Bosnia and Herzegovina - Multiple Indicator Cluster Survey - 2011

Publication date: 2011

BOSNIA AND HERZEGOVINA MULTIPLE INDICATOR CLUSTER SURVEY 2011–2012 Final Report February, 2013 BOSNIA AND HERZEGOVINA MULTIPLE INDICATOR CLUSTER SURVEY 2011–2012 Publisher UNICEF Office for Bosnia and Herzegovina Authors Aida Pilav Amela Lolic Ana Abdelbasit Dajana Mitrovic Irena Jokic Miroslav Stijak Translation Almir Comor Proofreading Chris Hughes Design Sandra Ozimica Cover photo Almir Panjeta Printed by Amos graf Print run 300 Published in February 2013 / Revised and edited in June 2014 The Multiple Indicator Cluster Survey (MICS) is an international household survey programme developed by the United Nations Children’s Fund (UNICEF). 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 Bosnia and Herzegovina MICS for 2011–2012 was conducted at the end of 2011 and the beginning of 2012 by the Federal Ministry of Health (FMH) together with the Institute for Public Heath of the Federation of Bosnia and Herzegovina (IPH FBiH) (as the implementing agency for the Federation of Bosnia and Herzegovina) and the Ministry for Health and Social Welfare of the Republic of Srpska (MHSW RS), in collaboration with the Agency for Statistics of Bosnia and Herzegovina (BHAS). Financial and technical support was provided by UNICEF and the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women), which supported the master sample frame development activities. Additional financial support was provided by the United Nations Population Fund (UNFPA) and the United Nations High Commissioner for Refugees (UNHCR). The survey was conducted as part of the fourth global round of the MICS programme (MICS4). Additional information on the global MICS programme can be obtained from www.childinfo.org. Suggested citation The Agency for Statistics of Bosnia and Herzegovina, the Federal Ministry of Health, the Ministry of Health and Social Welfare of the Republic of Srpska and the Institute for Public Health of the Federation of Bosnia and Herzegovina. (2013). Bosnia and Herzegovina Multiple Indicator Cluster Survey (MICS) 2011–2012, Final Report. Sarajevo: UNICEF. MONITORING THE SITUATION OF CHILDREN AND WOMEN iii Summary Table of Findings1 Multiple Indicator Cluster Survey (MICS) and Millennium Development Goals (MDG) Indicators for Bosnia and Herzegovina 2011–2012 Topic MICS4 Indicator Number MDG Indicator Number Indicator Value NUTRITION Nutritional status Underweight prevalence 2.1a 1.8 Moderate and Severe (- 2 SD) 1.6 per cent 2.1b 1.8 Severe (- 3 SD) 0.9 per cent Stunting prevalence 2.2a Moderate and Severe (- 2 SD) 8.9 per cent 2.2b Severe (- 3 SD) 3.8 per cent Wasting prevalence 2.3a Moderate and Severe (- 2 SD) 2.3 per cent 2.3b Severe (- 3 SD) 1.6 per cent Breastfeeding and infant feeding 2.4 Children ever breastfed 95.3 per cent 2.5 Early initiation of breastfeeding 42.3 per cent 2.6 Exclusive breastfeeding under 6 months 18.5 per cent 2.7 Continued breastfeeding at 1 year 12.4 per cent 2.8 Continued breastfeeding at 2 years 12.2 per cent 2.9 Predominant breastfeeding under 6 months 45.8 per cent 2.10 Duration of breastfeeding 8.0 months 2.11 Bottle feeding 79.5 per cent 2.12 Introduction of solid, semi-solid or soft foods 71.3 per cent 2.13 Minimum meal frequency 72.2 per cent 2.14 Age-appropriate breastfeeding 18.2 per cent 2.15 Milk feeding frequency for non-breastfed children 90.7 per cent Low birth weight 2.18 Low birth weight infants 3.1 per cent 2.19 Infants weighed at birth 97.8 per cent CHILD HEALTH Vaccinations 3.1 Tuberculosis immunisation coverage 97.8 per cent 3.2 Polio immunisation coverage 85.1 per cent 3.3 Immunisation coverage for diphtheria, pertussis and tetanus (DPT) 85.5 per cent 3.4 4.3 Measles, mumps and rubella immunisation coverage 79.9 per cent 3.5 Hepatitis B immunisation coverage 83.9 per cent Care for illness 3.8 Oral rehydration therapy with continued feeding 54.6 per cent 3.9 Care-seeking for suspected pneumonia 86.9 per cent 3.10 Antibiotic treatment of suspected pneumonia 76.2 per cent Solid fuel use 3.11 Solid fuels (used as the primary source of energy for cooking) 69.5 per cent WATER AND SANITATION Water and sanitation 4.1 7.8 Use of improved drinking water sources 99.6 per cent 4.2 Water treatment 8.5 per cent 4.3 7.9 Use of improved sanitation 94.3 per cent 4.4 Safe disposal of child’s faeces 19.6 per cent 4.5 Place for hand washing 97.9 per cent 4.6 Availability of soap 98.6 per cent 1 See Appendix E for details on indicator definitions. iv MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN v Topic MICS4 Indicator Number MDG Indicator Number Indicator Value HIV/AIDS, SEXUAL BEHAVIOUR AND ORPHANED AND VULNERABLE CHILDREN HIV/AIDS knowledge and attitudes 9.1 Comprehensive knowledge about HIV prevention women aged 15-49 years 43.4 per cent men aged 15-49 years 44.9 per cent 9.2 6.3 Comprehensive knowledge about HIV prevention amongst people aged 15-24 women aged 15-24 years 47.6 per cent men aged 15-24 years 47.4 per cent 9.3 Knowledge of mother-to-child transmission of HIV women aged 15-49 years 67.4 per cent men aged 15-49 years 49.2 per cent 9.4 Accepting attitudes towards people living with HIV women aged 15-49 years 15.1 per cent men aged 15-49 years 17.5 per cent 9.5 Women who know where to be tested for HIV 65.4 per cent Men who know where to be tested for HIV 71.0 per cent 9.6 Women who have been tested for HIV and know the results 0.4 per cent Men who have been tested for HIV and know the results 0.8 per cent 9.7 Sexually active women aged 15-24 who have been tested for HIV and know the results 0.1 per cent Sexually active men aged 15-24 who have been tested for HIV and know the results 1.2 per cent 9.8 HIV counselling during antenatal care 10.2 per cent 9.9 HIV testing during antenatal care 6.1 per cent Sexual behaviour 9.10 Women aged 15-24 who have never had sex 79.4 per cent Men aged 15-24 who have never had sex 52.8 per cent 9.11 Sex before age 15 amongst people aged 15-24 women aged 15-24 years 0.1 per cent men aged 15-24 years 1.5 per cent 9.12 Age mixing amongst sexual partners women aged 15-24 years 4.1 per cent men aged 15-24 years 0.6 per cent 9.13 Sex with multiple partners women aged 15-49 years 0.9 per cent men aged 15-49 years 6.5 per cent 9.14 Condom use during sex with multiple partners women aged 15-49 years (64.4) per cent men aged 15-49 years 60.9 per cent 9.15 Sex with non-regular partners women aged 15-24 years 58.8 per cent men aged 15-24 years 93.5 per cent 9.16 6.2 Condom use with non-regular partners women aged 15-24 years 71.4 per cent men aged 15-24 years 71.0 per cent Orphaned children 9.17 Children’s living arrangements 0.4 per cent 9.18 Prevalence of children with one or both parents dead 3.0 per cent Topic MICS4 Indicator Number MDG Indicator Number Indicator Value REPRODUCTIVE HEALTH Contraception and unmet need 5.1 5.4 Adolescent birth rate (women aged 15-19 years) 8 per 1,000 5.3 5.3 Contraceptive prevalence rate 45.8 per cent 5.4 5.6 Unmet need 9.0 per cent Maternal and newborn health Antenatal care coverage 5.5a 5.5 At least once by skilled personnel 87.0 per cent 5.5b 5.5 At least four times by any provider 84.2 per cent 5.6 Content of antenatal care 85.2 per cent 5.7 5.2 Skilled attendant at delivery 99.9 per cent 5.8 Institutional deliveries 99.7 per cent 5.9 Caesarean section 13.9 per cent CHILD DEVELOPMENT Child development 6.1 Support for learning 95.1 per cent 6.2 Father’s support for learning 76.2 per cent 6.3 Learning materials: children’s books 55.8 per cent 6.4 Learning materials: playthings 56.0 per cent 6.5 Inadequate care 1.6 per cent 6.6 Early Childhood Development Index 96.4 per cent 6.7 Attendance at early childhood education 13.1 per cent EDUCATION Literacy and education 7.1 2.3 Literacy rate amongst people aged 15-24 women aged 15-24 years 99.3 per cent men aged 15-24 years 99.9 per cent 7.2 School readiness 16.3 per cent 7.3 Net intake rate for primary education 83.2 per cent 7.4 2.1 Primary school net attendance ratio (adjusted) 97.6 per cent 7.5 Secondary school net attendance ratio (adjusted) 91.8 per cent 7.6 2.2 Children reaching last grade of primary school 99.5 per cent 7.7 Primary completion rate 146.1 per cent Net primary completion rate 91.5 per cent 7.8 Transition rate to secondary school 96.9 per cent 7.9 Gender Parity Index (primary school) 1.00 ratio 7.10 Gender Parity Index (secondary school) 1.03 ratio CHILD PROTECTION Child discipline 8.5 Violent discipline 55.2 per cent Early marriage 8.6 Marriage before age 15 women aged 15-49 years 0.4 per cent men aged 15-49 years 0.1 per cent 8.7 Marriage before age 18 women aged 20-49 years 9.5 per cent men aged 20-49 years 0.6 per cent 8.8 young women aged 15-19 years currently married or in union 0.6 per cent young men aged 15-19 years currently married or in union 0.0 per cent Spousal age difference 8.10a women aged 15-19 years (*) per cent 8.10b women aged 20-24 years 8.8 per cent Domestic violence 8.14 Attitudes towards domestic violence women aged 15-49 years 4.8 per cent men aged 15-49 years 6.0 per cent vi MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 Topic MICS4 Indicator Number MDG Indicator Number Indicator Value ACCESS TO MASS MEDIA AND USE OF INFORMATION/COMMUNICATION TECHNOLOGY Access to mass media MT.1 Exposure to mass media women aged 15-49 years 44.2 per cent men aged 15-49 years 55.8 per cent Use of information/ communication technology MT.2 Use of computers women aged 15-24 years 93.2 per cent men aged 15-24 years 94.0 per cent MT.3 Use of the Internet women aged 15-24 years 91.1 per cent men aged 15-24 years 92.1 per cent SUBJECTIVE WELL-BEING Subjective well-being SW.1 Life satisfaction women aged 15-24 years 53.5 per cent men aged 15-24 years 49.5 per cent SW.2 Happiness women aged 15-24 years 92.8 per cent men aged 15-24 years 91.1 per cent SW.3 Perception of a better life women aged 15-24 years 32.7 per cent men aged 15-24 years 35.7 per cent TOBACCO AND ALCOHOL USE Tobacco use TA.1 Tobacco use women aged 15-49 years 27.3 per cent men aged 15-49 years 39.9 per cent TA.2 Smoking before age 15 women aged 15-49 years 3.2 per cent men aged 15-49 years 9.4 per cent Alcohol use TA.3 Alcohol use women aged 15-49 years 18.3 per cent men aged 15-49 years 52.7 per cent TA.4 Use of alcohol before age 15 women aged 15-49 years 1.4 per cent men aged 15-49 years 8.4 per cent ( ) Figures that are based on 25–49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases SUMMARY TABLE OF FINDINGS . . . . . . . . . . . . . . . . . . .iii TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi LIST OF ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . xii ACkNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii ExECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . .xiv I INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Survey Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 II SAMPLE AND SURVEY METHODOLOGY . . . . 3 Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Training and Fieldwork . . . . . . . . . . . . . . . . . . . . . . . . 5 Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Report Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 How to Read the Tables . . . . . . . . . . . . . . . . . . . . . . . 6 III SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . . . . . . . . . . . . . . . . 7 Sample Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Characteristics of Households . . . . . . . . . . . . . . . . . 8 Characteristics of Female and Male Respondents 15-49 years of Age and Children Under-5 . . . . . . . . . . . . . . . . . . . . . . . . 11 Children’s Living Arrangements . . . . . . . . . . . . . . 14 IV NUTRITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Breastfeeding and Infant and young Child Feeding . . . . . . . . . . . . . . . . . . . . . 19 Low Birth Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 V CHILD HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Immunisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Oral Rehydration Treatment . . . . . . . . . . . . . . . . . . 34 Care-Seeking and Antibiotic Treatment of Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Solid Fuel Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 VI WATER AND SANITATION . . . . . . . . . . . . . . . . . . 47 Use of Improved Drinking Water Sources . . . . . 47 Use of Improved Sanitation . . . . . . . . . . . . . . . . . . 54 Hand Washing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 VII REPRODUCTIVE HEALTH . . . . . . . . . . . . . . . . . . . 63 Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Knowledge of Contraceptive Methods . . . . . . . . 63 Use of Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . 65 Unmet Need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Assistance at Delivery . . . . . . . . . . . . . . . . . . . . . . . . 73 Place of Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 VIII CHILD DEVELOPMENT . . . . . . . . . . . . . . . . . . . . . 76 Early Childhood Education and Learning . . . . . 76 Early Childhood Development . . . . . . . . . . . . . . . 80 Ix LITERACY AND EDUCATION . . . . . . . . . . . . . . . . 82 Literacy amongst Women and Men aged 15 to 25 years . . . . . . . . . . . . . . . . . 82 School Readiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Primary and Secondary School Participation . . 84 x CHILD PROTECTION . . . . . . . . . . . . . . . . . . . . . . . . 92 Child Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Early Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Attitudes towards Domestic Violence . . . . . . . . . 99 xI HIV/AIDS AND SExUAL BEHAVIOUR THAT INCREASES THE RISk OF HIV TRANSMISSION . . . . . . . . . . . . . . . . . . .102 Knowledge about HIV Transmission and Misconceptions about HIV/AIDS . . . . . . . .102 Accepting Attitudes towards People Living with HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care . . . . . . . . . . . . . . . . . . . . . . .117 Sexual Behaviour Related to HIV Transmission. .122 xII ACCESS TO MASS MEDIA AND USE OF INFORMATION/COMMUNICATION TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130 Access to Mass Media . . . . . . . . . . . . . . . . . . . . . . .130 Use of Information/Communication Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132 xIII TOBACCO AND ALCOHOL USE . . . . . . . . . . . .135 Tobacco Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135 Alcohol Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139 xIV SUBjECTIVE WELL-BEING . . . . . . . . . . . . . . . . .142 APPENDIx A: Sample Design . . . . . . . . . . . . . . . . . . . .150 APPENDIx B: List of Personnel Involved in the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155 APPENDIx C: Estimates of Sampling Errors . . . . . .159 APPENDIx D: Data Quality Tables . . . . . . . . . . . . . . .174 APPENDIx E: BiH MICS4 Indicators – Numerators and Denominators . . . . . . . . . .184 APPENDIx F: BiH MICS4 Questionnaires . . . . . . . . .191 APPENDIx G: Nutritional Status of Children (NCHS/CDC/WHO standard) . . . . . . . . . . . . . . .250 APPENDIx H: Education Tables by ISCED . . . . . . . .252 Table of Contents MONITORING THE SITUATION OF CHILDREN AND WOMEN vii List of Tables MONITORING THE SITUATION OF CHILDREN AND WOMEN ixviii MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 Table HH.1: Results of the household, women’s, men’s and under-5’s interviews . . . . . . . . . . . . . . . . . . . . . 7 Table HH.2: Household age distribution by sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Table HH.3: Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Table HH.4: Women’s background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Table HH.4M: Men’s background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Table HH.5: Under-5’s background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Table HA.6: Children’s living arrangements and orphanhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Table NU.1: Nutritional status of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Table NU.2: Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Table NU.3: Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Table NU.4: Duration of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Table NU.5: Age-appropriate breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Table NU.6: Minimum meal frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Table NU.7: Bottle feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Table NU.8: Low birth weight infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Table CH.1 (a): Vaccinations in first year of life, BiH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Table CH.1 (b): Vaccinations in first year of life, FBiH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Table CH.1 (c): Vaccinations in first year of life, RS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Table CH.2: Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Table CH.3: Oral rehydration solutions and recommended homemade fluids . . . . . . . . . . . . . . . . . . . . . .35 Table CH.4: Feeding practices during diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Table CH.5: Oral rehydration therapy with continued feeding and other treatments . . . . . . . . . . . . . . . .38 Table CH.6: Prevalence of suspected pneumonia by background characteristics . . . . . . . . . . . . . . . . . . .40 Table CH.7: Knowledge of the two danger signs of pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 Table CH.8: Solid fuel use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Table CH.9: Solid fuel use by place of cooking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Table WS.1: Use of improved water sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Table WS.2: Household water treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Table WS.3: Time to source of drinking water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Table WS.4: Person collecting water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Table WS.5: Types of sanitation facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Table WS.6: Use and sharing of sanitation facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Table WS.7: Disposal of child’s faeces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 Table WS.8: Drinking water and sanitation ladders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 Table WS.9: Water and soap at place for hand washing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 Table WS.10: Availability of soap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 Table RH.1: Adolescent birth rate and total fertility rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 Table RH.2: Knowledge of specific contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 Table RH.3: Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 Table RH.4: Use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Table RH.5: Unmet need for contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 Table RH.6: Antenatal care coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 Table RH.7: Number of antenatal care visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 Table RH.8: Content of antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 Table RH.9: Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74 Table RH.10: Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 Table CD.1: Early childhood education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 Table CD.2: Support for learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 Table CD.3: Learning materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78 Table CD.4: Inadequate care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 Table CD.5: Early childhood development index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81 Table ED.1: Literacy amongst women aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82 Table ED.1M: Literacy amongst men aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 Table ED.2: School readiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 Table ED.3: Primary school entry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85 Table ED.4: Primary school attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 Table ED.5: Secondary school attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 Table ED.6: Children reaching last grade of primary school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 Table ED.7: Primary school completion and transition to secondary school . . . . . . . . . . . . . . . . . . . . . . . .90 Table ED.8: Education gender parity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 Table CP.1: Child discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Table CP.2: Early marriage: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 Table CP.2M: Early marriage: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96 Table CP.3: Trends in early marriage: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97 Table CP.3M: Trends in early marriage: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97 Table CP.4: Spousal age difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98 Table CP.5: Attitudes towards domestic violence: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Table CP.5M: Attitudes towards domestic violence: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV/AIDS and comprehensive knowledge about HIV transmission: women aged 15-49 . . . . . . . . . 103 Table HA.1M: Knowledge about HIV transmission, misconceptions about HIV/AIDS and comprehensive knowledge about HIV transmission: men aged 15-49 . . . . . . . . . . . . 104 Table HA.2: Knowledge about HIV transmission, misconceptions about HIV/AIDS and comprehensive knowledge about HIV transmission: women aged 15-24 . . . . . . . . . 108 Table HA.2M: Knowledge about HIV transmission, misconceptions about HIV/AIDS and comprehensive knowledge about HIV transmission: men aged 15-24 . . . . . . . . . . . . 110 Table HA.3: Knowledge of mother-to-child HIV transmission: women . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Table HA.3M: Knowledge of mother-to-child HIV transmission: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Table HA.4: Accepting attitudes towards people living with HIV/AIDS: women . . . . . . . . . . . . . . . . . . . 115 Table HA.4M: Accepting attitudes towards people living with HIV/AIDS: men . . . . . . . . . . . . . . . . . . . . . . 116 Table HA.5: Knowledge of a place for HIV testing: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Table HA.5M: Knowledge of a place for HIV testing: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Table HA.6: Knowledge of a place for HIV testing amongst sexually active women aged 15-24 . . . . 119 Table HA.6M: Knowledge of a place for HIV testing amongst sexually active men aged 15-24 . . . . . . . 120 Table HA.7: HIV counselling and testing during antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Table HA.8: Sexual behaviour that increases the risk of HIV infection: women . . . . . . . . . . . . . . . . . . . . 122 Table HA.8M: Sexual behaviour that increases the risk of HIV infection: men . . . . . . . . . . . . . . . . . . . . . . . 123 Table HA.9: Sex with multiple partners: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Table HA.9M: Sex with multiple partners: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Table HA.10: Sex with multiple partners: women aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Table HA.10M: Sex with multiple partners: men aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Table HA.11: Sex with non-regular partners: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Table HA.11M: Sex with non-regular partners: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 List of Figures MONITORING THE SITUATION OF CHILDREN AND WOMEN xix MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 Table MT.1: Exposure to mass media: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Table MT.1M: Exposure to mass media: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Table MT.2: Use of computers and the Internet: women aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Table MT.2M: Use of computers and Internet: men aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Table TA.1: Current and ever use of tobacco: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Table TA.1M: Current and ever use of tobacco: men. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Table TA.2: Age at first use of cigarettes and frequency of use: women . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Table TA.2M: Age at first use of cigarettes and frequency of use: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Table TA.3: Use of alcohol: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Table TA.3M: Use of alcohol: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Table SW.1: Domains of life satisfaction: women aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Table SW.1M: Domains of life satisfaction: men aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Table SW.2: Life satisfaction and happiness: women aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Table SW.2M: Life satisfaction and happiness: men aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Table SW.3: Perception of a better life: women aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Table SW.3M: Perception of a better life: men aged 15-24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Table SD.1: Allocation of clusters (primary selection units) by stratum . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Table SD.2: Percentage of selected EAs within the sampling frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Table SD.3: Allocation of selected EAs, updated EAs and EAs in the sample by administrative unit in BiH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Table SD.4: Sample allocation by administrative unit and second stage strata in BiH . . . . . . . . . . . . . 152 Table SD.5: First stage and second stage selection probabilities by strata . . . . . . . . . . . . . . . . . . . . . . . . 153 Table SD.6: Adjusted (normalised) weights by sample strata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Table SE.1: Indicators selected for sampling error calculations, BiH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Table SE.2: Sampling errors: Total sample, BiH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Table SE.3: Sampling errors: Urban areas, BiH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Table SE.4: Sampling errors: Rural areas, BiH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Table SE.5: Sampling errors: FBiH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Table SE.6: Sampling errors: RS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Table SE.7: Sampling errors: BD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Table DQ.1: Age distribution of household population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Table DQ.2: Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Table DQ.2M: Age distribution of eligible and interviewed men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Table DQ.3: Age distribution of under-5’s in household and under-5 questionnaires . . . . . . . . . . . . . . 175 Table DQ.4: Women’s completion rates by socio-economic characteristics of households . . . . . . . . . 176 Table DQ.4M: Men’s completion rates by socio-economic characteristics of households . . . . . . . . . . . . 177 Table DQ.5: Completion rates for under-5 questionnaires by socio-economic characteristics of households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Table DQ.6: Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Table DQ.7: Completeness of information for anthropometric indicators . . . . . . . . . . . . . . . . . . . . . . . . . 180 Table DQ.8: Heaping in anthropometric measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Table DQ.9: Observation of places for hand washing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Table DQ.10: Observation of vaccination cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Table DQ.11: Presence of mother in the household and the person interviewed for the under-5 questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Table DQ.12: Selection of children aged 2-14 years for the child discipline module . . . . . . . . . . . . . . . . 182 Table DQ.13: School attendance by single age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Table NU.1 (a): Nutritional status of children (NCHS/CDC/WHO standard) . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Table ED.1 ISCED: Primary school attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Table ED.2 (a) ISCED: Lower secondary school attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Table ED.2 (b) ISCED: Upper secondary school attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Figure HH.1: Age and sex distribution of household population, BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . . . 9 Figure NU.1: Percentage of children under age 5 who are underweight, stunted, wasted or overweight, BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth, BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Figure NU.3: Infant feeding patterns by age, BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Figure CH.1: Percentage of children aged 18-29 months who received the recommended vaccinations by 12 months (18 months for MMR), BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . . .30 Figure CH.2: Percentage of children under age 5 with diarrhoea who received ORT with continued feeding, BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 Figure CH.3: Percentage of children under age 5 with diarrhoea who received ORT or increased fluids, BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Figure WS.1: Per cent distribution of household members by source of drinking water, BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Figure HA.1: Percentage of women who have comprehensive knowledge of HIV/AIDS transmission, BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Figure HA.1M: Percentage of men who have comprehensive knowledge of HIV/AIDS transmission, BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Figure DQ.1: Number of household population by single ages, BiH 2011–2012 . . . . . . . . . . . . . . . . . . . . . 182 xii MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN xiii Acknowledgments The report before you is the result of a joint effort by numerous institutions and individuals that contributed through their enthusiasm and commitment to the successful implementation of MICS 2011–2012 for Bosnia and Herzegovina (BiH), as part of the fourth global round of the MICS programme (MICS4). The Federal Office of Statistics (FOS) and the Republic of Srpska Institute of Statistics (RSIS), in cooperation with the Agency for Statistics of BiH (BHAS), enabled survey implementation through the development of the MICS4 master sample frame. Survey teams and fieldwork and data entry staff played a crucial role in the implementation of the survey enabling, through their enthusiasm and commitment, the collation of the data presented in this report. We would like to thank the global MICS team from the Division of Policy and Practice at UNICEF New York, UNICEF’s Central and Eastern Europe/Commonwealth (CEE/CIS) Regional Office in Geneva, especially the regional MICS Coordinator, and the UNICEF Office for BiH whose continuous technical and logistical support was of vital importance for all phases of the survey. Survey implementation was made possible through the financial support of UNICEF, UN Women, which supported activities to update the MICS4 master sample frame, as well as UNFPA and UNHCR. Our greatest appreciation goes to all of the households and individuals for their patience and the time they set aside. Their willingness to participate reflects their awareness of the need to present their living conditions with the aim to contribute towards an improvement of living conditions for children in BiH. It is our hope that this report will contribute to the fulfilment of this goal. AIDS Acquired Immune Deficiency Syndrome BCG Bacillis-Cereus-Geuerin (Tuberculosis) BD Brcko District of Bosnia and Herzegovina BHAS Agency for Statistics of Bosnia and Herzegovina BiH Bosnia and Herzegovina CDC Centres for Disease Control and Prevention CEDAW Convention on the Elimination of All Forms of Discrimination against Women CEE Central and Eastern Europe CIS Commonwealth of Independent States CRC Convention on the Rights of the Child CSPro Census and Survey Processing System DPT Diphtheria Pertussis Tetanus EA Enumeration Area ECDI Early Childhood Development Index EPI Expanded Programme on Immunisation FBiH Federation of Bosnia and Herzegovina FMH Federal Ministry of Health FOS Federal Office of Statistics GAP Gender Action Plan of Bosnia and Herzegovina GPI Gender Parity Index Hep B Hepatitis B Hib Haemophilus influenzae type B HIV Human Immunodeficiency Virus IUD Intrauterine Device IPH FBiH Institute for Public Health of the Federation of Bosnia and Herzegovina IPV Inactive polio vaccine JMP Joint Monitoring Programme LAM Lactational Amenorrhea Method MDG Millennium Development Goals MHSW RS Ministry of Health and Social Welfare of the Republic of Srpska MICS Multiple Indicator Cluster Survey MICS4 Fourth global round of the Multiple Indicator Cluster Surveys programme MMR Measles Mumps Rubella NAR Net Attendance Ratio NCHS National Center for Health Statistics OPV Oral polio vaccine ORS Oral rehydration salts ORT Oral rehydration treatment ppm Parts per million PSU Primary Sampling Unit RS Republic of Srpska RSIS Republic of Srpska Institute of Statistics SPSS Statistical Package for Social Sciences SSU Secondary Sampling Unit STI Sexually transmitted infection TFR Total Fertility Rate UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund UN Women United Nations Entity for Gender Equality and the Empowerment of Women WFFC A World Fit For Children WHO World Health Organization List of Abbreviations xiv Multiple indicator cluster survey 2011–2012 Monitoring the situation of children and woMen xv z About 19 per cent of children aged less than six months in BiH were exclusively breastfeed. The percentage of children aged 2-3 months being exclusively breastfed was half that of newborn children. However, every second child below six months of age was predominantly breastfed (46 per cent) and one in eight children were still being breastfed at age one. z Approximately one-fifth (18 per cent) of children aged 0-23 months were breastfed appropriately according to age. This includes exclusive breastfeeding during the initial six months and breastfeeding combined with supplemental food between six months and two years of age. Low Birth Weight Low birth weight (less than 2,500 grams) carries a range of severe health risks for children and therefore it is important for all children to be weighed at birth. z Almost all children born in the two years preceding the survey were weighed at birth (98 per cent), with 3 per cent of them weighing below 2,500 grams. Child Health Immunisation Coverage According to UNICEF and WHO guidelines children should receive the BCG vaccination, to protect against tuberculosis, three doses of DPT, to protect against diphtheria, pertussis, and tetanus, and three doses of the polio vaccine, and the measles vaccination by 12 months of age. A World Fit for Children goal is to ensure full immunisation coverage for children under one year of age at 90 per cent nationally, with at least 80 per cent coverage in every administrative unit. z Overall, at the time of the survey, vaccination cards or health booklets were available for 91 per cent of children under 5 year of age. z By the age of 12 months, 99 per cent of children had received a BCG vaccination. z Ninety-five per cent of children aged 18-29 months had received the first dose of the polio vaccine; however, coverage for the polio vaccine declined with subsequent doses to 93 per cent for the second and 85 per cent for the third dose. Similarly, 95 per cent of children had received the first dose of the DPT vaccination by the age of 12 months, yet the percentage declined to 86 per cent by the third dose. z The vaccine to protect against measles, rubella and mumps (MMR) is received by 18 months of age in BiH. The percentage of children immunised against MMR was lower than for other vaccines at 80 per cent; as a result, immunisation coverage of children aged 18-29 months by all listed vaccinations was somewhat lower at 68 per cent (this percentage includes children of this age that had received a BCG vaccine, three doses of the DPT vaccination and three doses of the polio vaccination during infancy as well as an MMR vaccine by 18 months of age). Oral Rehydration Treatment The goal of diarrhoea treatment is to help reduce the mortality rate amongst children under five by two-thirds between 1990 and 2015, while A World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 per cent. z Overall 6 per cent of children under 5 years of age had had diarrhoea in the two weeks preceding the survey. z About one-third of children of that age (36 per cent) with diarrhoea had received oral rehydration salts (ORS), either as a fluid from an ORS packet or as a pre-packaged ORS fluid. One quarter (25 per cent) of children were treated with antimotility medication in the form of tablets or syrups, while about 4 per cent of children were treated with antibiotics (administered as a pill, syrup or injection). Nearly one-fifth of children with diarrhoea (19 per cent) were treated with home remedies/herbal medicine. Twenty-one per cent of children did not receive any treatment or medication. z Nearly half of the children (45 per cent) were given more than usual to drink during an episode of diarrhoea, while 6 per cent were given much less than usual to drink. In 82 per cent of cases children with diarrhoea were given the same or less to eat, while in 6 per cent of cases children were given much less than usual to eat and in 5 per cent of cases feeding was stopped. z Two-thirds of children (65 per cent) with diarrhoea received ORS or drank more than usual, while 55 per cent received oral rehydration therapy (ORT) with continued feeding. Executive Summary The BiH MICS4 2011–2012 was conducted using a representative sample in order to provide estimates for a large number of indicators on the situation of children, women and men as well as household living conditions at the level of BiH, the Federation of BiH (FBiH), the Republic of Srpska (RS) and for urban and rural areas. The survey is based on a representative sample of 6,838 households in BiH (4,107 in FBiH, 2,408 in RS and 323 in Brcko District (BD) of BiH) with an overall response rate of 91 per cent (in total, 5,778 households were interviewed). The results reflect data collected during the period November 2011 and March 2012. The survey was undertaken as part of the fourth global round of the MICS programme and implemented by the Federal Ministry of Health (FMH) and the Ministry of Health and Social Welfare of the Republic of Srpska (MHSW RS) in cooperation with the Institute for Public Health of the FBiH (IPH FBiH) and the Agency for Statistics of BiH (BHAS). Financial and technical support was provided by UNICEF with additional financial support provided by UN Women for preparing the master sample frame, as well as by UNFPA and UNHCR. The primary aim of MICS is to provide indicators for monitoring the level of progress towards the Millennium Development Goals, the Plan of Action for A World Fit for Children as well as other international and national commitments undertaken by BiH. The survey findings are presented from the equity perspective by indicating disparities in accordance with administrative units, sex, area type, the level of education of the respondent or head of the household, household wealth and other characteristics. Nutrition Nutritional Status Under MICS4 the weight and height of all children under 5 years of age were measured using anthropometric equipment recommended by UNICEF. The indicators were based on the World Health Organization (WHO) standard for the reference population of children, that in 2006 superseded the US National Center for Health Statistics, US Centers for Disease Control and Prevention and WHO (NCHS/CDC/WHO) standards that had been in use since 1978. z The most prominent problem identified in BiH in terms of nutrition was that of overweight children: one in six children under 5 years of age in BiH (FBiH and RS) was overweight. z Stunting, at 9 per cent, was the second most prevalent issue amongst children under 5 years of age, whereby 4 per cent of children this age were severely stunted, indicating chronic malnutrition (largely due to a failure to receive adequate nutrition over a long period and recurrent and chronic illness). The highest percentage of stunted children of that age was found amongst children aged 0-5 months. z The prevalence of wasting was low and present amongst 2 per cent of children under 5 years of age, whereby nearly two-thirds of these children were severely wasted. Wasting is usually the result of a recent nutritional deficiency and this indicator may exhibit significant seasonal fluctuations. The highest percentage of wasted children was found amongst children aged 0-5 months. z The prevalence of underweight children was low and present amongst 2 per cent of children under 5 years of age in BiH, whereby half of these children were severely underweight. The highest percentage of underweight children was found amongst children aged 6-11 months. Breastfeeding and Child Feeding Breastfeeding in the first few years of life protects children from infection, provides an ideal source of nutrients and is economical and safe. According to WHO and UNICEF recommendations exclusive breastfeeding is considered appropriate feeding for infants aged 0-5 months, while infants aged 6-23 months are considered to be appropriately fed if they are receiving breast milk and solid, semi-solid or soft foods. z Less than half of the youngest children in the surveyed households (42 per cent) born in the two years preceding the survey were first breastfed within one hour of birth, while a higher percentage (87 per cent) of newborns were first breastfed within one day of birth. z One-fifth of newborns received a prelacteal feed. xvi MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN xvii z Improved sources of drinking water and improved sanitation were used by 94 per cent of the population in BiH, the percentage declined with reduced household wealth. z The percentage of children aged 0-2 years whose last stools were disposed of safely was 20 per cent; for the highest proportion of children (79 per cent), their last stools were were disposed of by throwing them into the rubbish, which is not considered a safe method of disposal. Hand Washing Hand washing with water and soap is the most cost-effective health intervention to reduce the incidence of both diarrhoea and pneumonia in children under five. z Most households in BiH had a specific place for hand washing (98 per cent). In 98 per cent of cases when the place for hand washing was observed during the survey this place had both water and soap present. While there were no obvious variations by background characteristics of the households, water and soap were present in the place for hand washing by 6 percentage units less amongst the poorest compared to the richest households. Reproductive Health Fertility The total fertility rate (TFR) denotes the average number of children which a woman will have had by the end of her reproductive years, if the current fertility rates prevail. z The TFR for one year preceding the survey was 1.3 births per woman aged 15-49. The adolescent birth rate in BiH was 8 births per 1,000 women aged 15-19 for the one year period preceding the survey. knowledge of Contraceptive Methods and Use of Contraceptives Being aware of available contraceptive methods is an important step towards accessing and using a suitable method of contraception, which in turn allows choices to be made concerning family planning. z Nearly all women aged 15-49 knew at least one contraceptive method (including both modern and traditional methods). On average women knew 9.4 different contraceptive methods. z The most widely known modern method was the male condom (98 per cent). The most widely known of the traditional methods was withdrawal (93 per cent). z Contraception was currently being used by 46 per cent of married or in-union women in BiH, with traditional methods more commonly used than modern ones (34 per cent versus 12 per cent). The most popular method was withdrawal, used by one-third of married women, while the subsequent most popular method was the male condom, used by 6 per cent of women. Amongst other methods of contraception, 4 per cent of women used an intrauterine device (IUD), 4 per cent practiced periodic abstinence and 2 per cent used the pill. z More than half of women aged 15-49 in RS used a contraceptive method (54 per cent), while this percentage was somewhat lower in the FBiH (43 per cent). The contraceptive prevalence rate was similar in urban and rural areas. Contraceptive prevalence is associated with the number of births a woman has had as well as her education level. Thus, the percentage of women using any method increased from 37 per cent amongst women who had had one live birth to 53 per cent amongst women who had had four or more live births and from 45 per cent amongst women with primary education to 55 per cent amongst women with higher education. The prevalence of modern contraceptive methods rose in line with household wealth. Unmet Need for Contraception Unmet need for contraception refers to fecund women who do not use any method of contraception but who wish to postpone their next birth (spacing) or who wish to stop childbearing altogether (limiting). z The total unmet need for contraception in BiH was low: being present amongst 9 per cent of women aged 15-49. The unmet need for contraception was higher amongst women aged 20-24 (24 per cent) and women aged 25-29 (21 per cent). z One in three women had met the need for limiting, while one in nine women had met need for spacing. Care-Seeking and Antibiotic Treatment of Pneumonia A World Fit for Children goal is to reduce by one-third deaths resulting from acute respiratory infection. z About 3 per cent of children under 5 years of age were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, 87 per cent were taken to an appropriate healthcare provider. Most children with suspected pneumonia were examined in public sector health facilities: nearly half of these children (48 per cent) were taken to a health centre and about one quarter to a hospital (24 per cent). Seventy-six per cent of children with suspected pneumonia in the two weeks preceding the survey were treated using antibiotics. z One in seven mothers (15 per cent) knew of two danger signs of pneumonia (fast and difficult breathing). The highest percentage of mothers (88 per cent) identified fever as a symptom for taking their child immediately to a health facility. In contrast, a lower proportion of mothers would take their children to a health facility in the event of difficult (39 per cent) or fast (20 per cent) breathing. Solid Fuel Use Cooking and heating with solid fuel in the household leads to high levels of indoor smoke, which consists of a complex mix of health-damaging pollutants. z Slightly more than two-thirds (70 per cent) of the household population in BiH use solid fuel for cooking, most of which use wood. The use of solid fuel for cooking was predominant in rural areas (83 per cent); however, this was not a rare occurrence in urban areas, where two-fifths of the household population (43 per cent) used solid fuel. Solid fuel used for cooking purposes was not common amongst the richest household population, but rose with the declining wealth status and decreasing level of education of the head of the household. z More than half of the household population in BiH living in households using solid fuels for cooking (59 per cent) had a designated room for cooking, the lowest percentage being amongst the poorest household population. Water and Sanitation One of the Millennium Development Goals is to reduce by half the proportion of people without sustainable access to safe drinking water and basic sanitation between 1990 and 2015. Use of Improved Drinking Water Sources Safe drinking water is a basic necessity for good health; unsafe drinking water can be a significant carrier of numerous diseases. z Nearly the entire population in BiH uses an improved source of drinking water, including piped water (into dwellings, compounds, yards or plots or to neighbours and public taps/standpipes), tube well/boreholes, protected wells, protected springs and rainwater collection and, in certain circumstances, bottled water. z Of the 89 per cent of the household members using piped water, 4 per cent had a source of drinking water outside the dwelling. Access to piped water was somewhat less frequent in rural areas (86 per cent) compared to urban areas (93 per cent), while it was 71 per cent amongst the poorest population compared to 92 per cent amongst the richest population. z Six per cent of the population in BiH had no water source on the premises. This percentage rose with the deteriorating wealth status. Amongst the household population with no water on the premises, in nearly two-thirds of cases water was collected by an adult male (62 per cent) and to a lesser extent by an adult female (32 per cent). In 3 per cent of cases water was collected by children under 15 years of age. Use of Improved Sanitation Improved sanitation can reduce diarrheal disease by more than a third and can significantly lessen the adverse health impact of other disorders. z Improved sanitation for excreta disposal in households were used by 94 per cent of the population in BiH. This was slightly more frequent in urban (99 per cent) compared to rural areas (92 per cent). In urban areas 92 per cent of the population used flush toilets, while the population in rural areas most commonly used septic tanks (58 per cent); the population in urban areas most often used flush toilets connected to a sewer system (83 per cent). xviii MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN xix Literacy and Education Literacy amongst Women and Men aged 15-24 Youth literacy is an important MDG indicator. z The literacy rate for women and men aged 15-24 was over 99 per cent, lower only amongst women with primary education (88 per cent). School Readiness Readiness of children for primary school can be improved through attendance at early childhood education programmes or preschool attendance. z One in six children in BiH (16 per cent) who were currently attending the first grade of primary school had attended preschool during the previous year. The proportion was higher amongst females (25 per cent) than males (10 per cent) and also amongst children living in urban areas (25 per cent) compared to children in rural areas (13 per cent). Primary and Secondary School Participation Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the Millennium Development Goals and A World Fit for Children. z Of the total number of children who were of primary school entry age in BiH 83 per cent were attending the first grade: 93 per cent in RS and 80 per cent in the FBiH. Children of primary school entry age in urban areas were less likely to attend school (77 per cent) compared to children in rural areas (86 per cent). The net primary school completion rate in BiH was 92 per cent. z Nearly all children of primary school age in BiH attended school (98 per cent): 99 per cent in RS and 97 per cent in the FBiH. Most children that start grade one eventually reach the last grade of primary school. z Of the children who had attended the last grade of primary school in the previous year 97 per cent were attending the first grade of secondary school during the school year in which the survey took place. z About 92 per cent of children aged 15-18 were attending secondary school in BiH, both in the FBiH and RS. Children from the poorest households were less likely to attend secondary school or higher education (84 per cent) compared to children from the richest households. z The Gender Parity Index (GPI) in BiH was 1.00 for primary school and 1.03 for secondary school. In the FBiH the GPI was 1.00 for primary and 1.03 for secondary school, while in RS the GPI was 1.00 for primary and 1.02 for secondary school. Child Protection Child Discipline A World Fit for Children states that children must be protected against any acts of violence. The Millennium Declaration also calls for the protection of children against abuse exploitation and violence. z Every other child aged 2-14 in BiH had been subjected to psychological aggression as punishment, or physical punishment, by an adult in the household during the past month preceding the survey (55 per cent). Forty-two per cent of children had been subjected to psychological aggression as punishment and a similar proportion of children (40 per cent) had been subjected to physical punishment. One in twenty children of that age had been subjected to severe physical punishment, while one-third of children had been disciplined using only non-violent methods. z Male children were to a higher extent subjected to violent methods of discipline compared to female children (60 per cent compared to 50 per cent). Children in households where the household head had no education were five times more likely to be subjected to severe physical violence as punishment compared to children from households where the household head had primary secondary or higher education. Antenatal Care During the antenatal period pregnant women may be reached through a number of interventions that may be vital to their health and well-being and that of their infants. The WHO recommends a minimum of four antenatal visits, with specific content including blood pressure measurement, urine testing, blood testing and weight/height measurement. z Eighty-seven present of women aged 15-49 in BiH who had given birth in the two years that preceded the survey had received antenatal care from a healthcare provider. Almost all of the women had received antenatal care from a healthcare provider in RS, while in the FBiH the percentage was lower at 82 per cent. Antenatal care was provided largely by medical doctors (86 per cent). z About 84 per cent of women aged 15-49 had received antenatal care four or more times. z Three essential antenatal care services (blood pressure measurement, urine and blood testing) were provided to 85 per cent of the women aged 15-49 who had given birth in the two years preceding the survey. Assistance at Delivery and Place of Delivery Three-quarters of all maternal deaths occur during delivery and the immediate post-partum period. An important A World Fit for Children goal is to ensure that women have ready and affordable access to skilled attendance at delivery. z Almost all births in the two years preceding the survey were delivered by skilled personnel and in public sector health facilities. z One in seven women had been attended during delivery by a nurse/midwife, while the rest of the women had been assisted by a medical doctor. z One in seven women (14 per cent) gave birth by Caesarean section. The percentage of women who gave birth by Caesarean section was highest amongst women from the richest households (21 per cent). Child Development Early Childhood Education and Learning A period of rapid brain development occurs in the first 3-4 years of life and the quality of home care is the major determinant in a child’s development during this period. Therefore, engagement of adults in activities with children, the presence of children’s books in the household and the conditions of care are important indicators of the quality of home care. z For the majority of children under-five (95 per cent) an adult had engaged in four or more activities that promote learning and school readiness during the three days preceding the survey. The average number of activities was 6, while fathers engaged on average in 3 activities. z Slightly more than half of the children aged 0-59 months (56 per cent) lived in households where at least 3 children’s books and 2 or more types of playthings were present (56 per cent). z About 2 per cent of children aged 0-59 months had been left with inadequate care during the week prior to the interview, including children who were left in the care of other children under 10 years of age or left alone at home. z Thirteen per cent of children aged 36-59 months in BiH were attending an organised early childhood programme. Compared to urban areas, where one in five children was attending an organised early childhood programme, such programmes were attended by only one in thirteen children in rural areas. Children in the poorest households and children of mothers or caretakers with primary education were much less likely to attend early childhood programmes. Early Childhood Development Index Early child development is defined as an orderly predictable process along a continuous path. The Early Childhood Development Index (ECDI) is calculated as the percentage of children who are developmentally on track in at least three of the following domains: literacy and numeracy skills, physical growth, socio-emotional development and learning. z Ninety-six per cent of children aged 36-59 months in BiH were developmentally on track (96 per cent in the FBiH and 98 per cent in RS). No clear variations were observed by sex, area or other background characteristics. z More than 90 per cent of children were developmentally on track in the physical, socio-emotional and learning domains, while a smaller proportion of children aged 36-59 months were developmentally on track in literacy and numeracy skills (25 per cent). xx MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN xxi Attitudes towards People Living with HIV/AIDS The indicators on attitudes towards people living with HIV measure stigma and discrimination within a community. z In BiH 15 per cent of women and 18 per cent of men aged 15-49 had accepting attitudes for all four indicators of attitudes towards people living with HIV/AIDS. Accepting attitudes were more common amongst women in urban areas, while no difference by area was observed amongst men. Both women and men with higher education were more likely to have accepting attitudes in this respect. z The most common accepting attitudes were expressed towards members of the respondent’s family. More than 90 per cent of women and men showed a willingness to care for a family member living with HIV in their own household, while slightly less than half of the women (45 per cent) and men (49 per cent) would not want to keep the HIV status of a family member a secret. knowledge of a Place for HIV Testing and Counselling and Testing during Antenatal Care In order to protect themselves and to prevent infecting others it is important for individuals to know their HIV status. Knowledge of where to be tested for HIV and use of such services is a critical factor in the decision to seek treatment. z A higher percentage of men (71 per cent) than women (65 per cent) aged 15-49 in BiH knew of a facility where they could be tested for HIV; however, an equally low percentage of men and women had ever been tested for HIV (3 per cent of women and 5 per cent of men). A higher percentage of women (79 per cent) and men (78 per cent) aged 15- 24 who were sexually active knew where to be tested for HIV, while the percentage of those who had been tested for HIV was approximately the same as that for the population of women and men aged 15-49. A higher percentage of people aged 15-24 in RS (92 per cent of women and 88 per cent of men) knew where to be tested for HIV compared to the FBiH (72 per cent of women and 73 per cent of men). z Of the women aged 15-49 who had given birth in the two years prior to the survey only 10 per cent had received HIV counselling during antenatal care. During the antenatal period 6 per cent of women had been offered an HIV test, been tested and told the result. In RS a higher percentage of women in this population had been offered an HIV test, tested during the antenatal period and told the result (12 per cent) compared to FBiH (3 per cent). Sexual Behaviour Related to HIV Transmission In most countries over half of new HIV infections occur amongst people aged 15-24, thus a change in behaviour amongst this age group is especially important if the number of new infections is to be reduced. In this respect, using a condom every time is of particular importance. z The proportion of women and men aged 15-24 who had had sex before age 15 was very low (less than 1 per cent for women and 2 per cent for men). z Within the last 12 months 4 per cent of women aged 15-24 in BiH had had sex with a man who was older by ten years or more, while less than 1 per cent of men of the same age had had sex with a woman who was older by ten years or more. z One per cent of women and 7 per cent of men aged 15-49 in BiH had had sex with more than one partner in the last 12 months and slightly less than two-thirds of these men indicated condom use when they had sex the last time (61 per cent). z Fifty-three per cent of women aged 20-24 and 73 per cent of men of this age reported having had sex in the last 12 months, while 2 per cent of women and 17 per cent of men of this age had had sex with more than one partner in the last 12 months. About two-thirds of these men indicated condom use when they had sex the last time (66 per cent). z Seven out of ten women and men aged 15-24 in BiH had used a condom the last time they had had sex with a non- marital/non-cohabiting partner. Early Marriage The right to ‘free and full’ consent to a marriage is recognised in the Universal Declaration of Human Rights through the recognition that consent cannot be ‘free and full’ when one of the parties involved is not sufficiently mature to make an informed decision about a life partner. Child marriage is a violation of human rights, compromising the development of girls and often resulting in social isolation and ultimately reinforcing the gendered nature of poverty. z Early marriage is more common amongst women than men. The proportion of women and men aged 15-49 who married before 15 years of age was very low (less than 1 per cent); however, the proportion rose to 10 per cent for women aged 20-49 who married before age 18 (amongst men the proportion remained at under 1 per cent). The practice of early marriage amongst women aged 20-49 was more common in rural areas and amongst women with primary education. z Less than 1 per cent of women aged 15-19 were married or in union at the time of survey, while no such cases were observed amongst the men. z One in eleven women aged 20-24 in BiH were married to or in union with a man who was older by ten years or more, while the highest percentage of women of this age (48 per cent) were currently married to a man who was up to 4 years older. Attitudes towards Domestic Violence It is believed that women who feel that a man has the right to hit or beat his wife are frequently abused by their husbands/partners and that those men who hold the same opinion frequently abuse their wives or partners. z Five per cent of women and 6 per cent of men in BiH felt that a husband/partner has the right to hit or beat his wife/ partner for at least one of the various reasons mentioned in the survey. z Women and men most often justified a husband’s violence by instances where a woman neglects the children (4 per cent for women and 5 per cent for men). Justification of wife-beating was more present amongst the less educated women and men and amongst those living in the poorest households. HIV/AIDS and Sexual Behaviour that Increases the Risk of HIV Transmission knowledge about HIV Transmission and Misconceptions about HIV/AIDS One of the most important prerequisites for reducing the rate of HIV infection is accurate knowledge of how HIV is transmitted and strategies for preventing transmission. The UN General Assembly Special Session on HIV/AIDS called on governments to improve the knowledge and skills of young people on how to protect themselves against HIV. z Nearly all women and men in BiH aged 15-49 had heard of HIV/AIDS (about 99 per cent), while a lower percentage of women (82 per cent) and men (88 per cent) knew about the two main ways to prevent HIV transmission: having only one faithful uninfected partner and using a condom every time. The percentages for women and men aged 15-24 were similar. z Less than 1 half of women (43 per cent) and men (45 per cent) aged 15-49 had comprehensive knowledge of HIV prevention methods and transmission, while such knowledge was somewhat higher amongst persons aged 15-24 (48 per cent for both sexes). z Forty-eight per cent of women and men aged 15-49 rejected the two most common misconceptions regarding HIV/ AIDS, namely that HIV can be transmitted by mosquito bites and that HIV can be transmitted by sharing food with an infected person, and knew that a healthy looking person can be infected. Amongst persons aged 15-24 this percentage was somewhat higher at 54 per cent for women and 52 per cent for men. z In BiH 85 per cent of women and 75 per cent of men aged 15-49 knew that HIV can be transmitted from mother-to- child. One in eight women and one in four men did not know of any specific means of mother-to-child transmission of HIV. The percentage of women and men with knowledge on mother-to-child HIV transmission increased with their level of education and wealth. xxii Multiple indicator cluster survey 2011–2012 Monitoring the situation of children and woMen 1 I Introduction Background This report presents findings based on the indicators taken from the BiH MICS conducted in 2011 and 2012 by the Federal Ministry of Health, the Ministry of Health and Social Welfare of RS and the Institute for Public Health of FBiH (as the implementing agency for the FBiH, under the auspices of FMH) as well as the Agency for Statistics of BiH. Technical and financial support was provided by UNICEF together with financial support from UN Women2 and UNFPA as well as UNHCR. An identical methodological approach as well as an identical approach towards fieldwork and data entry, data processing and analysis was applied in the FBiH, RS and BD. This survey provides valuable information on the situation of children, women and men in BiH and is based, to a large extent, on the need to monitor progress towards the goals and targets arising from current 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. These commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements governments have committed themselves to improve the conditions for children and to monitor progress towards that end. UNICEF has been assigned a supporting role in this task. A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the A World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with governments, relevant funds, programs and the specialised 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”. MICS4 results are of particular importance for assessing the progress made towards the 2015 goals and targets of the Millennium Declaration and the Plan of Action of A World Fit for Children and therefore they supplement available administrative data and official statistics. 2 un women supported the preparation of the Mics4 master sample frame. Access to Mass Media and Use of Information/Communication Technology MICS4 collected information on exposure of women and men aged 15-49 to newspapers/magazines, radio and television, as well as the use of computers and the Internet amongst persons aged 15-24. z Forty-four per cent of women and 56 per cent of men aged 15-49 had been exposed to all three types of media (newspaper, radio and television) on a weekly basis, while less than 1 per cent of women and men are not exposed to any type of media at least once a week. z Exposure of both sexes to television was near-universal, while exposure of both women and men aged 15-49 to the printed media rose in line with an increased level of education and or wealth and was higher amongst those living in urban areas. z Most women and men aged 15-24 had used a computer during their lifetime (97 per cent), while a lower proportion had used a computer at least once a week during the last month (84 per cent of women and 87 per cent of men). The pattern of Internet usage was similar to the pattern of computer use for both sexes. Tobacco and Alcohol Use Many studies have shown that using tobacco products is a risk factor for many deadly diseases, including cardiovascular disease and respiratory illness. Excessive and long-term alcohol use also increases the risk of cardiovascular problems, neurological impairment, liver disease and social problems. z Use of tobacco products in BiH was more common amongst men than amongst women. Two-thirds of men aged 15-49 and slightly less than half of women in this age group reported having used a tobacco product during their lifetime. z Twenty-seven per cent of women and 40 per cent of men in BiH indicated that they smoked cigarettes or had used smoke or smokeless tobacco products on one or more days during the last one month. z Seventy per cent of men that currently smoked cigarettes had smoked more than 20 cigarettes in the last 24 hours, while the highest proportion of those women that currently smoked cigarettes had smoked 10-19 cigarettes during the same period (41 per cent). z A higher percentage of men aged 15-49 (8 per cent) had had at least one drink of alcohol before age 15 compared to women (1 per cent). Alcohol consumption before age 15 for both sexes was most common in the youngest surveyed age group (15-19 years of age). z At least one drink of alcohol on one or more days during the last one month applied to a higher proportion of men (53 per cent) than women (18 per cent). Alcohol use was highest amongst women aged 20-24 (27 per cent). Alcohol use amongst women rose in line with increased wealth and level of education, while such differences were less pronounced amongst men. Subjective Well-Being Understanding the satisfaction of young women and young men in different areas of their lives and their happiness can help us to gain a comprehensive picture of young people’s life situations. z More than one half of young women (54 per cent) and half of men (50 per cent) aged 15-24 were satisfied with their life. The proportion of young persons of both sexes who were satisfied with life was higher amongst those with higher education compared to those with secondary or primary education. z In contrast to life satisfaction, happiness is a fleeting emotion that can be affected by numerous day-to-day factors. Ninety-three per cent of women and 91 per cent of men aged 15-24 years indicated that they were very happy or happy. z About one-third of women and men aged 15-24 in BiH thought that their lives had improved during the previous year and expect that their lives would get better after one year. Such positive perceptions were more common amongst people of both sexes aged 15-24 who were currently married/in union or were ever married/in union (42 per cent of women and 64 per cent of men) compared to those who had never been married/in union (31 per cent of women and 35 per cent of men). 2 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 3 II Sample and Survey Methodology Sample Design The sample for the BiH MICS4 was designed to provide estimates for a large number of indicators on the situation of children, women and men at the level of BiH, FBiH and RS (the main geographic sampling domains)3 together with urban and rural areas. The official population estimate for BiH is 3.8 million inhabitants living in about one million households.4 The FBiH covers approximately 51 per cent of the territory of BiH and 62 per cent of the population; the RS covers approximately 49 per cent of the territory and about 36 per cent of the population; and the BD covers less than 1 per cent of the territory and approximately 2 per cent of the population. The last census in BiH was conducted in 1991 and thus the representative samples for social surveys were selected using the Master Sample methodology. The 2009 Master Sample for BiH was used to select the BiH MICS4 master sample frame, which was updated for this purpose by BHAS, FOS and RSIS in December 2010.5 The cluster sample was selected in two stages. The primary sampling units (PSUs) were the 1991 Census enumeration areas (EAs). The EAs were stratified according to the three administrative units of BiH (FBiH, RS and BD) and a sample of 500 EAs was selected to be updated for the BiH MICS46. The low birth rate, typical for the region and neighbouring countries, and small household size in BiH were the main challenges that implied the need for sample stratification in BiH. Lessons learned from the previous MICS rounds in BiH were that there is a need to oversample the population in RS and BD. A higher sampling rate was used for the EAs in RS and BD during the selection process. Within each stratum the EAs were selected with equal probability. Following the master sample frame listing it was found that there was large variability in the number of households per EA.7 The MICS4 household sample was drawn from the 22,619 households8 listed in the 484 EAs9 in which the listing was successfully implemented in BiH. In order to improve sample efficiency of indicators related to the under 5 and 5-24 age groups, the list of households was divided into three second stage strata, the list of households was divided into three second stage strata:10 households with children under 5 (type 1), households with members aged 5-24 (type 2) and all remaining households without children and youth (type 3). Firstly all households with children under 5 were selected, followed by the selection of all households with members aged 5-24 from the remaining list of households. The list of households for each second stage stratum was combined across all sampled EAs and ordered in accordance with the FBiH/RS/BD, cantons in the FBiH, municipalities and urban/rural areas to provide implicit stratification. The sample households within each second stage stratum were selected systematically with equal probability from the combined listing. In this manner, a total of 6,800 households in 474 EAs were selected at the level of BiH:11 2,441 households with children under 5, 1,788 households with members aged 5-24 and 2,571 households without children and youth. Ten EAs with only 1 household were not selected during the sample selection procedure. During fieldwork an additional 38 households12 were identified in the sampled households, resulting in a final sample of 6,838 households. The sample was stratified by type of household and is not self-weighting. Sample weights have been used for reporting the results. A more detailed description of the sample design can be found in Appendix A. 3 Due to budgetary constraints, BD is represented in the same manner as municipalities in BiH. 4 Estimate of the Agency for Statistics of BiH from 30 June 2011. 5 Ten months prior to the start of MICS4 fieldwork. 6 The listing was conducted in 490 EAs because 10 EAs were inaccessible due to flooding (five each in the FBiH and RS). An additional 6 EAs were discarded because of the poor quality of data collection (3 each in the FBiH and RS). 7 Due to the large variability in the number of listed households by sample EA the number of households selected in each EA in all three second stage strata varies considerably, based on the sampling procedures. However, this sampling strategy reduces the variability in the weights of the sample households within each of the combined first and second stage strata. 8 13,394 households in the FBiH, 8,155 in RS and 1,070 in BD. Six households were discarded from the 2010 MICS4 master sample frame (that initially comprised of 22,625 households) because of a lack of data on the ages for all household members. 9 255 EAs in the FBiH, 204 in RS and 25 in BD. 10 The EAs were not selected with probability proportional to size due to the outdated character of the census information and the changes in EA sizes since the census. 11 251 EAs in the FBiH, 198 in RS and 25 in BD. 12 Due to multiple households being found in the same dwelling unit. MICS4 is also important as a source of information for monitoring the implementation of the Convention on the Rights of the Child and the Convention on the Elimination of All Forms of Discrimination against Women and the Gender Action Plan of BiH as well as other commitments arising from the European integration processes and human rights principles contained within the Constitution of BiH, the Constitution of the FBiH and the Constitution of RS. Towards the end of 2011 and the beginning of 2012 the Ministry for Human Rights and Refugees of BiH, in cooperation with the Agency for Statistics of BiH, conducted a MICS4 survey on a sample of Roma households in BiH using the same methodology and similar survey tools. The results of the MICS4 Roma Survey in BiH will be available in a separate survey report. This report presents the results of the indicators and topics covered by the BiH MICS4 survey. Survey Objectives The 2011–2012 BiH Multiple Indicator Cluster Survey has the following as its primary objectives: z provide essential information for evaluating the situation of children, women and men in BiH; z furnish data needed for monitoring progress towards the goals established through the Millennium Declaration and other internationally agreed upon goals as a basis for future action; z contribute towards the improvement of data and monitoring systems in BiH and strengthen the technical expertise in the design, implementation and analysis of such systems; z generate data on the situation of children, women and men, including the identification of vulnerable groups and disparities, to provide information for policies and interventions within health and social care services and for the reduction of poverty. 4 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 5 z Marriage/Union z Sexual Behaviour z HIV/AIDS z Tobacco and Alcohol Use z Life Satisfaction z Health Care17 The Questionnaire for Children Under Five was administered for mothers or caretakers of children under 5 years of age18 living in the households. Normally, the questionnaire was administered for mothers of children under 5; however, in cases where the mother was not listed on the household roster a primary caretaker for the child was identified and interviewed. The questionnaire included the below modules. z Age z Early Childhood Development z Breastfeeding z Care for Illness z Immunisation z Anthropometry The questionnaires were based on the MICS4 model questionnaire.19 From the MICS4 model English version, the questionnaires were translated into local languages used in BiH. The questionnaires were pre-tested in the FBiH and RS in the City of Banja Luka and in Sarajevo Canton during September 2011. The pre-test plan provided for interviews to be conducted in 48 households in the FBiH and 24 households in RS. The households, of which 50 per cent were urban and rural households respectively, were randomly selected from the Master Sample template. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the questionnaires used in BiH MICS4 is provided in Appendix F to this report. A separate MICS4 survey for a Roma sample was conducted by the Ministry for Human Rights and Refugees of BiH, in cooperation with the Agency for Statistics of BiH in parallel to MICS4 for a sample of the total population. The MICS4 Roma Survey used the same methodology and similar survey tools. The questionnaires provided in Appendix F of this report reflect the survey tools of both surveys (apart from the Questionnaire of Possession of Documents, which was an additional, country specific form used only within the Roma Survey). The results of the MICS4 Roma Survey will be available in a separate survey report. Training and Fieldwork Training for the fieldwork was conducted over 12 days20 during October 2011 for the survey teams in the FBiH and in November 2011 for the survey teams working in RS and BD. Training included lectures on interviewing techniques and the content of the questionnaires as well as practical work on presenting the questions. Towards the end of the training period the trainees spent two days conducting practice interviews in urban and rural areas in the City of Banja Luka and Sarajevo Canton. The fieldwork was conducted by eight teams in the FBiH and 4 teams in RS.21 These teams were generally comprised of 3 interviewers (two female and one male), one editor, one measurer and a supervisor. In some cantons in the FBiH the size of the team was determined by the number of households to be interviewed during the fieldwork. Fieldwork in the FBiH began in November 2011 and was concluded in February 2012, while fieldwork in RS began in November 2011 and was concluded in March 2012. 17 Country specific additional module that was only used within the MICS4 Roma Survey. 18 The terms ‘children under 5’, ‘children aged 0-4 years’ and ‘children aged 0-59 months’ are used interchangeably in this report. 19 The model MICS4 questionnaires can be found at <www.childininfo.org/mics4_questionnaire.html>. 20 The 12 day training included a 2 day practice pilot study. 21 One team from RS was tasked with conducting fieldwork in BD. Questionnaires Four sets of standard MICS4 questionnaires were used in the survey: 1) a household questionnaire that was used to collect information on all de jure household members,13 the household and the dwelling; 2) a women’s questionnaire administered in each household for all women aged 15-49 years, 3) a men’s questionnaire administered in each household for all men aged 15-49 years and 4) an under-5 questionnaire administered for mothers or caretakers for all children under 5 living in the household. The survey also included two country specific questionnaires that are not part of the standard MICS survey instruments: 1) Questionnaire Form for Drug Use Assessment (self-administered questionnaire for women and men age 15-49) and 2) Questionnaire Form for Defining Residency Status (asked to household questionnaire respondent or another knowledgeable adult). The findings for these questionnaires are not presented in this report and will be analysed separately. The Household Questionnaire included the below modules z Household Listing Form z Education z Water and Sanitation z Household Characteristics z Child Discipline z Hand Washing The Questionnaire for Individual Women was administered for all women living in the households aged 15-49 and included the below modules z Women’s Background z Access to Mass Media and Use of Information/Communication Technology z Child Mortality14 z Desire for Last Birth z Maternal and Newborn Health z Illness Symptoms z Contraception15 z Unmet Need z Attitudes towards Domestic Violence z Marriage/Union z Sexual Behaviour z HIV/AIDS z Tobacco and Alcohol Use z Life Satisfaction z Health Care16 The Questionnaire for Individual Men was administered for all men living in the households aged 15-49 and included the below modules z Men’s Background z Access to Mass Media and Use of Information/Communication Technology z Attitudes towards Domestic Violence 13 Persons who were usual residents in the household. 14 Only questions about the total number of live births, date of last birth and the country specific additional questions on wasted pregnancies 15 Included an additional, country specific question, on knowledge of contraceptive methods. 16 Country specific additional module that was only used within the MICS4 Roma Survey. 6 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 7 III Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 6,838 households in the sample 6,334 were found to be occupied; of these, 5,778 households were successfully interviewed for a household response rate of 91 per cent. In the interviewed households 4,645 women aged 15-49 were identified and 4,446 successfully interviewed, yielding a response rate of 96 per cent. In addition, 4,718 men aged 15-49 were listed in the household questionnaire as being household members. Questionnaires were completed for 4,353 eligible men, which corresponds to a response rate of 92 per cent within the interviewed households. There were 2,332 children under age five listed in the household questionnaire. Questionnaires were completed for 2,297 children, which corresponds to a response rate of 99 per cent within the interviewed households. The overall response rate for the women’s, men’s and children’s questionnaires were 87 per cent, 84 per cent, and 90 per cent, respectively (see Table HH.1). In the FBiH 3,618 households were successfully interviewed out of a total of 4,107 sampled households, which corresponds to a response rate of 93 per cent. Within the interviewed households 3,152 women and 3,133 men aged 15-49 were identified. Out of these, 3,067 women were interviewed with a response rate of 97 per cent and 2,960 men were interviewed with a response rate of 95 per cent. Questionnaires were completed for 1,518 children out of the 1,531 eligible children in the FBiH, which corresponds to a response rate of 99 per cent. In RS 1,945 households were successfully interviewed out of a total of 2,408 sampled households, which corresponds to a response rate of 90 per cent. Within the interviewed households, 1,360 women and 1,435 men aged 15-49 were identified; out of these, 1,252 women were interviewed with a response rate of 92 per cent and 1,258 men were interviewed with a response rate of 88 per cent. Of the 725 eligible children in RS questionnaires were completed for 704 children corresponding to a response rate of 97 per cent. Table HH.1: Results of the household, women’s, men’s and under-5’s interviews Number of households, women, men and children under 5 by results of the household, women’s, men’s and under-5’s interviews and the household, women’s, men’s and under-5’s response rates for, BiH 2011–2012   Area Administrative unit     Urban Rural FBiH RS BD Total Households  Sampled 2,708 4,130 4,107 2,408 323 6,838 Occupied 2,451 3,883 3,895 2,157 282 6,334 Interviewed 2,156 3,622 3,618 1,945 215 5,778 Household response rate 88.0 93.3 92.9 90.2 76.2 91.2 Women Eligible 1,649 2,996 3,152 1,360 133 4,645 Interviewed 1,576 2,870 3,067 1,252 127 4,446 Women’s response rate 95.6 95.8 97.3 92.1 95.5 95.7 Women’s overall response rate 84.1 89.4 90.4 83.0 72.8 87.3 Men Eligible 1,619 3,099 3,133 1,435 150 4,718 Interviewed 1,489 2,864 2,960 1,258 135 4,353 Men’s response rate 92.0 92.4 94.5 87.7 90.0 92.3 Men’s overall response rate 80.9 86.2 87.8 79.0 68.6 84.2 Children under 5 Eligible 812 1,520 1,531 725 76 2,332 Mothers/caretakers interviewed 802 1,495 1,518 704 75 2,297 Under-5’s response rate 98.8 98.4 99.2 97.1 98.7 98.5 Under-5’s overall response rate 86.9 91.7 92.1 87.6 75.2 89.9 Data Processing Data entry and processing was conducted separately for the FBiH, RS and BD. The data was entered using CSPro software. Data was entered into a total of 11 microcomputers by 8 data entry operators in the FBiH and 6 persons in RS; the process was supervised by data entry supervisors. Data entry commenced in the FBiH four weeks after the start of data collection (December 2011) and was concluded in April 2012. In RS data entry for the RS and BD started one week after data collection began (December 2011) and was concluded in May 2012. The data was analysed using the SPSS (Statistical Package for Social Sciences) software programme (Version 18) and the model syntax and tabulation plans developed by UNICEF were also used for this purpose. In order to ensure quality control all of the questionnaires were double entered and internal consistency checks were performed. Procedures and standard programmes developed under the global MICS4 programme and adapted to the BiH questionnaires were used throughout. Report Preparation The Constitution of BiH, which is an integral part of the Dayton Peace Agreement (Annex 4), defines the administrative structure of BiH, as a state comprised of two entities, the FBiH and RS, as well as a third administrative unit, the BD. The FBiH, RS and BD, have their own governments and all jurisdictions and responsibilities that have not been assigned through the Constitution of Bosnia and Herzegovina to its institutions. This includes legislative and executive jurisdiction over health care and social protection, which have, in the FBiH, been further assigned to 10 federal units (Cantons). The report preparation process in BiH included preparation of reports for RS, the FBiH and the BiH report. Due to the country’s administrative structure and the jurisdiction of the FBiH and RS over strategies addressing child well-being and development the data and analyses contained in the MICS4 report are presented so as to reflect data for BiH, the FBiH and RS. The relatively small sample size in BD provides too few cases to produce statistically sound estimates for all indicators for the report. Data for BD is presented in the tables in this report wherever possible. How to Read the Tables The following data, collected through this survey, has not been presented in the tables of this report: z data calculated on the basis of a small number of cases (fewer than 25 unweighted cases) for the education category ‘None’, unless it refers to the “Education level of the household head” – except in Tables HH.4, HH.4M and HH.5 (data for the education category ‘None’ is shown in tables when it refers to the “Education level of the household head”); z data disaggregated by the language of the household head; z data that is not part of the global MICS report template, except data on knowledge of contraceptive methods, (data not presented in the report, coming from country specific survey instruments, includes data on: drug use, residency status, wasted pregnancies and health care). Please note: z (M) — the letter ‘M’ after a table/figure code indicates that it refers to the male population; z (*) — an asterisk in a table indicates that a percentage or proportion has been suppressed because it is based on fewer than 25 unweighted cases; z (number) — values in parenthesis indicate that the percentage or proportion is based on only 25 to 49 unweighted cases and should be treated with caution; z age groups presented in this report also include those persons that had reached the full age indicated by the upper limit for an age group, for instance, respondents aged 15-49 include persons who had reached a full 49 years of age, while the age group of children aged 20-23 months includes those who had reached a full 23 months. 8 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 9 In the FBiH 13,374 household members were identified in the 3,618 households interviewed during the survey; of these, 6,737 were female and 6,636 male. The distribution of the surveyed population shows that the surveyed households included 19 per cent of children under 15 years of age (of which 5 per cent were children under 5 years), 72 per cent of persons aged 15-64 and 9 per cent of persons aged 65 or above. The proportion of children under 18 was 25 per cent. This distribution does not differ greatly from the estimates prepared by FOS based on the most recent surveys. In RS 6,524 household members were identified in the 2,157 households that were successfully interviewed during the survey; of these, 3,299 were female and 3,225 male. The distribution of the surveyed population shows that the surveyed households included 18 per cent of children under 15 years of age (of which 4 per cent were children under 5 years), 66 per cent of persons aged 15-64 and 16 per cent of persons aged 65 or above. The proportion of children under 18 was 22 per cent. This distribution does not differ greatly from the estimates made by RSIS based on the most recent household surveys. The overall dependency rate, namely the ratio of the inactive population (aged 0-14 and 65+) to the active population (aged 15-64), expressed as a percentage was 43 per cent, meaning that there were 43 inactive persons for each 100 active ones. Figure HH.1 shows a population pyramid with a narrow base, which indicates a low proportion of the population in the 0-4 age group and corresponds to the low birth rate. Figure HH.1: Age and sex distribution of household population, BiH 2011–2012 Tables HH.3 to HH.5 provide basic information on the households, female respondents aged 15-49, male respondents aged 15-49 and children under 5 years of age by presenting the unweighted as well as weighted figures. Information on the basic characteristics of the households, women, men and children under 5 interviewed in the survey is essential to interpret the findings presented later in the report. This information can also provide an indication of the representativeness of the survey. The remaining tables in this report are presented with weighted numbers only. See Appendix A for more details about the weighting procedures. Table HH.3 provides basic background information on the households. The sex of the household head, administrative unit (FBiH, RS and BD) area, the number of household members and education 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 contained in the report. Data on the background characteristics of interviewed household members in the FBiH, RS and BD is not shown in the tabular display of data within this report; however, it is presented in the reports for the FBiH and RS. As expected, the response rates for urban areas were lower than for rural areas (88 per cent compared to 93 per cent) and the rates were also lower amongst men compared to women and children in the FBiH, RS and BD and across both urban and rural areas. The response rate for households in BD (76 per cent) was additionally reduced compared to the FBiH and RS due to the inability to conduct interviews in two clusters for safety reasons. Characteristics of Households The weighted age and sex distribution of the survey population is provided in Table HH.2. The distribution was also used to produce the population pyramid in Figure HH.1. In the 5,778 households successfully interviewed during the survey 20,221 household members were listed; of these, there was an approximately equal number of males (10,036) and females (10,185). Table HH.2: Household age distribution by sex Per cent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (aged 0-17 years) and adult populations (aged 18 or above), by sex, BiH 2011–2012   Males Females Total Number Per cent Number Per cent Number Per cent Age (years) 0-4 437 4.4 454 4.5 891 4.4 5-9 706 7.0 546 5.4 1,252 6.2 10-14 871 8.7 794 7.8 1,665 8.2 15-19 817 8.1 763 7.5 1,580 7.8 20-24 895 8.9 824 8.1 1,719 8.5 25-29 644 6.4 593 5.8 1,237 6.1 30-34 559 5.6 662 6.5 1,222 6.0 35-39 710 7.1 734 7.2 1,443 7.1 40-44 740 7.4 802 7.9 1,542 7.6 45-49 856 8.5 847 8.3 1,703 8.4 50-54 814 8.1 744 7.3 1,558 7.7 55-59 637 6.3 609 6.0 1,246 6.2 60-64 427 4.3 460 4.5 887 4.4 65-69 236 2.4 376 3.7 613 3.0 70-74 323 3.2 436 4.3 759 3.8 75-79 237 2.4 325 3.2 562 2.8 80-84 91 0.9 142 1.4 233 1.2 85+ 31 0.3 68 0.7 99 0.5 Missing/DK 4 0.0 5 0.1 9 0.0 Dependency age groups 0-14 2,014 20.1 1,794 17.6 3,809 18.8 15-64 7,099 70.7 7,038 69.1 14,138 69.9 65+ 918 9.1 1,347 13.2 2,265 11.2 Missing/DK 4 0.0 5 0.1 9 0.0 Child and adult populations Children aged 0-17 years 2,522 25.1 2,333 22.9 4,855 24.0 Adults aged 18+ years 7,510 74.8 7,847 77.0 15,357 75.9 Missing/DK 4 0.0 5 0.1 9 0.0 Total 10,036 100.0 10,185 100.0 20,221 100.0 The age and sex distribution of the survey population in MICS4 does not deviate greatly from the estimates provided by the statistical institutions in BiH and reflects a distribution very similar to that obtained from other household surveys22 and MICS3. The proportion of children aged 0-14 from the total population is almost two times greater than the proportion of persons aged 65 and above of the population (19 per cent versus 11 per cent), which indicates a relatively young population. However, mean numbers of household members per household and the low proportion of children under 5 years of age confirm the current relatively negative population trends. While the sex distribution of the population does not show any clear differentials it is important to note that amongst the populations aged 5-29 and 45-59 there were a higher proportion of males compared to females. 22 2007 BiH Household Budget Survey: Final Results BHAS, FOS, RSIS, Banja Luka/Sarajevo 2008. 8 6 4 2 0 2 4 6 8 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Per cent Females Males 10 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 11 Characteristics of Female and Male Respondents 15-49 Years of Age and Children Under-5 Tables HH.4, HH.4M and HH.5 provide information on the background characteristics of female and male respondents aged 15-49 and of children under age 5. In all three tables the numbers of weighted and unweighted observations are presented. In addition, the tables also show the number of observations for each background category. These categories are used in the subsequent tabulations of this report. Table HH.4: Women’s background characteristics Per cent and frequency distribution of women aged 15-49 years by selected background characteristics, BiH 2011–2012   Weighted per cent Number of women   Weighted Unweighted Administrative unit  FBiH 71.5 3,180 3,067 RS 27.2 1,210 1,252 BD 1.3 56 127 Area Urban 34.8 1,548 1,576 Rural 65.2 2,898 2,870 Age (years) 15-19 14.4 642 424 20-24 15.2 677 632 25-29 11.2 498 881 30-34 12.8 568 860 35-39 14.5 646 643 40-44 15.5 690 494 45-49 16.3 724 512 Marital/Union status Currently married/in union 62.2 2,764 3,237 Widowed 2.6 116 83 Divorced 2.3 101 90 Separated 1.0 43 49 Never married/in union 32.0 1,422 986 Missing/DK 0.0 0 1 Motherhood status Ever gave birth 64.4 2,862 3,303 Never gave birth 35.6 1,581 1,139 Births in last two years Had a birth in last two years 6.7 298 718 Had no birth in last two years 93.3 4,148 3,728 Education None 0.4 16 20 Primary 23.9 1,064 1,044 Secondary 58.6 2,604 2,628 Higher 17.1 762 754 Wealth index quintile Poorest 14.0 620 689 Second 19.1 847 846 Middle 21.9 976 975 Fourth 22.9 1,020 929 Richest 22.1 983 1,007 Total 100.0 4,446 4,446 Table HH.3: Household composition Per cent and frequency distribution of households by selected characteristics, BiH 2011–2012   Weighted per cent Number of households   Weighted Unweighted Sex of household head  Male 81.1 4,686 4,669 Female 18.9 1,092 1,109 Administrative unit FBiH 64.2 3,710 3,618 RS 34.1 1,968 1,945 BD 1.7 100 215 Area Urban 36.7 2,118 2,156 Rural 63.3 3,660 3,622 Number of household members 1 11.5 664 760 2 17.0 982 1,078 3 20.1 1,160 1,088 4 28.0 1,618 1,367 5 13.6 784 750 6 6.5 375 459 7 2.3 134 183 8 0.6 33 54 9 0.3 19 23 10+ 0.2 9 16 Education of household head None 4.4 256 291 Primary 31.2 1,805 1,895 Secondary 53.9 3,114 2,995 Higher 10.4 601 594 Missing/DK 0.0 2 3 Total 100.0 5,778 5,778     Households with at least One child aged 0-4 years 13.2 5,778 5,778 One child aged 0-17 years 50.4 5,778 5,778 One woman aged 15-49 years 66.1 5,778 5,778 One man aged 15-49 years 66.9 5,778 5,778 Mean household size 3.5 5,778 5,778 The weighted and unweighted numbers of households are equal, since sample weights were normalised (see Appendix A). The table also shows the proportion of households with at least one child under 18, at least one child under 5, at least one woman aged 15-49 and at least one man aged 15-49. The table also shows the weighted average household size estimated by the survey. The age structure of the household heads does not differ greatly from the findings of surveys conducted by the statistical system in BiH.23 In 19 per cent of cases in this survey the household heads were women. The highest percentage of households were located in rural areas (63 per cent) and had a household head with secondary education (54 per cent). At 28 per cent, households with 4 members are the most frequent, while the proportion of households with 2 to 3 members was 37 per cent of the total household population (the estimated average household size was 3.5 members). The majority of interviewed households had at least one female member and one male member aged 15-49 (66 per cent), half of them had a child aged 0-17, while the lowest proportion of households had a child aged 0-4 (13 per cent). 23 Nearly 80 per cent of household heads in BiH were men. The 2007 BiH Household Budget Survey: Final Results BHAS, FOS, RSIS, Banja Luka/Sarajevo 2008 indicates that in 80 per cent of cases household heads were men (page 21). 12 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 13 Table HH.4M: Men’s background characteristics Per cent and frequency distribution of men aged 15-49 years by selected background characteristics, BiH 2011–2012   Weighted per cent Number of men   Weighted Unweighted Administrative unit  FBiH 69.2 3,010 2,960 RS 29.2 1,271 1,258 BD 1.6 71 135 Area Urban 32.7 1,422 1,489 Rural 67.3 2,931 2,864 Age (years) 15-19 15.7 684 442 20-24 17.1 743 465 25-29 12.3 534 700 30-34 10.5 459 837 35-39 13.7 597 809 40-44 14.2 617 577 45-49 16.5 719 523 Marital/Union status Currently married/in union 51.7 2,252 2,779 Widowed 0.1 4 4 Divorced 1.3 57 57 Separated 0.5 24 27 Never married/in union 46.3 2,017 1,486 Education None 0.2 10 10 Primary 12.5 543 584 Secondary 71.6 3,117 3,123 Higher 15.7 683 636 Wealth index quintile Poorest 15.7 685 750 Second 19.5 848 852 Middle 22.7 989 961 Fourth 20.5 893 840 Richest 21.5 938 950 Total 100.0 4,353 4,353 Similarly, Table HH.4M provides background characteristics for the male respondents aged 15-49. The table includes information on the distribution of men in the FBiH, RS and BD and their distribution by age, marital status, education and wealth (wealth index quintiles). Unlike women, the highest proportion of men in BiH and the FBiH fell within the 20-24 age group while in RS the highest percentage of men was within the 15-19 age group. As with women, the age distribution of men shows a declining trend after age 20 whereas a rising trend appears amongst women aged 30 and above and amongst men aged 35 and above. Most men (72 per cent) had secondary education, which is a higher percentage compared to the women (59 per cent). A higher percentage of men had higher education (16 per cent) than primary education (13 per cent), while a higher percentage of women had primary education (24 per cent) than higher education (17 per cent). Two-thirds of men lived in rural areas and slightly more than half of them (52 per cent) were married or in union. Slightly less than two-thirds of men (64 per cent) were in the three poorest wealth quintiles of the population. Background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by various background characteristics: FBiH, RS and BD; sex, area, age, education level of the mother or caretaker and the wealth index quintile. The overall sex distribution of children was almost even (49 per cent of boys and 51 per cent of girls). As with women and men, two-thirds of children under 5 years of age lived in rural areas. The majority of mothers with children under 5 years of age had secondary education (62 per cent), while a lower percentage had primary (23 per cent) or higher education (14 per cent). Mothers or caretakers with no education constituted less than 1 per cent of the survey population. More than half of children (58 per cent) were in the three poorest quintiles of the population. Table HH.4 provides background characteristics for female respondents aged 15-49. The table includes information on the distribution of women in the FBiH, RS and BD; their distribution by area, age, marital status, motherhood status, births in the last two years, level of education24 and wealth (wealth index quintiles25). The age distribution of women in BiH shows that the highest proportion of women of reproductive age was in the 45-49 age group. In the FBiH the highest percentage of women was also in the 45-49 age group, while in RS the highest percentage was in the 35-39 age group, followed by women aged 45-49. This data indicates clear differences by education level. Most women had secondary education (59 per cent), followed by primary education (24 per cent), while the lowest percentage of women had higher education (17 per cent). The distribution of women by marital status and motherhood status was very similar: 62 per cent of women were married or in union, while 64 per cent of women had given birth in their lifetime. Only 7 per cent of women had had a live birth in the two years preceding the survey. Almost two-thirds of women lived in rural households and slightly more than half (55 per cent) were in the three poorest wealth quintiles. 24 Unless otherwise stated, ‘education’ refers throughout this report, when it is used as a background variable, to the education level attained by the respondent. 25 Principal components analysis was performed using information on the ownership of consumer goods (assets), dwelling characteristics, water and sanitation as well as 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 were living in and finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). The assets used in these calculations are listed below. • Source of drinking water; • Type of sanitation facility; • Number of rooms used for sleeping; • Main material of dwelling floor, roof and exterior walls; • Type of fuel used for cooking; • Presence in the household of electricity, radio, a television, mobile and or non-mobile phone, refrigerator, bed, electric stove, personal computer/laptop, Internet connection, air-conditioner, digital camera, washing machine, tumble dryer, dishwasher, vacuum cleaner, DVD player, Jacuzzi and video surveillance system; • Presence in the household of a watch, bicycle, motorcycle/scooter, animal-drawn cart, car/truck, tractor; • Possession of a bank account. The wealth index is presumed 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 Filmer, D. and Pritchett, L., 2001. ‘Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India’. Demography 38(1): 115-132. Gwatkin, D.R., Rutstein, S., Johnson, K., Pande, R. and Wagstaff. A., 2000. ‘Socio-Economic Differences in Health, Nutrition and Population’. HNP/Poverty Thematic Group, Washington, DC: World Bank and Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro. 14 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 15 Ta bl e H A .6 : C hi ld re n’ s liv in g ar ra ng em en ts a nd o rp ha nh oo d Pe r c en t d is tr ib ut io n of c hi ld re n ag ed 0 -1 7 ye ar s ac co rd in g to li vi ng a rr an ge m en ts , p er ce nt ag e of c hi ld re n ag ed 0 -1 7 ye ar s in h ou se ho ld s no t l iv in g w ith a b io lo gi ca l p ar en t a nd p er ce nt ag e of ch ild re n w ho h av e on e or b ot h pa re nt s de ad , B iH 2 01 1– 20 12   Li vi ng w ith b ot h pa re nt s Li vi ng w it h ne it he r p ar en t Li vi ng w it h m ot he r on ly Li vi ng w it h fa th er o nl y Im po ss ib le to d et er m in e To ta l N ot li vi ng w ith a bi ol og ic al pa re nt 1 O ne o r bo th pa re nt s de ad 2 N um be r of c hi ld re n ag ed 0 -1 7 ye ar s O nl y m ot he r al iv e Bo th al iv e Bo th de ad Fa th er al iv e Fa th er de ad M ot he r al iv e M ot he r de ad Se x M al e 91 .0 0. 0 0. 3 0. 3 2. 8 2. 6 1. 0 0. 6 1. 5 10 0. 0 0. 6 3. 5 2, 52 2 Fe m al e 91 .5 0. 0 0. 1 0. 0 3. 9 2. 3 0. 6 0. 2 1. 3 10 0. 0 0. 2 2. 5 2, 33 3 A dm in is tr at iv e un it FB iH 90 .8 0. 0 0. 2 0. 2 3. 7 2. 1 0. 7 0. 3 1. 9 10 0. 0 0. 4 2. 7 3, 34 5 RS 92 .2 0. 0 0. 3 0. 0 2. 5 3. 3 1. 0 0. 5 0. 2 10 0. 0 0. 3 3. 9 1, 43 3 BD 95 .9 0. 0 0. 2 0. 0 3. 3 0. 4 0. 2 0. 0 0. 0 10 0. 0 0. 2 0. 4 77 A re a U rb an 88 .7 0. 0 0. 1 0. 1 5. 4 2. 7 0. 8 0. 8 1. 4 10 0. 0 0. 3 3. 6 1, 53 6 Ru ra l 92 .4 0. 0 0. 3 0. 1 2. 4 2. 4 0. 8 0. 2 1. 4 10 0. 0 0. 4 2. 7 3, 31 9 A ge (y ea rs ) 0- 4 95 .1 0. 0 0. 0 0. 0 3. 5 0. 2 0. 7 0. 0 0. 4 10 0. 0 0. 0 0. 2 89 1 5- 9 95 .2 0. 0 0. 2 0. 0 2. 4 1. 2 0. 5 0. 0 0. 5 10 0. 0 0. 2 1. 2 1, 25 2 10 -1 4 90 .3 0. 0 0. 1 0. 1 4. 2 2. 7 1. 1 0. 8 0. 6 10 0. 0 0. 2 3. 7 1, 66 5 15 -1 7 84 .8 0. 0 0. 6 0. 5 2. 9 5. 5 0. 8 0. 5 4. 4 10 0. 0 1. 0 6. 5 1, 04 6 W ea lt h in de x qu in ti le s Po or es t 86 .0 0. 0 0. 6 0. 0 4. 4 5. 6 2. 1 0. 0 1. 3 10 0. 0 0. 6 5. 6 79 5 Se co nd 89 .4 0. 0 0. 5 0. 0 3. 8 3. 3 0. 9 0. 3 1. 7 10 0. 0 0. 5 3. 6 97 3 M id dl e 93 .1 0. 0 0. 1 0. 0 2. 3 2. 0 0. 7 0. 5 1. 4 10 0. 0 0. 1 2. 5 1, 00 6 Fo ur th 92 .7 0. 0 0. 0 0. 4 2. 9 1. 0 0. 1 0. 6 2. 3 10 0. 0 0. 4 2. 1 1, 06 8 Ri ch es t 93 .8 0. 0 0. 0 0. 2 3. 5 1. 2 0. 6 0. 5 0. 2 10 0. 0 0. 2 1. 9 1, 01 3 To ta l 91 .3 0. 0 0. 2 0. 1 3. 3 2. 5 0. 8 0. 4 1. 4 10 0. 0 0. 4 3. 0 4, 85 5 1 M IC S in di ca to r 9 .1 7 2 M IC S in di ca to r 9 .1 8 Table HH.5: Under-5’s background characteristics Per cent and frequency distribution of children under five years of age by selected characteristics, BiH 2011–2012   Weighted per cent Number of under-5 children   Weighted Unweighted Sex  Male 48.9 1,124 1,131 Female 51.1 1,173 1,166 Administrative unit   FBiH 70.1 1,611 1,518 RS 28.1 646 704 BD 1.8 40 75 Area   Urban 33.7 774 802 Rural 66.3 1,523 1,495 Age (months)   0-5 10.3 236 117 6-11 10.0 231 126 12-23 19.8 454 509 24-35 20.0 459 514 36-47 21.1 485 556 48-59 18.8 432 475 Mother’s education*   None 0.9 21 16 Primary 22.9 526 507 Secondary 62.1 1,426 1,416 Higher 14.1 324 358 Wealth index quintile   Poorest 16.9 388 398 Second 21.0 482 464 Middle 19.8 455 483 Fourth 20.4 469 427 Richest 21.9 502 525 Total 100.0 2,297 2,297 * Mother’s education refers to the educational attainment of mothers and caretakers of children under 5. Children’s Living Arrangements Children without parental care are a vulnerable group and monitoring enables the development of strategic responses and plans of action to address their needs. Table HH.6 presents information on the living arrangements of children under age 18. According to the data, 91 per cent of children aged 0-17 in BiH live with both parents (91 per cent in the FBiH and 92 per cent in RS). Seven per cent of children live with only one parent, while less than 1 per cent of children do not live with either one of their biological parents. Three per cent of children in BiH had lost one or both parents (3 per cent in the FBiH and 4 per cent in RS). A higher percentage of older children had lost one or both parents compared to younger children (7 per cent of the oldest and less than 1 per cent of the youngest children). Table HH.6 also shows that, according to the wealth index quintile, the percentage of children living with both parents was lowest in the poorest households. 16 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 17 The survey results indicate that 2 per cent of children under 5 in BiH were classified as underweight (2 per cent in FBiH and less than 1 per cent in RS), while less than 1 per cent of children were severely underweight (1 per cent in FBiH and less than 1 per cent in RS). One in eleven children of this age (9 per cent) was too short for their age (10 per cent in FBiH and 6 per cent in RS), whereby 4 per cent were severely stunted (5 per cent in FBiH and 2 per cent in RS). The data shows that wasting was present amongst 2 per cent of children (3 per cent in FBiH and 2 per cent in RS). There were no clear differences in the percentages of children who were underweight or wasted when viewed by area. The highest percentage of stunted children (16 per cent) and wasted children (9 per cent) was found amongst children aged 0-5 months, while the highest percentage of underweight children (5 per cent) was amongst children aged 6-11 months. Table NU.1 shows that nearly one in six children under 5 years of age in BiH (17 per cent) were overweight. The proportion of overweight children increased with the mother’s education level and household wealth and was highest amongst children whose mothers had higher education (22 per cent) and amongst children living in households in the two richest wealth quintiles (21 per cent each). Overweight children were present across all age groups: the percentage rose from the youngest age group and peaked amongst children aged 12-23 months (25 per cent), but was then followed by a decline in the percentage of overweight children (Figure NU.1). Figure NU.1: Percentage of children under age 5 who are underweight, stunted, wasted or overweight, BiH 2011–2012 Table NU.1 (a) was created for the purpose of comparing the nutritional status of children with the findings of the BiH MICS3 (2005–2006) and BiH MICS2 (2000) and for global reporting purposes (see Appendix G). This table shows children’s nutritional status according to the NCHS/CDC/WHO standards that have been in use since 1978 and were superseded by the new WHO standard in 2006. IV 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. The Millennium Development target is to reduce by half between 1990 and 2015 the proportion of people who suffer from hunger; this will also assist in the goal to reduce child mortality. Malnutrition is associated with more than half of all child deaths worldwide. Three-quarters of the children who die from causes related to malnutrition are only mildly or moderately malnourished and showed no outward sign of their vulnerability. In addition, undernourished children are more likely to die from common childhood ailments and more frequently suffer from faltering growth. In a well-nourished population there is a reference distribution of height and weight for children under age five. The reference population used in the 2011–2012 BiH MICS survey was based on the WHO growth standards.26 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 moderately or severely stunted. Children 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. 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 i.e., they are falling behind in developing their body weight relative to their height. Children whose weight-for-height is more than three standard deviations below the median are classified as severely wasted i.e., they are severely falling behind in developing their body weight relative to their height. 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 this survey, 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.27 Table NU.1 shows percentages of children under age 5 in relation to the three anthropometric indicators – weight- for-age, height-for-age and weight-for-height – based on anthropometric measurements taken during the fieldwork. This table also includes the percentage of overweight children i.e., children whose weight-for-height is more than two standard deviations above the median of the reference population, as well as z-scores for all three indicators. 26 http://www.who.int/childgrowth/standards/second_set/technical_report_2.pdf 27 It is a known fact that a large amount of missing data can result in biased findings. The extent of anthropometric data and data on the child’s age is of particular importance for the quality of the survey. Thus, children whose measurements are outside a plausible range and children whose full birth date (month and year) were not obtained 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 is applicable. For example, if a child has been weighed but his/her height has not been measured then the child is included in underweight calculations but not in the calculations for stunting and wasting. Percentages of children by age and reasons for their exclusion are shown in the data quality tables DQ.6 and DQ.7. In Table DQ.6, for example, amongst the children under 5 four per cent did not have their weight as well as weight and height measured, while 6 per cent of children did not have their height measured. Table DQ.7 shows that due to incomplete dates of birth, implausible measurements and missing weight and or height 4 per cent of children were excluded from the calculations of the weight-for-age indicator, while the figures are 6 per cent for the height-for-age indicator and 9 per cent for the weight-for-height indicator. 0 5 10 15 20 25 30 0 6 12 18 24 30 36 42 48 54 60 Underweight Age (months) Per cent Stunted Wasted Overweight 18 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 19 Breastfeeding and Infant and Young Child Feeding Breastfeeding in 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 artificial feeding (infant formula). This can contribute to faltering growth and micronutrient malnutrition and is unsafe if clean water is not readily available. WHO/UNICEF have the below feeding recommendations z Exclusive breastfeeding for the first six months. z Continued breastfeeding for two years or more. z Safe and age-appropriate complementary foods beginning at 6 months. z Frequency of complementary feeding: 2 times per day for infants 6-8 months and 3 times per day for those of 9-11 months. z It is also recommended that breastfeeding be initiated within one hour of birth. The indicators related to recommended child feeding practices are as shown below z Early initiation of breastfeeding (within one hour of birth) z Exclusive breastfeeding rate (< 6 months) z Predominant breastfeeding (< 6 months) z Continued breastfeeding rate (at 1 year and at 2 years) z Duration of breastfeeding (exclusive, predominant and any breastfeeding) z Age-appropriate breastfeeding (0-23 months) z Introduction of solid, semi-solid and soft foods (6-8 months) z Minimum meal frequency (6-23 months) z Milk feeding frequency for non-breastfeeding children (6-23 months) z Bottle feeding (0-23 months) Table NU.2 shows the proportion of children born in the two years preceding the survey who were ever breastfed, those who were first breastfed within one hour or one day of birth and those who received a prelacteal feed. Although a very important step in the management of lactation and the establishment of a physical and emotional relationship between the baby and the mother less than half of babies in BiH (42 per cent) were breastfed for the first time within one hour of birth, while 87 per cent of newborns started breastfeeding within one day of birth (almost all deliveries took place in a public health sector facility). The percentage of children who received a prelacteal feed was 21 per cent. There were no large differences between the FBiH and RS in the percentage of children who were ever breastfed (95 per cent each) or in the percentage of children who were first breastfed within one day of birth (about 87 per cent) and children who received a prelacteal feed (about 21 per cent). Every other woman in the FBiH (52 per cent) started breastfeeding her child within one hour of birth; in RS this was done by one in five women (21 per cent) (see Figure NU.2). Table N U .1: N utritional status of children Percentage of children under age 5 by nutritional status according to three anthropom etric indices: w eight for age, height for age, and w eight for height, BiH 2011–2012   W eight for age N um ber of children under age 5 H eight for age N um ber of children under age 5 W eight for height N um ber of children under age 5 U nderw eight M ean Z-Score (SD ) Stunted M ean Z-Score (SD ) W asted O verw eight M ean Z-Score (SD ) per cent below per cent below per cent below per cent above - 2 SD 1 - 3 SD 2 - 2 SD 3 - 3 SD 4 - 2 SD 5 - 3 SD 6 + 2 SD SexMale 1.8 0.9 0.7 1,083 8.9 4.2 0.3 1,054 2.3 1.8 16.7 0.8 1,017 Fem ale 1.3 0.9 0.7 1,116 8.9 3.5 0.2 1,083 2.4 1.4 18.0 0.8 1,061 A dm inistrative unit FBiH 2.0 1.2 0.8 1,577 9.9 4.6 0.3 1,553 2.6 2.0 17.7 0.8 1,499 RS 0.4 0.1 0.6 592 6.4 1.7 0.1 554 1.7 0.6 16.4 0.8 550 BD 0.0 0.0 1.0 29 1.4 1.4 0.8 29 1.3 0.0 17.3 0.9 30 A rea U rban 1.9 0.9 0.8 734 10.8 5.8 0.2 710 1.8 0.9 21.1 0.9 675 Rural 1.4 0.9 0.7 1,465 7.9 2.9 0.3 1,427 2.6 1.9 15.6 0.7 1,403 A ge (m onths) 0-5 2.7 0.4 0.2 226 15.8 8.4 0.1 210 8.8 7.3 8.3 -0.1 207 6-11 4.7 3.9 0.8 209 9.8 2.4 0.5 201 1.7 0.0 16.8 1.0 192 12-23 1.1 0.4 1.0 438 13.8 6.1 0.2 416 1.2 0.6 24.7 1.1 398 24-35 0.4 0.0 0.8 446 7.8 3.9 0.1 439 1.4 0.7 17.9 0.9 435 36-47 0.7 0.3 0.8 468 5.0 1.6 0.4 462 1.8 0.7 18.2 0.8 454 48-59 2.1 1.9 0.6 411 5.4 2.3 0.3 409 2.2 2.2 13.5 0.6 393 M other’s education* Prim ary 1.2 0.7 0.6 514 9.4 3.6 0.1 501 2.7 1.7 15.9 0.7 498 Secondary 1.7 1.1 0.8 1,350 9.1 4.0 0.3 1,310 2.4 1.8 17.2 0.8 1,263 H igher 1.4 0.3 0.8 316 7.4 3.6 0.4 306 1.3 0.3 21.8 0.9 298 W ealth index quintile Poorest 0.9 0.2 0.5 373 10.1 2.2 0.0 361 1.9 0.9 13.6 0.8 357 Second 1.5 1.0 0.6 457 9.6 3.3 0.3 449 2.9 2.0 15.4 0.6 436 M iddle 0.7 0.2 0.8 432 6.8 2.9 0.4 421 2.6 1.8 15.7 0.7 422 Fourth 0.4 0.2 0.9 449 7.6 4.8 0.3 433 1.5 0.8 20.7 0.9 415 Richest 3.9 2.7 0.8 488 10.3 5.5 0.2 473 2.7 2.2 20.7 0.8 449 Total 1.6 0.9 0.7 2,199 8.9 3.8 0.2 2,137 2.3 1.6 17.4 0.8 2,078 1 M ICS indicator 2.1a and M D G indicator 1.8 2 M ICS indicator 2.1b 3 M ICS indicator 2.2a 4 M ICS indicator 2.2b 5 M ICS indicator 2.3a 6 M ICS indicator 2.3b * Figures for the education category “N one” are based on few er than 25 unw eighted cases and are not show n in the table. 20 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 21 Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth, BiH 2011–2012 Table NU.3 shows exclusive breastfeeding28 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. The data is based on the reports of mothers/caretakers on their children’s consumption of food and fluids during the day or night that preceded the interview. Approximately 19 per cent of children aged less than six months in BiH were exclusively breastfed, while nearly one half of these children in BiH were predominately breastfed (46 per cent). Fifteen per cent of children were exclusively breastfed in the FBiH and this percentage in RS was about 32 per cent, while the percentage of predominantly breastfed children aged less than six months was 42 per cent in the FBiH and 63 per cent in RS. About 12 per cent of children aged 12-15 months and 20-23 months continued breastfeeding. At age one there was a similar percentage of children still being breastfed in the FBiH (13 per cent) and in RS (11 per cent), while amongst children aged 20-23 months 15 per cent of children in the FBiH and 6 per cent in RS were still being breastfed. There were no large differences in the percentage of exclusive breastfeeding between girls and boys; however, there was a higher proportion of predominantly breastfed children amongst boys (61 per cent) compared to girls (33 per cent). 28 ‘Exclusively breastfed’ refers to infants who received only breast milk (and vitamins, mineral supplements or medicine as needed). ‘Predominantly breastfed’ refers to infants who received breast milk and certain other liquids (water, water-based drinks, fruit juice, oral rehydration solutions, drops, vitamins, minerals and medications) but who do not receive anything else, in particular any other milk, food-based liquids and semi-solid or solid foods. 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 prelacteal feed, BiH 2011–2012   Percentage who were ever breastfed1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last-born children in the two years preceding the survey   Within one hour of birth2 Within one day of birth Administrative unit FBiH 95.2 51.5 87.3 20.5 211 RS 95.3 20.9 87.6 21.5 82 BD (97.7) (7.0) (70.9) (41.8) 6 Area Urban 94.3 36.4 85.4 19.2 94 Rural 95.7 45.0 87.8 22.0 204 Months since last birth 0-11 months 97.6 48.4 89.6 22.5 146 12-23 months 92.9 35.9 84.2 19.9 149 Assistance at delivery Skilled attendant 95.3 42.2 87.0 21.2 298 Other (*) (*) (*) (*) 0 Mother’s education* Primary 93.4 53.3 89.0 10.1 66 Secondary 95.5 39.1 86.8 23.1 187 Higher 97.0 39.8 85.3 29.2 45 Wealth index quintile Poorest 97.6 40.3 91.1 18.7 45 Second 96.6 34.3 91.5 18.5 69 Middle 94.5 37.3 81.8 27.3 58 Fourth 97.0 51.4 88.9 22.3 61 Richest 91.4 48.0 82.5 19.1 65 Total 95.3 42.3 87.1 21.1 298 1 MICS indicator 2.4 2 MICS indicator 2.5 ( ) Figures that are based on 25–49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not The percentage of children who received a prelacteal feed increased with the mother’s education level (from 10 per cent amongst mothers with primary education to 29 per cent of mothers with higher education). It is interesting to note that slightly more than one half of mothers with primary education started breastfeeding within one hour of birth (53 per cent), while this was less common amongst mothers with secondary or higher education (about 39 per cent). 87 88 85 88 87 52 21 36 45 42 0 10 20 30 40 50 60 70 80 90 100 FBiH RS Urban Rural BiH Per cent Within one day Within one hour 22 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 23 Figure NU.3: Infant feeding patterns by age, BiH 2011–2012 Table NU.4 shows the median duration of breastfeeding amongst children at 0-35 months of age. Amongst children of this age the median duration of breastfeeding was 8.0 months (9.5 months for boys and 6.9 months for girls). The median duration of exclusive breastfeeding was 0.5 months, while the median duration of predominant breastfeeding was 1.9 months (3.6 months amongst boys and 0.7 amongst girls). The median duration of any breastfeeding was somewhat longer in the FBiH (8.6) compared to RS (7.1), while the pattern for the median duration of predominant breastfeeding was reversed (4.0 months for RS and 1.6 months for the FBiH). The median duration for any breastfeeding was shorter amongst children whose mothers had higher education (4.2 months) compared to children whose mothers had primary or secondary education (about 8 months in both cases). The median duration for predominant breastfeeding in months declined, although not uniformly, with increased wealth of the household (from 5.2 months for the poorest to 0.4 months for the richest households). Table NU.3: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, BiH 2011–2012     Children aged 0-5 months Children aged 12-15 months Children aged 20-23 months Per cent exclusively breastfed1 Per cent predominantly breastfed2 Number of children Per cent breastfed (Continued breastfeeding at 1 year)3 Number of children Per cent breastfed (Continued breastfeeding at 2 years)4 Number of children Sex   Male 18.1 60.9 110 13.0 74 15.1 74 Female 18.9 32.6 126 11.9 74 9.7 83 Administrative unit   FBiH 15.1 41.8 181 13.2 104 15.3 106 RS (31.7) (62.8) 51 (11.4) 41 6.2 50 BD (*) (*) 3 (*) 3 (*) 2 Area   Urban (7.1) (31.1) 55 5.5 57 7.0 58 Rural 22.0 50.3 180 16.8 91 15.2 100 Mother’s education*  Primary (*) (*) 50 (18.8) 21 (19.1) 34 Secondary 13.2 44.7 149 12.0 100 11.5 104 Higher (*) (*) 30 (9.1) 26 (*) 19 Wealth index   Poorest 60 per cent 25.5 52.4 149 14.7 87 15.8 86 Second 40 per cent 6.4 34.3 86 9.1 62 7.9 71 Total 18.5 45.8 236 12.4 148 12.2 157 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 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not shown in the table. Figure NU.3 shows the detailed pattern of breastfeeding according to a child’s age in months. By 10 months of age, 67 per cent of children were weaned. Data for age groups 0-1, 2-3, 4-5, 6-7 and 8-9 months is based on 25–49 unweighted cases and should be treated with caution. Exclusively breastfed Breastfed and complimentary foods Weaned (not breastfed) 0 10 20 30 40 50 60 70 80 90 100 0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Per cent Age (months) Weaned (not breastfed) Breastfed and complimentary foods Breastfed and other milk / formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed 24 Multiple indicator cluster survey 2011–2012 Monitoring the situation of children and woMen 25 Table NU.5: Age-appropriate breastfeeding percentage of children aged 0-23 months who were appropriately breastfed during the previous day, Bih 2011–2012   Children aged 0-5 months Children aged 6-23 months Children aged 0-23 months per cent exclusively breastfed1 number of children per cent currently breastfeeding and receiving solid, semi- solid or soft foods number of children per cent appropriately breastfed2 number of children Sex  Male 18.1 110 20.8 327 20.1 437 female 18.9 126 15.6 358 16.5 484 Administrative unit  fBih 15.1 181 21.6 474 19.8 655 rs (31.7) 51 10.3 195 14.8 246 Bd (*) 3 (7.3) 16 (6.0) 20 Area  urban (7.1) 55 12.3 238 11.3 294 rural 22.0 180 21.2 447 21.4 627 Mother’s education*  primary (*) 50 23.9 153 25.6 203 secondary 13.2 149 17.0 425 16.0 574 higher (*) 30 14.5 107 17.5 137 Wealth index quintile  poorest (*) 26 18.1 113 19.6 139 second (28.8) 72 20.0 142 23.0 214 Middle (*) 52 14.3 126 16.2 177 fourth (4.4) 55 24.8 135 18.9 190 richest (*) 32 13.9 169 13.2 200 Total 18.5 236 18.1 685 18.2 921 1 Mics indicator 2.6 2 Mics indicator 2.14 ( ) figures that are based on 25–49 unweighted cases (*) figures that are based on fewer than 25 unweighted cases * figures for the education category “none” are based on fewer than 25 unweighted cases and are not shown in the table. Appropriate complementary feeding of children from 6 months to two years of age is particularly important for growth and development and the prevention of undernutrition. Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary foods that help meet nutritional requirements when breastmilk 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. Overall, 71 per cent of infants aged 6-8 received solid, semi-solid, or soft foods (MICS indicator 2.12). Amongst currently breastfeeding infants this percentage was 64 per cent, while it was 79 per cent amongst infants currently not breastfeeding. The percentages for children currently breastfeeding and those not currently breastfeeding were based on 25-49 unweighted cases and should be treated with caution.29 Table NU.6 presents the proportion of children aged 6-23 months who received solid, semi-solid or soft foods the recommended minimum number of times or more during the day or night preceding the interview.30 The survey findings show that nearly three quarters of children aged 6-23 months (72 per cent) were receiving complementary foods the recommended minimum number of times (73 per cent in FBiH and 70 per cent in RS). The percentage of children who were receiving appropriate feeds the recommended minimum number of times increased with the mother’s education level (from 68 per cent for children whose mothers had primary education to 78 per cent for children whose mothers had higher education). 29 the table on introduction of solid, semi-solid or soft foods is not presented in the report since percentages for appropriate complementary feeding disaggregated by sex and area were based on fewer than 25 unweighted cases. 30 see the note in table nu.6 for a definition of the minimum number of times for the different age groups. Table NU.4: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding and predominant breastfeeding amongst children aged 0-35 months, Bih 2011–2012   Median duration (in months) number of children aged 0-35 monthsany breastfeeding 1 exclusive breastfeeding predominant breastfeeding Sex Male 9.5 0.6 3.6 668 female 6.9 0.5 0.7 712 Administrative unit fBih 8.6 0.5 1.6 976 rs 7.1 0.6 4.0 376 Bd (7.9) – – 28 Area urban 7.7 0.4 0.5 456 rural 8.2 0.6 2.5 924 Mother’s education* primary 7.5 1.8 3.3 300 secondary 8.0 0.5 1.1 863 higher 4.2 1.4 2.0 202 Wealth index quintile poorest 8.5 0.7 5.2 237 second 7.9 0.6 3.2 298 Middle 7.8 1.2 1.6 283 fourth 10.9 0.4 2.2 272 richest 4.8 0.4 0.4 291 Median 8.0 0.5 1.9 1,380 Mean for all children (0-35 months) 8.8 1.1 3.2 1,380 1 Mics indicator 2.10 ( ) figures that are based on 25–49 unweighted cases * figures for the education category “none” are based on fewer than 25 unweighted cases and are not shown in the table. Information on age-appropriate infant feeding for children under 24 months is provided in Table NU.5. Different criteria of feeding were 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. As a result of these feeding patterns less than one-fifth of children aged 0-5 months, children aged 6-23 months and children aged 0-23 months were being appropriately fed. The prevalence of age-appropriate breastfeeding was equal for boys and girls aged 0-5 months; it was however higher amongst children in rural areas. 26 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 27 Table NU.7: Bottle feeding Percentage of children aged 0-23 months who were fed with a bottle with a nipple during the previous day, BiH 2011–2012   Percentage of children aged 0-23 months fed with a bottle with a nipple1 Number of children aged 0-23 months Sex   Male 76.9 437 Female 81.8 484 Age (months)   0-5 60.3 236 6-11 88.6 231 12-23 84.8 454 Administrative unit   FBiH 78.8 655 RS 80.0 246 BD (94.0) 20 Area   Urban 84.8 294 Rural 77.0 627 Mother’s education*   Primary 73.6 203 Secondary 81.0 574 Higher 80.9 137 Wealth index quintile   Poorest 67.6 139 Second 76.8 214 Middle 84.8 177 Fourth 79.3 190 Richest 86.0 200 Total 79.5 921 1 MICS indicator 2.11 ( ) Figures that are based on 25–49 unweighted cases * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not shown in the table. Low Birth Weight Weight at birth is a good indicator not only of the mother’s health and nutritional status but also the newborn’s chances of 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 are undernourished in the womb face greatly increased risk of disease and dying during their early months and years. Low birth weight is most commonly associated with the mother’s poor health and inadequate feeding as well as cigarette smoking, especially during pregnancy. Teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. Because many infants in the developing world are not weighed at birth and those that are weighed may provide a biased sample of all births the reported birth weights usually cannot be used to estimate the prevalence of low birth weight amongst all children. Therefore, the percentage of births weighing below 2,500 grams is estimated in MICS through 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 recollection of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.31 The findings of this survey, shown in Table NU.8, show that a total of 98 per cent of newborns were weighed at birth, of which only 3 per cent weighed less than 2,500 grams. The percentage of low birth weight did not vary much between the FBiH and RS, by urban and rural areas or by household wealth. 31 For a detailed description of the methodology see Boerma, J. T., Weinstein, K. I., Rutstein, S.O. and Sommerfelt, A. E., 1996. ‘Data on Birth Weight in Developing Countries: Can Surveys Help?’ Bulletin of the World Health Organization, 74(2), 209-16. Amongst those children of this age currently breastfeeding about one-third were receiving complementary foods the recommended minimum number of times (34 per cent). Amongst children of this age who were currently not breastfeeding 91 per cent had received at least 2 milk feeds during the day or night prior to the interview, while 84 per cent had received solid semi-solid or soft foods or milk feeds 4 times or more during the day or night preceding the interview. Table NU.6: Minimum meal frequency Percentage of children aged 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, BiH 2011–2012   Currently breastfeeding Currently not breastfeeding All   Per cent receiving solid, semi- solid and soft foods the minimum number of times Number of children aged 6-23 months Per cent receiving at least 2 milk feeds1 Per cent receiving solid, semi- solid and soft foods or milk feeds 4 times or more Number of children aged 6-23 months Per cent with minimum meal frequency2 Number of children aged 6-23 months Sex Male 29.1 97 93.4 88.1 230 70.5 327 Female 42.6 62 88.5 80.3 296 73.8 358 Age (months)   6-8 (40.6) 51 (100.0) (69.8) 51 55.2 102 9-11 (21.6) 55 (98.9) (94.0) 74 63.3 129 12-17 (41.7) 28 92.1 83.3 191 78.0 219 18-23 (40.9) 26 84.2 83.9 210 79.2 236 Administrative unit   FBiH 36.8 126 90.6 85.7 348 72.7 474 RS (23.0) 30 90.1 78.0 165 69.5 195 BD (*) 3 (*) (*) 14 (91.7) 16 Area   Urban (31.7) 39 87.8 80.7 199 72.6 238 Rural 35.2 120 92.5 85.5 327 72.0 447 Mother’s education*   Primary (15.7) 51 92.1 93.7 101 67.5 153 Secondary 46.5 90 90.1 79.4 335 72.4 425 Higher (*) 18 91.1 88.4 89 78.0 107 Wealth index quintile   Poorest (*) 35 91.9 90.1 78 67.0 113 Second (*) 35 91.8 82.5 107 71.6 142 Middle (30.3) 22 92.4 83.2 103 73.8 126 Fourth (*) 35 92.1 88.9 100 76.9 135 Richest (43.5) 31 86.9 77.7 138 71.5 169 Total 34.3 159 90.7 83.7 526 72.2 685 1 MICS indicator 2.15 2 MICS indicator 2.13 ( ) Figures that are based on 25–49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not shown in the table. Amongst the currently breastfeeding children aged 6-8 months the minimum meal frequency is defined as children who also receive solid, semi-solid or soft foods 2 times or more. Amongst the currently breastfeeding children aged 9-23 months receipt of solid, semi-solid or soft foods at least 3 times constitutes the minimum meal frequency. For non-breastfeeding children aged 6-23 months the minimum meal frequency is defined as children receiving solid, semi-solid or soft foods and milk feeds at least 4 times during the previous day. The continued practice of bottle-feeding is a concern due to a number of factors, including possible contamination due to unsafe water and lack of hygiene during preparation. Table NU.7 shows that a high percentage of children aged 0-23 months in BiH are fed using a bottle with a nipple (80 per cent): about the same percentage of children in FBiH (79 per cent) and the RS (80 per cent) and a higher proportion of children in urban (85 per cent) than in rural areas (77 per cent). In addition to only one-fifth of children aged 0-23 months not being fed using a bottle with a nipple, it is worrying that a bottle with a nipple was used to feed over one half of children aged 0-5 months (60 per cent). 28 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 29 V Child Health Immunisation The Millennium Development Goal (MDG) 4 is to reduce child mortality by two-thirds between 1990 and 2015. Immunisation plays a key role in this goal. Immunisation has saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunisation (EPI) in 1974. According to UNICEF data, worldwide there are still 27 million children overlooked by routine immunisation 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 immunisation of children under one year of age at 90 per cent nationally, with at least 80 per cent coverage in every 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 the polio vaccine; three doses of the Hepatitis B (HepB) vaccine and a measles vaccination by the age of 12 months. In accordance with the UNICEF and WHO guidelines and the recommendations for immunisation against measles, rubella and mumps (MMR) outlined in the regulations on immunisation and prophylactics in the FBiH and RS, as well as for purposes of international comparison, estimates on full immunisation based on this survey refer to children aged 18-29 months that have received a BCG vaccine and three doses of DPT and the polio vaccine by 12 months of age and the MMR vaccine by 18 months.32 Information on vaccination coverage was collected for all children under five years of age. Mothers or caretakers were asked to provide vaccination cards or health booklets for all of these children. If the vaccination card for a child was available interviewers copied the vaccination information from the cards onto the questionnaire. If no vaccination card was available then the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccinations as well as how many doses were received for polio and DPT. The final vaccination coverage estimates were based on both the information obtained from the vaccination card and the mother’s report of vaccinations received by a child. The percentage of children aged 18-29 months in BiH who received each of the specific vaccinations recommended by UNICEF and WHO is shown in Table CH.1 (a) and in Tables CH.1 (b) for the FBiH and CH.1 (c) for RS. The denominator comprised children aged 18-29 months so that only those children who were old enough to be fully vaccinated with these vaccines were taken into consideration. In the first three columns of the table the numerator includes all children who were vaccinated at any time before the survey. In the last column only those children who were vaccinated by 12 months of age, as recommended, have been included (by 18 months of age for MMR). For children without vaccination cards the proportion of vaccinations given by 12 months of age was assumed to be the same as for children with vaccination cards. Overall 91 per cent of children in BiH, including 95 per cent of children in the FBiH and 84 per cent of children in RS, had available vaccination cards or health booklets at the time of the survey (see Table CH.2). According to the data shown in Table CH.1 (a), 98 per cent of children aged 18-29 months had received a BCG vaccination by the age of 12 months and 95 per cent of children had received the first dose of the polio vaccine. The percentage decreased for subsequent doses of this vaccine to 93 per cent for the second dose and 85 per cent for the third dose, thus incurring a 10 percentage point reduction in the immunisation coverage for this vaccine. Similar to immunisation to protect against polio, a total of 95 per cent of children had received the first dose of the DPT vaccine by the age of 12 months. This percentage decreased to 86 per cent by the third dose. By the age of 12 months, the first dose of the HepB vaccine has been received by 95 per cent of children, the second by 93 per cent, and the third dose by 94 per cent of children. Immunisation coverage against measles, rubella and mumps by the age of 18 months was somewhat lower than that of other vaccines at 80 per cent. In the FBiH 99 per cent of children aged 18-29 months had received a BCG vaccination by the age of 12 months (see Table CH.1 (b)). The first dose of the polio vaccine was given to 96 per cent of children, the second dose to 93 per cent and the third dose to 83 per cent of children. In RS 94 per cent of children aged 18-29 months had received a BCG vaccination by the age of 12 months (see Table CH.1 (c)). The first dose of the polio vaccine was given to 93 per cent of children, the 32 For the purposes of comparing the percentage of children who have received the UNICEF and WHO recommended vaccines during infancy with data from the BiH MICS3 (2005–2006), data on the Hepatitis B (HepB) vaccines is not included in the calculation of full immunisation. Data on immunisation against illnesses caused by Haemophilus influenzae type B (Hib), which is a part of the immunisation calendars in the FBiH and RS, are not presented in this report. Table NU.8: Low birth weight infants Percentage of last-born children in the 2 years preceding the survey that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, BiH 2011–2012   Per cent of live births Number of last-born children in the two years preceding the surveyBelow 2,500 grams 1 Weighed at birth2 Administrative unit   FBiH 3.2 97.3 211 RS 2.8 99.4 82 BD (4.5) (97.7) 6 Area   Urban 3.4 96.2 94 Rural 3.0 98.6 204 Mother’s education*   Primary 4.2 98.6 66 Secondary 3.0 97.1 187 Higher 2.4 100.0 45 Wealth index quintile   Poorest 3.9 97.9 45 Second 3.2 99.2 69 Middle 2.8 97.2 58 Fourth 2.7 95.4 61 Richest 3.3 99.2 65 Total 3.1 97.8 298 1 MICS indicator 2.18 2 MICS indicator 2.19 ( ) Figures that are based on 25–49 unweighted cases * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not shown in the table. 30 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 31 BCG DPT1 DPT2 DPT3 Polio1 Polio2 Polio3 MMR All vac cinatio ns* HepB1 HepB2 HepB3 second dose to 93 per cent and the third dose to 91 per cent of children. The first dose of the DPT vaccination by the age of 12 months had been received by 97 per cent of children in the FBiH and 92 per cent in RS; by the third dose this percentage had decreased to 84 per cent in the FBiH and 90 per cent in RS (see Tables CH.1 (b) and CH.1 (c)). The first dose of the HepB vaccine had been received by 98 per cent of children in the FBiH and 86 per cent of children in RS; the second, by 94 per cent of children in the FBiH and 91 per cent in RS; while 83 per cent of children in the FBiH and 88 per cent in RS had received the third dose of the HepB vaccine by the age of 12 months. Immunisation coverage against measles, rubella and mumps by age 18 months was 79 per cent in the FBiH and 82 per cent in RS. The percentage of children in BiH who had received all of the UNICEF and WHO recommended vaccinations during infancy was 68 per cent (67 per cent in FBiH and 72 per cent in RS). This indicator includes the percentage of children who had received a BCG vaccine as well as three doses of the DPT and three doses of the polio vaccine by 12 months of age and an MMR vaccine by 18 months of age (see Figure CH.1). Data on immunisation to protect against HepB and Hib, both of which are part of the immunisation calendars in FBiH and RS, is not included in the calculation of the percentage of children with all immunisations to allow for comparison with data from previous MICS rounds in BiH. Figure CH.1: Percentage of children aged 18-29 months who received the recommended vaccinations by 12 months (18 months for MMR), BiH 2011–2012 Table CH.1 (a): Vaccinations in first year of life, BiH Percentage of children aged 18-29 months immunised against childhood diseases at any time before the survey and by 12 months of age (by 18 months for MMR), BiH 2011–2012 Vaccinated at any time before the survey according to: Vaccinated by 12 months of age (18 months for MMR)Vaccination card Mother’s report Either BCG1 89.3 10.0 99.3 97.8 Polio   1 87.9 8.2 96.0 95.1 2 86.8 8.0 94.8 92.9 32 83.7 7.5 91.2 85.1 DPT   1 88.9 8.6 97.5 95.2 2 88.0 8.4 96.4 93.1 33 84.8 7.4 92.2 85.5 MMR4 80.2 7.6 87.8 79.9     All vaccinations (BCG, Polio, DPT and MMR) 78.3 5.9 84.2 68.0 No vaccinations (BCG, Polio, DPT and MMR) 0.0 0.3 0.3 0.3     HepB   1 at birth 90.8 6.0 96.8 95.4 2 86.0 9.3 95.3 93.0 35 80.7 7.5 88.2 83.9     Number of children aged 18-29 months 463 463 463 463 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 Table CH.1 (b): Vaccinations in first year of life, FBiH Percentage of children aged 18-29 months immunised against childhood diseases at any time before the survey and by 12 months of age (by 18 months for MMR), FBiH 2011–2012 Vaccinated at any time before the survey according to: Vaccinated by 12 months of age (18 months for MMR) Vaccination card Mother’s report Either BCG1 93.6 5.9 99.5 99.2 Polio   1 92.0 5.0 97.0 95.7 2 90.5 4.7 95.3 92.9 32 86.4 4.2 90.6 83.2 DPT   1 91.8 5.7 97.5 96.5 2 90.6 5.4 96.0 93.9 33 86.0 4.5 90.5 84.3 MMR4 83.8 4.5 88.3 79.3     All vaccinations (BCG, Polio, DPT and MMR) 81.2 2.5 83.7 67.0 No vaccinations (BCG, Polio, DPT and MMR) 0.0 0.2 0.2 0.2     HepB   1 at birth 94.3 4.0 98.3 98.0 2 87.8 6.7 94.5 93.7 35 83.0 4.5 87.5 82.5     Number of children aged 18-29 months 327 327 327 327 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 Table CH.1 (c): Vaccinations in first year of life, RS Percentage of children aged 18-29 months immunised against childhood diseases at any time before the survey and by 12 months of age (by 18 months for MMR), RS 2011–2012 Vaccinated at any time before the survey according to: Vaccinated by 12 months of age (18 months for MMR) Vaccination card Mother’s report Either BCG1 79.5 19.3 98.8 93.5 Polio   1 78.1 15.2 93.3 93.3 2 78.1 15.2 93.3 92.6 32 77.5 15.2 92.7 90.5 DPT   1 82.4 15.2 97.6 91.8 2 82.4 15.2 97.6 90.3 33 82.4 15.2 97.6 89.6 MMR4 71.8 15.3 87.1 82.1     All vaccinations (BCG, Polio, DPT and MMR) 72.5 14.7 87.1 71.6 No vaccinations (BCG, Polio, DPT and MMR) 0.0 0.6 0.6 0.6     HepB   1 at birth 82.4 10.9 93.3 88.5 2 81.8 15.8 97.6 91.0 35 75.1 15.2 90.3 88.1     Number of children aged 18-29 months 128 128 128 128 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 98 95 93 86 95 93 85 80 68 95 93 84 0 10 20 30 40 50 60 70 80 90 100 Per cent (BCG, Polio , DPT and M MR) * The percentage for all vaccines excludes vaccines to prevent hepatitis B. 32 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 33 Table CH.2 presents immunisation coverage amongst children aged 18-29 months by background characteristics. The figures indicate children receiving the listed vaccinations at any time before the survey and are based on information from both the vaccination cards and mothers/caretakers reports. There were no large differences with respect to background characteristics. The overall percentage of children who had received all of the recommended vaccinations at any time before the survey was 84 per cent: 87 per cent in RS and 84 per cent in the FBiH. Ninety-nine per cent of children had received the BCG vaccine at any time before the survey. The third dose of the polio vaccine had been received by 91 per cent of children at any time before the survey, the third dose of the DPT vaccine had been received by 92 per cent of children, while 88 per cent of children had received the third dose of the HepB vaccine. The MMR vaccine had been received by 88 per cent of children in BiH at any time before the survey. Almost all children in the FBiH and RS had received a BCG vaccine at any time before the survey. The third dose of the polio vaccine had been received by 91 per cent of children in the FBiH and 93 per cent of children in RS, the third dose of DPT was received by 91 per cent of children in the FBiH and 98 per cent of children in RS, while 88 per cent of children in the FBiH and 90 per cent in RS received the third dose of the HepB vaccine. The MMR vaccine had been received by 88 per cent of children in the FBiH and 87 per cent of children in RS BiH at any time before the survey. Table CH.2: Vaccinations by background characteristics Percentage of children aged 18-29 months currently vaccinated against childhood diseases, BiH 2011–2012 Percentage of children who received: Percentage with vaccination card seen Number of children aged 18-29 months BCG Polio DPT MMR None of the vaccinations (BCG, Polio, DPT and MMR) All of the vaccinations (BCG, Polio, DPT and MMR) HepB 1 2 3 1 2 3 1 2 3 Sex Male 99.0 97.2 96.4 93.6 97.4 97.0 92.9 89.0 0.3 86.1 94.5 96.4 90.1 89.0 227 Female 99.7 94.9 93.2 88.9 97.6 95.9 91.6 86.6 0.3 82.4 99.0 94.3 86.3 93.7 236 Administrative unit FBiH 99.5 97.0 95.3 90.6 97.5 96.0 90.5 88.3 0.2 83.7 98.3 94.5 87.5 94.8 327 RS 98.8 93.3 93.3 92.7 97.6 97.6 97.6 87.1 0.6 87.1 93.3 97.6 90.3 83.7 128 BD (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 8 Area Urban 99.5 97.5 97.0 91.4 98.5 97.0 91.0 87.9 0.0 84.9 97.0 97.7 89.6 89.2 162 Rural 99.2 95.3 93.6 91.1 97.0 96.1 92.9 87.7 0.5 83.8 96.7 94.1 87.4 92.5 301 Mother’s education* Primary 97.7 93.7 93.7 88.5 94.5 94.5 89.3 85.3 1.5 84.2 95.3 87.2 80.9 89.6 102 Secondary 99.7 95.9 94.5 91.8 97.9 96.5 92.9 88.2 0.0 83.9 97.1 97.1 89.3 91.7 291 Higher 100.0 100.0 97.6 92.8 100.0 98.8 94.0 89.4 0.0 85.7 97.6 100.0 94.0 93.0 68 Wealth index quintile Poorest 98.1 96.2 95.3 91.4 96.2 95.3 91.4 90.0 1.0 87.2 94.4 88.3 81.6 93.5 85 Second 99.1 95.3 93.4 89.6 95.3 94.3 90.5 85.1 0.9 83.1 95.3 96.2 91.5 90.7 85 Middle 100.0 99.2 98.3 93.7 99.2 99.2 91.7 94.2 0.0 89.1 97.9 96.2 89.1 91.1 98 Fourth 99.2 98.3 95.6 93.0 98.7 95.2 93.4 89.0 0.0 85.1 97.4 97.4 93.0 91.8 93 Richest 100.0 91.5 91.5 88.3 97.7 97.7 93.8 81.1 0.0 77.2 98.5 97.7 85.6 90.2 104 Total 99.3 96.0 94.8 91.2 97.5 96.4 92.2 87.8 0.3 84.2 96.8 95.3 88.2 91.4 463 (*) Figures that are based on fewer than 25 unweighted cases * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not shown in the table. Table CH.2 presents immunisation coverage amongst children aged 18-29 months by background characteristics. The figures indicate children receiving the listed vaccinations at any time before the survey and are based on information from both the vaccination cards and mothers/caretakers reports. There were no large differences with respect to background characteristics. The overall percentage of children who had received all of the recommended vaccinations at any time before the survey was 84 per cent: 87 per cent in RS and 84 per cent in the FBiH. Ninety-nine per cent of children had received the BCG vaccine at any time before the survey. The third dose of the polio vaccine had been received by 91 per cent of children at any time before the survey, the third dose of the DPT vaccine had been received by 92 per cent of children, while 88 per cent of children had received the third dose of the HepB vaccine. The MMR vaccine had been received by 88 per cent of children in BiH at any time before the survey. Almost all children in the FBiH and RS had received a BCG vaccine at any time before the survey. The third dose of the polio vaccine had been received by 91 per cent of children in the FBiH and 93 per cent of children in RS, the third dose of DPT was received by 91 per cent of children in the FBiH and 98 per cent of children in RS, while 88 per cent of children in the FBiH and 90 per cent in RS received the third dose of the HepB vaccine. The MMR vaccine had been received by 88 per cent of children in the FBiH and 87 per cent of children in RS BiH at any time before the survey. Table CH.2: Vaccinations by background characteristics Percentage of children aged 18-29 months currently vaccinated against childhood diseases, BiH 2011–2012 Percentage of children who received: Percentage with vaccination card seen Number of children aged 18-29 months BCG Polio DPT MMR None of the vaccinations (BCG, Polio, DPT and MMR) All of the vaccinations (BCG, Polio, DPT and MMR) HepB 1 2 3 1 2 3 1 2 3 Sex Male 99.0 97.2 96.4 93.6 97.4 97.0 92.9 89.0 0.3 86.1 94.5 96.4 90.1 89.0 227 Female 99.7 94.9 93.2 88.9 97.6 95.9 91.6 86.6 0.3 82.4 99.0 94.3 86.3 93.7 236 Administrative unit FBiH 99.5 97.0 95.3 90.6 97.5 96.0 90.5 88.3 0.2 83.7 98.3 94.5 87.5 94.8 327 RS 98.8 93.3 93.3 92.7 97.6 97.6 97.6 87.1 0.6 87.1 93.3 97.6 90.3 83.7 128 BD (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 8 Area Urban 99.5 97.5 97.0 91.4 98.5 97.0 91.0 87.9 0.0 84.9 97.0 97.7 89.6 89.2 162 Rural 99.2 95.3 93.6 91.1 97.0 96.1 92.9 87.7 0.5 83.8 96.7 94.1 87.4 92.5 301 Mother’s education* Primary 97.7 93.7 93.7 88.5 94.5 94.5 89.3 85.3 1.5 84.2 95.3 87.2 80.9 89.6 102 Secondary 99.7 95.9 94.5 91.8 97.9 96.5 92.9 88.2 0.0 83.9 97.1 97.1 89.3 91.7 291 Higher 100.0 100.0 97.6 92.8 100.0 98.8 94.0 89.4 0.0 85.7 97.6 100.0 94.0 93.0 68 Wealth index quintile Poorest 98.1 96.2 95.3 91.4 96.2 95.3 91.4 90.0 1.0 87.2 94.4 88.3 81.6 93.5 85 Second 99.1 95.3 93.4 89.6 95.3 94.3 90.5 85.1 0.9 83.1 95.3 96.2 91.5 90.7 85 Middle 100.0 99.2 98.3 93.7 99.2 99.2 91.7 94.2 0.0 89.1 97.9 96.2 89.1 91.1 98 Fourth 99.2 98.3 95.6 93.0 98.7 95.2 93.4 89.0 0.0 85.1 97.4 97.4 93.0 91.8 93 Richest 100.0 91.5 91.5 88.3 97.7 97.7 93.8 81.1 0.0 77.2 98.5 97.7 85.6 90.2 104 Total 99.3 96.0 94.8 91.2 97.5 96.4 92.2 87.8 0.3 84.2 96.8 95.3 88.2 91.4 463 (*) Figures that are based on fewer than 25 unweighted cases * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not shown in the table. 34 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 35 Oral Rehydration Treatment Diarrhoea is the second leading cause of death amongst children under five worldwide. In the treatment of diarrhoea of particular importance is increased fluid intake, continued adequate feeding of the child and use of oral rehydration salts (ORS). The goal is to reduce by two-thirds the mortality rate amongst children under five by 2015.33 In addition, A World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 per cent. In MICS the prevalence of diarrhoea was estimated by asking mothers or caretakers whether their child had had an episode of diarrhoea in the two weeks prior to the survey (see Table CH.3). In cases where mothers reported that the child had suffered diarrhoea a series of questions were asked about the treatment of the illness, including what the child had to drink and eat during the episode and whether this was more or less than the child usually drank and ate. Table CH.3 also shows the percentage of children who had diarrhoea in the two weeks preceding the survey as well as the percentage of children who received 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 up to 100. Overall 6 per cent of children under five in BiH had diarrhoea in the two weeks preceding the survey (see Table CH.3. Diarrhoea prevalence was at 7 per cent amongst children in the FBiH and 4 per cent amongst children in RS. Viewed by age, the peak of diarrhoea was amongst children aged 12-23 months (8 per cent). About 36 per cent of children received fluids from ORS packets or pre-packaged ORS fluids. Children of mothers with primary education were less likely to receive ORS than children of mothers with secondary education (14 per cent compared to 37 per cent). There was no evident difference in diarrhoea prevalence amongst girls and boys or in the percentage of boys and girls who received ORS. 33 Compared to 1990 (Millennium Development Goals) Table CH.3: Oral rehydration solutions and recommended homemade fluids Percentage of children aged 0-59 months with diarrhoea in the last two weeks and treatment with oral rehydration solutions and recommended homemade fluids, BiH 2011–2012   Had diarrhoea in last two weeks Number of children aged 0-59 months Children with diarrhoea who received ORS (Fluid from ORS packet or pre-packaged ORS fluid) Number of children aged 0-59 months with diarrhoea in last two weeks Sex         Male 6.9 1,124 35.2 78 Female 5.0 1,173 37.8 58 Administrative unit   FBiH 6.7 1,611 35.7 108 RS 4.3 646 (39.1) 28 BD 1.0 40 (*) 0 Area   Urban 5.3 774 (43.5) 41 Rural 6.2 1,523 33.2 95 Age (months)   0-11 5.8 466 (*) 27 12-23 7.7 454 (47.3) 35 24-35 4.2 459 (*) 19 36-47 6.8 485 (37.9) 33 48-59 5.1 432 (*) 22 Mother’s education*   Primary 5.5 526 13.8 29 Secondary 5.8 1,426 37.1 83 Higher 7.7 324 (*) 25 Wealth index quintile   Poorest 6.9 388 (*) 27 Second 7.7 482 (36.1) 37 Middle 3.9 455 (*) 18 Fourth 6.0 469 (*) 28 Richest 5.3 502 (67.1) 27 Total 5.9 2,297 36.3 136 ( ) Figures that are based on 25–49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not shown in the table. 36 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 37 Table CH.4: Feeding practices during diarrhoea Per cent distribution of children aged 0-59 months with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, BiH 2011–2012   Had diarrhoea in last two weeks Number of children aged 0-59 months Drinking practices during diarrhoea Total Eating practices during diarrhoea Total Number of children aged 0-59 months with diarrhoea in last two weeks Given much less to drink Given somewhat less to drink Given about the same to drink Given more to drink Given nothing to drink Given much less to eat Given somewhat less to eat Given about the same to eat Given more to eat Stopped food Sex   Male 6.9 1,124 8.9 11.3 30.8 46.9 2.1 100.0 6.2 37.7 46.2 9.9 0.0 100.0 78 Female 5.0 1,173 1.4 9.6 33.7 43.4 11.9 100.0 6.8 19.1 60.8 1.4 11.9 100.0 58 Administrative unit   FBiH 6.7 1,611 7.2 9.7 29.3 45.9 7.9 100.0 5.2 24.4 56.8 7.2 6.4 100.0 108 RS 4.3 646 (0.0) (14.0) (41.9) (44.1) (0.0) 100.0 (11.2) (49.7) (36.3) (2.8) (0.0) 100.0 28 BD 1.0 40 (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 0 Area   Urban 5.3 774 (0.0) (13.4) (20.9) (65.7) (0.0) 100.0 (11.6) (39.6) (33.9) (14.9) (0.0) 100.0 41 Rural 6.2 1,523 8.2 9.3 36.9 36.6 9.0 100.0 4.2 25.5 60.5 2.5 7.3 100.0 95 Age (months)   0-11 5.8 466 (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 27 12-23 7.7 454 (2.3) (9.3) (31.7) (39.1) (17.6) 100.0 (6.8) (27.5) (43.4) (4.6) (17.6) 100.0 35 24-35 4.2 459 (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 19 36-47 6.8 485 (18.6) (9.5) (21.6) (47.8) (2.4) 100.0 (2.4) (49.8) (45.4) (2.3) (0.0) 100.0 33 48-59 5.1 432 (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 22 Mother’s education *  Primary 5.5 526 (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 29 Secondary 5.8 1,426 8.4 10.7 25.1 46.4 9.4 100.0 9.6 32.2 47.8 2.9 7.4 100.0 83 Higher 7.7 324 (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 25 Wealth index quintile   Poorest 6.9 388 (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 27 Second 7.7 482 (2.2) (10.8) (23.5) (44.7) (18.8) 100.0 (6.5) (23.6) (51.1) (2.2) (16.7) 100.0 37 Middle 3.9 455 (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 18 Fourth 6.0 469 (*) (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 28 Richest 5.3 502 (3.0) (11.8) (23.6) (61.6) (0.0) 100.0 (5.9) (38.5) (32.6) (22.9) (0.0) 100.0 27 Total 5.9 2,297 5.7 10.5 32.0 45.4 6.3 100.0 6.4 29.8 52.4 6.3 5.1 100.0 136 ( ) Figures that are based on 25–49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not shown in the table. Fifty-five per cent of children received ORT with continued feeding, as is recommended (see Figure CH.2). Overall 65 per cent of children with diarrhoea received ORS or increased fluids (see Figure CH.3). Thirty-three per cent of children received diarrhoea antimotility medication in the form of tablets or syrup, while only 1 per cent of children received medication in the form of an injection. Diarrhoea was treated with home remedies/herbal medicine in 19 per cent of children, while 9 per cent of children were treated in some other way. Twenty-one per cent of children with diarrhoea were not given any treatment or medication. Table CH.4 shows the feeding practices of children during the episode of diarrhoea. The data show that during the episode of diarrhoea 45 per cent of children under 5 years of age drank more than usual while 43 per cent drank the same or less. With respect to food intake 82 per cent of children were given the same amount to eat or somewhat less and 6 per cent of children were given much less than usual to eat. In 5 per cent of cases children stopped food altogether. Table CH.5 shows the proportion of children aged 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy (ORT) with continued feeding and the percentage of children with diarrhoea who received other treatments. 38 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 39 Figure CH.2: Percentage of children under age 5 with diarrhoea who received ORT with continued feeding, BiH 2011–2012 * Data for RS and urban areas is based on 25-49 unweighted cases and should be interpreted with caution. Table CH.5: Oral rehydration therapy with continued feeding and other treatments Percentage of children aged 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, BiH 2011–2012   Children with diarrhoea who received: Other treatments: Not given any treatment or drug Number of children aged 0-59 months with diarrhoea in last two weeks ORS or increased fluids ORT with continued feeding1 Pill or syrup Injection Intravenous Home remedy, herbal medicine OtherAntibiotic Antimotility Zinc Other Unknown Antibiotic Non-antibiotic Unknown Sex   Male 65.0 59.9 4.1 24.2 0.0 2.0 2.1 1.0 0.0 0.0 0.0 9.8 8.9 21.2 78 Female 64.8 47.5 1.4 27.0 0.0 1.3 4.2 0.0 0.0 0.0 1.4 31.2 9.6 20.1 58 Administrative unit FBiH 64.8 54.6 2.2 24.8 0.0 0.7 3.7 0.0 0.0 0.0 0.7 21.4 10.2 22.5 108 RS (66.5) (55.3) (5.6) (27.9) (0.0) (5.6) (0.0) (2.8) (0.0) (0.0) (0.0) (8.4) (5.6) (14.0) 28 BD (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 0 Area   Urban (79.0) (69.4) (3.8) (24.8) (0.0) (1.9) (0.0) (1.9) (0.0) (0.0) (0.0) (28.3) (16.8) (7.7) 41 Rural 58.8 48.1 2.5 25.6 0.0 1.7 4.3 0.0 0.0 0.0 0.9 14.9 5.9 26.4 95 Age (months) 0-23 (62.2) (49.7) (2.6) (36.7) (0.0) (0.0) (1.3) (1.3) (0.0) (0.0) (0.0) (14.3) (13.9) (26.2) 62 24-59 67.2 58.7 3.2 16.0 0.0 3.2 4.3 0.0 0.0 0.0 1.1 22.8 5.3 16.1 74 Wealth index Poorest 60 per cent 57.6 45.2 2.9 27.8 0.0 1.0 5.0 1.0 0.0 0.0 1.0 21.2 4.9 24.3 81 Richest 40 per cent (75.8) (68.5) (2.9) (21.8) (0.0) (2.9) (0.0) (0.0) (0.0) (0.0) (0.0) (15.6) (15.6) (15.4) 55 Total 64.9 54.6 2.9 25.4 0.0 1.7 3.0 0.6 0.0 0.0 0.6 19.0 9.2 20.7 136 1 MICS indicator 3.8 ( ) Figures that are based on 25–49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases 55 (55) (69) 48 60 47 55 0 10 20 30 40 50 60 70 80 90 100 Per cent FBiH RS Urban Rural Male Female BiH Figure CH.3: Percentage of children under age 5 with diarrhoea who received ORT or increased fluids, BiH 2011–2012 * Data for RS and urban areas is based on 25-49 unweighted cases and should be interpreted with caution. 65 (66) (79) 59 65 65 65 0 10 20 30 40 50 60 70 80 90 FBiH RS Urban Rural Male Female BiH Per cent 40 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 41 Care-Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children worldwide and the use of antibiotics in under-fives 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 infection. In the BiH MICS4 the prevalence of suspected pneumonia was estimated by asking mothers or caretakers whether their child under age five had suffered an illness with a cough accompanied by rapid or difficult breathing, the symptoms of which were a problem with the chest or a problem with both the chest and a blocked nose. Table CH.6 presents the prevalence of suspected pneumonia. Survey findings indicate that, during the two weeks preceding the survey 3 per cent of children aged 0-59 months were reported to have had symptoms of pneumonia (3 per cent in the FBiH and 4 per cent in RS). Of these children, 87 per cent were taken to an appropriate service provider (MICS indicator 3.9, which is not shown in Table CH.6). The highest percentage of children were examined in public sector facilities, of which 48 per cent were taken to a health centre and 24 per cent to a hospital, while 7 per cent were examined by a visiting health worker (mobile health service). A small percentage of children were taken to a private medical practice (7 per cent) and a private pharmacy (2 per cent) – (data not shown in Table CH.6). The prevalence of suspected pneumonia amongst children under 5 did not vary much by sex. In relation to age, the prevalence of suspected pneumonia was highest amongst children aged 12-23 months (5 per cent). Overall, about three quarters (76 per cent) of children under 5 years of age with suspected pneumonia in the two weeks prior to the survey were treated with antibiotics (MICS indicator 3.10, which is not shown in Table CH.6). Table CH.6: Prevalence of suspected pneumonia by background characteristics Percentage of children aged 0-59 months with suspected pneumonia in the last two weeks, BiH 2011–2012   Had suspected pneumonia in the last two weeks Number of children aged 0-59 months Sex   Male 3.6 1,124 Female 2.8 1,173 Administrative unit FBiH 2.8 1,611 RS 4.2 646 BD 4.0 40 Area Urban 3.4 774 Rural 3.1 1,523 Age (months) 0-11 1.0 466 12-23 5.0 454 24-35 4.2 459 36-47 2.8 485 48-59 2.9 432 Mother’s education* Primary 3.8 526 Secondary 3.1 1,426 Higher 2.7 324 Wealth index quintile Poorest 5.3 388 Second 2.5 482 Middle 2.9 455 Fourth 2.8 469 Richest 2.8 502 Total 3.2 2,297 * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not shown in the table. MICS indicator 3.9: Percentage of children aged 0-59 months with suspected pneumonia in the last two weeks who were taken to a health provider; the indicator is not shown in Table CH.6 because of the low number of unweighted cases for the background characteristics (fewer than 25 unweighted cases). MICS indicator 3.10: Percentage of children aged 0-59 with suspected pneumonia who received antibiotics in the last two weeks; the indicator is not shown in Table CH.6 because of the low number of unweighted cases for the background characteristics (fewer than 25 unweighted cases). A mother’s knowledge of the danger signs of pneumonia is an important determinant of care-seeking behaviour. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.7. Overall 15 per cent of women knew of the two danger signs of pneumonia, namely fast and difficult breathing. Thirty-nine per cent of mothers identified difficult breathing and 20 per cent of mothers identified fast breathing as symptoms for taking the child immediately to a health facility. Fast breathing was recognised as a danger sign of pneumonia by an approximately equal percentage of mothers in urban and rural areas (about 20 per cent). It is interesting to note that, when viewed according to their level of education, the knowledge that fast breathing is a danger sign of pneumonia was most common amongst mothers with primary education (27 per cent) and decreased with an increase in the mother’s education level (12 per cent for higher education). A higher percentage of mothers in RS (50 per cent) than in the FBiH (34 per cent) believed that the child should immediately be taken to a health facility if experiencing difficulty in breathing. Twenty-two per cent of mothers in the FBiH and 15 per cent of mothers in RS believed that the child should immediately be taken to a health facility if experiencing fast breathing. The highest percentage of mothers believed that a child should be taken immediately to a health facility in the case of fever (88 per cent) and if the child became sicker (43 per cent). 42 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 43 Table CH.7: knowledge of the two danger signs of pneumonia Percentage of mothers and caretakers of children aged 0-59 months by symptoms that would cause them to take the child immediately to a health facility and percentage of mothers who recognise fast and difficult breathing as signs for seeking care immediately, BiH 2011–2012   Percentage of mothers/caretakers of children aged 0-59 months who think that a child should be taken immediately to a health facility if the child: Mothers/caretakers who recognise the two danger signs of pneumonia Number of mothers/caretakers of children aged 0-59 months   Is not able to drink or breastfeed Becomes sicker Develops a fever Has fast breathing Has difficulty breathing Has blood in stool Is drinking poorly Has other symptoms Administrative unit     FBiH 16.9 41.5 85.6 21.5 33.7 24.5 7.2 42.0 16.2 459 RS 14.6 46.8 92.6 15.0 49.5 17.0 6.4 27.3 10.4 183 BD 43.0 57.0 100.0 50.4 62.0 51.6 39.3 4.9 47.9 11 Area   Urban 16.4 41.8 86.9 19.2 43.0 24.5 5.4 32.7 14.3 219 Rural 16.8 44.0 88.2 20.7 36.3 21.9 8.5 39.5 15.5 433 Mother’s education*   Primary 18.1 47.8 86.1 27.1 37.0 27.4 8.2 34.3 19.5 154 Secondary 17.0 43.5 88.4 19.6 39.9 22.5 7.8 36.5 15.1 403 Higher 13.2 34.4 87.8 11.7 35.9 17.2 5.2 45.6 8.0 93 Wealth index quintile   Poorest 20.1 40.6 88.3 21.5 41.5 22.8 11.9 35.9 17.6 107 Second 17.4 52.7 87.6 25.2 40.6 24.6 10.0 35.3 19.9 136 Middle 17.9 40.7 86.7 19.0 42.8 25.0 6.2 37.7 15.2 132 Fourth 13.7 44.7 88.3 22.9 34.8 24.9 5.3 32.9 14.4 134 Richest 15.0 37.2 88.1 13.0 34.1 17.2 5.0 43.8 9.1 144 Total 16.7 43.2 87.8 20.2 38.6 22.8 7.5 37.3 15.1 652 * Figures for the education category “None” are based on fewer than 25 unweighted cases and are not shown in the table. 44 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 45 Solid Fuel Use More than 3 billion people around the world rely on solid fuel for their basic energy needs, including cooking and heating. Solid fuels include biomass such as wood, charcoal, crops or other agricultural residues, dung, shrubs, straw and coal. Cooking and heating with solid fuel leads to high levels of indoor smoke, which is a complex mix of health damaging pollutants. The main problem with the use of solid fuel is incomplete combustion, which produces toxic elements such as, amongst others, carbon monoxide and sulphur oxide (SO2). Use of solid fuel increases the risk of acute respiratory illness, pneumonia, chronic obstructive lung disease and cancer. The primary indicator of solid fuel use is the proportion of the population using solid fuel as their primary source of domestic energy for cooking. Table CH.8 shows that 70 per cent of the household population in BiH uses solid fuel for cooking, while a lower percentage uses electricity for this purpose (21 per cent). Use of solid fuel for cooking was more common in RS (74 per cent) than in the FBiH (67 per cent). There was a difference by area, with solid fuel being used for cooking by 83 per cent of the rural household population and 43 per cent by the urban household population. Solid fuel use was not common amongst the richest household population and increased with a decline in wealth and a decrease in the level of education of the household head. The highest percentage of the household population used wood for cooking (69 per cent), with a higher proportion in RS (73 per cent) than in the FBiH (67 per cent). The percentage of the household population that used charcoal and coal/lignite for cooking purposes was negligible. Table CH.8: Solid fuel use Per cent 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, BiH 2011–2012   Percentage of household members in households using: Number of household members   Electricity Liquefied petroleum gas (LPG) Natural gas Solid fuels No food cooked in the household Other fuel Missing Total Solid fuels for cooking1   Coal, lignite Charcoal Wood Agricultural crop residue Administrative unit   FBiH 23.5 6.7 2.3 0.1 0.7 66.5 0.1 0.0 0.0 0.1 100.0 67.4 13,374 RS 17.0 9.2 0.2 0.0 0.2 73.3 0.0 0.0 0.1 0.0 100.0 73.6 6,524 BD 23.4 4.1 0.0 3.0 1.8 67.7 0.0 0.0 0.0 0.0 100.0 72.5 323 Area 0.0   Urban 40.4 11.8 4.4 0.0 1.1 42.0 0.0 0.0 0.1 0.1 100.0 43.1 6,932 Rural 11.5 5.2 0.1 0.2 0.3 82.6 0.1 0.0 0.0 0.0 100.0 83.2 13,289 Education of household head   None 8.3 0.8 0.8 0.1 2.3 87.7 0.0 0.0 0.0 0.0 100.0 90.1 598 Primary 9.4 3.9 0.7 0.4 0.3 85.3 0.0 0.0 0.0 0.0 100.0 86.0 6,095 Secondary 24.1 8.5 1.9 0.0 0.7 64.7 0.1 0.0 0.0 0.0 100.0 65.5 11,497 Higher 45.9 14.3 3.0 0.1 0.1 36.1 0.0 0.0 0.1 0.4 100.0 36.3 2,025 Missing/DK (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 100.0 (*) 7 Wealth index quintiles   Poorest 3.4 0.6 0.0 0.1 0.6 95.0 0.0 0.1 0.0 0.2 100.0 95.7 4,043 Second 8.0 2.8 0.2 0.1 0.2 88.7 0.1 0.0 0.0 0.0 100.0 89.1 4,046 Middle 13.5 4.3 0.4 0.1 1.0 80.6 0.2 0.0 0.0 0.0 100.0 81.8 4,044 Fourth 25.8 6.2 1.0 0.3 0.5 66.1 0.0 0.0 0.1 0.0 100.0 66.9 4,044 Richest 56.4 23.5 6.3 0.0 0.7 13.1 0.0 0.0 0.0 0.0 100.0 13.8 4,044 Total 21.4 7.5 1.6 0.1 0.6 68.7 0.0 0.0 0.0 0.0 100.0 69.5 20,221 1 MICS indicator 3.11 (*) Figures that are based on fewer than 25 unweighted cases 46 MULTIPLE INDICATOR CLUSTER SURVEy 2011–2012 MONITORING THE SITUATION OF CHILDREN AND WOMEN 47 VI Water and Sanitation Safe drinking water is a basic necessity for good health and unsafe drinking water can be a significant carrier of numerous diseases.34 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 over long distances. One of the Millennium Development Goals (7, C) is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. A 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.35 The below list of indicators are used in MICS Water: z Use of improved drinking water sources z Use of an adequate water treatment method z Time to source of drinking water z Person collecting drinking water Sanitation: z Use of improved sanitation z Sanitary disposal of child’s faeces MICS also collects additional information on the availability of facilities and conditions for hand washing. The below indicators are collected z Place for hand washing observed z Availability of soap Use of Improved Drinking Water Sources The distribution of the population by main source of drinking water is shown in Table WS.1 and Figure WS.1. Improved sources of drinking water include piped water (into dwellings, compounds, yards or plots and to neighbours or public taps/standpipes), tube wells/boreholes, protected wells, protected springs and rainwater collection. Bottled water is considered as an improved water source only if the household is also using an improved water source for hand washing and cooking. Almost the entire population of BiH uses an improved source of drinking water. The majority of the population in BiH uses drinking water that is piped into their dwelling or into their yard or plot (86 per cent). Piped water (including water piped to a neighbour or a public tap) was used by the highest percentage of the population in RS (90 per cent) and a smaller percentage in the FBiH (88 per cent). In urban areas 91 per cent of the population had running water in their dwelling, yard or plot, whereas the corresponding proportion in rural areas was 83 per cent. A public tap was used by 2 per cent of the population in both urban and rural areas. The next most important sources of drinking water in BiH were protected wells (4 per cent) and protected springs (3 per cent), while a somewhat lower percentage of household members used tube wells (2 per cent). Less than 1 per cent of the population in BiH used unimproved sources. While the poorest population was less likely to have running water in their dwelling (71 per cent), when compared to the richest population, a high percentage of the poorest household population did use improved sources of drinking water (99 per cent). 34 Such as dysentery, cholera and hepatitis A. 35 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> The use of solid fuel is in itself a weak indicator of indoor air pollution since the concentration of pollutants varies when the same type of fuel is burned in different types of stoves or fireplaces. The use of sealed stoves with chimney flukes minimises indoor air pollution, whereas the use of open stoves or fireplaces without a chimney or smoke extractor provides no protection against the harmful effects of solid fuel combustion. Solid fuel use by place of cooking is depicted in Table CH.9. Indoor air pollution depends on cooking practices, place of cooking and the type of fuel used. The findings show that, in BiH, 59 per cent of the population living in households using solid fuels for cooking, cooked in a room designated to serve only as a kitchen, while 39 per cent cooked somewhere else in the house (no separate room for cooking available). A designated room for cooking was used by three quarters of the population in such households in the FBiH (76 per cent) and one quarter of the population in such households in RS (26 per cent). Survey results show that the percentage of the population with a room designated for cooking, in households using solid fuels for cooking, increased with wealth, being highest amongst the richest household population (about 76 per cent). There were no clear differences with respect to the level of education of the household head. Table CH.9: Solid fuel use by place of

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