (48.7 percent) follow the ethnic profile as seen in Table HH.3. 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 richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, Filmer and Pritchett, 2001, and Gwatkin et. Al., 2000. 1 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 2 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 5 equal parts (quintiles) from lowest (poorest) to highest (richest). The assets used in these calculations were as follows: Electricity, a radio, a television, a non-mobile telephone, a refrigerator, a fan, a micro wave oven, a security alarm system, a washing machine, a DVD player, a as bar-b-q grill, an air conditioner, a water cooler, a sofa, a dining room table, a clothes closet, a watch, a bicycle, a cell telephone a motorcycle or scooter, a car or truck, a computer, an mp3/mp4 player, a fishing rod, a weight training machine, a boat with a motor. 34 mics f inal report Table HH.5: Under-5’s background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Belize, 2011 Weighted percent Number of children Weighted Un-weighted Sex Male 50.6 984 995 Female 49.4 962 951 Region Corozal 13.5 263 314 Orange Walk 15.5 302 320 Belize (Excluding Belize City South Side) 12.3 240 153 Belize City South Side 13.0 252 252 Belize District 25.3 492 405 Cayo 23.1 450 295 Stann Creek 10.9 212 251 Toledo 11.6 226 361 Area Urban 38.2 743 681 Rural 61.8 1203 1265 Age 0-5 7.6 148 145 6-11 10.7 209 212 12-23 20.8 404 398 24-35 20.2 393 403 36-47 20.3 395 391 48-59 20.4 397 397 Mother’s education* None 5.1 100 108 Primary/Infant 48.6 946 994 Secondary + 43.1 839 778 CET/ITVET/VOTEC 0.7 14 11 Missing/DK 0.0 1 1 Other 2.4 47 54 Wealth index quintiles Poorest 25.2 490 580 Second 23.1 450 437 Middle 20.9 407 388 Fourth 17.0 330 312 Richest 13.8 268 229 Ethnicity of household head Creole 19.5 379 345 Mestizo 48.7 949 912 Garifuna 5.4 105 113 Maya 14.8 288 356 Other 10.0 195 192 Missing/DK 1.6 31 28 Total 100.0 1946 1946 * Mother’s education refers to educational attainment of mothers and caretakers of children under-5. mics f inal report 35 iv. Child morTaliTy One of the overarching goals of the Millennium Development Goals (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. Monitoring progress towards this goal is an important but difficult objective. Measuring childhood mortality may seem easy, but attempts using direct questions, such as “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust 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. 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. In MICS surveys, infant and under five mortality rates are calculated based on an indirect estimation technique known as the Brass method (United Nations, 1983; 1990a; 1990b). For the application of the technique, women are classified into 5-year groups of Time Since First Birth (TSFB), namely 0-4, 5-9, 10-14, 15-19 and 20-24 years. The average numbers of children ever born and proportion dead among these children are calculated for each group of women. The proportions dead calculated for each group are very closely related to mortality risks. The technique converts the proportions dead into conventional mortality risks by using several assumptions in regard to the length of exposure to the risk of dying among children born to each group of women, on the distribution of deaths of children over time, and on the level and pattern of fertility prevalent in the population. Simulations on model data have shown that proportions dead by TSFB groups of women can be converted into probabilities of dying by using modelled relationships, namely into 2q0 (probability of dying before age 2) for proportion dead among children of women in the 0-4 years TSFB group, under-5 mortality rates for the 5-9, 10-14 and 15-19 year TSFB groups, and 15q0 (probability of dying before age 15) for the 20-24 years TSFB group. The technique also time- locates these estimates, again by using several assumptions. This is necessary because children of women who have had their first births long ago have been exposed to mortality risks for a longer period of time, and therefore, their mortality experience refers to farther back in time, compared to that of children born to women who have had their first births recently. The final step in the calculations is the conversion of the estimated mortality risks into comparable probabilities of dying for each estimate derived from different TSFB groups of women. The Coale-Demeny model life tables are used for this purpose. Coale-Demeny model life tables are life table schedules at different levels of mortality, that embody typical age patterns of mortality in human populations, categorized into 4 ‘families’ of such typical patterns – North, South, East and West models. Using typical relationships between 2q0, 5q0 and 15q0 and the infant mortality rate embodied in these model life tables, the initial estimates of mortality 36 mics f inal report are converted into infant mortality rates, while the estimates of 2q0 and 15q0 are converted into estimates of 5q0 (Note that the 5-9, 10-14 and 15-19 year TSFB groups produce estimates of under-5 mortality rates at the initial calculation stage). By expressing mortality risks at different points in time with the same indicator, it then becomes possible to show trends in mortality during the last 15-20 years. Table CM.1: Children ever born, children surviving and proportion dead, Belize, 2011 CHildren ever born CHildren surviving ProPortion dead nuMber of woMen Mean Total Mean Total Time since first birth 0-4 1.3599 750 1.3357 737 0.0178 552 5-9 2.2279 1182 2.1929 1164 0.0157 531 10-14 3.0835 1636 2.9888 1586 0.0307 531 15-19 3.7395 1596 3.5844 1530 0.0415 427 20-24 4.7309 1779 4.5556 1713 0.0370 376 Total 2.8743 6944 2.7856 6729 0.0309 2416 For the calculations in this report, the Coale-Demeny , West model life table was selected as most appropriate, based on previous information on the age pattern of mortality in Belize. Table CM.2 provides estimates of child mortality. The infant mortality rate (IMR) is estimated at 14 per thousand, while the probability of dying under age 5 (U5MR) is around 17 per thousand. These estimates have been calculated using the 5-9 years since first birth and therefore refer to August 2006. table CM.2: Child mortality Infant and under-five mortality rates, based on WEST model, Belize, 2011 InfanT MorTalITy raTE [1] UndEr-fIvE MorTalITy raTE [2] sex Male 16 18 Female 14 16 area urban (17) (19) rural 13 15 Wealth index quintiles Poorest/second/Middle 16 19 Fourth/richest (11) (12) Total 14 17 [1] MICs indicator 1.2; MDG indicator 4.2 [2] MICs indicator 1.1; MDG indicator 4.1 rates refer to august 2006. The West Model was assumed to approximate the age pattern of mortality in Belize. ( ) Figures that are based on less than 250 un-weighted cases Overall, the data show that there are few differences by background characteristics. Differences by sex and place of residence of the child are small. The data do show some differences by wealth; wealthier households tend to have lower mortality rates than poorer households. mics f inal report 37 v. nuTriTion Nutritional Status 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 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, 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 sign 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 assist in the goal to reduce 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 standards1. 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 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 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 MICS, weights and heights of all children under 5 years of age were measured using anthropometric equipment recommended by UNICEF (www.childinfo.org). Findings in this section are based on the results of these measurements. Table NU.1 shows percentages of children classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above 2 standard deviations from the median of the reference population, and mean z-scores for all three anthropometric indicators. 1 http://www.who.int/childgrowth/standards/second_set/technical_report_2.pdf 38 mics f inal report Ta bl e NU .1 : N ut rit io na l s ta tu s of c hi ld re n Pe rc en ta ge o f c hi ld re n un de r a ge 5 b y nu tr iti on al s ta tu s ac co rd in g to th re e an th ro po m et ric in di ce s: w ei gh t f or a ge , h ei gh t f or a ge , a nd w ei gh t f or h ei gh t, B el iz e, 2 01 1 W ei gh t f or a ge N um be r of ch ild re n un de r ag e 5 H ei gh t f or a ge N um be r of ch ild re n un de r ag e 5 W ei gh t f or h ei gh t N um be r of ch ild re n un de r ag e 5 U nd er w ei gh t M ea n Z- Sc or e (S D ) St un te d M ea n Z- S co re (S D ) W as te d O ve rw ei gh t M ea n Z- Sc or e (S D ) P er ce nt be lo w -2 s d [1 ] Pe rc en t be lo w -3 s d [2 ] P er ce nt be lo w -2 s d [3 ] Pe rc en t be lo w -3 s d [4 ] Pe rc en t be lo w -2 s d [5 ] Pe rc en t be lo w -3 s d [6 ] P er ce nt a bo ve +2 s d Se x M al e 5. 7 0. 6 -0 .3 91 4 18 .6 5. 7 -0 .8 90 2 3. 2 0. 9 8. 6 0. 2 89 6 Fe m al e 6. 6 2. 0 -0 .4 89 5 20 .0 5. 2 -1 .0 87 8 3. 4 1. 5 7. 1 0. 2 87 2 Ar ea U rb an 5. 4 0. 7 -0 .1 67 8 15 .7 2. 8 -0 .7 66 2 2. 8 1. 2 9. 8 0. 3 66 1 R ur al 6. 6 1. 6 -0 .4 11 32 21 .4 7. 0 -1 .0 11 18 3. 6 1. 2 6. 7 0. 2 11 07 R eg io n C or oz al 7. 0 1. 6 -0 .4 25 1 19 .7 5. 0 -1 .0 24 9 3. 1 0. 3 5. 4 0. 2 24 8 O ra ng e W al k 4. 7 1. 0 -0 .3 28 0 17 .2 3. 1 -1 .0 27 8 2. 4 0. 7 7. 3 0. 4 28 0 B el iz e (E xc lu di ng B el iz e C ity S ou th S id e) 5. 0 0. 0 -0 .2 19 8 13 .9 6. 9 -0 .7 18 6 4. 2 2. 6 14 .1 0. 3 18 6 B el iz e C ity S ou th S id e 5. 6 0. 8 -0 .1 23 5 8. 1 1. 7 -0 .3 23 5 3. 4 1. 3 8. 5 0. 2 23 4 B el iz e D is tri ct 5. 3 0. 4 -0 .1 43 4 10 .7 4. 0 -0 .5 42 1 3. 8 1. 9 11 .0 0. 2 42 0 C ay o 5. 3 1. 6 -0 .3 42 1 18 .6 4. 1 -0 .8 41 3 2. 8 1. 6 6. 0 0. 1 41 0 S ta nn C re ek 9. 5 1. 6 -0 .5 20 7 17 .5 3. 5 -0 .7 20 6 4. 9 1. 2 4. 4 0. 0 20 5 To le do 7. 4 2. 0 -0 .4 21 6 41 .6 16 .1 -1 .6 21 4 3. 3 0. 9 12 .3 0. 5 20 6 Ag e 0- 5 7. 5 2. 7 -0 .1 12 6 13 .6 6. 9 -0 .4 12 3 5. 7 4. 5 12 .6 0. 2 11 9 6- 11 3. 3 1. 8 0. 0 19 1 10 .9 3. 0 -0 .2 18 8 4. 1 0. 8 6. 9 0. 2 18 6 12 -2 3 5. 1 0. 5 -0 .2 38 4 22 .8 4. 3 -1 .0 37 9 1. 7 0. 3 8. 7 0. 4 38 0 24 -3 5 6. 5 0. 8 -0 .3 36 0 19 .5 6. 8 -1 .0 35 1 3. 4 1. 4 7. 2 0. 2 34 7 36 -4 7 7. 5 1. 8 -0 .5 37 5 20 .7 6. 3 -1 .1 37 1 4. 1 0. 9 7. 4 0. 2 37 1 48 -5 9 6. 6 1. 4 -0 .5 37 2 20 .3 5. 1 -1 .0 36 9 2. 8 1. 4 7. 0 0. 1 36 4 M ot he r's ed uc at io n N on e 8. 5 .8 -0 .4 94 28 .4 9. 2 -1 .1 93 1. 8 0. 0 10 .9 0. 4 93 P rim ar y 7. 0 1. 6 -0 .5 90 7 26 .7 7. 5 -1 .2 89 1 2. 8 1. 3 5. 7 0. 2 88 4 S ec on da ry + 5. 2 0. 9 -0 .1 75 7 10 .4 2. 7 -0 .5 74 7 4. 1 1. 3 10 .6 0. 2 74 0 O th er (2 .3 ) (2 .3 ) (0 .0 ) 42 (4 .6 ) (2 .4 ) (-0 .4 ) 41 (2 .1 ) (2 .1 ) (0 .0 ) (0 .2 ) 42 W ea lth in de x qu in til es P oo re st 8. 8 2. 1 -0 .6 46 9 32 .9 11 .1 -1 .3 46 4 3. 8 1. 4 4. 9 0. 2 45 9 S ec on d 7. 0 1. 7 -0 .5 42 1 21 .5 3. 5 -1 .1 41 5 4. 4 0. 6 7. 5 0. 2 41 7 M id dl e 5. 0 0. 5 -0 .2 38 3 12 .3 3. 7 -0 .6 37 3 2. 2 1. 1 8. 9 0. 2 36 9 Fo ur th 4. 7 0. 6 -0 .2 30 5 11 .8 2. 9 -0 .6 30 2 3. 5 2. 3 8. 8 0. 2 30 0 R ic he st 3. 0 1. 1 0. 1 23 0 9. 0 3. 5 -0 .5 22 6 1. 8 0. 7 11 .7 0. 4 22 4 Et hn ic ity o f ho us eh ol d he ad C re ol e 4. 3 1. 0 -0 .2 33 2 9. 9 3. 5 -0 .5 33 3 4. 0 2. 1 7. 5 0. 1 32 6 M es tiz o 5. 9 1. 2 -0 .3 89 5 19 .1 4. 7 -1 .0 87 5 3. 1 0. 7 7. 6 0. 3 87 4 G ar ifu na 8. 4 0. 8 -0 .4 98 8. 5 0. 6 -0 .5 96 5. 1 0. 8 5. 2 0. 0 96 M ay a 9. 1 2. 7 -0 .7 27 8 44 .3 14 .0 -1 .7 27 5 2. 5 1. 8 9. 9 0. 4 27 1 O th er 4. 5 0. 6 -0 .1 17 6 6. 0 1. 9 -0 .4 17 2 3. 7 1. 4 6. 8 0. 1 17 1 M is si ng /D K (1 0. 9) (0 .0 ) (0 .1 ) 29 (1 1. 7) (5 .2 ) (-0 .4 ) 29 (0 .0 ) (0 .0 ) (1 3. 7) (0 .4 ) 29 To ta l 6. 2 1. 3 -0 .3 18 09 19 .3 5. 4 -0 .9 17 80 3. 3 1. 2 7. 9 0. 2 17 68 [1 ] M IC S in di ca to r 2 .1 a an d M D G in di ca to r 1 .8 ; [2 ] M IC S in di ca to r 2 .1 b; [3 ] M IC S in di ca to r 2 .2 a, [4 ] M IC S in di ca to r 2 .2 b; [5 ] M IC S in di ca to r 2 .3 a, [6 ] M IC S in di ca to r 2 .3 b; ( ) F ig ur es th at a re b as ed o n 25 -4 9 un -w ei gh te d ca se s; 7 u n- w ei gh te d ca se s in "C ET /IT VE T/ V O TE C " a nd "M is si ng /D K " o n th e M ot he r's E du ca tio n ar e no t s ho w n mics f inal report 39 Children whose full birth date (month and year) were not obtained, and children whose measurements are outside a plausible range are excluded from Table NU.1. 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 has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality Tables DQ.6 and DQ.7 in Appendix F. Overall 91.5 percentage of children under 5 years had both their weights and heights measured (Table DQ.7 in Appendix F). Both weights and age were measured in 93.6 percent of children and both height and age were measured in 92.4 percent of children under-5 years. It is seen that the percentages of children under age 6 months excluded from the analysis were about twice as high as the rates for other age groups. This is true for all three anthropomorphic indicators. Table DQ.7 shows that due to incomplete dates of birth, implausible measurements, and missing weight and/or height, 6.4 percent of children have been excluded from calculations of the weight-for-age indicator, while the figures are 7.6 for the height-for-age indicator, and 8.5 for the weight-for-height indicator. About 6 percent of children under age five in Belize are moderately underweight and 1 percent are classified as severely underweight (Table NU.1). Almost 20 percent of children (19.3 percent) are moderately stunted or too short for their age and 3.3 percent are moderately wasted or too thin for their height. About 7.9 percent of children under age 5 years are considered to be obese. Males and females show approximately the same rates for moderate underweight, stunting and wasting. A small difference in rates occur in urban and rural areas with rural children having higher rates than urban children in all three categories (urban/rural percentages are: 5.4/6.6 underweight, 15.7/21.4 stunting and 2.8/3.6 wasting). Generally urban children are more obese than rural children with rates of 9.8 percent urban and 6.7 percent rural. 40 mics f inal report Children from poor households are more likely to be underweight and stunted than other children from wealthier households (Figure NU.1). A clear distinction can not be made between children in different wealth categories with respect to wasting. In contrast, a trend for higher percentages for wealthier households is evident for obesity. Stunting is highest in Toledo District (41.6 Percent) and lowest in Belize City South Side (8.1 percent) (Figure NU.2). Also obesity is most pronounced in Toledo (12.3 percent) and Belize City Excluding Belize City South Side (14.1 percent). In general, Belize City South Side appears to be less disadvantaged with respect to all four anthropomorphic indicators, except for overweight (Figure NU.2). Children from Maya headed households have the highest rates for underweight (9.1 percent), stunting (44.3 percent) and obesity (9.9 percent) when compared to children of other ethnicities. Wasting is least prevalent in children from Maya headed households (2.5 percent) (Figure NU.3). mics f inal report 41 Breastfeeding and 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, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. WHO/UNICEF have the following feeding recommendations: o Exclusive breastfeeding for first six months o Continued breastfeeding for two years or more o Safe and age-appropriate complementary foods beginning at 6 months o Frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day for 9-11 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: o Early initiation of breastfeeding (within 1 hour of birth) o Exclusive breastfeeding rate (< 6 months) o Predominant breastfeeding (< 6 months) o Continued breastfeeding rate (at 1 year and at 2 years) o Duration of breastfeeding o Age-appropriate breastfeeding (0-23 months) o Introduction of solid, semi-solid and soft foods (6-8 months) o Minimum meal frequency (6-23 months) o Milk feeding frequency for non-breastfeeding children (6-23 months) o Bottle feeding (0-23 months) Table NU.2 provides the proportion of children born in the last two years who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a pre-lacteal feed. Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, 61.5 percent of babies are breastfed for the first time within one hour of birth, while 83.1 percent of newborns in Belize start breastfeeding within one day of birth, and 92 percent have ever been breastfed. Mother’s education does not seem to impact rates of early breastfeeding. However, pre-lacteal feeding increases significantly with increasing level of education (none at 9.8 percent to Secondary + at 16.6 percent). Rates of breastfeeding within one hour of birth for urban and rural children do not appear to be significantly different. However, rates for urban children breastfed within one day is 77.4 percent while the rate for rural children is 86.7 percent. 42 mics f inal report Table NU.2: Initial breastfeeding Percentage of last-born children in the 2 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 pre-lacteal feed, Belize, 2011 Percentage ever breastfed [1] Percentage who were first breastfed: Within one hour of birth [2] Percentage who were first breastfed: Within one day of birth Percentage who received a pre- lacteal feed Number of last- born children in the two years preceding the survey Region Corozal 97.4 56.5 78.4 27.4 95 Orange Walk 90.1 62.9 84.5 18.0 108 Belize (Excluding Belize City South Side) (89.6) (54.7) (83.1) (33.1) 74 Belize City South Side 89.2 69.7 84.1 25.8 77 Belize District 89.4 62.3 83.6 29.4 151 Cayo 88.6 59.1 80.9 22.9 189 Stann Creek 96.8 70.7 88.1 16.3 69 Toledo 96.7 61.7 87.5 3.8 73 Area Urban 87.9 61.1 77.4 22.5 262 Rural 94.5 61.8 86.7 20.9 424 Months since last birth 0-11 months 91.4 59.6 82.2 19.8 313 12-23 months 92.5 63.0 83.9 23.7 357  Assistance at delivery Skilled attendant 92.1 61.4 83.2 22.0 659 Traditional birth attendant (*) (*) (*) (*) 12 Other (*) (*) (*) (*) 8 Missing (*) (*) (*) (*) 6 Place of delivery Public sector health facility 93.7 65.2 86.8 17.8 526 Private sector health facility 84.1 47.0 68.5 38.9 117 Home (98.3) (60.4) (85.4) (21.6) 39 Other/Missing (*) (*) (*) (*) 4 Mother’s education None 92.0 54.4 80.7 9.8 41 Primary 92.8 61.4 85.8 16.6 311 Secondary + 91.1 62.0 81.1 27.6 315 CET/ITVET/VOTEC (*) (*) (*) (*) 3 Other (*) (*) (*) (*) 15 Wealth index quintiles Poorest 93.6 61.8 85.3 9.5 173 Second 91.5 61.5 83.5 22.6 156 Middle 90.9 60.8 85.0 22.7 134 Fourth 92.2 68.8 87.6 22.4 132 Richest 90.6 51.2 69.2 39.6 91 Ethnicity of household head Creole 89.4 63.5 82.6 28.3 113 Mestizo 91.2 59.9 81.5 21.6 355 Garifuna (96.9) (74.7) (89.8) (13.2) 43 Maya 97.9 66.0 88.0 9.3 96 Other 88.8 52.5 82.1 30.6 71 Missing/DK (*) (*) (*) (*) 8 Total 91.9 61.5 83.1 21.5 685 [1] MICS indicator 2.4; [2] MICS indicator 2.5 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases mics f inal report 43 Children from the richest families ever breastfed less frequently than children from less wealthy families while pre-lacteal feeding is most pronounced in the richest (39.6 percent) families and least evident in the poorest (9.5 percent) (Figure NU.4). The Maya and Garifuna children seem to be ever breastfed at rates slightly higher than the Creole or Mestizo children. Pre-lacteal feeding is accordingly least pronounced in the Maya and Garifuna (Figure NU.5). Breastfeeding rates are most pronounced for delivery at home or in a public sector hospital. Figure NU.6 indicates that private sector health facilities seem to be linked to reduced rates of early breast feeding and also to increased rates of pre-lacteal feeding. 44 mics f inal report Rates of early breastfeeding (within one hour or within one day) are lowest in the Corozal District and in Belize (excluding Belize City South Side) and highest in the Districts of Cayo and Toledo and in Belize City South Side (Figure NU.7). Pre-lacteal feeding seems to have a trend opposite to this with highest rates in the Corozal District and in Belize (excluding Belize City South Side) and lowest rates of breastfeeding in the Districts of Cayo and Toledo and in Belize City South Side. mics f inal report 45 In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids during the previous day or night prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life, as well as continued breastfeeding of children at 12-15 and 20-23 months of age. Table NU.3: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Belize, 2011 Children 0-5 months Children 12-15 months Children 20-23 months Percent exclusively breastfed [1]  Percent predominantly breastfed [2] 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 10.5 30.3 90 63.6 57 37.0 62 Female 21.0 40.4 58 60.7 59 33.4 94 Region Corozal (*) (*) 18 (71.8) 21 (53.8) 26 Orange Walk (15.0) 53.6 28 (*) 17 (*) 23 Belize District (8.0) 13.5 37 (*) 30 (*) 34 Cayo (4.9) 26.0 40 (*) 24 (33.6) 43 Stann Creek (*) (*) 9 (*) 9 (*) 15 Toledo (*) (*) 16 (*) 14 (*) 15 Area Urban 10.9 29.3 61 (49.7) 50 32.3 69 Rural 17.3 37.8 87 71.5 66 36.9 87 Mother’s education Primary 15.3 36.1 62 65.7 54 38.2 71 Secondary + 11.6 30.6 75 60.7 51 30.3 74 Other (*) (*) 11 (*) 11 (*) 11 Wealth index quintiles Poorest (23.7) 62.0 29 (71.8) 26 (33.2) 43 Second (12.9) 40.8 31 (*) 25 (39.0) 43 Middle (22.3) 36.2 36 (*) 26 (*) 27 Fourth (4.6) 11.5 31 (*) 23 (*) 19 Richest (*) (*) 22 (*) 16 (*) 24 Ethnicity of household head Creole (14.1) 33.8 31 (*) 22 (28.7) 29 Mestizo 9.0 27.1 71 57.2 53 42.3 87 Garifuna (*) (*) 11 (*) 8 (*) 4 Maya (*) (*) 14 (*) 18 (36.8) 20 Other (*) (*) 21 (*) 16 (*) 15 Total 14.7 34.3 148 62.1 116 34.9 156 [1] MICS indicator 2.6; [2] MICS indicator 2.9; [3] MICS indicator 2.7; [4] MICS indicator 2.8 ( ) Figures that are based on 25-49 un-weighted cases ; (*) Figures that are based on less than 25 un-weighted cases There is marked difference between the sexes for the rates of exclusively breastfed infants 0 – 5 months of age. Approximately 10.5 percent males and 21.0 percent females aged less than six months are exclusively breastfed. A similar difference is evident for children 0 – 5 months who are predominantly breastfed (males 30.3 and females 40.4 percent). By age 12-15 months rates for continued breastfeeding are approximately equal for males (63.6 percent) and females (60.7 percent). The same applies for continued breastfeeding for children 20 – 23 months (males 36.9 percent and females 33.8 percent). Table NU.3 shows urban/rural differences in the rates of breastfeeding in children 0 – 5 months and 12 – 15 months. Rates for exclusively breastfed 0 – 5 month old children are urban 11.2 percent and rural 17.0 percent. For predominantly breastfed children the rates are urban 30.0 percent and rural 37.1 percent. Differences are even more pronounced for continued breastfeeding in children 12 – 15 months of age (urban 46 mics f inal report 49.7 percent and rural 71.5 percent). At two years the rates for urban and rural children are approximately equal. A detailed examination of breastfeeding for variables other than sex and area can not be justified because the sample size is inadequate. Table NU.4 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3, the median duration is 16.0 months for any breastfeeding, 0.9 months for exclusive breastfeeding, and 3.1 months for predominant breastfeeding. The median duration for exclusive and predominant breastfeeding is small for all variables rarely exceeding 3 months. Similarly the median duration for any breastfeeding does not exceed two years. Table NU.4: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Belize, 2011 Median duration (in months) of Number of children age 0-35 months Any breastfeeding [1] Exclusive breastfeeding Predominant breastfeeding Sex Male 15.8 0.4 0.9 591 Female 16.6 0.7 1.4 563 Region Corazal 22.6 1.0 1.5 162 Orange Walk 14.8 0.5 2.8 184 Belize (Excluding Belize City South Side 15.4 na na 125 Belize City South Side 8.7 0.6 1.1 143 Belize District 11.9 0.5 0.6 268 Cayo 15.6 0.4 0.6 283 Stann Creek 16.4 1.4 2.9 121 Toledo 17.8 1.3 4.6 137 Area Urban 12.6 0.5 1.0 443 Rural 18.0 0.5 1.1 711 Mother’s education None 22.9 1.8 1.8 62 Primary 18.6 0.6 1.6 543 Secondary+ 14.8 0.5 0.7 514 CET/ITVET/VOTEC (*) (*) (*) 8 Wealth index quintile Poorest 19.5 0.9 3.5 293 Second 16.6 0.5 2.1 261 Middle 11.7 0.7 1.8 241 Fourth 20.5 0.4 0.4 190 Richest 6.1 0.4 0.5 169 Ethnicity of household head Creole 15.0 0.5 1.2 207 Mestizo 19.0 0.5 0.7 580 Garifuna 13.2 0.9 2.7 65 Maya 17.6 0.5 2.4 167 Other 14.3 0.7 0.7 118 Median 16.1 0.5 1.0 1154 Mean for all children (0-35 months) 16.0 0.9 3.1 1154 [1] MICS indicator 2.10 (*) Figures that are based on less than 25 un-weighted cases; na Not applicable The adequacy of infant feeding in children under 24 months is provided in Table NU.5. Different criteria of feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as age-appropriate feeding, while infants aged 6-23 months are considered to be appropriately fed if they are receiving breast milk and solid, semi-solid or soft food. mics f inal report 47 Overall, only 43.9 percent of children aged 6-23 months are being appropriately fed. Age-appropriate feeding among all infants 0-5 months old drops to 14.7 percent. Age-appropriate feeding rates for children 0 – 5 months are considerably different for the sexes (males 10.5 percent and females 21.0 percent) and also for urban/rural areas (urban 10.9 percent and rural 17.3 percent). Small sample sizes prevent comparisons for other variables for the 0 – 5 month old children. For 6 – 23 month old children small difference in age-appropriate feeding rates occur between the sexes (males 45.5 percent and females 42.2 percent) and between urban and rural areas (urban 38.7 percent and rural 47.1 percent). Surprisingly, children of mothers with primary education appropriately feed their children at a rate of 47.7 percent while mothers with a secondary education or better only appropriately feed their children at a rate of 38.1 percent. A similar pattern exists for wealthy families. Children from poor families are appropriately fed at a rate of 50.7 percent while the richest families adequately feed their children at a rate of 28.0 percent. Figure NU.8 clearly shows the decreasing pattern for all children less than 2 years with respect to wealth and educational level. 48 mics f inal report Table NU.5: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Belize, 2011 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed [1] Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed [2] Number of children Sex Male 10.5 90 45.5 306 37.6 396 Female 21.0 58 42.2 307 38.9 365 Region Corozal (*) 18 64.6 93 58.0 110 Orange Walk (15.0) 28 40.4 96 34.7 124 Belize (Excluding Belize City South Side) (*) 17 (48.1) 66 38.1 83 Belize City South Side (*) 20 37.2 71 32.3 91 Belize District (8.0) 37 42.4 137 35.1 174 Cayo (4.9) 40 35.1 154 28.8 195 Stann Creek (*) 9 38.3 68 36.1 77 Toledo (41.5) 16 48.9 66 47.5 82 Area Urban 10.9 61 38.7 237 33.0 298 Rural 17.3 87 47.1 376 41.5 463 Mother's education None (*) 7 (59.8) 38 (53.4) 45 Primary 15.3 62 47.7 285 41.9 347 Secondary + 11.6 75 38.9 275 33.0 350 CET/ITVET/VOTEC (*) 1 (*) 3 (*) 3 Missing/DK (*) 0 (*) 0 (*) 0 Other (*) 3 (*) 13 (*) 16 Wealth index quintiles Poorest (23.7) 29 50.7 160 46.6 189 Second (12.9) 31 45.4 141 39.6 172 Middle (22.3) 36 41.1 118 36.7 154 Fourth (4.6) 31 47.6 107 37.9 138 Richest (*) 22 28.0 87 23.8 108 Ethnicity of household head Creole (14.1) 31 36.1 97 30.7 129 Mestizo 9.0 71 46.6 323 39.9 394 Garifuna (*) 11 (33.5) 33 (31.9) 44 Maya (*) 14 47.6 91 45.5 105 Other (*) 19 43.4 60 37.4 80 Missing/DK (*) 2 (*) 8 (*) 10 Total 14.7 148 43.9 613 38.2 761 [1] MICS indicator 2.6; [2] MICS indicator 2.14 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases Appropriate complementary feeding of children from 6 months to two years of age is particularly important for growth and development and 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 meals of solid, semi-solid or soft foods are needed if they are six to eight months old, and three or more meals if they are 9-23 months of age. For children 6-23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. Appropriate complementary feeding of children from 6 months to two years of age is particularly important for growth and development and 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 meals of solid, semi-solid or soft foods are needed if they are six to eight months old, and three or more meals if they are 9-23 months of age. For children 6-23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. mics f inal report 49 About 68.0 percent of infants age 6-8 received solid, semi-solid, or soft foods (Table NU.6). Among currently breastfeeding infants this percentage is 68.5 while it is 67.0 among infants currently not breastfeeding. Females fare better than males in being fed adequate amounts of complementary foods (overall males 65.8 percent and females 70.6 percent). Urban children seem to fare better than rural children (73.0 percent to 65.7 percent). Table NU.6: Introduction of solid, semi-solid or soft food Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day, Belize, 2011 Currently breastfeeding Currently not breastfeeding All Percent re- ceiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi-solid or soft foods [1] Number of children age 6-8 months Sex Male (66.5) 40 (*) 14 64.6 54 Female (71.0) 30 (*) 15 (70.6) 46 Area Urban (*) 18 (*) 15 (70.8) 33 Rural 64.6 52 (*) 15 65.7 67 Total 68.5 70 (*) 29 67.4 100 [1] MICS indicator 2.12 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases Table NU.7 presents the proportion of children age 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 NU.7 for a definition of minimum number of times for different age groups). Overall, over a half of the children age 6-23 months (67.6 percent) were receiving solid, semi-solid and soft foods the minimum number of times. 50 mics f inal report Table NU.7: 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, Belize, 2011 Currently breastfeeding Currently not breastfeeding All Percent re- ceiving solid, semi-solid and soft foods the minimum number of times Number of children age 6-23 months Percent receiving at least 2 milk feeds [1] Percent re- ceiving solid, semi-solid and soft foods or milk feeds 4 times or more Number of children age 6-23 months Percent with minimum meal fre- quency [2] Num- ber of children age 6-23 months Sex Male 48.6 168 85.3 89.8 138 67.1 306 Female 51.2 157 83.5 85.7 150 68.1 307 Age 6-8 months 43.1 70 (88.3) (88.3) 29 56.4 100 9-11 months 42.3 70 (92.2) (92.2) 39 60.2 109 12-17 months 49.3 102 85.1 89.4 73 66.0 174 18-23 months 62.6 83 81.1 85.4 147 77.2 230 Region Corozal 67.4 62 (85.7) (88.3) 30 74.3 93 Orange Walk (56.9) 47 92.6 94.2 48 75.7 96 Belize (Excluding Belize City South Side) (*) 37 (*) (*) 29 (53.1) 66 Belize City South Side (42.6) 28 (91.1) (95.6) 43 74.4 71 Belize District 37.6 65 83.6 88.4 72 64.2 137 Cayo (44.0) 72 91.9 92.2 82 69.5 154 Stann Creek (45.0) 35 (90.3) (90.3) 32 66.6 68 Toledo (48.9) 42 (34.2) (52.0) 24 50.0 66 Area Urban 51.5 101 90.8 90.7 136 74.0 237 Rural 49.1 224 78.6 84.9 152 63.6 376 Mother’s edu- cation None (58.6) 28 (*) (*) 10 (65.4) 38 Primary 49.7 168 79.8 85.0 117 64.2 285 Secondary + 47.9 124 87.3 89.1 151 70.5 275 CET/ITVET/VOTEC (*) 0 (*) (*) 3 (*) 3 Other (*) 5 (*) (*) 7 (*) 13 Wealth index quintiles Poorest 53.7 103 58.8 73.5 57 60.8 160 Second 53.4 82 88.1 92.2 59 69.6 141 Middle 31.3 53 93.3 93.3 65 65.3 118 Fourth 51.5 61 (92.2) (89.5) 46 67.9 107 Richest (*) 26 89.4 89.1 61 79.7 87 Ethnicity of household head Creole (42.3) 40 91.4 90.1 58 70.6 97 Mestizo 52.5 183 87.6 88.5 140 68.1 323 Garifuna (*) 17 (*) (*) 16 (58.9) 33 Maya 42.1 55 (63.7) (80.1) 36 57.1 91 Other (59.9) 28 (90.8) (95.0) 33 78.8 60 Missing/DK (*) 3 (*) (*) 6 (*) 8 Total 49.8 325 84.4 87.6 288 67.6 613 [1] MICS indicator 2.15; [2] MICS indicator 2.13 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.8 shows that bottle-feeding is still prevalent in Belize. Almost sixty percent (57.8 percent) of children under 6 months of age are fed using a bottle with a nipple. mics f inal report 51 Table NU.8: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Belize, 2011 Percentage of children age 0-23 months fed with a bottle with a nipple [1] Number of children age 0-23 months: Sex Male 63.7 396 Female 51.4 365 Age 0-5 months 54.6 148 6-11 months 63.5 209 12-23 months 55.9 404 Region Corozal 49.0 110 Orange Walk 44.2 124 Belize (Excluding Belize City South Side) 71.7 83 Belize City South Side 75.5 91 Belize District 73.7 174 Cayo 64.0 195 Stann Creek 72.4 77 Toledo 27.6 82 Area Urban 69.9 298 Rural 49.9 463 Mother's education None (43.4) 45 Primary 49.6 347 Secondary + 68.7 350 CET/ITVET/VOTEC (*) 3 Other (*) 16 Wealth index quintiles Poorest 39.0 189 Second 53.3 172 Middle 64.2 154 Fourth 66.5 138 Richest 77.1 108 Ethnicity of household head Creole 71.6 129 Mestizo 56.1 394 Garifuna (73.9) 44 Maya 42.9 105 Other 53.9 80 Missing/DK (*) 10 Total 57.8 761 [1] MICS indicator 2.11 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases In children under 23 months males are more likely than females to be fed from a bottle with a nipple (males 63.7 percent and females 51.4 percent). It is clear that urban children are also more likely to be fed from a bottle (urban 69.9 percent and rural 49.9 percent). In Belize, the prevalence is highest in Belize City South Side (75.5 percent) and the rest of the Belize District (71.7 percent) and in the Stann Creek District (72.4 percent), and it is lowest in the Toledo District (27.6 percent). Rates of bottle feeding increase as the educational level of the mother increases (no education: 43.4 percent to Secondary+: 68.7 percent). A similar trend exists for the index of wealth with poorest families at 39.0 percent and the richest families at 77.1 percent (Figure NU.9). Children with Creole (71.6 percent) and Garifuna (73.9 percent) heads of household display elevated prevalence among ethnic groups for feeding from a bottle with a nipple. In children under 23 months males are more likely than females to be fed from a bottle with a nipple (males 63.7 percent and females 51.4 percent). It is clear that urban children are also more likely to be fed from a bottle (urban 69.9 percent and rural 49.9 percent). In Belize, the prevalence is highest in Belize City South Side (75.5 percent) and the rest of the Belize District (71.7 percent) and in the Stann Creek District (72.4 percent), and it is lowest in the Toledo District (27.6 percent). Rates of bottle feeding increase as the educational level of the mother increases (no education: 43.4 percent to Secondary+: 68.7 percent). A similar trend exists for the index of wealth with poorest families at 39.0 percent and the richest families at 77.1 percent (Figure NU.9). Children with Creole (71.6 percent) and Garifuna (73.9 percent) heads of household display elevated prevalence among ethnic groups for feeding from a bottle with a nipple. 52 mics f inal report 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 mics f inal report 53 critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high-dose vitamin A supplementation every four to six months, targeted to all children between the ages of six to 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 percent of children 6-59 months of age receiving at least one high dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, the Belize Ministry of Health recommends that children aged 6-11 months be given one high dose Vitamin A capsules and children aged 12-59 months given a vitamin A capsule every 6 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 increased Vitamin A requirements during pregnancy and lactation. Within the six months prior to the MICS, 65.1 percent of children aged 6-59 months received a high dose Vitamin A supplement (Table NU.10). Approximately 66.9 percent of females received the supplement in the last 6 months: males received treatment at a rate of 63.1 percent. Children from the Toledo District (51.3 percent) and the Belize City South Side (51.9 percent) were less likely to get Vitamin A supplement within the last 6 months. Maya children (58.2 percent) were least likely to receive Vitamin A supplement within the last 6 months. The age pattern of Vitamin A supplementation shows that supplementation in the last six months rises slowly from 53.3 percent among children aged 6-11 months to 68.0 percent among children aged 48-59 months. Rural children receive Vitamin A supplementation at a rate of 66.9 percent as compared to urban rate of 62.0 percent. 54 mics f inal report Table NU.10: 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, Belize, 2011 Percentage who received Vitamin A according to: Percentage of children who received Vitamin A during the last 6 months [1] Number of children age 6-59 months Child health book/card/ vaccination card Mother’s report Sex Male 2.8 63.2 63.2 894 Female 4.8 66.9 66.9 904 Region Corozal 10.3 57.0 57.0 246 Orange Walk 3.8 65.9 65.9 274 Belize (Excluding Belize City South Side) 3.5 67.6 67.6 223 Belize City South Side 1.4 51.9 51.9 232 Belize District 2.4 59.6 59.6 455 Cayo 4.4 78.2 78.2 409 Stann Creek 0.0 73.9 73.9 203 Toledo 2.1 51.3 51.3 211 Area Urban 2.7 62.0 62.0 682 Rural 4.5 66.9 66.9 1116 Age 6-11 5.0 53.3 53.3 209 12-23 3.6 65.5 65.5 404 24-35 4.3 66.5 66.5 393 36-47 4.8 66.5 66.5 395 48-59 2.0 68.0 68.0 397 Mother’s education None 3.4 45.5 45.5 93 Primary/Infant 3.7 66.9 66.9 884 Secondary + 4.0 65.3 65.3 764 CET/ITVET/VOTEC (*) (*) (*) 13 Missing/DK (*) (*) (*) 1 Other 2.1 60.3 60.3 43 Wealth index quintiles Poorest 3.6 55.9 55.9 462 Second 5.5 72.6 72.6 420 Middle 3.1 61.2 61.2 371 Fourth 5.1 69.0 69.0 299 Richest 1.0 70.6 70.6 247 Ethnicity of household head Creole 3.7 67.2 67.2 347 Mestizo 5.0 67.9 67.9 878 Garifuna 0.0 69.3 69.3 94 Maya 3.1 58.2 58.2 274 Other 1.0 54.9 54.9 175 Missing/DK 5.6 66.6 66.6 29 Total 3.8 65.1 65.1 1798 [1] MICS indicator 2.17 (*) Figures that are based on less than 25 un-weighted cases mics f inal report 55 Low Birth Weight Weight at birth is a good indicator not only of a mother’s health and nutritional status but also the newborn’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have most impact: the mother’s poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth2 . 2 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. 56 mics f inal report Table NU.11: Low birth weight infants Percentage of last-born children in the 2 years preceding the survey that are estimated to have weighed below 2500 grams at birth and percentage of live births weighed at birth, Belize, 2011 Percent of live births: Below 2500 grams [1] Weighed at birth [2] Number of live births in the last 2 years Region Corozal 13.5 98.2 95 Orange Walk 9.4 98.4 108 Belize (Excluding Belize City South Side) 12.9 87.5 74 Belize City South Side 10.2 96.4 77 Belize District 11.5 92.0 151 Cayo 10.4 98.3 189 Stann Creek 12.4 90.7 69 Toledo 10.6 87.8 73 Area Urban 11.4 96.3 262 Rural 11.0 94.3 424 Education None (11.2) (91.6) 41 Primary 12.2 94.5 311 Secondary + 10.5 95.8 315 CET/ITVET/VOTEC (*) (*) 3 Other (*) (*) 15 Wealth index quintiles Poorest 12.1 91.9 173 Second 14.1 96.0 156 Middle 9.6 95.9 134 Fourth 9.7 95.6 132 Richest 8.7 97.3 91 Ethnicity of household head Creole 13.4 95.1 113 Mestizo 10.1 95.6 355 Garifuna (10.1) (92.4) 43 Maya 13.9 91.7 96 Other 9.8 100.0 71 Missing/DK (*) (*) 8 Total 11.1 95.0 685 [1] MICS indicator 2.18; [2] MICS indicator 2.19 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases mics f inal report 57 Overall, 95.0 percent of births were weighed at birth and approximately 11.1 percent of infants are estimated to weigh less than 2500 grams at birth (Table NU.11). There was notable variation by wealth (Figure NU.10). Maya (13.9 percent) and Creole (13.4 percent) children show elevated rates low birth weights. Low birth weight infants are most prevalent in the Corozal District (13.5 percent), the Belize area (excluding Belize City South Side) (12.9 percent) and the Stann Creek District (12.4 percent). The percentage of low birth weight does not vary much by urban and rural areas or by mother’s education. 58 mics f inal report vi. Child healTh Vaccinations The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in 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. Worldwide there are still 27 million children overlooked by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure full immunization of children under-one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG 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 by the age of 18 months. Mothers were asked to provide vaccination cards for children under the age of five. Interviewers copied vaccination information from the cards onto the MICS questionnaire. Table CH.1: Vaccinations in first year of life Percentage of children age 18-29 months immunized against childhood diseases at any time before the survey and before the first birthday (and by 18 months for measles), Belize, 2011 Vaccinated at any time before the survey according to: vaccination card Vaccinated at any time before the survey according to: Mother’s report Vaccinated at any time before the survey according to: either Vaccinated by 12 months of age (18 months for measles) bCG [1] 75.5 22.5 98.0 97.5 Polio 1 75.0 22.4 97.3 95.6 Polio 2 75.6 1.8 77.4 75.2 Polio 3 [2] 69.2 0.8 70.0 65.3 Polio booster 1.5 0.8 2.3 1.4 DTP 1) 77.7 5.8 83.4 81.7 DTP 2) 75.4 1.2 76.6 74.2 DTP 3) [3] 72.3 1.2 73.5 67.8 DPT booster (Diphteria, Whooping Cough, Tetanus) 1.4 1.2 2.6 2.2 HIB 1 Haemophilus Influenzae B) 77.5 6.0 83.5 83.5 HIB 2 Haemophilus Influenzae B) 75.4 1.2 76.6 76.6 HIB 3 Haemophilus Influenzae B) 72.3 1.2 73.5 73.5 HIB 4 Haemophilus Influenzae B) 1.6 1.1 2.8 2.1 hepb 1 77.4 6.1 83.5 83.5 hepb 2 75.3 1.5 76.8 76.8 hepb 3 [5] 72.2 1.5 73.7 73.7 Measles [4] 72.2 17.5 89.8 84.9 all vaccinations 62.9 0.0 62.9 54.3 no vaccinations 0.0 1.7 1.7 1.7 Number of children age 18-29 months 405 405 405 405 [1] MICs indicator 3.1; [2] MICs indicator 3.2; [3] MICs indicator 3.3; [4] MICs indicator 3.4; MDG indicator 4.3; [5] MICs indicator 3.5 mics f inal report 59 Overall, 75.3 percent of children had health cards that were seen by the interviewers (Table CH.2). 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, Polio, HIB and Heb B, how many times. The percentage of children age 12 to 23 months who received each of the vaccinations is shown in Table CH.1. The denominator for the table is comprised of children age 12-23 months so that only children who are old enough to be fully vaccinated are counted. For measles, the denominator is 18-29 months as the vaccine is administered from age 6 months. 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 97.5 percent of children age 12-23 months received a BCG vaccination by the age of 12 months and the first dose of DPT was given to 81.7 percent. The percentage declines for subsequent doses of DPT to 74.2 percent for the second dose, and 67.8 percent for the third dose (Figure CH.1). Similarly, 95.6 percent of children received Polio 1 by age 12 months and this declines to 65.3 percent by the third dose. The coverage for measles vaccine by 18 months is somewhat lower than for the other vaccines at 84.9 percent. In Belize, influenza vaccinations are also recommended as part of the immunization schedule and three doses are provided to the child by age 12 months. These can be seen in Table CH1. Table CH.2 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 mothers’/caretakers’ reports. In general, Maya children seem to have the lowest levels of vaccinations followed by Creole children. There were too few cases of Garifuna children to make useable comparisons. Female children overall seem to have slightly higher coverage rates than male children, though the differences are generally small. The Toledo District and Belize City South Side have the lowest vaccination rates of all regions of the country for BCG, Polio 1, DPT 1 and Measles vaccinations. 60 mics f inal report Ta b le C H .2 : V ac ci n at io n s b y b ac kg ro u n d c h ar ac te ri st ic s Pe rc en ta g e o f ch ild re n a g e 18 -2 9 m o n th s cu rr en tl y va cc in at ed a ga in st c h ild h o o d d is ea se s, B el iz e, 2 01 1 P E R C E N TA G E O F C H IL D R E N W H O R E C E IV E D : Pe rc en ta g e w it h v ac ci - n at io n c ar d se en N u m b er o f ch ild re n ag e 18 -2 9 m o n th s B C G Po lio 1 Po lio 2 Po lio 3 D P T 1 D P T 2 D P T 3 D P T B o o st - er H IB 1 H IB 2 H IB 3 H IB 4 H ep B 1 H ep B 2 H ep B 3 M ea - sl es 1 N o n e A ll S ex M al e 99 .0 98 .2 75 .2 67 .4 83 .3 75 .9 73 .0 3. 2 83 .4 75 .9 73 .0 3. 2 83 .4 76 .4 73 .5 88 .7 0. 7 58 .6 72 .7 19 8 Fe m al e 97 .0 96 .4 79 .4 72 .4 83 .5 77 .2 73 .9 2. 1 83 .5 77 .2 73 .9 2. 5 83 .6 77 .3 74 .0 90 .8 2. 7 66 .8 77 .9 20 7 R eg io n C o ro za l 98 .3 96 .7 82 .1 82 .1 82 .3 82 .1 77 .3 3. 1 82 .3 82 .1 77 .3 3. 1 82 .6 82 .4 77 .7 93 .6 1. 7 74 .5 77 .2 56 O ra n g e W al k 10 0. 0 10 0. 0 80 .3 74 .4 85 .7 82 .5 78 .0 2. 1 85 .7 82 .5 78 .0 2. 1 85 .7 82 .5 78 .0 95 .7 0. 0 71 .7 81 .7 67 B el iz e (E xc lu d in g B el iz e C it y S o u th S id e) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 36 B el iz e C it y S o u th S id e 98 .0 98 .0 78 .3 73 .8 92 .2 80 .3 75 .8 6. 4 92 .3 80 .3 75 .8 6. 4 92 .2 80 .3 75 .8 92 .1 2. 0 68 .3 73 .9 52 B el iz e D is tr ic t 98 .8 98 .8 74 .5 64 .7 84 .4 72 .0 69 .5 3. 7 84 .6 72 .0 69 .5 3. 7 84 .4 72 .0 69 .5 93 .5 1. 2 61 .7 73 .8 88 C ay o 96 .9 95 .3 81 .6 69 .9 85 .5 80 .9 77 .8 0. 0 85 .5 80 .9 77 .8 .0 85 .5 80 .9 77 .8 82 .2 3. 1 60 .1 82 .9 99 S ta n n C re ek (1 00 .0 ) (9 7. 9) (8 6. 9) (7 9. 7) (8 8. 0) (8 1. 1) (7 9. 0) (4 .6 ) (8 8. 0) (8 1. 1) (7 9. 0) (6 .9 ) (8 8. 0) (8 3. 2) (8 0. 9) (9 3. 4) (0 .0 ) (7 5. 3) (7 9. 2) 40 .3 To le d o 94 .1 95 .3 58 .8 54 .3 72 .3 58 .4 57 .1 4. 4 72 .3 58 .4 57 .1 4. 4 72 .6 58 .8 57 .6 82 .7 3. 7 38 .3 51 .5 55 A re a U rb an 98 .9 98 .7 77 .1 69 .0 84 .1 75 .0 70 .4 2. 2 84 .2 75 .0 70 .4 2. 2 84 .1 75 .0 70 .4 89 .4 0. 7 61 .7 74 .7 14 5 R u ra l 97 .5 96 .5 77 .6 70 .6 83 .1 77 .5 75 .2 2. 8 83 .1 77 .5 75 .2 3. 2 83 .2 77 .9 75 .7 89 .9 2. 3 63 .5 75 .7 26 0 M o th er ’s ed u ca ti o n N o n e (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 22 Pr im ar y/ In fa n t 99 .3 98 .5 80 .7 74 .8 87 .8 81 .1 76 .3 1. 8 87 .8 81 .1 76 .3 2. 3 87 .9 81 .7 76 .9 91 .7 0. 3 67 .0 78 .8 18 7 S ec o n d ar y + 97 .9 97 .8 75 .3 66 .0 81 .7 74 .0 72 .4 3. 2 81 .8 74 .0 72 .4 3. 2 81 .7 74 .0 72 .4 89 .4 1. 7 59 .3 73 .2 18 4 E th n ic it y o f h o u se h o ld h ea d C re o le 99 .2 10 0. 0 81 .2 73 .1 89 .9 81 .7 80 .3 4. 0 90 .0 81 .7 80 .3 4. 0 89 .9 81 .7 80 .3 91 .6 0. 0 65 .2 78 .4 77 M es ti zo 99 .2 99 .2 80 .9 73 .6 84 .5 78 .1 75 .0 2. 4 84 .5 78 .1 75 .0 2. 8 84 .5 78 .6 75 .5 92 .9 0. 8 68 .2 80 .1 20 3 G ar if u n a (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 14 M ay a 96 .9 96 .1 69 .7 62 .8 74 .1 69 .8 68 .8 2. 9 74 .1 69 .8 68 .8 2. 9 74 .4 70 .1 69 .1 79 .3 3. 1 47 .2 59 .9 65 O th er (9 2. 5) (8 8. 0) (6 9. 4) (6 3. 4) (8 5. 2) (7 3. 6) (6 7. 6) (2 .1 ) (8 5. 2) (7 3. 6) (6 7. 6) (2 .1 ) (8 5. 2) (7 3. 6) (6 7. 6) (8 8. 2) (6 .1 ) (6 0. 5) (7 4. 0) 41 M is si n g /D K 10 0. 0 10 0. 0 48 .8 48 .8 48 .8 48 .8 48 .8 0. 0 48 .8 48 .8 48 .8 0. 0 48 .8 48 .8 48 .8 10 0. 0 0. 0 48 .8 48 .8 6 To ta l 98 .0 97 .3 77 .4 70 .0 83 .4 76 .6 73 .5 2. 6 83 .5 76 .6 73 .5 2. 8 83 .5 76 .8 73 .7 89 .8 1. 7 62 .9 75 .3 40 5 ( ) Fi g u re s th at a re b as ed o n 2 5- 49 u n -w ei g h te d c as es ; ( *) F ig u re s th at a re b as ed o n le ss t h an 2 5 u n -w ei g h te d c as es 4 u n -w ei g h te d c as es in “ C E T /IT V E T /V O T E C ” an d 9 u n -w ei g h te d c as es in “ O th er ” o n E d u ca ti o n a n d 6 u n -w ei g h te d c as es in M is si n g /D K ” in E th n ic it y o f th e h ea d o f h o u se h o ld a re n o t sh o w n mics f inal report 61 Neonatal Tetanus Protection One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than 1 case of neonatal tetanus per 1000 live births in every district. A World Fit for Children goal is to eliminate maternal and neonatal tetanus by 2005. • The strategy of preventing maternal and neonatal tetanus is to assure all pregnant women receive at least two doses of tetanus toxoid vaccine. If a woman has not received two doses of the tetanus toxoid during a particular pregnancy, she (and her newborn) are also considered to be protected against tetanus if the woman: • Received at least two doses of tetanus toxoid vaccine, the last within the previous 3 years; • Received at least 3 doses, the last within the previous 5 years; • Received at least 4 doses, the last within the previous 10 years; • Received at least 5 doses anytime during her life. To assess the status of tetanus vaccination coverage, women who gave birth during the two years before the survey were asked if they had received tetanus toxoid injections during the pregnancy for their most recent birth, and if so, how many. Women who did not receive two or more tetanus toxoid vaccinations during this pregnancy were then asked about tetanus toxoid vaccinations they may have received prior to this pregnancy. Interviewers also asked women to present their vaccination card, on which dates of tetanus toxoid are recorded and referred to information from the cards when available. Table CH.3 presents the results. Table CH.3 shows the protection status from tetanus of women who have had a live birth within the last 2 years by major background characteristics. Overall, 52.4 percent of women are protected. Belize City South Side (39.0 percent) has the lowest rates of tetanus protection among the other regions. Garifuna women have the lowest rates (47.6 percent) while the Maya have the highest (54.0 percent). Less educated women seem to have lower rates of protection against Tetanus. 62 mics f inal report Table CH.3: Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus, Belize, 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 tetanus [1] 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 Area Urban 33.0 16.7 0.3 0.0 0.0 50.1 262 Rural 35.5 18.2 0.2 0.0 0.0 53.9 424 Region Corozal 39.5 17.7 0.8 0.0 0.0 58.0 95 Orange Walk 52.8 12.0 0.0 0.0 0.0 64.8 108 Belize (Excluding Belize City South Side) (26.6) (30.8) (0.0) (0.0) (0.0) (57.5) 74 Belize City South Side 24.1 13.7 1.1 0.0 0.0 39.0 77 Belize District 25.4 22.1 0.6 0.0 0.0 48.1 151 Cayo 32.6 16.6 0.0 0.0 0.0 49.1 189 Stann Creek 31.9 19.0 0.0 0.0 0.0 50.9 69 Toledo 27.7 18.3 0.0 0.0 0.0 46.0 73 Education None (16.8) (14.5) (0.0) (0.0) (0.0) (31.3) 46 Primary 36.4 14.3 0.5 0.0 0.0 51.2 306 Secondary + 36.5 20.7 0.0 0.0 0.0 57.2 315 Other (*) (*) (*) (*) (*) (*) 15 Wealth index quintiles Poorest 31.6 16.6 0.4 0.0 0.0 48.6 173 Second 33.2 20.7 0.0 0.0 0.0 53.9 156 Middle 33.0 10.4 0.6 0.0 0.0 44.1 134 Fourth 39.7 21.7 0.0 0.0 0.0 61.4 132 Richest 37.3 19.4 0.0 0.0 0.0 56.7 91 Ethnicity of household head Creole 30.6 21.7 0.8 0.0 0.0 53.0 113 Mestizo 39.2 13.5 0.2 0.0 0.0 52.9 355 Garifuna (24.5) (23.1) (0.0) (0.0) (0.0) (47.6) 43 Maya 30.3 23.6 0.0 0.0 0.0 54.0 96 Other 28.9 21.3 0.0 0.0 0.0 50.3 71 Total 34.5 17.7 0.2 0.0 0.0 52.4 685 [1] MICs indicator 3.7 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases 3 un-weighted cases in “CET/ITvET/voTEC” on Education and 8 un-weighted cases in “Missing/dK” on Ethnicity of Household Head are not shown 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. mics f inal report 63 The goals are to: 1) reduce by one half death due to diarrhoea among children under five by 2010 compared to 2000 (A World Fit for Children); and 2) reduce by two thirds the mortality rate among children under five by 2015 compared to 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 percent. The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy (ORT) • Home management of diarrhoea • ORT with continued feeding 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. Overall, 7.9 percent of under-five children had diarrhoea in the two weeks preceding the survey (Table CH.4). Diarrhoea prevalence was slightly higher in rural areas (8.8 percent) than in urban areas (4.6 percent). Males had a higher prevalence (9.2 percent) than females (6.5 percent). Table CH.4 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Since children may have been given more than one type of liquid, the percentages do not necessarily add to 100. About 22.8 percent received fluids from ORS packets or pre-packaged ORS fluids and 42.7 percent received Pedialyte. Males and females received oral rehydration solution at about the same rates. Approximately 55.2 percent of children with diarrhoea received one or more of the recommended home treatments (i.e., were treated with ORS or any recommended homemade fluid). 64 mics f inal report Table CH.4: 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 solu- tions and recommended homemade fluids, Belize, 2011 Had diar- rhoea in last two weeks Number of children age 0-59 months Children with diarrhoea who received: Number of children aged 0-59 months with diarrhoea ORS (Fluid from ORS packet or pre-pack- aged ORS fluid) Pedialyte ORS or any rec- ommend- ed home- made fluid Sex Male 9.2 984 22.9 44.6 58.1 91 Female 6.5 962 22.8 39.9 50.8 62 Region Corozal 9.2 263 (38.8) (62.3) (72.4) 24 Orange Walk 3.4 302 (*) (*) (*) 10 Belize (Excluding Belize City South Side) 5.4 240 (*) (*) (*) 13 Belize City South Side 4.1 252 (*) (*) (*) 10 Belize District 4.7 492 (*) (*) (*) 23 Cayo 13.6 450 (15.5) (48.5) (61.4) 61 Stann Creek 8.2 212 (*) (*) (*) 18 Toledo 7.5 226 (*) (*) (*) 17 area urban 6.4 743 (13.7) (46.8) (58.5) 48 rural 8.8 1203 27.0 40.9 53.7 106 age 0-11 9.3 357 (17.8) (44.8) (56.1) 33 12-23 14.6 404 27.0 45.4 58.9 59 24-35 7.6 393 (16.4) (34.7) (46.8) 30 36-47 4.5 395 (*) (*) (*) 18 48-59 3.4 397 (*) (*) (*) 14 Mother’s education None 9.5 115 (*) (*) (*) 11 Primary 8.6 931 27.1 32.8 49.0 80 secondary + 7.2 839 19.4 54.3 63.0 61 other (3.2) 47 (*) (*) (*) 1 Wealth index quintiles Poorest 9.6 490 31.9 31.9 54.8 47 second 6.4 450 (20.7) (37.1) (45.2) 29 Middle 9.4 407 (25.2) (47.3) (55.2) 38 Fourth 6.1 330 (*) (*) (*) (*) richest 7.2 268 (*) (*) (*) (*) ethnicity of household head Creole 5.2 379 (*) (*) (*) (*) Mestizo 9.0 949 19.1 37.8 47.8 86 Garifuna 2.5 105 (*) (*) (*) 3 Maya 10.5 288 (29.1) (44.7) (62.4) 30 other 6.5 195 (*) (*) (*) (*) Missing/DK (7.8) 31 (*) (*) (*) (*) Total 7.9 1946 22.8 42.7 55.2 153 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases About 16.7 percent of under-five children with diarrhoea drank more than usual while 80.4 percent drank the same or less (Table CH.5). Seventy-two percent ate somewhat less, same or more (continued feeding), but 27.6 percent ate much less or stopped food or have not ever eaten. It is clear that males were denied drink at a higher rate than females but fared a little better in getting food. Also, rural children were not as likely as urban children to access drink and food. mics f inal report 65 Table CH.5. 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, Belize, 2011 Had diar- rhoea in last two weeks Number of children age 0-59 months Drinking practices during diarrhoea: Given much less to drink Given somewhat less to drink Given about the same to drink Given more to drink Given nothing to drink Miss- ing/DK Total Sex Male 9.2 984 14.1 24.6 40.8 16.1 3.7 0.7 100.0 Female 6.5 962 4.4 39.5 37.6 17.7 0.9 0.0 100.0 Area Urban 6.4 743 (8.1) (20.5) (47.2) (20.9) (2.0) (1.3) 100.0 Rural 8.8 1203 11.1 35.2 36.0 14.8 2.8 0.0 100.0 Total 7.9 1946 10.2 30.7 39.5 16.7 2.6 0.4 100.0 Eating practices during diarrhoea: Number of children aged 0-59 months with diar- rhoea 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 giv- en food Missing/ DK Total Sex Female Male 16.9 27.7 37.5 3.4 11.0 2.9 0.7 100.0 91 14.4 41.1 34.8 1.0 6.1 2.5 0.0 100.0 62 Area Rural Urban (11.6) (33.8) (43.9) (6.4) (1.7) (1.3) (1.3) 100.0 48 17.8 32.9 33.0 0.6 12.3 3.4 0.0 100.0 106 Total 15.9 33.2 36.4 2.4 9.0 2.7 0.4 100.0 153 ( ) Figures that are based on 25-49 un-weighted cases Table CH.6 provides the proportion 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. Overall, 34.4 percent of children with diarrhoea received ORS or increased fluids, 58.6 percent received ORT (ORS or recommended homemade fluids or increased fluids) and 42.5 percent received ORT with continued feeding. There are differences in the management of diarrhoea by area. ORT with continued feeding occurred at a higher rate in urban (58.0 percent) than in rural (35.6 percent) areas. Almost twice as many females (25.2 percent) versus males (14.5 percent) were not given any treatment or drug for diarrhoea. 66 mics f inal report Table CH.6: 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, Belize, 2011 Children with diarrhoea who received: Number of children aged 0-59 months with diarrhoea Not given any treatment or drug ORS or in- creased fluids ORT (ORS or recommend- ed home- made fluids or increased fluids) ORT with continued feeding [1] Sex Male 34.4 59.5 41.7 91 14.5 Female 34.5 57.5 43.8 62 25.2 Area Urban 27.6 62.1 58.0 48 19.7 Rural 37.5 57.1 35.6 106 18.5 Total 34.4 34.4 42.5 153 18.9 [1] MICS indicator 3.8 Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in under-5s with suspected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one-third the 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 mics f inal report 67 Ta b le C H .7 : C ar e se ek in g f o r su sp ec te d p n eu m o n ia a n d a n ti b io ti c u se d u ri n g s u sp ec te d p n eu m o n ia Pe rc en ta g e o f ch ild re n a g e 0- 59 m o n th s w it h s u sp ec te d p n eu m o n ia in t h e la st t w o w ee ks w h o w er e ta ke n t o a h ea lt h p ro vi d er a n d p er ce n ta g e o f ch ild re n w h o w er e g iv en an ti b io ti cs , B el iz e, 2 01 1 H ad s u s- p ec te d p n eu m o n ia in t h e la st tw o w ee ks N u m b er o f ch ild re n a g e 0- 59 m o n th s C H IL D R E N W IT H S U S P E C T E D P N E U M O N IA W H O W E R E T A K E N T O : A ny a p p ro - p ri at e p ro vi d - er [ 1] Pe rc en ta g e o f ch il- d re n w it h su sp ec te d p n eu m o n ia w h o r e- ce iv ed a n - ti b io ti cs in th e la st t w o w ee ks [ 2] N u m b er o f ch ild re n ag e 0- 59 m o n th s w it h s u s- p ec te d p n eu m o n ia in t h e la st tw o w ee ks P u b lic se ct o r: G ov - er n m en t h o sp it al Pu b lic se ct o r: G ov er n - m en t h ea lt h ce n te r O th er p u b lic Pr iv at e h o sp it al / cl in ic Pr iv at e p hy si ci an Pr iv at e p h ar m a- cy O th er p ri va te m ed ic al R el a- ti ve / Fr ie n d O th er S ex M al e 3. 2 98 4 (3 3. 7) (1 9. 6) (5 .1 ) (1 1. 3) (4 .9 ) (3 .1 ) (2 .6 ) (5 .0 ) (2 .0 ) (7 7. 3) (6 7. 7) 31 Fe m al e 2. 7 96 2 (3 4. 6) (2 5. 1) (0 .0 ) (2 9. 3) (3 .2 ) (0 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) (8 8. 1) (7 4. 1) 26 A re a U rb an 2. 0 74 3 (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 15 R u ra l 3. 5 12 03 32 .8 17 .4 3. 7 16 .7 5. 6 0. 0 1. 9 3. 7 1. 5 78 .2 63 .7 42 To ta l 3. 0 19 46 34 .1 22 .1 2. 8 19 .5 4. 1 1. 7 1. 4 2. 7 1. 1 82 .2 70 .7 57 [1 ] M IC S in d ic at o r 3. 9; [ 2] M IC S in d ic at o r 3. 10 ( ) F ig u re s th at a re b as ed o n 2 5- 49 u n -w ei g h te d c as es ; ( *) F ig u re s th at a re b as ed o n le ss t h an 2 5 u n -w ei g h te d c as es 68 mics f inal report Table CH.7 presents the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. Three percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, 82.2 percent were taken to an appropriate provider. Table CH.7 also presents the use of antibiotics for the treatment of suspected pneumonia in under-5s by sex, age, region, area, age, and socioeconomic factors. In Belize, 70.7 percent of under-5 children with suspected pneumonia had received an antibiotic during the two weeks prior to the survey. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.8. Obviously, mothers’ knowledge of the danger signs is an important determinant of care-seeking behaviour. Overall, 7.0 percent 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 develops a fever (73.3 percent). 13.0 percent of mothers identified fast breathing and 21.2 percent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. Mothers in the Stann Creek District recognized the two signs of pneumonia at a higher rate (24.5 percent) than in all other regions (a minimum of 0.4 percent in Orange Walk) (Table CH.8). As expected more educated mothers had a higher rate for recognizing the two signs of pneumonia (no education 5.3 percent, primary 5.3 percent and secondary+ 9.2 percent). Mothers from households with Garifuna heads recognized the two signs of pneumonia at a higher rate (17.2 percent) than in all other ethnicities. The next highest rate occurred in households with Creole heads (8.5 percent). mics f inal report 69 Table CH.8: 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 immedi- ately to a health facility, and percentage of mothers who recognize fast and difficult breathing as signs for seeking care immediately, Belize, 2011 Percentage of mothers/caretakers who think that a child should be taken immediately to a health facility if the child: Mothers/care- takers who recognize the two danger signs of pneu- monia Number of mothers/care- takers of chil- dren age 0-59 months Is not able to drink or breastfeed Becomes sicker Develops a fever Has fast breathing Has dif- ficulty breath- ing Has blood in stool Is drinking poorly Has other symp- toms Region Corozal 2.8 9.9 77.1 7.7 22.8 1.9 2.3 36.2 5.4 177 Orange Walk 1.5 5.0 57.6 6.8 18.5 2.5 2.2 5.6 0.4 206 Belize (Ex- cluding Belize City South Side) 5.4 24.8 78.5 11.5 20.6 3.9 0.9 12.0 4.3 166 Belize City South Side 3.6 3.7 67.6 9.9 23.4 5.4 1.5 36.1 5.3 181 Belize Dis- trict 4.4 13.8 72.8 10.7 22.1 4.7 1.3 24.6 4.9 347 Cayo 1.3 4.3 79.5 13.0 21.2 4.4 2.8 21.6 7.2 337 Stann Creek 17.6 28.3 71.6 27.5 33.0 24.5 17.0 46.4 24.5 150 Toledo 1.5 36.6 79.5 18.4 9.2 6.1 3.1 20.8 4.6 145 Area Urban 4.7 9.3 73.0 12.8 22.6 5.8 3.7 28.0 7.4 544 Rural 3.8 16.5 73.5 13.0 20.3 6.5 3.9 22.1 6.6 818 Education None 0.9 13.8 69.7 11.1 12.9 5.1 0.8 20.1 5.3 59 Primary/ Infant 3.0 14.2 73.2 11.2 18.4 5.1 4.1 21.5 5.3 647 Secondary + 5.8 13.5 74.7 15.3 25.1 7.6 3.9 28.5 9.2 625 Wealth index quin- tiles Poorest 1.9 16.3 73.2 13.8 17.5 4.6 3.0 20.3 5.4 306 Second 4.8 11.1 72.6 9.4 20.6 7.1 3.4 26.6 6.4 308 Middle 4.2 14.2 72.9 13.5 22.7 7.6 3.3 27.7 7.2 294 Fourth 5.2 14.3 73.3 15.3 24.9 6.3 6.5 19.9 8.6 254 Richest 5.0 11.7 75.2 13.4 21.1 5.6 3.3 28.8 7.7 201 Ethnicity of household head Creole 4.2 12.0 72.4 15.7 22.3 7.2 3.6 29.4 8.5 288 Mestizo 3.3 10.7 72.2 10.1 22.0 4.4 3.0 23.6 5.6 673 Garifuna 11.1 23.6 75.2 20.5 29.3 18.4 13.0 43.5 17.2 77 Maya 3.7 22.3 83.9 18.8 15.7 6.8 5.0 16.2 7.2 190 Other 5.4 16.1 63.4 7.9 15.0 6.9 2.2 16.2 3.1 113 Total 4.1 13.6 73.3 13.0 21.2 6.3 3.8 24.5 7.0 1362 7 un-weighted cases in “CET/ITVET/VOTEC” and 28 un-weighted cases in “Other” on Education and 21 un-weighted cases in “Missing/DK” on Ethnicity of Household Head are not shown Solid Fuel Use More than 3 billion people around the world rely on solid fuels for their basic energy needs, including cooking and heating. Solid fuels include biomass fuels, such as wood, charcoal, crops or other agricultural waste, dung, shrubs and straw, and coal. Cooking and heating with solid fuels leads to high levels of indoor smoke 70 mics f inal report which contains a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is their incomplete combustion, which produces toxic elements such as carbon monoxide, polyaromatic hydrocarbons, sulphur dioxide (SO2) among others. Use of solid fuels increases the risks of incurring acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, asthma and may contribute to low birth weight of babies born to pregnant women exposed to smoke. The primary indicator for monitoring use of solid fuels is the proportion of the population using solid fuels as the primary source of domestic energy for cooking, shown in Table CH.9. Table CH.9: 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, Belize, 2011 Percentage of household members in households using: Total Solid fuels for cooking [1] Number of house- hold members Electricity Butane Biogas Kerosene Charcoal Wood No food cooked in house- hold Region Corozal 0.2 66.3 0.1 0.1 0.1 32.6 0.6 100.0 32.7 2296 Orange Walk 0.8 81.1 0.0 0.1 0.2 17.3 0.4 100.0 17.4 2584 Belize (Excluding Belize City South Side) 3.1 92.5 0.0 0.2 0.0 2.9 1.4 100.0 2.9 2799 Belize City South Side 3.1 94.1 0.1 0.3 0.0 0.5 1.8 100.0 0.5 2177 Belize District 3.1 93.2 0.1 0.2 0.0 1.8 1.6 100.0 1.8 4976 Cayo 2.9 83.1 0.0 0.0 0.5 12.8 0.4 100.0 13.3 3865 Stann Creek 1.1 82.6 0.0 0.0 0.0 15.0 1.4 100.0 15.0 1833 Toledo 0.6 40.6 0.0 0.1 0.0 56.6 2.0 100.0 56.6 1733 Area Urban 2.1 92.9 0.0 0.1 0.3 3.0 1.5 100.0 3.3 7536 Rural 1.6 68.6 0.0 0.1 0.1 28.8 0.7 100.0 28.9 9752 Education of house- hold head None 1.8 51.1 0.0 0.2 0.2 45.8 0.9 100.0 46.0 1377 Primary 1.4 73.0 0.1 0.2 0.1 24.1 1.0 100.0 24.2 8782 Secondary + 2.5 92.1 0.0 0.0 0.1 4.0 1.1 100.0 4.1 6412 CET/ITVET/VO- TEC 0.0 98.5 0.0 0.0 0.0 0.5 0.9 100.0 0.5 172 Missing/DK 2.3 93.0 0.0 0.0 2.6 1.7 0.4 100.0 4.3 256 Other 0.0 89.1 0.0 0.0 0.0 10.9 0.0 100.0 10.9 288 Wealth index quintiles Poorest 1.4 31.6 0.0 0.5 0.2 62.5 3.8 100.0 62.8 3458 Second 1.6 79.4 0.1 0.0 0.4 17.7 0.7 100.0 18.1 3457 Middle 1.6 91.5 0.0 0.0 0.1 6.0 0.4 100.0 6.2 3459 Fourth 1.8 96.5 0.1 0.0 0.0 1.5 0.2 100.0 1.5 3456 Richest 2.9 96.8 0.0 0.0 0.0 0.1 0.1 100.0 0.1 3457 Ethnicity of house- hold head Creole 2.8 92.3 0.0 0.2 0.0 3.0 1.7 100.0 3.0 4048 Mestizo 1.2 78.1 0.1 0.1 0.3 19.2 0.9 100.0 19.5 8498 Garifuna 1.1 94.0 0.0 0.0 0.0 3.2 1.6 100.0 3.2 959 Maya 0.7 38.8 0.0 0.0 0.0 60.2 0.4 100.0 60.2 1933 Other 4.9 89.5 0.0 0.2 0.1 4.7 0.6 100.0 4.8 1552 Missing/DK 1.6 92.5 0.0 0.0 0.0 5.4 0.5 100.0 5.4 298 Total 1.8 79.2 0.0 0.1 0.2 17.6 1.0 100.0 17.7 17288 [1] MICS indicator 3.11 Overall, 17.7 percent of all households in Belize use solid fuels for cooking. Use of solid fuels is low in urban areas (3.3 percent) and higher in rural areas (28.9 percent). Solid fuel use is highest in the Toledo District (56.5 percent) and lowest in Belize City South Side (0.5 percent) (Table 9). Differentials with respect to household wealth and the educational level of the household head are also evident. The findings show that use of solid fuels is very common among households with Maya heads (60.2 percent), and very uncommon among the richest households (0.1 percent). mics f inal report 71 Solid fuel use by place of cooking is depicted in Table CH.10. The presence and extent of indoor pollution are dependent on cooking practices, places used for cooking, as well as types of fuel used. In Belize the use of solid fuels occurs in a separate building or outdoors in 63.6 percent of households that use solid fuels. Households with Creole heads seem to use solid fuels outside of the dwelling or in a separate building at a higher rate than other ethnicities (Creole 88.4 percent, Mestizo 72.3 percent and Maya 47.1 percent). Table CH.10: Solid fuel use by place of cooking Percent distribution of household members in households using solid fuels by place of cooking, Belize, 2011 Place of cooking: Number of household members in households using solid fuels for cooking In a sepa- rate room used as kitchen Elsewhere in the house In a separate building Outdoors Other Missing Total Region Corozal 13.8 2.5 52.2 31.6 0.0 0.0 100.0 750 Orange Walk 44.6 3.0 45.0 5.5 1.9 0.0 100.0 451 Belize (Excluding Belize City South Side) 15.1 0.0 63.6 21.2 0.0 0.0 100.0 81 Belize City South Side (*) (*) (*) (*) (*) (*) (*) 10 Belize District 15.5 0.0 56.4 27.0 0.0 1.0 100.0 91 Cayo 17.5 1.2 49.5 31.4 0.0 0.3 100.0 516 Stann Creek 35.9 10.7 34.7 16.3 0.9 1.5 100.0 274 Toledo 23.4 26.6 29.3 17.5 2.2 1.1 100.0 981 Area Urban 26.6 1.7 31.1 39.0 0.0 1.6 100.0 247 Rural 23.8 11.5 42.9 20.2 1.1 0.5 100.0 2817 Education of house- hold head None 23.5 16.5 40.7 15.5 2.4 1.3 100.0 633 Primary 24.0 9.8 42.0 23.2 0.7 0.4 100.0 2125 Secondary + 25.0 6.4 43.7 23.9 0.9 0.0 100.0 262 Wealth index quin- tiles Poorest 23.8 13.7 38.7 21.5 1.5 0.8 100.0 2170 Second 28.4 4.4 46.0 21.2 0.0 0.0 100.0 625 Middle 16.9 1.6 57.2 24.4 0.0 0.0 100.0 213 Fourth (12.3) (2.0) (60.9) (24.8) (0.0) (0.0) 100.0 53 Ethnicity of household head Creole 10.8 0.0 43.7 44.7 0.0 0.8 100.0 121 Mestizo 23.6 3.1 49.3 23.0 0.5 0.5 100.0 1658 Garifuna (6.2) (2.0) (7.5) (79.1) (0.0) (5.1) 100.0 31 Maya 27.1 23.2 31.8 15.3 2.0 0.6 100.0 1163 Other 20.5 8.9 38.1 32.5 0.0 0.0 100.0 75 Total 24.1 10.7 41.9 21.7 1.1 0.6 100.0 3064 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases 1 un-weighted case in “CET/ITVET/VOTEC”, 7 un-weighted cases in “Missing/DK” and 37 cases of “Other” on the Education of the Head of Household are excluded from the table. 3 un-weighted cases in “Richest” category in Wealth Index quintiles and 19 un-weighted cases in the “Missing/DK” category in Ethnicity of household head are excluded from the table. 72 mics f inal report Child Disability Disability is a general term describing impairments, participation restrictions and activity limitations. The term disability describes an interaction between the disabled person and negative attitudes, inaccessible buildings and transportation and limited support in the society. Disability is very diverse requiring in some cases extensive health care interventions. In general, however, all people with disabilities have the same general health care needs as everyone else, and therefore need access to mainstream health care services. MICS was designed to identify children 2 to 9 years at risk for disability in ten areas: walking (gross motor skills), hearing, seeing, understanding, movement (fine motor skills), learning, speaking and mental slowness. Table CH.11 indicates that in Belize, 2011 more than a third (36.4 percent) of children 2 to 9 years was at risk for one or more disabilities as reported by the mother or primary caretaker. The Stann Creek District recorded the highest at risk percentage (59.3 percent) and the Belize City South Side the lowest (23.0 percent). Rural children are at higher risk for disabilities than urban children (urban 28.3 percent, rural 41.5 percent). Increasing mother’s educational levels seems to correlate with decreasing risk of disability. The rate for children whose mothers had no education was 40.4 percent and for children whose mothers had secondary or better education, the rate was 32.2 percent. The three specific impairments that are most frequent are speech is not normal (14.9 percent), appears mentally backward, dull or slow (12.5 percent) and no speaking/ cannot be understood in words (8.4 percent). mics f inal report 73 Ta b le C H .1 1: C h ild re n a t in cr ea se d r is k o f d is ab ili ty Pe rc en ta g e o f ch ild re n a g e 2- 9 ye ar s re p o rt ed t o h av e im p ai rm en ts o r ac ti vi ty li m it at io n s, b y b ac kg ro u n d c h ar ac te ri st ic s, B el iz e, 2 01 1 Pe rc en ta g e o f ch ild re n a g e 2- 9 re p o rt ed t o h av e sp ec ifi ed im p ai rm en ts o r ac ti vi ty li m it at io n s 3- 9 ye ar s N u m - b er o f ch ild re n ag ed 3 -9 ye ar s 2 ye ar s N u m - b er o f ch ild re n ag ed 2 ye ar s Pe rc en ta g e o f ch ild re n ag e 2- 9 ye ar s w it h at le as t o n e re p o rt ed im p ai rm en t [1 ] N u m - b er o f ch ild re n ag ed 2 -9 ye ar s D el ay in si tt in g , st an d in g o r w al ki n g D iffi cu lt y se ei n g , e i- th er in t h e d ay ti m e o r at n ig h t A p p ea rs to h av e d iffi cu lt y h ea ri n g N o u n d er - st an d in g o f in st ru ct io n s D iffi - cu lt y in w al k- in g , m ov in g ar m s, w ea k- n es s o r st iff - n es s H av e fi ts , b ec o m e ri g id , l o se co n sc io u s- n es s N o t le ar n - in g t o d o th in g s lik e o th er c h il- d re n h is / h er a g e N o s p ea ki n g ca n n o t b e u n d er st o o d in w o rd s A p p ea rs m en ta lly b ac kw ar d , d u ll, o r sl o w S p ee ch is n o t n o rm al C an n o t n am e at le as t o n e o b je ct A re a U rb an 2. 1 2. 8 2. 0 4. 1 1. 9 2. 4 3. 2 6. 5 7. 7 11 .9 10 89 13 .6 14 6 28 .3 12 35 R u ra l 3. 9 5. 3 5. 2 7. 7 2. 7 1. 8 6. 5 9. 5 15 .4 16 .7 17 58 16 .8 24 1 41 .5 19 99 R eg io n C o ro za l 2. 9 4. 9 3. 5 3. 4 2. 4 1. 6 3. 4 7. 1 23 .2 9. 1 36 0 1. 7 52 37 .8 41 2 O ra n g e W al k 2. 0 3. 0 2. 4 6. 0 2. 1 1. 3 6. 3 8. 3 6. 5 9. 9 41 6 10 .9 59 29 .3 47 5 B el iz e (E xc lu d - in g B el iz e C it y S o u th S id e) 2. 9 5. 0 5. 1 4. 5 1. 8 2. 2 2. 2 4. 2 6. 2 7. 8 41 0 (7 .9 ) 42 24 .4 45 1 B el iz e C it y S o u th S id e 2. 5 2. 0 0. 8 4. 3 1. 9 1. 5 2. 9 5. 5 4. 0 8. 0 33 4 20 .7 51 23 .0 38 5 B el iz e D is tr ic t 2. 7 3. 6 3. 1 4. 4 1. 9 1. 9 2. 5 4. 8 5. 2 7. 9 74 4 15 .0 93 23 .8 83 7 C ay o 5. 1 4. 6 4. 2 10 .8 3. 8 3. 3 8. 6 12 .7 20 .3 35 .7 67 1 26 .2 91 59 .3 76 2 S ta n n C re ek 3. 2 8. 0 8. 4 3. 5 1. 5 1. 7 4. 3 7. 4 8. 6 10 .7 32 4 16 .8 44 33 .1 36 8 To le d o 2. 7 2. 9 3. 5 7. 9 2. 4 1. 0 6. 2 10 .0 12 .4 4. 9 33 1 16 .3 49 29 .1 37 9 A g e o f ch ild 2- 4 3. 7 3. 2 3. 3 6. 4 2. 6 2. 2 5. 3 12 .1 11 .2 15 .6 79 2 15 .6 38 7 37 .5 11 79 5- 6 2. 9 3. 8 4. 0 5. 9 2. 0 1. 8 4. 9 5. 3 12 .5 13 .8 80 6 n a n a 34 .2 80 6 7- 9 3. 0 5. 8 4. 6 6. 6 2. 6 1. 9 5. 4 6. 8 13 .7 15 .1 12 49 n a n a 36 .9 12 49 M o th er ’s ed u ca ti o n N o n e 7. 7 4. 6 6. 8 8. 7 7. 7 2. 3 7. 9 12 .9 18 .2 20 .0 19 5 (* ) 21 40 .4 21 6 Pr im ar y 3. 1 4. 6 4. 5 6. 6 2. 4 1. 7 5. 6 8. 7 14 .4 14 .7 14 83 17 .0 18 8 39 .2 16 71 S ec o n d ar y + 2. 8 4. 0 2. 8 5. 7 1. 5 2. 3 4. 4 6. 9 9. 4 14 .3 10 97 14 .1 16 2 32 .2 12 59 C E T /IT V E T / V O T E C (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 14 (* ) 4 (* ) 19 M is si n g /D K (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 2 (* ) 0 (* ) 2 O th er 2. 5 1. 4 5. 0 7. 9 3. 8 2. 5 6. 2 14 .9 5. 0 7. 1 56 (* ) 11 34 .5 67 W ea lt h in d ex q u in ti le s Po o re st 4. 3 3. 9 5. 7 8. 9 3. 3 1. 7 6. 2 10 .8 16 .6 15 .6 71 1 15 .9 99 40 .7 81 0 S ec o n d 3. 4 5. 2 4. 2 4. 9 2. 0 1. 9 6. 0 9. 1 13 .7 12 .8 64 7 13 .1 88 36 .2 73 5 M id d le 3. 3 4. 4 2. 8 6. 6 2. 2 1. 4 6. 2 7. 8 11 .1 13 .1 57 1 21 .7 87 35 .4 65 8 Fo u rt h 2. 4 4. 2 4. 1 4. 1 3. 2 3. 2 3. 7 5. 1 10 .9 14 .3 49 5 13 .6 53 32 .3 54 9 R ic h es t 2. 1 3. 9 2. 1 6. 6 1. 1 2. 0 3. 1 7. 7 7. 3 19 .8 42 2 11 .6 60 35 .8 48 2 To ta l 3. 2 4. 3 4. 0 6. 3 2. 4 2. 0 5. 2 8. 4 12 .5 14 .9 28 47 15 .6 38 7 36 .4 32 34 [1 ] M IC S in d ic at o r 3. 21 ( ) Fi g u re s th at a re b as ed o n 2 5- 49 u n -w ei g h te d c as es ; ( *) F ig u re s th at a re b as ed o n le ss t h an 2 5 u n - w ei g h te d c as es , n a = n o t ap p lic ab le 74 mics f inal report The educational level of the mother seems to have a great effect on the perception of disability in the child. As the educational level increased the perception of risk in all areas of disability decreased. In general, also, children from rural areas were perceived to be at higher risk for disabilities than urban children in all areas of disabilities considered. mics f inal report 75 vii. waTer and saniTaTion Safe drinking water is a basic necessity for good health. 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, especially in rural areas, who bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The list of indicators used in MICS is as follows: Water o Use of improved drinking water sources o Use of adequate water treatment method o Time to source of drinking water o Person collecting drinking water Sanitation o Use of improved sanitation facilities o Sanitary disposal of child’s faeces For more details on water and sanitation and to access some reference documents, please visit the UNICEF childinfo website http://www.childinfo.org/wes.html. Use of Improved Water Sources The distribution of the population by source of drinking water is shown in Table WS.1. 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, and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for other purposes, such as hand washing and cooking. 76 mics f inal report Table WS.1: Use of improved water sources Percent distribution of household population using improved drinking water sources, Belize, 2011 Main source of drinking water Improved sources Piped into dwelling Piped into compound, yard or plot Piped to neighbour Public tap / stand- pipe Tube well, bore- hole Protect- ed well Protected spring rainwater collection Bottled water* Number of household members region Corozal 7.0 10.8 0.8 0.0 0.0 3.2 0.0 26.1 47.7 2296 orange Walk 8.3 4.7 0.0 0.0 0.0 2.1 0.0 21.2 61.4 2584 belize (exclud- ing belize City south side) 11.7 1.9 0.0 0.0 0.0 0.6 0.0 17.9 67.5 2799 belize City south side 27.7 1.3 0.2 1.4 0.0 0.0 0.0 10.1 59.2 2177 belize District 18.7 1.6 0.1 0.6 0.0 0.4 0.0 14.5 63.9 4976 Cayo 23.1 10.7 2.1 0.0 0.0 1.3 0.3 11.3 46.8 3865 stann Creek 45.4 27.3 1.6 0.1 0.1 0.6 0.0 2.4 22.0 1833 Toledo 3.4 46.0 1.1 14.2 7.0 5.7 0.3 8.1 11.4 1733 area urban 21.5 3.4 0.6 0.7 0.0 0.1 0.0 7.6 65.6 7536 rural 15.1 19.5 1.0 2.3 1.3 3.0 0.2 19.6 34.1 9752 Education of house- hold head None 16.9 25.0 1.7 4.9 1.9 4.0 0.0 21.8 20.5 1507 Primary 19.6 17.1 0.8 2.0 1.0 2.2 0.2 16.1 37.4 8652 secondary + 16.2 4.2 0.8 0.6 0.1 0.7 0.0 8.7 68.2 6412 CeT/ITVeT/ VoTeC 14.8 3.3 0.0 0.0 0.0 0.0 0.0 5.5 76.4 172 Missing/DK 26.4 17.6 0.0 0.0 0.0 3.2 0.0 8.8 41.5 256 other 3.8 0.0 0.0 0.0 0.0 0.0 0.0 65.4 30.8 288 Wealth index quin- tiles Poorest 11.9 37.6 3.8 6.0 3.3 4.3 0.2 18.1 8.9 3458 second 27.8 19.5 0.6 1.2 0.2 2.3 0.4 16.8 29.4 3457 Middle 25.1 4.0 0.0 0.1 0.1 1.5 0.0 16.9 50.4 3459 Fourth 16.8 0.8 0.0 0.3 0.0 0.5 0.0 13.2 67.2 3456 richest 7.8 0.6 0.0 0.3 0.0 0.0 0.0 6.8 83.3 3457 ethnicity of house- hold head Creole 24.9 5.0 0.5 0.8 0.0 0.6 0.0 15.9 51.9 4048 Mestizo 14.3 12.6 1.0 0.4 0.0 2.6 0.1 13.6 52.3 8498 Garifuna 36.4 6.8 0.4 0.5 0.2 0.1 0.0 4.0 51.4 959 Maya 16.1 39.1 2.3 9.9 6.0 2.5 0.3 8.9 10.7 1933 other 10.1 3.8 0.0 0.8 0.2 0.7 0.0 29.4 54.0 1552 Missing/DK 19.0 3.3 0.0 0.0 0.0 0.0 0.0 7.7 63.6 298 Total 17.9 12.5 0.9 1.6 0.7 1.8 0.1 14.4 47.8 17288 mics f inal report 77 Table WS.1: Use of improved water sources [continued] Percent distribution of household population using unimproved drinking water sources, Belize, 2011 Unimproved sources Percent- age using improved sources of drinking water [1] Number of household members Unprotected well Unprotected spring Surface water (riv- er, stream, dam, lake, pond, canal, irrigation channel) Bottled water* Other Region Corozal 3.2 0.0 0.0 1.2 0.0 95.6 2296 Orange Walk 1.1 0.1 0.0 1.2 0.0 97.6 2584 Belize (Exclud- ing Belize City South Side) 0.1 0.0 0.0 0.2 0.0 99.7 2799 Belize City South Side 0.0 0.0 0.0 0.2 0.0 99.8 2177 Belize District 0.0 0.0 0.0 0.2 0.0 99.8 4976 Cayo 0.5 0.6 1.8 1.6 0.0 95.6 3865 Stann Creek 0.0 0.0 0.0 0.1 0.4 99.5 1833 Toledo 1.7 0.2 0.7 0.2 0.1 97.1 1733 Area Urban 0.0 0.0 0.0 0.5 0.0 99.5 7536 Rural 1.5 0.3 0.8 1.0 0.1 96.2 9752 Education of house- hold head None 2.0 0.0 1.3 0.0 0.0 96.7 1377 Primary 1.3 0.3 0.7 1.2 0.1 96.3 8782 Secondary + 0.1 0.1 0.0 0.3 0.0 99.5 6412 CET/ITVET/VO- TEC 0.0 0.0 0.0 0.0 0.0 100.0 172 Missing/DK 0.0 0.0 0.0 2.5 0.0 97.5 256 Other 0.0 0.0 0.0 0.0 0.0 100.0 288 Wealth index quintiles Poorest 3.4 0.4 1.4 0.6 0.2 94.0 3458 Second 0.7 0.0 0.3 0.7 0.1 98.3 3457 Middle 0.3 0.3 0.6 0.5 0.0 98.2 3459 Fourth 0.0 0.0 0.0 1.1 0.0 98.9 3456 Richest 0.0 0.1 0.0 1.0 0.0 98.9 3457 Ethnicity of house- hold head Creole 0.2 0.0 0.0 0.1 0.0 99.6 4048 Mestizo 1.1 0.2 0.8 1.1 0.0 96.8 8498 Garifuna 0.0 0.0 0.0 0.2 0.0 99.8 959 Maya 2.0 0.7 0.6 0.5 0.4 95.8 1933 Other 0.0 0.0 0.0 1.0 0.0 99.0 1552 Missing/DK 3.0 0.0 0.0 3.4 0.0 93.6 298 Total 0.9 0.2 0.5 0.8 0.1 97.7 17288 [1] MICS indicator 4.1; MDG indicator 7.8 * Households using bottled water as the main source of drinking water are classified into improved or unimproved drinking water users according to the water source used for other purposes such as cooking and hand-washing. 78 mics f inal report Overall, 97.7 percent of the population is using an improved source of drinking water – 99.5 percent in urban areas and 96.2 percent in rural areas. Use of improved sources of water is widespread across regions of the country with the lowest rates occurring in the Corozal and Cayo Districts (95.6 percent in both cases). There is a slight reduction in rates of use of improved sources of drinking water for less educated head of households (no education 96.4 percent) and families with wealth index of poorest (94.0 percent). Improved drinking water is obtained mainly from four sources: bottled water (47.8 percent), water piped into dwelling (17.9 percent), collected rainwater (14.4 percent) and water piped into yard or compound (12.5 percent) (Table WS.1). Urban and rural areas exhibit pronounced differences in the sources of improved drinking water: bottled water (urban 65.6 percent, rural 34.1 percent), piped into dwelling (urban 21.5 percent, rural 15.1 percent), collected rainwater ( urban 7.6 percent, rural 19.6 percent) and piped into yard or plot ( urban 3.4 percent, rural 19.5 percent ). Level of education of household head and the wealth index of the family seem to correlate to use of improved sources of drinking water in the same way. Presumably the more educated household heads live in households with higher wealth indices. Bottled water use rises with both increasing education and wealth index, rainwater collection decreases with the increase of wealth and education and water piped into compound is seen to decrease as wealth and education increase. The prevalence of the use of unimproved sources of drinking water is very small (Table WS.1). Unprotected wells are the main source and their use is most pronounced in rural areas, the Corozal (3.2 percent) and Toledo (1.7 percent) Districts, household where the heads have no education, households with the poorest wealth index and in households with Maya heads. Use of in-house water treatment is presented in Table WS.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 using solar disinfection were considered as proper treatment of drinking water. The table shows water treatment by all households and the percentage of household members living in households using unimproved water sources but using appropriate water treatment methods. About eight in ten (82.1 percent) of households did nothing to make the water safer to drink. About a third (31.2 percent) of household members using unimproved drinking water sources also use an appropriate water treatment measure. The most likely not to use any water treatment are households in the Corozal District (68.3 percent), urban areas (89.0 percent), households with heads having secondary or more education (87.1 percent), households with the richest wealth index (89.5 percent) and households with Garifuna heads (90.7 percent) (Table WS.2). In general the water treatment of choice was adding bleach or chlorine (9.9 percent) followed by boiling at 6.6 percent. mics f inal report 79 Table WS.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, Belize, 2011 Water treatment method used in the household Number of household membersNone boil add bleach / chlorine strain through a cloth use water filter solar disin- fection let it stand and set- tle other Don’t know region Corozal 68.3 4.3 27.4 0.8 0.6 0.0 0.0 0.0 0.0 2296 orange Walk 89.6 2.6 7.1 2.5 1.4 0.0 0.0 0.0 0.0 2584 belize (excluding belize City south side) 86.7 2.3 10.1 0.0 1.2 0.0 0.1 0.4 0.1 2799 belize City south side 89.9 5.2 3.0 0.1 1.1 0.0 0.1 1.0 0.0 2177 belize District 88.1 3.6 7.0 0.1 1.2 0.0 0.1 0.7 0.0 4976 Cayo 79.6 9.0 8.4 1.0 2.7 0.0 0.2 0.2 0.0 3865 stann Creek 84.5 7.4 6.6 0.6 1.3 0.0 0.0 0.0 0.0 1833 Toledo 75.0 17.9 6.1 0.9 0.6 0.0 0.2 0.2 0.0 1733 area urban 89.0 5.4 3.8 0.5 1.2 0.0 0.1 0.4 0.0 7536 rural 76.8 7.5 14.6 1.1 1.6 0.0 0.0 0.2 0.0 9752 Education of house- hold head None 74.2 11.8 12.9 2.2 1.1 0.0 0.0 0.0 0.0 1377 Primary 78.9 7.3 12.7 1.1 1.3 0.0 0.1 0.2 0.0 8782 secondary + 87.1 5.1 6.0 0.2 1.6 0.0 0.2 0.4 0.0 6412 CeT/ITVeT/VoTeC 99.6 0.0 0.0 0.0 0.4 0.0 0.0 0.0 0.0 172 Missing/DK 92.3 0.0 7.7 0.0 0.0 0.0 0.0 0.0 0.0 256 other 87.3 4.4 2.5 2.4 3.3 0.0 0.0 0.0 0.0 288 Wealth index quin- tiles Poorest 76.6 12.3 10.9 0.9 0.5 0.0 0.4 0.1 0.0 3458 second 77.3 8.0 13.6 1.5 1.2 0.0 0.0 0.4 0.0 3457 Middle 82.9 4.6 10.8 1.4 1.0 0.0 0.0 0.5 0.0 3459 Fourth 84.2 5.2 9.6 0.5 1.3 0.0 0.1 0.1 0.0 3456 richest 89.5 2.9 4.6 0.1 3.0 0.0 0.0 0.2 0.0 3457 ethnicity of household head Creole 86.0 3.3 8.4 0.3 1.6 0.0 0.1 0.8 0.0 4048 Mestizo 81.3 4.7 13.3 1.3 1.0 0.0 0.0 0.1 0.0 8498 Garifuna 90.7 4.1 3.7 0.2 1.4 0.0 0.1 0.0 0.0 959 Maya 70.4 23.7 5.5 0.6 0.9 0.0 0.6 0.0 0.0 1933 other 85.8 5.3 4.6 0.8 4.2 0.0 0.0 0.0 0.0 1552 Missing/DK 82.1 8.3 9.4 0.0 0.0 0.0 0.0 0.6 0.0 298 Total 82.1 6.6 9.9 0.9 1.4 0.0 0.1 0.2 0.0 17288 80 mics f inal report Table WS.2: Household water treatment [continued] 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, Belize, 2011 Percentage of household members in households using unimproved drinking water sources and using an appropriate water treatment method [1] Number of household members in households using unimproved drinking water sources Region Corozal 69.4 101 Orange Walk 27.9 63 Belize (Excluding Belize City South Side) (*) 7 Belize City South Side (*) 4 Belize District (*) 11 Cayo 7.4 171 Stann Creek (*) 9 Toledo (*) 50 Area Urban (0.0) 35 Rural 34.2 371 Education of household head None 32.5 46 Primary 28.9 321 Secondary + (58.6) 33 Missing/DK (*) 6 Wealth index quintiles Poorest 32.6 207 Second 43.8 60 Middle 37.3 61 Fourth (17.0) 39 Richest (9.0) 38 Ethnicity of household head Creole (*) 15 Mestizo 31.7 273 Garifuna (*) 2 Maya 27.2 82 Other (*) 15 Missing/DK (*) 19 Total 31.2 406 [1] MICS indicator 4.2 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases The amount of time it takes to obtain water is presented in Table WS.3 and the person who usually collected the water in Table WS.4. Note that these results refer to one roundtrip from home to drinking water source. Information on the number of trips made in one day was not collected. Table WS.3 shows that for 94.9 percent of households, the drinking water source is on the premises. In general few households bring water from a distance (1.9 percent for a round trip of less than 30 minutes and 0.7 percent a trip of 30 minutes or more). In households where water is collected from a distance, adult women fetch the water in 37.6 percent of the cases and adult men in 43.9 percent. In 9.1 percent of cases a male child fetches the water while in 6.7 percent it is a female child. mics f inal report 81 Table WS.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, Belize, 2011 Time to source of drinking water Total Number of household members Users of improved drinking water sources Users of unimproved drinking water sources Water on premises Less than 30 minutes 30 min- utes or more Missing/DK Water on premises Less than 30 minutes 30 min- utes or more Missing/DK Region Corozal 88.3 4.6 1.9 0.8 3.8 0.6 0.0 0.0 100.0 2296 Orange Walk 96.3 0.9 0.3 0.0 2.1 0.4 0.0 0.0 100.0 2584 Belize (Excluding Belize City South Side) 98.2 1.1 0.4 0.0 0.1 0.2 0.0 0.0 100.0 2799 Belize City South Side 96.2 3.4 0.1 0.0 0.2 0.0 0.0 0.0 100.0 2177 Belize District 97.3 2.1 0.3 0.0 0.1 0.1 0.0 0.0 100.0 4976 Cayo 94.7 0.4 0.4 0.1 2.0 1.8 0.6 0.0 100.0 3865 Stann Creek 99.0 0.3 0.2 0.0 0.0 0.4 0.1 0.0 100.0 1833 Toledo 90.2 4.5 2.1 0.4 1.9 0.7 0.1 0.1 100.0 1733 Area Urban 97.5 1.9 0.1 0.1 0.4 0.0 0.0 0.0 100.0 7536 Rural 92.9 2.0 1.1 0.3 2.4 1.2 0.3 0.0 100.0 9752 Education of house- hold head None 90.9 1.7 3.5 0.5 1.7 0.8 0.9 0.0 100.0 1377 Primary 93.0 2.7 0.5 0.2 2.3 1.2 0.2 0.0 100.0 8782 Secondary + 97.8 1.1 0.4 0.1 0.5 0.0 0.0 0.0 100.0 6412 CET/ITVET/VOTEC 99.5 0.5 0.0 0.0 0.0 0.0 0.0 0.0 100.0 172 Missing/DK 96.4 1.2 0.0 0.0 1.8 0.0 0.6 0.0 100.0 256 Other 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 288 Wealth index quin- tiles Poorest 86.9 4.4 2.1 0.6 3.4 2.5 0.1 0.0 100.0 3458 Second 94.5 2.8 0.7 0.2 0.9 0.5 0.4 0.0 100.0 3457 Middle 96.8 1.2 0.2 0.0 1.0 0.4 0.3 0.0 100.0 3459 Fourth 97.9 0.7 0.2 0.1 1.1 0.0 0.0 0.1 100.0 3456 Richest 98.2 0.4 0.2 0.0 1.1 0.0 0.0 0.0 100.0 3457 Ethnicity of household head Creole 97.2 2.1 0.3 0.1 0.2 0.1 0.0 0.0 100.0 4048 Mestizo 94.5 1.5 0.6 0.2 1.9 1.0 0.3 0.0 100.0 8498 Garifuna 99.2 0.6 0.0 0.0 0.0 0.0 0.0 0.2 100.0 959 Maya 89.6 4.3 1.7 0.2 2.6 1.5 0.1 0.0 100.0 1933 Other 95.3 1.4 1.7 0.6 0.9 0.0 0.0 0.0 100.0 1552 Missing/DK 91.5 2.1 0.0 0.0 6.4 0.0 0.0 0.0 100.0 298 Total 94.9 1.9 0.7 0.2 1.5 0.7 0.2 0.0 100.0 17288 82 mics f inal report Table WS.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, Belize, 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 (age 15+ years) adult man (age 15+ years) Female child (under 15) Male child (under 15) DK Missing region Corozal 8.0 519 (40.7) (47.3) (2.0) (9.9) (0.0) (0.0) 42 orange Walk 2.1 607 (*) (*) (*) (*) (*) (*) 13 belize (excluding belize City south side) 1.9 860 (*) (*) (*) (*) (*) (*) 16 belize City south side 3.3 614 (*) (*) (*) (*) (*) (*) 21 belize District 2.5 1474 (18.8) (59.5) (11.9) (9.7) (0.0) (0.0) 37 Cayo 2.5 918 (*) (*) (*) (*) (*) (*) (*) stann Creek 1.3 488 (*) (*) (*) (*) (*) (*) (*) Toledo 7.2 417 (*) (*) (*) (*) (*) (*) 30 area urban 1.9 2170 (20.3) (53.6) (9.0) (10.6) (6.6) (0.0) 42 rural 4.8 2254 (44.2) (40.2) (5.8) (8.5) (0.8) (0.5) 109 Education of household head None 7.0 311 (*) (*) (*) (*) (*) (*) 22 Primary 4.5 2104 35.2 42.6 9.0 9.3 3.9 0.0 94 secondary + 1.7 1851 (31.7) (57.7) (5.0) (5.6) (0.0) (0.0) 32 CeT/ITVeT/VoTeC (1.9) 47 (*) (*) (*) (*) (*) (*) 1 Missing/DK 4.0 58 (*) (*) (*) (*) (*) (*) 2 other (0.0) 52 (*) (*) (*) (*) (*) (*) . Wealth index quintiles Poorest 9.3 885 42.1 40.0 7.1 5.8 4.4 0.7 82 second 4.3 865 (30.5) (45.6) (8.6) (15.3) (0.0) (0.0) 37 Middle 1.9 863 (*) (*) (*) (*) (*) (*) 16 Fourth 1.1 889 (*) (*) (*) (*) (*) (*) 9 richest 0.6 922 (*) (*) (*) (*) (*) (*) 6 ethnicity of household head Creole 2.5 1182 (*) (*) (*) (*) (*) (*) 30 Mestizo 3.4 2058 34.7 46.0 2.4 12.3 3.8 0.8 70 Garifuna 1.2 286 (*) (*) (*) (*) (*) (*) 3 Maya 7.7 399 (*) (*) (*) (*) (*) (*) 31 other 3.3 409 (*) (*) (*) (*) (*) (*) 14 Missing/DK 3.3 91 (*) (*) (*) (*) (*) (*) 3 Total 3.4 4424 37.6 43.9 6.7 9.1 2.4 0.4 151 ( ) Figures that are based on 25-49 un-weighted cases; (*) Figures that are based on less than 25 un-weighted cases mics f inal report 83 Use of Improved Sanitation Facilities Inadequate disposal of human excreta and personal hygiene is 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 flush or pour flush to a piped sewer system, septic tank, or latrine; ventilated improved pit latrine, pit latrine with slab, and composting toilet. Table WS.5 indicates that use of improved sanitation facilities is linked to wealth and is quite different between urban and rural areas. In rural areas, the population is mostly using septic tanks (43.2 percent) and pit latrines with slabs (43.1 percent). In contrast, the most common facilities in urban areas are flush toilets with connection to a sewage system (22.7 percent) or septic tank (65.2 percent). Rich households mostly flush to septic tank (78.4 percent) while poorest households use a pit latrine with slab (62.8 percent) Table WS.5: Types of sanitation facilities Percent distribution of household population according to type of toilet facility used by the household, Belize, 2011 Improved sanitation facility Total Number of household members Flush to piped sewer system Flush to septic tank Flush to pit (latrine) Ventilated Improved Pit latrine (VIP) Pit latrine with slab Region Corozal 0.0 48.1 0.0 12.4 37.9 100.0 2296 Orange Walk 0.0 47.8 0.3 9.9 41.1 100.0 2584 Belize (Excluding Belize City South Side) 16.4 75.7 0.5 0.1 6.7 100.0 2799 Belize City South Side 47.4 47.1 0.0 0.0 0.6 100.0 2177 Belize District 30.0 63.2 0.3 0.1 4.0 100.0 4976 Cayo 6.7 53.8 0.3 1.9 36.3 100.0 3865 Stann Creek 0.0 64.6 0.7 0.4 28.1 100.0 1833 Toledo 0.2 21.7 1.0 17.6 49.5 100.0 1733 Area Urban 22.7 65.2 0.3 0.8 9.4 100.0 7536 Rural 0.4 43.2 0.4 8.9 43.1 100.0 9752 Education of household head None 1.4 27.9 0.1 7.4 53.3 100.0 1377 Primary 6.4 46.3 0.4 8.0 35.8 100.0 8782 Secondary + 17.4 67.9 0.3 1.5 11.3 100.0 6412 CET/ITVET/VOTEC 21.9 63.3 0.0 0.0 12.5 100.0 172 Missing/DK 6.8 56.1 0.0 2.5 34.6 100.0 256 Other 0.6 24.2 0.0 7.9 67.2 100.0 288 Wealth index quintiles Poorest 2.4 11.7 0.8 11.7 62.8 100.0 3458 Second 7.5 36.8 0.4 6.2 45.6 100.0 3457 Middle 9.8 61.9 0.1 5.9 22.2 100.0 3459 Fourth 12.3 75.0 0.0 2.6 9.8 100.0 3456 Richest 18.7 78.4 0.5 0.5 1.6 100.0 3457 Ethnicity of household head Creole 21.7 63.6 0.1 0.7 11.5 100.0 4048 Mestizo 5.7 50.5 0.4 7.0 34.6 100.0 8498 Garifuna 11.3 76.3 0.5 0.5 9.0 100.0 959 Maya 1.2 20.5 0.8 12.9 52.7 100.0 1933 Other 11.9 61.1 0.6 2.7 23.8 100.0 1552 Missing/DK 25.5 60.3 0.0 3.4 10.8 100.0 298 Total 10.1 52.8 0.4 5.4 28.4 100.0 17288 84 mics f inal report Table WS.5: Types of sanitation facilities [continued] Percent distribution of household population according to type of toilet facility used by the household, Belize, 2011 Number of household members Unimproved sanitation facility Flush to some- where else Pit latrine without slab / Open pit Bucket Other Missing No facili- ty, Bush, Field Region Corozal 0.0 0.7 0.0 0.0 0.0 0.9 2296 Orange Walk 0.0 0.7 0.0 0.0 0.0 0.3 2584 Belize (Excluding Belize City South Side) 0.1 0.0 0.2 0.0 0.0 0.4 2799 Belize City South Side 0.0 0.0 3.1 0.2 0.0 1.6 2177 Belize District 0.0 0.0 1.4 0.1 0.0 0.9 4976 Cayo 0.0 0.6 0.0 0.0 0.0 0.4 3865 Stann Creek 0.0 4.6 0.2 0.1 0.0 1.4 1833 Toledo 0.0 0.1 0.1 0.0 0.1 9.7 1733 Area Urban 0.0 0.0 0.9 0.1 0.0 0.7 7536 Rural 0.0 1.4 0.1 0.0 0.0 2.4 9752 Education of house- hold head None 0.0 0.9 0.1 0.0 0.0 8.9 1377 Primary 0.0 1.2 0.5 0.0 0.0 1.4 8782 Secondary + 0.0 0.4 0.4 0.1 0.0 0.6 6412 CET/ITVET/VOTEC 0.0 0.0 1.8 0.0 0.0 0.5 172 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 256 Other 0.0 0.0 0.0 0.0 0.0 0.0 288 Wealth index quin- tiles Poorest 0.0 2.7 0.9 0.0 0.1 6.9 3458 Second 0.0 0.9 1.3 0.0 0.0 1.2 3457 Middle 0.0 0.0 0.0 0.0 0.0 0.1 3459 Fourth 0.0 0.2 0.0 0.1 0.0 0.0 3456 Richest 0.0 0.2 0.0 0.0 0.0 0.0 3457 Ethnicity of household head Creole 0.0 0.2 1.5 0.1 0.0 0.6 4048 Mestizo 0.0 1.1 0.0 0.0 0.0 0.7 8498 Garifuna 0.0 0.5 1.1 0.1 0.0 0.8 959 Maya 0.0 2.0 0.3 0.0 0.0 9.7 1933 Other 0.0 0.0 0.0 0.0 0.0 0.0 1552 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 298 Total 0.0 0.8 0.4 0.0 0.0 1.6 17288 Access to safe drinking-water and to basic sanitation is measured by the proportion of population using an improved sanitation facility. MDGs and 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. As shown in Table WS.6, 96.9 percent of the household population is using an improved sanitation facility of which 89.2 percent is not shared. Only 7.7 percent of households use an improved toilet facility that is shared with other households. Rural households are more likely than urban households to use a shared improved toilet facility (9.1 percent and 6.0 percent, respectively). Improved sanitation facilities are shared less by more educated households and by households with the richest wealth index. Households in the Corozal District share improved sanitary facilities more than households in other districts (12.2 percent). mics f inal report 85 Table WS.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, Belize, 2011 Users of improved sanitation facilities Users of unimproved sanitation facilities Open defe- cation (no facility, bush field) Number of house- hold members Not shared [1] Public facility Shared by: 5 house- holds or less Shared by: More than 5 house- holds Missing/ DK Not shared Shared by: 5 house- holds or less Shared by: More than 5 house- holds Miss- ing/DK Region Corozal 85.5 0.4 12.2 0.0 0.2 0.4 0.2 0.0 0.0 0.9 2296 Orange Walk 93.5 0.5 3.1 2.0 0.0 0.7 0.0 0.0 0.0 0.3 2584 Belize (Excluding Belize City South Side) 93.3 0.3 5.3 0.5 0.0 0.2 0.0 0.0 0.0 0.4 2799 Belize City South Side 88.3 0.5 4.7 1.3 0.3 2.8 0.5 0.0 0.0 1.6 2177 Belize District 91.1 0.4 5.0 0.8 0.1 1.3 0.2 0.0 0.0 0.9 4976 Cayo 90.3 0.5 6.1 2.2 0.0 0.6 0.0 0.0 0.0 0.4 3865 Stann Creek 86.1 0.0 5.1 2.5 0.0 3.6 0.3 0.8 0.1 1.4 1833 Toledo 82.9 0.8 4.1 1.9 0.2 0.2 0.0 0.1 0.0 9.7 1733 Area Urban 92.2 0.3 4.6 1.1 0.1 0.8 0.2 0.0 0.0 0.7 7536 Rural 86.9 0.5 6.8 1.8 0.1 1.3 0.1 0.2 0.0 2.4 9752 Education of house- hold head None 79.5 0.7 5.5 1.6 0.1 0.7 0.1 0.2 0.0 11.7 1577 Primary 86.7 0.3 7.3 1.8 0.1 1.5 0.2 0.2 0.0 1.9 9242 Secondary + 93.1 0.6 3.7 1.1 0.1 0.7 0.2 0.0 0.0 0.6 6412 CET/ITVET/VOTEC 93.1 0.0 4.6 0.0 0.0 1.8 0.0 0.0 0.0 0.5 172 Missing/DK 84.2 0.0 9.6 6.2 0.0 0.0 0.0 0.0 0.0 0.0 256 Other 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 288 Wealth index quintiles Poorest 74.2 0.4 11.5 3.1 0.1 3.0 0.5 0.2 0.1 6.9 3458 Second 82.6 0.6 10.8 2.4 0.2 1.8 0.2 0.3 0.0 1.2 3457 Middle 92.3 0.9 4.9 1.6 0.1 0.0 0.0 0.0 0.0 0.1 3459 Fourth 98.4 0.0 1.3 0.0 0.0 0.3 0.0 0.0 0.0 0.0 3456 Richest 98.4 0.3 0.7 0.4 0.0 0.2 0.0 0.0 0.0 0.0 3457 Ethnicity of house- hold head Creole 91.2 0.3 4.9 1.0 0.2 1.6 0.2 0.0 0.0 0.6 4048 Mestizo 88.9 0.4 6.8 1.9 0.1 0.9 0.1 0.1 0.0 0.7 8498 Garifuna 91.0 0.1 5.2 1.4 0.0 0.7 0.5 0.2 0.2 0.8 959 Maya 79.1 0.5 6.3 1.8 0.2 1.9 0.0 0.4 0.0 9.7 1933 Other 96.4 0.9 2.4 0.3 0.0 0.0 0.0 0.0 0.0 0.0 1552 Missing/DK 92.6 0.5 6.9 0.0 0.0 0.0 0.0 0.0 0.0 0.0 298 Total 89.2 0.4 5.8 1.5 0.1 1.1 0.1 0.1 0.0 1.6 17288 [1] MICS indicator 4.3; MDG indicator 7.9 Safe disposal of a child’s faeces is disposing of the stool, by the child using a toilet or by rinsing the stool into a toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table WS.7. About a quarter of children’s faeces (25.6 percent) were disposed of safely in Belize. The Toledo District (15.2 percent) and the Belize City South Side (17.7 percent) were the regions with the lowest safety disposal rates. Households in rural areas tended to dispose of children’s faeces safely more often than households in urban areas (urban 17.5 percent, rural 30.7 percent). Also of interest is that households with less educated heads and richer families seem to safely dispose of children’s faeses at higher rates . 86 mics f inal report Table WS.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, Belize, 2011 Place of disposal of child’s faeces Total Percentage of children whose last stools were disposed of safely [1] 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 Type of sanitaton facility in dwelling Improved 13.1 12.7 0.7 68.2 1.6 1.1 2.0 0.5 100.0 25.8 1110 unimproved (*) (*) (*) (*) (*) (*) (*) (*) 100.0 (*) 15 open defacation (*) (*) (*) (*) (*) (*) (*) (*) 100.0 (*) 27 region Corozal 14.2 23.0 2.5 57.1 0.0 2.2 1.1 0.0 100.0 37.2 162 orange Walk 15.3 26.8 0.8 50.7 0.5 0.9 3.1 1.9 100.0 42.1 184 belize (excluding belize City south side) 17.5 1.3 0.0 81.1 0.0 0.0 0.0 0.0 100.0 18.9 123 belize City south side 13.8 3.8 0.0 81.0 0.0 0.0 1.3 0.0 100.0 17.7 143 belize District 15.6 2.7 0.0 81.0 0.0 0.0 0.7 0.0 100.0 18.2 266 Cayo 13.8 6.5 0.6 75.8 1.7 0.0 1.7 0.0 100.0 20.3 283 stann Creek 8.0 17.4 0.0 56.9 7.7 2.9 5.6 1.4 100.0 25.4 121 Toledo 5.8 9.3 0.9 71.9 2.2 4.9 4.0 1.0 100.0 15.2 136 area urban 13.5 4.1 0.0 82.1 0.0 0.0 0.4 0.0 100.0 17.5 443 rural 12.7 18.0 1.2 59.1 2.5 2.2 3.5 0.9 100.0 30.7 709 Mother’s education None 17.2 16.5 3.5 51.0 2.2 3.9 4.6 1.2 100.0 33.7 62 Primary 10.6 15.7 0.7 65.8 1.8 1.8 3.0 0.5 100.0 26.4 543 secondary + 15.1 6.2 0.2 75.2 1.3 0.3 1.4 0.3 100.0 21.3 512 CeT/ITVeT/VoTeC (*) (*) (*) (*) (*) (*) (*) (*) 100.0 (*) 8 other (*) (*) (*) (*) (*) (*) (*) (*) 100.0 (*) 27 Wealth index quin- tiles Poorest 10.9 20.5 2.5 50.6 2.7 5.0 6.5 1.3 100.0 31.3 292 second 12.4 16.6 0.0 66.9 1.9 0.3 1.8 0.0 100.0 29.1 261 Middle 12.6 9.7 0.0 76.6 0.3 0.0 0.4 0.4 100.0 22.3 241 Fourth 13.2 5.4 0.4 77.4 2.2 0.0 0.4 0.9 100.0 18.6 190 richest 17.7 5.3 0.0 76.5 0.0 0.0 0.5 0.0 100.0 23.0 168 ethnicity of household head Creole 15.9 4.4 0.0 77.1 1.3 0.0 0.5 0.8 100.0 20.4 207 Mestizo 12.9 15.3 1.0 65.2 1.4 0.9 2.9 0.4 100.0 28.2 579 Garifuna 9.5 14.5 0.0 74.8 0.0 1.3 0.0 0.0 100.0 24.0 65 Maya 10.7 8.2 0.7 67.7 4.3 3.5 4.5 0.4 100.0 18.9 167 other 11.2 21.3 1.3 61.1 0.0 3.0 0.8 1.4 100.0 32.5 118 Missing/DK (*) (*) (*) (*) (*) (*) (*) (*) 100.0 (*) 17 Total 13.0 12.6 0.7 67.9 1.6 1.3 2.3 0.6 100.0 25.6 1152 [1] MICS indicator 4.4 (*) Figures that are based on less than 25 un-weighted cases In its 2008 report1, the JMP developed a new way of presenting the access figures, by disaggregating and refining the data on drinking-water and sanitation and reflecting them in “ladder” format. This ladder allows a disaggregated analysis of trends in a three rung ladder for drinking-water and a four-rung ladder for sanitation. For sanitation, this gives an understanding of the proportion of population with no sanitation facilities at all, of those reliant on technologies defined by JMP as “unimproved,” of those sharing sanitation facilities of otherwise acceptable technology, and those using “improved” sanitation facilities. Table WS.8 presents the percentages of household population by drinking water and sanitation ladders. 1 WHO/UNICEF JMP (2008), MDG assessment report - http://www.wssinfo.org/download?id_document=1279 mics f inal report 87 The table also shows the percentage of household members using improved sources of drinking water and sanitary means of excreta disposal. Almost all households (97.7 percent) have improved drinking water and 89.2 percent have improved sanitation (Table WS.8). Improved sanitation rates differ by area with 92.2 percent in urban areas and 86.9 percent in rural areas. Residents of the Toledo (82.9 percent) and Stann Creek (86.1 percent) Districts are less likely than others to use improved sanitation facilities. Use of improved sanitary facilities increase with increasing education (no education 81.9 percent, secondary + education 93.1 percent). Also, use of improved sanitation increases with increasing wealth (poorest 74.2 percent, richest 98.4 percent). The Maya are the least likely to use improved sanitation (79.1 percent). 88 mics f inal report Table WS.8: Drinking water and sanitation ladders Percentage of household population by drinking water and sanitation ladders, Belize, 2011 Percentage of household population using: Number of house- hold members Improved drinking water [1] Unim- proved drinking water Total Improved sanitation [2] Unimproved sanitation Total Improved drinking water sources and im- proved sanitation Piped into dwelling, plot or yard Other im- proved Shared improved facilities Unim- proved facilities Open defeca- tion Region Corozal 59.2 36.4 4.4 100.0 85.5 12.9 0.7 0.9 100.0 82.4 2296 Orange Walk 72.3 25.3 2.4 100.0 93.5 5.5 0.7 0.3 100.0 92.1 2584 Belize (Excluding Belize City South Side) 77.6 22.2 0.3 100.0 93.3 6.1 0.2 0.4 100.0 93.2 2799 Belize City South Side 88.2 11.6 0.2 100.0 88.3 6.8 3.3 1.6 100.0 88.3 2177 Belize District 82.2 17.5 0.2 100.0 91.1 6.4 1.6 0.9 100.0 91.1 4976 Cayo 76.0 19.6 4.4 100.0 90.3 8.8 0.6 0.4 100.0 85.9 3865 Stann Creek 94.6 4.9 0.5 100.0 86.1 7.6 4.9 1.4 100.0 86.0 1833 Toledo 58.4 38.7 2.9 100.0 82.9 7.1 0.3 9.7 100.0 80.9 1733 Area Urban 89.3 10.3 0.5 100.0 92.2 6.1 1.0 0.7 100.0 91.9 7536 Rural 64.3 31.9 3.8 100.0 86.9 9.2 1.6 2.4 100.0 83.9 9752 Education of house- hold head None 58.2 38.2 3.6 100.0 79.5 7.9 1.0 11.7 100.0 77.0 1577 Primary 71.5 25.2 3.3 100.0 86.7 9.6 1.9 1.9 100.0 84.2 9242 Secondary + 85.2 14.2 0.5 100.0 93.1 5.4 0.9 0.6 100.0 92.7 6412 CET/ITVET/VO- TEC 94.5 5.5 0.0 100.0 93.1 4.6 1.8 0.5 100.0 93.1 172 Missing/DK 82.3 15.3 2.5 100.0 84.2 15.8 0.0 0.0 100.0 81.7 256 Other 27.0 73.0 0.0 100.0 100.0 0.0 0.0 0.0 100.0 100.0 288 Wealth index quintiles Poorest 56.6 37.4 6.0 100.0 74.2 15.1 3.8 6.9 100.0 70.2 3458 Second 74.1 24.1 1.7 100.0 82.6 13.9 2.3 1.2 100.0 81.2 3457 Middle 76.3 21.9 1.8 100.0 92.3 7.6 0.0 0.1 100.0 90.7 3459 Fourth 80.8 18.0 1.1 100.0 98.4 1.3 0.3 0.0 100.0 97.3 3456 Richest 88.1 10.8 1.1 100.0 98.4 1.4 0.2 0.0 100.0 97.4 3457 Ethnicity of house- hold head Creole 80.4 19.3 0.4 100.0 91.2 6.4 1.8 0.6 100.0 90.9 4048 Mestizo 75.0 21.8 3.2 100.0 88.9 9.3 1.1 0.7 100.0 86.3 8498 Garifuna 94.0 5.8 0.2 100.0 91.0 6.6 1.7 0.8 100.0 90.8 959 Maya 65.3 30.4 4.2 100.0 79.1 8.9 2.3 9.7 100.0 76.0 1933 Other 61.7 37.3 1.0 100.0 96.4 3.6 0.0 0.0 100.0 95.5 1552 Missing/DK 85.6 7.9 6.4 100.0 92.6 7.4 0.0 0.0 100.0 89.2 298 Total 75.2 22.5 2.3 100.0 89.2 7.9 1.3 1.6 100.0 87.4 17288 [1] MICS indicator 4.1; MDG indicator 7.8 [2] MICS indicator 4.3; MDG indicator 7.9 Handwashing Handwashing with water and soap is the most cost effective health intervention to reduce both the incidence of diarrhoea and pneumonia in children under five. It is most effective when done using water and soap after visiting a toilet or cleaning a child, before eating or handling food and, before feeding a child. Monitoring correct hand washing behaviour at these critical times is challenging. A reliable alternative to observations or self-reported behaviour is assessing the likelihood that correct hand washing behaviour takes place by observing if a household has a specific place where people most often wash their hands and observing if water and soap (or other local cleansing materials) are present at a specific place for hand washing. mics f inal report 89 Ta b le W S .9 : W at er a n d s o ap a t p la ce f o r h an d -w as h in g Pe rc en ta g e o f h o u se h o ld s w h er e p la ce f o r h an d -w as h in g w as o b se rv ed a n d p er ce n t d is tr ib u ti o n o f h o u se h o ld s b y av ai la b ili ty o f w at er a n d s o ap a t p la ce f o r h an d -w as h in g , B el iz e, 20 11 Pe rc en ta g e o f h o u se - h o ld s w h er e p la ce f o r h an d -w as h in g w as o b se rv ed Pe rc en ta g e o f h o u se h o ld s w h er e p la ce fo r h an d -w as h in g w as n o t o b se rv ed To ta l N u m b er o f h o u se - h o ld s Pe rc en t d is tr ib u ti o n o f h o u se h o ld s w h er e p la ce f o r h an d -w as h in g w as o b se rv ed , a n d : To ta l N u m b er o f h o u se - h o ld s w h er e p la ce f o r h an d -w as h - in g w as o b - se rv ed N o t in d w el l- in g /p lo t/ ya rd N o p er m is - si o n t o s ee O th er re as o n s W at er a n d so ap a re av ai la b le [1 ] W at er is av ai la b le , so ap is n o t av ai l- ab le W at er is n o t av ai l- ab le , s o ap is a va il- ab le W at er an d s o ap ar e n o t av ai la b le R eg io n C o ro za l 69 .5 9. 3 19 .6 1. 6 10 0. 0 51 9 93 .0 3. 6 3. 2 0. 2 10 0. 0 36 1 O ra n g e W al k 84 .5 9. 4 4. 4 1. 8 10 0. 0 60 7 98 .5 0. 7 0. 8 0. 0 10 0. 0 51 3 B el iz e (E xc lu d in g B el iz e C it y S o u th S id e) 78 .6 2. 1 13 .9 5. 4 10 0. 0 86 0 99 .4 0. 4 0. 2 0. 0 10 0. 0 67 6 B el iz e C it y S o u th S id e 49 .7 5. 1 18 .8 26 .5 10 0. 0 61 4 93 .7 1. 3 5. 0 0. 0 10 0. 0 30 5 B el iz e D is tr ic t 66 .5 3. 3 15 .9 14 .2 10 0. 0 14 74 97 .6 0. 7 1. 7 0. 0 10 0. 0 98 1 C ay o 83 .2 8. 8 3. 0 5. 0 10 0. 0 91 8 98 .1 0. 2 1. 3 0. 4 10 0. 0 76 4 S ta n n C re ek 75 .5 10 .1 9. 2 5. 2 10 0. 0 48 8 95 .3 3. 6 0. 4 0. 7 10 0. 0 36 8 To le d o 88 .9 8. 9 0. 3 1. 9 10 0. 0 41 7 73 .2 24 .7 1. 9 A re a U rb an 72 .4 4. 6 12 .2 10 .9 10 0. 0 21 70 97 .5 1. 0 1. 5 0. 0 10 0. 0 15 70 R u ra l 79 .3 9. 9 7. 6 3. 1 10 0. 0 22 54 91 .7 6. 4 1. 5 0. 4 10 0. 0 17 88 E d u ca ti o n o f h o u se - h o ld h ea d N o n e 81 .5 9. 8 7. 1 1. 6 10 0. 0 31 1 87 .6 10 .5 0. 6 1. 3 10 0. 0 25 4 Pr im ar y 75 .6 9. 0 9. 6 5. 9 10 0. 0 21 04 92 .9 5. 1 1. 9 0. 1 10 0. 0 15 90 S ec o n d ar y + 74 .6 5. 2 10 .9 9. 3 10 0. 0 18 51 97 .0 1. 5 1. 4 0. 1 10 0. 0 13 81 C E T /IT V E T /V O T E C (8 7. 0) (0 .0 ) (8 .9 ) (4 .1 ) 10 0. 0 47 (1 00 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) 10 0. 0 41 M is si n g /D K 75 .9 8. 1 9. 4 6. 6 10 0. 0 58 (1 00 .0 ) (0 .0 ) (0 .0 ) (0 .0 ) 10 0. 0 44 O th er 93 .7 4. 5 1. 8 0. 0 10 0. 0 52 98 .5 1. 5 0. 0 0. 0 10 0. 0 49 W ea lt h in d ex q u in - ti le s Po o re st 74 .5 11 .8 7. 8 5. 9 10 0. 0 88 5 84 .0 12 .1 2. 9 1. 0 10 0. 0 65 9 S ec o n d 71 .8 9. 4 11 .6 7. 3 10 0. 0 86 5 93 .5 3. 9 2. 5 0. 1 10 0. 0 62 1 M id d le 75 .6 6. 6 11 .1 6. 7 10 0. 0 86 3 96 .6 2. 3 1. 1 0. 0 10 0. 0 65 2 Fo u rt h 80 .0 4. 2 8. 9 6. 9 10 0. 0 88 9 97 .8 0. 9 1. 3 0. 0 10 0. 0 71 1 R ic h es t 77 .6 4. 6 10 .0 7. 9 10 0. 0 92 2 99 .4 0. 6 0. 0 0. 0 10 0. 0 71 5 E th n ic it y o f h o u se h o ld h ea d C re o le 69 .6 4. 9 13 .1 12 .4 10 0. 0 11 82 95 .6 2. 1 2. 2 0. 0 10 0. 0 82 2 M es ti zo 78 .3 9. 1 8. 3 4. 3 10 0. 0 20 58 95 .5 2. 7 1. 5 0. 3 10 0. 0 16 11 G ar if u n a 74 .8 5. 3 9. 2 10 .8 10 0. 0 28 6 96 .2 2. 4 1. 4 0. 0 10 0. 0 21 4 M ay a 86 .1 7. 1 3. 1 3. 7 10 0. 0 39 9 82 .7 16 .1 0. 6 0. 7 10 0. 0 34 4 O th er 76 .2 6. 3 12 .7 4. 8 10 0. 0 40 9 96 .5 2. 3 1. 2 0. 0 10 0. 0 31 2 M is si n g /D K 62 .8 8. 2 21 .0 8. 1 10 0. 0 91 98 .5 1. 5 0. 0 0. 0 10 0. 0 57 To ta l 75 .9 7. 3 9. 9 6. 9 10 0. 0 44 24 94 .4 3. 9 1. 5 0. 2 10 0. 0 33 59 [1 ] M IC S in d ic at o r 4. 5; ( ) F ig u re s th at a re b as ed o n 2 5- 49 u n -w ei g h te d c as es . 90 mics f inal report In Belize, a specific place for hand washing was observed in 75.9 percent of the households while 7.3 percent households could not indicate a specific place where household members usually wash their hands and 9.9 percent of the households did not give a permission to see the place used for hand washing (Table WS.9). Of those households where place for hand-washing was observed, 94.4 percent had both water and soap present at the designated place. In 3.9 percent of the households only water was available at the designated place, while in 1.5 percent of the households the place only had soap but no water. The remaining 0.2 percent of households had neither water nor soap available at the designated place for hand washing (Table WS.9). Soaps were available at rates in excess of 93 percent in all regions except the Cayo District (73.2 percent). There is tendency for water and soap to be present at higher rates in households with more educated heads. Households with richer wealth indices tend to have higher rates of available water and soap. Households with Maya heads were the least likely to have water and soap available (Table WS.10). Table WS.10: Availability of soap Percent distribution of households by availability of soap in the dwelling, Belize, 2011 Place for hand washing observed Place for hand washing not observed Total Percent- age of house- holds with soap any- where in the dwell- ing [1] Number of households Soap ob- served Soap shown No soap in house- hold Not able/ Does not want to show soap Soap shown No soap in house- hold Not able/ Does not want to show soap Region Corozal 66.9 1.4 1.1 0.2 28.0 0.5 2.0 100.0 96.3 519 Orange Walk 84.0 0.1 0.4 0.0 14.7 0.3 0.5 100.0 98.7 607 Belize (Exclud- ing Belize City South Side) 78.3 0.3 0.0 0.0 4.5 0.3 16.5 100.0 83.1 860 Belize City South Side 49.0 0.5 0.0 0.2 38.3 1.6 10.4 100.0 87.8 614 Belize District 66.1 0.4 0.0 0.1 18.6 0.9 14.0 100.0 85.1 1474 Cayo 82.7 0.2 0.4 0.0 15.8 0.3 0.7 100.0 98.6 918 Stann Creek 72.3 3.0 0.2 0.0 19.7 0.2 4.6 100.0 95.0 488 Toledo 66.8 19.3 2.8 0.0 9.8 1.0 0.3 100.0 95.9 417 Area Urban 71.7 0.6 0.1 0.0 20.1 0.6 6.9 100.0 92.4 2170 Rural 74.0 4.3 1.0 0.0 15.7 0.6 4.4 100.0 94.0 2254 Education of house- hold head None 71.9 6.1 3.5 0.0 14.6 2.8 1.1 100.0 92.6 311 Primary 71.6 3.3 0.6 0.1 19.6 0.6 4.3 100.0 94.5 2104 Secondary + 73.4 1.2 0.1 0.0 17.0 0.2 8.2 100.0 91.6 1851 CET/ITVET/ VOTEC (87.0) (0.0) (0.0) (0.0) (10.1) (0.0) (2.9) 100.0 (97.1) 47 Missing/DK (75.9) (0.0) (0.0) (0.0) (17.0) (0.0) (7.1) 100.0 (92.9) 58 Other (92.4) (1.4) (0.0) (0.0) (6.3) (0.0) (0.0) 100.0 (100.0) 52 Wealth index quintiles Poorest 64.7 7.4 2.3 0.1 18.3 1.8 5.4 100.0 90.5 885 Second 68.9 2.4 0.5 0.0 21.2 0.8 6.2 100.0 92.5 865 Middle 73.8 1.8 0.0 0.0 19.8 0.3 4.3 100.0 95.4 863 Fourth 79.3 0.6 0.0 0.1 14.8 0.0 5.2 100.0 94.7 889 Richest 77.1 0.4 0.0 0.0 15.4 0.0 7.0 100.0 93.0 922 Ethnicity of house- hold head Creole 68.1 1.3 0.1 0.1 18.8 0.7 10.9 100.0 88.2 1182 Mestizo 75.9 1.9 0.4 0.0 18.4 0.5 2.9 100.0 96.2 2058 Garifuna 72.9 1.8 0.0 0.0 18.0 0.7 6.5 100.0 92.8 286 Maya 71.7 10.9 3.5 0.0 12.0 1.0 0.8 100.0 94.6 399 Other 74.5 1.7 0.0 0.0 16.4 0.3 7.1 100.0 92.6 409 Missing/DK 61.9 0.9 0.0 0.0 25.4 0.0 11.8 100.0 88.2 91 Total 72.8 2.5 0.6 0.0 17.9 0.6 5.6 100.0 93.2 4424 [1] MICS indicator 4.6; ( ) Figures that are based on 25-49 un-weighted cases. mics f inal report 91 viii. reproduCTive healTh Fertility In MICS4, adolescent birth rates and total fertility rates are calculated by using information on the date of last birth of each woman and are based on the one-year period (1-12 months) preceding the survey. Rates are underestimated by a very small margin due to absence of information on multiple births (twins, triplets etc) and on women having multiple deliveries during the one year period preceding the survey. Table RH.1 shows adolescent birth rates and total fertility rate. The adolescent birth rate (age-specific fertility rate for women age 15-19) is defined as the number of births to women age 15-19 years during the one year period preceding the survey, divided by the average number of women age 15-19 (number of women-years lived between ages 15 through 19, inclusive) during the same period, expressed per 1000 women. The total fertility rate (TFR) is calculated by summing the age-specific fertility rates calculated for each of the 5-year age groups of women, from age 15 through to age 49. The TFR denotes the average number of children to which a woman will have given birth by the end of her reproductive years if current fertility rates prevailed. Table RH.1: Adolescent birth rate and total fertility rate Adolescent birth rates and total fertility rates, Belize, 2011 Adolescent birth rate [1] (Age- specific fertility rate for women age 15-19) Total Fertility Rate Region Corozal 61 2.3 Orange Walk 79 3.0 Belize (Excluding Belize City South Side) 45 1.7 Belize City South Side 59 1.9 Belize District 51 1.8 Cayo 56 3.1 Stann Creek 84 3.1 Toledo 81 3.4 Area Urban 39 2.1 Rural 85 3.1 Mother’s education None 0 6.0 Primary 145 3.3 Secondary+ 37 2.0 CET/ITVET/VOTEC 0 .0 Wealth index quintile Poorest 96 4.2 Second 88 2.8 Middle 62 2.4 Fourth 53 2.5 Richest 23 1.7 Ethnicity of household head Creole 34 1.4 Mestizo 83 2.8 Garifuna 64 3.1 Maya 74 3.8 Other 23 3.8 Total 64 2.6 [1] MICS indicator 5.1; MDG indicator 5.4 92 mics f inal report Adolescent birth rate is twice as in rural areas (85 per thousand) than in urban areas (39 per thousand). High adolescent birth rates are also found in the Mestizo (83 per thousand) and in the Stann Creek District (84 per thousand). Wealthy families are less likely to have high adolescent birth rates; for poor families the rate is 96 per thousand while for the richest it is 23 per thousand. Sexual activity and childbearing early in life carry significant risks for young people all around the world. Table RH.2 presents some early childbearing indicators for women age 15-19 and 20-24 while Table RH.3 presents the trends for early childbearing. As shown in Table RH.2, 11.4 percent of women age 15-19 have already had a birth, 4.2 percent are pregnant with their first child, 15.6 percent have begun childbearing and 0.6 percent have had a live birth before age 15. The percentage of women age 20-24 years who have had a live birth before age 18 is 16.9. Women with a live birth before age 15 years are slightly more likely to be from rural areas while for live births before age 18 years it is clear that rural women have higher rates (Figure RH.1). There are also some interesting patterns in the percentage of women 20 to 24 who have had a live birth before age 18 years. Richer women seem to have fewer births before age 18 years (TableRH.2). For the poorest index the rate is 32.5 percent and this reduces for the richest index at 6.0 percent. Toledo (27.6 percent) and Stann Creek (21.2 percent) are the districts with highest rates of live births before age 18 years for women 20 to 24 years. Among the ethnic groups, highest rates are observed in the Maya (21.4 percent) and

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