Gambia - Multiple Indicator Cluster Survey - 2005

Publication date: 2005

Copyright Gambia Bureau of Statistics 2007 Published 2007 Front Cover: UNICEF/Gam 00705/Giacomo Pirozzi Published by UNICEF UN House 5 Kofi Annan Street Cape Point Bakau,The Gambia All rights reserved. PRINTED BY Polykrome, Dakar Senegal ii • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • iii Contributors to the Report Alieu S M Ndow - Gambia Bureau of Statistics Alieu Sarr - Gambia Bureau of Statistics Sheriffo S T Sonko - UNICEF Banjul Edrissa Ceesay - Gambia Bureau of Statistics Nyakassi Sanyang - Central Bank of The Gambia Omar Ngum - Department of Community Development Lolley Kah Jallow - Gambia Bureau of Statistics Baba Suwareh - Gambia Bureau of Statistics Modou Lamin Cham - Directorate of Planning, DoSHSW Amat Bah - National Nutrition Agency Paul Mendy - Directorate of Planning, DoSBSE Alieu Saho - Gambia Bureau of Statistics We acknowledge the substantial comments on the earlier draft as well as support in data proces- sing from the following colleagues from the MICS Global Team, Blancroft Research International and the Strategic Information Section, Division of Policy and Planning (DPP), UNICEF, New York: Attila Hancioglu, MICS III Global Coordinator Trevor Croft, Blancroft Research International Emma Holmberg, Strategic Information Section, DPP Rhiannon James, Strategic Information Section, DPP Editor: Fodeh Baldeh, University of The Gambia, Kanifing Design and Layout: Polykrome, Dakar, Senegal The Gambia Multiple Indicator Cluster Survey (MICS) was carried out by the Gambia Bureau of Statistics in collaboration with the Department of State for Basic and Secondary Education, the Department of State for Health and Social Welfare, the Women's Bureau, the National Nutrition Agency, the Department of Community Development, the Department of Water Resources and the Department of Social Welfare. Financial and technical support was provided by the United Nations Children's Fund (UNICEF) and the World Bank through their assisted HIV/AIDS Rapid Response Project (HARRP). The survey was conducted as part of the third round of MIC surveys (MICS III), carried out around the world in more than 50 countries, in 2005-2006, following the first two rounds of MIC surveys that were conducted in 1995 and 2000. Survey tools are based on the models and standards developed by the Global MICS project, designed to collect information on the situation of children and women in countries around the world. Additional information on the Global MICS project may be obtained from www.childinfo.org. Suggested citation Gambia Bureau of Statistics (GBoS), 2007, The Gambia Multiple Indicator Cluster Survey 2005/2006 Report, Banjul. iv • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report CONTENTS List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi Summary Table of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiv Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvi 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 SURVEY OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 2 Sample and Survey Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 SAMPLE DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 QUESTIONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 TRAINING AND FIELDWORK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 3 Sample Coverage and the Characteristics of Households . . . . . . . . . . . . . . . . . . . .15 SAMPLE COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 CHARACTERISTICS OF HOUSEHOLDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 CHARACTERISTICS OF RESPONDENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 4 Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 5 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 NUTRITIONAL STATUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 BREASTFEEDING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 SALT IODIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 VITAMIN A SUPPLEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 LOW BIRTH WEIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 6 Child Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 IMMUNIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 TETANUS TOXOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 ORAL REHYDRATION TREATMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 CARE SEEKING AND ANTIBIOTIC TREATMENT OF PNEUMONIA . . . . . . . . . . . . .37 SOLID FUEL USE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 MALARIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 SOURCES AND COSTS OF SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 7 The Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 WATER AND SANITATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 SECURITY OF TENURE AND DURABILITY OF HOUSING . . . . . . . . . . . . . . . . . . . . .46 The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • v 8 Reproductive Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 ANTENATAL CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 ASSISTANCE AT DELIVERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 9 Child Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 10 Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 PRE-SCHOOL ATTENDANCE AND SCHOOL READINESS . . . . . . . . . . . . . . . . . . . . .55 PRIMARY AND SECONDARY SCHOOL PARTICIPATION . . . . . . . . . . . . . . . . . . . . . .55 ADULT LITERACY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 11 Child Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 BIRTH REGISTRATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 CHILD LABOUR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 CHILD DISCIPLINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 EARLY MARRIAGE AND POLYGYNY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 FEMALE GENITAL MUTILATION/CUTTING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 DOMESTIC VIOLENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 12 HIV/AIDS, Sexual Behaviour, and Orphaned and Vulnerable Children . . . . . .69 KNOWLEDGE OF HIV TRANSMISSION AND CONDOM USE . . . . . . . . . . . . . . . . . .69 ORPHANS AND VULNERABLE CHILDREN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 List of References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 Appendix A. Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155 Appendix B. List of Personnel Involved in the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Appendix C. Estimates of Sampling Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Appendix D. Data Quality Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Appendix E. MICS Indicators: Numerators and Denominators . . . . . . . . . . . . . . . . . . . . 192 Appendix F. Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Appendix G. Urban Definition and Settlements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 vi • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome BCG Bacillus-Calmette-Guérin CEDAW Convention on the Elimination of Discrimination Against Women CRC Convention on the Rights of the Child CSPro Census and Survey Processing System DoSBSE Department of State for Basic and Secondary Education DoSHSW Department of State for Health and Social Welfare DPT Diphteria, Pertussis and Tetanus EPI Expanded Programme on Immunization FGM/C Female Genital Mutilation/Cutting GBoS Gambia Bureau of Statistics GPI Gender Parity Index HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders ITN Insecticide Treated Net IUD Intrauterine Device LAM Lactational Amenorrhea Method LGA Local Government Area MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey NAR Net Attendance Rate NaNA National Nutrition Agency ORS Oral Rehydration Solution ORT Oral Rehydration Ttreatment OVC Orphans and Vulnerable Children PPM Parts Per Million SPSS Statistical Package for Social Sciences STIs Sexually Transmitted Infections TVET Technical, Vocational Education and Training UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children's Fund WFFC World Fit for Children WHO World Health Organization Notations (x) This notation implies that the percentage or proportion, x, in brackets is calculated on a number of cases that fall in the range 25 to 49 cases. (*) This notation implies that the percentage or proportion, *, in brackets is calculated on a number of cases that fall in the range 1 to 24 unweighted cases and the actual percentage or proportion is not shown but it is represented by an asterisk. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • vii CHILD MORTALITY Child mortality 1 13 Under-five mortality rate 131 per thousand 2 14 Infant mortality rate 93 per thousand NUTRITION Nutritional 6 4 Underweight prevalence 20.3 per cent status 7 Stunting prevalence 22.4 per cent 8 Wasting prevalence 6.4 per cent Breastfeeding 45 Timely initiation of breastfeeding 47.7 per cent 15 Exclusive breastfeeding rate of 0-5 months 40.8 per cent 16 Continued breastfeeding rate at 12-15 months 92.3 per cent at 20-23 months 53.2 per cent 17 Timely complementary feeding rate 43.8 per cent 18 Frequency of complementary feeding 39 per cent 19 Adequately fed infants - 0-11 months 40 per cent Salt iodization 41 Iodized salt consumption 6.6 per cent Vitamin A 42 Vitamin A supplementation (under-fives) 80.1 per cent 43 Vitamin A supplementation (post-partum mothers) 78 per cent Low birth 9 Low birth weight infants 19.9 per cent weight 10 Infants weighed at birth 51.8 per cent CHILD HEALTH Immunization 25 Tuberculosis immunization coverage 96.6 per cent 26 Polio immunization coverage 87.6 per cent 27 DPT immunization coverage 86.8 per cent 28 15 Measles immunization coverage 92.4 per cent 31 Fully immunized children 74.5 per cent 29 Hepatitis B immunization coverage 79.6 per cent 30 Yellow fever immunization coverage 83.5 per cent Tetanus toxoid 32 Neonatal tetanus protection 75.6 per cent Care of illness 33 Use of oral rehydration therapy (ORT) 48.2 per cent 34 Home management of diarrhoea 29.4 per cent 35 Received ORT or increased fluids, and continued feeding 37.9 per cent 23 Care seeking for suspected pneumonia 68.9 per cent 22 Antibiotic treatment of suspected pneumonia 61.3 per cent Solid fuel use 24 29 Solid fuel 90.9 per cent Malaria 36 Household availability of insecticide-treated nets (ITNs) 49.5 per cent 37 22 Under-fives sleeping under insecticide-treated nets 49.0 per cent 38 Under-fives sleeping under mosquito nets 63.0 per cent 39 22 Antimalarial treatment (under-fives) 52.4 per cent 40 Intermittent preventive malaria treatment (pregnant women) 32.5 per cent Topic MICS MDG Indicator Indicator Number Number Indicator Value Summary Table of Findings Multiple Indicator Cluster Survey (MICS) and Millennium Development Goals (MDGs) Indicators, The Gambia, 2005/2006 viii • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Topic MICS MDG Indicator Indicator Number Number Indicator Value Source and 96 Source of supplies (from public sources) cost of supplies Insecticide treated nets per cent Antimalarials 66.9 per cent Antibiotics 65.0 per cent Oral rehydration salts 82.7 per cent 97 Cost of supplies (median costs) Insecticide treated nets Public sources 60.0 Dalasis private sources 137.9 Dalasis Antimalarials Public sources 25.0 Dalasis private sources 85.0 Dalasis Antibiotics Public sources 34.6 Dalasis private sources 68.1 Dalasis Oral rehydration salts Public sources 10.0 Dalasis private sources 10.0 Dalasis ENVIRONMENT Water and 11 30 Use of improved drinking water sources 85.1 per cent Sanitation 13 Water treatment 3.0 per cent 12 31 Use of improved sanitation facilities 84.2 per cent 14 Disposal of child's faeces 81.2 per cent Security of 93 Security of tenure 45.6 per cent tenure and 94 Durability of housing 1.8 per cent durability of 95 32 Slum household 70.2 per cent housing REPRODUCTIVE HEALTH Maternal and 20 Antenatal care provided by skilled personnel 97.8 per cent newborn health 44 Content of antenatal care Blood test taken 89.7 per cent Blood pressure measured 96.6 per cent Urine specimen taken 86.7 per cent Weight measured 97.5 per cent 4 17 Skilled attendant at delivery 56.8 per cent 5 Institutional deliveries 54.5 per cent CHILD DEVELOPMENT Child 46 Support for learning 46.9 per cent Development 47 Father's support for learning 20.6 per cent 51 Non-adult care 17.4 per cent The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • ix Topic MICS MDG Indicator Indicator Number Number Indicator Value EDUCATION Education 52 Pre-school attendance 19.7 per cent 53 School readiness 27.3 per cent 54 Net intake rate in primary education 29.9 per cent 55 6 Net primary school attendance rate 61.0 per cent 56 Net secondary school attendance rate 36.5 per cent 57 7 Children reaching grade five 96.6 per cent 58 Transition rate to secondary school 56.2 per cent 59 7b Primary completion rate 73.6 per cent 61 9 Gender parity index primary school 1.03 ratio secondary school 0.87 ratio Literacy 60 8 Adult literacy rate for females aged 15-24 years 43.1 per cent CHILD PROTECTION Birth 62 Birth registration 55.1 per cent registration Child labour 71 Child labour 24.7 per cent 72 Labourer students 64.5 per cent 73 Student labourers 24.2 per cent Child discipline 74 Child discipline Any psychological/physical punishment 82.4 per cent Early marriage 67 Marriage before age 15 9.9 per cent and polygyny Marriage before age 18 48.7 per cent 68 Young women aged 15-19 currently married/in union 25.1 per cent 70 Polygyny 43.6 per cent 69 Spousal age difference, 10 years and above Women aged 15-19 59.4 per cent Women aged 20-24 56.5 per cent Female genital 66 Approval for FGM/C 71.1 per cent mutilation/ 63 Prevalence of female genital mutilation/cutting Cutting (FGM/C) 78.3 per cent Like daughter to undergo FGM/C 72.9 per cent Domestic 100 Attitudes towards domestic violence 74.0 per cent violence x • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN HIV/AIDS 82 19b Comprehensive knowledge about HIV prevention 39.2 per cent knowledge among young people and attitudes 89 Knowledge of mother- to-child transmission of HIV 66.7 per cent 86 Attitude towards people with HIV/AIDS (no discrimination) 16.3 per cent 87 Women who know where to be tested for HIV 54.7 per cent 88 Women who have been tested for HIV 13.6 per cent 90 Counselling coverage for the prevention of mother-to-child transmission of HIV 45.4 per cent 91 Testing coverage for the prevention of mother-to-child transmission of HIV 20.8 per cent Sexual 84 Women aged 15-19 who had sex before age 15 3.9 per cent behaviour 92 Age-mixing among sexual partners 51.2 per cent 83 19a Condom use with non-regular partners 54.3 per cent 85 Higher risk sex in the last year 16.0 per cent Support to 75 Prevalence of orphans 8.7 per cent orphaned 78 Children's living arrangements 15.9 per cent and vulnerable 76 Prevalence of vulnerable children 12.6 per cent children 77 20 School attendance of orphans versus non-orphans 0.87 Ratio 79 Malnutrition among children orphaned and made vulnerable by HIV/AIDS (Ratio of OVC to non-OVC) 1.10 Ratio 80 Early sex among children orphaned and made vulnerable by HIV/AIDS (Ratio of OVC to non-OVC) 0.80 Ratio Topic MICS MDG Indicator Indicator Number Number Indicator Value The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • xi LIST OF TABLES Table HH.1 Results of household and individual interviews.78 Table HH.2 Household age distribution by sex.79 Table HH.3 Household composition .80 Table HH.4 Women's background characteristics.81 Table HH.5 Children's background characteristics .82 Table CM.1 Child mortality.83 Table CM.2 Children ever born and proportion dead.83 Table NU.1 Child malnourishment .84 Table NU.2 Initial breastfeeding.85 Table NU.3 Breastfeeding .86 Table NU.4 Adequately fed infants .87 Table NU.5 Iodized salt consumption .88 Table NU.6 Children's Vitamin A supplementation.89 Table NU.7 Post-partum mothers'Vitamin A supplementation .90 Table NU.8 Low birth weight infants.91 Table CH.1 Vaccinations in first year of life .92 Table CH.1c Vaccinations in first year of life (continued) .92 Table CH.2 Vaccinations by background characteristics .93 Table CH.2c Vaccinations by background characteristics (continued) .94 Table CH.3 Neonatal tetanus protection.95 Table CH.4 Oral rehydration treatment.96 Table CH.5 Home management of diarrhoea .97 Table CH.6 Care seeking for suspected pneumonia.98 Table CH.7 Antibiotic treatment of pneumonia.99 Table CH.7A Knowledge of the two danger signs of pneumonia .100 Table CH.8 Solid fuel use .101 Table CH.9 Solid fuel use by type of stove or fire.102 Table CH.10 Availability of insecticide treated nets.103 Table CH.11 Children sleeping under bednets .104 Table CH.12 Treatment of children with anti-malarial drugs.105 Table CH.13 Intermittent preventive treatment for malaria .106 Table CH.15 Source and cost of supplies for antimalarials.107 Table CH.16 Source and cost of supplies for antibiotics.108 Table CH.17 Source and cost of supplies for oral rehydration salts .109 Table EN.1 Use of improved water sources .110 Table EN.2 Household water treatment .111 Table EN.3 Time to source of water .112 Table EN.4 Person collecting water .113 Table EN.5 Use of sanitary means of excreta disposal .114 Table EN.6 Disposal of child's faeces .115 Table EN.7 Use of improved water sources and improved sanitation.116 Table EN.8 Security of tenure .117 Table EN.9 Durability of housing.118 Table EN.10 Slum housing.119 xii • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Table RH.3 Antenatal care provider .120 Table RH.4 Antenatal care .121 Table RH.5 Assistance during delivery.122 Table CD.1 Family support for learning .123 Table CD.3 Children left alone or with other children .124 Table ED.1 Early childhood education .125 Table ED.2 Primary school entry.126 Table ED.3 Primary school net attendance ratio .127 Table ED.4 Secondary school net attendance ratio.128 Table ED.4W Secondary school age children attending primary school.129 Table ED.5 Children reaching Grade 5.130 Table ED.6 Primary school completion and transition to secondary education.131 Table ED.7 Education gender parity.132 Table ED.8 Adult literacy.133 Table CP.1 Birth registration .134 Table CP.2 Child labour.135 Table CP.3 Labourer students and student labourers .136 Table CP.4 Child discipline.137 Table CP.5 Early marriage and polygyny.138 Table CP.6 Spousal age difference.139 Table CP.7 Female genital mutilation/cutting (FGM/C).140 Table CP.8 Female genital mutilation/cutting (FGM/C) among daughters.141 Table CP.9 Attitudes towards domestic violence.142 Table HA.1 Knowledge of preventing HIV transmission.143 Table HA.2 Identifying misconceptions about HIV/AIDS.144 Table HA.3 Comprehensive knowledge of HIV/AIDS transmission.145 Table HA.4 Knowledge of mother-to-child HIV transmission.146 Table HA.5 Attitudes towards people living with HIV/AIDS .147 Table HA.6 Knowledge of a facility for HIV testing.148 Table HA.7 HIV testing and counselling coverage during antenatal care.149 Table HA.8 Sexual behaviour that increases risk of HIV infection.150 Table HA.9 Condom use at last high-risk sex.151 Table HA.10 Children's living arrangements and orphanhood .152 Table HA.11 Prevalence of orphanhood and vulnerability among children .153 Table HA.12 School attendance of orphaned and vulnerable children.154 Table HA.14 Malnutrition among orphans and vulnerable children.154 Table HA.15 Sexual behaviour among young women by orphanhood and vulnerability status due to AIDS.154 The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • xiii List of Figures Figure HH.1: Age and sex distribution of household population . . . . . . . . . . . . . . . . . . . . . . .16 Figure CN 1 Age and sex distribution, Census 2003, The Gambia . . . . . . . . . . . . . . . . . . . . .16 Figure CM.1: Under-5 mortality rates by background characteristics . . . . . . . . . . . . . . . . . . . .20 Figure CM.2: Trend in under-5 mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Figure NU.1: Percentage of children under-5 who are undernourished . . . . . . . . . . . . . . . . . . .24 Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Figure NU.3: Infant feeding patterns by age: Percentage distribution of children aged under 3 years by feeding pattern and age group . . . . . . . . . . . . . . . . . . . . . . . . .27 Figure NU.5: Percentage of households consuming adequately iodized salt . . . . . . . . . . . . . . .28 Figure NU.8: Percentage of infants weighing less than 2500 grams at birth . . . . . . . . . . . . . . .31 Figure CH.1: Percentage of children aged 12-23 months who received the recommended vaccination by 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Figure CH.3: Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Figure CH.4: Percentage of children aged 0-59 months with diarrhoea who received oral rehydration treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Figure CH.5: Percentage of children aged 0-59 months with diarrhoea who received ORT or increased fluids, and continued feeding . . . . . . . . . . . . . . . . . . . . . . . . .37 Figure EN 1: Percentage distribution of household members by source of drinking water . . .40 Figure HA.1: Percentage of women who have comprehensive knowledge of HIV/AIDS transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 Figure HA.2: Percentage of young women aged 15-19 and 20-24 who had sex befor ages 15 and 18 respectively and percentage of women aged 20-24 who had sex with a man 10 or years older . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73 xiv • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Acknowledgements The Declaration and Plan of Action adopted at the World Summit for Children, held in New York in September 1990, established a set of goals for the decade 1990 to 2000. With regard to this, a study was first conducted in 1996, another similar or even more comprehensive one was conducted in May/June 2000 and a third one was conducted in December 2005/January 2006. These studies were aimed at monitoring progress made by The Gambia towards the attainment of the mid-decade and end-decade goals set during the above-mentioned Summit. By the ratification of the CRC and CEDAW, The Gambia, like many UN member states, commit- ted itself to the improvement of the plight of children and women by the year 2000. The two conventions are not only comprehensive and holistic in nature but also have a high impact on the plight of children and women when implemented simultaneously. The social and welfare status of both women and children is expected to be markedly improved, thereby enhancing sustainable development in each member state. To evaluate the efforts towards implementation of these conventions, UNICEF in collaboration with other UN agencies such as the WHO, UNFPA and the US Public Health Services developed the Multiple Indicator Cluster Survey (MICS). The MICS is a household survey that examines the behaviour of a comprehensive set of indicators related to the welfare of children and women. The module development for the survey captured data on households (economy), education, child labour, water and sanitation, salt iodization and health, ie oral rehydration solution (ORS), child mortality, tetanus toxoid, maternal and newborn health, HIV/AIDS, Vitamin A supplementation, breastfeeding care of illness, malaria, immunization and anthropometry, etc. In 2005/2006, the Government of The Gambia in collaboration with UNICEF and the World Bank conducted the third MICS to monitor progress made at end-decade as articulated in the National Plan of Action. The survey was conducted through inter-agency collaboration with the Central Statistics Department (CSD), now called Gambia Bureau of Statistics (GBoS), acting as the lead agency. Collaborating agencies included the: • Department of State for Health and Social Welfare(DoSHSW) • Department of State for Basic and Secondary Education (DoSBSE) • Department of Community Development • Women's Bureau • Department of Water Resources • Department of Social Welfare • Gambia Family Planning Association (GFPA). The prototype questionnaires developed by UNICEF were used with some modification to suit local conditions. However, in The Gambia a module on knowledge on rehydration solutions was added to determine the rate at which women know how to prepare the salt-sugar solution (SSS), as an oral rehydration solution (ORS) packet may not be available and/or affordable at certain times when needed. I wish to express my gratitude to all persons and agencies that participated in the different phases of the survey. Our sincere thanks go to UNICEF, Banjul Office, and the World Bank for providing The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • xv the much-needed financial support for the conduct of the MICS III. I am also indebted to the staff of GBoS, namely, Alieu Sarr (Demographer and Survey Coordinator), Edrissa Ceesay (Statistician/Programmer), Wally Ndow, Baba Suwareh and Lolley Jallow-Kah (Programmer). Thanks also go to Alieu Saho for his administrative support and guidance to the field staff. I am also grateful to Sheriffo Sonko, Project Officer, Monitoring and Evaluation, UNICEF, Banjul Office, for editing and providing useful comments on the final report as well as technical and logistical support throughout the design and conduct of the survey. Finally, my sincere thanks go to Ngagne Diakhaté, Project Officer, Statistics/Monitoring, DPP/SI, New York Headquarters, for his technical support in data processing and in solving the structural problems and inconsistencies in our dataset at the analysis stage. Throughout the numerous MICS workshops, Mr Diakhaté was quite supportive to the Gambian team. Again, during a mission to The Gambia in the early stages of the data processing, Messrs Diakhaté and Abdoulaye Sadio, Regional Adviser, Monitoring and Evaluation, also provided useful technical backstopping and advice on the data. For this, I am also grateful to Mr Sadio. I hope that scholars, researchers, institutions, planners and decision-makers will find the MICS III results useful. Alieu S M Ndow Statistician General October 2007 xvi • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report EXECUTIVE SUMMARY The Gambia Multiple Indicator Cluster Survey 2005/2006 is a nationally representative survey of households, children and women. The main objectives of the survey are to provide up-to-date information for assessing the situation of children and women in The Gambia. Another objective is to furnish data needed for monitoring progress towards the goals established at the World Summit for Children and the Millennium Development Goals as a basis for future action. The findings of this survey would also be utilized by government and development partners in planning and monitoring programme implementation. Infant and Under-5 Mortality • The data from the MICS III 2005/2006 show that the infant and under-5 mortality rates were 93 and 131 per 1, 000 respectively. These figures represent an impressive fall in mortality indicators compared to MICS II, which showed 98 and 141 per 1,000 respectively for infant and under-5 mortality. Education • Sixty-one per cent of children of primary school age in The Gambia are attending primary school. Although over the past five years primary school attendance in the Basse LGA has increased from 29 per cent to 46 per cent, it is still among the lowest attendance rates. The lowest primary school attendance (41 per cent) is found in Kuntaur LGA. At the national level, there is a slight difference between male (60 per cent) and female (62 per cent) primary school attendance. • Almost all (97 per cent) of the children who enter the first grade of primary school eventually reach Grade 5. • Literacy level among women aged 15-24 is 43 per cent. The highest level is found in Banjul and the lowest in Basse and Kuntaur, each of which registered less than 20 per cent. Water and Sanitation • Eighty-five per cent of the population has access to improved drinking water - 91 and 81 per cent in the urban1 and rural areas respectively. Apart from Kanifing, which has the highest (91 per cent), the differences among the remaining LGAs are small. • Eighty-four per cent of the population of the country live in households with sanitary means of excreta disposal. The traditional pit latrine is inclusive and this, in most places of the country, is not regarded as a sanitary means of excreta disposal. Child Malnutrition • Twenty per cent of children under-5 in the country are underweight or too thin for their age. Twenty-two per cent of the children are stunted or too short for their age and six per cent are wasted or too thin for their height. 1 See Appendix 7 for definition and list of urban settlements The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • xvii • Children whose mothers have secondary or higher education are the least likely to be under- weight and stunted. • Children of women in the richest quintile are least likely to be underweight and stunted. Breastfeeding • Approximately 53 per cent of children aged less than four months are exclusively breastfed. At age 6-9 months, 44 per cent of children receive breast milk and solid or semi-solid foods. By age 20-23 months, about half (53 per cent) of the children continue to breastfeed. Salt Iodization • About 7 per cent of households in The Gambia have adequately iodized salt, a level considera- bly lower than the recommended level. The percentage of households with adequately iodized salt ranges from 1 per cent in Banjul to 41 per cent in the Basse LGA. Vitamin A Supplementation • Within the six months prior to the MICS, 80 per cent of children aged 6-59 months received a high dose of Vitamin A supplement and a further 4 per cent received the Vitamin A supplement six months prior to that. • About 78 per cent of mothers with a birth in the last 2 years before the MICS received a high dose of Vitamin A supplement within eight weeks of the birth. Low Birth Weight • Approximately 20 per cent of infants were estimated to weigh less than 2,500 grams at birth. Of the total number of births only 52 per cent were weighed. Immunization Coverage • About 98 per cent of children aged 12-23 months received a BCG vaccination by the age of 12 months and the first dose of DPT was given to 93 per cent. The second and third doses of DPT were respectively given to 90 and 82 per cent of children aged 12-23 months. • Similarly, 93 per cent of children received Polio 1 by age 12 months and this declined to 83 per cent for the third dose. • The coverage for measles was 85 per cent among children vaccinated by 12 months of age. • Over half, 55 per cent of the children, had all nine antigens as recommended in the first 12 months of life. • There are small differences of vaccination coverage across sex, education and wealth quintiles (household wealth status). Diarrhoea • About 19 per cent of children aged 0-59 months had diarrhoea in the last two weeks prior to the date of interview of the survey. Of these, 37.9 per cent received one or more of the recom- mended home treatments (ie, were treated with ORS or RHF) and continued feeding. xviii • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Acute Respiratory Infection • Six per cent of under-5 children had an acute respiratory infection in the two weeks prior to the survey. About 69 per cent of these children were taken to an appropriate health provider. Malaria • In The Gambia, 63 per cent of under-5 children slept under a bednet the night prior to the survey interview. However, about 49 per cent of these bednets were impregnated with insecticide. • Approximately 65 per cent of children with a fever in the two weeks prior to the MICS interview were given Paracetamol/Panadol to treat the fever and 58 per cent were given Chloroquine while 13 per cent were given Fansidar. Sixty-three per cent of these children were given any appropriate anti-malarial drug and 48 per cent received the drug within 24 hours of the onset of symptoms. HIV/AIDS • Sixty-five per cent of women aged 15-49 know all three of the main ways to prevent HIV trans- mission - having only one faithful uninfected sex partner, using a condom every time, and abstaining from sex. • Forty-five per cent of women aged 15-49 correctly identified two most common misconceptions of HIV transmission - that HIV can be transmitted through supernatural means, that it can be transmitted through mosquito bites, and that a healthy looking person cannot be infected. • Fifty-five per cent of women aged 15-49 know a place to get tested for AIDS and about 14 per cent have been tested. • The percentage of women who have sufficient knowledge of preventing HIV transmission tends to increase with the level of education but is higher among the poorest than the richest quintiles. Antenatal Care • Almost all pregnant women (99 per cent) receive antenatal care (ANC) one or more times during pregnancy. Assistance at Delivery • A doctor, nurse, or midwife delivered about 57 per cent of births occurring in the year preceding the MICS. This percentage is highest in Banjul (95 per cent) and lowest in Kuntaur (28 per cent). Overall, 56.8 per cent of births occurring in the two years preceding the survey were delivered by skilled personnel and 54.5 per cent of the births were delivered in health facilities. The level of education and wealth quintiles are highly correlated to assistance at delivery by skilled personnel. Birth Registration • Births of 55 per cent of under-5 children have been registered. Birth registration coverage increases with age of child. Coverage is influenced by maternal education and wealth index quintile. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • xix Orphanhood and Living Arrangements of Children • Overall, 62 per cent of children aged 0-14 live with both parents. This proportion is highest for the poorest households and lowest for the richest households. Children who do not live with a biological parent comprise 16 per cent. This percentage increases with the age of the child; it is lowest for the poorest households and highest for the richest households. Children who have one or both parents dead account for 9 per cent of all children aged 0-14. Child Labour • About 25 per cent of children aged 5-14 are engaged in child labour. About 21 per cent of the children aged 5-14 work for family business. • About 2 per cent of these children are engaged in domestic tasks, such as cooking, fetching water, and caring for other children for 28 hours or more in a week. xx • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report The Gambia The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 1 1. INTRODUCTION Background This report is based on The Gambia Multiple Indicator Cluster Survey, conducted in 2005/2006 by the Central Statistics Department, now called The Gambia Bureau of Statistics, in collaboration with the: • Department of State for Basic and Secondary Education • Department of State for Health and Social Welfare • National Nutrition Agency • Women's Bureau • Gambia Family Planning Association • Department of Community Development Financial and technical support was provided by UNICEF and the World Bank. The survey provides valuable information on the situation of children and women in The Gambia, and was based, in large part, on the need to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations member states in September 2000, and the Plan of Action of A World Fit for Children, adopted by 189 member states at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see table below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and sub-national levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: 2 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Introduction “… As the world's lead agency for children, the United Nations Children's Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” Population Policy Faced with largely unfavourable economic conditions, rapid deforestation aggravated by rapid population growth, the Government of The Gambia decided to adopt a National Population Policy in 1992. The policy, designed to curb the rapid rate of population growth, has the overall goal of improving the quality of life and raising the standard of living of the population. This policy was first revised in 1996 and then later in 2006 to reflect the current demographic and socio-economic realities of the country. The revision of the policy was quite participatory and the strategies outlined for the attainment of the objectives took a cue from the experience gained from the implementation of past programmes. The 2007-2015 Policy aims at addressing current population trends which are not considered commensurable with sustainable socio-economic and environmental development. With the suc- cessful implementation of programmes planned under the current policy, it is envisaged that this will result in changes in population trends and address the shortcomings of the past policies, and fill in gaps emerging from new issues in national development strategies. The overall goals of the 2007-2015 National Population Policy are the same as those of the 1992 and 1996 policies, which sought to improve the quality of life by raising the standard of living of the population. In view of the crosscutting nature of some of the activities of the population programme, an attempt has been made to harmonise the National Population Policy with other policies. Key among these are the National Education Policy, the Gambia Environment Action Plan, the Housing, Health and Family Planning policies. The major targets of the National Population Policy are identified as: 1 To reduce the present annual population growth rate of 2.7 per cent (2003 Census) to 2.0 per cent by 2013 2 To reduce the proportion of girls who marry before the age of 18 years by 30 per cent by 2009 and by 80 per cent by 2015 3 To reduce the proportion of girls below 20 years and women below 40 years being pregnant to 50 per cent by 2010 and to 80 per cent by 2015 4 To increase the proportion of deliveries attended by skilled birth attendants to 60 per cent by 2010 5 To achieve an average birth spacing of at least two years for all birth intervals by 2015 6 To increase the gross enrolment ratio (7-15 years) from 91 per cent in 2002/2003 to 100 per cent by 2015 The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 3 Introduction 7 To improve the completion rate from 80 per cent in 2002/2003 to 100 per cent by 2015 8 To achieve full immunization coverage of 100 per cent of infants (0-11 months) by 2015 9 To increase the life expectancy of the population from its current level of about 64 years to 70 years by 2013 and to 75 years by 2015 10 To reduce the HIV 1 prevalence rate among pregnant women aged 15-49 from 1.1 per cent in 2005 to less than 1 per cent by 2015 11 To reduce the under-5 mortality rate from 99 per 1,000 live births in 2003 to 54 per 1000 live births by 2015 12 To reduce the rate of urban population growth from 5.9 per cent in 2003 to 4 per cent by 2010 13 To increase the modern contraceptive prevalence rate from the estimated rate of 13.4 per cent in 2001 to 20 per cent by 2009 and 30 per cent by 2015 14 To reduce the maternal mortality rate from 730 per 100,000 live births in 2001 to 260 per 100,000 live births by 2015 15 To reduce the total fertility rate from 5.4 in 2003 to 4.5 by 2015 16 To reduce the infant mortality rate from 75 per 1,000 in 2003 to 56 per 1,000 by 2015 17 To reduce the crude death and birth rates from 9 and 41 per 1,000 respectively in 2003 to 5 and 37 per 1,000 respectively by 2015 18 To reduce the unemployment rate from 6 per cent in 2003 to 4 per cent by 2015. A key strategy identified in the policy geared towards the achievement of these goals is improved access to health services throughout the country and the introduction of measures towards the improvement of the quality of health services in general. Improvements in the area of maternal and child health services have been particularly singled out for attention. Education cannot be divorced from population issues; hence the policy identifies strategies to improve educational attainment, particularly for girls. Other strategies developed relate to youth and women's empowerment, environmental development, agriculture and food security and HIV/AIDS, etc. Health Situation The health sector in The Gambia has, over the years, been under great pressure due to a number of factors, namely: • high population growth rate • inadequate financial and logistic support • shortage of adequate and appropriately trained health staff • high attrition rate • lack of an efficient and effective referral system. Poverty and ignorance have, in some instances, led to inappropriate health seeking behaviour and contributed to ill health. These factors have seriously constrained efforts to reduce morbidity and mortality rates in the country. A considerable number of indices in this report may be affected by the state of health of the population in general and the state of health services in the country in particular. It would be useful, therefore, to provide some information on the state of health of The Gambia in this chapter for a better understanding of some of the findings of this study. 4 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Introduction Health Care Delivery System Until the adoption of the Primary Health Care (PHC) strategy in 1979, the health care delivery system in The Gambia was largely centralized with the only government referral hospitals in Banjul and Bansang. The PHC strategy was adopted with the main aim of making health care more accessible and affordable to the majority of Gambians. A key target of the PHC was mainly rural settlements with a population of over 400 persons. For each PHC village, a village health worker (VHW) and a traditional birth attendant (TBA) are trained to provide primary health care in their communities. The village health workers (VHWs) are assigned the role of maintaining the supply of essential drugs, the provision of outpatient care, making home visits and carrying out health education programmes. The traditional birth attendants assist in deliveries, identify and refer at-risk mothers to health facilities at the tertiary level. At the tertiary level, health services are currently provided by the four government hospitals. These hospitals are located in Banjul, Bwiam, Farafenni and Bansang. The Royal Victoria Teaching Hospital (RVTH), located in Banjul, is the main referral hospital offering specialist consultant services. The hospital operates a pharmacy, laboratory services and a polyclinic, which provides secondary level health services to Banjul and the surrounding urban area. Farafenni Hospital provides referral services to people of the North Bank Region and adjacent rural areas. Although the hospital provides most specialist services, it is yet to be fully operational. Sulayman Junkung Hospital at Bwiam also provides referral services to surrounding villages in both the Western Region and some parts of the Lower River Region. Bansang Hospital, the oldest rural hospital, serves the eastern part of the country with the catchment area covering about a third of the country's population. In addition to operating as a referral hospital, it also has an outpatient department. Health services obtained by government-funded health institutions are complemented by services provided by the private sector and non-governmental organizations (NGOs). Individuals and NGOs have established a number of health facilities, mainly in the urban areas. Probably due to the higher costs involved in the provision of health services by these sectors, only a small proportion of the population is able to afford their services, hence the increasing demand for services from public-funded health facilities. Human Resources In the light of marked improvements both in terms of number of service delivery points and the quality of services, there has been a corresponding increase in the number of technical and professional health personnel. The public health services depend to a large extent on expatriate doctors, the majority of whom are Cubans and Nigerians provided through technical assistance. The increase in the number of doctors serving in the rural areas might have had the most impact, particularly with the posting of Cuban doctors to areas that have never been served by a resident doctor. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 5 Introduction A critical problem the health sector has been facing for many years now is the retention of trained nurses in the system. Nurses have been leaving the service in large numbers and DoSHSW has been facing the problem of trying to replenish those leaving through training. A large number of nurses have, over the years, been attracted to the higher income levels for nurses in Europe and the USA, which has in some instances caused a shortage of nurses for the health sector. Major Challenges of the Health Care System Notwithstanding the significant gains made in the health sector over the years, the sector continues to be faced with major challenges. With a rapidly growing population and increasing pressure on limited resources for the health sector, the sector has, over the years, struggled to meet the demand for services. Inadequate financial and logistical support, shortage of adequately and appropriately trained health staff, high staff attrition and an inefficient referral system have, over the years, aggravated the problems of the sector. These problems have curtailed the gains made in reducing morbidity and mortality in the country. Specialist services are still in high demand in The Gambia. Since most specialists are non-Gambian and usually on technical assistance, the withdrawal of such assistance could adversely affect the quality of services in the country. This state of affairs renders the health service delivery system of the country quite vulnerable. In addition to vulnerability due to reliance on non-Gambian health specialists, health funding in the country is heavily dependent on donor assistance. This raises issues of sustainability in the light of evidence of donor fatigue in the recent past. The introduction of a course in medicine at the University of The Gambia provides a ray of hope in the provision of much-needed trained medical personnel. The first batch of 11 medical doctors graduated from the university in 2006. Notwithstanding the potential of the university to train a sizeable number of doctors and other health personnel, the health sector continues to be faced with the perennial problem of high staff attrition which has aggravated the problem of staff shortages. Health Policy The National Health Policy Framework, 2007-2020, “Health is Wealth”, seeks to address the common health desires of the population through a number of initiatives both in the area of preventive and curative health services. With a vision to improve the health of all Gambians with a per capita income of US$ 1,500 by 2020, the policy has a mission to promote and protect the health of the population. It seeks to promote equity in access and affordability of quality services, maintain ethics and standards, promote health system reforms, and improve staff retention and client satisfaction. Cognizant of the multi-dimensional nature of health and the potential for health status to be influenced by a variety of factors, a number of areas have been identified in the policy that would collectively have the potential to impact on the health status. Under the current policy, areas identified for interventions relate to health care programmes and clinical care delivery, health system streng- thening and capacity development, and technical support services. The policy recognizes the need for community participation and the contribution of traditional medicine to the attainment of the national health goals. 6 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Introduction The major targets of the health policy have been identified as follows: 1 To reduce infant mortality rate from 75 per 1000 to 28 per 1000 by 2015 2 To reduce under-5 mortality rate from 99 per 1000 t0 43 per 1000 by 2015 3 To reduce maternal mortality ratio from 730 per 100,000 to 150 per 100,000 by 2015 4 To increase life expectancy at the national level to from 63.4 to 69 years by 2015 5 To increase life expectancy for women from 65 years to 70 years by 2015 6 To increase life expectancy for men from 62.4 years to 68 years by 2015 7 To reduce malaria incidence by 50% by 2015 8 To reduce HIV/AIDS prevalence (HIV 1 from 1.1% to 0.5% and HIV 2 from 0.7% to 0,1% by 2015) 9 To reduce total fertility rate from 5.4 to 4.6 by 2015 10 To reduce tuberculosis incidence rate from 120 per 100,000 to 60 per 100,000 by 2015 11 To reduce morbidity due to non communicable diseases by 10% by 2015 (2007 base) 12 To reduce morbidity due to other communcable diseases by 50% (2007 base) Education Policy 2004-2015 The aims and objectives of education in The Gambia are synchronized with the education-related Millennium Development Goals (MDGs), Education for All (EFA) goals, the New Partnership for African Development (NEPAD) education-related goals and the country's Poverty Reduction Strategy Paper (PRSP). The policy priorities are identified to allow for the growth of educational opportunities and improve the effectiveness of education at all levels, from early childhood development (ECD) to higher education. Based on these principles and the economic development prospects of the country, the basic aims of the Education Policy are: 1 To promote a broad-based education at the basic level for lifelong learning and training 2 To mainstream gender in the creation of opportunities for all to acquire literacy, livelihood skills and the utilization of these skills in order to earn a living and become economically self-reliant members of the community 3 To develop the physical and mental skills, which will contribute to nation building - economi- cally, socially and culturally in a sustainable environment 4 To encourage creativity and the development of a critical and analytical mind The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 7 Introduction 5 To further an understanding and appreciation of the contribution of science and technology to development 6 To cultivate sound moral and ethical values in the development of life skills 7 To develop a healthy body and an appreciation of the value of a healthy mind in response to life threatening diseases like HIV/AIDS, malaria and tuberculosis 8 To create an awareness of the importance of peace, democracy and human rights, duties and responsibilities of the individual in fostering these qualities 9 To foster an appreciation of and respect for the cultural heritage of The Gambia 10 To promote a sense of patriotism: service, loyalty, integrity and dedication to the nation and humanity. Considering the high population growth rate, the cost of education in relation to the poor and the current share of education in the government budget, the policy has been prioritized in the follo- wing five components aimed at providing equitable access to high quality education to the popula- tion of the country: Access to Education; Quality Education; Vocational and Technical Education; Tertiary and Higher Education. Policy Objectives Given the above priority areas and key strategies in mind, the policy seeks to attain the following objectives: 1 To increase the basic education GER to 100 per cent by 2015, taking into account enrolment in the Madrassas 2 To increase the completion rates in basic education to 100 per cent by 2015 3 To increase the supply of trained teachers and make more efficient use of the teaching force by maintaining the pupil/teacher ratio at 45:1 at the basic level 4 To increase double-shift classes from 25 per cent to 32 per cent by 2015 across all levels 5 To phase out double-shift teachers by 2015 6 To maintain multi-grade teaching in a combined class size not exceeding 40 7 To increase the share of enrolment of girls to 50 per cent of total enrolment at the levels of basic and secondary education by 2015 8 To improve the quality of teaching and learning at all levels 9 To improve learning outcomes at all levels - at least 80 per cent of students will attain minimum grade competencies/mastery levels by 2015 8 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Introduction 10 To increase the enrolment ratio of early childhood by 50 per cent especially in the rural areas by 2015 11 To increase access, for adults and out-of-school youth, to functional literacy and numeracy pro- grammes in order to have the illiterate population by 2015 12 To provide marketable and social skills to enable individuals to deal effectively with the demands and challenges of everyday life 13 To introduce the teaching of the five most commonly used languages - Mandinka, Wollof, Fula, Jola and Serahule - at the basic, senior secondary, higher education levels as subjects 14 To increase the transition rate from Grades 9 to 10 to a minimum of 50 per cent 15 To increase the quota of graduate teachers of Gambian nationality at the level of senior secon- dary from 26 per cent to 100 per cent by 2015 16 To strengthen the institutional and management capacity of the Technical, Vocational Education and Training (TVET) system 17 To establish a sound financial basis for the long-term development and sustainability of TVET 18 To increase cost sharing and cost recovery at post-secondary training institutions 19 To develop and strengthen public - private partnership in the financing of higher education 20 To institutionalize access programmes for higher education, especially for girls, particularly in science, mathematics and technology 21 To improve the organizational structure of the sector for efficient and effective service delivery. National Nutrition Policy The National Nutrition Agency (NaNA) is responsible for the implementation of the 2000-2004 National Nutrition Policy. The goal of the policy is to attain the basic nutritional requirements for the population. The policy also addresses issues that could impact on children's life, eg protecting, promoting and supporting breastfeeding, caring for the socio-economically deprived and nutritionally vulnerable and improving food security at national, community and household levels. The goal of the policy will be realized through the following seven priority substantive areas: • Protecting, promoting and supporting breastfeeding • Improving food security at the national, community and household levels • Improving food standards, quality and safety • Preventing and managing infectious diseases • Preventing and managing micro-nutrient malnutrition • Preventing and managing diet-related non-communicable diseases • Caring for the socio-economically deprived and nutritionally vulnerable. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 9 A key factor in the strategies to attain the policy objectives is an intensive information, education and communication (IEC) programme aimed at sensitizing stakeholders to the critical roles in the successful implementation of programmes identified to meet policy objectives. These programmes do not only target communities but also decision-makers who can influence policy formulation of relevance to the National Nutrition Policy. It is important to note that apart from the national policies discussed above, several laws exist that promote the interest of children and women. Below are the following policies and Acts. • The Children's Act, 2005 • National Youth Policy and Programme of Action • National Policy on the Advancement of Gambian Women • Early Childhood Development Policy Framework • Policy for the Prevention of Sexual Abuse of Students in Schools • Tourism Offences Act , 2005 Survey Objectives The Gambia Multiple Indicator Cluster Survey 2005/2006 has the following primary objectives: • To provide up-to-date information for assessing the situation of children and women in The Gambia • To furnish data needed for monitoring progress towards the goals established in the Millennium Declaration, the goals of A World Fit for Children (WFFC) and other internationally agreed upon goals as a basis for future action • To contribute to the improvement of data and monitoring systems in The Gambia and to strengthen technical expertise in the design, implementation and analysis of such systems. 10 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F/ G am 00 59 5/ G ia co m o P ir o zz i The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 11 2. SAMPLE AND SURVEY METHODOLOGY Sample Design The sample for The Gambia Multiple Indicator Cluster Survey was designed to provide estimates on a large number of indicators on the situation of children and women at the national level, for urban and rural areas, and for eight LGAs (LGAs): Banjul, Kanifing, Brikama, Mansakonko, Kerewan, Kuntaur, Janjangbureh and Basse. The LGAs were identified as the main sampling domains and the sample was selected in two stages. Within each LGA, at least 14 and at most 99 census enumeration areas were selected with probability proportional to size. After a household listing was carried out within the selected enumeration areas, a systematic sample of 6,175 households was drawn. The sample was stratified by LGA and urban and rural areas; it is not self-weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three sets of questionnaires were used in the survey: • a household questionnaire which was used to collect information on all de facto household members, the household and the dwelling • a women's questionnaire administered in each household to all women aged 15-49 • an under-5 questionnaire, administered to mothers or caretakers of all children under-5 living in the household. The questionnaires included the following modules: Household Questionnaire • Household Listing • Education • Water and Sanitation • Household Characteristics • Security of Tenure/Durability of Housing • ITN/Malaria-related questions • Child Labour • Child Discipline • Salt Iodization The Questionnaire for Individual Women was administered to all women aged 15-49 living in the households, and included the following modules: • Child Mortality • Tetanus Toxoid • Maternal and Newborn Health • Marriage and Union • Security of Tenure • Attitudes Towards Domestic Violence • Female Genital Mutilation/Cutting • Sexual Behaviour • HIV Knowledge The Questionnaire for Children Under-5 was administered to mothers or caretakers of children under-5 years of age2 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: • Birth Registration and Early Learning • Child Development • Vitamin A • Breastfeeding • Care of Illness • Malaria • Immunization • Anthropometry • Rehydration Solutions The questionnaires are based on the MICS III model questionnaire.3 Although translated versions of the questionnaires could not be produced for the survey, an attempt was made during the training of data collection personnel to translate all the questions into Mandinka, Fula and Wollof to ensure that there was a common approach to administering the questions to respondents in the local languages. All the questionnaires were pre-tested. Based on the results of the pre-test, modifications were made to the wording of some questions and translation problems identified and suitable alternatives discussed. A copy of The Gambia MICS III questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, and measured the weights and heights of under-5 children. Details and findings of these measurements are provided in the respective sections of this report. Training and Fieldwork Training for fieldwork staff lasted for 19 days in the Kanifing Municipality. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. In addition, since the questionnaires were not translated into the local languages, it was deemed necessary to conduct interviews in the three main local languages - Mandinka, Fula and Wollof - to ensure that there was a common translation of the questions. Mock interviews were repeated in the local languages to ensure a thorough unders- tanding of the questionnaires. 12 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Sample and Survey Methodology 2 The terms “children under 5”, “children aged 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 3 The model MICS III questionnaire can be found at www.childinfo.org, or in UNICEF, 2006 The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 13 Sample and Survey Methodology Towards the end of the training period, trainees spent five days in practice interviewing in Kanifing, Brikama and Mansakonko LGAs. This exercise gave the MICS team the opportunity to assess the suitability of the questionnaires and also to gauge the workload based on the sample size of the survey. The data were collected by seven teams; each comprised five interviewers, one driver, one editor/measurer and a supervisor. Fieldwork began in December 2005 and ended in March 2006. There were numerous breaks during the data collection exercise which were due to the observance of religious feasts of the Eid El Adha (locally known as Tobaski), Christmas and the New Year. These breaks delayed the data collection exercise immensely. To avoid the additional cost of teams having to travel to their homes during the holidays, mostly to the Greater Banjul Area, it was decided to begin the data collection in this area. Data Processing Data were entered using the CSPro software. The data were entered on 18 microcomputers and carried out by 36 data entry operators and two data entry supervisors. In order to ensure quality control, all the questionnaires were double entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS III project and adapted to The Gambia's questionnaires were used throughout. Data processing began simultaneously with data collection in January 2006 and was completed in March 2006. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 14, and the model syntax and tabulation plans developed by UNICEF for this purpose. 14 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F/ G am 00 50 6/ G ia co m o P ir o zz i The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 15 3. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Sample Coverage Of the 6,175 households selected for the sample, 6,171 were found to be occupied. Of these, 6,071 were successfully interviewed for a household response rate of 98.4 per cent. In the interviewed hou- seholds, 10,252 women aged 15-49 were identified. Of these, 9,982 were successfully interviewed, yielding a response rate of 97.4 per cent. In addition, 6,641 under -5 children were listed in the hou- sehold questionnaire. Copies of the questionnaires were completed for 6,543 of these children, which corresponds to a response rate of 98.5 per cent. Overall response rates of 95.8 per cent and 96.9 per cent are calculated for the women's and under-5's interviews respectively (Table HH.1). The differentials in response rates across LGAs are small. The lowest household response rate of 97.6 per cent is in the Brikama LGA and the highest of 100 per cent is in Banjul and Mansakonko. In the case of women's response rate, the lowest, which is 98.4 per cent, is in Kuntaur and the highest (99.4 per cent) is found in three other LGAs. Banjul has the lowest child response rate of 95.8 per cent. Characteristics of Households The age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 6,071 households successfully interviewed in the survey, 44,877 household members were listed. Of these, 22,072 were males, and 22,805 were females. These figures also indicate that the survey estimated the average household size at 7.4 persons. The percentage distribution of the MICS III survey population by the 5-year age group is very similar to the distribution of the 2003 population of The Gambia for all age groups. However, a marked percentage difference has been noticed between the two distributions at the age group 50-54 for females. This particular age group in the survey showed 4.6 per cent of the female population listed in the survey. This almost doubles the percentage of male population in this age group (2.6 per cent). The 2003 census results show that about 2.4 females were in this age group. The reason for the differences is not yet quite obvious. However, it is assumed that enumerators knowingly or otherwise shifted the women aged 45-49 to the age category 50-54 years to avoid having to interview large numbers of eligible women. For both distributions (survey and census) the age group 0-14 consists of 44 per cent of the population. The age group 15-64 consists of 52 per cent of the population. A similar correspondence exists between the survey and census age distributions for other age groups except the particular one mentioned above. 16 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Sample Coverage and the Characteristics of Households and Respondents Note that the figure below Figure HH.1 is the distribution of the 2003 population by age group. The population pyramid in Figure HH.1 is the distribution of the MICS III population listed by the 5-year age group. In general, under-enumeration of under-5 children due to age shifting to 5-9 years is evident in both the 2003 Census and the MICS III distributions. However, there is evidence of age shifting among women aged 45-49 to 50-54 in Figure HH.1. Figure HH.1. Population pyramid,The Gambia, 2006 Figure CN.1. Pyramid, Population and Housing Census 2003,The Gambia The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 17 Sample Coverage and the Characteristics of Households and Respondents Table HH.3 provides basic background information on the households. Within households, the sex of the household head, LGA, urban/rural status, number of household members and ethnicity of the household head is shown in the table. These background characteristics are also used in subse- quent tables in the report. The figures in the table are also intended to show the number of obser- vations by major categories of analysis in the report. The weighted and unweighted numbers of households are equal, since sample weights were normalized (See Appendix A). The table also shows the proportions of households where at least one child under 18, at least one child under 5, and at least one eligible woman aged 15-49 were found. About 84 per cent of the household heads are males. Rural settlements account for about 52 per cent of household heads. Table HH.3 also shows that 25 per cent of the households have 10 or more persons. Characteristics of Respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respon- dents 15-49 years of age and of under-5 children. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of children and women, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 provides background characteristics of female respondents aged 15 - 49. The table includes information on the distribution of women according to region, urban-rural areas, age, marital status, motherhood status, education4, wealth index quintiles5, and ethnicity. The table shows that 68.6 per cent of the females interviewed were married at the time of the survey and 57.4 per cent (interviewed females) were in the rural areas. The never-married category accounts for 26.8 per cent of the interviewed females aged 15-49 years. About 61 per cent of these women did not receive any form of formal education. The table also shows that 22.3 per cent of these are in the richest category and 17.1 per cent in the poorest category of the wealth index quintile. Some background characteristics of under-5 children are presented in Table HH.5. These include distribution of children by several attributes: sex, region and area of residence, age in months, mother's or caretaker's education, wealth and ethnicity. Of the under-5 children whose mothers/caretakers were interviewed, 51.1 per cent are males and 64.8 per cent live in the rural areas. The majority of under-5 children who were interviewed are in the age group 12-23 months. They account for 22.7 per cent of the under-5s. Twenty-three per cent are in the poorest households and 16.5 per cent in the richest households. 4 Unless otherwise stated, education refers to educational level attained by the respondent throughout this report when it is used as a background variable. 5 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and obtain wealth scores for each household in the sample. (The assets used in these calculations were as follows: persons per sleeping room; type of roof, floor and wall of house; type of cooking fuel; ownership of cars, mobiles, refrigerators, TVs and other means of transportation; and type of toilet facilities. Each household was then weighted by the number of household members, and the household population was divided into five groups of equal size, from the poorest quintile to the richest quintile, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to pro- duce 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, and the wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. 18 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F/ G am 00 51 8/ G ia co m o P ir o zz i The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 19 4. CHILD MORTALITY One of the overarching goals of the Millennium Development Goals (MDGs) and the WFFC is to reduce infant and under-5 mortality. Specifically, the MDGs call for a reduction in under-5 mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but dif- ficult objective. Measuring childhood mortality may seem easy, but attempts using direct questions, such as “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods develo- ped to measure child mortality produce robust estimates that are comparable with the ones obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions and poor interviewing technique. Infant mortality rate is the probability of dying before the first birthday. Under-5 mortality rate is the probability of dying before the fifth birthday. In MIC surveys, infant and under-5 mortality rates are calculated based on an indirect estimation technique known as the Brass method (United Nations, 1983; 1990a; 1990b). The data used in the estimation are: the mean number of children ever born for 5-year age groups of women aged 15 to 49, and the proportion of these children who are dead, also for 5-year age groups of women. The technique converts these data into probabilities of dying by taking into account both the mortality risks to which children are exposed and their length of exposure to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in The Gambia, the south model life table was selected as most appropriate. Table CM.1 provides estimates of child mortality by various background characteristics, while Table CM.2 provides the basic data used in the calculation of the mortality rates for the national total. These estimates have been calculated by averaging mortality estimates obtained from women aged 25-29 and 30-34, and refer to mid-2003. The infant mortality rate is estimated at 93 per thousand, while the probability of dying at the under-5 mortality rate (U5MR) is around 131 per thousand. As expected, male children experience higher mortality than female children. 20 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Child Mortality Figure CM.2 shows estimates of under-5 mortality by LGA, residence, mother's education and wealth. The LGA differentials should be viewed with caution due to the small sample sizes that some of the estimates are based on; this is particularly the case for Mansakonko and Kuntaur. The urban LGAs (Banjul and Kanifing) are shown as one category to overcome the effect of the small sample size of Banjul. Generally, infant and under-5 mortality rates are lowest in the Brikama LGA and highest in Kuntaur. The under-5 mortality rate in Banjul and Kanifing is 122 per thousand. There are notable differences in mortality in terms of mother's educational level, wealth and ethnicity. In particular, the probabilities of dying among children living in the richest households are considerably lower compared to the national average, ie infant mortality (58 vs 93 per 1000) and under-5 mortality (72 vs 131 per 1000). Figure CM.2 shows the series of U5MR estimates of the survey, based on the responses of women in different age groups, and referring to various points in time, thus showing the estimated trend in U5MR based on the survey. Despite the downward trend in mortality in both the censuses and the MICS estimates, the latter indicate a higher level of mortality during the previous 13 years (1993-2006) when compared to the census mortality estimates. The 2006 U5MR estimate (131 per thousand live births) from the MICS is about 24 per cent higher than the estimate of 99 per thousand live births for the 2003 census. Further qualification of these apparent differences and their determinants should be taken up in a more detailed and separate analysis. Figure CM.1:Under-5 mortality rates by background characteristics,The Gambia The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 21 Child Mortality Figure CM.2:Trend in under-5 Mortality Rates,The Gambia 22 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F/ G am 00 65 5/ G ia co m o P ir o zz i The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 23 5. NUTRITION Nutritional Status Children's nutritional status is a reflection of their overall health. When children have access to adequate food supply, are not exposed to repeated illness, and are well cared for, they are considered well nourished and reach their growth potential. Under-nutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and those who survive have recurring sicknesses and faltering growth. Three quarters of the children who die from causes related to mal- nutrition were only mildly or moderately malnourished - showing no outward sign of their vulnerability. The MDGs target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. The WFFC goal is to reduce the prevalence of malnutrition among under-5 children by at least one third between 2000 and 2010, with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition will assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for under-5 children. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is the WHO/CDC/NCHS reference, which was recommended for use by UNICEF and the World Health Organization (WHO) at the time the survey was implemented. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. 24 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Nutrition In the MICS III, weights and heights of all under-5 children were measured using anthropometric equipment recommended by UNICEF (UNICEF, 2006). The findings in this section are based on the results of these measurements. Table NU.1 shows the percentages of children classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above two standard deviations from the median of the reference population. In Table NU.1, children who were not weighed and measured (approximately 2.3 per cent of children) and those whose measurements are outside a plausible range are excluded. One in five children under-five in The Gambia is moderately underweight (20.3 per cent) and four per cent severely underweight (Table NU.1). Almost a quarter of the children (22 per cent) are moderately stunted or too short for their age. Six per cent are moderately wasted or too thin for their height. Children in Mansakonko, Janjangbureh and Kuntaur are more likely to be underweight than other children. Rural children are more likely to be underweight, stunted or wasted than urban children. Those children whose mothers have primary or higher education are least likely to be underweight and stunted than children of mothers with no education. Figure NU.1: Percentage of children under-5 who are undernourished, The Gambia, 2006 The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 25 Nutrition The age pattern shows that a higher proportion of children aged 12-23 months are undernourished according to all the three indices in comparison to children who are younger and older (Figure NU.1). This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food and the environment. Child obesity is being recognized even in developing countries as something that should be taken note of as the obesity may persist into adulthood. Two per cent of the children assessed were found to be overweight. Breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon. There are often pressures to switch to an infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. The WFFC goal states that children should be exclusively breastfed for six months and continue to be breastfed for two years of age and beyond, and introduced to safe, appropriate and adequate complementary feeding at six months. The WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for the first six months • Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at six months • Frequency of complementary feeding: at least twice per day for 6-8-month-olds; at least three times per day for 9-11 month olds It is also recommended that breastfeeding should be initiated within one hour of birth. The indicators of recommended child feeding practices are as follows: • Exclusive breastfeeding rate (< 6 months & < 4 months) • Timely complementary feeding rate (6-9 months) • Continued breastfeeding rate (12-15 & 20-23 months) • Timely initiation of breastfeeding (within 1 hour of birth) • Frequency of complementary feeding (6-11 months) • Adequately fed infants (0-11 months) Table NU.2 and Figure NU.2 provide the proportion of women who started breastfeeding their infants within one hour of birth, and women who started breastfeeding within one day of birth (which includes those who started within one hour). Approximately 48 per cent of women who gave birth within the previous two years breastfed their babies within one hour after birth and 90 per cent within one day after birth. Women in the Kerewan and Basse LGAs are more likely to breastfeed within the first hour (78 and 59 per cent respectively) and for the first day (96 and 92 per cent respectively). 26 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Nutrition In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children's consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breastfeeding of children at 12-15 and 20-23 months of age. Table NU.3 shows that 41 per cent of children aged less than six months are exclusively breastfed. At age 6-9 months, 44 per cent of the children are receiving breast milk and solid or semi-solid foods. By age 12-15 months, 92 per cent are still being breastfed and by age 20-23 months, 53 per cent are still breastfed. Girls are more likely to be exclusively breastfed than boys. Figure NU.3 shows the detailed pattern of breastfeeding by the child's age in months. Even in the earliest ages a considerable proportion of infants are receiving liquids or foods other than breast milk. Children in the rural areas are breastfed longer than to those in the urban areas. Figure NU.2: Percentage of mothers who started breastfeeding within one hour and within one day of birth,The Gambia, 2006 The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 27 Nutrition The adequacy of infant feeding in children less than 12 months is provided in Table NU.4. Different criteria of adequate feeding are used, depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as adequate feeding. Infants aged 6-8 months are considered to be adequately fed if they receive breast milk and complementary food at least twice a day, while infants aged 9-11 months are considered to be adequately fed if they receive breast milk and eating complementary food at least three times a day. Thirty-three per cent of infants 6-8 months old received breast milk and complementary food at least twice a day. For the infants between 9 and 11 months, 44 per cent received both breast milk and complementary food at least three times a day. As a result of these feeding patterns, only 40 per cent of children aged 0-11 months and 39 per cent aged 6-11 months are adequately and appropriately fed. A higher proportion of infants aged 6-8 months from the urban areas were found to be receiving breast milk and complementary food at least twice a day. Mothers with secondary education are more likely to feed their infants appropriately. Figure NU.3: Percentage distribution of children aged under 3 years by feeding pattern, and age group,The Gambia, 2006 28 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Nutrition Salt Iodization Iodine Deficiency Disorders (IDD) is the world's leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine defi- ciency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability and impaired work performance. The international goal is to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of households consuming adequately iodized salt (≥15 parts per million). In The Gambia, over 80 per cent of the salt consumed comes from outside the country and most of it is not iodized. Until 2003 salt had not been iodized in The Gambia. However, with assistance from partners, mainly UNICEF, salt is now being iodized in the country. Legislation has also been enacted on salt iodization. Intensive IEC is also currently being implemented to increase the household consumption of iodized salt. In about 90 per cent of households, salt used for cooking was tested for iodine content by using salt test kits testing for the presence of potassium iodate. Table NU.5 shows that in a very small proportion of households (9 per cent), there was no salt available. In Banjul a quarter of households contacted had no salt during the MICS III data collection. In 7 per cent of households, salt was found to contain 15 parts per million (ppm) or more of iodine. Use of iodized salt is highest in the eastern part of the country where 41 per cent of the households in the Basse area had adequately iodized salt. Only 5 per cent of salt in the urban areas was adequately iodized compared to 8 per cent in the rural areas. The results of the survey show that households in the poorest quintiles consumed more iodized salt compared to households in the richest quintiles. Figure NU.5: Percentage of households consuming adequately iodized salt, The Gambia, 2006 The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 29 Nutrition Vitamin A Supplements Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red or orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In the developing areas of the world, where Vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in the developing world and particularly in countries with the highest burden of under-5 deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of the deficiency a primary component of child survival efforts, and therefore is critical to the achievement of the fourth MDG: a two-thirds reduction in under-5 mortality by 2015. For countries with Vitamin A deficiency problems, current international recommendations call for high-dose Vitamin A supplementation every four to six months, targeting all children between the ages of 6-59 months living in the affected areas. Providing young children with two high-dose Vitamin A capsules a year (at six-monthly intervals) is a safe, cost-effective, efficient strategy for eliminating Vitamin A deficiency and improving child survival. Giving Vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother's stores of Vitamin A, which are depleted during pregnancy and lactation. For countries with Vitamin A supplementation programmes, the definition of the indicator is the percentage of children 6-59 months of age receiving at least one high dose of Vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, NaNA and the DOSHSW recommend that children aged 6-11 months should be given one high dose of Vitamin A capsules (100,000 IU) and children aged 12-59 months should be given a Vitamin A capsule (200,000 IU) every six months. Vitamin A sup- plementation has been incorporated into the Reproductive and Child Health Services in the entire country and all children aged 6-59 months receive a high dose every six months, which is then recorded on their infant welfare cards. Lactating mothers are also supplemented within eight weeks of giving birth due to increased Vitamin A requirements during pregnancy and lactation and encouraged to exclusively breastfeed. The supplement is expected to benefit the young infant in the first six months of life. Within the six months prior to the MICS, 80 per cent of children aged 6-59 months received a high dose of Vitamin A supplement (Table NU.6). Approximately 4 per cent did not receive the supplement in the previous six months but received one prior to that time. Eight per cent of children received a Vitamin A supplement at some time in the past but their mother/caretaker was unable to specify when this was done. Vitamin A supplementation coverage is lower in the urban areas (77 per cent) than in the rural areas (82 per cent). 30 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Nutrition The age pattern of Vitamin A supplementation shows that supplementation in the last six months rises from 76 per cent among children aged 6-11 months to 84 per cent among children aged 12-23 months and then declines with age to 76 per cent among the oldest children. About 78 per cent of mothers who gave birth in the previous two years before the MICS received a Vitamin A supplement within eight weeks of birth (Table NU.7). This percentage is higher in the rural areas (81 per cent) than in the urban areas (72 per cent). The Kanifing Municipality has the lowest Vitamin A coverage at 67 per cent. Mothers' education does not have an effect on the coverage. Vitamin A supplementation is higher among children from the poorest households than those from the richest. Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances of survival, growth, long-term health and psycho-social development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face an increased risk of dying during their early months and years. Those who survive have an impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower intelligence quotient (IQ) and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have the most impact: • the mother's poor nutritional status before conception • short stature (due mostly to under-nutrition and infections during her childhood) • poor nutrition during pregnancy. Inadequate weight gain during pregnancy is particularly important, since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are, represent only a small sample of all births. Since many infants are not weighed at birth, the weights of those who are weighed may bias the sample of all births. The reported birth weights usually cannot be used to estimate the prevalence The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 31 Nutrition of low birth weight among all children. Therefore, the percentage of births weighing below 2,500 grams is estimated from two items in the questionnaire: the mother's assessment of the child's size at birth (ie very small, smaller than average, average, larger than average, very large) and the mother's recall of the child's weight or the weight as recorded on a health card if the child was weighed at birth.6 Overall, 52 per cent of births were weighed at birth and approximately 20 per cent of infants are estimated to weigh less than 2500 grams at birth (Table NU.8). There was no marked variation by LGA (Figure NU.8). The percentage of low birth weight does not vary much by urban and rural areas or by mother's education or by ethnic group. Figure NU.8: Percentage of infants weighing less than 2500 grams at birth, The Gambia, 2006 32 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F/ G am 00 59 0/ G ia co m o P ir o zz i The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 33 6. CHILD HEALTH Immunization MDG 4 aims to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. Immunization has saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1979. Worldwide, there are still 27 million children overlooked by routine immunization and, as a result, vaccine-preventable diseases cause more than two million deaths every year. A WFFC goal is to ensure full immunization of children under one year of age at 90 per cent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to the UNICEF WHO guidelines, children should receive a BCG vaccination to protect them against tuberculosis, three doses of DPT to protect them against diphtheria, pertussis and tetanus, three doses of polio vaccine, and a measles vaccination by the age of 12 months. Mothers were asked to provide vaccination cards for under-5. Interviewers copied vaccination information from the cards on to the MICS questionnaire. In The Gambia, Hepatitis B and yellow fever vaccination are also given to children in addition to the others and are also recommended as part of the immunization schedule. It is recommended that Hepatitis B should be given at the same time as DPT and polio and yellow fever vaccination should be given by age nine together with measles. Hepatitis B was introduced in The Gambia in the mid- 1990s while yellow fever vaccines started around 1979. Figure CH.1: Percentage of children aged 12-23 months who received the recommended vaccination by 12 months,The Gambia, 2006 34 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Child Health BCG vaccination coverage is one key MICS indicator (25). Overall, 97.6 per cent of children were vaccinated against tuberculosis by the age of 12 months. DPT 3, according to the results in Table CH.1 and Figure CH.1, shows coverage of 82.4 per cent by 12 months of age. Polio 3 and measles show coverage of 83.3 and 84.9 per cent respectively. One would expect polio coverage to be higher than this, since a great amount of donor funding was made available for its total eradication. Yellow fever coverage indicates that 76.9 per cent of the children were vaccinated by 12 months of age (Table CH.1c). In fact, yellow fever coverage is the lowest compared to the other antigens observed above. Tables CH.2 and CH.2c show vaccination coverage rates among children 12-23 months by back- ground characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and mothers'/caretakers' reports. Overall, total vaccination coverage rate among the sample of children is 74.5 per cent (Table CH.2). Mansakonko LGA has the highest vaccination coverage rate of 86.7 per cent. Kuntaur has the second highest with a rate of 83.7 per cent, followed by Janjangbureh with 81.2 per cent. There is also a slight disparity in the coverage rate among the different ethnic groups with the Mandinka having the highest coverage of 77.0 per cent and the Serer having the lowest (6 per cent). As a whole, the results indicate that there are no large differences in vaccination coverage among the other background characteristics except in household wealth quintiles, where children from the poorest households are more likely to be vaccinated with all antigens compared to children from the richest households. Tetanus Toxoid Generally, there is 75.6 percent protection against neonatal tetanus among mothers with a birth in the last 24 months prior to the survey. Huge disparities exist among the regions, for example, Banjul has the lowest protection rate of 51.3 per cent compared to Mansakonko, which has the highest rate (89.6 per cent.) A similar trend is evident in urban-rural differentials, with the rural areas showing the highest protection rate of 81.4 per cent compared to 64.3 per cent for the urban areas (Figure CH.3). Huge differences exist among wealth quintiles ie mothers from the poorest households are more likely to receive the tetanus toxoid vaccine than mothers from the richest households. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 35 Child Health Overall, 19 per cent of under-5 children had diarrhoea in the two weeks preceding the survey (Table CH.4). There are notable differences in diarrhoea prevalence between the regions, with Kuntaur having a prevalence rate of 31.9 per cent and Mansakonko having the lowest rate (13.2 per cent). The urban areas have a prevalence rate of 15.7 per cent compared to the rural area, with 21.0 per cent. The results indicate that diarrhoea prevalence reduces as age increases with the lowest rate, 6.9 per cent, experienced by children aged 48-59 months. The results further indicate that the peak of diarrhoea prevalence occurs in the weaning period, among children aged 6-23 months (Table CH.4). Oral Rehydration Treatment Diarrhoea is the second leading cause of death among under-5 children worldwide. Most diar- rhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea - either through oral rehydration salts (ORS) or a recommended home fluid (RHF) - can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to reduce by one half death due to diarrhoea among under-5 children by 2010 com- pared to 2000 (WFFC) (2) and to reduce by two thirds the mortality rate among under-5 children by 2015 compared to 1990 (MDGs). In addition, the WFFC calls for a reduction in the incidence of diarrhoea by 25 per cent. Figure CH.3: Percentage of women with a live birth in the last 12 months who are protected against neonatal tetanus,The Gambia, 2006 36 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Child Health The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy • Home management of diarrhoea • ORT or increased fluids and continued feeding In the MICS questionnaire, mothers (or caretakers) were asked to report whether their child had had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Overall, ORT use rate was 48.2 per cent and no treatment rate was 51.8 per cent (Table CH.4). Nonetheless, there were disparities in the prevalence by local government area, urban and rural and educational levels (Figure CH.4). Figure CH.4: Percentage of children aged 0-59 months with diarrhoea who received oral rehydration treatment,The Gambia, 2006 The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 37 Child Health Generally, 29.4 per cent of diarrhoeal cases were managed at home. About 53 per cent of under-5 children with diarrhoea drank more fluids than usual while 45.2 per cent drank the same or less (Table CH.5). About 53 per cent ate somewhat less, the same or more (continued feeding), but 46 per cent ate much less or none. Nationally, 38 per cent of under-5 children received increased fluids and at the same time continued feeding (Figure CH.5). There are marked differences in the home management of diarrhoea by background characteristics. Basse LGA had the highest home management rate of 48.5 per cent while Mansakonko had the lowest rate (11.6 per cent). (Table CH.5) Figure CH.5: Percentage of children aged 0-59 months with diarrhoea who received ORT or increased fluids, and continued feeding,The Gambia, 2006 38 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Child Health Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in under-5s with suspected pneumonia is a key intervention. A WFFC goal is to reduce by one third the deaths due to acute respiratory infections. Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were not due to a problem in the chest and a blocked nose. The indicators are: • Prevalence of suspected pneumonia • Care seeking for suspected pneumonia • Antibiotic treatment for suspected pneumonia • Knowledge of the danger signs of pneumonia Out of the 1,082 children aged 0-59 months surveyed, 9.5 per cent sought care for suspected pneumonia at government hospitals, 47.9 per cent at government health centres, 1.8 per cent at government health posts, 2.4 per cent from village health workers, 1.6 per cent at mobile/outreach clinics and none at other public health facilities (Table CH.6). The prevalence of acute respiratory infection was 5.6 per cent. The lowest prevalence was observed in Banjul (0.6 per cent). Overall, there were no marked differences observed among urban-rural categories (Table CH.6). The results show that most mothers/caretakers of children aged 0-59 months sought care for suspected pneumonia at a pharmacy (10.9 per cent). This is followed by private hospital clinics (6 per cent) and then private physicians, relatives and traditional practitioners each at 1.4 per cent (Table CH.6). About 69 per cent of care seeking for suspected pneumonia was referred to an appropriate provider. Care seeking was highest in the rural areas (72 per cent), compared to the urban areas (64 per cent). Care was sought more for females (71 per cent) compared to males (67 per cent). Overall, 61.3 per cent of children 0-59 months with suspected pneumonia received antibiotic treatment in the last two weeks prior to the survey (Table CH.7). Only 4.1 per cent of mothers/caretakers were able to recognize the two danger signs of pneumonia (fast breathing and difficulty in breathing). Kerewan LGA has the highest proportion of mothers/caretakers who recognize the two danger signs (14.3 per cent). All other LGAs range from a proportion of 0.6 per cent in Banjul to 3.7 per cent in Basse (Table CH.7A). The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 39 Child Health Solid Fuel Use More than 3 billion people around the world rely on solid fuel (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuel lead to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuel is products of incomplete combustion, including CO, polyaromatic hydrocarbons, SO2, and other toxic elements. Use of solid fuel increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts and asthma. The primary indicator is the proportion of the population using solid fuel as the primary source of domestic energy for cooking. Out of a total of 6,071 households interviewed, 90.9 per cent reported that they used solid fuel for cooking. Among the solid fuel, wood was used by the majority of households (77.8 per cent). The least used is electricity and coal/ignite (0.1 per cent each). Charcoal was the third highest solid fuel used in cooking (12.8 per cent). The use of solid fuel for cooking is highest in Kuntaur (99.6 per cent) and lowest in Banjul (71 per cent). With the exception of Kanifing (84 per cent) and Banjul, over 90 per cent of households in all the other LGAs use solid fuel for cooking (See Table CH.8). Solid fuel use for cooking is more common among rural households than urban ones. Almost all rural households use solid fuel for cooking. Households headed by people with no formal education are more likely to use solid fuel for cooking than those headed by people with higher levels of education. Virtually all the households in the poorest quintiles use solid fuel for cooking. In the MICS III, questions were asked on three main types of stoves: closed stove, open stove/fire or hood, open stove and others. The open stove or hood was found to be the most commonly used stove (74. 1 per cent) followed by the closed stove (19.9 per cent). The least used was the other category (Table CH.9). Malaria Malaria is a leading cause of death of under-5 children in The Gambia. It also contributes to anaemia in children and is a common cause of school absenteeism. Preventive measures, especially the use of mosquito nets treated with insecticide (ITNs), can dramatically reduce malaria mortality rates among children. In areas where malaria is common, international recommendations suggest treating any fever in children as if it were malaria and immediately giving the child a full course of recommended anti- malarial tablets. Children with severe malaria symptoms, such as fever or convulsions, should be taken to a health facility. Also, children recovering from malaria should be given extra liquids and food and, for younger children, should continue breastfeeding. The questionnaire incorporates questions on the availability and use of bednets, both at the household level and among under-5 children, as well as anti-malarial treatment, and intermittent preventive therapy for malaria. Six thousand and seventy-one households were interviewed on the availability of insecticides treated nets. Out of these, 59.4 per cent reported having at least one mosquito net and 49.5 per cent had at least one insecticide treated net (See Table CH.10). 40 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Child Health Banjul households have the lowest proportion of ITNs (28.6 per cent) compared to the highest, Mansakonko, with 76.4 per cent. Households in the rural areas were nearly twice (64.0 per cent) more likely to use ITNs compared to those in the urban areas (31.0 per cent). Out of 6,543 children aged 0-59 months, 63 per cent of mothers or caretakers reported that the child slept under a bednet the night prior to the survey and of this, 49.0 per cent were reported to have slept under an ITN. A large proportion was reported not to have slept under a bednet (36.7 per cent). There were no major differences in bednet and ITN use by gender. Among the LGAs, Mansakonko has both the highest bednet and ITN usage rates (See Table CH.11). Eight per cent of children aged 0-59 months were reported to have had fever two weeks prior to the survey. Children from households headed by the Jola are more likely to have had fever children than the Mandinka and Fula (See Table CH.12). Among the children reported to have had fever, 13.3 per cent were given anti-malarial SP/Fansidar, 57.6 per cent were given chloroquine, 1.6 per cent had Armodaquine, 2.8 per cent had anti-malarial quinine drugs and 2.9 per cent other anti-malarial drugs. In general, about 63 per cent of children had some appropriate anti-malarial drugs and 65.3 per cent were given other medications such as Paracetemol/Panadol/Acetaminophan while 52.4 per cent had some appropriate anti-malarial drugs within 24 hours of the onset of symptoms (Table CH.12). Of the 3,070 women interviewed, 59.1 per cent took medicine to prevent malaria during pregnancy, 21.1 per cent took SP/Fansidar only once, 32.5 per cent took SP/Fansidar two or more times. In Banjul, very few women reported having taken SP/Fansidar two or more times (21.1 per cent). Janjangbureh has the highest percentage of women (49.4 per cent), who reported taking SP/Fansidar only once. No major differences have been observed in SP/Fansidar intake of two or more times by wealth index quintiles (Table CH.13). Sources and Costs of Supplies The results in Table CH.15 show various sources of anti-malarial drugs percentage that are free, and the median cost. Most respondents reported that they obtained anti-malarial drugs from public health facilities (66.9 per cent). Private facilities and other sources (mission and NGO facilities) constituted 20.5 and 12.6 per cent respectively. Eighty-four per cent reported having supplies free from public facilities and 14.7 per cent free from the private sector. The median cost of anti-malarial drugs in public facilities was D25.00 compared to D85.00 in private facilities (Table CH.15). Sixty-five per cent of the respondents reported having their antibiotics supplies from public facilities, while 27.9 per cent reported having them from private facilities. Very few obtained supplies from other sources (7.1 per cent). About 79 per cent obtained supplies free of charge from the public sec- tor while 22.8 per cent obtained theirs for free from private facilities. On average, supplies cost D34.60 in public facilities and D68.10 in private facilities (Table 6.16). The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 41 Sources and Cost of Supplies for Oral Rehydration Salts Oral rehydration salts are obtained from three different sources, namely public, private and others. On average, 82.7 per cent obtained them from public sources, 13.2 per cent from private sources and 4 per cent from other sources. About 93 per cent of the respondents got supplies free of charge from public facilities and 34.6 per cent from private facilities. Median cost of supplies was found to be D10.00 in both public and private facilities (Table CH.17). 42 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F G am b ia /2 00 7/ B .D o w n es -T h o m as The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 43 7.THE ENVIRONMENT Water and Sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid and schistosomiasis. Drinking water can also be tainted with chemical, physical and radiological contaminants with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for children and women, especially in the rural areas, where they bear the primary responsibility of carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The WFFC goal calls for a reduc- tion in the proportion of households without access to hygienic sanitation facilities and affordable safe drinking water by at least one third. The list of indicators used in MICS is as follows: Water • Use of improved drinking water sources • Use of adequate water treatment methods • Time to source of drinking water • Person collecting drinking water Sanitation • Use of improved sanitation facilities • Sanitary disposal of child's faeces The distribution of the population by source of drinking water is shown in Table EN.1 and Figure 7.1. The population using improved sources of drinking water are those using any of the following sources of supply: piped water (into dwelling, yard or plot), public tap/standpipe, tubewell/bore- hole, protected well and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for other purposes, such as hand- washing and cooking. Generally, 85.1 per cent of the population uses an improved source of drinking water - 91.2 per cent in the urban areas and 81.3 per cent in the rural areas. The data also show that as the level of education of the household heads increases, the more they are likely to have access to improved sources of drinking water. The results of the survey show that the richest households are more likely to have better access to improved sources of drinking water than the poorest households (95 per cent of the richest vs 82.5 per cent of the poorest households) (Table EN.1). 44 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report The Environment When comparing access to improved water source by ethnicity of household heads, the Mandinka have better access to safe drinking water, with 85.8 per cent and those headed by the Serer have the lowest, with 80.4 per cent. Across LGAs, there is not much difference in terms of access to safe drinking water. Kanifing Municipality had the highest proportion with about 91 per cent followed by Banjul with about 81 per cent and the lowest was recorded in Brikama with 79 per cent (Table EN.1). The source of drinking water for the population varies strongly across LGAs (Table EN.1). In Banjul and Kanifing, the most common source of drinking water is piped into dwelling or piped into yard or plot while in the other LGAs less than 10 per cent of their population use drinking water that is piped into their dwelling or into their yard or plot. Unprotected wells, which are the most unsafe source of drinking water, are common in the predo- minantly rural LGAs particularly in Brikama and Janjangbureh LGAs with 20 and 18 per cent respectively of their population using such a source of water. Other than Banjul and Kanifing, the public tap/standpipe is the most important source of drinking water in the other LGAs. Use of in-house water treatment is presented in Table EN.2. Households were asked about ways they may be treating water at home to make it safer to drink - boiling, adding bleach or chlorine, using a water filter and using solar disinfection were considered as proper treatment of drinking water. Table EN.2 shows the percentage of household members using appropriate water treatment methods, separately for all households and households using improved and unimproved drinking water sources. Table EN.2 shows that the use of strain through a cloth is the most common water purification method used by households with 19.4 per cent. The proportion is highest in Janjangbureh with about 35 per cent and lowest in Banjul with 2.1 per cent. The rural - urban differentials show that the method is in most use in the rural rather than the urban areas. Figure EN 1: Percentage distribution of household members by source of drinking water, The Gambia, 2006 The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 45 The Environment The second most commonly used method is adding bleach/chlorine and the method was reportedly used more in Kuntaur than the other LGAs. The other methods were not used much across all LGAs. Of the households who get their water from unimproved sources and use water treatment methods, 7.3 per cent use appropriate water treatment methods compared to 2.2 per cent of households who use improved drinking water. Combining all sources of drinking water, only 3 per cent of households use appropriate water purification methods. The amount of time it takes to obtain water is presented in Table EN.3 and the person who usually collected the water in Table EN.4. Note that these results refer to one round trip from the home to the drinking water source. Information on the number of trips made in one day was not collected. Table EN.3 shows that for 33 per cent of households, the drinking water source is on the premises and, as expected, the proportion is highest in Banjul and Kanifing with 80 per cent and 63 per cent respectively. For 46.9 per cent of households, it takes less than 30 minutes to get to the water source and bring water, while 4 per cent spend more than one hour to get water from its source. Excluding those households with water on the premises, the average time to the source of drinking water is 21 minutes. Interestingly, the time spent in urban areas in collecting water is slightly higher than in the rural areas. This could be attributed to the fact that in the urban areas, particularly Banjul and Kanifing, there are few public taps/standpipes and, as such, people spend a lot of time queuing up for water. One striking finding is the high average time spent in Basse in collecting water (31 minutes). Table EN.4 shows that for the majority of households (82 per cent), an adult female is usually the person collecting the water, when the source of drinking water is not on the premises. Adult men collect water in only 7 per cent of cases, while for the rest of the households, female children under age 15 collect water more (9 per cent) compared to the male children of the same age (0.8 per cent). Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases including diarrhoeal diseases and polio. Improved sanitation facilities for excreta disposal include: flush or pour flush to a piped sewerage system, septic tank or latrine; ventilated improved pit latrine, pit latrine with a slab and composting toilet. Sanitary means of excreta disposal include the following: flush to piped sewer system, flush to septic tank, flush to pit (latrine), ventilated improved pit latrine (VIP) and pit latrine with slab. Eight-four per cent of the sampled population live in households using improved sanitation facilities (Table EN.5). This percentage is 93 in the urban areas and 78 per cent in the rural areas. Across regions the proportion of the population with improved sanitary means of excreta disposal ranged from 31 per cent in Janjangbureh to 97 per cent in Banjul. This indicates that the residents of Janjangbureh are less likely than others to use improved toilet facilities. Table EN.5 indicates that use of improved sanitation facilities is strongly correlated with wealth and is profoundly different between the urban and rural areas. In the rural areas, the population mostly use pit latrines with slabs or traditional pit latrines. In contrast, the most common facilities in the urban areas are flush toilets with connection to a sewerage system or septic tank. 46 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report The Environment Safe disposal of a child's faeces was related to a question on whether the last stool by the child was disposed of by use of a toilet or rinsed into a toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table 7.6. The data show that most of the mothers or primary caretakers of children put or rinsed the child's faeces into a toilet or latrine and the proportion is higher in Banjul, Kanifing and Brikama, while about 11 per cent reported they throw the faeces into the dusbin. The proportion is highest in Kuntaur and virtually does not exist in Banjul. About 5 per cent reported that the faeces are put or rinsed into the drain or ditch.The proportion is highest in Janjangbureh with 16 per cent and lowest in Kanifing and Brikama with 1.3 per cent of mothers/caretakers in these LGAs reported to dispose of children's faeces in this way. The data indicate that 81 per cent of mothers/caretakers in the country dispose of children's faeces safely. The percentage of mothers/caretakers who dispose of faeces of their children safely is highest in Banjul (93 per cent) and lowest in Kuntaur (42 per cent). A higher proportion of mothers/caretakers dispose of their children's faeces properly in the urban areas than those in the rural areas. The data further reveal that the wealthier the household, the higher the chances of disposing of the children's stool safely. A similar trend has also been observed with the level of education of the mother or the primary caretaker. The more educated the mother/primary caretaker is, the higher the chances of disposing of the child's faeces safely. An overview of the percentage of households with improved sources of drinking water and sanitary means of excreta disposal is presented in Table EN.7. The data show a positive correlation between level of education and access to improved sources of drinking water and using sanitary means of excreta disposal among households on one hand and income level of the household on the other. The more educated the head of the household or the higher the wealth category of the household, the more likely they are to have access to improved sources of drinking water and sanitary means of excreta disposal. Security of Tenure and Durability of Housing Target 11 of the MDGs is the achievement of significant improvements in the lives of at least 100 million slum dwellers, and the related indicator is the proportion of urban household members living in slum housing. In the MICS, three indicators were introduced to measure issues related to slum housing: security of tenure, durability of housing and proportion of people living in slum households. An urban household is considered a slum in the MICS if it fulfils one of the following conditions: improved drinking water sources are not used, improved sanitation facilities are not used, insufficient living area, housing is not durable, or lack of security of tenure. Lack of security of tenure is defined as the lack of formal documentation for the residence or perceived risk of eviction. Table EN.8 is on security of tenure. In the urban areas covered in The Gambia MICS, 41 per cent of households do not have formal documentation for their residences. The proportion is higher in Banjul with 68 per cent and lowest in Mansakonko with 20 per cent. Fifteen per cent of respondents to the household questionnaire indicated that there is a risk of eviction; the proportion is higher in Janjangbureh with 30 per cent and lowest in Brikama with 2 per cent. Combining these figures, it has been observed that 45.6 per cent of households reported that they did not have security of tenure. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 47 The Environment As additional information, Table EN.8 shows that 6 per cent of household members were indeed evicted from any dwelling they were residing during the five years prior to the survey. Across regions, the proportion of those evicted is highest in Kanifing (6.9 per cent). No household members reported they were been evicted in Janjangbureh. The data also indicate that the richest households have more security of tenure but are reported to have experienced more eviction in the past than the poorest households. Structures that household members live in are considered as non-durable in the MICS, if the floor material is natural. Two or more bad conditions were identified with the structure. The findings of the survey in this regard are presented in Table EN.9. Generally, 1.8 per cent of households and 1.9 per cent of household members were reported to be living in dwellings, which are considered as non-durable. Table EN.10 brings together all the five components of slum housing. Overall, 59 per cent of household members were reported to be living in slum housing and, as expected, the proportion is highest for the poorest households (86 per cent) and lowest for the richest households (48 per cent). The proportion of household members reported to be living in slums is also higher for households headed by the Fula (76 per cent) when compared to households headed by other ethnic groups. 48 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F/ G am 00 56 2/ G ia co m o P ir o zz i The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 49 8. REPRODUCTIVE HEALTH Antenatal Care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. A better understanding of foetal growth and development and its relationship to the mothers health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs, symptoms and the risks of labour and delivery, it may provide the route for ensuring that pregnant women do, in practice, give birth to babies with the assistance of skilled health care providers. The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. The pre- vention and treatment of malaria among pregnant women, management of anaemia during pregnancy and treatment of sexually transmitted infections (STIs) can significantly improve foetal outcomes and maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women's nutritional status and prevent infections, eg, malaria and sexually transmitted infactions during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to, and use of, antenatal services. The WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. The WHO guidelines are specific on the content on antenatal care visits, which include: • Blood pressure measurement • Urine testing for bateriuria and proteinuria • Blood testing to detect syphilis and severe anaemia • Weight/height measurement (optional) Coverage of antenatal care by skilled personnel (doctor, nurse, or midwife) is relatively high in The Gambia with 97.8 per cent of women receiving antenatal care at least once during their last pre- gnancy from these skilled personnel. The lowest level of antenatal care among women with a birth in the two years preceding the survey was found in Kerewan and Kuntaur (96 per cent). Antenatal care coverage is the same in both urban and rural areas, each with about 98 per cent (Table RH.3). The type of personnel providing antenatal care to women aged 15-49 years who gave birth in the two years preceding the survey is presented in Table RH.3. The results show that 73.1 per cent received such care from a nurse/midwife and 12.6 per cent from an auxiliary midwife. However, the use of traditional birth attendants and community health workers for antenatal care is not so much; the proportion is higher in Kerewan for the former and in Kuntaur for the latter. 50 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Reproductive Health The types of services which pregnant women received are shown in Table RH.3. Ninety per cent of the women had their blood samples taken, 96.6 per cent had their pressure measured, 86.5 per cent had their urine specimen taken and 97.5 per cent had their weight measured. Assistance at Delivery Three quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure that a competent health worker with midwifery skills is present at every birth, and transport is available to a referral facility for obstetric care in case of emergency. A WFFC goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at the delivery indicator is also used to track progress towards the MDGs target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. The MICS included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. About 57 per cent of births occurring in the year preceding the MICS were delivered by skilled personnel (Table RH.5). This percentage is highest in Banjul (about 95 per cent) and lowest in Kerewan (28.4 per cent). Women with high levels of education are more likely to have been assisted at delivery by skilled personnel than women with lower levels of education. About 47 per cent of the births in the year preceding the MICS were delivered with the assistance of a nurse/midwife. Doctors assisted with the delivery of about 6 per cent of births and auxiliary midwives helped with about 5 per cent of the deliveries. Generally, about 57 per cent of births were delivered by skilled personnel but these births occurred mostly among women in Banjul, Kanifing and Brikama, where the type of personnel providing delivery assistance is noticeably different from other LGAs. The data further show that women assisted by traditional birth attendants during delivery were more common in the predominantly rural LGAs (Mansakonko, Kerewan, Kuntaur, Janjangbureh and Basse), and those assisted by community health workers were more common in those regions as well. Women with secondary education and above (85 per cent) were more likely to have been delivered by skilled personnel than women with primary (68.1 per cent) or no education at all (49 per cent). On the other hand, women from the richest households (88.6 per cent) were more likely to be delivered by skilled personnel than women from the poorest households (28 per cent). It is worth noting that the data presented on the cadre of health care provider who attended the birth of women should be viewed in consideration of their inherent limitations. This is because in a largely illiterate population like The Gambia it would be extremely difficult, if not impossible, for women interviewed during the MICS to identify the cadre of health care providers who delivered their babies with precision. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 51 Reproductive Health Although during the training of field workers an attempt was made to provide guidelines for the accurate identification of the cadre of health care providers assisting during delivery, it was obser- ved that such data might be fraught with errors. This limitation is however unlikely to significantly affect the proportion of births attended by skilled personnel. This is because women at least are able to definitively say if their deliveries were made in health facilities and the fact that those delivering babies in these facilities are most likely to fall in the skilled personnel category. 52 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F/ G am 00 66 3/ G ia co m o P ir o zz i The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 53 9. CHILD DEVELOPMENT It is well recognized that 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 of the child's development during this period. In this context, adult activities with children, the presence of books in the home for the child, and the conditions of care are important indicators of quality of home care. A WFFC goal is that “children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning was collected in the survey. This included the involvement of adults with children in the following activities: • reading books or looking at picture books • telling stories • singing songs • taking children outside the home, compound or yard • playing with children • spending time with children naming • counting • drawing things. Almost half (47 per cent) of under-5 children were reported to have household members engaged in four or more activities that promote learning and school readiness during the three days prece- ding the survey (Table CD.1). The average number of activities that adult members engaged in with children was 3.4 activities. The table also indicates that the father's involvement in such activities was somewhat limited. Only 21 per cent of the under-5s had fathers who engaged in one or more activities to promote learning and school readiness. About 26 per cent of children were living in households without their biological fathers. There are slight gender differentials in terms of adult activities with children with a larger proportion of fathers engaged in activities with male children (22 per cent) than with female children (19 per cent). The proportion of adults engaged in learning and school readiness activities with children in the urban areas is slightly higher (48 per cent) than in the rural areas (46 per cent). Differentials have been observed across regions. Adult engagement in activities with children was highest in Kerewan LGA (89 per cent) and lowest in Banjul (26 per cent). The figures show that children in the richest households are more likely to be engaged in activities that promote learning and school readiness with household members than children in the poorest households. Children of better-educated mothers are slightly more likely to be engaged in such activities than those with less educated mothers. Table CD.3 shows that 13.9 per cent of children aged 0-59 months were left in the care of other children, while 4.4 per cent were left alone during the week preceding the inter- view. Combining the two care indicators, it is calculated that 17 per cent of children were left with inadequate care during the week preceding the survey. Slight differences were observed by the sex of the child or between the urban and rural areas. Inadequate care was more prevalent among children whose mothers had no education (19 per cent), as opposed to children whose mothers had secondary education (11 per cent). Children aged 24-59 months were left under inadequate care in the past week (22 per cent) compared to those aged 0-23 months (12 per cent). 54 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F/ G am 00 83 2/ G ia co m o P ir o zz i The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 55 10. EDUCATION Pre-School Attendance and School Readiness Attendance of pre-school education in an organized learning or child education programme is important for the readiness of children to school. One of the WFFC goals is the promotion of early childhood education. Generally, 19.7 per cent of children aged 36-59 months were reported to be currently attending early childhood schools. Twenty per cent of males and 19.4 per cent females of were attending some form of organized early childhood education programme in The Gambia in 2006 (Table ED.1). Gender differentials in school attendance are small (0.6 per cent); however there exist large diffe- rentials in attendance between the urban and rural areas and also across LGAs. Attendance in the urban areas is 30.2 per cent compared to 13.0 per cent in the rural areas. Among children aged 36-59 months, pre-school attendance is more prevalent in Banjul and Kanifing (36.1 and 34.8 per cent respectively), and less in Kerewan and Kuntaur LGAs (6.6 and 7.5 per cent respectively). Comparatively, a smaller proportion of children (13.7 per cent) have some form of organized early childhood learning activities at age 36-47 months than older children with 28.2 per cent of children aged 48-59 months attending early childhood school. Household poverty status appears to have a positive correlation with school readiness - while the indicator is only 6.7 per cent among the poorest households, it is 41.6 per cent among children living in the richest households. The more educated a woman is, the more likely it is that her children will attend an early childhood education programme. The proportion of children who have early childhood education increases with the level of education of women. Among the ethnic groups, households headed by the Jola tend to send more of their children to early childhood school than other ethnic groups. Thirty-two per cent of their children have some form of early childhood education followed by the Serer (30 per cent), the Mandinka, the Wollof with 19 per cent each and the Fula with the lowest (14 per cent). The table also shows that the proportion of children in the first grade of primary school who attended pre-school the previous year (Table ED.1), an important indicator of school readiness, is nearly a third of the children (27.3 per cent). The proportion among boys is higher (29.6 per cent) than girls (25.2 per cent). Analysis by LGA, urban-rural, mothers' education and wealth index could not be done due to a small number of cases of less than 50 (see Table ED.1). 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 MDGs and WFFC. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment, and influencing population growth. 56 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Education The indicators for primary and secondary school attendance include: • Net intake rate in primary education • Net primary school attendance rate • Net secondary school attendance rate • Net primary school attendance rate of children of secondary school age • Female to male education ratio (GPI) The indicators of school progression include: • Survival rate to Grade 5 • Transition rate to secondary school • Net primary completion rate The analysis in Table ED.2 indicates that 29.9 per cent of children who are of primary school entry age (age 7) in The Gambia are currently attending the first grade of primary school. No marked sex differentials have been observed (29.5 per cent for boys compared to 30.4 per cent for girls). However, huge differentials have been observed across LGAs and urban-rural residence. Kanifing LGA has the highest proportion (33.3 per cent) of children of primary school entry age currently attending Grade 1 compared to Kuntaur at 21 per cent. Children's primary school attendance is highest in the urban areas (35.5 per cent) than in the rural areas (27.4 per cent). A positive correlation has been observed between mother's education and school attendance and also between household poverty status and school attendance. Of the children aged 7 whose mothers have at least a secondary school education, 42.0 per cent were attending Grade 1 compared to 28.3 per cent of children whose mothers had never been to school. In the richest households, the proportion is 38.9 per cent, while it is 22.5 per cent among children living in the poorest households. For children of primary school entry age from households headed by the Mandinka 31.1 per cent were currently attending Grade 1 compared to 29.8 per cent of those from households headed by the Jola and 27 per cent of those from Fula headed households. Table ED.3 provides the percentage of children of primary school age attending primary or secondary school. The majority of children of primary school age are attending school (61.0 per cent). However, 39.0 per cent of the children are out of school when they are expected to be attending school. The net attendance ratio varies across regions. Banjul had the highest ratio with 77.6 per cent followed by Kanifing (73.5 per cent) and Kuntaur the lowest ratio (41.2 per cent). Among boys, Kanifing had the highest net attendance rate (75.4 per cent) and Mansakonko the lowest (46.2 per cent). Banjul had the highest rate for girls (81.5 per cent) while Basse had the lowest (45.1 per cent). There are also marked differences in net attendance ratio between the urban and rural areas. The net attendance ratio in the urban areas for boys is 74.8 per cent compared to 52.9 per cent in the rural areas. Among the girls, the net attendance ratio is 72.5 per cent for the urban areas com- pared to 56.5 per cent for the rural areas. There is a positive relationship between children's net attendance ratio and the women's level of education as well as the poverty status of households. The more educated a woman is, the higher the likelihood of her children being sent to primary school, as the indicator ranges from 57.7 per cent of children of women with no education to 80.7 per cent of children of women with secondary education and above. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 57 Education Children from the richest households have a higher attendance rate (75.8 per cent) than children from the poorest households (44.4 per cent). Seven-year-old children have a lower attendance rate (35.3 per cent) than older children, while those aged 11 years have a higher attendance rate (74.5 per cent). Across ethnic groups, children from households headed by the Jola have a net attendance ratio of 72.9 per cent and households headed by the Wollof and Fula have the lowest proportions each with 53 per cent. The secondary school net attendance ratio is presented in Table ED.4. Secondary school attendance rates are relatively lower than those of primary schools with only 36.5 per cent of children of secondary school age attending secondary school. A larger proportion of boys of secondary school going age were found to be attending secondary school than girls. In general, 39.2 per cent of boys were attending school compared to 34.0 per cent of girls. Across LGAs, the net attendance ratio is lowest in Basse for both boys and girls and highest in Banjul. The net attendance ratio for both boys and girls for Banjul is 56.0 per cent compared to only 14.7 per cent in Basse LGA. Across all the regions, the net attendance rate is higher for boys except in Banjul and Mansakonko where the ratio is higher for girls. In the urban areas, slightly above half of the children of secondary school age were attending secondary or higher school compared to 26.4 per cent of their counterparts in the rural areas. The educational attainment of women is positively related to the net attendance ratio. School atten- dance ratios range from 35.0 per cent for children of women with no education to 57.4 per cent for those of women with secondary education and above. The data also show that the richer the household, the higher the net attendance rate of its children. Across the ethnic groups, households headed by the Serer have the highest net attendance ratio. The primary school net attendance ratio of children of secondary school age is presented in Table ED. 4W. About one in four (24.3 per cent) of the children of secondary school age was attending primary school when they should have been attending secondary school. Small differences exist in the proportion of such children attending primary school across the sexes with 25.1 per cent and 23.4 per cent of boys and girls, respectively, attending primary school. This observed phenomenon of older children attending primary school has been found to be more prevalent in Brikama (31.1 per cent) and Janjangbureh (29.5 per cent) LGAs but the least prevalent in Banjul (16.1 per cent). The proportion of children of secondary school age attending primary school is higher in the rural areas (26.3 per cent) than in the urban areas (21.1 per cent). Thirteen-year-old children accounted for the highest (53.1 per cent) proportion of children of secondary school age attending primary school while the 18-year-olds accounted for the lowest (4.3 per cent). Women with primary education had the highest number of children (44.0 per cent) of secondary school age attending primary school and children from the richest households had lower attendance rates than children from the poorest households. The percentage of children entering the first grade who eventually reach Grade 5 is presented in Table ED.5. Of all the children starting Grade 1, the majority of them (96.6 per cent) eventually reach Grade 5. Male children entering the first grade of primary school are more likely to go up to Grade 5 than female children. 58 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Education Across ethnic groups, not much difference has been observed but Kerewan had the highest number of children entering Grade 1 and eventually reaching Grade 5 with 100 per cent and Janjangbureh had the lowest proportion with 87.9 per cent. Virtually no differences have been observed in the proportion of children entering the first grade and reaching the fifth grade in primary school across household poverty status. The net primary school completion rate and transition rate to secondary education is presented in Table ED.6. At the time of the survey the net primary school completion rate was estimated at 73.6 per cent. This value should be distinguished from the gross primary com- pletion ratio which includes children of any age attending the last grade of primary school. However, the sex differential is not much, as the completion rate for males is 74.9 per cent and that of females is 72.4 per cent. Basse had the lowest (47.4 per cent). The net primary school completion rate is higher in the urban areas (84.3 per cent) than in the rural areas (67.7 per cent). Children from the richest households have higher net primary school completion rates (85.6 per cent) than those from the poorest households (60.4 per cent). Children from households headed by the Jola have the highest net primary school completion rate (86.6 per cent) and those headed by the Wollof have the lowest rate (71.1 per cent). Only 56.2 per cent of the children who successfully completed the last grade of primary school transited to the first grade of secondary school. Boys have a higher transition rate to secondary education than girls (61.5 per cent compared to 51.1 per cent). Across the regions, Banjul has the highest transition rate (91.3 per cent) and Basse the lowest (34.2 per cent). The rural-urban differentials are huge, as the transition rate in the urban areas is 74.0 per cent compared to 43.1 per cent in the rural areas. Ironically, children of women with no education have higher transition rates from primary to secondary school (63.8 per cent) than those of women with some formal education. Transition rates across the poverty status of households show that children from rich households have higher transitions rates (87.5 per cent) than those from the poorest households (27.4 per cent). Households headed by the Serer have a higher transition than those of other ethnic groups. The ratio of girls to boys attending primary and secondary education is provided in Table ED.7. These ratios are better known as the Gender Parity Index (GPI). Notice that the ratios included here are obtained from net attendance ratios rather than gross attendance ratios. The last ratios provide an erroneous description of the GPI mainly because in most of the cases the majority of over-aged children attending primary school tend to be boys. The table shows that gender parity for primary school is close to 1.00, indicating no major difference in the primary school attendance of girls and boys. However, the indicator drops to 0.87 for secondary education. The disadvantage of girls regarding secondary school attendance is particularly pronounced in Basse LGA, as well as among children living in the poorest households and also in the rural areas. The GPI in Banjul, Mansakonko, Kuntaur and Janjangbureh shows that more girls than boys attend primary school in these LGAs. The GPI for children of women with no education is the same as those whose mothers or primary caretakers have secondary education or above (1.03) for primary schools. Not much difference has been observed among children of varying household poverty categories and ethnicity of household heads. The disadvantage of girls is particularly pronounced in the rural areas where the GPI is low (0.82), as well as among children living in the poorest households with secondary school gender parity of 0.68. Across LGAs, the secondary school attendance gap between boys and girls is widest in Kuntaur in favour of boys. The secondary school GPI for Kuntaur is 0.60. Only small differences were observed between the urban and rural GPIs. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 59 Education Adult Literacy One of the WFFC goals is to assure adult literacy, which is also an MDG indicator, relating to both men and women. In the MICS, since only a women's questionnaire was administered, the results are based only on females aged 15-24. Literacy was assessed on the ability of women to read a short simple statement or on school attendance. The literacy percentage is presented in Table ED.8. According to the results, 43.1 per cent of the women aged 15-24 were literate. The literacy rates were highest in Banjul (65.2 per cent) and lowest in Basse (13.2 per cent). The data further show that literacy rates are highest in the urban areas. As expected, there are variations in the literate population across age groups. The literacy rate is highest for those aged 15-19 (50.8 per cent) com- pared to those aged 20-24 (34.3 per cent). Literacy rates range from 0.7 per cent for women with no education to 100 per cent for those with secondary education and above. The data also indicate that women living in the richest households have better chances of being literate than those from the poorest households. Across ethnic groups, women from households headed by the Serer have the highest literacy rate (58.5 per cent) while those from households headed by the Fula have the lowest rate (30.2 per cent). 60 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F/ G am 00 55 3/ G ia co m o P ir o zz i The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 61 11. CHILD PROTECTION Birth Registration The Convention on the Rights of the Child states that every child has the right to a name and a nationality and the right to being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. The WFFC states the goal to develop systems to ensure the registration of every child at or shortly after birth, and fulfil his or her right to acquire a name and a nationality, in accordance with national laws and relevant international instruments. The indicator is the percentage of under-5 children whose birth is registered. The births of 55.1 per cent of under-5s in The Gambia have been registered (Table CP.1). Mansakonko LGA has the highest percentage of births that were registered (86.4 per cent), followed by Banjul with about 77 per cent. Basse has the lowest proportion of its births being registered (39.4 per cent). Across ethnic groups, only small differences have been observed in birth registration. Children from the richest households (64.3 per cent) are more likely to have their births registered than children from the poorest households (52.1 per cent). Generally, the main reason why a large proportion of births were not registered (28 per cent) was lack of knowledge that a child's birth should be registered. Child Labour Article 32 of the Convention on the Rights of the Child states: "States Parties recognize the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child's education, or to be harmful to the child's health or physical, mental, spiritual, moral or social development." The WFFC mentions seven strategies to combat child labour and the Millennium Declaration calls for the protection of children against exploitation. In the MICS questionnaire, a number of questions addressed the issue of child labour, that is, children aged 5-14 involved in labour activities. A child is considered to be involved in child labour activities at the time of the survey if during the week preceding the survey: • Ages 5-11: did at least one hour of economic work or 28 hours of domestic work per week • Ages 12-14: did at least 14 hours of economic work or 28 hours of domestic work per week. This definition allows differentiation between child labour and child work to identify the type of work that should be eliminated. As such, the estimate provided here is a minimum of the prevalence of child labour since some children may be involved in hazardous labour activities for a number of hours that could be less than the numbers specified in the criteria explained above. Table CP.2 shows the distribution of children aged 5-14 who were involved in child labour activities by type of work. According to the table, about 25 per cent of children in this age bracket were involved in some form of child labour. Of these children 21.1 per cent were working on family business, 62 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Child Protection 1.8 per cent worked on household chores for 28 hours or more per week,3.3 per cent were engaged in unpaid work outside their households and only 0.6 per cent did paid work. The data further show that boys were more likely to be engaged in paid work than girls. Children in Banjul, Kanifing and Brikama LGAs are less likely to be engaged in work than children in the other LGAs. Similarly, children from the poorest households are more likely to be engaged in work than their counterparts from the richest households. Presented in Table CP.3 is the percentage of children classified as student labourers or as labourer students. Student labourers are children attending school who were involved in child labour activi- ties at the time of the survey. More specifically, about 25 per cent of children aged 5-14 were invol- ved in child labour. Of the child labourers, about 65 per cent were also attending school whereas 24 per cent of the students are also involved in some form of child labour. Across LGAs, child labour is highest in Kerewan (36.1 per cent) and lowest in Banjul (11.5 per cent). Child labour is more prevalent in the rural areas (28.6 per cent) than in the urban areas (16.9 per cent). Children of mothers with no education (26.1 per cent) are more likely to be engaged in child labour than those of mothers with secondary education and above (16.1 per cent). On the other hand, children from the poorest households (33.7 per cent) are more likely to be engaged in child labour than those from the richest households (11.3 per cent). Child Discipline As stated in the WFFC, “children must be protected against any acts of violence …” the Millennium Declaration calls for the protection of children against abuse, exploitation and violence. In The Gambia MICS study, mothers/caretakers of children aged 2-14 were asked a series of questions on the ways parents discipline their children when they misbehave: Note that to administer the child discipline module, one child aged 2-14 years was randomly selected per household for the interview. From the questions asked, two indicators were identified to deter- mine the extent and nature of child discipline. These are: • the number of children aged 2-14 who experience psychological aggression as punishment or minor physical punishment or severe physical punishment • the number of parents/caretakers of children and 2-14 who believe that in order to raise their children properly, they need to physically punish them. In The Gambia, 84.2 per cent of children aged 2-14 were subjected to at least one form of psycho- logical or physical punishment by their mothers/caretakers or other household members. More importantly, 21.5 per cent of children were subjected to severe physical punishment. On the other hand, 31.2 per cent of mothers/caretakers believed that children should be physically punished, contrary to the high prevalence of physical discipline among children. The prevalence rates of both minor and severe physical discipline were higher among boys (71.7 and 22.4 per cent respectively) than girls (69.5 and 20.7 per cent respectively). Psychological or physical punishment of children is highest in Kuntaur (97.4 per cent) and lowest in Janjangbureh (77.2 per cent). There were negligible differences between the urban and rural areas. Children from the poorest households (87.9 per cent) tend to be more psychologically and physically punished than children from the richest households (82.7 per cent) (Table CP.4) The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 63 Child Protection Early Marriage and Polygyny Marriage before the age of 18 is a reality for many young girls. According to UNICEF's worldwide estimates, over 60 million women aged 20-24 were married/in union before the age of 18. Factors that influence child marriage rates include: • the state of the country's civil registration system, which provides proof of age for children • the existence of an adequate legislative framework with an accompanying enforcement mechanism to address cases of child marriage • the existence of customary or religious laws that condone the practice. In many parts of the world parents encourage the marriage of their daughters while they are still children in hopes that the marriage will benefit them both financially and socially. In actual fact, child marriage is a violation of human rights, compromising the development of girls and often resulting in early pregnancy and social isolation, with little education and poor vocational training reinforcing the gendered nature of poverty. The right to a 'free and full' consent to a marriage is recognized in the Universal Declaration of Human Rights - with 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. The Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) mentions the right to protection from child marriage in article 16, which states: "The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage.” While marriage is not considered directly in the Convention on the Rights of the Child, child mar- riage is linked to other rights - such as the right to express their views freely, the right to protection from all forms of abuse; and the right to be protected from harmful traditional practices - and is frequently addressed by the Convention on the Rights of the Child. Other international agreements related to child marriage are the Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages and the African Charter on the Rights and Welfare of the Child and the Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa. Child marriage is also identified by the Pan-African Forum against the Sexual Exploitation of Children as a type of commercial sexual exploitation of children. Young married girls are a unique, though often invisible, group. Required to perform heavy amounts of domestic work, under pressure to demonstrate fertility and responsible for raising children while still children themselves, married girls and child mothers face constrained decision-making and reduced life choices. Boys are also affected by child marriage but the issue impacts girls in far larger numbers and with more intensity. Cohabitation - when a couple lives together as if married - raises the same human rights concerns as marriage. Where a girl lives with a man and takes on the role of caretaker for him, the assumption is often that she has become an adult woman, even if she has not yet reached the age of 18. Additional concerns due to the informality of the relationship - for example, inheritance, citizenship and social recognition - might make girls in informal unions vulnerable in different ways than those who are in formally recognized marriages. 64 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Child Protection Research suggests that many factors interact to place a child at risk of marriage. Poverty, protection of girls, family honour and the provision of stability during unstable social periods are considered as significant factors in determining a girl's risk of becoming married while still a child. Women who married at a younger age are more likely to believe that it is sometimes acceptable for a husband to beat his wife and are more likely to experience domestic violence themselves. The age gap between partners is thought to contribute to these abusive power dynamics and to increase the risk of untimely widowhood. Closely related to the issue of child marriage is the age at which girls become sexually active. Women who are married before the age of 18 tend to have more children than those who marry later in life. Pregnancy-related deaths are known to be a leading cause of mortality for both married and unmarried girls between the ages of 15 and 19, particularly among the youngest of this cohort. There is evi- dence to suggest that girls who marry at a young age are more likely to marry older men, which puts them at an increased risk of HIV infection. Parents seek to marry off their girls to protect their honour, and men often seek younger women as wives as a means to avoid choosing a wife who might already be infected. Two indicators used to determine early marriage among females are the percentage of women married before 15 years of age and the percentage married before 18 years of age. Table ED.5 shows that 10 per cent of women aged 15-49 and married or in union actually marry before their 15th birthday whereas 49 per cent of married or in union women aged 20-49 are married or in union before they reach 18 years of age. The number of women aged 15-49 in polygamous marriage/union accounted for 44 per cent. For women aged 15-49 early marriage is more prevalent in Kerewan and the least prevalent in Banjul. Women in the poorest households and those with no education are more likely to marry at an earlier age than other women. Across ethnic groups, Fula women are more likely to marry at an earlier age than women of other ethnic origins. Another area of interest is the spousal age difference, with the indicator being the percentage of women in marriage/in union younger than their current partner by 10 years or more. Table CP.6 shows the percentage distribution of currently married/in union women aged 15-49 according to the age difference with a husband/partner. The table shows that 59.4 per cent of women aged 15-19 have husbands/partners who are at least 10 years older than them. Interestingly, among women aged 15-19, spousal age difference is highest in Brikama LGAs (71.3 per cent) and lowest in Janjangbureh (37.3 per cent). Among women aged 15-24, spousal age dif- ference is highest in Kerewan (67.1 per cent) and lowest in Basse (43.9 per cent). Across all ages, spousal age difference tends to be higher among women with no education than women with secon- dary education and above. Female Genital Mutilation/Cutting Female genital mutilation/cutting (FGM/C) is the partial or total removal of the female external genitalia or other injury to the female genital organs. FGM/C is always traumatic with immediate complications including excruciating pain, shock, urine retention, ulceration of the genitals and injury to adjacent tissue. Other complications include septicaemia, infertility, obstructed labour, and even death. The procedure is generally carried out on girls between the ages of 4 and 14; it is also done to infants, women who are about to be married and, sometimes, to women who are pregnant with their first child or who have just given birth. It is often performed by traditional practitioners, including midwives, without anaesthesia, using scissors, razor blades or broken glass. FGM/C is a violation of human rights. In the absence of any perceived medical necessity, it subjects girls and women to health risks and has life-threatening consequences. Among those rights violated are the rights to the highest attainable standard of health and to bodily integrity. Furthermore, it could be argued that girls (under 18) cannot be said to give informed consent to such a potentially damaging practice as FGM/C. In the MICS III, a series of 16 questions were asked to determine knowledge of FGM/C, prevalence of FGM/C and details of the type of FGM/C performed. However, in The Gambia, the questions were reduced to 10 after deleting questions considered offensive or sensitive and those that were considered of little importance or interest to the country. Table CP.7 shows the prevalence of FGM/C among women as well as women's attitude towards FGM/C. Overall, 64.3 per cent of women reported that at least one of their living daughters had undergone FGM/C. Among the LGAs, Basse registered the highest proportion of women (91.4 per cent) who had at least one living daughter exposed to FGM/C. Daughters of women living in Banjul are least exposed to FGM/C compared to other LGAs. Daughters whose mothers have no education (69.5 per cent) are more likely to be exposed to the practice of FGM/C compared to daughters whose mothers have primary education (57.7 per cent) or secondary education (41.3 per cent), (see Table CP.8) The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 65 Child Protection U N IC E F- To st an G am b ia /2 00 7/ R ac h el U n ko vi c 66 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report Child Protection The table shows that 78 per cent of women aged 15-49 had some form of female genital mutilation. The percentages declined from 81 per cent for women without formal education to 71 per cent for women with secondary education and above. The practice of FGM/C is popular among the Mandinka, Fula and Jola ethnic groups, each of which has prevalence rates of more than 80 per cent. The practice is moderate among the Serer ethnic group with a prevalence rate of 45 per cent whereas among the Wollof the practice is unpopular, with a prevalence rate of 12 per cent. The practice appers more common among households in the middle wealth quintiles than the poorest and richest households. Differences have been observed among women in the various LGAs with the practice more common in Basse (99.0 per cent) and Mansakonko (95.9 per cent) and less common in Banjul (44.8 per cent) and Kerewan (60.8 per cent) LGAs. The practice is more common in the rural areas than in the urban areas. FGM/C is practised slightly less among women with secondary education and above than those who either have never been to school or only stopped at primary school. Regarding opinion as to whether the practice should be continued or discontinued, 71.1 per cent of women thought it should be continued while 23 per cent believed it should be discontinued. Across ethnic groups, the belief that the practice should be continued is highest among the Mandinka (89.2 per cent), the Jola (80.7 per cent) and the Fula (79.5 per cent) and least common among the Wollof. Women in the Mansakonko area are more likely to approve of the continuation of the practice of FGM/C than women in other LGAs. Banjul women are less likely to approve of the continuation of the practice. Approval of the continuation of the practice is highest among women with no edu- cation (76.9 per cent) than those with secondary education and above (57.7 per cent). Women from the richest households are less likely to approve of the continuation of the practice than women from the poorest households. Overall, 72.9 per cent of the women interviewed reported that they would like their daughters to be circumcised. Among the LGAs a larger proportion of women in Basse (97.4 per cent) reported that they would like their daughters to be circumcised compared to Banjul with 30.7 per cent. In the rural areas, 81.3 per cent of women were reported to approve of FGM/C for their daughters compared to 61.5 per cent in the urban areas. Women with no education (78.5 per cent) are more likely to approve of FGM/C for their daughters than those with secondary education and above (59.0 per cent). Similarly, a larger proportion of women from the poorest households approved of FGM/C for their daughters than those from the richest households (Table CP.7). Domestic Violence A number of questions were asked of women aged 15-49 to assess their attitudes towards whether husbands are justified to hit or beat their wives/partners for a variety of scenarios. These questions were asked to have an indication of cultural beliefs that tend to be associated with the prevalence of violence against women by their husbands/partners. The main assumption here is that women who agree with the statements indicating that their husbands/partners are justified to beat their wives/partners under the situations described in reality tend to be abused by their own husbands/partners. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 67 Child Protection The responses to these questions are tabulated in Table CP.9. The table shows that 74 per cent of women aged 15-49 believed that a husband is justified in beating his wife/partner under any one of the following circumstances: when she goes out without informing the husband, when she neglects the children, when she argues with him, when she refuses sex with him and when she burns the food. The data show that a woman in Banjul is less likely to approve of wife/partner beating than any woman in other LGAs where more than half of the women approve of the practice. Similarly, poorer women are more likely to approve of wife beating than women in the richest households. On the other hand, the higher the education of a woman is, the less likely it is for her to approve of wife beating. 68 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U N IC E F/ G am 00 41 1/ G ia co m o P ir o zz i The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 69 12. HIV/AIDS, SEXUAL BEHAVIOUR AND ORPHANED AND VULNERABLE CHILDREN Knowledge of HIV Transmission and Condom Use 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. Correct information is the first step towards raising awareness and giving young people the tools to protect them from infection. Misconceptions of HIV are common and can confuse young people and hinder prevention efforts. Different regions are likely to have variations in misconceptions, although some appear to be universal (for example that sharing food can transmit HIV or mosquito bites can transmit HIV). The UN General Assembly Special Session on HIV/AIDS (UNGASS) called on governments to improve the knowledge and skills of young people to protect them from HIV. The indicators to measure this goal as well as the MDG of reducing HIV infections by half include improving the level of knowledge of HIV and its prevention, and changing behaviour to prevent further spread of the disease. The HIV module was administered to women aged 15-49. One indicator, which is both an MDG and UNGASS indicator, is the percentage of young women who have comprehensive and correct knowledge of HIV prevention and transmission. Women were asked whether they knew of the three main ways of preventing HIV transmission - having only one faithful uninfected partner, using a condom every time, and abstaining from sex. The results are presented in Table HA.1. In The Gambia, almost all the interviewed women (99 per cent) have heard of HIV/AIDS. However, only 65 per cent of women know of all the three ways of preventing HIV transmission. About 92 per cent of women know of having one faithful uninfected sex partner, 82 per cent know of using a condom every time and 77 per cent know of abstaining from sex as ways of preventing HIV trans- mission. While 97 per cent of women know at least one way, a low proportion of women (3 per cent) do not know any of the three ways. The percentage of women knowing all the three ways of preventing HIV/AIDS transmission was lowest in the Kanifing and Mansakonko LGAs (53 per cent each), followed by Banjul (56 per cent). The percentage of women who knew all three ways was higher in the poorest category than in the richest category. Presented in Table HA.2 is the percentage of women who can correctly identify misconceptions about HIV. The indicator is based on the two most common and relevant misconceptions in The Gambia: that HIV can be transmitted by mosquito bites and supernatural means. The table also provides information on whether women know that HIV cannot be transmitted by sharing food with an infected person, and that HIV can be transmitted by sharing needles. Of the women interviewed, 45 per cent reject the two most common misconceptions and know that a healthy-looking person can be infected. About 62 per cent of women know that HIV cannot be transmitted by mosquito bites, while 75 per cent know that it cannot be transmitted by sharing food. Seventy-three per cent of women know that a healthy-looking person can be infected. 70 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report HIV/AIDS, Sexual behaviour, and Orphaned and Vulnerable Children Across LGAs, women in Banjul, Kanifing and Brikama were found to be more knowledgeable about misconceptions than women in other LGAs with more than half of the women interviewed in these LGAs rejecting the most common misconceptions. They know that a healthy looking person can be infected. Women from the richest households are more knowledgeable about misconceptions than women from the poorest households. Across ethnic groups, Serer women seem to be more knowledgeable about misconceptions than other ethnic groups. Table HA.3 summarizes information from Tables HA.1 and HA.2 and presents the percentage of women who know two ways of preventing HIV transmission and reject three common misconcep- tions. Comprehensive knowledge of HIV prevention methods and transmission is still fairly low, although there are differences across areas of residence. As a whole, 38 per cent of women were found to have comprehensive knowledge of HIV, which was slightly higher in the urban areas (41 per cent). As expected, the percentage of women with comprehensive knowledge increases with the women's education level. (Figure HA.1). Knowledge of mother-to-child transmission of HIV is also an important first step for women to seek HIV testing when they are pregnant to avoid infection in the baby. Women should know that HIV could be transmitted during pregnancy, delivery and breastfeeding. The level of knowledge among women aged 15-49 concerning mother-to-child transmission is presented in Table HA.4. Figure HA.1: Percentage of women who have comprehensive knowledge of HIV/AIDS transmission,The Gambia, 2006 The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 71 HIV/AIDS, Sexual behaviour, and Orphaned and Vulnerable Children Generally, 94 per cent of women know that HIV can be transmitted from mother to child. The percentage of women who know all three ways of mother-to-child transmission is 67 per cent, while 5 per cent do not know of any specific way. Minor differentials have been observed in know- ledge of mother-to-child transmission among women across educational attainment of women and ethnicity of head of household. Knowledge of mother-to-child transmission is higher in the rural areas (72.7 per cent) than in the urban areas (58.6 per cent). Similarly, women in the poorest house- holds (72.7 per cent) tend to be more knowledgeable on mother-to-child transmission of HIV/AIDS than those from the richest households (56.1 per cent). The indicators on attitude towards people living with HIV measure stigma and discrimination in the community. Stigma and discrimination are low if respondents report a favourable attitude on the following four statements: • would care for family member sick with AIDS • would buy fresh vegetables from a vendor who was HIV positive • thinks that a teacher who is HIV positive should be allowed to teach in school • would not want to keep the HIV status of a family member a secret. Table HA.5 presents the attitudes of women towards people living with HIV/AIDS. About 84 per cent of the women interviewed during the MICS agreed with at least one of the dis- criminatory statements. The analysis of the data by LGA, residence and household poverty status each shows that more than 75 per cent of women agreed with at least one discriminatory statement. It is worth noting that 16.3 per cent of the women agreed with none of the discriminatory state- ments. One out of every 10 women would not care for a family member who was with AIDS, 55 per cent would want to keep secret if a family member was with AIDS, a little more than a third of the women believed that a teacher with HIV should not be allowed to work and half of the women would not buy fresh vegetables from a person with HIV/AIDS. Another important indicator is the knowledge of where to be tested for HIV and use of such services. Questions related to knowledge among women of a facility for HIV testing and whether they have ever been tested is presented in Table HA.6. About 55 per cent of women know where to be tested, while 14 per cent have actually been tested. Of these, a large proportion has been told the result (89 per cent). Women in Kuntaur LGA are less likely to know a place to get tested for HIV than women in other LGAs and those in Banjul, Kanifing and Brikama are more likely to know where to get tested. Women in the Brikama and Kanifing areas are more likely to have been tested for HIV than women from other LGAs with nearly a fifth claiming to have been tested. Knowledge of where to be tested for HIV is more extensive in the urban than rural areas. In the former, 64 per cent of women know where to go for testing whereas in the latter, only 48 per cent know of such a facility. The proportion of women having this knowledge increases with education as well as the wealth status of their households. 72 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report HIV/AIDS, Sexual behaviour, and Orphaned and Vulnerable Children Among women who had given birth within the two years preceding the survey, the proportion who received counselling and HIV testing during antenatal care is presented in Table HA.7. Data in the table show that there is almost universal access to antenatal care in The Gambia. As already observed, nearly 98 per cent of women with a birth in the two years preceding the survey received antenatal care from a health professional during their last pregnancy. About 45 per cent of these women were provided with information of HIV prevention during antenatal visits, 23 per cent were tested for HIV and 21 per cent received the results of their test. Sexual Behaviour Related to HIV Transmission Promoting safer sexual behaviour is critical for reducing HIV prevalence. The use of condoms during sex, especially with non-regular partners, is especially important for reducing the spread of the virus. In most countries, over half of new HIV infections are among young people aged 15-24. Thus a change in behaviour among this age group will be especially important to reduce new infections. A module of questions was administered to women aged 15-24 to assess their exposure to the risk of HIV infection. Risk factors for HIV include sex at an early age, sex with older men, sex with a non-marital non-cohabitating partner and failure to use a condom. The sexual behaviour that increases the risk of HIV infection among women is presented in Table HA.8 and Figure HA.2. Table HA.8 shows that 4 per cent of women aged 15-19 had sex before age 15, and 51 per cent aged 15-24 had sex with men 10 or more years older than them in the 12 months preceding the survey. The first sexual encounter is earlier among women in Kuntaur and later in Banjul. Education appears to delay women's exposure to sex and women from the poorest households seem to encounter sex at an earlier age than those from the richest households. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 73 HIV/AIDS, Sexual behaviour, and Orphaned and Vulnerable Children Figure HA.2: Percentage of young women aged 15-19 and 20-24 who had sex befor ages 15 aand 18 respectively and percentage of women aged 20-24 who had sex with a man 10 or years older, The Gambia, 2006 Condom use during sex with men other than husbands or live-in partners (non-marital, non-coha- biting) was assessed among women aged 15-24 who had sex with such a partner in the previous year (Table HA.9). About 16 per cent of women aged 15-24 reported having sex with a non-regular partner in the 12 months prior to the MICS. Of those women, over half reported using a condom when they had sex with the high risk partner. Forty-five per cent of women aged 15-24 with primary education used a condom during higher risk sex in the year before the MICS while 58 per cent (aged 15-24) with secondary or more education used a condom with such a partner. Orphans and Vulnerable Children As the HIV/AIDS pandemic progresses, more and more children are becoming orphaned and vul- nerable. Children who are orphaned or in vulnerable households may be at an increased risk of neglect or exploitation, if the parents are not available to assist them. Monitoring the variations in different outcomes for orphans and vulnerable children and comparing them to their peers gives us a measure of how well communities and governments are responding to their needs. To monitor these variations, a measurable definition of orphaned and vulnerable children needed to be created. The UNAIDS Monitoring and Evaluation Reference Group developed a proxy definition of children who have been affected by adult morbidity and mortality. This should capture many of the children affected by AIDS in countries where a significant proportion of the adults are HIV infected. 74 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report HIV/AIDS, Sexual behaviour, and Orphaned and Vulnerable Children This definition classifies children as orphaned and vulnerable if they have experienced the death of either parent, if either parent is chronically ill, or if an adult (aged 18-59) in the household either died (after being chronically ill) or was chronically ill in the year prior to the survey. The frequency of children living with neither parent, mother only, and father only is presented in Table HA.10. The proportion of children aged 0-17 living with mother only was 17 per cent (ie 13 per cent father alive and 4 per cent father dead). On the other hand, only 5 per cent of children aged 0-17 years were living with father only (ie 4 per cent mother alive and 1 per cent mother dead). About 9 per cent of children aged 0-17 were reported to have lost one parent. A review of the data presented in the table shows that the living arrangements of children do not differ markedly among children from different backgrounds. Table HA.11 shows that the percentage of orphaned and vulnerable children aged 0-17 was 12.6 per cent. Children in Kuntaur were observed to be more likely to be orphaned and vulnerable (15.3 per cent). Kerewan children were the least likely to be orphaned and vulnerable (6.4 per cent) than children in other LGAs. Urban children are more likely to be orphaned and vulnerable (14.1 per cent) than rural children (11.7 per cent). One of the measures developed for the assessment of the status of orphaned and vulnerable children relative to their peers looks at the school attendance of children 10-14 for children who have lost both parents (double orphans) versus children whose parents are alive (and who live with at least one of these parents). If children whose parents have died do not have the same access to school as their peers, then families and schools are not ensuring that these children's rights are being met. In The Gambia, one per cent of children aged 10-14 have lost both parents (Table HA.12). Among these, only 65 per cent are currently attending school. Among children aged 10-14 who have not lost a parent and who live with at least one parent, 72 per cent are attending school. This would suggest that double orphans are disadvantaged compared to non-orphaned children in terms of school attendance. In many countries few services are available to families who have taken in orphaned or vulnerable children. Community-based organizations and governments need to be sure that families are sup- ported to care for these children. The prevalence of malnutrition among orphans and vulnerable children under five years of age is presented in Table HA.14. Of the orphaned or vulnerable children, 22 per cent are underweight, 23 per cent stunted and 6 per cent wasted. Compared to non-orphaned children, there appears not to be many differences in their nutritional status. Research suggests that in some areas children who were orphaned are more likely to have worse sexual and reproductive health outcomes than other children. Table HA.15 presents information on the sexual behaviour of orphaned and vulnerable women aged 15-17. According to the table, the proportion of young orphaned or vulnerable women aged 15-17 who had sex before age 15 is lower (3 per cent) than the non-orphaned or vulnerable children (4 per cent). This is contrary to expectations. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 75 The ratio of the percentages estimated for orphaned and vulnerable children to those who are not orphaned or vulnerable is estimated at 0.8, which indicates only a marginal difference between vulnerable and non-vulnerable children when it comes to the timing of exposure to sex. 76 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report LIST OF REFERENCES Blanc, A. and Wardlaw, T. 2005. Monitoring Low Birth Weight: An Evaluation of International Estimates and an Updated Estimation Procedure. WHO Bulletin, 83 (3), 178-185. 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. 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. Gambia, Government of The, and UNICEF, 2002, The Gambia MICS Report, 2000, Central Statistics Department, Banjul Gambia, Government of The, 2003, Population and Housing Census, Fertility Estimates, Gambia Bureau of Statistics (GBoS), Banjul. Gambia, Government of The, 2003, Population and Housing Census, Housing and Household Characteristics, Gambia Bureau of Statistics (GBoS), Banjul. Gambia, Government of The, 2003, Population and Housing Census, Mortality Estimates, Gambia Bureau of Statistics (GBoS), Banjul. Gambia, Government of The, Education Policy 2004- 2015, Department of State for Education (DoSE), Banjul Gambia, Government of The, The National Health Policy Framework, 2007-2020, Department of State for Health (DoSHSW), Banjul Gambia, Government of The, The National Nutrition Policy 2000- 2004, National Nutrition Agency (NaNA), Banjul Gambia, Government of The, The National Population Policy 2007-2015, National Population Secretariat, Banjul Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro. UNICEF, 2006, Monitoring the Situation of Children and Women, Multiple Indicator Cluster Survey Manual, New York. United Nations Children's Fund, 2002, A World Fit for Children, New York United Nations Convention on the Rights of the Child (CRC), New York United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations publication, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Population Division United Nations, 1990b. Step-by-step Guide to the Estimation of Child Mortality. New York, UN www.Childinfo.org. The Gambia Multiple Indicator Cluster Survey 2005/2006 Report • 77 TABLES 78 • The Gambia Multiple Indicator Cluster Survey 2005/2006 Report U rb an Ru ra l Ba nj ul Ka ni fin g Br ik am a M an sa ko nk o Ke re w an Ku nt au r Ja nj an gb ur eh Ba ss e To ta l N u m b er o f h o u se h o ld s Sa m pl ed 29 45 32 30 26 6 18 81 16 91 36 1 76 0 26 6 41 8 53 2 61 75 O cc up ie d 29 45 32 26 26 6 18 81 16 87 36 1 76 0 26 6 41 8 53 2 61 71 In te rv ie w ed 28 90 31 81 26 6 18 37 16 46

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