Ghana - Demographic and Health Survey - 2009

Publication date: 2009

Ghana 2008 G hana 2008 D em ographic and H ealth Survey Demographic and Health Survey Ghana Demographic and Health Survey 2008 Ghana Statistical Service Ghana Health Service Accra, Ghana ICF Macro Calverton, Maryland, U.S.A. September 2009 Ghana Statistical Service Ghana Health Service Ghana AIDS Commission This report summarises the findings of the 2008 Ghana Demographic and Health Survey (GDHS) carried out by the Ghana Statistical Service and the Ghana Health Service. ICF Macro provided financial and technical assistance for the survey through the USAID-funded MEASURE DHS programme, which is designed to assist developing countries to collect data on fertility, family planning, and maternal and child health. Local costs for the survey were partially funded by the Ministry of Health (MOH), the Ghana Statistical Service (GSS), the Ghana AIDS Commission (GAC), UNICEF, UNFPA, and DANIDA. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of USAID or donor organisations. Additional information about the 2008 GDHS may be obtained from the Ghana Statistical Service (GSS), P.O. Box 1098, Accra, Ghana (Telephone: 233-21-671-732; Fax: 233-21-671-731). Additional information about the MEASURE DHS programme may be obtained from MEASURE DHS, ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, U.S.A. (Telephone: 1-301-572-0200; Fax: 1-301-572-0999; Email: reports@macrointernational.com). Suggested citation: Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro. 2009. Ghana Demographic and Health Survey 2008. Accra, Ghana: GSS, GHS, and ICF Macro. Contents | iii CONTENTS Page TABLES AND FIGURES . ix CONTRIBUTORS TO THE REPORT . xvii FOREWORD . xix SUMMARY OF FINDINGS . xxi MILLENNIUM DEVELOPMENT GOAL INDICATORS . xxvii MAP OF GHANA . xxviii CHAPTER 1 INTRODUCTION 1.1 Geography, History, and Economy . 1 1.1.1 Geography . 1 1.1.2 History. 1 1.1.3 Economy . 2 1.2 Demographic Profile . 2 1.3 Population Policy and Reproductive Health Programmes . 3 1.4 Objectives and Organization of the Survey . 4 1.5 Sample Design . 5 1.6 Questionnaires . 5 1.7 Haemoglobin Testing . 6 1.8 Pre-test, Training, and Fieldwork . 7 1.8.1 Pre-test . 7 1.8.2 Training and Fieldwork . 7 1.9 Data Processing . 8 1.10 Response Rates . 8 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Household Population by Age and Sex . 11 2.2 Household Composition . 12 2.2.1 Children’s Living Arrangements and Orphanhood . 13 2.2.2 School Attendance by Survivorship of Parents . 15 2.3 Educational Attainment of Household Members . 15 2.3.1 Grade Repetition and Dropout Rates . 20 2.4 Housing Characteristics . 22 2.5 Household Durable Goods . 26 2.6 Wealth Quintiles . 27 2.7 Birth Registration . 28 iv | Contents CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS 3.1 Background Characteristics of Respondents . 31 3.2 Educational Attainment . 33 3.3 Literacy . 35 3.4 Access to Mass Media . 37 3.5 Employment . 39 3.6 Occupation . 42 3.7 Type of Employer, Form of Earnings, and Continuity of Employment . 45 3.8 Health Insurance Coverage . 48 3.9 Knowledge and Attitude Concerning Tuberculosis . 57 3.10 Smoking . 59 3.11 Alcohol Consumption . 60 CHAPTER 4 FERTILITY 4.1 Fertility Levels and Trends . 67 4.1.1 Fertility Levels . 67 4.1.2 Differentials in Current and Completed Fertility . 69 4.1.3 Trends in Fertility . 71 4.2 Children Ever Born and Living . 72 4.3 Birth Intervals . 73 4.4 Age at First Birth . 74 4.5 Median Age at First Birth by Background Characteristics . 76 4.6 Teenage Fertility . 77 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods . 79 5.2 Ever Use of Contraception . 82 5.3 Current Use of Contraceptive Methods . 85 5.4 Differentials in Contraceptive Use by Background Characteristics . 87 5.5 Trends in the Use of Family Planning . 87 5.6 Number of Children at First Use of Contraception . 89 5.7 Use of Social Marketing Brands . 90 5.8 Knowledge of Fertile Period . 92 5.9 Timing of Sterilisation . 93 5.10 Source of contraception . 94 5.11 Cost of Contraception . 95 5.12 Informed Choice . 96 5.13 Future Use of Contraception . 98 5.14 Reasons for Not Intending to Use Contraception . 98 5.15 Preferred Method of Contraception for Future Use . 100 5.16 Exposure to Family Planning Messages . 100 5.17 Contact of Non-users with Family Planning Providers . 102 5.18 Husband/Partner’s Knowledge about Woman’s Use of Family Planning . 103 5.19 Attitudes towards Family Planning . 105 5.20 Attitudes towards Having too Many Children . 107 Contents | v CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Current Marital Status . 111 6.2 Polygyny . 112 6.3 Age at First Marriage . 115 6.4 Age at First Sexual Intercourse . 118 6.5 Recent Sexual Activity . 121 6.6 Amenorrhoea, Abstinence, and Insusceptibility . 124 6.7 Menopause . 125 CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children . 127 7.2 Need and Demand for Family Planning . 130 7.3 Ideal Family Size . 132 7.4 Fertility Planning . 134 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Definition, Data Quality, and Methodology. 137 8.2 Levels and Trends in Infant and Child Mortality . 138 8.3 Socio-economic Differentials in Mortality . 140 8.4 Demographic Characteristics and Child Mortality . 141 8.5 Perinatal Mortality . 142 8.6 High-Risk Fertility Behaviour . 144 CHAPTER 9 MATERNAL HEALTH 9.1 Antenatal Care . 147 9.1.1 Antenatal Care Coverage . 147 9.1.2 Number and Timing of Antenatal Care Visits . 149 9.1.3 Components of Antenatal Care. 150 9.1.4 Tetanus Immunisation . 152 9.2 Delivery Care . 154 9.2.1 Place of Delivery . 154 9.2.2 Assistance at Delivery . 155 9.2.3 Complications of Delivery . 157 9.3 Postnatal Care . 158 9.3.1 Timing of First Postnatal Check-up . 158 9.3.2 Type of Provider of First Postnatal Check-up . 159 9.4 Problems in Accessing Health Care . 161 vi | Contents CHAPTER 10 CHILD HEALTH 10.1 Child’s Size at Birth . 163 10.2 Vaccination Coverage . 165 10.3 Trends in Vaccination Coverage . 168 10.4 Acute Respiratory Infection . 168 10.5 Fever. 170 10.6 Diarrhoeal Disease . 170 10.6.1 Incidence and Treatment of Diarrhoea . 172 10.6.2 Feeding Practices . 174 10.7 Knowledge of ORS Packets . 176 10.8 Stool Disposal . 176 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS 11.1 Nutritional Status of Children . 179 11.1.1 Measurement of Nutritional Status among Young Children . 179 11.1.2 Results of Data Collection . 180 11.1.3 Levels of Malnutrition . 182 11.1.4 Trends in Children’s Nutritional Status . 183 11.2 Initiation of Breastfeeding. 184 11.3 Breastfeeding Status by Age . 186 11.4 Duration and Frequency of Breastfeeding . 188 11.5 Types of Complementary Foods . 188 11.6 Infant and Young Child Feeding (IYCF) Practices . 191 11.7 Anaemia in children . 193 11.8 Micronutrient Intake among Children. 196 11.9 Nutritional Status of Women . 199 11.10 Foods Consumed by Mothers . 200 11.11 Anaemia in Women . 202 11.12 Micronutrient Intake among Mothers . 204 11.13 Regenerative Health . 206 11.13.1 Vigorous Physical Activity . 206 11.13.2 Duration of Rest . 210 11.13.3 Consumption of Water . 211 11.13.4 Consumption of Fruits . 212 11.13.5 Consumption of Vegetables . 215 11.13.6 Types of Cooking Oil Used in Ghana . 219 CHAPTER 12 MALARIA 12.1 Mosquito Nets . 222 12.1.1 Ownership of Mosquito Nets . 222 12.1.2 Use of Mosquito Nets by Children . 223 12.1.3 Use of Mosquito Nets by Women . 225 12.1.4 Trends in Household Ownership and Use of Mosquito Nets . 227 Contents | vii 12.2 Intermittent Preventive Treatment of Malaria in Pregnancy . 229 12.2.1 Malaria Prophylaxis during Pregnancy . 229 12.2.2 Prevalence and Management of Childhood Malaria . 230 12.3 Exposure to Messages on Malaria . 234 12.3.1 Exposure to Specific Messages on Malaria . 235 CHAPTER 13 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13.1 Knowledge of AIDS . 238 13.2 Knowledge of HIV Prevention Methods . 238 13.3 Beliefs about AIDS . 240 13.4 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 243 13.5 Stigma Associated With Aids and Attitudes Related To HIV/AIDS . 245 13.6 Attitudes towards Negotiating Safer Sex . 247 13.7 Attitudes towards Condom Education for Youth . 249 13.8 Higher-Risk Sex . 250 13.8.1 Multiple Partners and Condom Use . 250 13.8.2 Transactional Sex . 253 13.9 Coverage of prior HIV testing . 255 13.9.1 HIV Testing during Antenatal Care . 255 13.10 Male Circumcision . 258 13.11 Self-reporting of Sexually Transmitted Infections. 259 13.12 Prevalence of Medical Injections . 261 13.13 HIV/AIDS-Related Knowledge and Sexual Behaviour among Youth . 263 13.13.1 HIV/AIDS-Related Knowledge among Young Adults . 263 13.13.2 Knowledge of Condom Sources among Young Adults . 265 13.13.3 Trends in Age at First Sex . 265 13.13.4 Condom Use at First Sex . 266 13.13.5 Abstinence and Premarital Sex . 268 13.13.6 Higher-risk Sex and Condom Use among Young Adults . 269 13.13.7 Age Mixing in Sexual Relationships among Women . 272 13.13.8 Drunkenness during Sex among Young Adults . 273 13.13.9 Recent HIV Tests among Youth . 274 CHAPTER 14 WOMEN’S EMPOWERMENT AND HEALTH OUTCOMES 14.1 Employment and Forms of Earnings . 277 14.2 Control over Women’s and Men’s Earnings . 277 14.3 Women’s Participation in Household Decision-making . 282 14.4 Attitudes towards Wife Beating . 286 14.5 Attitudes towards Refusing Sex with Husband . 290 14.6 Women’s Employment Indicators . 293 14.7 Current Use of Contraception by Women’s Status . 295 14.8 Ideal Family Size and Unmet Need by Women’s Status. 296 14.9 Reproductive Health Care and Women’s Empowerment Status. 298 viii | Contents CHAPTER 15 DOMESTIC VIOLENCE 15.1 Measurement of Violence . 300 15.1.1 The Use of Valid Measures of Violence . 300 15.1.2 Ethical Considerations . 301 15.1.3 Special Training for Implementing the Domestic Violence Module . 302 15.1.4 Characteristics of the Sub-sample of Respondents for the Domestic Violence Module . 302 15.2 Experience of Domestic Violence by Women and Men . 302 15.3 Perpetrators of Physical Violence against Women and Men . 305 15.4 Women’s Experience of Force at Sexual Initiation . 305 15.5 Experience of Sexual Violence and Perpetrators of Sexual Violence . 307 15.6 Experience of Different Types of Violence . 309 15.7 Violence during Pregnancy . 309 15.8 Marital Control . 310 15.9 Types of Spousal Violence . 314 15.10 Violence by Spousal Characteristics and Women’s Indicators . 320 15.11 Frequency of Spousal Violence by Husbands . 322 15.12 Onset of Spousal Violence . 323 15.13 Types of Injuries to Women Resulting from Spousal Violence . 323 15.14 Physical Violence by Women and Men against Their Spouse . 324 15.15 Help-seeking to Stop Violence . 328 REFERENCES . 331 APPENDIX A SAMPLE DESIGN FOR THE 2008 GDHS . 335 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 341 APPENDIX C DATA QUALITY TABLES . 359 APPENDIX D PERSONS INVOLVED IN THE 2008 GHANA DEMOGRAPHIC AND HEALTH SURVEY . 365 APPENDIX E QUESTIONNAIRES . 369 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . 9 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 12 Table 2.2 Household composition . 13 Table 2.3 Children's living arrangements and orphanhood . 14 Table 2.4.1 Educational attainment of the female household population . 16 Table 2.4.2 Educational attainment of the male household population . 17 Table 2.5 School attendance ratios . 19 Table 2.6 Grade repetition and dropout rates for primary school . 21 Table 2.7 Household drinking water . 23 Table 2.8 Household sanitation facilities . 24 Table 2.9 Household characteristics . 25 Table 2.10 Household durable goods . 27 Table 2.11 Wealth quintiles . 28 Table 2.12 Birth registration of children under age five . 29 Figure 2.1 Population Pyramid . 12 Figure 2.2 Age-Specific School Attendance Rates . 22 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS Table 3.1 Background characteristics of respondents . 32 Table 3.2.1 Educational attainment: Women . 33 Table 3.2.2 Educational attainment: Men . 34 Table 3.3.1 Literacy: Women . 35 Table 3.3.2 Literacy: Men . 36 Table 3.4.1 Exposure to mass media: Women . 37 Table 3.4.2 Exposure to mass media: Men . 38 Table 3.5.1 Employment status: Women . 40 Table 3.5.2 Employment status: Men. 41 Table 3.6.1 Occupation: Women . 43 Table 3.6.2 Occupation: Men . 44 Table 3.7.1 Type of employment: Women . 46 Table 3.7.2 Type of employment: Men . 47 Table 3.8.1 Health insurance coverage: Women . 48 Table 3.8.2 Health insurance coverage: Men . 49 Table 3.9.1 N/DHIS Membership Payment: Women . 50 Table 3.9.2 N/DHIS Membership Payment: Men . 51 Table 3.10 Possession of valid N/DHIS card . 52 Table 3.11 Out-of-pocket payment for drugs and services by respondents insured with N/DHIS . 53 Table 3.12 Reported need for health services not covered by N/DHIS . 54 x | Tables and Figures Table 3.13 N/DHIS card holders’ perceived quality of services received . 55 Table 3.14 Client satisfaction . 56 Table 3.15.1 Knowledge and attitudes concerning tuberculosis: Women . 57 Table 3.15.2 Knowledge and attitude concerning tuberculosis: Men . 58 Table 3.16.1 Use of tobacco: Women . 59 Table 3.16.2 Use of tobacco: Men . 60 Table 3.17.1 Use of alcohol: Women . 62 Table 3.17.2 Use of alcohol: Men . 63 Table 3.18 Frequency of drunkenness among men . 65 Figure 3.1 Employment Status of Women and Men age 15-49 . 42 Figure 3.2 Occupation of Women and Men Age 15-49 . 45 Figure 3.3 Type of Earnings of Employed Women and Men Age 15-49 . 47 CHAPTER 4 FERTILITY Table 4.1 Current fertility . 68 Table 4.2 Fertility by background characteristics . 70 Table 4.3 Trends in age-specific fertility rates . 71 Table 4.4 Children ever born and living . 73 Table 4.5 Birth intervals . 75 Table 4.6 Age at first birth . 76 Table 4.7 Median age at first birth . 77 Table 4.8 Teenage pregnancy and motherhood . 78 Figure 4.1 Age-Specific Fertility Rates by Urban-Rural Residence . 68 Figure 4.2 Total Fertility Rates, Selected Sub-Saharan Countries . 69 Figure 4.3 Trends in Fertility, 1988-2008 .72 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 80 Table 5.2 Knowledge of contraceptive methods by background characteristics . 81 Table 5.3.1 Ever use of contraception: Women . 83 Table 5.3.2 Ever use of contraception: Men . 84 Table 5.4 Current use of contraception by age . 86 Table 5.5 Current use of contraception by background characteristics . 88 Table 5.6 Number of children at first use of contraception . 90 Table 5.7 Pill brand and cost . 91 Table 5.8 Condom brand and cost . 92 Table 5.9 Knowledge of fertile period . 93 Table 5.10 Source of modern contraception methods . 94 Table 5.11 Cost of modern contraceptive methods . 96 Table 5.12 Informed choice . 97 Table 5.13 Future use of contraception . 98 Table 5.14 Reason for not intending to use contraception in the future . 99 Table 5.15 Preferred method of contraception for future use . 100 Table 5.16 Exposure to family planning messages . 101 Table 5.17 Contact of non-users with family planning providers . 103 Table 5.18 Husband/partner's knowledge of women's use of contraception . 104 Table 5.19.1 Women’s attitudes towards use of contraception by women . 105 Table 5.19.2 Men’s attitudes towards use of contraception by men . 106 Table 5.20.1 Women’s attitudes towards having too many children . 108 Table 5.20.2 Men’s attitudes towards having too many children . 109 Tables and Figures | xi Figure 5.1 Trends in Contraceptive Use among Currently Married Women Age 15-49 . 89 Figure 5.2 Trends in Source of Modern Contraceptive Methods, Ghana 1988-2008 . 95 Figure 5.3 Percentage of Women and Men Exposed to Family Planning Messages in the Media . 102 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status . 111 Table 6.2.1 Number of women's co-wives . 113 Table 6.2.2 Number of men's wives . 114 Table 6.3 Age at first marriage . 116 Table 6.4.1 Median age at first marriage: Women . 117 Table 6.4.2 Median age at first marriage: Men . 118 Table 6.5 Age at first sexual intercourse . 119 Table 6.6.1 Median age at first sexual intercourse: Women . 120 Table 6.6.2 Median age at first intercourse: Men . 121 Table 6.7.1 Recent sexual activity: Women . 122 Table 6.7.2 Recent sexual activity: Men . 123 Table 6.8 Post-partum amenorrhoea, abstinence and insusceptibility . 124 Table 6.9 Median duration of amenorrhoea, post-partum abstinence and Post-partum insusceptibility . 125 Table 6.10 Menopause . 126 Figure 6.1 Percentage of Married Men Age 15-49 with Two or More Wives, by Region . 115 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 128 Table 7.2.1 Desire to limit childbearing: Women . 129 Table 7.2.2 Desire to limit childbearing: Men . 130 Table 7.3 Need and demand for family planning: Currently married women . 131 Table 7.4 Ideal number of children . 133 Table 7.5 Mean ideal number of children . 134 Table 7.6 Fertility planning status . 135 Table 7.7 Wanted fertility rates . 136 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 139 Table 8.2 Early childhood mortality rates by socio-economic characteristics . 140 Table 8.3 Early childhood mortality rates by demographic characteristics . 142 Table 8.4 Perinatal mortality . 143 Table 8.5 High-risk fertility behaviour . 144 Figure 8.1 Mortality Trends, Ghana 1988-2008 . 139 xii | Tables and Figures CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care . 148 Table 9.2 Number of antenatal care visits and timing of first visit . 150 Table 9.3 Components of antenatal care . 152 Table 9.4 Tetanus toxoid injections . 153 Table 9.5 Place of delivery . 155 Table 9.6 Assistance during delivery . 156 Table 9.7 Timing of first postnatal check-up . 159 Table 9.8 Type of provider of first postnatal check-up . 160 Table 9.9 Problems in accessing health care . 162 Figure 9.1 Trends in Maternity Care Indicators, Ghana 1988-2008 . 149 Figure 9.2 Trends in Tetanus Toxoid Injections, Ghana 2003 and 2008 . 154 Figure 9.3 Assistance by Skilled Provider during Childbirth . 157 CHAPTER 10 CHILD HEALTH Table 10.1 Child's weight and size at birth . 164 Table 10.2 Vaccinations by source of information . 165 Table 10.3 Vaccinations by background characteristics . 167 Table 10.4 Vaccinations in first year of life . 168 Table 10.5 Prevalence and treatment of symptoms of ARI . 169 Table 10.6 Prevalence and treatment of fever . 171 Table 10.7 Prevalence of diarrhoea . 172 Table 10.8 Diarrhoea treatment . 173 Table 10.9 Feeding practices during diarrhoea . 175 Table 10.10 Knowledge of ORS packets or pre-packaged liquids . 176 Table 10.11 Disposal of children's stools . 177 Figure 10.1 Vaccination Coverage at Any Time Before the Survey Among Children 12-23 Months . 166 Figure 10.2 Trends in Vaccination Coverage, Ghana 1988-2008 . 166 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS Table 11.1 Nutritional status of children . 181 Table 11.2 Initial breastfeeding . 185 Table 11.3 Breastfeeding status by age . 187 Table 11.4 Median duration and frequency of breastfeeding . 189 Table 11.5 Foods and liquids consumed by children in the day and night preceding the interview . 190 Table 11.6 Infant and young child feeding (IYCF) practices . 192 Table 11.7 Prevalence of anaemia in children . 195 Table 11.8 Micronutrient intake among children . 197 Table 11.9 Nutritional status of women . 200 Table 11.10 Foods consumed by mothers in the day and night preceding the interview . 202 Table 11.11 Micronutrient intake among mothers . 203 Table 11.12 Prevalence of anaemia in women . 205 Table 11.13.1 Frequency of vigorous physical activity: Women . 208 Table 11.13.2 Frequency of vigorous physical activity: Men . 209 Table 11.14.1 Daily duration of rest: Women . 210 Tables and Figures | xiii Table 11.14.2 Daily duration of rest: Men . 211 Table 11.15.1 Weekly consumption of fruits: Women . 212 Table 11.15.2 Weekly consumption of fruits: Men . 213 Table 11.16.1 Number of servings of fruits consumed: Women . 214 Table 11.16.2 Number of servings of fruits consumed: Men . 215 Table 11.17.1 Weekly consumption of vegetables: Women . 216 Table 11.17.2 Weekly consumption of vegetables: Men . 217 Table 11.18.1 Number of servings of vegetables consumed: Women . 218 Table 11.18.2 Number of servings of vegetables consumed: Men . 219 Table 11.19 Types of cooking oil used in Ghana . 220 Figure 11.1 Nutritional Status of Children by Age . 182 Figure 11.2 Trends in Nutritional Status of Children under Five Years . 184 Figure 11.3 Infant Feeding Practices by Age . 187 Figure 11.4 Infant and Young Child Feeding (IYCF) Practices . 193 Figure 11.5 Trends in Anaemia Status among Children under Five Years. 196 Figure 11.6 Trends in Nutritional Status among Women 15-49 Years . 201 Figure 11.7 Trends in Anaemia Status among Women 15-49 Years . 204 CHAPTER 12 MALARIA Table 12.1 Ownership of mosquito nets . 223 Table 12.2 Use of mosquito nets by children . 224 Table 12.3.1 Use of mosquito nets by women . 226 Table 12.3.2 Use of mosquito nets by pregnant women . 227 Table 12.4 Prophylactic use of anti-malarial drugs and use of Intermittent Preventive Treatment (IPT) by women during pregnancy . 230 Table 12.5 Prevalence and prompt treatment of fever . 231 Table 12.6 Type and timing of anti-malarial drugs . 233 Table 12.7 Sources of messages on malaria . 234 Table 12.8 Exposure to specific messages on malaria . 236 Figure 12.1 Trends in Household Ownership of Mosquito Nets, GDHS 2003 and GDHS 2008 . 228 Figure 12.2 Trends in Use of Mosquito Nets by Children under Five and Pregnant Women (Any Net and ITNs), GDHS 2003 and GDHS 2008 . 228 CHAPTER 13 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 13.1 Knowledge of AIDS . 238 Table 13.2 Knowledge of HIV prevention methods . 239 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 241 Table 13.3.2 Comprehensive knowledge about AIDS: Men . 242 Table 13.4 Knowledge of prevention of mother to child transmission of HIV . 244 Table 13.5.1 Accepting attitudes towards those living with HIV/AIDS: Women . 246 Table 13.5.2 Accepting attitudes towards those living with HIV/AIDS: Men . 247 Table 13.6 Attitudes towards negotiating safer sexual relations with husband . 248 Table 13.7 Adult support of education about condom use to prevent AIDS . 249 Table 13.8.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Women . 251 Table 13.8.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men . 252 xiv | Tables and Figures Table 13.9 Payment for sexual intercourse and condom use at last paid sexual intercourse: Men . 254 Table 13.10.1 Coverage of prior HIV testing: Women . 255 Table 13.10.2 Coverage of prior HIV testing: Men . 256 Table 13.11 Pregnant women counselled and tested for HIV . 258 Table 13.12 Male circumcision . 259 Table 13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STIs symptoms . 260 Table 13.14 Prevalence of medical injections . 262 Table 13.15 Comprehensive knowledge about AIDS and of a source of condoms among youth . 264 Table 13.16 Age at first sexual intercourse among youth . 266 Table 13.17 Condom use at first sexual intercourse among youth . 267 Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 268 Table 13.19.1 Higher-risk sexual intercourse among youth and condom use at last higher-risk sexual intercourse in the past 12 months: Women . 270 Table 13.19.2 Higher-risk sexual intercourse among youth and condom use at last higher-risk sexual intercourse in the past 12 months: Men . 271 Table 13.20 Drunkenness during sexual intercourse among youth . 273 Table 13.21 Recent HIV tests among youth . 274 Figure 13.1 Women and Men Seeking Treatment for STIs . 261 Figure 13.2 Abstinence, Being Faithful, and Condom Use (ABC) Among Young Women and Men Age 15-24 . 272 CHAPTER 14 WOMEN’S EMPOWERMENT AND HEALTH OUTCOMES Table 14.1 Employment and cash earnings of currently married women and men . 278 Table 14.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings: Women . 279 Table 14.2.2 Control over men’s cash earnings . 280 Table 14.3 Women's control over their own earnings and those of their husbands . 281 Table 14.4.1 Women's participation in decision-making . 282 Table 14.4.2 Women's participation in decision-making according to men . 283 Table 14.5.1 Women's participation in decision-making by background characteristics . 284 Table 14.5.2 Men's attitudes towards wives' participation in decision-making . 285 Table 14.6.1 Attitudes towards wife beating: Women . 287 Table 14.6.2 Attitudes towards wife beating: Men . 289 Table 14.7.1 Attitudes towards refusing sexual intercourse with husband: Women . 291 Table 14.7.2 Attitudes towards refusing sexual intercourse with husband: Men . 292 Table 14.7.3 Men's attitudes towards a husband's rights when his wife refuses to have sexual intercourse . 294 Table 14.8 Indicators of women's empowerment . 295 Table 14.9 Current use of contraception by women's status . 296 Table 14.10 Women's empowerment and ideal number of children and unmet need for family planning . 297 Table 14.11 Reproductive health care by women's empowerment . 298 Figure 14.1 Number of Decisions in Which Currently Married Women Participate . 286 Tables and Figures | xv CHAPTER 15 DOMESTIC VIOLENCE Table 15.1 Experience of physical violence . 303 Table 15.2 Persons committing physical violence . 305 Table 15.3 Force at sexual initiation . 306 Table 15.4 Experience of sexual violence . 307 Table 15.5 Age at first experience of sexual violence . 308 Table 15.6 Persons committing sexual violence . 308 Table 15.7 Experience of different forms of violence . 309 Table 15.8 Violence during pregnancy . 310 Table 15.9.1 Degree of marital control exercised by husbands, according to wives . 311 Table 15.9.2 Degree of marital control exercised by wives, according to husbands . 313 Table 15.10.1 Forms of spousal violence: Women . 314 Table 15.10.2 Forms of spousal violence: Men . 316 Table 15.11.1 Spousal violence by background characteristics: Women . 318 Table 15.11.2 Spousal violence by background characteristics: Men . 319 Table 15.12 Spousal violence by husband's characteristics and empowerment indicators . 321 Table 15.13 Frequency of spousal violence among women who report violence . 322 Table 15.14 Injuries to women and men as a result of spousal violence . 324 Table 15.15.1 Violence by women against their spouse . 325 Table 15.15.2 Violence by men against their spouse . 327 Table 15.16.1 Help-seeking to stop violence: Women . 328 Table 15.16.2 Help-seeking to stop violence: Men . 329 Table 15.17 Sources where help was sought to stop violence . 330 Figure 15.1 Percentage of Ever-married Women Who Have Experienced Specific Forms of Physical or Sexual Violence Committed by Their Current or Most Recent Husband/Partner during the Past 12 Months . 315 Figure 15.2 Percentage of Ever-married Men Who Have Experienced Specific Forms of Physical Violence Committed by Their Current or Most Recent Wife/Partner during the Past 12 Months . 316 APPENDIX A SAMPLE DESIGN FOR THE 2008 GDHS Table A.1 Proportional distribution of 412 EAs by region . 335 Table A.2 Expected number of selected households by region . 336 Table A.3 Final allocation of households by region, and number of EAs by urban and rural areas . 336 Table A.4 Sample implementation: All households selected for the interview with the Household Questionnaire (the verbal autopsy survey and individual interviews) . 337 Table A.5 Sample implementation: Women . 338 Table A.6 Sample implementation: Men . 339 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Ghana 2008 . 344 Table B.2 Sampling errors for National sample, Ghana 2008 . 345 Table B.3 Sampling errors for Urban sample, Ghana 2008 . 346 Table B.4 Sampling errors for Rural sample, Ghana 2008 . 347 Table B.5 Sampling errors for Western sample, Ghana 2008 . 348 Table B.6 Sampling errors for Central sample, Ghana 2008 . 349 xvi | Tables and Figures Table B.7 Sampling errors for Greater Accra sample, Ghana 2008 . 350 Table B.8 Sampling errors for Volta sample, Ghana 2008 . 351 Table B.9 Sampling errors for Eastern sample, Ghana 2008 . 352 Table B.10 Sampling errors for Ashanti sample, Ghana 2008 . 353 Table B.11 Sampling errors for Brong Ahafo, Ghana 2008 . 354 Table B.12 Sampling errors for Northern sample, Ghana 2008 . 355 Table B.13 Sampling errors for Upper East sample, Ghana 2008 . 356 Table B.14 Sampling errors for Upper West sample, Ghana 2008 . 357 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 359 Table C.2.1 Age distribution of eligible and interviewed women . 360 Table C.2.2 Age distribution of eligible and interviewed men . 360 Table C.3 Completeness of reporting . 361 Table C.4 Births by calendar years . 361 Table C.5 Reporting of age at death in days . 362 Table C.6 Reporting of age at death in months . 362 Table C.7 Nutritional status of children by NCHS/CDC/WHO International Reference Population. 363 Contributors to the Report | xvii CONTRIBUTORS TO THE REPORT This report was authored by the following persons: Mr. Sylvester Gyamfi, Ghana Statistical Service Mr. Peter Takyi Peprah, Ghana Statistical Service Mr. Louis Toboh, Ghana Statistical Service Ms. Joyce Ami Amedoe, National Population Council Dr. Gloria J. Quansah Asare, Ghana Health Service, Ministry of Health Rev. Mrs. Emma Sepah, Ghana Statistical Service Mr. Emmanuel George Ossei, Ghana Statistical Service Mr. Marfo Yentumi Nkansah, Ghana Statistical Service Mrs. Gladys Brew, Ghana Health Service, Ministry of Health Ms. Eunice Sackey, Ghana Health Service, Ministry of Health Mr. James Frimpong, National Malaria Control Programme, Ghana Health Service. Dr. Sylvia Anie-Akwetey, Ghana AIDS Commission Ms. Efua Amponsaa Anyanful, the Ministry for Women and Children's Affairs Ms. Patience Cofie, Ghana Health Service, Ministry of Health Dr. Gulnara Semenov, ICF Macro Mrs. Zhuzhi Moore, ICF Macro Dr. Pav Govindasamy, ICF Macro Foreword | xix FOREWORD The 2008 Ghana Demographic and Health Survey (GDHS) is a national survey covering all ten regions of the country. The survey was designed to collect, analyse, and disseminate information on housing and household characteristics, education, maternal health and child health, nutrition, family planning, gender, and knowledge and behaviour related to HIV/AIDS. It included, for the first time, a module on domestic violence as one of the topics of investigation. The 2008 GDHS is the fifth DHS survey to be undertaken in Ghana since 1988. All five surveys have been implemented by the Statistical Service of Ghana, in close collaboration with other stakeholders in various sectors of government, researchers, civil society organisations, and international organisations. The planning and implementation of the survey was carried out jointly by the Statistical Service and the Ministry of Health/Ghana Health Service management team. The Statistical Service is grateful to the Ministry of Health and the Ghana Health Service for their valuable partnership and especially for providing vehicles for the monitoring exercises during the fieldwork; and the ethical committee for the ethical clearance that allowed us to perform the anaemia testing. The Service is also grateful to USAID, UNFPA, DANIDA, UNICEF, and the Ghana AIDS Commission for co-funding the survey. The Statistical Service further acknowledges the technical assistance provided by ICF Macro during preparation and finalisation of the survey instruments, training of fieldworkers, and monitoring of field data collection. We also extend our appreciation to all who participated directly or indirectly in this study: the authors, who are cited at the beginning of this report, the field staff, and other survey personnel whos names appear in Appendix D. Above all, we appreciate the co-operation of all the survey respondents for making the 2008 GDHS a success. It is our hope that this report will be useful for advocacy, results-oriented decision-making, and inform service delivery. This report provides only a snapshot of the analysis that can be done with the data that have been collected. It is our sincere hope that researchers will deepen our understanding of the topics covered in the survey by undertaking further research with the survey dataset. Dr. Grace Bediako Government Statistician Ghana Statistical Service Summary of Findings | xxi SUMMARY OF FINDINGS The 2008 Ghana Demographic and Health Survey (2008 GDHS) is the fifth in a series of national-level population and health surveys conducted in Ghana as part of the global Demo- graphic and Health Surveys (DHS) programme. The survey is designed to provide information to monitor the population and health situation in Ghana as a follow-on to the 1988, 1993, 1998 and 2003 GDHS surveys. The survey used a two- stage sample based on the 2000 Population and Housing Census to produce separate estimates for key indicators for each of the ten regions in Ghana. The GDHS 2008 household sample of more than 12,000 households was large enough to provide a sampling frame for conducting case- specific child mortality surveillance for children under five years using a Verbal Autopsy Ques- tionnaire. Each household selected for the GDHS was eligible for interview with the Household Questionnaire, and a total of 11,778 households were interviewed. In half of the households se- lected for the survey, all eligible women age 15- 49 and all eligible men age 15-59 were inter- viewed with the Women’s and Men’s Question- naires, respectively. A total of 4,916 women age 15-49 and 4,568 men age 15-59 from 6,141 households were interviewed. Data collection took place over a three-month period, from early September to late November 2008. The survey obtained detailed information on fertility, marriage, sexual activity, fertility pref- erences, awareness and use of family planning methods, breastfeeding practices, nutritional sta- tus of women and young children, childhood mortality, maternal and child health, awareness and behaviour regarding HIV/AIDS, and other sexually transmitted infections (STIs). In addi- tion, the 2008 GDHS collected information on domestic violence, malaria and use of mosquito nets, and carried out anaemia testing and anthro- pometric measurements for women and children. Data on causes of child mortality based on verbal autopsy reports are not included to this report and will be presented as a separate publication. The 2008 GDHS was implemented by the Ghana Statistical Service (GSS) in collaboration with the Ghana Health Service. Technical assis- tance was provided by ICF Macro through the MEASURE DHS programme. Financial support for the survey was provided by the U.S. Agency for International Development (USAID), the Government of Ghana, UNICEF, UNFPA and Danish International Development Agency (DANIDA). FERTILITY Fertility Levels and Trends. Comparison of the results from the 2008 GDHS with the four earlier DHS surveys indicates that the total fertil- ity rate (TFR) has declined dramatically over the past 20 years, from 6.4 children per woman in 1988 to 4.4 children per woman in 1998. It stabi- lised at that level until 2003 and then declined again to 4.0 in 2008. Women in all age groups have shared in the declining fertility rates. The decline in fertility was especially rapid during the period between 1988 and mid-1998. With a TFR of 4.0 in 2008, Ghana is seen as having achieved its fertility target of 4.0 children per woman two years before the target year (2010). This TFR is also considered as one of the lowest in sub- Saharan Africa Fertility Differentials. There are substantial variations in fertility by background character- istics. The TFR for rural areas (4.9 births) is higher than the TFR for urban areas (3.1 births). Over the five-year period preceding the 2008 GDHS there was a decline in fertility among women in rural areas from 5.6 births per woman in 2003 to 4.9 births currently, while the TFR for women in urban areas remained the same. The total fertility rate is highest in the Northern region (6.8 children per woman) and lowest in the Greater Accra region (2.5 children per woman). As expected, women’s education is strongly associated with lower fertility, decreasing from 6.0 children among women with no education to 2.1 children among women with at least secondary education. Similar differentials are seen by wealth quintile, with the TFR decreasing from 6.5 children among women in the lowest wealth quintile to 2.3 children among women in the highest wealth quintile. Unplanned Fertility. Despite a steady rise in the level of contraceptive use over the past xxii | Summary of Findings twenty years, the 2008 GDHS data indicate that unplanned pregnancies are still common in Gha- na. Overall, 14 percent of births in Ghana are un- wanted, while 23 percent are mistimed (wanted later). The proportion of unplanned births de- clined slightly from 42 percent in 1993 to 36 per- cent in 1998, but rose again to 40 percent in 2003 before declining to 37 percent in 2008. The pro- portion of births that are unwanted increased substantially from 9 percent in 1993 to 16 per- cent in 2003, but dropped slightly to 14 percent by 2008. Fertility Preferences. There is considerable desire among currently married Ghanaians to control the timing and number of births. Thirty- six percent of currently married women would like to wait two or more years before the next birth, and 36 percent do not want to have another child, or are sterilised. About one-fifth (19 per- cent) of currently married women would like to have a child soon (within two years). A compari- son of the results over the five DHS surveys show that the desire to space births among cur- rently married women has declined in the past 20 years, from 45 percent in 1988 to 36 percent in 2008. However, the desire to limit births has in- creased from 23 percent in 1988 to 35 percent in 2008. There has been a decline in ideal family size among currently married women over time, from a mean of 5.5 children in 1988 to 4.6 children in 2008. FAMILY PLANNING Knowledge of Contraception. Knowledge of family planning is nearly universal, with 98 percent of all women and 99 percent of all men age 15-49 knowing at least one modern method of family planning. Among all women, the most widely known methods of family planning are the male condom (94 percent), the pill (87 per- cent), injectables (86 percent), the female con- dom (81 percent), and rhythm (70 percent). About six in ten women have heard of female sterilisation, implants, and withdrawal, while 43 percent of all women have heard of the IUD and 35 percent have heard about emergency contra- ception. The lactational amenorrhoea method (LAM) is the least known method of family planning among both women and men There has been an increase in the level of awareness of contraceptive methods over time. The proportion of all women who know any method of contraception has risen from 76 per- cent in 1988 to 98 percent in 2003 and 2008. The proportion of women who know about implants has risen steeply from 4 percent in 1993 to 64 percent in 2008. A similar trend is seen among men. Use of Contraception. At the time of the 2008 GDHS, 24 percent of currently married women were using a method of contraception. The most commonly used modern method of contraception among married women is injecta- bles (6 percent), followed by the pill (5 percent). Male condoms and female sterilisation are used by 2 percent each, while implants are used by 1 percent of married women. The most commonly used traditional method is rhythm, which is used by 5 percent of married women. Trends in Contraceptive Use. Overall con- traceptive use among married women in Ghana has nearly doubled over the past 20 years. The survey results indicate a relatively large increase in the late 1980s and 1990s, from 13 to 22 percent of married women currently using family planning. However, there has been only a small increase in contraceptive use over the past ten years. The contraceptive prevalence rate increased from 22 percent among currently married women in 1998 to 25 percent in 2003 and has remained steady over the past five years (24 percent in 2008). Similarly, the use of modern methods nearly doubled over the past 15 years from 10 percent in 1993 to 19 percent in 2003, before declining slightly to 17 percent in 2008. Overall, there has been only a small decrease in use of traditional methods over the past 20 years. While there was an increase in the use of traditional methods from 8 percent in 1988 to 10 percent in 1993, use of these methods decreased to 9 percent in 1998 and to 7 percent in 2003, and remained at this level in 2008. Differentials in Contraceptive Use. Wom- en in urban areas are more likely to use contra- ceptive methods (27 percent) than their rural counterparts (21 percent). The highest contracep- tive prevalence rate by region is in the Greater Accra region (33 percent), followed by the Brong-Ahafo and Volta regions (29 percent each). The Northern region reports the lowest level of contraceptive use (6 percent). Women with at least some secondary education are more than twice as likely to use contraception as wom- en with no education. Household wealth status is Summary of Findings | xxiii related to the use of contraception; 14 percent of currently married women in the lowest wealth quintile are using a contraceptive method, com- pared with 31 percent of their counterparts in the highest wealth quintile. Source of Modern Methods. In Ghana, both the public and private sectors are important sources of supply for users of modern methods (39 and 51 percent, respectively). Government hospitals or polyclinics are the most common public source (20 percent), followed by govern- ment health centres (14 percent). In addition, 5 percent combined obtain their methods from government health posts or community-based health and planning services (CHPS) com- pounds, and family planning clinics. In the past 20 years, there has been a shift in the source of modern contraceptive methods from the public to the private sector. The propor- tion of current users relying on private medical sources has increased from 43 percent in 1988 to 51 percent in 2008, although there was a slight decline over the past five years from 54 percent in 2003. The reliance on public sources for all modern methods decreased from 47 percent in 1998 to 39 percent in 2008. Unmet Need for Family Planning. Thirty- five percent of married women have an unmet need for family planning. Unmet need for spac- ing births is higher than unmet need for limiting births (23 and 13 percent, respectively), and is unchanged since 2003. Only 40 percent of the demand for family planning is currently being met, implying that the needs of more than one in two Ghanaian women are currently not being met. MATERNAL HEALTH Antenatal Care. The survey shows that over nine in ten mothers (95 percent) received antena- tal care from a health professional (doctor, nurse, midwife, or community health officer). The re- sults indicate that there has been a marked im- provement in antenatal care coverage in Ghana over the past 20 years. In 1988, 82 percent of mothers received antenatal care for their most re- cent birth in the five years preceding the survey, compared with 95 percent of mothers in 2008. The proportion of women receiving no antenatal care declined slightly from 6 percent in 2003 to 4 percent in 2008. In the Volta region, however, about one in ten pregnant women did not receive any antenatal care in the five years preceding the survey (the same as in 2003). Neonatal tetanus is a leading cause of neo- natal death in developing countries where a high proportion of deliveries occur at home or in plac- es where hygienic conditions may be poor. Teta- nus toxoid (TT) vaccinations are given to preg- nant women to prevent neonatal tetanus. The survey results show that, for the most recent live birth in the five years preceding the survey, more than half (56 percent) of women in Ghana re- ceived two or more tetanus injections during pregnancy and 72 percent of births are protected against neonatal tetanus. A comparison between the 2003 and 2008 surveys on the percentage of women who had two or more TT injections dur- ing their last pregnancy that ended in a live birth shows that there has been an increase from 50 percent in 2003 to 56 percent in 2008. The larg- est increases were seen in the Upper East region (46 percent in 2003, compared with 62 percent in 2008) and the Greater Accra region (52 percent in 2003, compared with 66 percent in 2008). With regard to anti-malarial indicators, the results show that 32 percent of pregnant women and 26 percent of all women slept under a mos- quito net the night before the survey interview; 28 and 24 percent, respectively, slept under an ever-treated net, and 27 and 24 percent, respec- tively, slept under an insecticide-treated net (ITN). There has been a substantial increase in the use of nets by women and children, con- sistent with the overall increase in the ownership of ITNs. For example, the proportion of pregnant women who slept under an ITN the night before the survey increased from 3 percent in 2003 to 27 percent in 2008. The Ministry of Health and the Ghana Na- tional Malaria Control Programme recommend that pregnant women take at least two doses of SP/Fansidar during pregnancy as intermittent preventive treatment (IPT) against malaria. Over half (56 percent) of women with a birth in the two years preceding the survey who used IPT re- ceived SP/Fansidar during an antenatal visit. On- ly 44 percent of women said they received 2 or more doses, and at least one during an ANC visit. Delivery Care. Nationally, 57 percent of births in the five years preceding the survey oc- curred in health facilities, with 48 percent in pub- lic health facilities and 9 percent in private health facilities. Forty-two percent of births take place xxiv | Summary of Findings at home. The results also show that medically trained providers assisted 59 percent of deliver- ies, TBAs assisted 30 percent of deliveries, and relatives or friends assisted 8 percent of deliver- ies. There has been an increase in access to pro- fessional assistance during delivery over the past five years, from 47 percent in 2003 to 59 percent in 2008; over the same period, there has been a decrease in the use of relatives or no assistance at delivery, from 21 to 11 percent. Despite these improvements, medically assisted deliveries con- tinue to be low in Ghana, with 41 percent not benefiting from professional delivery assistance over the past five years. Postnatal Care. Two in three women who had a live birth in the five years preceding the survey received postnatal care within two days of delivery (67 percent) and one in fourteen re- ceived postnatal care 3-41 days after delivery (7 percent). About one in five women who had a birth in the five years preceding the survey did not receive postnatal care at all (23 percent). CHILD HEALTH Childhood Mortality. Results from the five GDHS surveys show a marked decline in child- hood mortality over the past 20 years. This de- cline appears to have halted briefly during the period 1999-2003, and then continued a further decline between 2003 and 2008. For example, the under-five mortality rate decreased from 111 per 1,000 live births for the period 0-4 years pre- ceding the 2003 GDHS to 80 per 1,000 during the same period prior to the 2008 GDHS. Despite this decline, the results show that one in every thirteen Ghanaian children dies before reaching the age of five. Over two-thirds of these deaths occur in the first year of life―infant mortality is 50 deaths per 1,000 live births and child mortali- ty is 31 deaths per 1,000 children age one. Neo- natal mortality is 30 deaths per 1,000 live births in the most recent five-year period, while post- neonatal mortality is 21 deaths per 1,000 live births. Neonatal deaths account for 60 percent of the deaths in infancy. Childhood Vaccination Coverage. Seven- ty-nine percent of Ghanaian children age 12-23 months are fully immunised at any time before the survey, while only 1 percent received no vac- cinations at all. At least 96 percent of children have received the BCG and first dose of DPT and polio vaccines. While the coverage for the first dose of DPT and polio is high, coverage declines for subsequent doses of DPT and polio, with about 86 to 88 percent of children receiving the recommended three doses of these vaccines. Nine in ten children received the measles vaccine and have also been vaccinated against yellow fe- ver. The percentage of children age 12-23 months who have been fully vaccinated has in- creased over the past twenty years, from 47 per- cent in 1988 to 79 percent in 2008. Child Illness and Treatment. Among chil- dren under five years of age, 6 percent were re- ported to have had symptoms of acute respiratory illness (ARI) in the two weeks preceding the sur- vey. Of these, half were taken to a health facility or provider for treatment. Twenty percent of children under five years had diarrhoea in the two weeks preceding the survey and 41 percent of these children were taken to a health provider. Less than half of children with diarrhoea (45 per- cent) were given a solution made from oral rehy- dration salts (ORS), 13 percent received recom- mended home fluids (RHF), and 38 percent were given increased fluids. Overall, 67 percent re- ceived ORS, RHF, or increased fluids, compared with 63 percent in 2003. One in five children under five years (20 percent) had a fever in the two weeks preceding the survey. Of these, 43 percent of children took an anti-malarial drug. Only 24 percent of chil- dren took the anti-malarial drug on the same or the next day after the onset of the illness. Arte- misinin Combination Therapy (ACT) was the most common anti-malarial drug given for fever in 2008 (22 percent), followed by chloroquine (9 percent), Fansidar (4 percent), and Camoquine (2 percent). Quinine, reserved for treatment of se- vere and complicated malaria cases in health fa- cilities, is taken by less than 2 percent of children with a fever. Four percent of children were given other anti-malarial drugs. NUTRITION Breastfeeding Practices. The results indi- cate that almost all (98 percent) Ghanaian chil- dren are breastfed for some period of time. Over half of infants were put to the breast within one hour of birth, and 82 percent started breastfeed- ing within the first day. Exclusive breastfeeding is recommended by the World Health Organisa- tion through the age of 6 months, but in Ghana only 63 percent of children under 6 months are exclusively breastfed. Overall, the median dura- tion of breastfeeding in Ghana is 20 months and Summary of Findings | xxv the median duration of exclusive breastfeeding is 3 months. The findings show that over the past five years there has been little change in the percent- age of children ever breastfed; however, the per- centage who started breastfeeding within one day of birth increased from 46 percent in 2003 to 52 percent in 2008, and the percentage who started breastfeeding within 1 day of birth increased from 75 to 82 percent over the same five-year pe- riod. The proportion of children who received a prelacteal feed decreased slightly from 20 per- cent in 2003 to 18 percent in 2008. The percentage of young children bottle-fed has not changed over the past five years, in the 2008 GDHS, 11 percent of children under six months were given a feeding bottle with a nipple, compared with 12 percent of children in the 2003 GDHS. Bottle-feeding peaks at age 6-8 months (21 percent). Intake of Vitamin A. Ensuring that chil- dren age 6-59 months receive enough vitamin A may be the single most effective child survival intervention. Deficiencies in this micronutrient can cause blindness and can increase the severity of infections such as measles and diarrhoea. Fif- ty-six percent of children age 6-59 months were reported to have received a vitamin A supple- ment in the 6 months preceding the survey—a considerable decline from 78 percent in 2003. However, in 2008, twice as many children under three who live with their mother consumed fruits and vegetables rich in vitamin A, compared with their counterparts in 2003 (81 and 41 percent, re- spectively). Sixty percent of mothers with a birth in the past five years reported receiving a vitamin A dose postpartum, an increase from 43 percent in 2003. Fourteen percent of interviewed women reported night blindness during pregnancy. How- ever, after adjusting for blindness not attributed to vitamin A deficiency during pregnancy, the results showed that only 2 percent of women ex- perienced night blindness during their last preg- nancy. Prevalence of anaemia. Iron-deficiency anaemia is a major threat to maternal health and child health. Overall, 78 percent of Ghanaian children age 6-59 months have some level of anaemia, including 23 percent of children who are mildly anaemic, 48 percent who are moder- ately anaemic, and 7 percent who are severely anaemic. Children in the Upper East and Upper West regions are the most likely to be anaemic (88-89 percent). The prevalence of anaemia in children has increased slightly over the past five years, from 76 percent in 2003 to 78 percent in 2008. The prevalence of anaemia is less pro- nounced among women than among children. Fifty-nine percent of Ghanaian women age 15-49 are anaemic, with 39 percent mildly anaemic, 18 percent moderately anaemic, and 2 percent se- verely anaemic. Anaemia is lowest among wom- en is in the Upper East region (48 percent) and highest in the Western region (71 percent). The level of anaemia among women age 15-49 in Ghana has increased over the past five years from 45 percent in 2003 to 59 percent in 2008, with the most noticeable increase occurring in the prevalence of moderate anaemia (9 percent in 2003 and 18 percent in 2008). Nutritional Status of Children. According to the 2008 GDHS, 28 percent of children under five are stunted and 10 percent are severely stunted. Nine percent of children under five are wasted and 2 percent are severely wasted. Weight-for-age results show that 14 percent of children under five are underweight, with 3 per- cent severely underweight. Children whose bio- logical mothers were not in the household are more likely to be stunted (33 percent) than chil- dren whose mothers were interviewed (28 per- cent). Data from the 1988, 1993, 1998, 2003, and 2008 GDHS surveys were all re-calculated ac- cording to the new WHO child growth reference standards, but restricted to children living with their mother and the mother was interviewed with the Women’s Questionnaire. Overall, the proportion of children under five who are stunted decreased from 34 percent in 1988, to 31 percent in 1998, and then rose to 35 percent in 2003 be- fore decreasing to 28 percent in 2008. The pro- portion of underweight children decreased from 23 percent in 1988 and 1993 to 14 percent in 2008. The proportion of children who are wasted decreased over the past 15 years from 14 percent in 1993 to 9 percent in 2008, with no marked change over the past five years. Infant and Young Child Feeding (IYCF). Infant and young child feeding (IYCF) practices include timely introduction of solid and semi- xxvi | Summary of Findings solid foods beginning at age six months, and thereafter increasing the amount and variety of foods and the frequency of feeding as the child gets older, while still maintaining frequent breastfeeding. Guidelines have been established with respect to IYCF practices for children age 6-23 months. Overall, only 36 percent of Ghana- ian children age 6-23 months are fed in accord- ance with IYCF practices. Nutritional Status of Women. Only 1 per- cent of Ghanaian women are below 145 centime- tres in height. The mean BMI for women age 15- 49 in Ghana is 23.6, and falls in the normal range (18.5-24.9) for all categories of background characteristics. Nine percent of women were found to be chronically malnourished (BMI less than 18.5), while 30 percent were overweight or obese. Over the past fifteen years (from 1993 to 2008), there has been little change in the percent- age of mothers whose height is below 145 centi- metres, and little change in the mean BMI. The proportion of women who are obese or over- weight has increased somewhat from 25 percent in 2003 to 30 percent in 2008 HIV/AIDS Awareness of AIDS. Knowledge of AIDS is universal in Ghana: 98 percent of women and 99 percent of men have heard of AIDS. Never- theless, the 2008 GDHS results indicate that only one in four women (25 percent) and one in three men (33 percent) have a comprehensive knowledge of HIV/AIDS prevention and trans- mission, i.e., know that consistent use of con- doms during sexual intercourse and having just one faithful, HIV-negative partner can reduce the chances of getting HIV/AIDS, knowing that a healthy-looking person can have HIV (the virus that causes AIDS), and rejecting two of the most common local misconceptions about the trans- mission of AIDS in Ghana—namely, that AIDS can be transmitted through mosquito bites and by supernatural means. General knowledge of HIV transmission during breastfeeding is high: 85 percent among women and 78 percent among men. However, only half of women and 44 percent of men know that the risk of mother-to-child-transmission (MTCT) of HIV can be reduced if a mother takes special drugs during pregnancy. Although low, these levels of knowledge about the special drugs that can prevent transmission of HIV to babies, are a substantial increase from the 16 percent for both sexes in 2003. Attitudes towards People Living with HIV/AIDS. It is encouraging to see that 75 per- cent of women and 79 percent of men age 15-49 are willing to care for a family member with HIV in their own household, and that nearly half of women and 58 percent of men do not want to keep secret that a family member is HIV posi- tive. Approximately two-thirds of women and men also believe that an HIV-positive female teacher should be allowed to continue teaching. However, only one in three women and two in five men say that they would buy fresh vegeta- bles from a vendor with AIDS. HIV-Related Behavioural Indicators. One of the strategies for reducing the risk of contract- ing an STI is for young people to delay the age at which they become sexually active. Eight percent of women and 4 percent of men reported that they had sexual intercourse by age 15. Forty-four percent of women and 28 percent of men said that they first had sexual intercourse by age 18. Sexual intercourse with a non-marital, non- cohabiting partner is associated with an increased risk of contracting sexually transmitted diseases. The GDHS results on higher-risk sexual behav- iour indicate that the proportion of women en- gaging in higher-risk sexual intercourse has in- creased slightly from 21 percent in the 2003 GDHS to 23 percent in the 2008 GDHS. At the same time, the proportion of women who used a condom during their last higher-risk sexual inter- course decreased from 28 percent in the 2003 GDHS to 25 percent in the 2008 GDHS. As with women, the proportion of men who engage in higher-risk sexual intercourse has in- creased slightly from 38 percent in the 2003 GDHS to 42 percent in 2008 GDHS; however, the proportion using condoms during their last higher-risk sexual intercourse has not changed (45 percent in the 2003 GDHS and 2008 GDHS). The mean number of lifetime sexual partners reported in the 2008 GDHS was two for women and five for men. Millennium Development Goal Indicators | xxvii Millennium Development Goal Indicators Goal Indicator Value Male Female Total 1. Eradicate extreme poverty and hunger 4. Prevalence of underweight children under five years1 15.4 12.4 13.9 2. Achieve universal primary education 6. Net attendance ratio in primary education2 73.4 74.2 73.8 7. Percentage of pupils starting grade 1 who reach grade 53 83.5 84.2 83.9 7a. Primary completion rate4 0.9 0.9 0.9 8. Literacy rate for those age 15-24 years5 78.3 68.0 na 3. Promote gender equality and empower women 9. Ratio of girls to boys in primary, secondary, and tertiary education6 na na 93.3 10. Ratio of literate women to men age 15-24 years5 na na 86.9 11. Share of women in wage employment in the non- agricultural sector7 na na 48.7 4. Reduce child mortality 13. Under-five mortality rate8 na na 80.0 14. Infant mortality rate8 na na 50.0 15. Percentage of children age one year immunised against measles9 88.5 91.7 90.2 5. Improve maternal health 16. Maternal mortality ratio na na na 17. Percentage of births attended by skilled health personnel10 na na 58.7 6. Combat HIV/AIDS, malaria and other diseases 19. Percentage of current users of contraception using condoms11 29.6 11.3 na 19A. Condom use at last higher-risk sex12 46.4 28.2 na 19B. Percentage of population age 15-24 years with comprehensive correct knowledge of HIV/AIDS13 34.2 28.3 na 19C. Contraceptive prevalence rate14 na 23.5 na 20. Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years15 0.7 na 0.8 22. Percentage of population in malaria-risk areas using effective malaria prevention and treatment measures16 na na 48.8 22A. Percentage of children under five sleeping under ITN 37.5 40.0 38.7 22B. Percentage of children under five with fever appropriately treated with anti-malarial drugs 43.7 42.1 43.0 Urban Rural Total 7. Ensure environmental sustainability 29. Percentage of population using solid fuels17 74.9 96.8 87.2 30. Percentage of population with sustainable access to an improved water source, urban and rural18 93.0 76.6 83.8 31. Percentage of population with access to improved sanitation, urban and rural19 17.9 8.1 12.4 32. Percentage of households with access to secure tenure na na na na = Not applicable 1 Based on children who slept in the household the night before the interview (de facto). 2 Based on de facto population. Numerator is children age 6-11 currently attending school; denominator is children age 6-11 years. 3 Based on de facto population. This indicator is calculated using rates of promotion, dropout, and repetition for a given school year. The rates are used to project an estimate for the percentage of students attending grade 1 who are expected to reach grade 5, with or without repetition. 4 Ratio of the total number of students completed grade 6 of primary school to the total number of children of official graduation age (11-13 years). 5 Literacy rate for those age 15–24 is the percentage of the population age 15–24 who can read a short simple statement on everyday life and is not equivalent to literacy rate in the DHS report. The ratio of literate women to men age 15–24 is the ratio of the female literacy rate to the male literacy rate for the age group 15–24. 6 Based on de facto population age 6-24 years 7 Numerator is all women working in the non-agricultural sector who received payment in cash, or in cash and in kind; denominator is all women and all men with non-agricultural occupation. 8 Mortality rates refer to a 5-year period before the survey. 9 In Ghana, the measles vaccinations are given at the age of 9 months. The values presented in the table are for children age 12-23 months who have been vaccinated at any time against measles. 10 Skilled health personnel includes: doctor, nurse, midwife, auxiliary midwife, and community health officer. 11 The number of women age 15-49 in marital or consensual unions who report they are using a condom to avoid pregnancy (regardless of whether they are also using additional methods) is divided by the total number of women age 15-49 in union who are practicing, or whose sexual partners are practicing, contraception. The indicator is not equivalent to condom use prevalence as a main method of contraception. 12 Based on de facto population age 15-24. Higher-risk sex is sexual intercourse with a non-marital, non-cohabiting partner. 13 Respondents with “comprehensive correct knowledge” of AIDS are those who say that using a condom every time for sexual intercourse and having just one HIV-negative and faithful partner can reduce the chances of getting the AIDS virus, and furthermore, say that a healthy-looking person can have the AIDS virus, and who reject the common misconception that HIV can be spread by mosquito bites and by sharing food with someone with AIDS. 14 Based on women age 15-49 in marital or consensual unions 15 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent. Note that these indicators do not take into account children who live outside of households, e.g., in institutions or on the street, because the GDHS includes only households in its sample. 16 Based on de facto population with at least one insecticide-treated bednet (ITN) and is not equivalent to the percentage of households with at least one ITN in the DHS report 17 Solid fuel includes: coal, charcoal, wood, straw, crops, animal dung and other. 18 Improved drinking water sources include: water from pipe/tap, public tap, borehole or pump, protected well, protected spring or rainwater. Improved water sources do not include: vendor-provided water, bottled water, tanker trucks or unprotected wells and springs. 19 Improved sanitary means of excreta disposal includes: facilities that hygienically separate human excreta from human, animal and insect contact. Facilities such as sewers or septic tanks, pour-flush latrines and simple pit or ventilated improved pit (VIP) latrines are assumed to be adequate, provided that they are not public (not shared) xxviii | Map of Ghana GHANA ^ Cote d’Ivoire Burkina Faso Togo Northern Volta Ashanti Brong-Ahafo Western Eastern Upper West Central Upper East Greater Accra � 0 60 12030 Kilometers Gulf of Guinea Introduction | 1 INTRODUCTION 1 1.1 GEOGRAPHY, HISTORY, AND ECONOMY 1.1.1 Geography The Republic of Ghana is centrally located on the West African coast and has a total land area of 238,537 square kilometres. It is bordered by three French-speaking countries: Togo on the east, Burkina Faso on the north and northwest, and Côte d’Ivoire on the west. The Gulf of Guinea on the south forms a coastline extending 560 kilometres. Ghana is a lowland country except for a range of hills on the eastern border and Mt. Afadjato—the highest point above sea level (884 metres)—which is west of the Volta River. Ghana can be divided into three ecological zones: the sandy coastline backed by a coastal plain, which is crossed by several rivers and streams; the middle belt and western parts of the country, which are heavily forested and have many streams and rivers; and a northern savannah, which is drained by the Black and White Volta rivers. The Volta Lake, created by the hydroelectric dam in the east, is one of the largest artificial lakes in the world. Ghana has a tropical climate with temperatures and rainfall varying according to distance from the coast and elevation. The average annual temperature is about 26ºC (79ºF). There are two distinct rainy seasons, April to June and September to November. In the north, however, the rainy season begins in March and lasts until September. Annual rainfall ranges from about 1,015 millimetres (40 inches) in the north to about 2,030 millimetres (80 inches) in the southwest. The harmattan, a dry desert wind, blows from the northeast between December and March, lowering the humidity and creating very warm days and cool nights in the north. In the south, the effects of the harmattan are felt mainly in January. 1.1.2 History Ghana gained independence from British rule on 6 March 1957, and became a republic in the British Commonwealth of Nations on 1 July 1960. Its administrative and political capital is Accra, with a population of 1.7 million (GSS, 2002). Ghana operates a multi-party democratic presidential system of government with an Executive Presidency elected for four years with a maximum of two terms. There is a parliament elected every four years, an independent judiciary, and a vibrant media. There are 10 administrative regions, Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Northern, Upper East, and Upper West. The regions are sub-divided into 170 districts to ensure equitable resource allocation and efficient and effective administration at the local levels. The distribution of Ghana’s population by urban-rural residence shows that the proportion of the population living in urban areas has increased substantially since 1960. In that year, only 23 percent of the population lived in the urban areas. This proportion increased to 29 percent in 1970 and then 32 percent in 1984. In 2000, the proportion of the population living in urban areas reached 44 percent. The population is made up of several ethnic groups. The Akans constitute the largest ethnic group (49 percent) followed by the Mole-Dagbon (17 percent), Ewe (13 percent), and Ga/Dangme (8 percent) (GSS, 2002). 2 | Introduction 1.1.3 Economy The structure of the economy has seen marginal changes over the past two decades. Agriculture is still the most important area of economic activity, followed by services, and then industry. Agriculture contributes 34 percent of the gross domestic product (GDP) (GSS, 2008) and it employs about 50 percent of the population (GSS, 2002). Within the agriculture sector, crops and livestock are the most important sub-sector, contributing 66 percent to the sector’s growth. Between 2003 and 2008, however, there was a slight decline in the growth rate of the agriculture sector, from 6 to 5 percent. The service sector, with a growth rate of 10 percent, is the fastest growing sector of the economy and it contributes one-third of the country’s GDP. Wholesale and retail trade is the most important sub-sector, accounting for one-quarter of the sector’s growth. The industrial sector contributes a little over one-quarter (26 percent) to the country’s GDP. The construction sub-sector has the greatest impact on the sector’s contribution to the GDP as well as sector growth. The leading export commodities of the country are cocoa, gold, and timber. In recent times, the economy has diversified to include exports of non-traditional commodities such as pineapples, bananas, yams, and cashew nuts. Tourism is fast gaining prominence as a foreign exchange earner. Over the past decade the Government of Ghana has embarked on various economic and poverty-reduction programmes with the aim of improving the living conditions of its citizenry. In 2007, the Livelihood Empowerment Against Poverty Programme (LEAP) was introduced, and in 2008 individuals identified as poor started receiving monthly allowances. There have been many changes in the education sector over the past decade. At the Basic Education Level, pre-school education has officially been incorporated into the education system and all primary schools are required to have nurseries or kindergartens. In the 2005/2006 academic year, the Capitation Grant was introduced countrywide and the government absorbed school fees of all pupils in government basic schools (Darko et al., 2009). As a result, all pupils in government basic schools now have free education. During the same period, the School Feeding Programme was introduced on a pilot basis, and it has since been extended to all basic schools. While the feeding programme aims at improving the nutritional status of school pupils, it has also resulted in increased enrolment in schools. At the secondary level, the three-year Senior Secondary School System was changed to the four-year Senior High School after the 2007/2008 academic year1. The introduction of the Ghana Education Trust Fund (GETFUND) has brought many improvements to the education system. The fund provides educational infrastructure such as buildings to the country’s tertiary institutions and, as a result, has improved teaching and learning in educational institutions. 1.2 DEMOGRAPHIC PROFILE There are a variety of sources that provide demographic information about the Ghanaian population, including censuses, administrative/routine data, and surveys. Population censuses provide more comprehensive demographic information than all the other sources. Ghana has undertaken four censuses since independence in 1957. The first post-independence census was conducted in 1960, reporting a population of 6.7 million. This was followed by the 1970 Census, reporting a population 8.6 million, giving an inter-censual growth rate of 2.4 percent. The 1984 and 2000 censuses recorded populations of 12.3 million and 18.9 million, respectively, with an average growth rate of 2.7 percent between the two census periods. The population density per square kilometre has more than doubled from 36 persons in 1970 to 79 persons in 2000. The sex ratio over the past 30 years has fallen slightly from 98.5 males per 100 females in 1970 to 97.9 in 2000. The proportion of the population under 15 years however has decreased from 47 1 The change in name from Senior Secondary to Senior High School and the change from three years to four years have not affected the results of the 2008 GDHS. Introduction | 3 percent in 1970 to 41 percent in 2000, while the proportion 65 years and older increased from less than 4 percent to a little more than 5 percent over the same period. Life expectancy at birth has increased from 50 years among males in 1984 to 55 years in 2000 and among females from 54 years to 60 years over the same period. (GSS, 1979; 1985; 2002). Because population censuses are resource intensive, expensive to implement, and generally take place at intervals of ten years, sample surveys are important for informing demographic profiles. During inter-censual periods, sample surveys are conducted to collect a wide range of data to complement the census data. Because sample surveys are cheaper and can be implemented more quickly, they are conducted at regular intervals. The Ghana Demographic and Health Survey (GDHS), which is a household survey, is an example of the collection of sample survey data. One other important but often neglected data source in Ghana is administrative (or routine) data. These data are generated as a by-product of events and processes and they provide relatively up- to-date information to fill the data gaps in both censuses and surveys. Vital registration systems (birth and death registration), health systems (immunisations), and education data (enrolment) are examples of administrative data. 1.3 POPULATION POLICY AND REPRODUCTIVE HEALTH PROGRAMMES The 1969 National Population Policy was revised in 1994 after 25 years of implementation. The revision took into account emerging issues such as HIV/AIDS, population and the environment, concerns about the elderly and children, and the development of new strategies to ensure achievement of the revised policy objectives. The revision of population policy also entailed concerted effort to systematically integrate population variables in all areas of development planning. The major goals of the revised population policy include: • Reducing the total fertility rate from 5.5 in 1993 to 5.0 by the year 2000, 4.0 by 2010, and 3.0 by 2020. Accordingly, the policy aims at achieving a contraceptive prevalence rate (CPR) of 15 percent for use of modern methods by the year 2000, 28 percent by 2010, and 50 percent by the year 2020; • Reducing the population growth rate from about 3 percent per annum to 1.5 percent by the year 2020; and • Increasing life expectancy from the current level of 58 years, to 65 years by 2010, and to 70 years by 2020 (NPC, 1994). The attainment of these population goals is recognised as an integral component of the national strategy to accelerate economic development, eradicate poverty, and enhance the quality of life of all Ghanaians. The National Population Council and its Secretariat were established in 1992 as the highest statutory body to advise the government on population related issues as well as to facilitate, monitor, coordinate, and evaluate the implementation of population programmes. In collaboration with the United Nations Population Fund (UNFPA), the United States Agency for International Development (USAID), the World Bank, and other development partners, Ghana has implemented several projects aimed at reducing reproductive health problems in the population. Support from these agencies has targeted policy coordination, implementation, and service delivery. The government is committed to improving access and equity of access to essential health care services. The priority areas identified include addressing the problems of HIV/AIDS and other sexually transmitted infections (STIs), malaria, tuberculosis, guinea worm disease, poliomyelitis, 4 | Introduction reproductive health, maternal and child health, accidents and emergencies, non-communicable diseases, oral health and eye care, and specialised services. Emphasis is also being placed on preventive as well as community-based health care services. This has necessitated the introduction of the Community-based Health Planning and Services (CHPS) programme in which trained nurses are stationed in selected communities to provide health care services to the people of the community. The scare associated with the spread of HIV/AIDS attracted considerable attention from the government and its development partners. The government set up the National AIDS Commission to oversee the implementation of HIV/AIDS programmes using a multi-sectoral approach. This was to ensure that HIV/AIDS prevention education, treatment, care and support reached every corner of the country. The Ghana Health Service (GHS) also set up the National AIDS Control Programme (NACP) to offer HIV/AIDS prevention education and services. The combined efforts of all stakeholders ensured the implementation of the Ghana HIV/AIDS Strategic Framework: 2001-2005 (World Bank, 2003). This collaborative effort had a positive impact and in 2003 only 2 percent of Ghanaian adults had contracted HIV (GSS, 2004). This level is expected to decline. Roll back malaria, tuberculosis (TB-DOTS), and Integrated Management of Childhood Illnesses (IMCI) are still priority areas under the country’s health care system. Other health interventions instituted as part of government’s efforts to make health care accessible and affordable to all include the introduction of the National Health Insurance Scheme (NHIS) and the free maternal care programme (United Nations, 2008). 1.4 OBJECTIVES AND ORGANISATION OF THE SURVEY The 2008 GDHS is designed to provide data to monitor the population and health situation in Ghana. This is the fifth round in a series of national level population and health surveys conducted in Ghana under the worldwide Demographic and Health Surveys programme. Specifically, the 2008 GDHS has the primary objective of providing current and reliable information on fertility levels, marriage, sexual activity, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood mortality, maternal and child health, domestic violence, and awareness and behaviour regarding AIDS and other sexually transmitted infections (STIs). The information collected in the 2008 GDHS will provide updated estimates of basic demographic and health indicators covered in the earlier rounds of 1988, 1993, 1998, and 2003 surveys. The long-term objective of the survey includes strengthening the technical capacity of major government institutions, including the Ghana Statistical Service (GSS). The 2008 GDHS also provides comparable data for long-term trend analysis in Ghana, since the surveys were implemented by the same organisation, using similar data collection procedures. It also adds to the international database on demographic and health–related information for research purposes. The 2008 GDHS was carried out by the Ghana Statistical Service (GSS) and the Ghana Health Service (GHS). ICF Macro, an ICF International Company, provided technical support for the survey through the MEASURE DHS programme. Funding for the survey came from the United States Agency for International Development (USAID), through its office in Ghana, and the Government of Ghana, with support from the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the Ghana AIDS Commission (GAC), and the Danish Development Agency (DANIDA). The survey was conducted from 8 September to 25 November 2008 on a nationally representative sample of 12,323 households.2 Each of these households was visited to obtain information about the household using the Household Questionnaire. The Household Questionnaire 2 The GDHS 2008 sample was designed to be large enough to provide a sampling frame to conduct case-specific child mortality surveillance for children under five years of age using a Verbal Autopsy Questionnaire. Introduction | 5 was also used to identify deaths of children under five years occurring in the household since January 2005. Based on this information, a Verbal Autopsy Questionnaire was administered in each household with identified deaths. Data on causes of childhood mortality based on the verbal autopsy are not included in this report and will be presented later as a separate publication. 1.5 SAMPLE DESIGN The 2008 GDHS was a household-based survey, implemented in a representative probability sample of more than 12,000 households selected nationwide. This sample was selected in such a manner as to allow for separate estimates of key indicators for each of the 10 regions in Ghana, as well as for urban and rural areas separately. The 2008 GDHS utilised a two-stage sample design. The first stage involved selecting sample points or clusters from an updated master sampling frame constructed from the 2000 Ghana Population and Housing Census. A total of 412 clusters were selected from the master sampling frame. The clusters were selected using systematic sampling with probability proportional to size. A complete household listing operation was conducted from June to July 2008 in all the selected clusters to provide a sampling frame for the second stage selection of households. The second stage of selection involved the systematic sampling of 30 of the households listed in each cluster. The primary objectives of the second stage of selection were to ensure adequate numbers of completed individual interviews to provide estimates for key indicators with acceptable precision and to provide a sample large enough to identify adequate numbers of under-five deaths to provide data on causes of death. Data were not collected in one of the selected clusters due to security reasons, resulting in a final sample of 12,323 selected households. Weights were calculated taking into consideration cluster, household, and individual non-responses, so the representations were not distorted. 1.6 QUESTIONNAIRES Each household selected for the GDHS was eligible for interview with the Household Questionnaire. In half of the households selected for the survey, all women age 15-49 and all men age 15-59 were eligible to be interviewed if they were either usual residents of the households or visitors present in the household on the night before the survey. Height and weight measurements of female respondents and children under the age of five years were done only in the households selected for the individual interview. Eligible women and children age 6 to 59 months in the households selected for individual interview were also tested for anaemia. Three questionnaires were used for the 2008 GDHS: the Household Questionnaire, the Women’s Questionnaire and the Men’s Questionnaire. The content of these questionnaires was based on model questionnaires developed by the MEASURE DHS programme and the 2003 GDHS Questionnaires. A questionnaire design workshop organised by GSS was held in Accra to obtain input from the Ministry of Health and other stakeholders on the design of the 2008 GDHS Questionnaires. Based on the questionnaires used for the 2003 GDHS, the workshop and several other informal meetings with various local and international organisations, the DHS model questionnaires were modified to reflect relevant issues in population, family planning, domestic violence, HIV/AIDS, malaria and other health issues in Ghana. These questionnaires were translated from English into three major local languages, namely Akan, Ga, and Ewe. The questionnaires were pre-tested in July 2008. The lessons learnt from the pre-test were used to finalise the survey instruments and logistical arrangements. 6 | Introduction The Household Questionnaire was used to list all the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. The Household Questionnaire collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor and roof of the house, ownership of various durable goods, and ownership and use of mosquito nets. The Household Questionnaire was also used to record height and weight measurements, consent for, and the results of, haemoglobin measurements for women age 15-49 and children under five years. The haemoglobin testing procedure is described in detail in the next section. The Household Questionnaire was also used to record all deaths of household members that occurred since January 2003. Based on this information, in each household that reported the death of a child under age five years since January 2005,3 field editors administered a Verbal Autopsy Questionnaire. Data on child mortality based on the verbal autopsy will be presented in a separate publication. The Women’s Questionnaire was used to collect information from all women age 15-49 in half of selected households. These women were asked questions about themselves and their children born in the five years since 2003 on the following topics: education, residential history, media exposure, reproductive history, knowledge and use of family planning methods, fertility preferences, antenatal and delivery care, breastfeeding and infant and young child feeding practices, vaccinations and childhood illnesses, marriage and sexual activity, woman’s work and husband’s background characteristics, childhood mortality, awareness and behaviour about AIDS and other sexually transmitted infections (STIs), awareness of TB and other health issues, and domestic violence. The Women’s Questionnaire included a series of questions to obtain information on women’s exposure to malaria during their most recent pregnancy in the five years preceding the survey and the treatment for malaria. In addition, women were asked if any of their children born in the five years preceding the survey had fever, whether these children were treated for malaria and the type of treatment they received. The Men’s Questionnaire was administered to all men age 15-59 living in half of the selected households in the GDHS sample. The Men’s Questionnaire collected much of the same information found in the Women’s Questionnaire, but was shorter because it did not contain a reproductive history or questions on maternal and child health or nutrition. 1.7 HAEMOGLOBIN TESTING In half of households selected for the 2008 GDHS survey, consenting women age 15-49 and children age 6-59 months were tested for anaemia. The protocol for haemoglobin testing was approved by the ICF Macro Institutional Review Board (IRB) in Calverton, Maryland, USA and the Ghana Health Service Ethical Review Committee in Accra, Ghana. Haemoglobin testing is the primary method of anaemia diagnosis. Testing was done using the HemoCue system. A consent statement was read to the eligible respondent or to the parent or responsible adult for young children and unmarried women age 15-17. This statement explained the purpose of the test, indicated that the results would be made available as soon as the test was completed, and requested permission for the test to be carried out. In the case of persons whose haemoglobin level was lower than the cut-off point, a referral form was provided to the respondent to be taken to a doctor or a health facility. 3 Data were collected for all members of the household who had died in the five years preceding the survey (January 2003-November 2008). However, the verbal autopsy questionnaire was only administered for children under age five at the time of death, who died in the three years preceding the survey (between January 2005- November 2008). Introduction | 7 Before the blood was taken, the finger was wiped with an alcohol prep swab and allowed to air-dry. Then, the palm side of the end of a finger (in the case of adults and children six months of age and older) was pricked with a sterile, non-reusable, self-retractable lancet and a drop of blood collected on a HemoCue microcuvette, which serves as a measuring device, and placed in a HemoCue photometer which displays the result. For children under six months of age (or for children under one year of age who were particularly undernourished and bony) a heel puncture was made to draw a drop of blood. The results were recorded in the Household Questionnaire, as well as on a brochure, which was given to each woman, parent, or responsible adult, that explained what the results meant. For each person whose haemoglobin level was lower than the cut-off point and who agreed to have their condition reported, a referral form was given to be taken to a local health personnel or health facility. 1.8 PRE-TEST, TRAINING, AND FIELDWORK 1.8.1 Pre-test Pre-test training and practice fieldwork were conducted from 23 June to 12 July 2008 for 14 participants: seven women and seven men. Training entailed classroom discussions and practice focusing on the three questionnaires: Household Questionnaire, Women’s Questionnaire, and Men’s questionnaire. Two trainers assigned by the GSS conducted the training with support from ICF Macro. Guest speakers from the MOH were invited to make short presentations on family planning, child health, and nutrition programmes in place in Ghana. The participants, most of whom had been involved in the previous DHS survey, actively discussed the questionnaires and made suggestions for modifications. Based on these suggestions, all versions of the questionnaires (English, Akan, Ewe, and Ga) were updated for the pre-test fieldwork. Pre-test fieldwork was done in several stages. Interviewers were divided into four teams and during the period July 7-11 all teams worked in three urban areas and two rural areas. A total of 68 women’s interviews, 66 men’s interviews, and 79 household interviews were completed. Interviews were conducted in English, Akan, Ewe, and Ga. By the end of the pre-test, a few errors in skip patterns and translation were identified and corrected. 1.8.2 Training and Fieldwork Fieldwork training began on 11 August 2008 at Winneba Sports College, located about 35 miles west of Accra. Three weeks of training on the GDHS were followed by three days of training on the Verbal Autopsy Questionnaire for deaths of children under five years. A total of 160 persons were trained on the GDHS at one training location. The first week of training also included 10 data entry personnel. Most of the trainees had prior experience as interviewers in previous GDHS surveys. The trainees were also recruited on the basis of language skills. Interviewer training was conducted mostly in English by senior staff from GSS, with technical input from ICF Macro. In addition, resource persons from other agencies made presentations on family planning, Ghana’s programme on Integrated Management of Childhood Illnesses (IMCI), nutrition and anthropometric measurements, and malaria. All participants were trained on interviewing techniques and the contents of the GDHS questionnaires. The training was conducted following the standard DHS training procedures, including class presentations, mock interviews, and written tests. All of the participants were trained on how to complete the Household Questionnaire, the Women’s Questionnaire and the Men’s Questionnaire, and how to collect anthropometric measurements. In addition to interviewer training, all female interviewers were trained in anaemia testing and in informed consent procedures. Training included four days of field practice, three days implementing the Household and Individual Questionnaires, and one day implementing the Verbal Autopsy Questionnaires. Trainees also practiced interviewing (mock interviews) in English as well as in the local languages. During training, it was emphasised that only female interviewers interview respondents for the Women’s Questionnaire and only male interviewers interview respondents for the Men’s Questionnaire. Trainees selected as supervisors and field editors were given an additional two days of training on 8 | Introduction how to supervise fieldwork and edit questionnaires, followed by three days of training on the Verbal Autopsy Questionnaire for deaths of children under five years. At the end of the main training 23 teams were designated to carry out the fieldwork. Each team was composed of one supervisor, one editor, two female interviewers, two male interviewers, and a driver. A standby list of 22 people was kept for replacement in cases of interviewer attrition. Interviewers were selected on the basis of in-class participation, field practice, fluency in the Ghanaian languages, and an assessment test. The most experienced trainees, those who had participated in the pre-test and those who did extremely well during the training were selected to be supervisors and editors. Senior staff from GSS coordinated and supervised the fieldwork activities. ICF Macro partici- pated in field supervision of interviews, weight and height measurements, and blood sample col- lection. Data collection took place over a two and half-month period, from early September to late November 2008.4 1.9 DATA PROCESSING The processing of the GDHS results began shortly after the fieldwork commenced. Com- pleted questionnaires were returned periodically from the field to the GSS office in Accra, where they were entered and edited by data processing personnel who were specially trained for this task. Data were entered using CSPro, a programme specially developed for use in DHS surveys. All data were entered twice (100 percent verification). The concurrent processing of the data was a distinct advan- tage for data quality, because GSS had the opportunity to advise field teams of problems detected during data entry. The data entry and editing phase of the survey was completed in February 2009. 1.10 RESPONSE RATES Table 1.1 shows response rates for the 2008 GDHS. A total of 12,323 households were selected in the sample, of which 11,913 were occupied at the time of the fieldwork. This difference between selected and occupied households occurred mainly because some of the selected structures were found to be vacant or destroyed. The number of occupied households successfully interviewed was 11,778, yielding a household response rate of 99 percent. In the households selected for individual interview in the survey (50 percent of the total 2008 GDHS sample), a total of 5,096 eligible women were identified; interviews were completed with 4,916 of these women, yielding a response rate of 97 percent. In the same households, a total of 4,769 eligible men were identified and interviews were completed with 4,568 of these men, yielding a response rate of 96 percent. The response rates are slightly lower among men than women. The principal reason for non-response among both eligible women and men was the failure to find individuals at home despite repeated visits to the household. The lower response rate for men reflects the more frequent and longer absences of men from the household. 4 Several weeks before the start of training, GSS decided to increase the number of field teams from the originally planned 15 to a total of 23. The increase in field teams was done in order to conclude all data collection prior to national elections held on 7 December 2008. The increase in the number of field teams reduced the period of data collection from 120 to 79 days. Introduction | 9 Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Ghana 2008 Residence Result Urban Rural Total Household interviews Households selected 5,458 6,865 12,323 Households occupied 5,252 6,661 11,913 Households interviewed 5,175 6,603 11,778 Household response rate1 98.5 99.1 98.9 Interviews with women age 15-49 Number of eligible women 2,239 2,857 5,096 Number of eligible women interviewed 2,162 2,754 4,916 Eligible women response rate2 96.6 96.4 96.5 Interviews with men age 15-59 Number of eligible men 2,014 2,755 4,769 Number of eligible men interviewed 1,914 2,654 4,568 Eligible men response rate2 95.0 96.3 95.8 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Household Population and Housing Characteristics | 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 Presented in this chapter are descriptive summaries of the social, economic, and demographic characteristics of households sampled for the survey. The basic characteristics of the sampled population, that is, age, sex, education, and place of residence and the socio-economic conditions of the households, form the basis of the background information by which most key demographic and health indices are analysed throughout this report. This information is crucial for the interpretation of key demographic and health indicators from which to draw meaningful policies and programmes for intervention, and for measuring the representativeness of the survey. One focus of this chapter is to describe the environment in which men, women, and children live. This description presents the general characteristics of the population, such as the age-sex structure, literacy and education, household arrangements (headship, size), and housing facilities (sources of water supply, sanitation facilities, dwelling characteristics and household possessions). A distinction is made between urban and rural areas because many of these indicators differ by urban- rural residence. In the 2008 GDHS, a household is defined as a person or a group of persons, related or unrelated, who live together in the same house or compound, share the same housekeeping arrange- ments, and eat together as a unit. The Household Questionnaire was used to collect information on all usual residents and visitors who spent the night preceding the survey in the household. This mode of data collection allows the analysis of either the de jure (usual) residents of the household or the de facto household population (including visitors who spent the night preceding the interview in the household and who were present at the time of the interview). 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Age and sex are important variables in analysing demographic trends. Table 2.1 and Figure 2.1 present the distribution of the de facto household population in the 2008 GDHS survey by five- year age groups, according to sex and urban-rural residence. The age structure is typical of a young population characterised by high fertility. This type of population structure imposes a heavy burden on the social and economic assets of a country. However, while the results of the 2008 GDHS indicate that 41 percent of the population is under 15 years, this is an improvement since the 2003 survey in which 44 percent of the population was under 15 years. Five percent of the population is in the older age groups (65 years and above), and this has not changed much since 2003. 12 | Household Population and Housing Characteristics Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Ghana 2008 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 13.0 10.8 11.8 15.2 13.8 14.5 14.3 12.5 13.3 5-9 13.2 11.7 12.4 16.6 15.0 15.7 15.2 13.5 14.3 10-14 12.7 12.3 12.5 14.7 12.4 13.5 13.8 12.4 13.1 15-19 10.7 10.3 10.5 10.8 9.1 9.9 10.7 9.7 10.2 20-24 9.1 9.6 9.4 6.3 7.4 6.8 7.5 8.4 7.9 25-29 7.9 9.3 8.7 5.7 7.5 6.6 6.7 8.3 7.5 30-34 6.4 6.9 6.7 4.9 5.6 5.3 5.5 6.2 5.9 35-39 5.8 6.3 6.0 5.3 5.7 5.5 5.5 6.0 5.7 40-44 4.2 4.7 4.5 3.9 4.5 4.2 4.0 4.6 4.3 45-49 4.1 4.3 4.2 3.9 4.0 3.9 4.0 4.1 4.0 50-54 3.6 4.4 4.1 3.0 4.0 3.5 3.3 4.2 3.7 55-59 2.8 2.6 2.7 2.2 2.7 2.5 2.4 2.7 2.5 60-64 2.3 2.0 2.1 2.3 2.3 2.3 2.3 2.1 2.2 65-69 1.5 1.3 1.4 1.7 1.8 1.8 1.6 1.6 1.6 70-74 1.2 1.6 1.4 1.6 1.8 1.7 1.5 1.7 1.6 75-79 0.7 0.9 0.8 0.9 0.9 0.9 0.8 0.9 0.9 80+ 0.7 1.0 0.8 1.0 1.4 1.2 0.9 1.2 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 8,706 10,144 18,850 11,920 12,510 24,430 20,626 22,654 43,280 Figure 2.1 Population Pyramid 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0246810 0 2 4 6 8 10 GDHS 2008 Male Percent Female Age 2.2 HOUSEHOLD COMPOSITION The size and composition of households and the sex of the head of household are important factors affecting the welfare of the household. Table 2.2 shows the information collected in the 2008 GDHS on the sex of the head of household and the mean household size. In Ghana, the mean household size is 3.7 persons, with households in rural areas being larger (4.0 persons) than those in urban areas (3.4 persons). Household Population and Housing Characteristics | 13 Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18, according to residence, Ghana 2008 Characteristic Residence Total Urban Rural Household headship Male 63.2 69.2 66.3 Female 36.8 30.8 33.7 Total 100.0 100.0 100.0 Number of usual members 1 24.7 19.3 21.9 2 16.1 13.8 14.9 3 16.1 14.8 15.4 4 14.0 14.0 14.0 5 12.1 12.2 12.1 6 7.4 9.8 8.7 7 4.5 6.4 5.5 8 2.1 4.0 3.1 9+ 2.7 5.6 4.2 Total 100.0 100.0 100.0 Mean size of households 3.4 4.0 3.7 Percentage of households with orphans and foster children under 18 years of age Foster children1 18.0 19.0 18.6 Double orphans 1.0 0.7 0.9 Single orphans 6.5 7.7 7.1 Foster and/or orphan children 20.9 22.5 21.7 Number of households 5,627 6,150 11,777 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under 18 years of age living in households where neither their mother nor their father is a de jure resident. Two-thirds (66 percent) of households are headed by males, while one-third (34 percent) are headed by females. The percentage of female-headed households is higher in urban areas (37 percent) than in rural areas (31 percent). Single-person households are more common in urban areas (25 percent) than rural areas (19 percent). This may be due to an influx of unmarried young persons migrating to urban areas in search of employment or to further their education. 2.2.1 Children’s Living Arrangements and Orphanhood Information on households with foster children and orphans was collected in the 2008 GDHS. Foster children are defined here as children under age 18 living in households with neither their mother nor their father present; orphans are children with one or both parents dead. Foster children and orphans are of concern because they may be at increased risk of neglect or exploitation when their mothers or fathers are not present to assist them. Table 2.3 shows the distribution of foster children and children with one or both parent dead, according to background characteristics. The table is based on de jure household members. Eighteen percent of children under age 18 are foster children and 8 percent are orphan children. The percentage of foster and orphan children is higher in urban areas (20 and 8 percent, respectively) than rural areas (16 and 7 percent, respectively). 14 | Household Population and Housing Characteristics Table 2.3 Children’s living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents; the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Ghana 2008 Background characteristic Living with both parents Living with mother but not with father Living with father but not with mother Not living with either parent Total Percent- age not living with a biological parent Percent- age with one or both parents dead Number of children Both alive Only father alive Only mother alive Both dead Missing informa- tion on father/ mother1 Father alive Father dead Mother alive Mother dead Age 0-4 65.2 23.9 1.3 2.0 0.2 6.4 0.4 0.2 0.2 0.2 100.0 7.2 2.3 5,832 <2 69.1 27.0 0.7 0.7 0.1 2.0 0.3 0.0 0.2 0.1 100.0 2.4 1.2 2,243 2-4 62.8 21.9 1.6 2.9 0.3 9.1 0.6 0.3 0.3 0.4 100.0 10.2 3.0 3,589 5-9 54.4 18.3 3.3 5.3 0.7 15.1 1.1 1.1 0.4 0.3 100.0 17.6 6.6 6,261 10-14 47.3 16.8 5.0 6.4 1.0 18.9 1.4 2.0 1.0 0.2 100.0 23.4 10.5 5,717 15-17 41.4 16.5 6.4 6.5 1.5 19.8 1.7 3.9 1.6 0.7 100.0 27.0 15.1 2,727 Sex Male 55.5 18.5 3.6 5.6 0.8 12.8 0.9 1.3 0.6 0.4 100.0 15.6 7.2 10,378 Female 52.0 19.9 3.6 4.0 0.7 15.9 1.3 1.6 0.7 0.3 100.0 19.5 8.0 10,159 Residence Urban 48.2 22.0 3.9 4.6 0.7 16.5 1.2 1.6 0.9 0.3 100.0 20.2 8.4 8,224 Rural 57.5 17.3 3.4 5.0 0.8 12.9 1.0 1.3 0.5 0.3 100.0 15.7 7.0 12,313 Region Western 59.7 15.8 2.7 5.2 0.6 12.8 1.0 1.5 0.3 0.2 100.0 15.7 6.2 1,969 Central 43.0 27.8 3.4 4.7 0.7 17.0 1.2 1.4 0.4 0.4 100.0 20.0 7.0 2,047 Greater Accra 52.6 19.4 4.8 4.5 1.1 13.9 1.1 1.4 1.2 0.1 100.0 17.5 9.5 2,483 Volta 48.7 22.6 2.1 3.5 0.5 18.4 1.6 1.7 0.4 0.5 100.0 22.1 6.3 1,830 Eastern 49.7 20.7 2.3 7.3 0.9 16.7 0.9 0.5 0.5 0.4 100.0 18.6 5.1 2,052 Ashanti 43.9 26.3 3.8 5.1 0.4 16.9 1.3 1.8 0.4 0.1 100.0 20.4 7.7 3,673 Brong Ahafo 50.7 21.7 5.0 3.7 0.8 15.1 1.4 0.9 0.5 0.3 100.0 17.8 8.7 2,015 Northern 75.5 5.9 1.7 4.4 0.9 8.1 0.5 0.7 1.7 0.7 100.0 11.0 5.5 2,580 Upper East 63.6 9.7 7.6 5.0 1.2 8.5 0.6 3.4 0.3 0.1 100.0 12.9 13.1 1,289 Upper West 61.7 10.9 4.9 4.4 1.1 12.2 1.6 2.4 0.4 0.3 100.0 16.7 10.5 598 Wealth quintile Lowest 68.6 10.0 3.9 5.1 1.2 8.0 0.6 1.4 0.8 0.2 100.0 10.9 8.0 4,654 Second 51.5 21.9 3.4 4.2 0.5 15.3 1.2 1.1 0.6 0.4 100.0 18.2 6.8 4,405 Middle 41.0 27.9 4.1 5.2 0.6 17.1 1.7 1.3 0.5 0.5 100.0 20.7 8.3 4,161 Fourth 49.9 21.1 4.0 4.6 0.6 16.6 1.0 1.5 0.5 0.3 100.0 19.6 7.6 3,886 Highest 56.5 15.4 2.5 5.1 0.8 15.7 0.8 2.1 1.0 0.1 100.0 19.5 7.2 3,431 Total <15 55.7 19.6 3.2 4.6 0.7 13.5 1.0 1.1 0.5 0.3 100.0 16.1 6.4 17,810 Total <18 53.8 19.2 3.6 4.8 0.8 14.3 1.1 1.5 0.7 0.3 100.0 17.5 7.6 20,537 Note: Table is based on de jure children who usually live in the household. 1 Includes children with father dead, mother dead, both dead and one parent dead but missing information on survival status of the other parent. Detailed information on living arrangements and orphanhood for children under age 18 is presented in Table 2.3. Of the 20,537 children under age 18 reported in the 2008 GDHS, about 54 percent live with both parents, 19 percent live with their mother only, although their father is alive, 5 percent live with their father only, although their mother is alive, and 14 percent live with neither of their natural parents, although both parents are alive. Table 2.3 also provides data on the extent of orphanhood, that is, the proportion of children who have lost one or both parents. Less than one percent of children under age 18 have both parents dead while 8 percent have one or both parents dead. The percentage of children living with both biological parents decreases with increasing age of the child. Children in rural areas are more likely than those in urban areas to live with both parents. The highest proportion of children living with both parents is in the Northern region (76 percent), followed by the Upper East and Upper West regions (64 and 62 percent, respectively). By wealth status, the proportion of children under age 18 living with both parents shows a U-shaped pattern with increasing wealth quintile. The highest proportions are among children in the lowest and highest wealth quintiles (69 and 57 percent, respectively) and the lowest proportion is in the middle wealth quintile (41 percent). Household Population and Housing Characteristics | 15 2.2.2 School Attendance by Survivorship of Parents Children who are orphaned or live in a house with chronically ill adults may be at a greater risk of dropping out of school because of lack of money to pay school fees or the need to stay at home to care for the sick relative. The GDHS included information to monitor such situations and collected information on school attendance of children age 10-14 by parental survival. The proportion of children age 10-14 attending school whose parents are both dead is 67 percent and the proportion whose parents are both living and the child is residing with at least one parent is 88 percent (data not shown separately). The overall ratio of school attendance of children whose parents are dead to those whose parents are living, and the child resides with at least one parent, is 0.76. Further breakdown by background characteristics was not possible due to the low number of orphans (60 unweighted cases). 2.3 EDUCATIONAL ATTAINMENT OF HOUSEHOLD MEMBERS Education is important because it helps individuals make informed decisions that impact their health and well-being. Ghana’s educational system has undergone several stages of restructuring over the past 25 years (Sedgwick, 2000). The current system of formal education was introduced in 1989. It is based on a three-tier system: six years of primary education, followed by three years of junior secondary school (JSS), and a further three years at the senior secondary school (SSS) level. From the mid-1970s until the introduction of the current system of education, the six years of primary education were followed by five years of secondary education―three years of JSS and two years of SSS. Prior to the mid-1970s, students who completed six years of primary education had a choice. They could attend four years of middle school or attend five years of secondary school with a small group having the further option to pursue an additional two years of pre-university education. Upon completion of formal schooling, a student could choose to further his or her education at the tertiary level. In addition to university education, there are many institutions offering vocational, technical, and professional training that may be tertiary or non-tertiary. Over the past decade there have been many changes in the education sector. At the Basic Education Level, pre-school education has officially been incorporated into the education system and all primary schools are required to have nurseries or kindergarten. At the secondary level, since the 2007/2008 academic year, the three-year Senior Secondary School System has been changed to the four-year Senior High School.1 The different systems of formal education have been taken into account in tabulating the educational attainment of women and men interviewed in the 2008 GDHS. Table 2.4.1 shows the percent distribution of the de facto female household population age six years and over by highest level of education attended or completed, according to background characteristics. Thirty-one percent of women have never been to school, about 31 percent have some primary or have completed primary school, 36 percent have some secondary or have completed secondary school, and about 3 percent have more than secondary school education. The data show that the proportion of women with no education is higher among older women, suggesting some improvement in education over the years. This may be due to the impact of the Free Compulsory Universal Basic Education (FCUBE) programme, which was introduced in 1996. Education varies by place of residence. Urban women are more likely to be educated than rural women. For instance, 21 percent of urban females have no education, compared with 40 percent of rural females. The proportion of urban females with some secondary education or higher (52 percent) is almost twice as high as that of rural females (27 percent). 1 The change in name from Senior Secondary to Senior High School and the change from three years to four years have not affected the results of the GDHS. 16 | Household Population and Housing Characteristics It is notable that females in the northern half of the country (the Northern, Upper East, and Upper West regions) are seriously disadvantaged. More than half to two-thirds of women in these three regions have never been to school, compared with less than one-fifth in the Greater Accra and Ashanti regions. In addition, 21 percent of females in Greater Accra have completed secondary education or higher, compared with 4 percent or less in the Northern, Upper East and Upper West regions. It is worth noting that the proportion of female household members who have never attended school decreases with higher wealth status. Sixty-two percent of women in the lowest wealth quintile have no education, compared with only 10 percent in the highest quintile. Table 2.4.1 Educational attainment of the female household population Percent distribution of the de facto female household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Ghana 2008 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 48.2 51.3 0.1 0.1 0.0 0.0 0.2 100.0 2,506 0.0 10-14 7.9 67.7 9.7 14.6 0.0 0.0 0.1 100.0 2,806 3.4 15-19 10.1 15.8 9.4 58.7 5.7 0.3 0.0 100.0 2,189 6.9 20-24 16.8 11.3 5.7 41.6 19.8 4.8 0.0 100.0 1,897 8.3 25-29 23.1 12.5 5.3 39.2 12.9 6.9 0.0 100.0 1,876 8.1 30-34 30.0 13.3 5.6 37.6 9.2 4.2 0.2 100.0 1,400 6.2 35-39 33.3 13.6 4.8 39.0 6.3 2.8 0.3 100.0 1,353 5.6 40-44 36.1 12.4 5.1 38.3 5.4 2.6 0.0 100.0 1,046 5.3 45-49 38.9 12.3 3.6 35.0 5.8 4.3 0.0 100.0 928 4.5 50-54 42.1 11.7 4.0 32.7 4.4 4.7 0.4 100.0 945 3.6 55-59 50.5 9.8 2.9 26.1 5.1 5.1 0.4 100.0 603 0.0 60-64 65.0 7.8 0.7 18.7 3.1 4.6 0.0 100.0 482 0.0 65+ 79.9 6.9 1.2 9.4 1.1 1.3 0.1 100.0 1,233 0.0 Residence Urban 20.5 22.2 5.4 36.6 10.4 4.8 0.2 100.0 8,830 6.2 Rural 40.3 28.0 5.0 23.4 2.4 0.8 0.1 100.0 10,453 1.6 Region Western 24.9 28.1 5.5 32.0 5.9 3.5 0.1 100.0 1,738 4.5 Central 30.6 29.6 5.4 29.5 3.5 1.4 0.1 100.0 1,965 3.3 Greater Accra 15.7 19.2 5.6 38.2 14.8 6.6 0.0 100.0 2,904 8.1 Volta 33.3 27.5 7.2 26.1 4.0 1.8 0.2 100.0 1,817 3.0 Eastern 24.8 25.1 7.1 36.4 4.7 1.6 0.3 100.0 1,966 5.0 Ashanti 19.0 28.1 4.0 39.1 6.9 2.7 0.2 100.0 3,629 5.5 Brong Ahafo 33.6 26.6 6.6 28.7 3.6 1.1 0.0 100.0 1,727 3.0 Northern 67.5 17.9 2.7 7.9 2.7 1.0 0.2 100.0 1,886 0.0 Upper East 55.0 27.5 2.9 10.1 2.5 1.9 0.1 100.0 1,136 0.0 Upper West 54.0 27.4 2.9 12.2 2.6 0.8 0.1 100.0 515 0.0 Wealth quintile Lowest 62.1 25.3 3.3 8.5 0.6 0.1 0.1 100.0 3,506 0.0 Second 39.0 30.4 5.5 23.6 1.2 0.1 0.1 100.0 3,816 1.6 Middle 29.9 28.2 6.3 31.9 3.1 0.5 0.2 100.0 4,051 3.6 Fourth 19.2 24.6 5.8 40.4 7.9 2.0 0.1 100.0 3,892 5.9 Highest 10.1 18.5 4.6 40.0 16.6 10.0 0.1 100.0 4,019 8.5 Total 31.3 25.4 5.2 29.4 6.1 2.6 0.1 100.0 19,283 3.7 Note: Total includes females with information missing on age who are not shown separately. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Household Population and Housing Characteristics | 17 Table 2.4.2 shows that 22 percent of males have never been to school, 30 percent have had some primary or have completed primary education, 42 percent have had some secondary or have completed secondary education, and nearly 6 percent have more than secondary education. Twenty- nine percent of males in rural areas have no education, compared with 13 percent in urban areas. There is a marked urban-rural differential in secondary and higher education: 25 percent of males in urban areas have completed secondary or higher education, compared with only 8 percent in rural areas. Across regions, the pattern for males is similar to the pattern for females. Males in the three northern regions are disadvantaged because 41 to 51 percent have never been to school, compared with less than 20 percent in the other regions, except Brong Ahafo region (26 percent). Variation in education among males according to household wealth status shows a pattern similar to that observed for the female population. Males in households in the upper wealth quintiles are less likely to have no education than those in other quintiles. For example, only 5 percent of males in the highest wealth quintile have no education, compared with 48 percent of those in the lowest quintile. Table 2.4.2 Educational attainment of the male household population Percent distribution of the de facto male household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Ghana 2008 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 49.9 49.7 0.1 0.2 0.0 0.0 0.1 100.0 2,584 0.0 10-14 8.3 69.6 8.4 13.6 0.0 0.0 0.1 100.0 2,848 3.2 15-19 6.8 17.9 9.5 59.7 5.8 0.4 0.1 100.0 2,215 7.1 20-24 10.0 7.3 3.9 43.4 27.8 7.5 0.1 100.0 1,542 8.7 25-29 13.7 7.2 4.6 40.7 19.5 14.2 0.2 100.0 1,374 8.6 30-34 16.0 6.1 4.8 43.6 18.5 10.9 0.1 100.0 1,143 8.6 35-39 22.5 9.8 3.2 42.2 14.0 8.0 0.3 100.0 1,133 8.9 40-44 24.2 6.8 3.8 44.9 10.8 9.3 0.2 100.0 834 9.2 45-49 25.5 5.6 2.4 43.0 13.2 10.4 0.0 100.0 815 9.3 50-54 20.4 9.1 2.2 42.5 11.3 14.2 0.3 100.0 671 9.4 55-59 21.5 5.0 2.1 44.1 12.8 14.3 0.3 100.0 499 9.4 60-64 37.1 6.6 2.7 34.6 7.9 11.1 0.0 100.0 476 9.0 65+ 53.2 7.0 2.2 26.9 3.9 6.5 0.3 100.0 985 0.0 Residence Urban 13.3 21.2 4.1 36.2 15.4 9.7 0.1 100.0 7,385 8.2 Rural 29.1 28.5 4.9 29.8 4.9 2.7 0.1 100.0 9,743 3.5 Region Western 15.7 22.6 5.4 38.9 9.2 8.2 0.0 100.0 1,712 7.0 Central 18.0 29.1 4.6 37.3 6.6 4.3 0.2 100.0 1,581 5.6 Greater Accra 9.2 18.7 3.7 35.7 20.8 11.8 0.2 100.0 2,476 8.9 Volta 19.6 26.4 6.1 36.4 7.1 4.3 0.1 100.0 1,541 5.6 Eastern 15.0 25.6 5.9 42.8 6.7 3.9 0.1 100.0 1,756 6.6 Ashanti 13.3 25.8 3.7 40.7 10.5 6.0 0.0 100.0 2,991 7.0 Brong Ahafo 26.4 29.0 5.4 28.2 7.2 3.6 0.1 100.0 1,559 3.8 Northern 51.1 23.6 3.0 13.2 5.4 3.3 0.3 100.0 1,956 0.0 Upper East 43.0 31.7 5.0 12.9 4.2 3.2 0.0 100.0 1,080 0.8 Upper West 41.1 31.2 4.1 15.1 5.3 2.9 0.3 100.0 477 1.0 Wealth quintile Lowest 48.2 29.5 4.6 15.4 1.8 0.3 0.1 100.0 3,518 0.1 Second 25.8 30.3 5.4 32.7 4.2 1.4 0.1 100.0 3,353 3.8 Middle 19.7 27.9 5.7 37.5 6.7 2.3 0.1 100.0 3,276 5.4 Fourth 12.1 22.7 4.0 42.9 12.5 5.7 0.1 100.0 3,440 8.1 Highest 5.4 16.7 3.1 34.9 21.3 18.4 0.2 100.0 3,541 9.4 Total 22.3 25.4 4.5 32.6 9.4 5.7 0.1 100.0 17,128 5.4 Note: Total includes males with information missing on age who are not shown separately. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level 18 | Household Population and Housing Characteristics Males are more likely to be educated than females at all levels of education; thus females continue to lag behind males in education. The median number of years of schooling completed is higher for males (5.4 years) than females (3.7 years). There has been some improvement in the proportion of the population with no education since the last GDHS survey. The proportion of females with no education dropped from 37 percent in 2003 to 31 percent in 2008 and the median number of years of schooling for females nearly doubled from 2.1 to 3.7 years. Similarly, the proportion of males with no education dropped from 26 to 22 percent, with the median years of schooling increasing from 3.9 to 5.4 years. Thus, the male-female gap in educational attainment has narrowed slightly over the period. The 2008 GDHS collected information on school attendance for the population age 3-24 years that allows the calculation of net attendance ratios (NARs) and gross attendance ratios (GARs). The NAR for primary school is the percentage of the primary-school-age (6-11 years) population that is attending primary school. The NAR for secondary school is the measure of the secondary-school-age (12-17 years) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. The GAR however, measures participation at each level of schooling among persons age 6-25. The GAR is almost always higher than the NAR for the same level because the GAR includes participation by those who may be older, because they may have started school late, may have repeated one or more grades in school, or may have dropped out of school and later returned, or may be younger than the official age range for that level. Table 2.5 presents data on the NAR and GAR for the de facto household population by level of schooling and sex, according to place of residence, region and wealth quintile. Seventy-four percent of children age 6-11, who should be attending primary school, are currently doing so. At the same time, the GAR at the primary school level is 108 percent. The distribution shows that both the NAR and GAR are much lower at the secondary school level: 42 percent of students age 12-17 who should be attending secondary school are in school (NAR). The GAR for secondary school is 57 percent. The 2008 GAR was calculated based on the de facto secondary-school-age (12-17) population; however, the 2003 GAR was calculated based on the de jure secondary-school-age (12- 18) population. To enable comparison, the 2008 data were re-calculated using the de jure secondary- school-age (12-18) population. The resulting GAR was 49 percent, which indicates that there has been an increase (improvement) in the proportion of underage or overage youths in secondary school since 2003 (41 percent). The results show slightly higher NARs for females than males at both the primary and secondary school levels, which indicates that that there is not much of a gender gap in school attendance for the Ghanaian school-age population who should be attending school at a given level. However, the GARs at primary and secondary school levels are slightly higher for males than females, indicating relatively higher overage or underage attendance among males than females. School attendance ratios at both the primary and secondary levels are lower in rural than in urban areas. For instance, the NAR at the primary school level in rural areas is 70 percent compared with 80 percent in urban areas. Similarly, the GAR at the secondary school level is 48 percent in rural areas, compared with 68 percent in urban areas. Regional differences are obvious for the NAR and GAR with attendance ratios notably lower in the Northern and Upper West regions, compared with all other regions, and especially in the case of the GAR at the primary school level for the Northern region (76 percent, compared with the overall GAR of 108 percent). There is a strong relationship between household economic status and school attendance that can be seen at both the primary and secondary levels and among males and females. For example, the NAR increases from 59 percent among students from poorer households (lowest wealth quintile) in primary school to 86 percent among pupils from richer households (highest wealth quintile). Similarly, the GAR rises from 34 percent among secondary school attendees in the lowest wealth quintile to 76 percent among those in the highest wealth quintile. Household Population and Housing Characteristics | 19 Table 2.5 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the gender parity index (GPI), by background characteristics, Ghana 2008 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index (GPI)3 Male Female Total Gender Parity Index (GPI)3 PRIMARY SCHOOL Residence Urban 81.0 79.5 80.3 0.98 110.2 108.9 109.5 0.99 Rural 68.8 70.8 69.8 1.03 107.1 105.9 106.6 0.99 Region Western 72.0 71.3 71.6 0.99 105.7 102.7 104.2 0.97 Central 74.3 76.1 75.2 1.02 105.0 114.3 109.6 1.09 Greater Accra 82.7 77.7 80.3 0.94 111.4 106.9 109.2 0.96 Volta 67.9 75.5 71.7 1.11 114.7 120.2 117.4 1.05 Eastern 75.9 74.8 75.4 0.99 116.5 104.3 110.3 0.90 Ashanti 86.8 85.7 86.2 0.99 118.4 113.9 116.1 0.96 Brong Ahafo 73.9 77.4 75.6 1.05 115.4 115.7 115.6 1.00 Northern 55.7 50.4 53.3 0.90 78.4 72.3 75.6 0.92 Upper East 68.5 75.9 71.9 1.11 115.2 120.9 117.8 1.05 Upper West 62.1 67.5 64.7 1.09 105.9 103.8 104.9 0.98 Wealth quintile Lowest 58.2 60.1 59.1 1.03 97.7 93.7 95.8 0.96 Second 72.3 71.6 71.9 0.99 111.5 106.6 109.1 0.96 Middle 74.8 78.1 76.5 1.04 112.0 115.5 113.7 1.03 Fourth 82.1 81.5 81.8 0.99 113.5 113.9 113.7 1.00 Highest 87.6 84.4 85.9 0.96 109.2 108.0 108.6 0.99 Total 73.4 74.2 73.8 1.01 108.3 107.1 107.7 0.99 SECONDARY SCHOOL Residence Urban 53.0 50.9 51.9 0.96 72.8 63.6 67.8 0.87 Rural 34.3 34.9 34.5 1.02 51.1 44.6 48.1 0.87 Region Western 49.1 43.7 46.6 0.89 66.5 58.0 62.6 0.87 Central 43.3 36.5 39.6 0.84 64.5 43.3 53.0 0.67 Greater Accra 52.0 52.2 52.1 1.00 69.5 64.6 66.8 0.93 Volta 37.9 40.6 39.3 1.07 63.6 57.2 60.4 0.90 Eastern 41.1 44.5 42.8 1.08 51.2 56.7 53.8 1.11 Ashanti 52.6 52.8 52.7 1.00 68.8 59.7 64.1 0.87 Brong Ahafo 38.8 38.7 38.8 1.00 58.2 50.9 54.6 0.87 Northern 25.1 26.2 25.6 1.05 46.8 37.0 42.2 0.79 Upper East 28.0 33.3 30.5 1.19 42.4 44.1 43.2 1.04 Upper West 26.6 26.0 26.3 0.98 44.6 44.5 44.6 1.00 Wealth quintile Lowest 24.4 19.3 22.2 0.79 38.5 27.9 33.9 0.72 Second 33.9 36.0 34.9 1.06 52.2 45.7 49.1 0.88 Middle 43.4 39.9 41.7 0.92 60.8 52.6 56.7 0.86 Fourth 50.5 52.0 51.3 1.03 72.1 64.6 68.0 0.90 Highest 62.8 59.1 60.7 0.94 82.7 70.8 76.1 0.86 Total 41.8 42.4 42.1 1.01 59.8 53.6 56.7 0.90 1 The NAR for primary school is the percentage of the primary-school-age (6-11 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (12-17 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR (GAR) for females to the NAR (GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR (GAR) for females to the NAR (GAR) for males. 20 | Household Population and Housing Characteristics The Gender Parity Index (GPI) represents the ratio of the NAR (or GAR) for females to the NAR (or GAR) for males. It is presented in Table 2.5 at both the primary and secondary levels and offers a summary measure of gender differences in school attendance rates. A GPI of less than 1 indicates that a smaller proportion of females than males attend school. In Ghana, the GPI is almost 1 (0.99) for primary school attendance and slightly lower than 1 (0.90) for secondary school attendance, indicating that the gender gap is relatively small. There are no differences in the GPI by urban-rural residence. The Eastern and Northern regions showed the widest gap for primary school attendance, and the Central and Northern regions showed the widest gap for secondary school attendance. 2.3.1 Grade Repetition and Dropout Rates Table 2.6 presents school repetition and dropout rates for the de facto household population age 5-24 who attended primary school in the previous school year, by school grade and background characteristics. Repetition and drop-out rates describe the flow of pupils through the educational system in Ghana. Repetition rates indicate the percentage of pupils who attended a particular class during the previous school year who are repeating that grade in the current school year, that is, those who were in a particular grade in the 2006/2007 academic year who attended the same grade during the 2007/2008 academic year. Drop-out rates show the percentage of pupils who attended class during the 2006/2007 academic year but did not attend school the following year. Repetition and drop-out rates approach zero when pupils nearly always progress to the next grade at the end of the school year. They often vary across grades, indicating points in the school system where pupils are not regularly promoted to the next grade or they decide to drop out of school. For both sexes the repetition rate declines from grade 1 to grade 4, rises in grade 5 and then declines again in grade 6. The repetition rates are higher for males in grades 1, 2, and 5. In grade 1 the repetition rate is 4 percent for males, compared with 3 percent for females, but in grade 6 the repetition rate for females (2 percent) is higher than that for males (1 percent). There are small variations by urban-rural residence in almost all grades, except for grade 1 where rural residents have a higher repetition rate (4 percent) than their urban counterparts (2 percent). Larger differentials are observed by region, especially in grade 1. While as high as 12 percent and 13 percent of pupils in the Upper West and Northern region, respectively, repeat grade 1, only 1 percent of pupils repeat grade 1 in the Eastern and Central regions. In the Greater Accra region no pupils repeat grades 4 through grade 6. In general, dropout rates are higher than repetition rates in all grades. Dropout rates across grades are similar (4 percent), except for grade 3, which is 5 percent. Males have higher dropout rates than females in almost all grades. From grades 3 through 6, dropout rates are higher for pupils in urban areas than those in rural areas. There are wide regional variations in dropout rates. The regions with worse rates are the Upper West, Northern, and Central regions. Almost one-fifth (17 percent) of grade 6 pupils in the Upper West region drop out of school. Dropout rates are lower for pupils in the Volta, Ashanti, and Upper East regions. Household Population and Housing Characteristics | 21 Table 2.6 Grade repetition and dropout rates for primary school Repetition and dropout rates for the de facto household population age 5-24 who attended primary school in the previous school year, by school grade and background characteristics, Ghana 2008 Background characteristic School grade 1 2 3 4 5 6 REPETITION RATE1 Sex Male 4.0 2.3 1.4 1.3 1.8 0.8 Female 2.7 1.8 1.8 1.5 1.7 1.5 Residence Urban 1.6 2.5 1.2 0.8 2.5 0.8 Rural 4.3 1.7 1.8 1.9 1.2 1.5 Region Western 2.5 2.5 2.3 4.9 3.5 0.8 Central 1.3 5.2 5.4 0.9 2.4 2.7 Greater Accra 2.2 2.0 1.6 0.0 0.0 0.0 Volta 2.0 0.0 0.4 1.5 1.4 3.1 Eastern 0.8 1.4 1.1 2.6 1.5 0.0 Ashanti 1.7 1.3 1.1 1.1 1.4 1.3 Brong Ahafo 1.5 1.3 0.0 0.0 1.2 1.5 Northern 13.0 3.2 1.1 1.5 3.6 0.0 Upper East 1.6 1.5 0.9 1.5 0.9 0.0 Upper West 12.4 2.0 2.6 0.6 1.8 3.1 Total 3.3 2.0 1.6 1.4 1.7 1.1 DROPOUT RATE2 Sex Male 4.2 4.4 4.1 4.3 3.4 4.9 Female 3.1 3.7 5.9 3.5 3.8 3.5 Residence Urban 3.3 3.9 5.5 4.6 3.8 4.5 Rural 3.9 4.1 4.6 3.4 3.6 3.9 Region Western 5.2 5.0 5.8 5.8 3.5 3.7 Central 7.3 8.2 10.7 8.5 8.6 6.2 Greater Accra 3.1 4.3 5.5 4.6 4.9 5.8 Volta 0.0 0.0 1.4 1.0 3.1 1.6 Eastern 5.0 1.3 4.5 6.7 2.0 3.0 Ashanti 0.0 2.4 2.8 0.6 0.7 0.9 Brong Ahafo 0.8 1.4 2.1 0.7 0.8 5.5 Northern 9.6 10.0 8.7 7.7 8.2 8.4 Upper East 1.6 0.5 0.0 0.0 0.0 0.0 Upper West 11.3 13.5 12.9 9.4 8.8 17.3 Total 3.7 4.0 4.9 3.9 3.7 4.2 1 The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. 2 The dropout rate is the percentage of students in a given grade in the previous school year who are not attending school. Figure 2.2 shows the age-specific attendance rates (ASAR) for the de facto household population age 5-24 by sex. The ASAR shows participation in schooling at any level, from primary through higher education. The closer the ASAR is to 100, the higher the participation of a given age population at that level. A little over 66 percent of children age seven are attending school. School attendance rises markedly up to age 11, remains high up to age 13, and then gradually declines. There are no marked differences in the proportion of males and females attending school up to age 16, after which there are substantially higher proportions of males than females attending school. 22 | Household Population and Housing Characteristics Figure 2.2 Age-Specific School Attendance Rates 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 Percent Female Male GDHS 2008 2.4 HOUSING CHARACTERISTICS There is a strong correlation between the socio-economic condition of households and the vulnerability of its members, especially children, to common diseases. The amenities and assets available to households are important in determining the general socio-economic status of the population. The 2008 GDHS included questions on the household’s access to electricity, source of drinking water, type of sanitation facilities, flooring materials, and ownership of durable goods. The availability of and accessibility to improved drinking water may, to a large extent, minimise the prevalence of water-borne diseases among household members, especially young children. The source of drinking water is important because potentially fatal diseases, such as diarrhoeal diseases, guinea worm, bilharzia, typhoid, cholera, schistosomiasis, trachoma, and dysentery, are common in Ghana. Table 2.7 shows the percent distribution of main sources of drinking water, time to collect drinking water, and person who usually collects drinking water and treatment of water according to residence. Overall, 77 percent of households obtain drinking water from an improved source. Fourteen percent of households have access to piped water in their dwelling, yard, or plot, while 29 percent access drinking water from a public tap. Thirty-three percent of households get their drinking water from a tube well or borehole, or a protected dug well. Thirteen percent of households use non- improved sources of drinking water and about 9 percent use either bottled or sachet water. Surprisingly, there is little difference between urban and rural households in access to improved sources of drinking water (79 and 76 percent, respectively). Household Population and Housing Characteristics | 23 Table 2.7 Household drinking water Percent distribution of households and de jure population by source of drinking water, time to obtain drinking water, and person who usually collects drinking water; and percentage of households and the de jure population that treat water before drinking, according to residence, Ghana 2008 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 78.6 76.2 77.3 81.0 75.4 77.9 Piped water into dwelling/yard/plot 27.0 2.5 14.2 27.0 2.2 13.1 Public tap/standpipe 39.2 19.7 29.0 40.0 17.9 27.6 Tube well or borehole 6.4 47.8 28.0 7.4 49.6 31.2 Protected dug well 5.7 5.1 5.4 6.2 4.9 5.5 Protected spring 0.0 0.1 0.1 0.1 0.1 0.1 Rainwater 0.2 1.0 0.6 0.1 0.7 0.5 Non-improved source 4.6 21.5 13.4 5.4 23.1 15.4 Unprotected dug well 0.9 3.4 2.2 1.2 3.7 2.6 Unprotected spring 0.1 0.9 0.6 0.2 1.1 0.7 Tanker truck/cart with small tank 1.8 0.2 1.0 2.0 0.3 1.0 Surface water 1.7 17.0 9.7 2.0 18.2 11.1 Bottled/sachet water, improved source for cooking/washing1 15.2 1.8 8.2 12.0 1.1 5.9 Bottled/sachet water, non-improved source for cooking/washing1 1.6 0.4 1.0 1.6 0.3 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 93.8 78.0 85.5 93.0 76.6 83.8 Time to obtain drinking water (round trip) Water on premises 41.6 6.1 23.1 40.2 5.5 20.7 Less than 30 minutes 50.5 72.4 61.9 50.5 69.9 61.4 30 minutes or longer 7.2 21.2 14.5 8.7 24.3 17.5 Don’t know/missing 0.7 0.4 0.5 0.7 0.3 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 31.1 56.0 44.1 33.9 60.6 49.0 Adult male 15+ 12.8 15.0 14.0 7.8 8.0 7.9 Female child under age 15 5.3 8.2 6.8 6.5 9.5 8.2 Male child under age 15 3.1 5.1 4.1 4.1 5.6 5.0 Female age 15-17 3.3 5.1 4.2 4.0 5.8 5.0 Male age 15-17 1.7 2.8 2.3 2.0 3.3 2.7 Other 1.1 1.6 1.3 1.4 1.5 1.4 Water on premises 41.6 6.1 23.1 40.2 5.5 20.7 Missing 0.0 0.1 0.1 0.0 0.1 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking2 Boiled 2.6 1.9 2.3 2.6 1.8 2.1 Bleach/chlorine added 1.3 1.4 1.4 1.2 1.4 1.3 Strained through cloth 1.8 5.1 3.5 2.2 6.9 4.8 Ceramic, sand or other filter 1.0 0.8 0.9 1.4 0.8 1.1 Other 2.4 1.4 1.9 2.2 1.2 1.7 No treatment 91.3 90.3 90.8 90.9 88.9 89.8 Percentage using an appropriate treatment method3 6.2 8.6 7.5 6.8 10.2 8.7 Number 5,627 6,150 11,777 19,262 24,818 44,080 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or non-improved source according to their water source for cooking and washing. 2 Respondents could report multiple treatment methods so the sum of treatments can exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. 24 | Household Population and Housing Characteristics The major source of drinking water for rural households is tube wells or boreholes (48 percent). One-fifth of rural households use a public tap or standpipe as their main source of drinking water. Access to piped drinking water has remained about the same over the past five years (GSS and ORC Macro, 2004). It takes nine in ten urban households and nearly eight in ten rural households less than 30 minutes to obtain water from their nearest source of drinking water. Table 2.7 provides information on persons who usually collect the drinking water. Overall, adult females age 15 and above are more likely to collect drinking water for the household than men and children, and this pattern is more prevalent in the rural areas (56 percent) than in urban areas (31 percent). In about 10 percent of households, it is the responsibility of the child (either male or female) to collect drinking water. Regarding treatment of water, nine in ten households do not treat their water prior to drinking. Of households that do treat their drinking water, the most common treatment methods are straining through cloth (4 percent) and boiling (2 percent). The proportion of the population with access to improved toilet facilities, according to the WHO/UNICEF Joint Monitoring Programme (JMP), which is the UN officially mandated mechanism to monitor global progress in drinking water and sanitation (toilet facility), is the percentage of people using improved and sustainable toilet facilities. An improved toilet facility is considered the most efficient and hygienic method of human waste disposal. Table 2.8 shows the percent distribution of households by type of toilet facility, according to residence. Overall, only 11 percent of households use improved, not shared toilet facilities. There are marked differences by urban-rural residence. Sixteen percent of urban households and 7 percent of rural households use improved toilet facilities that are not shared with other households. However, nearly one in five households (18 percent) has no toilet facilities, a situation that is more common in rural areas (30 percent) than in urban areas (6 percent). Table 2.8 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Ghana 2008 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 15.6 7.3 11.3 17.8 8.2 12.4 Flush/pour flush to piped sewer system 2.2 0.6 1.4 2.6 0.5 1.4 Flush/pour flush to septic tank 8.8 0.9 4.7 9.7 1.0 4.8 Flush/pour flush to pit latrine 2.0 0.2 1.1 2.1 0.2 1.0 Ventilated improved pit (VIP) latrine 1.9 1.9 1.9 2.6 2.2 2.4 Pit latrine with slab 0.7 3.6 2.2 0.8 4.2 2.7 Composting toilet 0.0 0.1 0.0 0.0 0.1 0.1 Non-improved facility 84.3 92.8 88.8 82.1 91.8 87.7 Any facility shared with other households 72.2 48.6 59.9 68.8 42.3 53.9 Flush/pour flush not to sewer/septic tank/ pit latrine 0.1 0.0 0.1 0.1 0.0 0.1 Pit latrine without slab/open pit 4.1 14.0 9.3 4.0 13.6 9.4 Bucket 2.0 0.3 1.1 1.8 0.2 0.9 No facility/bush/field 5.6 29.5 18.1 7.2 35.4 23.1 Missing 0.3 0.4 0.3 0.2 0.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 5,627 6,150 11,777 19,262 24,818 44,080 Table 2.9 presents the distribution of households by household characteristics, according to residence. Overall, six in ten households (61 percent) in Ghana have electricity; four-fifths (85 percent) of the households in urban areas have electricity, compared with two-fifths (38 percent) of the households in rural areas. The 2008 GDHS findings show an increase in the use of electricity over the past five years, especially among rural households (48 percent in all households and 24 percent in rural households in 2003) (GSS and ORC Macro, 2004). Household Population and Housing Characteristics | 25 Table 2.9 Household characteristics Percent distribution of households and de jure population by housing characteristics; and among households using solid fuel, percent distribution by type of fire/stove, according to residence, Ghana 2008 Housing characteristic Households Population Urban Rural Total Urban Rural Total Electricity Yes 84.8 38.2 60.5 83.8 34.4 56.0 No 15.2 61.7 39.5 16.1 65.5 43.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 3.8 21.5 13.0 4.1 23.6 15.1 Dung 0.1 2.0 1.1 0.1 2.7 1.6 Wood/planks 0.1 0.0 0.1 0.1 0.0 0.1 Palm/bamboo 0.0 0.0 0.0 0.0 0.0 0.0 Parquet or polished wood 0.2 0.0 0.1 0.2 0.0 0.1 Ceramic tiles/terrazzo 5.0 0.7 2.7 5.0 0.7 2.6 Cement 56.0 65.3 60.8 58.0 64.3 61.6 Woolen carpet/synthetic carpet 18.3 3.6 10.6 17.3 2.8 9.1 Linoleum/rubber carpet 16.2 6.8 11.3 14.9 5.7 9.7 Other 0.3 0.0 0.1 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 63.4 56.3 59.7 48.8 39.3 43.5 Two 23.8 26.0 24.9 30.1 30.4 30.3 Three or more 12.0 17.4 14.8 20.2 29.9 25.7 Missing 0.8 0.4 0.6 0.8 0.4 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 46.6 33.5 39.8 49.3 35.3 41.4 In a separate building 11.2 26.5 19.2 11.9 27.6 20.7 Outdoors 37.9 37.5 37.7 37.3 36.3 36.7 Missing 4.3 2.5 3.3 1.5 0.9 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 0.9 0.2 0.5 1.0 0.1 0.5 LPG/natural gas/biogas 24.0 3.1 13.1 22.1 2.1 10.8 Kerosene 0.8 0.2 0.5 0.6 0.1 0.3 Charcoal 55.9 18.9 36.6 56.6 15.0 33.2 Wood 14.1 74.9 45.8 18.2 81.6 53.9 Straw/shrubs/grass 0.1 0.2 0.2 0.1 0.2 0.2 No food cooked in household 4.3 2.4 3.3 1.5 0.9 1.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 70.1 94.0 82.6 74.9 96.8 87.2 Number of households/ population 5,627 6,150 11,777 19,262 24,818 44,080 Type of fire/stove among households using solid fuels1 Closed stove/coal pot with chimney 0.1 0.2 0.2 0.1 0.3 0.2 Open fire/coal pot/open stove without chimney or hood 99.8 99.7 99.8 99.8 99.6 99.7 Missing 0.1 0.1 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/ population using solid fuel 3,945 5,783 9,728 14,433 24,024 38,457 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung LPG = Liquid petroleum gas 26 | Household Population and Housing Characteristics The type of flooring material used in dwellings is a proxy indicator of the socio-economic status of the household as well as the likelihood of exposure to disease-causing agents. Most households in Ghana (85 percent) have finished floors (terrazzo, tiles, cement, carpet, and linoleum), with only 14 percent of households having rudimentary or natural flooring material (earth, sand, or mud mixed with dung). However, over the past five years there has been a small decline in the percentage of households with finished floors, 88 percent in 2003, compared with 86 percent in 2008 (GSS and ORC Macro, 2004). Rural households are much more likely to have cement floors (65 percent) than urban households (56 percent). The second most common flooring material in rural areas is earth and sand (22 percent). About 16 percent of urban households have linoleum floors and 18 percent have carpeted floors. The number of rooms used for sleeping provides an indication of the extent of crowding in households. Overcrowding increases the risk of contracting infectious diseases like acute respiratory infections and skin diseases, which particularly affect children. In the 2008 GDHS, only 15 percent of households had three or more rooms for sleeping; most (60 percent) had one room. Households in rural areas are more likely than those in urban areas to have three or more rooms for sleeping (17 and 12 percent, respectively). Four in ten households (40 percent) do their cooking inside their house, 19 percent cook in a separate building, and 38 percent cook outdoors. This pattern was observed in both urban and rural areas. The majority of households use solid fuels (primarily wood and charcoal) for cooking in Ghana (83 percent). While in rural areas three in four households (75 percent) use wood for cooking, only 14 percent of urban households use wood. More than one in two urban households (56 percent) and nearly one-fifth of rural households (19 percent) use charcoal. Liquefied petroleum gas (LPG) or natural gas is used more commonly by urban households (24 percent) than rural households (3 percent). Few households use electricity for cooking (1 percent), even in urban areas, presumably because of the higher cost. The 2008 GDHS results indicate that all (100 percent) households that use solid fuel for cooking do so without a chimney or hood, and there is no marked difference between urban and rural areas. A closed fire or stove with a chimney is used by less than 1 percent of households in Ghana. 2.5 HOUSEHOLD DURABLE GOODS Information was collected in the 2008 GDHS on the availability of household durable goods such as household effects, means of transportation, and ownership of agricultural land and farm animals. Table 2.10 shows that 74 percent of households own a radio, 57 percent own a mobile telephone, 43 percent own a television, and 26 percent own a refrigerator. Urban households are much more likely than rural households to own these goods. For instance, 79 percent of urban households own a radio, compared with 69 percent of rural households. Mobile telephones are available in 78 percent of households in urban areas and 37 percent of rural households. While 67 percent of urban households have a television, only 21 percent of households in rural areas have a television. Twenty-six percent of households have a bicycle; this means of transportation is more common in the rural areas than in urban areas (31 and 20 percent, respectively). Urban households are four times more likely than rural households to own a car or truck (12 and 3 percent, respectively). Household Population and Housing Characteristics | 27 Table 2.10 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land and livestock/farm animals, by residence, Ghana 2008 Possession Households Population Urban Rural Total Urban Rural Total Household effects Radio 79.4 68.6 73.7 80.9 70.3 74.9 Television 67.1 20.7 42.9 69.1 20.0 41.5 Mobile telephone 78.4 37.3 57.0 80.4 37.6 56.3 Non-mobile telephone 6.5 0.6 3.4 7.2 0.7 3.5 Refrigerator 43.6 9.1 25.6 46.5 8.9 25.3 Means of transport Bicycle 19.7 31.2 25.7 25.2 39.7 33.4 Animal drawn cart 0.5 1.3 0.9 0.6 2.0 1.4 Motorcycle/scooter 4.7 4.4 4.5 6.0 6.0 6.0 Car/truck 11.9 2.5 7.0 14.0 2.9 7.7 Boat with a motor 0.2 0.8 0.5 0.3 1.1 0.7 Ownership of agricultural land 23.4 66.7 46.0 28.1 73.1 53.4 Ownership of farm animals1 21.0 57.9 40.3 27.8 68.3 50.6 Number 5,627 6,150 11,777 19,262 24,818 44,080 1 Cattle, milk cows, bulls, horses, donkeys, mules, goats, sheep, pigs, rabbits, grasscutter, chickens, or other poultry Nearly half of households (46 percent) own agricultural land and 40 percent have farm animals. Table 2.10 shows that rural households are almost three times as likely to own agricultural land as urban households (67 and 23 percent, respectively). Similarly, 58 percent of rural households own farm animals, compared with only 21 percent of urban households. 2.6 WEALTH QUINTILES Using the wealth quintile index, the fifth round DHS survey (2008 GDHS) and the 2003 GDHS were able to provide information on the wealth status of Ghanaian households. Wealth quintiles provide a consistent measure of combined indicators of household income and expenditures that was not available during the first three DHS surveys in Ghana. The wealth quintile, as constructed, used information on household ownership of consumer items, ranging from a television to a bicycle or car, as well as dwelling characteristics, such as source of drinking water, sanitation facilities, and type of flooring material. Each asset was assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores were standardised in relation to a normal distribution with a mean of zero and standard deviation of one. Each household was then assigned a score for each asset, and the scores were summed for each household; individuals were ranked according to the total score of the household in which they resided. The sample was then divided into quintiles from one (lowest) to five (highest). A single asset index was developed for the whole sample; separate indices were not prepared for the urban and rural populations. The 2008 GDHS provides an opportunity to examine the distribution of Ghana’s population by household wealth status. Table 2.11 shows the percent distribution of the de jure population by wealth quintiles, according to residence and region. Seventy-four percent of the urban population is in the two highest wealth quintiles, compared with only 14 percent of the rural population. The rural population predominates in the two lowest quintiles. The regional distribution shows that Greater Accra is the richest region, with 64 percent of the population in the highest quintile, whilst the Upper West region has less than 4 percent of its population in the highest quintile. Residents of the three northern regions are most likely to be in the lowest wealth quintile. 28 | Household Population and Housing Characteristics Table 2.11 Wealth quintiles Percent distribution of the jure population by wealth quintiles, according to residence and region, Ghana 2008 Residence/ region Wealth quintile Total Number of population Lowest Second Middle Fourth Highest Residence Urban 1.9 5.6 19.1 32.3 41.2 100.0 19,262 Rural 34.0 31.2 20.7 10.5 3.6 100.0 24,818 Region Western 9.0 26.9 22.3 21.0 20.8 100.0 4,186 Central 3.2 28.1 31.1 24.3 13.3 100.0 4,234 Greater Accra 0.6 2.5 8.0 25.2 63.7 100.0 6,338 Volta 19.2 27.9 29.3 16.0 7.6 100.0 4,006 Eastern 12.7 26.9 27.2 22.6 10.6 100.0 4,437 Ashanti 6.2 20.1 23.0 27.0 23.7 100.0 8,021 Brong Ahafo 25.2 24.0 22.9 21.3 6.6 100.0 4,100 Northern 58.6 17.1 12.5 7.6 4.2 100.0 4,948 Upper East 71.6 12.5 4.7 5.2 6.0 100.0 2,613 Upper West 52.7 21.8 12.3 9.9 3.4 100.0 1,196 Total 20.0 20.0 20.0 20.0 20.0 100.0 44,080 2.7 BIRTH REGISTRATION The Convention on the Right of the Child (UN General Assembly, 1989) states that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. Parents are required to give their children a name and to register the child because the child has a right to know who his or her parents are and to have a nationality through registration in accordance with national laws and relevant international instruments. Table 2.12 shows the percentage of children under five whose births were officially registered and the percentage with a birth certificate at the time of the survey. Not all children reported as registered had a birth certificate at the time of the survey because some certificates may have been lost or were never issued. However, all children with a certificate had been registered. The births of 71 percent of children under five in Ghana have been registered; 55 percent have birth certificates and 16 percent do not. There is no substantial variation in birth registration by sex of child. There were, however, marked differences by urban-rural residence. While 82 percent of children under five in urban areas have had their births registered, only 65 percent of their rural counterparts have been registered. The distribution of children whose births are registered varies by region. Children in the Greater Accra region are more likely to be registered (85 percent) than children in all other regions. Central, Eastern, and Brong Ahafo regions each have more than 20 percent of children who have had their births registered but do not have a birth certificate. The Volta region has the lowest level of birth registration (58 percent). Households in the highest wealth quintile (88 percent) are much more likely to have a birth registered than those in the lowest wealth quintile (60 percent). Household Population and Housing Characteristics | 29 Table 2.12 Birth registration of children under age five Percentage of de jure children under five years whose births are registered with the civil authorities, according to background characteristics, Ghana 2008 Background characteristic Percentage of children whose births are registered Number of children Has birth certificate Does not have a birth certificate Total registered Age <2 51.7 18.7 70.4 2,243 2-4 57.5 14.3 71.8 3,589 Sex Male 56.2 16.0 72.2 2,972 Female 54.3 16.0 70.2 2,859 Residence Urban 71.5 10.3 81.8 2,242 Rural 45.1 19.5 64.6 3,590 Region Western 52.9 12.5 65.4 535 Central 44.6 22.0 66.6 576 Greater Accra 76.2 8.8 85.1 684 Volta 51.3 6.7 58.0 478 Eastern 48.0 28.1 76.1 521 Ashanti 57.9 16.9 74.8 1,059 Brong Ahafo 51.1 20.5 71.7 615 Northern 47.8 16.8 64.6 882 Upper East 69.1 8.8 77.9 317 Upper West 59.3 11.2 70.4 166 Wealth quintile Lowest 40.3 19.2 59.5 1,433 Second 45.8 17.7 63.5 1,272 Middle 54.2 18.2 72.4 1,130 Fourth 67.1 13.8 80.9 1,119 Highest 79.7 8.1 87.8 877 Total 55.3 16.0 71.2 5,832 Characteristics of Survey Respondents | 31 CHARACTERISTICS OF SURVEY RESPONDENTS 3 The purpose of this chapter is to provide a descriptive summary of the demographic and socio-economic profile of respondents in the 2008 GDHS. The basic information on women and men in the reproductive age group is crucial for the interpretation of the 2008 GDHS finding within the context of reproduction, health, and women’s status. The percent distribution of respondents by the various demographic and socio-economic characteristics can also be used as an approximate indicator of the representativeness of the survey sample to the general population. The main background characteristics described in detail that will be used in subsequent chapters on reproduction and health are: age at the time of the survey, marital status, residence, education, and wealth quintile. This chapter also includes information on literacy, exposure to mass media, employment and earnings, health insurance coverage, knowledge and attitudes concerning tuberculosis, and use of tobacco and alcohol. 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Table 3.1 shows the distribution of women age 15-49 and men age 15-49 by selected background characteristics including age, marital status, urban-rural residence, region, education, religion, ethnicity, and wealth status. The age distribution shows that more than half of women (56 percent) and men (55 percent) are under age 30. The proportion of respondents in each age group generally decreases as age increases reflecting the comparatively young age structure of the Ghanaian population. The results of the 2008 GDHS indicate that 59 percent of women are married or in union (living in an informal arrangement with a partner), compared with 48 percent of men. Because men marry later in life than women, almost half of the men interviewed in the survey (48 percent) have never married, compared with about one-third (32 percent) of women. On other hand, women are more likely than men to be widowed, divorced, or separated (9 and 4 percent, respectively) The distribution of respondents by urban-rural residence shows that over half of women (52 percent) and men (54 percent) live in the rural areas. The distribution by region shows that about one in five respondents are from the Ashanti region, one in six are from Greater Accra, and about one in ten are from the Western, Central, Eastern, Northern, Volta, and Brong Ahafo regions. The regions with smallest proportion of respondents are the Upper East and Upper West regions. Men are more likely than women to have received education at every level of schooling. About one in five women and one in six men have only primary education, while 17 percent of women and 29 percent of men have secondary or higher education. Twenty-one percent of women and 13 percent of men have no education. The majority of respondents are Christians: 78 percent of women and 72 percent of men. Fifteen percent of women and 17 percent of men are Muslims. As expected, Akan is the largest ethnic group, with 51 percent of women and 47 percent of men, followed by the Mole-Dagbani, who make up 16 percent of women and 17 percent of men, and the Ewe, with 13 percent of women and 15 percent of men. 32 | Characteristics of Survey Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Ghana 2008 Background characteristic Women Men Weighted percentage Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 20.8 1,025 1,037 22.4 911 942 20-24 17.9 878 869 17.4 704 706 25-29 16.9 832 817 15.4 624 608 30-34 13.1 644 636 13.1 533 524 35-39 13.0 638 637 13.0 528 511 40-44 9.6 470 485 9.7 394 393 45-49 8.7 429 435 9.0 364 366 Marital status Never married 32.4 1,593 1,546 47.7 1,936 1,934 Married 45.4 2,232 2,361 42.5 1,724 1,752 Living together 13.1 644 589 5.6 226 206 Divorced/separated 7.0 345 316 3.9 157 142 Widowed 2.1 101 104 0.4 15 16 Residence Urban 48.5 2,383 2,162 46.0 1,866 1,696 Rural 51.5 2,533 2,754 54.0 2,191 2,354 Region Western 9.1 447 438 9.9 403 382 Central 8.6 424 334 8.0 326 249 Greater Accra 17.3 853 692 16.0 649 531 Volta 8.8 431 433 9.2 373 367 Eastern 9.8 483 479 10.1 411 394 Ashanti 20.6 1,011 815 19.4 785 621 Brong Ahafo 8.7 425 403 8.5 347 324 Northern 9.5 467 497 10.7 435 472 Upper East 5.1 253 373 5.4 219 313 Upper West 2.5 122 452 2.7 108 397 Education No education 21.2 1,042 1,243 13.3 540 662 Primary 20.1 988 999 15.3 619 677 Middle/JSS 41.5 2,039 1,893 42.4 1,721 1,616 Secondary + 17.2 844 777 28.8 1,167 1,085 Missing 0.1 4 4 0.3 11 10 Religion Catholic 12.4 610 733 13.1 530 593 Anglican/Methodist/Presbyterian 16.9 829 723 16.6 672 589 Pentecostal/Charismatic 37.2 1,827 1,696 29.1 1,179 1,082 Other Christian 11.1 544 478 13.5 548 484 Moslem 15.0 738 832 17.0 691 780 Traditional/spiritualist 4.2 205 266 5.3 215 291 No religion 3.1 153 178 5.2 211 216 Other/missing 0.1 9 10 0.3 12 15 Ethnicity Akan 50.7 2,493 2,136 47.2 1,915 1,619 Ga/Dangme 7.0 343 309 6.2 253 225 Ewe 12.9 633 637 14.7 597 580 Guan 2.5 122 117 2.3 94 97 Mole-Dagbani 16.2 795 1,071 16.9 685 982 Grussi 2.4 118 226 2.6 104 133 Gruma 3.7 184 202 5.1 205 223 Mande 0.6 29 28 0.5 20 19 Other 4.0 197 188 4.5 182 168 Missing 0.0 1 2 0.1 3 4 Wealth quintile Lowest 15.9 783 1,089 17.5 708 953 Second 18.3 900 921 18.2 738 777 Middle 19.9 979 897 17.2 699 654 Fourth 22.8 1,119 1,024 24.0 974 867 Highest 23.1 1,135 985 23.1 939 799 Total 15-49 100.0 4,916 4,916 100.0 4,058 4,050 50-59 na na na na 510 518 Total 15-59 na na na na 4,568 4,568 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable Characteristics of Survey Respondents | 33 3.2 EDUCATIONAL ATTAINMENT Education provides people with the knowledge and skills that can lead to a better quality of life. Level of education has been found to be closely associated with the health of women and children, as well as reproductive health behaviours of women and men. Tables 3.2.1 and 3.2.2 show the distribution of women and men by highest level of schooling attended or completed, and the median number of years of schooling, according to background characteristics. Twenty-one percent of women have never been to school, 15 percent have some primary education, 6 percent completed primary education, 45 percent have some secondary education, 10 percent completed secondary school, and 4 percent have attained more than secondary education. Younger persons have generally reached higher levels of schooling than older persons. The median years of schooling for women and men are 7.2 and 8.5 years, respectively. The results show that men have more education than women at all levels. For example, about twice as many men as women have completed secondary education or higher (24 percent, compared with 14 percent). Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median number of years completed, according to background characteristics, Ghana 2008 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Missing Age 15-24 10.6 13.1 6.9 52.6 14.2 2.5 0.1 100.0 7.7 1,902 15-19 7.1 13.4 8.3 62.7 8.3 0.2 0.0 100.0 7.3 1,025 20-24 14.7 12.6 5.3 40.9 21.2 5.1 0.2 100.0 8.2 878 25-29 18.9 14.7 4.7 42.7 10.3 8.7 0.0 100.0 8.2 832 30-34 28.3 15.3 5.2 38.6 8.8 3.7 0.0 100.0 6.0 644 35-39 27.5 19.1 4.7 40.1 5.4 3.1 0.1 100.0 5.6 638 40-44 33.6 14.6 4.6 38.8 5.9 2.5 0.0 100.0 5.3 470 45-49 39.0 12.6 4.0 35.7 4.7 3.7 0.2 100.0 4.6 429 Residence Urban 10.9 10.8 4.8 50.3 16.4 6.7 0.0 100.0 8.5 2,383 Rural 30.8 18.1 6.3 39.4 4.1 1.2 0.1 100.0 5.1 2,533 Region Western 13.9 17.7 6.7 47.7 10.1 3.4 0.4 100.0 7.9 447 Central 16.2 19.0 7.9 47.1 7.4 2.5 0.0 100.0 7.0 424 Greater Accra 7.7 9.3 5.4 46.5 21.8 9.4 0.0 100.0 8.8 853 Volta 22.9 16.8 7.8 40.7 9.4 2.2 0.2 100.0 6.1 431 Eastern 10.7 16.9 7.1 56.5 6.1 2.7 0.0 100.0 7.7 483 Ashanti 9.9 15.7 3.5 58.3 9.4 3.2 0.0 100.0 8.1 1,011 Brong Ahafo 24.9 11.6 8.2 47.2 6.6 1.5 0.0 100.0 6.4 425 Northern 65.7 8.0 2.7 16.3 5.1 2.1 0.0 100.0 0.0 467 Upper East 49.0 20.0 3.7 17.7 4.5 4.8 0.4 100.0 0.2 253 Upper West 48.1 21.2 2.2 22.4 4.7 1.3 0.0 100.0 0.2 122 Wealth quintile Lowest 59.6 16.9 5.2 16.7 1.4 0.1 0.1 100.0 0.0 783 Second 26.2 21.9 7.4 42.8 1.6 0.1 0.0 100.0 5.2 900 Middle 16.7 16.4 6.4 52.7 6.9 0.9 0.1 100.0 7.3 979 Fourth 10.5 13.5 5.4 55.8 11.9 2.7 0.2 100.0 8.1 1,119 Highest 5.1 6.5 3.7 47.6 23.7 13.3 0.0 100.0 9.3 1,135 Total 21.2 14.5 5.6 44.7 10.1 3.9 0.1 100.0 7.2 4,916 1 Completed 6th grade at the primary level 2 Completed 12th grade at the secondary level 34 | Characteristics of Survey Respondents As a result of the government’s intervention, girls who drop out of school because of pregnancy can now return to school after delivery and continue their education. The government’s policy has led to a marked improvement in education among girls age 15-24; whereas 16 percent of girls age 15-24 had no education in 2003 (GSS and ORC Macro, 2004), only 11 percent had no education in 2008. The results of the 2008 GDHS indicate that educational attainment among both women and men has improved substantially over time; this can be seen in the changes between age cohorts. For example, 39 percent of women in the oldest age cohort (45-49) have no education, compared with 7 percent of those age 15-19; the corresponding percentages for men are 23 and 5 percent, respectively. There is also a marked difference in educational attainment by rural-urban residence. Thirty- one percent of women and 20 percent of men in rural areas have no education, compared with 11 percent of women and 6 percent of men in urban areas. Among regions, the Greater Accra region has by far the largest proportion of women and men who have completed secondary school. Educational attainment is lowest for both women and men in the Northern, Upper East, and Upper West regions. As expected, level of education increases with wealth quintile. Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median number of years completed, according to background characteristics, Ghana 2008 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Missing Age 15-24 6.2 12.9 6.5 53.5 16.7 3.9 0.3 100.0 8.1 1,615 15-19 4.8 16.4 8.8 62.3 7.0 0.5 0.1 100.0 7.3 911 20-24 8.0 8.4 3.6 42.2 29.1 8.3 0.5 100.0 8.8 704 25-29 13.2 8.8 4.4 41.0 17.8 14.4 0.3 100.0 8.5 624 30-34 16.2 6.5 5.5 40.0 17.2 14.4 0.2 100.0 8.6 533 35-39 19.7 11.0 3.6 43.3 13.0 9.2 0.3 100.0 8.9 528 40-44 21.0 8.0 4.1 47.6 11.4 7.8 0.0 100.0 9.3 394 45-49 23.2 7.0 2.2 49.1 10.3 7.7 0.6 100.0 9.2 364 Residence Urban 5.6 6.1 3.3 48.7 23.1 12.9 0.4 100.0 9.3 1,866 Rural 19.9 13.7 6.6 46.5 8.8 4.3 0.1 100.0 7.4 2,191 Region Western 6.1 7.1 5.2 59.3 13.8 8.2 0.2 100.0 8.8 403 Central 6.6 11.9 5.8 54.5 11.0 9.9 0.3 100.0 8.5 326 Greater Accra 3.5 5.5 3.5 46.3 24.9 15.8 0.5 100.0 9.7 649 Volta 8.4 12.3 8.0 53.2 12.6 5.6 0.0 100.0 8.3 373 Eastern 2.5 6.6 7.6 65.4 11.2 6.7 0.0 100.0 8.6 411 Ashanti 6.6 9.4 3.2 56.3 19.0 5.4 0.2 100.0 8.7 785 Brong Ahafo 17.1 13.9 6.9 39.7 12.9 8.4 1.0 100.0 7.6 347 Northern 48.4 10.9 2.3 19.6 12.4 6.4 0.1 100.0 0.9 435 Upper East 34.4 21.5 7.8 22.0 7.6 6.4 0.2 100.0 3.9 219 Upper West 30.2 19.4 5.1 28.4 11.5 5.4 0.0 100.0 5.0 108 Wealth quintile Lowest 45.6 19.0 7.4 24.4 3.0 0.5 0.1 100.0 1.4 708 Second 15.1 14.6 7.1 53.3 7.9 1.6 0.3 100.0 7.4 738 Middle 7.6 10.2 6.4 58.9 12.3 4.2 0.3 100.0 8.4 699 Fourth 3.9 6.8 3.7 57.2 19.9 8.2 0.3 100.0 8.9 974 Highest 1.6 3.6 2.1 42.0 28.0 22.5 0.3 100.0 11.0 939 Total 15-49 13.3 10.2 5.1 47.5 15.4 8.3 0.3 100.0 8.5 4,058 50-59 19.4 6.2 2.0 46.8 10.7 14.5 0.3 100.0 9.4 510 Total 15-59 14.0 9.7 4.7 47.5 14.8 9.0 0.3 100.0 8.6 4,568 1 Completed 6th grade at the primary level 2 Completed 12th grade at the secondary level Characteristics of Survey Respondents | 35 3.3 LITERACY The ability to read and write is an important personal asset, allowing individuals increased opportunities in life. Knowing the distribution of the literate population can help programme managers—especially those concerned with health and family planning—know how to reach women and men with their messages. The 2008 GDHS assessed respondents’ ability to read by asking them to read a simple sentence in the local language (or in English). Only women and men who had never attended school and those who had attended only primary school or middle/JSS1 were asked to read the sentence; it was assumed that everyone with secondary or higher education was literate. Literacy was measured by whether the respondent could read none, part, or all, of the sentence. Persons who were blind or visually impaired were excluded. Tables 3.3.1 and 3.3.2 show the percent distribution of women and men age 15-49 respectively, by level of literacy, and percent literate, according to background characteristics. Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Ghana 2008 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-19 71.2 4.2 6.4 18.1 0.0 0.0 0.1 100.0 81.8 1,025 20-24 67.1 1.4 2.4 28.6 0.0 0.2 0.3 100.0 70.9 878 25-29 61.7 0.5 1.3 36.1 0.1 0.0 0.2 100.0 63.6 832 30-34 51.1 0.4 1.6 46.7 0.2 0.0 0.0 100.0 53.1 644 35-39 48.6 0.3 1.8 49.3 0.0 0.0 0.0 100.0 50.7 638 40-44 47.2 1.0 1.4 50.3 0.0 0.0 0.0 100.0 49.7 470 45-49 44.1 0.9 2.3 52.1 0.0 0.3 0.2 100.0 47.4 429 Residence Urban 73.5 1.2 2.4 22.8 0.1 0.0 0.1 100.0 77.0 2,383 Rural 44.7 1.8 3.1 50.1 0.0 0.1 0.1 100.0 49.6 2,533 Region Western 61.3 1.0 2.8 34.7 0.0 0.0 0.2 100.0 65.1 447 Central 57.0 1.1 3.9 37.8 0.0 0.2 0.0 100.0 62.0 424 Greater Accra 77.6 1.8 2.9 17.5 0.1 0.0 0.0 100.0 82.4 853 Volta 52.2 2.8 3.1 41.3 0.3 0.4 0.0 100.0 58.1 431 Eastern 65.4 1.1 4.4 29.0 0.0 0.0 0.2 100.0 70.8 483 Ashanti 70.9 0.9 1.9 26.0 0.0 0.0 0.3 100.0 73.7 1,011 Brong Ahafo 55.3 2.2 1.3 41.1 0.0 0.0 0.0 100.0 58.9 425 Northern 23.6 0.7 1.4 74.1 0.0 0.0 0.2 100.0 25.7 467 Upper East 27.0 3.6 3.8 65.7 0.0 0.0 0.0 100.0 34.3 253 Upper West 28.4 1.1 4.2 65.6 0.0 0.7 0.0 100.0 33.8 122 Wealth quintile Lowest 18.2 1.7 2.7 77.0 0.0 0.1 0.3 100.0 22.6 783 Second 44.5 1.6 3.6 50.2 0.0 0.2 0.0 100.0 49.6 900 Middle 60.4 1.1 2.6 35.6 0.1 0.0 0.1 100.0 64.2 979 Fourth 70.4 1.8 3.0 24.5 0.1 0.0 0.2 100.0 75.2 1,119 Highest 84.6 1.4 2.0 11.9 0.0 0.1 0.0 100.0 88.0 1,135 Total 58.6 1.5 2.8 36.9 0.0 0.1 0.1 100.0 62.9 4,916 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence 1 Middle/JSS (3 years) and Senior Secondary School (3 years) are the education levels used in this report, although, at the secondary level, the 3-year Senior Secondary School was changed to the 4-year Senior High School after the 2007/2008 academic year. This change did not affect the Ghana DHS data 36 | Characteristics of Survey Respondents Sixty-three percent of women and 77 percent of men are literate, while 37 percent of women and 22 percent of men cannot read at all. As in the case of educational attainment, men are more likely to be literate than women. The male-female difference is larger at older than younger ages. There is also a strong urban-rural difference in literacy for both sexes. Fifty percent of rural women are literate, compared with 77 percent of urban women. Similarly, 67 percent of rural men are literate, compared with 89 percent of urban men. Regional differences are marked. The Greater Accra region has the highest proportion of women and men who are literate, while the Northern, Upper East, and Upper West regions have the lowest proportions who are literate. In general, literacy increases with wealth quintile. Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Ghana 2008 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-19 69.8 6.1 8.0 15.9 0.1 0.0 0.0 100.0 84.0 911 20-24 79.6 1.1 3.6 15.4 0.0 0.0 0.3 100.0 84.3 704 25-29 73.3 1.2 2.1 22.3 0.3 0.1 0.8 100.0 76.6 624 30-34 71.5 0.9 2.6 24.7 0.0 0.0 0.2 100.0 75.1 533 35-39 65.5 0.4 3.2 30.7 0.0 0.0 0.3 100.0 69.0 528 40-44 66.8 0.4 2.6 29.6 0.6 0.0 0.0 100.0 69.8 394 45-49 67.1 1.3 0.9 29.5 0.0 0.7 0.6 100.0 69.3 364 Residence Urban 84.7 1.6 2.5 10.6 0.2 0.0 0.5 100.0 88.8 1,866 Rural 59.7 2.5 5.0 32.5 0.1 0.1 0.1 100.0 67.1 2,191 Region Western 81.4 0.5 1.9 15.8 0.4 0.0 0.0 100.0 83.8 403 Central 75.4 3.0 3.0 16.5 0.0 0.7 1.3 100.0 81.4 326 Greater Accra 87.0 2.1 3.7 6.5 0.0 0.0 0.7 100.0 92.8 649 Volta 71.3 3.2 6.5 18.8 0.0 0.2 0.0 100.0 81.0 373 Eastern 83.3 1.6 3.6 11.3 0.2 0.0 0.0 100.0 88.5 411 Ashanti 80.7 1.6 1.9 15.6 0.2 0.0 0.0 100.0 84.2 785 Brong Ahafo 61.1 2.5 6.1 30.1 0.2 0.0 0.0 100.0 69.6 347 Northern 38.3 1.6 4.4 55.4 0.0 0.0 0.3 100.0 44.3 435 Upper East 36.0 4.2 6.1 53.5 0.0 0.0 0.2 100.0 46.3 219 Upper West 45.2 2.9 6.9 44.5 0.0 0.0 0.3 100.0 55.1 108 Wealth quintile Lowest 27.9 1.7 6.7 63.4 0.1 0.1 0.1 100.0 36.2 708 Second 62.9 3.3 4.0 29.6 0.1 0.0 0.1 100.0 70.2 738 Middle 75.4 2.8 4.5 17.0 0.2 0.0 0.0 100.0 82.8 699 Fourth 85.3 1.5 3.3 9.0 0.2 0.2 0.4 100.0 90.2 974 Highest 92.5 1.4 1.7 3.8 0.0 0.0 0.7 100.0 95.5 939 Total 15-49 71.2 2.1 3.9 22.4 0.1 0.1 0.3 100.0 77.1 4,058 50-59 72.1 0.5 1.5 25.1 0.4 0.0 0.4 100.0 74.1 510 Total 15-59 71.3 1.9 3.6 22.7 0.1 0.1 0.3 100.0 76.8 4,568 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence Characteristics of Survey Respondents | 37 3.4 ACCESS TO MASS MEDIA Access to information is essential in increasing people’s knowledge and awareness of what is taking place around them. In the 2008 GDHS, information was collected on respondents’ exposure to print and broadcast media, both of which are effective in reaching the population with important health messages such as those on reproductive health and HIV/AIDS. In the survey, exposure to media was assessed by asking how often a respondent reads a newspaper, watches television, or listens to the radio. Tables 3.4.1 and 3.4.2 show that exposure of women and men to print and broadcast media in Ghana is high, although men are more likely to have access to the media than women. Seventy-six percent of women and 88 percent of men listen to the radio at least once a week, and a high proportion of women and men watch television. For example, 54 percent of women and 61 percent of men watch television at least once a week. Twice as many women (17 percent) as men (8 percent) have no access to the media. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Ghana 2008 Background characteristic At least once a week Not exposed to any media Number of women Reads the newspaper Watches television Listens to the radio Exposed to all three media Age 15-19 25.6 62.1 73.9 19.4 15.2 1,025 20-24 18.8 61.1 79.5 14.4 12.7 878 25-29 14.0 57.3 77.9 10.5 15.4 832 30-34 8.7 52.8 76.4 7.6 17.8 644 35-39 8.3 45.0 76.9 7.6 19.4 638 40-44 9.4 42.4 76.7 8.0 19.3 470 45-49 7.5 41.7 72.6 6.0 22.3 429 Residence Urban 23.3 73.9 81.3 19.6 9.2 2,383 Rural 6.9 35.3 71.9 4.3 23.7 2,533 Region Western 23.9 56.9 89.6 18.3 7.0 447 Central 10.6 52.0 70.9 8.6 19.8 424 Greater Accra 27.6 80.8 80.5 23.5 8.0 853 Volta 20.4 41.4 79.3 12.8 15.1 431 Eastern 9.9 57.7 88.1 7.6 8.0 483 Ashanti 11.2 58.5 75.7 9.1 15.8 1,011 Brong Ahafo 5.3 41.9 80.8 3.6 15.5 425 Northern 7.0 33.2 55.9 5.6 38.4 467 Upper East 10.5 30.6 61.0 9.6 36.0 253 Upper West 9.5 27.4 63.9 5.0 29.9 122 Education No education 0.4 24.1 59.7 0.1 34.9 1,042 Primary 2.0 43.7 73.2 1.2 19.8 988 Middle/JSS 13.2 61.3 81.4 9.8 11.9 2,039 Secondary+ 51.9 85.4 88.9 42.9 2.2 844 Wealth quintile Lowest 3.2 12.3 56.0 1.5 41.4 783 Second 4.6 28.4 71.3 2.2 24.5 900 Middle 9.8 49.3 81.7 6.5 12.8 979 Fourth 17.7 71.6 80.9 13.8 9.3 1,119 Highest 32.6 89.8 85.7 28.6 4.0 1,135 Total 14.8 54.0 76.4 11.7 16.7 4,916 Note: Total includes women with information missing on education who are not shown separately. 38 | Characteristics of Survey Respondents Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Ghana 2008 Background characteristic At least once a week Not exposed to any media Number of men Reads the newspaper Watches television Listens to the radio Exposed to all three media Age 15-19 20.5 62.8 83.7 16.0 10.2 911 20-24 32.1 67.7 87.8 26.2 8.1 704 25-29 27.9 65.8 90.4 23.7 4.4 624 30-34 27.9 63.2 91.3 25.0 6.6 533 35-39 23.8 58.2 89.9 20.3 7.6 528 40-44 27.4 52.5 91.0 24.0 8.2 394 45-49 20.8 48.0 87.2 16.9 9.6 364 Residence Urban 40.8 85.1 91.2 36.2 3.1 1,866 Rural 12.9 40.9 85.8 9.1 12.0 2,191 Region Western 27.7 63.5 94.4 22.3 3.0 403 Central 16.6 71.3 91.7 14.3 5.4 326 Greater Accra 48.9 88.1 90.6 43.2 2.5 649 Volta 26.4 44.9 91.9 19.3 6.1 373 Eastern 25.5 59.0 93.0 20.7 5.2 411 Ashanti 22.1 70.7 91.3 20.2 4.3 785 Brong Ahafo 19.2 52.8 88.7 15.4 8.5 347 Northern 17.2 39.2 75.2 12.8 20.6 435 Upper East 12.9 27.1 67.9 9.5 28.6 219 Upper West 13.6 42.0 81.6 10.2 13.7 108 Education No education 0.6 23.3 74.0 0.6 24.3 540 Primary 4.2 44.7 82.1 2.6 13.5 619 Middle/JSS 17.6 63.8 91.5 14.1 4.8 1,721 Secondary+ 60.9 83.9 93.5 52.5 1.8 1,167 Wealth quintile Lowest 5.1 14.7 75.4 1.6 22.8 708 Second 9.9 34.6 86.4 5.9 10.6 738 Middle 18.1 57.7 90.9 13.4 7.0 699 Fourth 31.8 85.1 93.1 27.4 2.0 974 Highest 53.2 95.1 92.4 48.9 1.3 939 Total 15-49 25.8 61.2 88.3 21.5 7.9 4,058 50-59 36.1 52.9 89.4 28.1 7.8 510 Total 15-59 26.9 60.3 88.4 22.3 7.9 4,568 Note: Total includes men with information missing on education who are not shown separately. Characteristics of Survey Respondents | 39 Media exposure is higher among younger women (15-19) than older women (45-49). However, among men, exposure is lowest among those age 15-19 and highest among those age 20-24. Men and women in urban areas are about four times more likely to be exposed to mass media than those in rural areas. Likewise, residents in the Greater Accra region (24 percent of women and 43 percent of men) are more likely to be exposed to all three media than those in the other nine regions. Exposure to mass media is positively associated with level of education and household wealth status; the proportion exposed to all three media increases with level of education and wealth quintile. Exposure to all three media changed little over the five-year period between 2003 and 2008 for both women and men (GSS and ORC Macro, 2004). 3.5 EMPLOYMENT Male and female respondents age 15 and older were asked whether they were employed at the time of the survey and, if not, whether they were employed in the 12 months preceding the survey. The measurement of employment, however, is difficult because some work, especially work on family farms, in family businesses, or in the informal sector, is often not perceived as employment and hence not reported as such. To avoid underestimating respondent’s employment, the DHS questionnaire asks respondents several questions to probe for their employment status and to ensure complete coverage of employment in both the formal and informal sectors. Respondents are asked a number of questions to elicit their current employment status and continuity of employment in the 12 months before the survey. Respondents are considered “employed” if they are currently working (i.e. worked in the past seven days) or if they worked at any time during the 12 months preceding the survey. Tables 3.5.1 and 3.5.2 show the percent distribution of women and men age 15-49 by employment status, according to background characteristics. Overall, 75 percent of women and 78 percent of men age 15-49 are currently employed and 3 percent of women and men were employed during the past year but are not currently employed (Figure 3.1). Current employment increases with age and number of living children for both women and men. The low level of current employment among younger women and men is related to the majority being still in school. Women and men who have never married are less likely to be currently employed than those who are currently married, divorced, separated, or widowed. Women and men in rural areas are more likely to be currently employed than those living in urban areas. 40 | Characteristics of Survey Respondents Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Ghana 2008 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Age 15-19 32.7 3.1 64.2 100.0 1,025 20-24 70.0 4.1 25.9 100.0 878 25-29 85.1 4.4 10.5 100.0 832 30-34 90.3 2.0 7.6 100.0 644 35-39 94.1 2.0 3.9 100.0 638 40-44 93.0 1.9 5.1 100.0 470 45-49 92.8 1.9 5.2 100.0 429 Marital status Never married 45.7 3.9 50.5 100.0 1,593 Married or living together 88.5 2.8 8.8 100.0 2,876 Divorced/separated/widowed 90.4 1.3 8.4 100.0 446 Number of living children 0 47.8 3.9 48.3 100.0 1,691 1-2 84.5 3.3 12.3 100.0 1,447 3-4 92.3 1.9 5.8 100.0 1,050 5+ 92.8 1.9 5.3 100.0 729 Residence Urban 70.5 3.3 26.1 100.0 2,383 Rural 78.8 2.7 18.6 100.0 2,533 Region Western 76.7 1.7 21.6 100.0 447 Central 76.6 1.5 21.9 100.0 424 Greater Accra 66.9 3.9 29.1 100.0 853 Volta 79.7 5.4 14.9 100.0 431 Eastern 75.7 2.1 22.2 100.0 483 Ashanti 75.0 2.7 22.3 100.0 1,011 Brong Ahafo 76.4 1.3 22.3 100.0 425 Northern 78.1 4.7 17.2 100.0 467 Upper East 78.3 4.0 17.7 100.0 253 Upper West 67.5 1.2 31.1 100.0 122 Education No education 88.0 2.6 9.3 100.0 1,042 Primary 79.2 2.2 18.7 100.0 988 Middle/JSS 70.8 2.6 26.6 100.0 2,039 Secondary+ 62.7 5.4 31.9 100.0 844 Wealth quintile Lowest 82.4 2.4 15.2 100.0 783 Second 77.5 2.9 19.6 100.0 900 Middle 75.9 4.3 19.9 100.0 979 Fourth 74.0 1.7 24.3 100.0 1,119 Highest 67.2 3.6 29.2 100.0 1,135 Total 74.8 3.0 22.2 100.0 4,916 Note: Total includes women with information missing on education who are not shown separately. 1 Currently employed is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Characteristics of Survey Respondents | 41 Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Ghana 2008 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Currently employed1 Not currently employed Age 15-19 37.3 2.5 60.1 100.0 911 20-24 70.7 4.8 24.4 100.0 704 25-29 91.1 3.2 5.7 100.0 624 30-34 96.1 1.9 2.0 100.0 533 35-39 96.7 2.1 1.3 100.0 528 40-44 97.7 1.1 1.2 100.0 394 45-49 96.5 2.4 1.1 100.0 364 Marital status Never married 57.3 3.9 38.8 100.0 1,936 Married or living together 97.5 1.5 1.0 100.0 1,950 Divorced/separated/widowed 89.7 4.0 6.2 100.0 172 Number of living children 0 60.1 3.8 36.1 100.0 2,086 1-2 95.3 2.4 2.4 100.0 893 3-4 97.5 1.5 1.0 100.0 655 5+ 99.6 0.4 0.1 100.0 424 Residence Urban 74.2 3.7 22.1 100.0 1,866 Rural 81.2 1.9 16.9 100.0 2,191 Region Western 76.9 0.7 22.4 100.0 403 Central 74.2 4.0 21.8 100.0 326 Greater Accra 75.4 4.2 20.4 100.0 649 Volta 83.0 1.9 15.1 100.0 373 Eastern 73.6 1.7 24.7 100.0 411 Ashanti 77.4 3.8 18.8 100.0 785 Brong Ahafo 80.7 1.9 17.4 100.0 347 Northern 83.2 1.6 15.2 100.0 435 Upper East 80.5 3.9 15.6 100.0 219 Upper West 78.2 2.1 19.7 100.0 108 Education No education 96.3 1.2 2.4 100.0 540 Primary 76.5 1.5 21.9 100.0 619 Middle/JSS 76.1 2.3 21.6 100.0 1,721 Secondary+ 73.1 4.7 22.2 100.0 1,167 Wealth quintile Lowest 87.0 1.3 11.6 100.0 708 Second 78.7 1.1 20.2 100.0 738 Middle 74.3 3.4 22.3 100.0 699 Fourth 75.5 2.9 21.5 100.0 974 Highest 76.0 4.4 19.6 100.0 939 Total 15-49 78.0 2.7 19.3 100.0 4,058 50-59 93.1 2.3 4.6 100.0 510 Total 15-59 79.7 2.7 17.6 100.0 4,568 Note: Total includes men with information missing on education who are not shown separately. 1 Currently employed is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 42 | Characteristics of Survey Respondents Figure 3.1 Employment Status of Women and Men Age 15-49 GDHS 2008 Currently employed 75% Not employed in past 12 months 22% Not currently employed but worked in past 12 months 3% Not currently employed but worked in past 12 months 3%Not employed in past 12 months 19% Currently employed 78% The proportion of women currently employed ranges from 67 percent in the Greater Accra region to 80 percent in the Volta region. There is little variation in the proportion of women currently employed in other regions. Current employment is inversely related to education, falling from 88 percent among women with no education to 63 percent among women with at least secondary education. The corresponding proportions for men are 96 and 73 percent, respectively. A similar pattern is seen by wealth quintile for both women and men. 3.6 OCCUPATION Respondents who are currently employed were asked to state their occupation. Tables 3.6.1 and 3.6.2 show the percent distribution of currently employed women and men by occupation, according to background characteristics. About one-third of working women (30 percent) and two- fifths (41 percent) of men are employed in the agricultural occupations (Figure 3.2). Four times as many women (51 percent) as men (12 percent) work in sales and services. Eleven percent of employed women and 22 percent of employed men are skilled manual workers. Twice as many men (11 percent) as women (5 percent) are working in professional, technical, and managerial positions. Occupation varies by age. Among women, the proportion engaged in agriculture increases with age. For example, 20 percent of working women age 20-24 are engaged in agriculture, compared with 42 percent of women age 45-49. In contrast, the proportion of women engaged in skilled manual work decreases with age. A similar pattern is seen for men. The proportion of men engaged in agriculture increases with age, from 33 percent among men age 20-24 to 59 percent among men in the oldest age group. The proportion of men working in skilled manual work decreases with age. Characteristics of Survey Respondents | 43 A higher proportion of never-married women than ever-married women are engaged in most occupations, with the exception of agriculture. One in three (35 percent) currently married women who are working are engaged in the agricultural sector, compared with about one in four formerly married women (27 percent), and 14 percent of never-married women. Among working men, about two-fifths of those who are currently or formerly married are engaged in the agricultural sector, compared with less than one-third of never-married men. Twenty-four percent each of never-married men and formerly married men are engaged in skilled manual work, compared with 20 percent of married men. Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Ghana 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agri- culture Missing Total Number of women Age 15-19 3.2 0.9 43.7 14.8 0.4 30.3 6.8 100.0 366 20-24 8.4 2.9 51.4 16.1 0.2 19.5 1.5 100.0 651 25-29 5.8 3.5 53.8 13.5 0.0 23.0 0.3 100.0 745 30-34 3.0 1.8 55.0 11.1 0.0 28.4 0.6 100.0 595 35-39 2.8 0.4 50.7 7.4 0.2 37.7 0.8 100.0 613 40-44 2.1 1.0 52.5 5.5 0.7 36.9 1.4 100.0 446 45-49 5.6 0.4 48.3 3.6 0.0 41.7 0.4 100.0 406 Marital status Never married 9.6 4.4 50.5 17.5 0.2 13.5 4.4 100.0 789 Married or living together 3.5 1.2 50.0 9.1 0.2 35.4 0.6 100.0 2,624 Divorced/separated/widowed 2.2 0.6 61.9 8.3 0.0 26.6 0.3 100.0 409 Number of living children 0 11.1 4.9 49.1 17.1 0.3 13.6 3.8 100.0 874 1-2 3.8 1.6 57.3 13.6 0.1 22.7 0.9 100.0 1,269 3-4 2.9 0.4 54.9 6.1 0.0 35.2 0.5 100.0 989 5+ 0.5 0.1 38.2 4.1 0.4 56.3 0.4 100.0 690 Residence Urban 7.7 3.5 68.2 11.6 0.2 7.5 1.3 100.0 1,760 Rural 2.0 0.3 37.0 10.0 0.2 49.0 1.4 100.0 2,062 Region Western 4.7 3.3 49.9 9.7 0.4 31.8 0.2 100.0 351 Central 4.7 0.6 51.9 8.7 0.0 33.1 1.1 100.0 331 Greater Accra 6.7 6.0 70.3 12.5 0.3 3.4 0.8 100.0 605 Volta 4.2 0.5 45.4 7.1 0.5 34.9 7.4 100.0 367 Eastern 3.8 1.4 60.2 11.8 0.0 22.5 0.4 100.0 375 Ashanti 5.1 1.1 57.5 12.0 0.0 24.0 0.3 100.0 785 Brong Ahafo 3.0 0.0 44.7 6.9 0.3 45.0 0.0 100.0 330 Northern 3.0 0.1 30.6 11.4 0.0 52.4 2.5 100.0 387 Upper East 5.7 0.4 28.8 13.1 0.2 51.0 0.9 100.0 208 Upper West 2.1 1.4 26.6 16.2 0.0 52.0 1.5 100.0 84 Education No education 0.0 0.1 33.6 6.7 0.0 58.5 1.0 100.0 945 Primary 0.5 0.0 54.2 11.1 0.2 33.0 0.9 100.0 803 Middle/JSS 1.0 0.3 62.1 14.2 0.1 20.7 1.7 100.0 1,496 Secondary+ 27.4 11.0 48.7 7.8 0.5 2.7 1.8 100.0 575 Wealth quintile Lowest 0.8 0.1 17.7 7.5 0.2 73.0 0.7 100.0 664 Second 0.6 0.1 35.3 8.7 0.1 54.0 1.3 100.0 723 Middle 3.8 0.2 57.5 12.3 0.0 23.7 2.4 100.0 785 Fourth 5.1 2.0 71.4 12.3 0.1 7.4 1.7 100.0 847 Highest 11.7 6.2 66.5 12.1 0.4 2.4 0.7 100.0 804 Total 4.6 1.8 51.4 10.7 0.2 29.9 1.4 100.0 3,822 Note: Total includes women with information missing on education who are not shown separately. 44 | Characteristics of Survey Respondents Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Ghana 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agri- culture Missing Total Number of men Age 15-19 2.2 4.6 7.0 23.6 2.3 43.4 16.9 100.0 363 20-24 17.2 10.1 13.7 21.2 0.8 32.5 4.5 100.0 532 25-29 11.8 9.6 15.8 25.9 2.0 32.4 2.4 100.0 588 30-34 14.1 10.8 15.0 22.6 0.4 35.2 1.9 100.0 522 35-39 11.1 8.2 12.2 23.1 0.7 42.8 2.0 100.0 522 40-44 9.2 9.0 9.2 19.3 0.8 48.5 4.0 100.0 389 45-49 10.5 7.9 8.7 11.9 0.2 58.9 1.8 100.0 360 Marital status Never married 14.0 7.1 13.0 24.0 1.9 31.2 8.8 100.0 1,185 Married or living together 10.0 9.5 12.0 20.0 0.6 46.2 1.8 100.0 1,930 Divorced/separated/widowed 9.7 14.0 9.0 23.4 0.0 41.5 2.4 100.0 161 Number of living children 0 14.2 8.4 13.7 23.4 1.8 30.9 7.6 100.0 1,333 1-2 13.2 11.0 14.3 23.7 0.7 34.9 2.1 100.0 872 3-4 8.5 8.5 10.3 20.6 0.4 49.4 2.3 100.0 648 5+ 3.6 6.3 6.0 13.1 0.2 69.0 1.7 100.0 424 Residence Urban 17.9 11.7 20.9 30.4 2.0 13.2 3.9 100.0 1,454 Rural 6.3 6.6 5.3 14.5 0.3 62.4 4.7 100.0 1,822 Region Western 14.6 8.8 11.6 25.4 0.0 37.2 2.4 100.0 313 Central 15.3 8.7 10.0 26.4 0.8 35.7 3.1 100.0 255 Greater Accra 19.8 11.7 24.9 31.7 3.1 4.3 4.5 100.0 517 Volta 10.7 6.5 7.6 15.1 0.6 44.1 15.5 100.0 316 Eastern 9.3 12.0 10.0 18.8 1.1 45.0 3.8 100.0 309 Ashanti 8.5 13.0 13.8 30.0 1.5 31.5 1.7 100.0 638 Brong Ahafo 10.9 5.9 11.2 14.6 0.0 55.9 1.5 100.0 286 Northern 6.7 3.6 5.1 9.4 0.0 72.7 2.5 100.0 369 Upper East 5.0 3.9 5.8 7.5 0.0 69.5 8.4 100.0 185 Upper West 6.3 2.1 6.3 9.8 0.7 71.2 3.6 100.0 87 Education No education 0.5 2.1 3.7 8.4 0.0 84.1 1.2 100.0 527 Primary 1.7 6.7 8.5 20.4 0.3 58.5 4.0 100.0 483 Middle/JSS 3.1 13.1 10.8 30.1 1.2 35.9 5.9 100.0 1,349 Secondary+ 35.1 7.6 21.3 17.4 1.8 12.7 4.1 100.0 908 Wealth quintile Lowest 1.2 0.9 0.8 4.9 0.0 88.5 3.7 100.0 626 Second 3.7 5.5 3.1 14.8 0.1 68.6 4.4 100.0 588 Middle 7.3 10.8 9.7 25.3 0.5 40.4 6.0 100.0 543 Fourth 14.6 13.4 20.5 28.9 1.9 15.4 5.3 100.0 764 Highest 25.7 12.0 22.3 30.7 2.1 4.6 2.6 100.0 755 Total 15-49 11.4 8.8 12.2 21.6 1.0 40.6 4.3 100.0 3,276 50-59 17.1 5.7 13.7 13.0 0.2 49.0 1.4 100.0 487 Total 15-59 12.2 8.4 12.4 20.5 0.9 41.6 4.0 100.0 3,763 Note: Total includes men with information missing on education who are not shown separately. Characteristics of Survey Respondents | 45 Figure 3.2 Occupation of Women and Men Age 15-49 GDHS 2008 Agriculture 30% Unskilled manual 1% Unskilled manual <1% Skilled manual 11% Agriculture 41% Professional/ technical/ managerial 5% Professional/ technical/ managerial 11% Sales and services 51% Clerical 9% Clerical 2% Skilled manual 22% Sales and services 12% Half of never-married women and currently married women, and two-thirds of divorced, separated, or widowed women (62 percent) are employed in sales and services, but less than 1 percent of each group of women is engaged in unskilled manual work. For both women and men, there is a direct relationship between the number of living children and agriculture as an occupation. Not surprisingly, most working women and men in rural areas are engaged in the agricultural sector, in contrast to women and men in urban areas, who are mostly engaged in sales and services and skilled manual work. Agricultural work is the predominant occupation among both women and men in the Northern, Upper West, Upper East, and Brong Ahafo regions. In contrast, the majority of working women in the Greater Accra, Eastern, and Ashanti regions are in sales and services. Among working men, the highest proportions engaged in the professional, technical and managerial work, sales and services, and skilled manual work, are in the Greater Accra and Ashanti regions. Respondents’ occupation is related to level of education. Among women and men with no education, 59 percent of women and 84 percent of men work in agriculture. In contrast, the majority of women and men with secondary or higher education are employed in non-agricultural occupations. Likewise, women and men in the lowest wealth quintile are predominantly engaged in agriculture, while those in the highest wealth quintile are mostly in sales and services or professional, technical and managerial work. 3.7 TYPE OF EMPLOYER, FORM OF EARNINGS, AND CONTINUITY OF EMPLOYMENT Tables 3.7.1 and 3.7.2 show the percent distribution of women and men age 15-49 employed in the 12 months preceding the survey by the type of earnings and employer, and continuity of employment, according to type of employment (agricultural or non-agricultural). Nearly two-thirds of respondents who work receive cash earnings while about one in five receives earnings in cash and in- kind. Fourteen percent of women and 15 percent of men are not paid at all (Figure 3.3). 46 | Characteristics of Survey Respondents Table 3.7.1 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non-agricultural), Ghana 2008 Employment characteristic Agricultural work Non- agricultural work Total Type of earnings Cash only 39.4 75.1 63.8 Cash and in-kind 34.6 11.5 18.3 In-kind only 7.3 2.6 4.0 Not paid 18.5 10.7 13.7 Missing 0.2 0.1 0.1 Total 100.0 100.0 100.0 Type of employer Employed by family member 18.5 5.0 9.0 Employed by non-family member 10.5 23.7 19.7 Self-employed 70.9 71.3 71.2 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Continuity of employment All year 63.4 87.0 79.9 Seasonal 33.5 9.3 16.5 Occasional 2.8 3.5 3.4 Missing 0.2 0.2 0.2 Total 100.0 100.0 100.0 Number of women employed during the past 12 months 1,144 2,626 3,822 Note: Total includes women with information missing on type of employment who are not shown separately. The majority of women (71 percent) are self-employed, compared with 52 percent of men. Another 9 percent of women and 11 percent of men are employed by a family member, and 20 percent of women and 37 percent of men are employed by a non-family member. Most working women (80 percent) and the majority of working men (71 percent) are employed throughout the year, and 17 and 25 percent of women and men, respectively, have seasonal jobs. Women and men are more likely to do seasonal work if they are employed in agriculture than if they are in non-agricultural occupations. Continuity of employment is more assured for women and men who are engaged in non-agricultural work. Characteristics of Survey Respondents | 47 Table 3.7.2 Type of employment: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non- agricultural), Ghana 2008 Employment characteristic Agricultural work Non- agricultural work Total Type of earnings Cash only 35.7 83.1 62.3 Cash and in-kind 33.7 8.7 18.7 In-kind only 6.4 1.8 3.7 Not paid 24.2 6.4 15.2 Missing 0.0 0.0 0.1 Total 100.0 100.0 100.0 Type of employer Employed by family member 19.4 5.1 11.2 Employed by non-family member 11.3 54.9 36.8 Self-employed 69.2 39.9 51.9 Missing 0.1 0.1 0.1 Total 100.0 100.0 100.0 Continuity of employment All year 53.8 83.1 70.5 Seasonal 43.1 11.9 25.0 Occasional 2.6 4.7 4.1 Missing 0.5 0.2 0.3 Total 100.0 100.0 100.0 Number of men employed during the last 12 months 1,329 1,806 3,276 Note: Total includes men with information missing on type of employment who are not shown separately. Figure 3.3 Type of Earnings of Employed Women and Men Age 15-49 Women Men Cash only 64% Not paid 14% Cash and in-kind 18% Not paid 15% Cash only 62% In-kind only 4% Cash and in-kind 19% In-kind only 4% Note: Total may not add to 100 due to rounding. GDHS 2008 48 | Characteristics of Survey Respondents 3.8 HEALTH INSURANCE COVERAGE The national health insurance scheme (Act 650) was passed in 2003 with the aim of making health care accessible to all. Tables 3.8.1 and 3.8.2 show the percent distribution of women and men by membership in the national or district health insurance scheme (N/DHIS) or mutual health organisation or community-based insurance scheme, according to background characteristics. Thirty- nine percent of women and 29 percent of men are covered by the N/DHIS, compared with 1 percent of women and men who are covered by the community-based and mutual health organisation insurance schemes. Health insurance through an employer is almost non-existent, with less than 1 percent of respondents covered by insurance through their employer or by privately purchased commercial insurance. A high proportion of women (60 percent) and men (70 percent) say that they are not covered by any

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