Montenegro - Multiple Indicator Cluster Survey - 2006
Publication date: 2006
Montenegro Multiple Indicator Cluster Survey 2005 Montenegro Monitoring the situation of children and women Multiple Indicator Cluster Survey 2005 M ontenegro M ultiple Indicator C luster S urvey M IC S Statistical Office of Montenegro Strategic Marketing Research Agency United Nations Children’s Fund MICS Monitoring the Situation of Children and Women MONTENEGRO MULTIPLE INDICATOR CLUSTER SURVEY 2005 FINAL REPORT STATISTICAL OFFICE OF MONTENEGRO- MONSTAT STRATEGIC MARKETING RESEARCH AGENCY UNITED NATIONS CHILDREN’S FUND 2 3 Montenegro Multiple Indicator Cluster Survey 2005 Statistical Office of Montenegro UNICEF United Nations Children’s Fund Strategic Marketing Research Agency March-November, 2007 4 Contributors to the report: Snezana Remikovic Branka Kovacevic Dragisa Bjeloglav Ivana Bjelic Oliver Petrovic The Montenegro Multiple Indicator Cluster Survey (MICS) was carried by the Statistical Office of Montenegro (MONSTAT) in collaboration with Strategic Marketing Research Agency (SMMRI). The United Nations Children’s Fund (UNICEF) provided financial and technical support. The survey has been conducted as part of the third round of MICS surveys (MICS3), carried out around the world in more than 50 countries, in 2005-2006, following the first two rounds of MICS surveys that were conducted in 1995 and the year 2000. Survey tools are based on the models and standards developed by the global MICS project, designed to collect information on the situation of children and women in countries around the world. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: Statistical Office of Montenegro (MONSTAT) and Strategic Marketing Research Agency (SMMRI). 2006. Montenegro Multiple Indicator Cluster Survey 2005, Final Report. Podgorica. 5 SUMMARY TABLE OF FINDINGS Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators Montenegro, 2005 Topic MICS Indicator Number MDG Indicator Number Indicator Value NUTRITION Nutritional status 6 4 Underweight prevalence 2.6 percent 7 Stunting prevalence 5.2 percent 8 Wasting prevalence 2.9 percent Breastfeeding 45 Timely initiation of breastfeeding 25.2 percent 15 Exclusive breastfeeding rate 19.3 percent 16 Continued breastfeeding rate at 12-15 months at 20-23 months 24.6 12.8 percent percent 17 Timely complementary feeding rate 35.3 percent 18 Frequency of complementary feeding 30.3 percent 19 Adequately fed infants 25.3 percent Low birth weight 9 Low birth weight infants 3.9 percent 10 Infants weighed at birth 96.4 percent CHILD HEALTH Immunization 25 Tuberculosis immunization coverage 87.6 percent 26 Polio immunization coverage 85.8 percent 27 DPT immunization coverage 88.6 percent 28 15 Measles immunization coverage 78.3 percent 31 Fully immunized children 55.6 percent Care of illness 33 Use of oral rehydration therapy (ORT) 98.1 percent 34 Home management of diarrhoea 14.8 percent 35 Received ORT or increased fluids, and continued feeding 64.3 percent 23 Care seeking for suspected pneumonia 89.4 percent 22 Antibiotic treatment of suspected pneumonia 56.6 percent Solid fuel use 24 29 Solid fuels 31.8 percent ENVIRONMENT Water and Sanitation 11 30 Use of improved drinking water sources 98.3 percent 13 Water treatment 5.7 percent 12 31 Use of improved sanitation facilities 99.0 percent 14 Disposal of child's faeces 37.0 percent Security of tenure and durability of housing 93 Security of tenure 21.5 percent 94 Durability of housing 1.9 percent 95 32 Slum household 30.0 percent 6 Topic MICS Indicator Number MDG Indicator Number Indicator Value REPRODUCTIVE HEALTH Contraception and unmet need 21 19c Contraceptive prevalence 39.4 percent 98 Unmet need for family planning 26.4 percent 99 Demand satisfied for family planning 59.8 percent Maternal and newborn health 20 Antenatal care 97.4 percent 44 Content of antenatal care Blood test taken 89.4 percent Blood pressure measured 81.7 percent Urine specimen taken 90.2 percent Weight measured 68.6 percent 4 17 Skilled attendant at delivery 98.8 percent 5 Institutional deliveries 99.5 percent CHILD DEVELOPMENT Child development 46 Support for learning 88.9 percent 47 Father's support for learning 77.7 percent 48 Support for learning: children’s books 76.9 percent 49 Support for learning: non-children’s books 79.2 percent 50 Support for learning: materials for play 13.6 percent 51 Non-adult care 6.3 percent EDUCATION Education 52 Pre-school attendance 29.1 percent 53 School readiness 64.1 percent 54 Net intake rate in primary education 93.6 percent 55 6 Net primary school attendance rate 97.5 percent 56 Net secondary school attendance rate 84.3 percent 57 7 Children reaching grade five 97.2 percent 58 Transition rate to secondary school 98.0 percent 59 7b Primary completion rate 91.1 percent 61 9 Gender parity index primary school secondary school 1.01 1.01 ratio ratio Literacy 60 8 Adult literacy rate 93.4 percent CHILD PROTECTION Birth registration 62 Birth registration 97.9 percent Child labour 71 Child labour 9.9 percent 72 Labourer students 87.1 percent 73 Student labourers 9.8 percent Child discipline 74 Child discipline Any psychological/physical punishment 61.4 percent Early marriage 67 Marriage before age 15 Marriage before age 18 0.2 6.8 percent percent 68 Young women aged 15-19 currently married/in union 1.9 percent 69 Spousal age difference Women aged 15-191 Women aged 20-24 * 17.4 percent percent Domestic violence 100 Attitudes towards domestic violence 10.9 percent Disability 101 Child disability 12.5 percent 1 7 cases with “Women aged 15-19” not shown 7 Topic MICS Indicator Number MDG Indicator Number Indicator Value HIV/AIDS, SEXUAL BEHAVIOUR HIV/AIDS knowledge and attitudes 82 19b Comprehensive knowledge about HIV prevention among young people 29.8 percent 89 Knowledge of mother- to-child transmission of HIV 65.1 percent 86 Attitude towards people with HIV/AIDS 31.3 percent 87 Women who know where to be tested for HIV 70.1 percent 88 Women who have been tested for HIV 3.0 percent 90 Counselling coverage for the prevention of mother- to-child transmission of HIV 10.7 percent 91 Testing coverage for the prevention of mother-to- child transmission of HIV 1.8 percent Sexual behaviour 84 Age at first sex among young people 0.4 percent 92 Age-mixing among sexual partners 12.5 percent 83 19a Condom use with non-regular partners 66.4 percent 85 Higher risk sex in the last year 45.4 percent 8 TABLE OF CONTENTS Summary Table of Findings . 5 Table of Contents . 8 List of Tables . 10 List of Figures . 12 List of Abbreviations . 13 Acknowledgements . 14 Executive Summary . 15 I. Introduction Background . 20 Survey Objectives . 21 II. Sample and Survey Methodology Sample Design . 22 Questionnaires . 22 Training and Fieldwork . 23 Data Processing . 24 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage . 25 Characteristics of Households . 25 Characteristics of Respondents . 27 IV. Nutrition Nutritional Status . 28 Breastfeeding . 30 Low Birth Weight . 32 V. Child Health Immunization . 34 Oral Rehydration Treatment . 35 Care Seeking and Antibiotic Treatment of Pneumonia . 36 Solid Fuel Use . 37 VII. Environment Water and Sanitation. 39 Security of Tenure and Durability of Housing . 41 VIII. Reproductive Health Contraception . 44 Unmet Need . 44 Antenatal Care . 45 Assistance at Delivery . 46 IX. Child Development . 48 X. Education Pre-School Attendance and School Readiness . 50 Primary and Secondary School Participation . 50 Adult Literacy . 52 9 XI. Child Protection Birth Registration . 53 Child Labour . 53 Child Discipline . 54 Early Marriage . 54 Domestic Violence . 56 Child Disability . 57 XII. HIV/AIDS, Sexual Behaviour Knowledge of HIV Transmission and Condom Use . 58 Sexual Behaviour Related to HIV Transmission . 61 List of References . 63 Appendix A. Sample Design . 64 Appendix B. List of Personnel Involved in the Survey . 69 Appendix C. Estimates of Sampling Errors . 70 Appendix D. Data Quality Tables . 78 Appendix E. MICS Indicators: Numerators and Denominators . 86 Appendix F. Questionnaires . 93 MICS Tables . 126 10 LIST OF TABLES Table HH.1: Results of household and individual interviews . 126 Table HH.2: Household age distribution by sex . 127 Table HH.3: Household composition . 128 Table HH.4: Women's background characteristics . 129 Table HH.5: Children's background characteristics . 130 Table NU.1: Child malnourishment . 131 Table NU.2: Initial breastfeeding . 132 Table NU.3: Breastfeeding . 133 Table NU.4: Adequately fed infants . 134 Table NU.5: Low birth weight infants . 135 Table CH.1: Vaccinations in first year of life . 136 Table CH.2: Vaccinations by background characteristics . 137 Table CH.3: Oral rehydration treatment . 138 Table CH.4: Home management of diarrhoea . 139 Table CH.4A: Knowledge of the two danger signs of pneumonia . 140 Table CH.5: Solid fuel use . 141 Table CH.6: Solid fuel use by type of stove or fire . 142 Table EN.1: Use of improved water sources . 143 Table EN.2: Household water treatment . 144 Table EN.3: Time to source of water . 145 Table EN.4: Person collecting water . 146 Table EN.5: Use of sanitary means of excreta disposal . 147 Table EN.6: Disposal of child's faeces . 148 Table EN.7: Use of improved water sources and improved sanitation . 149 Table EN.8: Security of tenure . 150 Table EN.9: Durability of Housing. 151 Table EN.10: Slum housing . 152 Table RH.1: Use of contraception . 153 Table RH.2: Unmet need for contraception . 154 Table RH.3: Antenatal care provider . 155 Table RH.4: Antenatal care . 156 Table RH.5: Assistance during delivery . 157 Table CD.1: Family support for learning . 158 Table CD.2: Learning materials . 159 Table CD.3: Children left alone or with other children . 160 Table ED.1: Early childhood education . 161 Table ED.2: Primary school entry . 162 Table ED.3: Primary school net attendance ratio . 163 Table ED.4: Secondary school net attendance ratio . 164 Table ED 4W Secondary school age children attending primary school . 165 Table ED.5: Children reaching grade 5. 166 Table ED.6: Primary school completion and transition to secondary education. 167 Table ED.7: Education gender parity . 168 Table ED.8: Adult literacy . 169 Table CP.1: Birth registration . 170 Table CP.2: Child labour . 171 Table CP.3: Labourer students and student labourers . 172 Table CP.4: Child discipline . 173 Table CP.5: Early marriage . 174 Table CP.6: Spousal age difference . 175 11 Table CP.7: Attitudes toward domestic violence . 176 Table CP.8: Child disability . 177 Table HA.1: Knowledge of preventing HIV transmission . 178 Table HA.2: Identifying misconceptions about HIV/AIDS . 179 Table HA.3: Comprehensive knowledge of HIV/AIDS transmission. 180 Table HA.4: Knowledge of mother-to-child HIV transmission . 181 Table HA.5: Attitudes toward people living with HIV/AIDS . 182 Table HA.6: Knowledge of a facility for HIV testing . 183 Table HA.7: HIV testing and counselling coverage during antenatal care . 184 Table HA.8: Sexual behaviour that increases risk of HIV infection . 185 Table HA.9: Condom use at last high-risk sex . 186 12 LIST OF FIGURES Figure HH.1: Age and sex distribution of household population . 26 Figure NU.1: Percentage of children under-5 who are undernourished. 29 Figure NU.2: Percentage of mothers who started breastfeeding within hour and within one day of birth . 31 Figure NU.3: Percentage of infants weighing less than 2500 grams at birth . 33 Figure CH.1: Percentage of children aged 18-29 months who received the recommended vaccination by 12 months (by 18 months in case of MMR) . 35 Figure EN.1: Percentage distribution of household members by source of drinking water . 40 Figure HA.1: Percent of women who have comprehensive knowledge of HIV/AIDS transmission . 60 Figure HA.2: Sexual behaviour that increases risk of HIV infection . 62 13 LIST OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome BCG Bacillis-Cereus-Geuerin (Tuberculosis) CSPro Census and Survey Processing System DPT Diphtheria Pertussis Tetanus EPI Expanded Programme on Immunization GPI Gender Parity Index HIV Human Immunodeficiency Virus IPV Inactivated Polio Vaccine IUD Intrauterine Device LAM Lactational Amenorrhea Method MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MMR Measles, Mumps, and Rubella MoH Ministry of Health NAR Net Attendance Rate ORT Oral rehydration treatment SPSS Statistical Package for Social Sciences SRSWoR Simple Random Sample Without Replacement STI Sexually Transmitted Infection UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit For Children WHO World Health Organization 14 ACKNOWLEDGEMENTS The Montenegro 2005 Multiple Indicator Cluster Survey publication provides key data on the status of children and women in Montenegro. The data enable evaluation of policies and programmes in the period between this and previous surveys, identification of priority problems and estimation of the degree to which Montenegro managed to achieve the goals of “A World Fit for Children”, the Millennium Development Goals and other major international commitments. The Montenegro 2005 Multiple Indicator Cluster Survey was designed by UNICEF’s Global MICS team. The survey process benefited from the leadership and advice of Attila Hancioglu and George Sakvarelidze. The study team would also like to thank Tessa Wardlaw, Trevor Croft, Edilberto Loiaiza, Marco Segone, Emma Holmberg and Ngagne Diakhate for survey design advice and technical support. Special thanks must be given to the former UNICEF Area Representative for Serbia, Croatia and Montenegro Ann-Lis Svensson. She supported the MICS team and provided valuable advice on the inclusion of marginalized population groups into the survey. Thanks also go to Branka Kovacevic and Oliver Petrovic from the UNICEF Offices in Podgorica and Belgrade, for their support, insight and coordination. The Statistical Office of Montenegro (MONSTAT) professionally implemented the survey. Their team was successfully led by Snezana Remikovic. The other implementing agency, Strategic Marketing Research Agency was lead by Dragisa Bjeloglav, whose knowledge and experience were critical to overcoming numerous constraints. Ivana Bjelic of Strategic Marketing Team was in charge of operational communication and data processing. Thanks also go to the coordinators and supervisors of the field groups: Vladimir Raicevic and Biljana Sekulovic. Many ministers and institute members contributed to the successful implementation of the survey. Members of the Institute for Public Health, Ministry of Health and Social Welfare and Bureau for Education provided valuable advice and recommendations during all phases of work. The Montenegro MICS 2005 would not have been accomplished without the financial support of the Canadian International Development Agency, the Swedish International Development Agency and UNICEF. 15 EXECUTIVE SUMMARY The Montenegro Multiple Indicator Cluster Survey is a nationally representative sample survey of households, women and children. The results are related to October 2005 – January 2006, when the survey was conducted. Nutrition status • Almost three percent of children under five are moderately underweight and nearly five percent are too short for their age (stunted) while three percent are too thin for their height (wasted). • 13 percent of children under the age of five are overweight. Breastfeeding • In Montenegro, only 25 percent of children were breastfed for the first time within one hour of birth. • The survey indicates that 19 percent of infants are exclusively breastfed during the first six months of life. • Between the ages of 6-9 months, 35 percent of children receive breastmilk and solid or semi-solid foods. By the ages of 12-15 months and 20-23 months respectively, 25 and 13 percent of children are still being breastfed. Low birth weight • The survey shows that 96 percent of live births were weighed and 4 percent of them were below 2,500 grams. Immunization • Only 89 percent of children aged 18-29 months received a BCG vaccination in the first year of life. Such low coverage was due to the lack of information on BCG vaccination from their vaccination cards. • All three doses of DPT and oral polio were given to 92 percent and 89 percent of children, respectively. 83 percent of children aged 18-29 months received a measles vaccine (in the form of the measles-mumps-rubella (MMR) vaccine) by the age of 18 months. • 68 percent of children had all eight recommended vaccinations according to the national immunization schedule. Oral rehydration treatment • Overall, 5 percent of children under the age of five had diarrhoea in the two weeks preceding the survey. 98 percent of them used oral rehydration treatment (ORS fluid). • Home management of diarrhoea in Montenegro is only 15 percent. • However, 64 percent of children who had diarrhoea in two weeks prior to the survey 16 received oral rehydration therapy or increased fluids and continued feeding. Care seeking and antibiotic treatment of pneumonia • Three percent of children aged 0-59 months had acute respiratory infection two weeks prior to the survey. 89 percent of children with suspected pneumonia were taken to the appropriate health provider. • Fifty-seven percent of children with suspected pneumonia received antibiotics in the two weeks prior to the survey. Solid fuel use • Almost one third of households in Montenegro are using solid fuels for cooking. 88 percent of household in the North and for 56 percent of household in rural areas use of solid fuels. Water sanitation • The survey indicates that 98 percent of the population of Montenegro has access to improved drinking water sources. • An appropriate water treatment is used for all drinking water sources by 6 percent of population in Montenegro. • Over 99 percent of the population lives in households with improved sanitation facilities. 51 percent of the population have a flush toilet connected to a sewage system and 40 percent have a flush toilet connected to a septic tank. Security of tenure and durability of housing • Almost 22 percent of households do not have security of tenure. 18 percent of households do not have formal residential documentation. The worst situation is in the North region where 19 percent of population does not have formal residential documentation. • Moreover, 14 percent of the population were evicted from their dwelling in the 15 years preceding the survey. • In regard to housing characteristics, 30 percent of households are considered overcrowded and inappropriate for living. Contraception • Current use of contraception was reported by 39 percent of married women or women in union. Traditional methods are more popular than modern ones, 22 compared to 17 percent. Contraceptive prevalence is highest in the North (about 56 percent), and lowest in the Central region (27 percent). Unmet needs • Almost one third of married women or women in union in Montenegro have an unmet need for contraception. Antenatal care 17 • 97 percent of pregnant women received antenatal care one or more times during pregnancy. Assistance at delivery • Almost 100 percent of births which occurred in the past two years were delivered in a health facility. Child development • For about 89 percent of children under the age of 5, an adult was engaged in four or more activities promoting learning and school readiness during 3 days preceding the survey. The average number of activities was 5. • The involvement of fathers in such activities is lower (78 percent), with the average number of activities at 3. • Over 79 percent of children aged 0-59 months live in households containing three or more non-children books, and 77 percent of them live in households with 3 or more children books. The median number of both types of books is 10. • 14 percent of children live in households with 3 or more types of playthings. Most common are the toys that come from stores, at 89 percent. • About 6 percent of children under the age of 5 in Montenegro were left with inadequate care in the week preceding the survey. The inadequate care is more present in the North and in the rural areas. Also, male children are more often left with inadequate care compared to females. Pre-School attendance and school readiness • Only 29 percent of children aged 36-59 months were attending some form of organised early childhood education programme. The attendance was three times higher in urban than in rural areas. The highest proportions of children attending such education programmes are found in the South (44 percent) and the lowest in the North (15 percent). Primary and secondary school participation • Ninety four percent of children of primary school entry age in Montenegro are currently attending first grade. • Ninety eight percent of children of primary school age attended primary school and only 84 percent of children of secondary school age attended secondary school. • 97 percent of the children who entered the first grade of primary school eventually reach grade five. • Transition rate to secondary education is satisfactory at 98 percent. • The Gender Parity Index for primary and secondary school is 1.0, indicating no difference in primary and secondary school attendance of girls and boys. Adult literacy • The literacy rate of females, aged between 15 and 24 in Montenegro is 93 percent, however 3 percent of women this age do not know whether they are literate. There are some disparities between regions. The proportion of literate women from the 18 North region is 96 percent, while the literacy rates for women in the South and in the Central region is 92 percent. Birth Registration • The births of 98 percent of children under five have been registered. There was virtually no difference by sex and region. Child Labour • 10 percent of children aged between 5 and 14 are involved in child labour activities. If disaggregated by region, the South and the Central have the lowest percentages of children involved in labour activities, at 4 percent and 5 percent, respectively. The North region has the highest proportion (20 percent). The survey indicates that children living in rural areas (17 percent) are more involved in child labour activities compared to urban areas (6 percent). • 87 percentage of child labourers are also attending school, in the other hand 10 percent of students are also involved in child labour. Child Discipline • In Montenegro, 61 percent of children aged between 2 and 14 were subjected to at least one form of psychological or physical punishment by their mothers/caretakers or other household members. 6 percent of children were exposed to severe physical punishment. • Also, 5 percent of mothers/caretakers believe that children should be physically punished. Early marriage • There are no women aged between 15 and 49 who got married before the age of 15. • Two percent of women aged 15 to 19 are currently married or in union. These cases are most common in the Central and North regions. Domestic violence • In Montenegro, 36 percent of young married women aged 15 to 19 are married to a partner 10 or more years older. This percentage is lower (17 percent) among married women aged 20 to 24 years. • 11 percent of women believe that their husband/partner has a right to hit or beat them for at least one reason. Domestic violence is more accepted in the South (14 percent ) and in the North (15 percent), than in the Central region (6 percent). Child disability • 13 percent of children between the ages of 2 and 9 have at least one reported disability. Knowledge of HIV transmission and condom use 19 • 97 percent of women aged 15 to 49 have heard of AIDS. • Half of women aged 15-49, know the three main methods of preventing HIV/AIDS transmission (being faithful to one partner, using condoms, and abstaining from sex). • Only 26 percent of women have comprehensive knowledge on how HIV/AIDS is transmitted. Women from Central (34 percent) and South region (23 percent) show the highest proportions of understanding compared to the North (17 percent). • 65 percent of women of reproductive age know three ways in which HIV can be transmitted from mother to child. • 70 percent of women know a place where AIDS can be tested. Three percent have been tested, of whom 87 percent have been given the result. • 69 percent of women expressed a discriminatory attitude towards people with HIV/AIDS. 20 I. INTRODUCTION Background This report is based on the Montenegro Multiple Indicator Cluster Survey, conducted in 2005 by UNICEF, the Statistical Office of Montenegro and Strategic Marketing Research Agency. The survey provides valuable information on the situation of children and women in Montenegro, and was based in large part on the need to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see table below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and sub national levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” 21 The Government of the Republic of Montenegro adopted the Poverty Reduction Strategy Plan in 2003, and the National Plan of Action for Children (NPA) in 2004. By undertaking these international obligations, Montenegro committed itself to monitor and assess progress towards internationally defined goals and targets. MICS3 is the third round of a nation-wide household Multiple Indicator Cluster Survey. The survey provides the largest single source of data for reporting on progress towards the aforementioned goals, which will give a rich foundation of comparative data for comprehensive progress reporting. This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The 2005 Montenegro Multiple Indicator Cluster Survey has as its primary objectives: • To provide up-to-date information for assessing the situation of children and women in Montenegro; • To furnish data needed for monitoring progress toward goals established by the Millennium Development Goals, the goals of A World Fit For Children (WFFC), and other internationally agreed upon goals, as a basis for future action; • To contribute to the improvement of data and monitoring systems in Montenegro and to strengthen technical expertise in the design, implementation, and analysis of such systems. 22 II. SAMPLE AND SURVEY METHODOLOGY Sample Design The sample for the Montenegro Multiple Indicator Cluster Survey (MICS) was designed to provide estimates on a large number of indicators on the situation of children and women at the national level, for urban and rural areas, and for three regions: South, Central and North. Regions were identified as the main sampling domains and the sample was selected in two stages. Within each region, 141 census enumeration areas were selected with probability proportional to size. Based on updated data from the last census (2003), those units were divided into clusters of 18 households on average. An important factor which influenced the sample design is a very low fertility rate and small number of household members. Due to these facts, we stratified the households in selected enumeration areas to two strata. One stratum contained households with children, and the other contained households without children. The allocation size of the sample in the stratum of households with children was significantly bigger than allocation size of the sample in the stratum of households without children. After a household listing was carried out within the selected enumeration areas, a systematic sample of 2,575 households was drawn. Each selected enumeration area has been visited during the fieldwork period. The sample was stratified by region and two more strata: households with children and household without children, and is not self-weighting. For reporting national level results, sample weights are used. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect information on all de jure household members, the household, and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15- 49 years; and 3) an under-5 questionnaire, administered to mothers or caretakers of all children under 5 living in the household. The questionnaires included the following modules: The Household Questionnaire included the following modules: o Household listing (exact date of birth of the household members was added) o Education (extended with additional questions considering travelling to school - distance, costs, way and duration of travelling) o Water and Sanitation o Household characteristics (extended with additional household characteristics and security of tenure and durability of housing important for calculation of wealth index) o Child Labour o Child Discipline o Child Disability The Questionnaire for Individual Women was administered to all women aged 15-49 years living in the households, and included the following modules: 23 o Women’s information panel o Maternal and Newborn Health o Security of tenure on eviction for the Woman o Marriage/Union (sections involving polygamy are excluded from the questionnaire) o Contraception o Attitudes toward domestic violence o Sexual behaviours o HIV/AIDS The Questionnaire for Children Under Five was administered to mothers or caretakers of children under 5 years of age2 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Under five child’s information panel o Birth Registration and Early Learning o Child development o Breastfeeding o Care of Illness o Immunization o Anthropometry The questionnaires are based on the MICS3 model questionnaire3. From the MICS3 model English version, the questionnaires were translated into the language which is in official usage in Montenegro, and Albanian and were pre-tested during October 2005. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Montenegro MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams measured the weights and heights of children age under 5 years. Details and findings of these measurements are provided in the respective sections of the report. Training and Fieldwork Training for the fieldwork was conducted for 3 days in October. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. At the end of the training period trainees spent two days in practice interviewing in Podgorica. The data was collected by 6 teams; each was comprised of three or four interviewers, one driver, one editor/measurer and a supervisor. Fieldwork began in October 2005 and concluded in January 2006. Data Processing 2 The terms “children under 5”, “children age 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. 3 The model MICS3 questionnaire can be found at www.childinfo.org, or in UNICEF, 2006. 24 Data was entered using the CSPro software. The data was entered into fourteen microcomputers and carried out by 22 data entry operators and 8 data entry supervisors. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS3 project and adapted to the Montenegro questionnaire were used throughout. Data processing began simultaneously with data collection in December 2005 and was completed in January 2006. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 14, and the model syntax and tabulation plans developed for by UNICEF this purpose. 25 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Sample Coverage Of the 2,575 households selected for the sample, 2,494 were found to be occupied. Of these, 2,358 were successfully interviewed for a household response rate of 95 percent. The household response rate was higher in the North (97 percent) than in the Central and in the South (93 percent). In the interviewed households, 2,385 women (age 15-49) were identified. Of these, 2,258 were successfully interviewed, yielding a response rate of 95 percent. The women’s response rate was higher in the Central and North region (95 percent) than in the in the South (93 percent). In addition, 1,072 children under age five were listed in the household questionnaire. Questionnaires were completed for 1,061 of these children, which corresponds to a response rate of 99 percent. The response rates are very similar across the regions. Overall response rates of 90 and 94 are calculated for the women’s and under-5’s interviews, respectively (Table HH.1). Characteristics of Households The age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 2,358 households successfully interviewed in the survey, 8,991 household members were listed. Of these, 4,419 were males, and 4,571 were females. These figures also indicate that the survey estimated the average household size at 3.8 household members. There are almost no differences in distribution of population by age group according to Census data and MICS3 data. Table HH.2 shows that 24 percent of total population is under 15 years old, the population aged 15-64 is the biggest group with 65 percent and 11 percent of the total population is over 65. There is the same distribution of population by sex. The male-female ratio shows small variations in the first 50 years of life after which the number of women increases and exceeds that of men. The age and sex distribution of the surveyed population is in accordance with the 2003 Census and indicates a decrease in population growth during the past five years. It is important to note that 28 percent of total population are under 18. The ages of almost all the surveyed population were collected. Although, one percent of all eligible interviewed women did not know their complete date of birth (i.e. day, month and year), the data (year of birth and age) for these women were gathered. For all children under 5, the complete date of birth (month and year) was collected. Field supervisors were instructed to repeat interviews in case information was missing. 26 Figure HH.1: Age and Sex Distribution of Household Population, Montenegro, 2005 8 6 4 2 0 2 4 6 8 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ Percent Males Females Table HH.3 provides basic background information on the households. Within households, the sex of the household head, region, urban/rural status, number of household members, and ethnicity4 group of the household head are shown in the table. These background characteristics are also used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. In more than two thirds of interviewed households the head of the household is male, which correlates strongly with Montenegrin tradition. The majority of households (43 percent) have between four and five members. The weighted and unweighted numbers of households are equal, since sample weights were normalized (See Appendix A). The table also shows the proportions of households with at least one child under 18, at least one child under 5, and at least one eligible woman aged 15- 49 were found. In 68 percent of interviewed households, there is at least one woman aged 15 to 49, and in 21 percent of interviewed households at least one child under 5. In more than half of interviewed households there is at least one child aged under 18. 4 This was determined by asking which national or ethnic group the head of household belonged to. 27 Characteristics of Respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 provides background characteristics of female respondents 15-49 years of age. The table includes information on the distribution of women according to region, areas, age, marital status, motherhood status, education, wealth index quintiles and ethnicity. Almost half of interviewed women live in the Central region. The majority (64 percent) of interviewed women live in urban areas and all other (36 percent) in rural areas. According to marital status, 60 percent of interviewed women are currently in marriage or in union, 36 percent were never married or in union and all other (5 percent) used to be married or in union. With regard to motherhood status, 61 percent of women have given birth compared to 39 percent that never gave birth. About two thirds of the interviewed women have a secondary education, while the percent of women with primary education or less, and those with university education is approximately the same (about 18 percent). It is important to notice that education levels are categorised, according to national educational system, into three groups: primary or less, secondary and university. Some background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, region and area of residence, age in months, mother’s or caretaker’s education, wealth, and ethnicity. Male and female children under 5 have approximately the same proportion in the sample. Almost half of interviewed under five children live in the Central region, about 20 percent in the South and 30 percent in the North. The proportion of children by urban and rural area is the same as the proportion of women. 64 percent are in urban and 36 percent are in rural areas. The number of interviewed children under 5 follows the increase of age, from 7 percent under six months to 25 percent of children age 48-59 months. Only 15 percent of mothers from the survey have a university degree, compared to the number with secondary education (62 percent). About 23 percent of mothers with children under five have primary school or less. 28 IV. NUTRITION Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. The World Fit for Children goal is to reduce the prevalence of malnutrition among children under five years of age by at least one-third (between 2000 and 2010), with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition will assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is the WHO/CDC/NCHS reference, which was recommended for use by UNICEF and the World Health Organization at the time the survey was implemented. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight- for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. On the other hand children whose weight-for-height is two or more standard deviations above the median of the reference population are considered as moderately or severely obese. Obesity is typically a result of bad nutritional practices (low intake of proteins, fruit and vegetables, 29 high intake of saturated fats and sugar…) and is a risk factor for some of the chronic diseases of future life, like cardiovascular diseases and diabetes. In MICS, weights and heights of all children under 5 years of age were measured using anthropometric equipment recommended by UNICEF (UNICEF, 2006). Findings in this section are based on the results of these measurements. Table NU.1 shows percentages of children classified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above 2 standard deviations from the median of the reference population. In Table NU.1, children who were not weighed and measured (approximately 18.4 percent of children) and those whose measurements are outside a plausible range are excluded. In addition, a small number of children whose birth dates are not known are excluded. Since the share of children not included in the analysis is high, all presented results should be taken with consideration. Less than 3 percent of children under age five in Montenegro are moderately underweight and less than one percent are classified as severely underweight (Table NU.1). More than a 5 percent of them are moderately stunted or too short for their age and 3 percent are moderately wasted or too thin for their height. Figure NU.1: Percentage of children under-5 who are undernourished, Montenegro, 2005 0 2 4 6 8 10 12 0 6 12 18 24 30 36 42 48 54 60 Age (in Months) Pe rc en t Underweight Stunted Wasted Children in the North are more likely to be underweight and wasted than children in other regions. The situation with stunted is similar in all three regions (about five percent). Those 30 children whose mothers have secondary or higher education are the least likely to be underweight and stunted compared to children of mothers with primary or no education. Boys appear to be slightly more likely to be underweight, stunted, and wasted in comparison with girls. The age pattern shows that a higher percentage of children aged 12- 23 months are undernourished in comparison to children who are younger and older (Figure NU.1). Also, children 6 - 11 months old have the highest height for age and the highest weight for height is within the children 24-35 months old . This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food, and environment. The figure for overweight is the highest compared to each of the previous indicators. About 13 percent of children under five years are overweight. This indicator has the highest value for 12-23 months old children (21 percent). Breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering, micronutrient malnutrition and is unsafe if clean water is not readily available. The World Fit for Children goal states that children should be exclusively breastfed for 6 months and continue to be breastfed with safe, appropriate and adequate complementary feeding for up to 2 years of age and beyond. WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for first six months • Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at 6 months • Frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day for 9-11 month olds It is also recommended that breastfeeding be initiated within one hour of birth. The indicators of recommended child feeding practices are as follows: • Exclusive breastfeeding rate • Timely complementary feeding rate • Continued breastfeeding rate • Timely initiation of breastfeeding • Frequency of complementary feeding • Adequately fed infants Table NU.2 provides the proportion of women who started breastfeeding their infants within one hour of birth, and women who started breastfeeding within one day of birth (which includes those who started within one hour). About one quarter of women in Montenegro (25 percent) started breastfeeding their baby within one hour of birth. The highest proportion is among women in the North of Montenegro (58 percent), and the lowest among women in the South (only 5 percent). Differences depend on women’s residential area, women’s education and household socio-economic status. According to mother’s education level, the percentage of women who started breastfeeding within one 31 hour of birth decreases from 42 percent of those with primary or no education, to 22 percent with secondary education, and further to 15 percent of women with higher education. The same indicator grows from 8 percent of the richest, to 40 percent of the poorest population. On the other hand, the proportion of women who started breastfeeding within one day of birth (which includes those who started within one hour) is 73 percent. Distribution by region, area of residence, education level of mother and socio-economic status of households is very similar to the previous indicator. The highest proportion was among women in the North (about 81 percent). Figure NU.2 Percentage of mothers who started breastfeeding within one hour and within one day of birth, Montenegro, 2005 62.8 72.4 80.9 72.1 74.8 73.2 5.3 15.6 53 17.9 36.3 25.2 0 10 20 30 40 50 60 70 80 90 Pe rc en t Within one day Within one hour In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breastfeeding of children at 12-15 and 20-23 months of age. Approximately 19 percent of children aged less than six months are exclusively breastfed, a level considerably lower than recommended. At age 6-9 months, 35 percent of children are receiving breast milk and solid or semi-solid foods. By age 12-15 months, 25 percent of children are still being breastfed and by age 20-23 months, the percentage of children still receiving breast milk is 13. Taking into consideration the low number of children by each subgroup (sex, type of settlement and region) it is not possible to draw any firm conclusion from the data. The adequacy of infant feeding in children less than 12 months is provided in Table NU.4. Different criteria of adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as adequate feeding. Infants aged 6-8 32 months are considered to be adequately fed if they are receiving breast milk and complementary food at least two times per day, while infants aged 9-11 months are considered to be adequately fed if they are receiving breast milk and eating complementary food at least three times a day. The description of exclusively breastfed for infants aged 0-5 months has already been explained in the previous paragraph. About 30 percent of children aged 6-8 months received breast milk and complementary food at least two times in prior 24 hours. This indicator is two times higher for male population than female. There is a similar situation is for settlement type where the percentage is twice higher in urban than in the rural area. Additionally, 32 percent of infants age 9-11 months receive breast milk and complementary food at least the minimum recommended number of times per day. The distribution of data according to each relevant subgroup (sex, type of settlements, region) is similar for the previous two indicators. As a result of these feeding patterns, only 30 percent of children aged 6-11 months are being adequately fed. Adequate feeding among all infants (aged 0-11) drops to 25 percent. By region, 36 percent and 31 percent of infants aged 6-11 and 0-11 months in the Central region are adequately fed. In the other regions, this indicator is lower. According to the type of settlements, children in urban areas are more adequately fed than those living in the rural area. Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have the most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. The percentage of births weighing below 2,500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth5 . 5 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. 33 Overall, 96 percent of born children were weighed at birth and approximately 4 percent of infants are estimated to weight less than 2,500 grams at birth (Table NU.5). There is no significant variation by region (Figure NU.3), or by urban and rural areas or by mother’s education. Figure NU.3 Percentage of Infants Weighing Less Than 2500 Grams at Birth, Montenegro, 2005 4.4 4.3 3.1 3.9 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 South Central North Montenegro Regions Pe rc en t 34 V. CHILD HEALTH Immunization The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children overlooked by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure full immunization of children less than one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine and a measles vaccination by the age of 12 months. The national immunization calendar in Montenegro differs slightly, with the measles vaccine being administered between the ages 12 and 18 months in the MMR form (Measles, Mumps and Rubella). Mothers were asked to provide vaccination cards for children under the age of five. Interviewers copied vaccination information from the cards onto the MICS questionnaire. Overall, 71 percent of children had health cards (Table CH.2). If the child did not have a card or the card was not shown, the mother was asked to recall whether the child had received each of the vaccinations and, for DPT and Polio, how many times. The percentage of children aged 18 to 29 months who received each of the vaccinations is shown in Table CH.1. The denominator for the table is comprised of children aged 18 to 29 months, so that only children who are old enough to be fully vaccinated are counted. In the top panel, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In the bottom panel, only those who were vaccinated before their first birthday are included. For MMR vaccine in the bottom of panel, the numerator includes only those children who were vaccinated before 18 months of age. For children without vaccination cards, the proportion of vaccinations given before the first birthday (18 months in the case of MMR) is assumed to be the same as for children with vaccination cards. Approximately, 88 percent of children, aged 18 to 29 months received a BCG vaccination by the age of 12 months and the first dose of DPT was given to 97 percent of children. The percentage declines for subsequent doses of DPT to 94 percent for the second dose, and 89 percent for the third dose (Figure CH.1). Similarly, 94 percent of children received Polio 1 by age of 12 months and this declines to 86 percent for the third dose. The coverage for MMR vaccine is 78 percent and it is lower than the other vaccines. As a result, the percentage of children who had all the recommended vaccinations by their first birthday is low, and it is only 56 percent. 35 Figure CH.1 Percentage of children aged 18-29 months who received the recommended vaccinations by 12 months (18 months in case of MMR), Montenegro, 2005 88 96.5 93.7 88.6 93.7 91.9 85.8 78.3 55.6 0 20 40 60 80 100 120 BCG DPT1 DPT2 DPT3 Polio1Polio2Polio3 Measles All Pe rc en t Tables CH.2 show vaccination coverage rates among children aged 18-29 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and mothers’/caretakers’ reports. For any of background characteristics there are no significant differences. Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) - can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to: 1) reduce by one half death due to diarrhoea among children under five by 2010 compared to 2000 (A World Fit for Children); and 2) reduce by two thirds the mortality rate among children under five by 2015 compared to 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 percent. The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy (ORT) • Home management of diarrhoea • (ORT or increased fluids) AND continued feeding 36 In the MICS questionnaire, mothers (or caretakers) were asked to report whether their child had had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a series of questions about what the child had had to drink and eat during the episode of diarrhoea. Overall, 5 percent of under-five children had had diarrhoea in the two weeks preceding the survey (Table CH.3). 98 percent of children with diarrhoea received ORT with oral rehydration solution (ORS). Regional distribution shows that the smallest number of children with diarrhoea was in the South (2 percent), while in Central region about 8 percent of children under five had had diarrhea. Table CH.3 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Since mothers were able to name more than one type of liquid, the percentages do not necessarily add to 100. About 16 percent received fluids from ORS packets, 14 percent received breast milk and 80 percent received porridge (from cereals, leguminous plants and root vegetables) or soup. Furthermore, 91 percent received some other fluid (yogurt, sour milk, tea, sugar and salt solution, sugar-free fruit juice), 43 percent of children received cow /sheep/goat milk or adapted baby milk, while 73 percent received water and food combined. Moreover, 77 percent children under five received only water, 64 percent sweetened water, sweetened tea or sweetened fruit juice. Overall, 2 percent of children had diarrhoea treatment and 98 percent received some kind of oral rehydration treatment. Table CH.4. shows home management of diarrhoea. Approximately fifteen percent of children with diarrhoea received one or more of the recommended home treatments of diarrhoea, and 64 percent of them received ORT or increased fluids and continued feeding. Discussion of disparities by background characteristics is not shown because of the small number of cases. Approximately 18 percent of under five children with diarrhoea drank more than usual, while, 80 percent drank the same or less (Table CH.4). Furthermore, 64 percent ate somewhat less, the same or more (continued feeding), and 36 percent ate much less or almost none. Given these figures, over 64 percent children received increased fluids and at the same time continued feeding. Combining the information in Table CH.4 with those in Table CH.3 in regards to oral rehydration therapy, it is observed that 64 percent of children either received ORT or increased fluid and at the same time, feeding was continued, as recommended. Again, the small numbers of shown cases didn’t allow for a discussion of disparity by region, age, education level or other characteristics. Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in under-5s with suspected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one-third the deaths due to acute respiratory infections. Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were NOT due to a problem in the chest and a blocked nose. The indicators are: 37 • Prevalence of suspected pneumonia • Care seeking for suspected pneumonia • Antibiotic treatment for suspected pneumonia • Knowledge of the danger signs of pneumonia The table that presents the prevalence of suspected pneumonia, if care was sought outside the home, and the site of care is not shown since the total number of cases is too low. 3 percent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey. 89 percent of these children were taken to an appropriate provider. Additionally, 70 percent of children aged 0-59 months who had acute respiratory infections in the last two weeks had visited a health centre, 17 percent of them a hospital and 12 percent visited a private doctor. According to recommended number of cases there are no explanations of differences by background characteristics. Also, the table that presents the use of antibiotics for the treatment of suspected pneumonia in under-5s is not shown since the number of cases is too low. In Montenegro, 57 percent of under-5 children with suspected pneumonia had received an antibiotic during the two weeks prior to the survey. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.4A. Obviously, mothers’ knowledge of the danger signs is an important determinant of care- seeking behaviour. Overall, 5 percent of women are familiarized with two danger signs of pneumonia – fast breathing and difficult breathing. The most commonly identified symptom for taking a child to a health facility is when the child develops a fever (91 percent). The survey shows that only 12 percent of mothers identified fast breathing and 16 percent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. Solid Fuel Use More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is products of incomplete combustion, including CO, polyaromatic hydrocarbons, SO2, and other toxic elements. Use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts, and asthma. The primary indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. Overall, one third (32 percent) of all households in Montenegro are using solid fuels for cooking. Use of solid fuels is lower in urban areas (18 percent), than in rural areas, where over half of the households (56 percent) are using solid fuels. Differences with respect to household wealth and the education level of the household head are also significant. The findings show that use of solid fuels is very uncommon among households in the South, and among the richest households. In contrast, 88 percent households in the North and 83 percent of the poorest households use solid fuels for cooking. The Table CH.5 also clearly shows that the overall percentage is high due to high level of using wood (28 percent) for cooking purposes. It is also important to notice, that the 66 percent of interviewed 38 households use electricity for cooking. Cooking with electricity is the highest in the South and in urban area, and also in the richest households. Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. The type of stove used with a solid fuel is depicted in Table CH.6. Almost all households (98 percent) who use solid fuel for cooking have closed stove with chimney. The proportion of other types of stoves are one percent or less. 39 VI. ENVIRONMENT Water and Sanitation Safe drinking water is a necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid, and schistosomiasis. Drinking water can also be tainted with chemical, physical and radiological contaminants with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The list of indicators used in MICS is as follows: Water • Use of improved drinking water sources • Use of adequate water treatment method • Time to source of drinking water • Person collecting drinking water Sanitation • Use of improved sanitation facilities • Sanitary disposal of child’s faeces The distribution of the population by source of drinking water is shown in Table EN.1 and Figure EN.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, yard or plot, from public or local piped system), public tap/standpipe, tube well/borehole or a protected well and spring. Bottled water is an improved water source only if the household is using an improved water source for other purposes, such as hand washing and cooking. 40 Figure EN.1 Percentage distribution of household members by source of drinking water, Montenegro, 2005 Public w ater supply 77% Bottled w ater 3% Protected w ell or spring 5% Tube w ell/borehole 6% Public tap/standpipe 1% Local w ater supply 7% Unprotected w ell or spring 1% Overall, 98 percent of the population is using an improved source of drinking water – 100 percent in urban areas and 86 percent in rural areas. The source of drinking water for the population varies by region (Table EN.1). In the Central region, 84 percent of the population use drinking water from public water supply and 10 percent use tube well / borehole. In the North, 64 percent of the household population have access to public water supply and 18 percent to local water supply. Furthermore, in the South, about 80 percent of the population use drinking water from public water supply. The other most important source of drinking water in the South region is bottled water (9 percent), and protected well or spring (5 percent). Use of in-house water treatment is presented in Table EN.2. Households were asked for ways they may be treating water at home to make it safer to drink – boiling, adding bleach or chlorine, using a water filter, and using solar disinfection were considered as proper treatment of drinking water. The table shows the percentages of household members using appropriate water treatment methods, separately for all households, for households using improved and unimproved drinking water sources. In Montenegro, 90 percent of the population drink untreated water and only 6 percent uses appropriately treated water. Sources of water before treatment are from both, improved and un-improved drinking water sources (6 percent and 3 percent, respectively). While in the South region 8 percent of the population treats water to make it safer, 6 and 3 percent of the population in Central and North region, respectively, do the same. The percentage of the population who use adequate water treatment methods has a positive correlation with the level of education of household’s head and with the wealth index. The amount of time it takes to obtain water is presented in Table EN.3 and the person who usually collected the water in Table EN.4. Note that these results refer to one roundtrip from home to drinking water source. Information on the number of trips made in one day was not collected. 41 Table EN.3 shows that for 96 percent of households, the drinking water source is on premises, while 4 percent of households had to go outside for water supply. For these households, the average amount of time to obtain water is about 15 minutes. For 3 percent of all households, it takes less than 30 minutes to get to water source and bring water, while only two percent of households spend more than 15 minutes for this purpose. The time spent in Central region in collecting water is slightly higher than in other regions. Table EN.4 shows that for the majority of households, an adult female is usually the person collecting the water (62 percent), when the source of drinking water is not on the premises. An adult male collects water in 30 percent of cases, while for the rest of the households, female or male children under age 15 collect water (8 percent). Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases. Improved sanitation facilities for excreta disposal include: flush or pour flush to a piped sewer system, septic tank, no flush with a water-proof septic tank and traditional pit latrine. Ninety nine percent of the population in Montenegro are living in households using improved sanitation facilities (Table EN.5). This percentage is almost 100 in urban areas and 97 in rural areas. Residents of the North and in rural areas are less likely than others to use improved facilities. In rural areas, the population is mostly using flush to septic tank (54 percent). In contrast, the most common facilities in urban areas are flush to piped sewer system (67 percent). Over 50 percent of households in Montenegro use flush to piped sewer system, 40 percent use flush to septic tank and 8 percent traditional pit latrine. Safe disposal of a child’s faeces is when the last stool by the child was disposed of by use of a toilet or rinsed into toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table EN.6. According to these data, there are only 37 percent of households with children aged 0-2 years whose stools are disposed of safely. In 12 percent of households children use a toilet, and in 26 percent of the cases their faeces were put/rinsed into toilet or latrine. 57 percent of households in Montenegro use unsafe disposal method (faeces are thrown in garbage). Regional distributions show that there is a higher percent of safe disposals of child faeces is in the North (51 percent) than in the South and Central of Montenegro (34 and 30 percent, respectively). An overview of the percentage of households with improved sources of drinking water and sanitary means of excreta disposal is presented in Table EN.7. There is very high percentage of households with improved sources of drinking water and sanitary means of excreta disposal. All indicators are very close to 100 percent. There is small decrease in the North and in rural areas according to both indicators. Security of Tenure and Durability of Housing Target 11 of MDG is on the achievement of significant improvements in the lives of at least 100 million slum dwellers, and the related indicator is the proportion of urban household members living in slum housing. In MICS, three indicators were introduced to measure issues related to slum housing: security of tenure, durability of housing, and proportion 42 living in slum households. An urban household is considered a slum in MICS if it fulfils one of the following conditions: improved drinking water sources are not used, improved sanitation facilities are not used, living area is not sufficient, housing is not durable, or security of tenure is lacking. Lack of security of tenure is defined as the lack of formal documentation for the residence or perceived risk of eviction. Table EN.8 is on the security of tenure. In urban areas covered in Montenegro MICS, 18 percent of households do not have formal documentation for their residence, and 10 percent of respondents to the household questionnaire indicated that there is a risk of eviction. Combining these figures, it is observed that 22 of households do not have security of tenure. In addition, the table also shows that 14 of household members were indeed evicted from a dwelling they were residing in during the last 15 years. While 20 percent of households in the Central and in the North do not have formal documentation, this percentage in the South is lower (11 percent). The highest level of differences is according to wealth index. The situation among the poorest population is the following: 29 percent of the poorest households do not have formal documentation for their house, 35 percent feel there is a risk of eviction and as a result 45 percent of the poorest households do not have security of tenure. All present indicators are much lower when observing the richest twenty percent of the population. 11 percent of the richest households do not have formal documentation for their residence, only 3 percent of them feel there is a risk of eviction and as a result, 13 percent of the richest households do not have security of tenure. Structures that households are living in are considered as non-durable in MICS if the floor material is natural and two or more bad conditions were identified like cracks or openings in the wall; no windows or windows with broken glass; visible holes in the walls; an incomplete roof or an insecure door; where conditions of vulnerability to accidents in terms of the dwelling’s surroundings exist, or if the structure is located in or near a hazardous area (e.g. a landside area, a flood-prone area, a river bank, a steep hill, a rubbish pile, an industrial pollution area, a railway line, power plant or flyover). Table EN.9 provides information on the findings of the survey. Overall, 2 percent of households and household members are living in dwellings which are considered as non-durable. There are no households and household members living in dwellings in urban areas with natural floor materials, in which the dwelling is in poor condition, or in which the dwelling is located in hazardous location. 5 percent of households in the North live in dwellings considered non- durable. In the South this is only 2 percent. In the South, there are no households living in a dwelling considered non-durable. Over 4 percent of households in which the household head has a primary education are considered as non-durable. For the highest level of education of household head, this percentage is decreased to 1 percent. Less then one percent of the richest households and more then eight percent of the poorest households are living in dwellings considered non-durable. Table EN.10 brings together all 5 components of slum housing (see above). Overall, 30 percent of households are considered to be living in slum housing. This coincides with 33 percent of household members. The structure of this complex indicator is the following: 20 percent of households lack security of tenure; 12 percent households exhibit over-crowding with more than three persons per sleeping room and 2 percent of households have a dwelling which is considered non durable. As the data shows, lack of use of improved water source and lack of use of improved sanitation do not have an influence on slum housing. The percent of households considered to be living in slum housing in the North is 39, in the 43 Central region is 31 and in the South is 20. As the level of education of household head increases, the percentage of households considered to be living in slum housing decreases. The same is true of the wealth index. Over 56 percent of the poorest households are living in slum housing and 19 percent of the richest households live in the same housing. 44 VII. REPRODUCTIVE HEALTH Contraception Appropriate family planning is important to the health of women and children by: 1) preventing pregnancies that are too early or too late; 2) extending the period between births; and 3) limiting the number of children. A World Fit for Children goal is access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. Current use of contraception was reported by 39 percent of women currently married or in union (Table RH.1). The most popular contraceptive method is withdrawal, which is used by 18 percent of married women in Montenegro. The next most popular method is intrauterine device (IUD), which accounts for 10 percent of married women. Four percent of women reported use of a condom and periodic abstinence, while 2 percent use the pill. Less than one percent use female sterilization, female condom, diaphragm/foam/jelly, or the lactation amenorrhea method (LAM). Contraceptive prevalence is the highest in the North region (56 percent), and relatively high in the South region (39 percent), while only twenty-seven percent of married women in the Central region use a method of contraception. Adolescents are far less likely to use contraception than older women do. Only about 36 percent of married or in union women, aged 20-24 currently use a method of contraception compared to 48 percent of those 35-40 years old. There are no significant differences in contraceptive prevalence by women’s education level. Unmet Need An unmet need6 for contraception refers to fecund women who are not using any method of contraception, but who wish to postpone the next birth or who wish to stop childbearing altogether. Unmet need is identified in MICS by using a set of questions eliciting current behaviours and preferences pertaining to contraceptive use, fecundity, and fertility preferences. Women with an unmet need for spacing include women who are currently married (or in union), fecund (are currently pregnant or think that they are physically able to become pregnant), currently not using contraception, and want to space their births. Pregnant women are considered to want to space their births when they did not want the child at the time they became pregnant. Women who are not pregnant are classified in this category if they want to have a (nother) child, but want to have the child at least two years later, or after marriage. 6 Unmet need measurement in MICS is somewhat different than that used in other household surveys, such as the Demographic and Health Surveys (DHS). In DHS, information that is more detailed is collected on additional variables, such as postpartum amenorrhea, and sexual activity. Results from the two types of surveys are strictly not comparable. 45 Women with an unmet need for limiting are those women who are currently married (or in union), fecund (are currently pregnant or think that they are physically able to become pregnant), currently not using contraception, and want to limit their births. The latter group includes women who are currently pregnant but had not wanted the pregnancy at all, and women who are not currently pregnant but do not want to have a (nother) child. Total unmet need for contraception is simply the sum of unmet need for spacing and unmet need for limiting. Using information on contraception and unmet need, the percentage of demand for contraception satisfied is also estimated from the MICS data. Percentage of demand for contraception satisfied is defined as the proportion of women currently married or in union who are currently using contraception, of the total demand for contraception. The total demand for contraception includes women who currently have an unmet need (for spacing or limiting), plus those who are currently using contraception. Table RH.2 shows the results of the survey on contraception, unmet need, and the demand for contraception satisfied. 26 percent of married women or women in union aged 15-49 in Montenegro have an unmet need for contraception. Regional distribution shows that an unmet need for contraception is the highest for the Central region at 35 percent, and it decreases for the South to 22 percent, and more, to 18 percent for the North. Unmet need for contraception mainly manifests as unmet need for limiting, while younger women, 15-24 years old are mainly manifested as a need for spacing. Sixty percent of interviewed women’s demand for contraception is satisfied. This time, the highest level of the indicator is in the North (76 percent), slightly lower in the South (64 percent) and the lowest in the Central region (44 percent). All other categories don’t have significant differences by background characteristics. Antenatal Care The antenatal period presents an important opportunity for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. Better understanding of foetal growth and development and its relationship to the mother's health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about the risks of labour and delivery, it may provide the route for ensuring that pregnant women do, in practice, deliver with the assistance of a skilled health care provider. The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. The prevention and management of anaemia during pregnancy and treatment of STIs can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women's nutritional status and prevent infections (e.g., STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for 46 HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. The WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content on antenatal care visits, which include: • Blood pressure measurement • Urine testing for bateriuria and proteinuria • Blood testing to detect syphilis and severe anaemia • Weight/height measurement (optional) Coverage of antenatal care (by a doctor, nurse, or midwife) is relatively high in Montenegro with 97 percent of women receiving antenatal care at least once during the pregnancy. There are no significant differences by region and type of area. The type of personnel providing antenatal care to women aged 15-49 years who gave birth in the two years preceding is presented in Table RH.3. All 97 percent cases of antenatal are provided by medical doctor. Provision of antenatal care is not influenced by region, area, education level or other category . The types of services pregnant women received are shown in table RH.4. In Montenegro 90 percent of pregnant women aged 15-49 had urine specimen taken and blood sample taken. Blood pressure is measured for 82 percent, and weight is measured for 69 percent of pregnant women. Only 27 percent of pregnant women had papanicolau test. The higher level of antenatal care content is in the South, than in other region, as it is higher in the urban in comparison with rural area. Assistance at Delivery Three quarters of all maternal deaths occur during delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure a competent health worker with midwifery skills is present at every birth, and transport is available to a referral facility for obstetric care in case of emergency. A World Fit for Children goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at delivery indicator is also used to track progress toward the Millennium Development target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. The MICS included a number of questions to assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. About 99 percent of births occurring in the year prior to the MICS survey were delivered by skilled personnel (Table RH.5). This percentage is almost same in all regions and in all types of area, and for all level of education of mother and for all other criteria. Over 85 percent of babies born in the year prior to the MICS survey were delivered with assistance of doctors Auxiliary midwife assisted at the delivery of 12 percent of births and nurses assisted at only 2 percent. In the Central region, about 91 percent of births are 47 delivered by medical doctor assistants, 10 percent by auxiliary midwife and 7 percent by nurse. In other regions, the percentage of delivery by doctor assistant is lower (about 80 percent), but there is much more delivery with assistance of auxiliary midwife. 48 IX. CHILD DEVELOPMENT It is well recognized that a period of rapid brain development occurs in the first 3-4 years of life, and the quality of home care is the major determinant of the child’s development during this period. In this context, adult activities with children, presence of books in the home for the child, and the conditions of care are important indicators of quality of home care. A World Fit for Children goal is that “children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning was collected in the survey. This included the involvement of adults with children in the following activities: reading books or looking at picture books, telling stories, singing songs, taking children outside the home, compound or yard, playing with children, and spending time with children naming, counting, or drawing things. An adult engaged with 89 percent of under-five children in more than four activities that promote learning and school readiness during the 3 days preceding the survey (Table CD.1). The average number of activities that adults engaged with children was 5.2. The table also indicates that the father’s involvement in such activities was somewhat limited. Father’s involvement with one or more activities was only 78 percent. Only 3 percent of children were living in a household without their fathers. There are no significant gender differences in terms of adult activities with children. Larger proportions of adults engaged in learning and school readiness activities with children in urban areas (91 percent) than in rural areas (86 percent). Strong differences by region and socio-economic status are also observed: adult engagement in activities with children was highest in the South region (95 percent) and lowest in the North region (85 percent), while the proportion for children living in the richest households was 96 percent, as opposed to those living in the poorest households (79 percent). Father’s involvement showed a similar pattern in terms of adults’ engagement in such activities. It can be noted that fathers are engaged more in such activities with children whose mothers are more educated. Exposure to books in early years not only provides the child with greater understanding of the nature of print, but may also give the child opportunities to see others reading, such as older siblings doing school work. Presence of books is important for later school performance and IQ scores. In Montenegro, 79 percent of children live in households where at least 3 non-children’s books are present (Table CD.2). However, almost the same (77 percent) percent of children aged 0-59 months have children’s books. Both the median number of non-children’s books and children’s books are the same (10). While no gender differences are observed, urban children appear to have more access to both types of books than those living in rural households. 84 percent of children under 5 living in urban areas live in households with more than 3 non-children’s books, while in rural households the figure is 70 percent. The proportion of children under 5 who have 3 or more children’s books is 82 percent in urban areas, compared to 68 percent in rural areas. The presence of both, non-children’s and children’s books is positively correlated with the child’s age; in the homes of 81 percent of children aged 24-59 months, there are 3 or more non-children’s books, while the figure is 76 49 percent for children aged 0-23 months. Similar differences exist in terms of children’s books. For 81 percent of children aged 24-59 months there are 3 or more children’s books, while the figure is 69 percent for children aged 0-23 months. Table CD.2 also shows that only 14 percent of children aged 0-59 months had 3 or more playthings to play with in their homes, while 6 percent had none of the playthings (Table CD.2). The playthings in MICS included household objects, homemade toys, toys that came from a store, and objects and materials found outside the home. It is interesting to note that 89 percent of children play with toys that come from a store; however, the percentages for other types of toys is below 30 percent. The proportion of children who have 3 or more playthings to play with is 12 percent among male children and 15 percent among female children. No urban-rural differences are observed in this respect; small but interesting differences are observed in terms of mother’s education – 12 percent of children whose mother’s are educated have 3 or more playthings, while the proportion is 20 percent for children whose mother’s have no education. Differences are similarly small by socio- economic status of the households, and regions. The only background variable, which appears to have a strong correlation with the number of playthings children have, is the age of the child, a somewhat expected result. Leaving children alone or in the presence of other young children is known to increase the risk of accidents. In MICS, two questions were asked to find out whether children aged 0-59 months were left alone during the week preceding the interview, and whether children were left in the care of other children under 10 years of age. Table CD.3 shows that 6 percent of children aged 0-59 months were left in the care of other children, while 2 percent were left alone during the week preceding the interview. Combining the two care indicators, it is calculated that 6 percent of children were left with inadequate care during the week preceding the survey. There are no differences by the sex of the child, between urban and rural areas or by education level of the mother. Some differences are observed concerning socio-economic status of the household. 11 percent of the children from the poorest households and only 3 percent from the children from the richest households were left with inadequate care. 50 X. EDUCATION Pre-School Attendance and School Readiness Pre-school education attendance in an organized learning or child education program is important for the readiness of children for school. One of the World Fit for Children goals is the promotion of early childhood education. Only 30 percent of children aged 36-59 months are attending some form of organized early childhood education programme. (Table ED.1). The limited national coverage is even less among the poorest, mother’s with primary or less education (6 percent), and in rural areas (12 percent). The percentage of children in the South who are currently attending pre-school education (44 percent) is higher than for children in the Central (33 percent) and North regions (15 percent). The table also shows the proportion of children in the first grade of primary school who attended pre-school the previous year (Table ED.1), an important indicator of school readiness. Overall, 64 percent of children in the first grade of primary school attended pre- school in the previous year. The proportion among males is slightly higher (68 percent) than for females (59 percent). Differences by region, urban-rural areas and socio-economic status for this indicator are minimal. Primary and Secondary School Participation Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the Millennium Development Goals and A World Fit for Children. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment, and influencing population growth. The indicators for primary and secondary school attendance include: • Net intake rate in primary education • Net primary school attendance rate • Net secondary school attendance rate • Net primary school attendance rate of children of secondary school age • Female to male education ratio (GPI) The indicators of school progression include: • Survival rate to grade five • Transition rate to secondary school • Net primary completion rate Of children who are of primary school entry age (children that are to turn 7 in the observed calendar year) in Montenegro, 94 percent are attending the first grade of primary school (ED.2). 51 Table ED.3 provides the percentage of children of primary school age attending primary or secondary school. The majority of children of primary school age are attending school (98 percent of children that are to turn 7 to 14 in the observed calendar year). Only two percent of children are out of school, although they are expected to be participating in school. There are no significant differences by region and urban-rural areas. A positive correlation is observed with mother’s education and socio-economic status. Among children of secondary school age, 84 percent are attending secondary school (Table ED.4), 2 percent are attending primary school (Table ED.4w), while the rest are out of school. Secondary school attendance is influenced by household wealth. Only 69 percent of children from the poorest households compared to 97 percent of the children from the richest household are attending secondary school. The percentage of children entering first grade who eventually reach grade 5 is presented in Table ED.5. Data shows that 97 percent of children in Montenegro entering first grade will eventually reach grade five. Notice, that this number includes children that repeat grades and that eventually move up to reach grade five. There are no significant differences by region, urban-rural areas, educational level of mother and socio-economic status of household. The net primary school completion rate and transition rate to secondary education is presented in Table ED.6. At the time of the survey, 91 percent of the children of primary completion age (14 years) were attending the last grade of primary education. Almost all of children (98 percent) that successfully completed the last grade of primary school, at the time of the survey, were attending the first grade of secondary school. This indicator is higher for females (94 percent), compared to males (87 percent). No significant difference by other background characteristics was detected. The ratio of girls to boys attending primary and secondary education is provided in Table ED.7. These ratios are better known as the Gender Parity Index (GPI). Notice that the ratios included here are obtained from net attendance ratios instead of gross attendance ratios. The last ratios provide an erroneous description of the GPI mainly because in most of the cases the majority of over-aged children attending primary education tend to be boys. The table shows that gender parity for primary school is close to 1.00, indicating no difference in the attendance of girls and boys to primary and secondary school. The disadvantage of girls is somewhat pronounced in the South region, as well as among children living in the poorest households and rural areas. 52 Adult Literacy One of the World Fit for Children goals is to assure adult literacy. Adult literacy is also an MDG indicator, relating to both men and women. In MICS, since only a women’s questionnaire was administered, the results are based only on females age 15-24. Literacy was assessed based on the ability of women to read a short simple statement on school attendance. The percent literate is presented in Table ED.8. Percentage of women aged 15- 24 who are literate is 93 and 3 percent of women that do not know whether they are able to read or write. The women in the Central and South regions are somewhat less literate (92 percent) then women in the North (96 percent). The percentage is almost the same in urban and rural areas. The percentage increases from 82 percent of literacy between the poorest women aged 15-24 , to 96 percent of the richest. Of course, there are differences by level of education. 67 percent women with only a primary education or less are literate, while 100 percent of women with a higher level of education. 53 XI. CHILD PROTECTION Birth Registration The Convention on the Rights of the Child states that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. The World Fit for Children states the goal to develop systems to ensure the registration of every child at or shortly after birth, and fulfil his or her right to acquire a name and a nationality, in accordance with national laws and relevant international instruments. The indicator is the percentage of children under 5 years of age whose birth is registered. The births of 98 percent of children under five years in Montenegro have been registered (Table CP.1). There are no significant variations in birth registration across sex, age, or education categories. Only one percent of interviewed mothers/caretakers does not know if their child’s birth was registered. Child Labour Article 32 of the Convention on the Rights of the Child states: "States Parties recognize the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child's education, or to be harmful to the child's health or physical, mental, spiritual, moral or social development." The World Fit for Children mentions nine strategies to combat child labour and the MDGs call for the protection of children against exploitation. In the MICS questionnaire, a number of questions addressed the issue of child labour, that is, children 5-14 years of age involved in labour activities. A child is considered involved in child labour activities at the moment of the survey if during the week preceding the survey: • Ages 5-11: at least one hour of economic work or 28 hours of domestic work per week. • Ages 12-14: at least 14 hours of economic work or 28 hours of domestic work per week. This definition allows for differentiating child labour from child work to identify the type of work that should be eliminated. As such, the estimate provided here is a minimum of the prevalence of child labour since some children may be involved in hazardous labour activities for a number of hours that could be less than the numbers specified in the criteria explained before. Table CP.2 presents the results of child labour by the type of work. Almost 10 percent of children aged 5-14 are involved in child labour, mainly unpaid work and working for family business. There is a strong correlation between child labour and region and type of settlement. Children living in rural areas are three times more likely to be involved in child labour activities (17 percent) compared to urban children (6 percent). Every fifth child in the North of Montenegro is involved in child labour activities, while for South and Central region this percentage is lower, (4 percent and 5 percent, respectively). Boys are slightly more involved in child labour activities than girls. The poorest children are the most exploited group, 24 percent of children from the poorest households are involved in child labour. 54 Table CP.3 presents the percentage of children classified as student labourers or as labourer students. Student labourers are the children attending school that were involved in child labour activities at the time of the survey. More specifically, the survey shows that 88 percent of children aged 5-14 attend school, and 10 percent of them are involved in child labour activities. On the other hand, out of the 10 percent of the children classified as child labourers, the majority of them are also attending school (87 percent). Child Discipline As stated in A World Fit for Children, “children must be protected against any acts of violence …” and the Millennium Declaration calls for the protection of children against abuse, exploitation and violence. In the Montenegro MICS survey, mothers/caretakers of children age 2-14 years were asked a series of questions on the ways parents tend to discipline their children when they misbehave. Note that for the child discipline module, one child aged 2-14 per household was selected randomly during fieldwork. Out of these questions, the two indicators used to describe aspects of child discipline are: • The number of children 2-14 years that experience psychological aggression as punishment or minor physical punishment or severe physical punishment; and • The number of parents/caretakers of children 2-14 years of age that believe that in order to raise their children properly, they need to physically punish them. In Montenegro, 61 percent of children aged 2-14 years were subjected to at least one form of psychological or physical punishment by their mothers/caretakers or other household members. More importantly, 6 percent of children were subjected to severe physical punishment. On the other hand, only 5 percent of mothers/caretakers believed that children should be physically punished, which implies an interesting contrast with the actual prevalence of physical discipline. Male children were subjected more to both minor and severe physical discipline (46 and 7 percent) than female children (38 and 4 percent, respectively). It is interesting to note that differences with respect to many of the background variables were relatively small. Physical punishment decreases with the age of the child. Mother’s education is strongly correlated with the child disciplining methods used. Less educated mothers more often use violent methods in child discipline than non-violent methods. The same pattern is seen when observing the wealth index – use of violent methods decreases and use of non-violent methods increases according to the degree of wealth. Early Marriage Marriage before the age of 18 is a reality for many young girls. According to UNICEF's worldwide estimates, over 60 million women aged 20-24 were married/in union before the age of 18. Factors that influence child marriage rates include: the state of the country's civil registration system, which provides proof of age for children; the existence of an adequate legislative framework with an accompanying enforcement mechanism to address cases of child marriage; and the existence of customary or religious laws that condone the practice. In many parts of the world parents, encourage the marriage of their daughters while they are still children in hopes that the marriage will benefit them both financially and socially, 55 while also relieving financial burdens on the family. In actual fact, child marriage is a violation of human rights, compromising the development of girls and often resulting in early pregnancy and social isolation, with little education and poor vocational training reinforcing the gendered nature of poverty. The right to 'free and full' consent to a marriage is recognized in the Universal Declaration of Human Rights - with the recognition that consent cannot be 'free and full' when one of the parties involved is not sufficiently mature to make an informed decision about a life partner. The Convention on the Elimination of all Forms of Discrimination against Women mentions the right to protection from child marriage in article 16, which states: "The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage.” While marriage is not considered directly in the Convention on the Rights of the Child, child marriage is linked to other rights - such as the right to express their views freely, the right to protection from all forms of abuse, and the right to be protected from harmful traditional practices - and is frequently addressed by the Committee on the Rights of the Child. Young married girls are a unique, though often invisible, group. Required to perform heavy amounts of domestic work, under pressure to demonstrate fertility, and responsible for raising children while still children themselves, married girls and child mothers face constrained decision-making and reduced life choices. Boys are also affected by child marriage but the issue impacts girls in far larger numbers and with more intensity. Cohabitation - when a couple lives together as if married - raises the same human rights concerns as marriage. Where a girl lives with a man and takes on the role of caregiver for him, the assumption is often that she has become an adult woman, even if she has not yet reached the age of 18. Additional concerns due to the informality of the relationship - for example, inheritance, citizenship and social recognition - might make girls in informal unions vulnerable in different ways than those who are in formally recognized marriages. Research suggests that many factors interact to place a child at risk of marriage. Poverty, protection of girls, family honour and the provision of stability during unstable social periods are considered as significant factors in determining a girl's risk of becoming married while still a child. Women who married at younger ages were more likely to believe that it is sometimes acceptable for a husband to beat his wife and were more likely to experience domestic violence themselves. The age gap between partners is thought to contribute to these abusive power dynamics and to increase the risk of untimely widowhood. Closely related to the issue of child marriage is the age at which girls become sexually active. Women who are married before the age of 18 tend to have more children than those who marry later in life. Pregnancy related deaths are known to be a leading cause of mortality for both married and unmarried girls between the ages of 15 and 19, particularly among the youngest of this cohort. There is evidence to suggest that girls who marry at young ages are more likely to marry older men that puts them at increased risk of HIV infection. Parents seek to marry off their girls to protect their honour, and men often seek younger women as wives as a means to avoid choosing a wife who might already be infected. The demand for the young wife to reproduce, and the power imbalance resulting from the age differential leads to very low condom use among such couples. Two of the indictors used estimate the percentage of women married before 15 years of age and the percentage married before 18 years of age. The percentage of women married at various ages is provided in Table CP.5. In Montenegro, there are no women aged 15-49 who married before 15, but 7 percent of women aged 20-49 married before 18. By region: 10 56 percent of women in the North married before 18, and 7 percent in the Central and 5 percent in the South. Over 20 percent of the women with primary education or less married before 18, 5 percent of women with secondary and only one percent with university. A similar situation is demonstrated when observing wealth; the poorest women are more likely to get married before 18. Only two percent of women 15-19 years in Montenegro are currently married or in union. Another component of this issue is spousal age difference, with an indicator being the percentage of married/in union women with a difference of 10 or more years of age compared to their current spouse. Table CP.6 presents the results of the age difference between husbands and wives. The percentage of currently married/in union women aged 15-19 whose husband or partner is 10 and over years older is 36, and the same percentage for women aged 20-24 older is 17. Only two percent of currently married/in union women aged 20-24 have a younger husband or partner. Domestic Violence A number of questions were asked of women age 15-49 years to assess their attitudes towards whether husbands are justified to hit or beat their wives/partners in a variety of scenarios. These questions were asked to have an indication of cultural beliefs that tend to be associated with the prevalence of violence against women by their husbands/partners. The main assumption here is that women that agree with the statements indicating that husbands/partners are justified to beat their wives/partners under the situations described in reality tend to be abused by their own husbands/partners. The responses to these questions can be found in Table CP.7 . In Montenegro women believe that her partner is justified to beat her for one of the following reasons: • 4 percent when she goes out without telling him • 10 percent when she neglects the children • 3 percent when she argues with him • 2 percent when she refuses sex with him • 2 percent when she burns the food Summary, every tenth women in Montenegro believes that her partner is justified to beat her because of any of previous reasons. In the North, the South and in rural areas this percentage is 14, while 6 percent women from Central region and 9 percent of women in urban area have same opinion. According to education level, 16 percent of women with primary or less and 11 percent with secondary and only 6 percent of women with university believe that her partner are justified to beat her because of any of previous reasons. The same is true when looking at the wealth index, almost 23 percent of the poorest and only 4 percent of the richest women believe in the same. 57 Child Disability One of the World Fit for Children goals is to protect children against abuse, exploitation, and violence, including the elimination of discrimination against children with disabilities. For children age 2 through 9 years, a series of questions were asked to assess a number of disabilities/impairments, such as sight impairment, deafness, and difficulties with speech. This approach rests in the concept of functional disability developed by WHO and aims to identify the implications of any impairment or disability for the development of the child (e.g. health, nutrition, education, etc.). Table CP.8 presents the results of these questions. In Montenegro, 1 percent of children aged 2-9 has difficulty seeing, either in the daytime or at night, 7 percent have no understanding of instructions, furthermore, 1 percent are not learning to do things like other children his/her age, 3 percent are not speaking or cannot be understood in words and 1 percent appears mentally backward, dull, or slow. According to previous data, 13 percent of children age 2-9 have at least one reported disability. The highest level of reporting of at least one disability is in the South of Montenegro at 23 percent, while in the North it is 12 percent, and in the Central 8 percent. Such a high percentage of children with at least one reported disability in the South is quite unexpected and there is a question of whether mothers/caretakers misunderstood the question” When you tell a child to do something, does he/she seem to understand what you are saying?”. There are no significant differences by type of area, age of children or wealth index. 58 XII. HIV/AIDS, SEXUAL BEHAVIOUR Knowledge of HIV Transmission and Condom Use One of the most important prerequisites for reducing the rate of HIV infection is accurate knowledge of how HIV is transmitted and strategies for preventing transmission. Correct information is the first step toward raising awareness and giving young people the tools to protect them from infection. Misconceptions about HIV are common and can confuse young people and hinder prevention efforts. Different regions are likely to have variations in misconceptions although some appear to be universal (for example that sharing food can transmit HIV or mosquito bites can transmit HIV). The UN General Assembly Special Session on HIV/AIDS (UNGASS) called on governments to improve the knowledge and skills of young people to protect themselves from HIV. The indicators to measure this goal as well as the MDG of reducing HIV infections by half include improving the level of knowledge of HIV and its prevention, and changing behaviours to prevent further spread of the disease. The HIV module was administered to women 15-49 years of age. One indicator which is both an MDG and UNGASS indicator is the percent of young women who have comprehensive and correct knowledge of HIV prevention and transmission. Women were asked whether they knew of the three main ways for HIV transmission – having only one faithful uninfected partner, using a condom every time, and abstaining from sex. The results are presented in Table HA.1. In Montenegro, almost all of the interviewed women (97 percent) have heard of AIDS. However, the percentage of women who know of all three main ways of preventing HIV transmission is only 50 percent. Seventy percent of women know of having one faithful uninfected sex partner, 86 percent know of using a condom every time, and 64 percent know of abstaining from sex as the main ways of preventing HIV transmission. While 91 percent of women know at least one way, only a small proportion of women, 9 percent, do not know any of the three ways. Knowledge about HIV is positively correlated with level of education. Almost all women with a university education compared to 86 percent women with primary or less had heard of HIV/AIDS. There is a similar situation with level of wealth index. Ninety- nine percent of the richest women and 90 percent of the poorest women had heard of HIV/AIDS. Almost the same number of women had heard of HIV in the Central, North and South regions. The percent is also equal in urban and rural areas. There are no differences by age. Women in the Central region have the best knowledge about ways of preventing HIV transmission (53 percent) and in the North (51 percent), while this percent in the South is slightly lower (42 percent). There are no differences by area and age. 39 percent of women with primary school or less know all three ways to prevent HIV transmission, while 54 percent women with university education have this knowledge. The figures are similar when observing the wealth of women; 42 percent of the poorest women and 54 percent the richest women know all three prevention ways of HIV transmissions. At least one way to prevent HIV transmissions is known by 69 percent of women with primary or less education and 99 percent of women with university education. A lower value (75 percent) of the same indicator relates to the poorest women, while it is 97 percent among the richest women. 7 percent of interviewed women in the South do not know any ways to prevent HIV 59 transmission, while in the North this percentage is more than double. The values are the same when comparing urban and rural areas. Over 30 percent of women with a primary education or less and only one percent of women with a university education do not know any ways to prevent HIV transmission. The situation is similar with 25 percent of the poorest and only 3 percent of the richest women. Table HA.2 presents the percent of women who can correctly identify misconceptions concerning HIV. The indicator is based on the two most common and relevant misconceptions in Montenegro, that HIV can be transmitted by sharing food with an infected person and mosquito bites. The table also provides information on whether women know that HIV cannot be transmitted by supernatural means, and that HIV can be transmitted by sharing needles. Of the interviewed women, 34 percent reject the two most common misconceptions and know that a healthy-looking person can be infected. 66 percent of women know that HIV cannot be transmitted by sharing food, and 49 percent of women know that HIV cannot be transmitted by mosquito bites, while 76 percent of women know that a healthy-looking person can be infected. 84 percent of women in Montenegro know that HIV cannot be transmitted by supernatural means and 92 percent know that HIV can be transmitted by sharing needles. Women in the North of Montenegro demonstrated the lowest ability to correctly identify misconceptions related to HIV/AIDS. Only 24 percent of women aged 15-49 in the North rejected two most common misconceptions and know a healthy-looking person can be infected, and 74 percent think that HIV cannot be transmitted by supernatural means. 86 percent of interviewed women in the South, 78 percent in Central and 65 percent in the North know that a healthy looking person can be infected. Women in urban areas have greater knowledge than those in rural areas on all indicators. 81 percent of women in urban areas and 68 percent in rural areas, aged 15-49, know that a healthy looking person can be infected. In general, there are no significant differences in knowledge about transmission of HIV by age of interviewed women but there is positive correlation with level of education of interviewed women and with the wealth index. Table HA.3 summarizes information from Tables HA.1 and HA.2 and presents the percentage of women who know two ways of preventing HIV transmission and reject three common misconceptions. Comprehensive knowledge of HIV prevention methods and transmission is still low although there are differences by area of residence. Overall, 26 percent of women were found to have comprehensive knowledge, which was slightly higher in urban areas (30 percent) then in rural areas (21 percent). As expected, the percent of women with comprehensive knowledge increases with the woman’s education level (Figure HA.1). Only ten percent of women with primary education or less, 27 percent with secondary education and 43 percent with university education have comprehensive knowledge of HIV prevention methods and transmission. There is a similar correlation with the wealth index. 14 percent of the poorest women and 38 percent of the richest women aged 15-49 identify 2 prevention methods and 3 misconceptions. There are no significant differences according to the age of interviewed women. 60 Figure HA.1 Percent of women who have comprehensive knowledge of HIV/AIDS transmission, Montenegro, 2005 50.1 69.0 74.0 66.3 11.7 35.3 55.8 34.5 9.8 26.6 43.0 26.4 0 10 20 30 40 50 60 70 80 Primary or less Secondary University Montenegro Pe rc en t Knows 2 ways to prevent HIV Identify 3 misconceptions Comprehensive knowledge Knowledge of mother-to-child transmission of HIV is also an important first step for women to seek HIV testing when they are pregnant to avoid infection in the baby. Women should know that HIV could be transmitted during pregnancy, delivery, and through breastfeeding. The level of knowledge among women age 15-49 years concerning mother-to-child transmission is presented in Table HA.4. Overall, 86 percent of women know that HIV can be transmitted from mother to child. The percentage of women who know all three ways of mother-to-child transmission is 65 percent, while 11 percent of women did not know any specific way. 84 percent women know HIV can be transmitted from mother to child during pregnancy, this percentage is little bit lower among women who know HIV can be transmitted from mother to child at delivery (76 percent) and through breast milk (71 percent). The table HA.4. shows the percentage of women aged 15-49 who correctly identify means of HIV transmission from mother to child. There are no significant differences by urban/rural area, region, age of women or wealth index. In addition, there are no differences by education level. The indicators on attitudes toward people living with HIV measure stigma and discrimination in the community. Stigma and discrimination are low if respondents report an accepting attitude on the following four questions: 1) would care for family member sick with AIDS; 2) would buy fresh vegetables from a vendor who was HIV positive; 3) thinks that a female teacher who is HIV positive should be allowed to teach in school; and 4) would not want to keep HIV status of a family member a secret. Table HA.5 presents the attitudes of women towards people living with HIV/AIDS. In Montenegro, 35 percent of women aged 15-49 years who have heard of AIDS agree with none of the discriminatory statements, and this means that 65 percent agree with at least one discriminatory statement. The structure of discriminatory statement is the following: 60 percent of interviewed women would not buy food from a person with HIV/AIDS; 43 percent believe that a female teacher with HIV should not be allowed to work, 21 percent 61 think that if a family member had HIV they would want to keep it a secret and finally even 4 percent of interviewed women would not care for a family member who was sick with AIDS. Over 50 percent of women in the South agree with none of the discriminatory statements. In the Central and in the North regions this figure was less than 25%. There are no significant differences by urban and rural area and by age of women, but with increasing of level of education this percentage also increases. Among the poorest women, 17 percent agree with none of the discriminatory statements compared to 43 percent of the richest women. Another important indicator is the knowledge of where to be tested for HIV and use of such services. Questions related to the knowledge among women of a facility for HIV testing and whether they have ever been tested is presented in Table HA.6. 70 percent of women know where to be tested, while only 3 percent have actually been tested. Of these, a large proportion have been told the result (87 percent). In the South 86 percent women know a place to get a tested, while this percent in the Central region is 67 and in the North 62. Women in urban areas know better where to get a test (74 percent) compared with women in rural areas (63 percent). There are no differences by age, but there are by education level and wealth index. Only 43 percent of women with primary education or less know place to get a test, this percentage increases with level of education. However, 87 percent of women have a good knowledge of a facility for HIV testing. Similarly, this indicator is 40 percent among the poorest women and more then twice higher among the richest women (84 percent). A very small number of women have been tested and there are no differences by region, area and age of women. The percent of women who have been tested increases from 1 percent among women with primary education or less and among the poorest women to 7 percent among women with university education and among the richest women. Among women who had given birth within the two years preceding the survey, the percent who received counselling and HIV testing during antenatal care is presented in Table HA.7. Among the 97 percent women who received antenatal care from a health professional for last pregnancy, only 11 percent were provided with information about HIV prevention during an antenatal care visit, only 2 percent were tested for HIV and all of them received results of HIV test. Women in the South had access to better information about HIV prevention during antenatal care compared with their counterparts in the North and Central regions. As a women’s education level and position along the wealth index increases the value of this indicator also increases. Sexual Behaviour Related to HIV Transmission Promoting safer sexual behaviour is critical for reducing HIV prevalence. The use of condoms during sex, especially with non-regular partners, is especially important for reducing the spread of HIV. In most countries, over half of new HIV infections are among young people 15-24 years, thus a change in behaviour among this age group is especially important for reducing new infections. A module of questions was administered to women 15-24 years of age to assess their risk of HIV infection. Risk factors for HIV include sex at an early age, sex with older men, sex with a non-marital, non-cohabitating partner, and failure to use a condom. The frequency of sexual behaviours that increase the risk of HIV infection among women is presented in Table HA.8 and Figure HA.2. In Montenegro, there are almost no women aged 15-19 who had sex before age 15. Only 7 percent of women aged 20-24 had sex before age 18. 62 This percentage is in opposite correlation with education level and wealth index. From 25 percent of women with primary education or less, this percentage decreases to 3 percent of women with university education. Similarly, from 11 percent among the poorest women this percent decreases to 3 percent of the richest women. The third group of high risk sex is sex with a man 10 or more years older. 13 percent of women aged 15-24 had sex with a man 10 or more years older. In the North, it is 21 percent, while in the Central region it is 12 percent, and in the South only 6 percent. By other categories (area, education level, wealth index, age) there are no significant differences. Figure HA.2 Sexual behaviour that increases risk of HIV infection, Montenegro, 2005 0.6 0.0 0.4 7.5 6.8 7.3 11.0 14.9 12.5 0 2 4 6 8 10 12 14 16 Urban Rural Country Pe rc en t Women 15-19 w ho had sex before age 15 Women 20-24 w ho had sex before age 18 Women 20-24 w ho had sex in last 12 months w ith a man 10 years or more older Condom use during sex with men other than husbands or live-in partners (non-marital, non- cohabiting) was assessed in women 15-24 years of age who had sex with such a partner in the previous year (Table HA.9). 27 percent of women aged 15-24 ever had sex, 21 percent had sex in last 12 month. Almost no women aged 15-24 reported that they had sex with more than one partner in the last 12 months. However, of women 15-24 years who reported having sex in the 12 months prior to MICS, 45% had sex with a non-regular partner. 66 percent of these women report using a condom when they had sex with the high-risk partner. 50 percent of women with primary or less education used a condom during higher risk sex in the year before the MICS while 70 and 66 percent of women with secondary and university education used a condom with such a partner. 63 LIST OF REFERENCES Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization, 74(2), 209-16. Blanc, A. and Wardlaw, T. 2005. "Monitoring Low Birth Weight: An Evaluation of International Estimates and an Updated Estimation Procedure". WHO Bulletin, 83 (3), 178-185. Filmer, D. and Pritchett, L., 2001. Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India. Demography 38(1): 115-132. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro. UNICEF, 2006. Monitoring the Situation of Children and Women. Multiple Indicator Cluster Survey Manual, New York. United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations publication, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Pop Division United Nations, 1990b. Step-by-step Guide to the Estimation of Child Mortality. New York, UN WHO and UNICEF, 1997. The Sisterhood Method for Estimating Maternal Mortality. Guidance notes for potential users, Geneva. www.Childinfo.org. 64 APPENDIX A. SAMPLE DESIGN The major features of sample design are described in this appendix. Sample design features include target sample size, sample allocation, sample frame and listing, choice of domains, sampling stages, stratification, and the calculation of sample weights. The primary objective of the sample design for the Montenegro Multiple Indicator Cluster Survey was to produce statistically reliable estimates of most indicators, at the national level, for urban and rural areas, and for the three regions of the country: South, Central and North. A stratified, two-stage random sampling approach was used for the selection of the survey sample. Sample Size and Sample Allocation Montenegro is characterised by a very low fertility rate and a small number of household members. For example, one generation of children born makes up less than 1 percent of the population, and the average number of household members is around 3. Owing to these facts a modification of the recommended sample plan had to be made, resulting in the stratification of households in selected census block units into two categories: households with children and households without children under 5. The allocation of the sample in the category of households with children was significantly bigger than the allocation of the sample in the category of households without children. The target sample size for the Montenegro MICS was calculated as 2300 households. For the calculation of the sample size, the key indicator used was the percentage of children aged 0- 4 years who had had Acute Respiratory infections. The following formula was used to estimate the required sample size for these indicators: where • n is the required sample size, expressed as number of households • 4 is a factor to achieve the 95 per cent level of confidence • r is the predicted or anticipated prevalence (coverage rate) of the indicator • nr is the factor necessary to raise the sample size by 100(nr -1) percent for non- response • f is the shortened symbol for deff (design effect) • me*r is the margin of error to be tolerated at the 95 percent level of confidence, defined as me percent of r (relative sampling error of r) • p is the proportion of the total population upon which the indicator, r, is based • nh is the average household size. n = [ 4 (r) (1-r) (f) (nr) ] (1) [ (me) 2 (r)2 (p) (nh) ] 65 For the calculation, r (percentage of children aged 0-4 years who had had Acute Respiratory infections) was assumed to be 12 percent. The expected non-response rate nr, was determined at 15 percent. The value of deff (design effect) was taken as 1.5 based on estimates from previous surveys. The maximum relative error allowed (me) was 20 percent, p (percentage of children aged 0-4 years in the total population) was taken as 6.5 percent and nh (average household size) was taken as 3. The resulting number of households from this exercise was 6478 households. Only a sample of that size would provide a significant number of children under 5 for drawing reliable conclusions. Therefore, in order to cut down the number of households in the sample, but not to lose estimation reliability, the stratification of the sample into categories with and without children aged 0-4 years was needed. For calculation of the necessary number of households in each category, the following formula was used: n = (ns) (nc) (ps) (2) where • n is the required sample size, expressed as the number of households • ns is the expected number of households with, or the number of households without children under 5 in a cluster, depending on what category the calculation is used • nc is the number of clusters in the sample, and • ps is the probability of selection of the household in each category. Taking into account that the proportion of children under 5 in the total population, p was 6.5 percent, and if the average household size is 3, the estimated number of households with children was 19.5 per 100 households (the average number of households in each cluster). So the ns was assumed to be 19.5 for the category with children, and 80.5 for the category without children. The probability of selection of a household (ps) with at least one child out of all households with children was assumed to be 0.5, and the probability of selecting a household without children from all households with children in each cluster was 0.1. Supposing that 140 clusters were about to be selected, the total number of households was calculated at 1365 households with, and 1127 of households without children under 5, which makes a total of 2492 households. The average cluster size in the Montenegro MICS was determined as 18 households, plus 3 backup households. Back-up households were to be interviewed only if some of the first 18 households were not found. In cases where a household refused to be interviewed, the substitution with a back-up household was not possible. The calculation was based on a number of considerations, including the budget available, and the time that would be needed per team to complete one cluster. Dividing the total number of households by the number of households per cluster, it was calculated that the selection of a total number of 141 clusters in Montenegro would be needed in all regions. Allocation of the total sample size to the three regions was targeted with probability proportional to the regions’ size. Therefore, 141 Montenegro sample clusters were allocated across the regions, with the final sample size calculated at 2538 households (141) clusters * 18 households per cluster). In each region, the clusters (primary sampling units) were distributed to urban and rural domains, proportional to the size of the urban and rural 66 populations in that region. The table below shows the allocation of clusters to the sampling domains. Table SD.1: Allocation of Sample Clusters (Primary Sampling Units) to Sampling Domains Region Population (Census 2003) Number of Clusters Urban Rural Total Urban Rural Total North 24789 16961 41750 19 13 32 Central 65235 18266 83501 50 14 64 South 24789 33922 58712 19 26 45 Total 114814 69149 183963 88 53 141 Sampling Frame and Selection of Clusters The 2003 Montenegro Population Census framework was used for the selection of clusters. Census enumeration areas (app. 100 households) were defined as primary sampling units (PSUs), and were selected from each of the sampling domains by using systematic pps (probability proportional to size) sampling procedures, based on the estimated sizes of the enumeration areas from the 2003 Population Census. The first stage of sampling was thus completed by selecting the required number of enumeration areas from each of the 3 regions by urban and rural areas separately. Listing Activities Since the sample frame (the 2003 Population Census) was not up to date, household lists in all selected enumeration areas were updated prior to the selection of households. For this purpose, listing teams were formed, who visited each enumeration area, and listed the occupied households. The Statistical Office of the Republic of Montenegro (MONSTAT) and The Strategic Marketing Research Agency were responsible for updating household lists. The listing exercise was performed by teams which were the direct implementers of the field work during the course of data collection that came later. The whole territory of Montenegro was divided into 5 districts according to the regional network of institutions responsible for listing and fieldwork. In each district one or two teams of people was selected – one supervisor for the district and the interviewers (whose number depended on the number of clusters in the region). Criteria for the selection of the interviewers and supervisors were their qualifications, communication skills, experience in the field work and knowledge of the region where research was to be conducted. A total of 7 teams were formed. For each team, the list of all households in the selected cluster from the last census was provided. The interviewers’ task was to go to the addresses listed and to mark any change that had happened, e.g. the dwelling didn’t exist any more, the household had moved away from the dwelling and another household was living there, and to note the number of children under five living in the household. The listing process was performed during September 2005. Besides providing updated information on households, updating household lists made interviewers more acquainted with the field. 67 Selection of Households Lists of households were prepared by the listing teams in the field for each enumeration area. The households were then sequentially numbered from 1 to n (the total number of households in each enumeration area) at the Strategic Marketing Research Agency. Selection of 18 plus 3 back-up households with equal probability in each enumeration area was carried out using the method of random start and equal random walk (simulation of the SRSWoR scheme). Before the selection of households, updated census block units were put into two categories: households with children and households without children under 5. Calculation of Sample Weights The Montenegro Multiple Indicator Cluster Survey sample is not self-weighted. Sample weights were used essentially because the sample stratification according to region, type of settlement and households with and without children under 5 was made. Calculated sample weights were used in the subsequent analyses of the survey data. The major component of weight for both samples is the reciprocal value of the sampling fraction employed in selecting the number of sample households in that particular stratum: Wh = 1 / fh (3) The term fh, the sampling fraction at the h-th stratum, is the product of probabilities of selection at every stage in each stratum: fh = P1h * P2h (4) where Pih is the probability of selection of the sampling unit in the i-th stage for the h-th stratum. where Pih is the probability of selection of the sampling unit in the i-th stage for the h-th strata. Since the estimated numbers of households per enumeration area prior to the first stage selection (selection of primary sampling units) and the updated number of households per enumeration area were different, individual sampling fractions for households in each enumeration area (cluster) were calculated. The sampling fractions for households in each enumeration area (cluster) therefore included the probability of selection of the enumeration area in that particular sampling domain, and the probability of selection of a household in the sample enumeration area (cluster). A second component which has to be taken into account in the calculation of sample weights is the level of non-response for household and individual interviews. The adjustment for household non-response is equal to the inverse value of: RR = Number of interviewed households / Number of occupied households listed (5) After completion of the fieldwork, response rates were calculated for each sampling domain. These were used to adjust the sample weights calculated for each cluster. Response rates in the Montenegro Multiple Indicator Cluster Survey are shown in Table HH.1 in this report. 68 Similarly, the adjustment for non-response at the individual level (women and under-5 children) is equal to the inverse value of: RR = Completed women’s (or under-5’s) questionnaires / Eligible women (or under-5s) (6) The numbers of eligible women and under-5 children were obtained from the household listing in the Household Questionnaire in households where interviews were completed. The unadjusted weights for the households were calculated by multiplying the above factors for each enumeration area. These weights were then standardised (or normalised), one purpose of which is to make the sum of the interviewed sample units equal to the total sample size at the national level. Normalisation is performed by multiplying the aforementioned unadjusted weights by the ratio of the number of completed households to the total unadjusted weighted number of households. A similar standardisation procedure was followed in obtaining standardised weights for the women’s and under-5s questionnaires. Adjusted (normalised) weights varied between 0.48 and 1.28. Sample weights were appended to all data sets and analyses were performed by weighting each household, woman or under-5 with these sample weights. 69 APPENDIX B. LIST OF PERSONNEL INVOLVED IN THE SURVEY Overall supervision and management: Ann-Lis Svensson Project Management: Oliver Petrovic Coordination team: Dragisa Bjeloglav Dragana Djokovic-Papic Itana Labovic Oliver Petrovic Snežana Remiković Sampling: Dragisa Bjeloglav Questionnaire Design: Dragisa Bjeloglav Dragana Djoković-Papic Itana Labovic Ivana Bjelic Natalija Biliskov Olivera Miljanovic Oliver Petrovic Snezana Remikovic Tatjana Jovanov Data Processing/Programming: Aleksanar Zoric Ivana Bjelic Field Coordinators: Itana Labovic Snezana Remikovic Vladimir Raicevic Field supervisors: Biljana Sekulovic Cvetana Toskovic Radule Lainovic Vladimir Knezevic Zdenka Brajovic 70 APPENDIX C. ESTIMATES OF SAMPLING ERRORS The sample of respondents selected in the Montenegro Multiple Indicator Cluster Survey is only one of the samples that could have been selected from the same population, using the same design and size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. The extent of variability is not known exactly, but can be estimated statistically from the survey results. The following sampling error measures are presented in this appendix for each of the selected indicators: Standard error (se): Sampling errors are usually measured in terms of standard errors for particular indicators (means, proportions etc). Standard error is the square root of the variance. The Taylor linearization method is used for the estimation of standard errors. Coefficient of variation (se/r) is the ratio of the standard error to the value of the indicator Design effect (deff) is the ratio of the actual variance of an indicator, under the sampling method used in the survey, to the variance calculated under the assumption of simple random sampling. The square root of the design effect (deft) is used to show the efficiency of the sample design. A deft value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a deft value above 1.0 indicates the increase in the standard error due to the use of a more complex sample design. Confidence limits are calculated to show the interval within which the true value for the population can be reasonably assumed to fall. For any given statistic calculated from the survey, the value of that statistics will fall within a range of plus or minus two times the standard error (p + 2.se or p – 2.se) of the statistic in 95 percent of all possible samples of identical size and design. For the calculation of sampling errors from MICS data, SPSS Version 14 Complex Samples module has been used. The results are shown in the tables that follow. In addition to the sampling error measures described above, the tables also include weighted and unweighted counts of denominators for each indicator. Sampling errors are calculated for indicators of primary interest, for the national total, for the regions, and for urban and rural areas. One of the selected indicators is based on households, 6 are based on household members, 11 are based on women, and 10 are based on children under 5. All indicators presented here are in the form of proportions. Table SE.1 shows the list of indicators for which sampling errors are calculated, including the base population (denominator) for each indicator. Tables SE.2 to SE.9 show the calculated sampling errors. 71 Table SE.1: Indicators selected for sampling error calculations List of indicators selected for sampling error calculations, and base populations (denominators) for each indicator, Montenegro, 2002 MICS Indicator Base Population HOUSEHOLDS 74 Child discipline Children aged 2-14 years selected HOUSEHOLD MEMBERS 11 Use of improved drinking water sources All household members 12 Use of improved sanitation facilities All household members 55 Net primary school attendance rate Children of primary school age 56 Net secondary school attendance rate Children of secondary school age 59 Primary completion rate Children of primary school completion age 71 Child labour Children aged 5-14 years WOMEN 4 Skilled attendant at delivery Women aged 15-49 years with a live birth in the last 2 years 20 Antenatal care Women aged 15-49 years with a live birth in the last 2 years 21 Contraceptive prevalence Women aged 15-49 currently married/in union 60 Adult literacy Women aged 15-24 years 67 Marriage before age 18 Women aged 20-49 years 82 Comprehensive knowledge about HIV prevention among young people Women aged 15-24 years 83 Condom use with non-regular partners Women aged 15-24 years who had a non-marital, non-cohabiting partner in the last 12 months 84 Age at first sex among young people Women aged 15-24 years 86 Attitude towards people with HIV/AIDS Women aged 15-49 years 88 Women who have been tested for HIV Women aged 15-49 years 89 Knowledge of mother- to-child transmission of HIV Women aged 15-49 years UNDER-5s 6 Underweight prevalence Children under age 5 - Tuberculosis immunization coverage Children aged 12-23 months - Polio immunization coverage Children aged 12-23 months - Immunization coverage for DPT Children aged 12-23 months - Measles immunization coverage Children aged 12-23 months - Fully immunized children Children aged 12-23 months - Diarrhoea in last two weeks Children under age 5 35 Received ORT or increased fluids and continued feeding Children under age 5 with diarrhoea in the last 2 weeks 46 Support for learning Children under age 5 62 Birth registration Children under age 5 72 Table SE.2: Sampling errors: Total sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, Montenegro, 2005 Table Value (r) Standard error (se) Coefficient of variation (se/r) Design effect (deff) Square root of design effect (deft) Weighted count Unweighted count Confidence limits r - 2se r + 2se HOUSEHOLDS Child discipline CP.4 0.6137 0.0176 0.0286 1.5408 1.2413 1004 1183 0.579 0.649 HOUSEHOLD MEMBERS Use of improved drinking water sources EN.1 0.9829 0.0035 0.0035 1.7010 1.3042 8991 2358 0.976 0.990 Use of improved sanitation facilities EN.5 0.9898 0.0021 0.0021 1.0449 1.0222 8991 2358 0.986 0.994 Net primary school attendance rate ED.3 0.9750 0.0052 0.0053 1.3563 1.1646 1151 1229 0.965 0.985 Net secondary school attendance rate ED.4 0.8435 0.0184 0.0218 1.2957 1.1383 556 505 0.807 0.880 Primary completion rate ED.6 0.9108 0.0184 0.0202 0.5774 0.7599 142 139 0.874 0.948 Child labour CP.2 0.0985 0.0131 0.1334 3.1293 1.7690 1479 1610 0.072 0.125 WOMEN Skilled attendant at delivery RH.5 0.9884 0.0052 0.0053 0.8245 0.9080 212 351 0.978 0.999 Antenatal care RH.3 0.9736 0.0082 0.0085 0.9237 0.9611 212 351 0.957 0.990 Contraceptive prevalence RH.1 0.3937 0.0166 0.0423 1.7298 1.3152 1352 1492 0.360 0.427 Adult literacy ED.8 0.9339 0.0076 0.0081 0.5798 0.7615 674 629 0.919 0.949 Marriage before age 18 CP.5 0.0680 0.0066 0.0976 1.3605 1.1664 1912 1959 0.055 0.081 Comprehensive knowledge about HIV prevention among young people HA.3 0.2976 0.0256 0.0861 1.9708 1.4039 674 629 0.246 0.349 Condom use with non-regular partners HA.9 0.6636 0.0510 0.0769 0.6060 0.7785 64 53 0.562 0.766 Age at first sex among young people HA.8 0.0035 0.0035 1.0017 1.0538 1.0265 346 299 0.000 0.011 Attitude towards people with HIV/AIDS HA.5 0.3135 0.0163 0.0521 2.6899 1.6401 2178 2168 0.281 0.346 Women who have been tested for HIV HA.6 0.0302 0.0046 0.1522 1.6261 1.2752 2258 2258 0.021 0.039 Knowledge of mother- to-child transmission of HIV HA.4 0.6507 0.0163 0.0250 2.6341 1.6230 2258 2258 0.618 0.683 UNDER-5s Underweight prevalence NU.1 0.0263 0.0051 0.1933 0.8404 0.9167 829 834 0.016 0.036 Tuberculosis immunization coverage CH.2 0.8922 0.0185 0.0208 0.7137 0.8448 198 201 0.855 0.929 Polio immunization coverage CH.2 0.8874 0.0193 0.0217 0.6626 0.8140 174 179 0.849 0.926 Immunization coverage for DPT CH.2 0.9227 0.0129 0.0140 0.4130 0.6427 172 177 0.897 0.949 Measles immunization coverage CH.2 0.8326 0.0207 0.0249 0.6076 0.7795 195 198 0.791 0.874 Fully immunized children CH.2 0.6705 0.0298 0.0444 0.7066 0.8406 172 177 0.611 0.730 Diarrhoea in last two weeks CH.3 0.0510 0.0092 0.1813 1.8702 1.3676 1061 1061 0.032 0.069 Received ORT or increased fluids and continued feeding CH.4 0.6433 0.0438 0.0681 0.4603 0.6785 54 56 0.556 0.731 Support for learning CD.1 0.8894 0.0104 0.0117 1.1721 1.0826 1061 1061 0.869 0.910 Birth registration CP.1 0.9792 0.0086 0.0087 3.8088 1.9516 1061 1061 0.962 0.996 73 Table SE.3: Sampling errors: Urban areas Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, Montenegro, 2005 Table Value (r) Standard error (se) Coefficient of variation (se/r) Design effect (deff) Square root of design effect (deft) Weighted count Unweighted count Confidence limits r - 2se r + 2se HOUSEHOLDS Child discipline CP.4 0.6114 0.0208 0.0340 1.3529 1.1631 632 743 0.570 0.653 HOUSEHOLD MEMBERS Use of improved drinking water sources EN.1 0.9989 0.0011 0.0011 1.7097 1.3076 5587 1490 0.997 1.000 Use of improved sanitation facilities EN.5 0.9991 0.0007 0.0007 0.8690 0.9322 5587 1490 0.998 1.000 Net primary school attendance rate ED.3 0.9700 0.0070 0.0072 1.2356 1.1116 694 735 0.956 0.984 Net secondary school attendance rate ED.4 0.8761 0.0179 0.0204 0.8758 0.9359 335 299 0.840 0.912 Primary completion rate ED.6 0.8901 0.0314 0.0353 0.7656 0.8750 82 77 0.827 0.953 Child labour CP.2 0.0553 0.0142 0.2564 3.7160 1.9277 897 967 0.027 0.084 WOMEN Skilled attendant at delivery RH.5 0.9952 0.0003 0.0003 0.0031 0.0560 128 210 0.995 0.996 Antenatal care RH.3 0.9735 0.0106 0.0109 0.9094 0.9536 128 210 0.952 0.995 Contraceptive prevalence RH.1 0.3673 0.0200 0.0544 1.5939 1.2625 844 928 0.327 0.407 Adult literacy ED.8 0.9163 0.0109 0.0119 0.5821 0.7630 415 377 0.894 0.938 Marriage before age 18 CP.5 0.0598 0.0085 0.1420 1.5896 1.2608 1225 1241 0.043 0.077 Comprehensive knowledge about HIV prevention among young people HA.3 0.3056 0.0280 0.0917 1.3920 1.1798 415 377 0.250 0.362 Condom use with non-regular partners HA.9 (0.6707) (0.0474) (0.0707) (0.3764) (0.6135) 46 38 (0.576) (0.765) Age at first sex among young people HA.8 0.0058 0.0058 1.0029 1.0379 1.0188 210 178 0.000 0.017 Attitude towards people with HIV/AIDS HA.5 0.3224 0.0198 0.0614 2.4303 1.5589 1380 1356 0.283 0.362 Women who have been tested for HIV HA.6 0.0401 0.0067 0.1677 1.6679 1.2915 1434 1419 0.027 0.054 Knowledge of mother- to-child transmission of HIV HA.4 0.6414 0.0204 0.0317 2.5562 1.5988 1434 1419 0.601 0.682 UNDER-5s Underweight prevalence NU.1 0.0316 0.0074 0.2341 0.9463 0.9728 532 531 0.017 0.046 Tuberculosis immunization coverage CH.2 0.8915 0.0264 0.0296 0.9233 0.9609 129 129 0.839 0.944 Polio immunization coverage CH.2 0.8727 0.0231 0.0265 0.5479 0.7402 113 115 0.826 0.919 Immunization coverage for DPT CH.2 0.9051 0.0173 0.0191 0.3924 0.6264 112 114 0.871 0.940 Measles immunization coverage CH.2 0.8417 0.0284 0.0337 0.7736 0.8795 129 129 0.785 0.898 Fully immunized children CH.2 0.6730 0.0403 0.0599 0.8331 0.9127 112 114 0.592 0.754 Diarrhoea in last two weeks CH.3 0.0631 0.0137 0.2165 2.0945 1.4472 671 665 0.036 0.090 Received ORT or increased fluids and continued feeding CH.4 (0.6300) (0.0449) (0.0712) (0.3629) (0.6024) 42 43 (0.540) (0.720) Support for learning CD.1 0.9059 0.0118 0.0130 1.0793 1.0389 671 665 0.882 0.929 Birth registration CP.1 0.9758 0.0126 0.0129 4.4589 2.1116 671 665 0.951 1.000 Note: () Figures in parentheses are based on 25-49 unweighted cases. 74 Table SE.4: Sampling errors: Rural areas Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, Montenegro, 2005 Table Value (r) Standard error (se) Coefficient of variation (se/r) Design effect (deff) Square root of design effect (deft) Weighted count Unweighted count Confidence limits r - 2se r + 2se HOUSEHOLDS Child discipline CP.4 0.6177 0.0317 0.0513 1.8680 1.3667 373 440 0.554 0.681 HOUSEHOLD MEMBERS Use of improved drinking water sources EN.1 0.9567 0.0091 0.0095 1.7323 1.3162 3404 868 0.939 0.975 Use of improved sanitation facilities EN.5 0.9745 0.0055 0.0056 1.0458 1.0226 3404 868 0.964 0.985 Net primary school attendance rate ED.3 0.9827 0.0075 0.0076 1.6205 1.2730 457 494 0.968 0.998 Net secondary school attendance rate ED.4 0.7939 0.0372 0.0469 1.7342 1.3169 221 206 0.719 0.868 Primary completion rate ED.6 0.9388 0.0077 0.0082 0.0624 0.2497 60 62 0.924 0.954 Child labour CP.2 0.1651 0.0252 0.1526 2.9580 1.7199 582 643 0.115 0.216 WOMEN Skilled attendant at delivery RH.5 0.9780 0.0133 0.0136 1.1466 1.0708 84 141 0.952 1.000 Antenatal care RH.3 0.9739 0.0131 0.0134 0.9399 0.9695 84 141 0.948 1.000 Contraceptive prevalence RH.1 0.4376 0.0293 0.0669 1.9602 1.4001 509 564 0.379 0.496 Adult literacy ED.8 0.9621 0.0086 0.0089 0.5059 0.7112 258 252 0.945 0.979 Marriage before age 18 CP.5 0.0826 0.0104 0.1260 1.0262 1.0130 687 718 0.062 0.103 Comprehensive knowledge about HIV prevention among young people HA.3 0.2847 0.0493 0.1731 2.9946 1.7305 258 252 0.186 0.383 Condom use with non-regular partners HA.9 (*) (*) (*) (*) (*) 18 15 0.389 0.903 Age at first sex among young people HA.8 0.0000 0.0000 . . . 136 121 0.000 0.000 Attitude towards people with HIV/AIDS HA.5 0.2979 0.0282 0.0947 3.0877 1.7572 799 812 0.241 0.354 Women who have been tested for HIV HA.6 0.0128 0.0043 0.3377 1.2416 1.1143 824 839 0.004 0.021 Knowledge of mother- to-child transmission of HIV HA.4 0.6670 0.0270 0.0405 2.7487 1.6579 824 839 0.613 0.721 UNDER-5s Underweight prevalence NU.1 0.0168 0.0053 0.3149 0.5131 0.7163 297 303 0.006 0.027 Tuberculosis immunization coverage CH.2 0.8935 0.0196 0.0219 0.2858 0.5346 69 72 0.854 0.933 Polio immunization coverage CH.2 0.9152 0.0349 0.0381 0.9858 0.9929 61 64 0.845 0.985 Immunization coverage for DPT CH.2 0.9560 0.0178 0.0186 0.4660 0.6827 59 63 0.920 0.992 Measles immunization coverage CH.2 0.8147 0.0262 0.0321 0.3086 0.5555 66 69 0.762 0.867 Fully immunized children CH.2 0.6657 0.0403 0.0605 0.4524 0.6726 60 63 0.585 0.746 Diarrhoea in last two weeks CH.3 0.0301 0.0094 0.3124 1.1960 1.0936 390 396 0.011 0.049 Received ORT or increased fluids and continued feeding CH.4 (*) (*) (*) (*) (*) 12 13 (*) (*) Support for learning CD.1 0.8611 0.0193 0.0224 1.2304 1.1092 390 396 0.822 0.900 Birth registration CP.1 0.9851 0.0086 0.0088 2.0027 1.4152 390 396 0.968 1.000 Note: (*) Figures that are based on less than 25 unweighted cases. 75 Table SE.5: Sampling errors: South Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, Montenegro, 2005 Table Value (r) Standard error (se) Coefficient of variation (se/r) Design effect (deff) Square root of design effect (deft) Weighted count Unweighted count Confidence limits r - 2se r + 2se HOUSEHOLDS Child discipline CP.4 0.5039 0.0438 0.0869 1.8721 1.3682 251 245 0.416 0.592 HOUSEHOLD MEMBERS Use of improved drinking water sources EN.1 0.9897 0.0064 0.0065 2.1952 1.4816 2178 542 0.977 1.000 Use of improved sanitation facilities EN.5 0.9962 0.0027 0.0027 1.0598 1.0294 2178 542 0.991 1.000 Net primary school attendance rate ED.3 0.9820 0.0103 0.0105 1.2978 1.1392 248 219 0.961 1.000 Net secondary school attendance rate ED.4 0.8735 0.0402 0.0460 1.6253 1.2749 136 112 0.793 0.954 Primary completion rate ED.6 (*) (*) (*) (*) (*) 27 23 (*) (*) Child labour CP.2 0.0382 0.0191 0.5016 2.9752 1.7249 332 299 0.000 0.076 WOMEN Skilled attendant at delivery RH.5 0.9823 0.0178 0.0182 0.9507 0.9750 42 53 0.947 1.000 Antenatal care RH.3 1.0000 0.0000 0.0000 . . 42 53 1.000 1.000 Contraceptive prevalence RH.1 0.3940 0.0308 0.0782 1.2294 1.1088 345 310 0.332 0.456 Adult literacy ED.8 0.9226 0.0130 0.0141 0.3422 0.5850 178 145 0.897 0.949 Marriage before age 18 CP.5 0.0474 0.0130 0.2748 1.5384 1.2403 476 411 0.021 0.073 Comprehensive knowledge about HIV prevention among young people HA.3 0.2201 0.0457 0.2075 1.7504 1.3230 178 145 0.129 0.311 Condom use with non-regular partners HA.9 (*) (*) (*) (*) (*) 23 18 (*) (*) Age at first sex among young people HA.8 0.0000 0.0000 . . . 96 74 0.000 0.000 Attitude towards people with HIV/AIDS HA.5 0.5152 0.0444 0.0862 3.7320 1.9318 559 474 0.426 0.604 Women who have been tested for HIV HA.6 0.0441 0.0135 0.3074 2.1080 1.4519 571 485 0.017 0.071 Knowledge of mother- to-child transmission of HIV HA.4 0.4764 0.0458 0.0961 4.0632 2.0157 571 485 0.385 0.568 UNDER-5s Underweight prevalence NU.1 0.0178 0.0122 0.6815 0.9786 0.9893 157 117 0.000 0.042 Tuberculosis immunization coverage CH.2 (0.8833) (0.0109) (0.0124) (0.0279) (0.1669) 34 25 (0.861) (0.905) Polio immunization coverage CH.2 (*) (*) (*) (*) (*) 23 17 (*) (*) Immunization coverage for DPT CH.2 (*) (*) (*) (*) (*) 20 15 (*) (*) Measles immunization coverage CH.2 (0.7665) (0.0470) (0.0614) (0.2966) (0.5446) 34 25 (0.672) (0.861) Fully immunized children CH.2 (*) (*) (*) (*) (*) 21 16 (*) (*) Diarrhoea in last two weeks CH.3 0.0182 0.0138 0.7585 1.7645 1.3283 222 166 0.000 0.046 Received ORT or increased fluids and continued feeding CH.4 (*) (*) (*) (*) (*) 4 3 (*) (*) Support for learning CD.1 0.9471 0.0147 0.0156 0.7152 0.8457 222 166 0.918 0.977 Birth registration CP.1 0.9937 0.0065 0.0065 1.1024 1.0500 222 166 0.981 1.000 Note: () Figures in parentheses are based on 25-49 unweighted cases. (*) Figures that are based on less than 25 unweighted cases. 76 Table SE.6: Sampling errors: Central Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, Montenegro, 2005 Table Value (r) Standard error (se) Coefficient of variation (se/r) Design effect (deff) Square root of design effect (deft) Weighted count Unweighted count Confidence limits r - 2se r + 2se HOUSEHOLDS Child discipline CP.4 0.6655 0.0251 0.0377 1.4900 1.2207 432 527 0.615 0.716 HOUSEHOLD MEMBERS Use of improved drinking water sources EN.1 0.9890 0.0015 0.0015 0.2049 0.4526 4093 1059 0.986 0.992 Use of improved sanitation facilities EN.5 0.9969 0.0025 0.0025 2.1284 1.4589 4093 1059 0.992 1.000 Net primary school attendance rate ED.3 0.9648 0.0090 0.0093 1.2332 1.1105 482 521 0.947 0.983 Net secondary school attendance rate ED.4 0.8321 0.0256 0.0308 1.0164 1.0082 241 217 0.781 0.883 Primary completion rate ED.6 0.9299 0.0370 0.0398 1.1540 1.0742 61 56 0.856 1.000 Child labour CP.2 0.0487 0.0125 0.2570 2.3459 1.5316 624 695 0.024 0.074 WOMEN Skilled attendant at delivery RH.5 0.9894 0.0048 0.0049 0.3992 0.6318 104 180 0.980 0.999 Antenatal care RH.3 0.9671 0.0137 0.0142 1.0627 1.0309 104 180 0.940 0.995 Contraceptive prevalence RH.1 0.2728 0.0252 0.0925 2.1661 1.4718 586 676 0.222 0.323 Adult literacy ED.8 0.9246 0.0118 0.0128 0.6064 0.7787 322 305 0.901 0.948 Marriage before age 18 CP.5 0.0648 0.0102 0.1571 1.5635 1.2504 877 915 0.044 0.085 Comprehensive knowledge about HIV prevention among young people HA.3 0.3823 0.0367 0.0959 1.7316 1.3159 322 305 0.309 0.456 Condom use with non-regular partners HA.9 (0.7257) (0.0606) (0.0835) (0.4981) (0.7057) 34 28 (0.604) (0.847) Age at first sex among young people HA.8 0.0081 0.0082 1.0039 1.0664 1.0327 149 130 0.000 0.024 Attitude towards people with HIV/AIDS HA.5 0.2280 0.0201 0.0884 2.2697 1.5065 975 985 0.188 0.268 Women who have been tested for HIV HA.6 0.0314 0.0059 0.1893 1.2114 1.1007 1026 1045 0.019 0.043 Knowledge of mother- to-child transmission of HIV HA.4 0.6919 0.0159 0.0230 1.2413 1.1141 1026 1045 0.660 0.724 UNDER-5s Underweight prevalence NU.1 0.0147 0.0036 0.2463 0.3859 0.6212 410 427 0.007 0.022 Tuberculosis immunization coverage CH.2 0.9271 0.0248 0.0267 1.0167 1.0083 108 113 0.878 0.977 Polio immunization coverage CH.2 0.8670 0.0196 0.0226 0.3550 0.5958 103 108 0.828 0.906 Immunization coverage for DPT CH.2 0.8955 0.0098 0.0109 0.1085 0.3293 102 107 0.876 0.915 Measles immunization coverage CH.2 0.8558 0.0266 0.0311 0.6296 0.7935 106 111 0.803 0.909 Fully immunized children CH.2 0.7278 0.037 0.0508 0.7309 0.8549 102 107 0.654 0.802 Diarrhoea in last two weeks CH.3 0.0771 0.0168 0.2178 2.1240 1.4574 514 537 0.044 0.111 Received ORT or increased fluids and continued feeding CH.4 (0.6041) (0.0460) (0.0761) (0.3535) (0.5946) 40 41 (0.512) (0.696) Support for learning CD.1 0.8896 0.0157 0.0177 1.3512 1.1624 514 537 0.858 0.921 Birth registration CP.1 0.9710 0.0162 0.0167 5.0146 2.2393 514 537 0.939 1.000 Note: () Figures in parentheses are based on 25-49 unweighted cases. 77 Table SE.7: Sampling errors: North Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, Montenegro, 2005 Table Value (r) Standard error (se) Coefficient of variation (se/r) Design effect (deff) Square root of design effect (deft) Weighted count Unweighted count Confidence limits r - 2se r + 2se HOUSEHOLDS Child discipline CP.4 0.6298 0.0257 0.0409 1.1650 1.0793 322 411 0.578 0.681 HOUSEHOLD MEMBERS Use of improved drinking water sources EN.1 0.9683 0.0101 0.0105 2.5321 1.5913 2720 757 0.948 0.989 Use of improved sanitation facilities EN.5 0.9739 0.0055 0.0057 0.9098 0.9538 2720 757 0.963 0.985 Net primary school attendance rate ED.3 0.9826 0.0076 0.0077 1.6274 1.2757 420 489 0.967 0.998 Net secondary school attendance rate ED.4 0.8359 0.0333 0.0399 1.4175 1.1906 179 176 0.769 0.903 Primary completion rate ED.6 0.9062 0.0231 0.0255 0.3699 0.6082 54 60 0.860 0.952 Child labour CP.2 0.1963 0.0313 0.1593 3.8104 1.9520 523 616 0.134 0.259 WOMEN Skilled attendant at delivery RH.5 0.9908 0.0095 0.0096 1.1509 1.0728 66 118 0.972 1.000 Antenatal care RH.3 0.9670 0.0154 0.0159 0.8688 0.9321 66 118 0.936 0.998 Contraceptive prevalence RH.1 0.5618 0.0305 0.0543 1.9110 1.3824 421 506 0.501 0.623 Adult literacy ED.8 0.9625 0.0147 0.0153 1.0638 1.0314 174 179 0.933 0.992 Marriage before age 18 CP.5 0.0906 0.0118 0.1303 1.0689 1.0339 559 633 0.067 0.114 Comprehensive knowledge about HIV prevention among young people HA.3 0.2200 0.0513 0.2334 2.7347 1.6537 174 179 0.117 0.323 Condom use with non-regular partners HA.9 (*) (*) (*) (*) (*) 8 7 (*) (*) Age at first sex among young people HA.8 0.0000 0.0000 . . . 101 95 0.000 0.000 Attitude towards people with HIV/AIDS HA.5 0.2677 0.0260 0.0970 2.4366 1.5610 644 709 0.216 0.320 Women who have been tested for HIV HA.6 0.0163 0.0050 0.3038 1.1134 1.0552 661 728 0.006 0.026 Knowledge of mother- to-child transmission of HIV HA.4 0.7375 0.0294 0.0398 3.2419 1.8005 661 728 0.679 0.796 UNDER-5s Underweight prevalence NU.1 0.0494 0.0125 0.2533 0.9623 0.9810 263 290 0.024 0.074 Tuberculosis immunization coverage CH.2 0.8312 0.0446 0.0536 0.8785 0.9373 57 63 0.742 0.920 Polio immunization coverage CH.2 0.9302 0.0434 0.0466 1.5338 1.2385 49 54 0.843 1.000 Immunization coverage for DPT CH.2 0.9477 0.0393 0.0415 1.6814 1.2967 50 55 0.869 1.000 Measles immunization coverage CH.2 0.8281 0.0446 0.0538 0.8518 0.9229 56 62 0.739 0.917 Fully immunized children CH.2 0.6217 0.0666 0.1072 1.0007 1.0003 49 54 0.488 0.755 Diarrhoea in last two weeks CH.3 0.0319 0.0102 0.3200 1.2056 1.0980 325 358 0.011 0.052 Received ORT or increased fluids and continued feeding CH.4 (*) (*) (*) (*) (*) 10 12 (*) (*) Support for learning CD.1 0.8498 0.0199 0.0234 1.1077 1.0525 325 358 0.810 0.890 Birth registration CP.1 0.9821 0.0104 0.0105 2.1823 1.4773 325 358 0.961 1.000 Note: (*) Figures that are based on less than 25 unweighted cases. 78 APPENDIX D. DATA QUALITY TABLES Table DQ.1: Age distribution of household population Single-year age distribution of household population by sex (weighted), Montenegro, 2005 Males Females Males Females Number Percent Number Percent Number Percent Number Percent 0 48 1.1 55 1.2 41 74 1.7 51 1.1 1 61 1.4 59 1.3 42 63 1.4 66 1.4 2 62 1.4 68 1.5 43 68 1.5 59 1.3 3 77 1.7 54 1.2 44 56 1.3 44 1.0 4 74 1.7 78 1.7 45 58 1.3 66 1.4 5 103 2.3 80 1.7 46 51 1.1 61 1.3 6 76 1.7 74 1.6 47 61 1.4 66 1.5 7 67 1.5 71 1.6 48 72 1.6 57 1.2 8 76 1.7 75 1.6 49 50 1.1 50 1.1 9 78 1.8 75 1.6 50 54 1.2 67 1.5 10 82 1.9 62 1.4 51 59 1.3 67 1.5 11 88 2.0 64 1.4 52 73 1.6 51 1.1 12 73 1.6 61 1.3 53 50 1.1 52 1.1 13 67 1.5 60 1.3 54 44 1.0 49 1.1 14 70 1.6 77 1.7 55 44 1.0 42 .9 15 67 1.5 78 1.7 56 51 1.2 55 1.2 16 64 1.4 66 1.4 57 33 .7 49 1.1 17 65 1.5 78 1.7 58 40 .9 51 1.1 18 68 1.5 68 1.5 59 36 .8 40 .9 19 68 1.5 66 1.4 60 27 .6 33 .7 20 76 1.7 66 1.4 61 36 .8 43 .9 21 71 1.6 79 1.7 62 24 .5 37 .8 22 62 1.4 72 1.6 63 37 .8 38 .8 23 71 1.6 62 1.4 64 32 .7 33 .7 24 58 1.3 72 1.6 65 25 .6 38 .8 25 63 1.4 59 1.3 66 43 1.0 45 1.0 26 77 1.7 77 1.7 67 38 .9 43 .9 27 77 1.7 66 1.4 68 31 .7 35 .8 28 61 1.4 79 1.7 69 33 .8 38 .8 29 72 1.6 59 1.3 70 19 .4 51 1.1 30 54 1.2 67 1.5 71 23 .5 33 .7 31 59 1.3 63 1.4 72 23 .5 44 1.0 32 58 1.3 69 1.5 73 34 .8 45 1.0 33 61 1.4 62 1.4 74 31 .7 20 .4 34 68 1.5 65 1.4 75 24 .6 25 .5 35 48 1.1 65 1.4 76 18 .4 28 .6 36 59 1.3 71 1.6 77 19 .4 23 .5 37 59 1.3 61 1.3 78 15 .3 15 .3 38 62 1.4 56 1.2 79 11 .2 16 .4 39 78 1.8 67 1.5 80+ 45 1.0 82 1.8 40 70 1.6 60 1.3 Total 4419 100.0 4571 100.0 79 Table DQ.2: Age distribution of eligible and interviewed women Household population of women age 10-54, interviewed women age 15-49, and percentage of eligible women who were interviewed (weighted), by five-year age group, Montenegro, 2005 Household population of women age 10- 54 Interviewed women age 15-49 Percentage of eligible women interviewed Number Number Percent Age 10-14 324 . . . 15-19 355 325 15.2 91.5 20-24 351 310 14.5 88.3 25-29 340 326 15.3 95.9 30-34 326 315 14.7 96.5 35-39 320 309 14.5 96.5 40-44 280 269 12.6 96.2 45-49 300 280 13.1 93.6 50-54 286 . . . 15-49 2272 2134 100.0 93.9 Table DQ.3: Age distribution of eligible and interviewed under-5s Household population of children age 0-4, children whose mothers/caretakers were interviewed, and percentage of under-5 children whose mothers/caretakers were interviewed (weighted), by five-year age group, Montenegro, 2005 Household population of children age 0-7 Interviewed children age 0-4 Percentage of eligible children interviewed Number Number Percent Age 0 103 103 16.5 100.0 1 120 117 18.6 97.7 2 129 128 20.4 99.1 3 131 129 20.6 98.8 4 152 150 23.9 98.9 5 183 na na na 6 150 na na na 7 138 na na na 0-4 635 628 100.0 98.9 na: Not applicable Note: Weights for both household population of children and interviewed children are household weights. Age is based on the household schedule. 80 Table DQ.4: Age distribution of under-5 children Age distribution of under-5 children by 3-month groups (weighted), Montenegro, 2005 Male Female Total Number Percent Number Percent Number Percent Age in months 0-2 16 2.9 16 3.1 32 3.0 3-5 20 3.7 22 4.2 42 4.0 6-8 24 4.4 31 5.9 55 5.2 9-11 19 3.5 17 3.2 36 3.4 12-14 18 3.3 23 4.5 41 3.9 15-17 28 5.3 35 6.7 64 6.0 18-20 23 4.3 22 4.1 45 4.2 21-23 28 5.3 19 3.6 47 4.5 24-26 24 4.5 34 6.5 58 5.5 27-29 27 4.9 25 4.7 51 4.8 30-32 29 5.4 26 4.9 55 5.2 33-35 23 4.3 30 5.8 54 5.1 36-38 31 5.7 28 5.4 59 5.6 39-41 26 4.8 26 4.9 52 4.9 42-44 34 6.4 16 3.0 50 4.7 45-47 35 6.5 21 4.1 56 5.3 48-50 30 5.5 45 8.6 75 7.1 51-53 32 6.0 29 5.4 61 5.7 54-56 24 4.4 24 4.5 47 4.5 57-59 46 8.5 35 6.7 81 7.6 Total 536 100.0 525 100.0 1061 100.0 81 Table DQ.5: Heaping on ages and periods Age and period ratios at boundaries of eligibility by type of information collected (weighted), Montenegro, 2005 Age in household questionnaire Age and period ratios Total Male Female 1 1.07 .97 1.02 2 .93 1.13 1.02 3 1.09 .81 .95 4 .87 1.11 .98 5 1.22 1.03 1.13 6 .93 .98 .95 8 1.03 1.02 1.02 9 .99 1.06 1.02 10 .99 .93 .96 13 .96 .91 .94 14 1.03 1.07 1.05 15 1.00 1.06 1.03 16 .98 .89 .93 17 .99 1.11 1.05 18 .97 1.11 1.04 23 1.12 .91 1.01 24 .91 1.11 1.01 25 .95 .86 .90 48 1.18 .99 1.09 49 .85 .86 .86 50 .99 1.10 1.05 Age in women's questionnaire Age and period ratios Female 23 .95 24 1.13 25 .84 Months since last birth in women's questionnaire Age and period ratios Female 6-11 1.00 12-17 1.10 18-23 .90 24-29 1.05 30-35 1.01 82 Table DQ.6: Completeness of reporting Percentage of observations missing information for selected questions and indicators (weighted), Montenegro, 2005 Questionnaire and Subject Reference group Percent with missing information* Number of cases Women Date of Birth All women aged 15-49 Month only .4 2258 Month and year missing - 2258 Date of last birth All women aged 15-49 with at least one live birth Month only .1 1381 Month and year missing .1 4897 Date of first marriage/union Total married women aged 15-49 Month only 4.7 1457 Month and year missing 4.5 1457 Age at first marriage/union Total married women age 15-49 1.7 1457 Age at first intercourse All women aged 15-24 who have ever had sex 4.4 674 Time since last intercourse All women aged 15-24 who have ever had sex 20.8 186 Under-5s Date of Birth All under-five children surveyed Month only .3 1061 Month and year missing - 1061 Anthropometry All under-five children surveyed Height 18.4 1061 Weight 15.8 1061 Height or Weight 18.4 1061 * Includes "Don't know" responses 83 Table DQ.7: Presence of mother in the household and the person interviewed for the under-5 questionnaire Distribution of children under five by whether the mother lives in the same household, and the person interviewed for the under-5 questionnaire (weighted), Montenegro, 2005 Mother in the household Mother not in the household Total Number of children aged 0- 4 years Mother interviewed Father interviewed Other adult female interviewed Age 0 100.0 - - 100.0 103 1 99.0 1.0 - 100.0 120 2 99.5 .5 - 100.0 129 3 98.6 - 1.4 100.0 131 4 100.0 - - 100.0 152 Total 99.4 0.3 0.3 100.0 635 84 Table DQ.8: School attendance by single age Distribution of household population age 5-24 by educational level and grade attended in the current year, Montenegro, 2005 Preschool/kindergarten Primary Secondary Higher University Not attending school Total Total 1 2 3 4 5 6 7 8 1 2 3 4 Age 5 31.7 5.2 - - - - - - - - - - - - - 63.1 100.0 183 6 12.0 60.9 3.4 - - - - - - - - - - - - 23.6 100.0 150 7 - 53.3 39.7 1.8 .4 - - - - - - - - - - 4.8 100.0 138 8 - 3.5 66.8 26.9 .4 - - - - - - - - - - 2.4 100.0 151 9 - 1.2 4.1 62.7 30.5 - - - - - - - - - - 1.6 100.0 153 10 - .4 .6 6.6 59.7 26.8 2.3 .8 - - - - - - - 2.8 100.0 144 11 - - .8 2.0 6.1 63.2 26.4 - - - - - - - - 1.6 100.0 152 12 - - .4 .0 1.7 2.1 71.6 22.8 .0 - - - - - - 1.3 100.0 134 13 - - .5 .5 - 1.8 4.1 69.6 20.7 - - - - - - 2.9 100.0 127 14 - - - - .9 - 1.2 3.4 60.9 29.6 .9 - - - - 3.2 100.0 146 15 - - - - - - - - 5.5 67.6 20.8 .9 - - - 5.2 100.0 144 16 - - - .8 - - - - 1.9 3.9 61.0 23.0 1.0 - - 8.4 100.0 129 17 - - - - - - - - - - 6.7 53.6 25.1 - - 14.6 100.0 143 18 - - - - - - - - - - 1.9 6.7 47.5 - 16.3 27.6 100.0 136 19 - - - - - - - - - - .9 4.1 2.2 4.9 44.2 43.7 100.0 134 20 - - - - - - - - - - - .9 .8 - 38.2 59.2 100.0 142 21 - - - - - - - - - - - .4 - 2.4 37.2 60.0 100.0 150 22 - - - - - - - - - - - - - 3.1 38.5 58.3 100.0 134 23 - - - - - - - - - - - - - 1.8 20.3 77.9 100.0 134 24 - - - - - - - - - - - - - 1.8 24.9 73.3 100.0 130 Total 2.6 6.4 6.0 5.4 5.2 4.9 5.1 4.4 4.4 5.1 4.3 4.3 3.7 .7 10.6 26.9 100.0 2855 85 Table DQ.9: Distribution of women by time since last birth Distribution of women aged 15-49 with at least one live birth, by months since last birth (weighted), Country, Year Months since last birth Number Percent Number Percent 0 4 1.3 19 10 3.2 1 8 2.6 20 8 2.5 2 7 2.3 21 11 3.4 3 9 3.0 22 4 1.4 4 7 2.4 23 8 2.4 5 11 3.5 24 10 3.1 6 13 4.2 25 8 2.6 7 7 2.2 26 11 3.7 8 11 3.4 27 8 2.6 9 4 1.2 28 10 3.1 10 11 3.4 29 7 2.3 11 8 2.5 30 8 2.6 12 11 3.5 31 9 2.9 13 6 1.9 32 9 3.0 14 6 2.1 33 10 3.3 15 12 4.0 34 8 2.4 16 12 3.8 35 8 2.4 17 11 3.6 18 8 2.5 Total 313 100.0 86 Appendix E. MICS Indicators: Numerators and Denominators INDICATOR NUMERATOR DENOMINATOR 4 Skilled attendant at delivery Number of women aged 15-49 with a birth in the 2 years preceding the survey that were attended during childbirth by skilled health personnel Total number of women surveyed aged 15-49 with a birth in the 2 years preceding the survey 5 Institutional deliveries Number of women aged 15-49 with a birth in the 2 years preceding the survey that delivered in a health facility Total number of women surveyed aged 15-49 with a birth in 2 years preceding the survey 6 Underweight prevalence Number of children under age five that fall below minus two standard deviations from the median weight for age of the NCHS/WHO standard (moderate and severe); number that fall below minus three standard deviations (severe) Total number of children under age five that were weighed 7 Stunting prevalence Number of children under age five that fall below minus two standard deviations from the median height for age of the NCHS/WHO standard (moderate and severe); number that fall below minus three standard deviations (severe) Total number of children under age five measured 8 Wasting prevalence Number of children under age five that fall below minus two standard deviations from the median weight for height of the NCHS/WHO standard (moderate and severe); number that fall below minus three standard deviations (severe) Total number of children under age five weighed and measured 9 Low-birth weight infants Number of last live births in the 2 years preceding the survey weighing below 2,500 grams Total number of last live births in the 2 years preceding the survey 10 Infants weighed at birth Number of last live births in the 2 years preceding the survey that were weighed at birth Total number of last live births in the 2 years preceding the survey 11 Use of improved drinking water sources Number of household members living in households using improved sources of drinking water Total number of household members in households surveyed 12 Use of improved sanitation facilities Number of household members using improved sanitation facilities Total number of household members in households surveyed 13 Water treatment Number of household members using water that has been treated Total number of household members in households surveyed 14 Disposal of child’s faeces Number of children under age three whose (last) stools were disposed of safely Total number of children under age three surveyed 87 INDICATOR NUMERATOR DENOMINATOR 15 Exclusive breastfeeding rate Number of infants aged 0-5 months that are exclusively breastfed Total number of infants aged 0-5 months surveyed 16 Continued breastfeeding rate Number of infants aged 12-15 months, and 20-23 months, that are currently breastfeeding Total number of children aged 12-15 months and 20-23 months surveyed 17 Timely complementary feeding rate Number of infants aged 6-9 months that are receiving breastmilk and complementary foods Total number of infants aged 6-9 months surveyed 18 Frequency of complementary feeding Number of infants aged 6-11 months that receive breastmilk and complementary food at least the minimum recommended number of times per day (two times per day for infants aged 6-8 months, three times per day for infants aged 9-11 months) Total number of infants aged 6-11 months surveyed 19 Adequately fed infants Number of infants aged 0-11 months that are appropriately fed: infants aged 0-5 months that are exclusively breastfed and infants aged 6-11 months that are breastfed and ate solid or semi-solid foods the appropriate number of times (see above) yesterday Total number of infants aged 0-11 months surveyed 20 Antenatal care Number of women aged 15-49 years that were attended to at least once during pregnancy in the 2 years preceding the survey by skilled health personnel Total number of women surveyed aged 15-49 with a birth in the 2 years preceding the survey 21 Contraceptive prevalence Number of women currently married or in union aged 15-49 years that are using (or whose partner is using) a contraceptive method (either modern or traditional) Total number of women aged 15-49 years that are currently married or in union 22 Antibiotic treatment of suspected pneumonia Number of children aged 0-59 months with suspected pneumonia in the previous 2 weeks receiving antibiotics Total number of children aged 0-59 months with suspected pneumonia in the previous 2 weeks 23 Care-seeking for suspected pneumonia Number of children aged 0-59 months with suspected pneumonia in the previous 2 weeks that are taken to an appropriate health provider Total number of children aged 0-59 months with suspected pneumonia in the previous 2 weeks 24 Solid fuels Number of residents in households that use solid fuels (wood, charcoal, crop residues and dung) as the primary source of domestic energy to cook Total number of residents in households surveyed 25 Tuberculosis immunization coverage Number of children aged 18-29 months receiving BCG vaccine before their first birthday Total number of children aged 18-29 months surveyed 26 Polio immunization coverage Number of children aged 18-29 months receiving OPV3 vaccine before their first birthday Total number of children aged 18-29 months surveyed 88 INDICATOR NUMERATOR DENOMINATOR 27 Immunization coverage for diphtheria, pertussis and tetanus (DPT) Number of children aged 18-29 months receiving DPT3 vaccine before their first birthday Total number of children aged 18-29 months surveyed 28 MMR immunization coverage Number of children aged 18-29 months receiving MMR vaccine before 18 months of age Total number of children aged 18-29 months surveyed 31 Fully immunized children Number of children aged 18-29 months receiving DPT1-3, OPV-1-3, BCG and MMR vaccines within recommended time (DPT1-3, OPV-1-3, BCG before first birthday and MMR before 18 months of age) Total number of children aged 18-29 months surveyed 33 Use of oral rehydration therapy (ORT) Number of children aged 0-59 months with diarrhoea in the previous 2 weeks that received oral rehydration salts and/or an appropriate household solution Total number of children aged 0-59 months with diarrhoea in the previous 2 weeks 34 Home management of diarrhoea Number of children aged 0-59 months with diarrhoea in the previous 2 weeks that received more fluids AND continued eating somewhat less, the same or more food Total number of children aged 0-59 months with diarrhoea in the previous 2 weeks 35 Received ORT or increased fluids and continued feeding Number of children aged 0-59 months with diarrhoea that received ORT (oral rehydration salts or an appropriate household solution) or received more fluids AND continued eating somewhat less, the same or more food Total number of children aged 0-59 months with diarrhoea in the previous 2 weeks 44 Content of antenatal care Number of women with a live birth in the 2 years preceding the survey that received antenatal care during the last pregnancy Total number of women with a live birth in the 2 years preceding the survey 45 Timely initiation of breastfeeding Number of women with a live birth in the 2 years preceding the survey that put the newborn infant to the breast within 1 hour of birth Total number of women with a live birth in the 2 years preceding the survey 46 Support for learning Number of children aged 0-59 months living in households in which an adult has engaged in four or more activities to promote learning and school readiness in the past 3 days Total number of children aged 0-59 months surveyed 47 Father’s support for learning Number of children aged 0-59 months whose father has engaged in one or more activities to promote learning and school readiness in the past 3 days Total number of children aged 0-59 months 48 Support for learning: children’s books Number of households with three or more children’s books Total number of households surveyed 49 Support for learning: non-children’s books Number of households with three or more non-children’s books Total number of households surveyed 89 INDICATOR NUMERATOR DENOMINATOR 50 Support for learning: materials for play Number of households with three or more materials intended for play Total number of households surveyed 51 Non-adult care Number of children aged 0-59 months left alone or in the care of another child younger than 10 years of age in the past week Total number of children aged 0-59 months surveyed 52 Pre-school attendance Number of children aged 36-59 months that attend some form of early childhood education programme Total number of children aged 36-59 months surveyed 53 School readiness Number of children in first grade that attended some form of pre-school the previous year Total number of children in the first grade surveyed 54 Net intake rate in primary education Number of children of school-entry age that are currently attending first grade Total number of children of primary- school entry age surveyed 55 Net primary school attendance rate Number of children of primary-school age currently attending primary or secondary school Total number of children of primary- school age surveyed 56 Net secondary school attendance rate Number of children of secondary-school age currently attending secondary school or higher Total number of children of secondary-school age surveyed 57 Children reaching grade five Proportion of children entering the first grade of primary school that eventually reach grade five 58 Transition rate to secondary school Number of children that were in the last grade of primary school during the previous school year that attend secondary school Total number of children that were in the last grade of primary school during the previous school year surveyed 59 Primary completion rate Number of children (of any age) attending the last grade of primary school (excluding repeaters) Total number of children of primary school completion age (age appropriate to final grade of primary school) surveyed 60 Adult literacy rate Number of women aged 15-24 that are able to read a short simple statement about everyday life Total number of women aged 15-24 years surveyed 61 Gender parity index Proportion of girls in primary and secondary education Proportion of boys in primary and secondary education 62 Birth registration Number of children aged 0-59 months whose births are reported registered Total number of children aged 0-59 months 90 INDICATOR NUMERATOR DENOMINATOR surveyed 67 Marriage before age 15 and age 18 Number of women that were first married or in union by the exact age of 15 and the exact age of 18, by age groups Total number of women aged 15-49 years and 20-49 years surveyed, by age groups 68 Young women aged 15-19 years currently married or in union Number of women aged 15-19 years currently married or in union Total number of women aged 15-19 years surveyed 69 Spousal age difference Number of women married/in union aged 15-19 years and 20-24 years with a difference in age of 10 or more years between them and their current spouse Total number of women aged 15-19 and 20-24 years surveyed that are currently married or in union 71 Child labour Number of children aged 5-14 years that are involved in child labour Total number of children aged 5-14 years surveyed 72 Labourer students Number of children aged 5-14 years involved in child labour activities that attend school Total number of children aged 5-14 years involved in child labour activities 73 Student labourers Number of children aged 5-14 years attending school that are involved in child labour activities Total number of children aged 5-14 years attending school 74 Child discipline Number of children aged 2-14 years that (1) experience only non-violent aggression, (2) experience psychological aggression as punishment, (3) experience minor physical punishment, (4) experience severe h i l i h t Total number of children aged 2-14 years selected and surveyed 82 Comprehensive knowledge about HIV prevention among young people Number of women aged 15-24 years that correctly identify two ways of avoiding HIV infection and reject three common misconceptions about HIV transmission Total number of women aged 15-24 years surveyed 83 Condom use with non-regular partners Number of women aged 15-24 years reporting the use of a condom during sexual intercourse with their last non-marital, non-cohabiting sex partner in the previous 12 months Total number of women aged 15-24 years surveyed that had a non-marital, non-cohabiting partner in the previous 12 months 84 Age at first sex among young people Number of women aged 15-24 years that have had sex before age 15 Total number of women aged 15-24 surveyed 85 Higher risk sex in the last year Number of sexually active women aged 15-24 that have had sex with a non-marital, non-cohabitating partner in the previous 12 months Total number of women aged 15-24 that were sexually active in the previous 12 months 91 INDICATOR NUMERATOR DENOMINATOR 86 Attitude towards people with HIV/AIDS Number of women expressing acceptance on all four questions about people with HIV or AIDS Total number of women surveyed 87 Women who know where to be tested for HIV Number of women that state knowledge of a place to be tested Total number of women surveyed 88 Women who have been tested for HIV Number of women that report being tested for HIV Total number of women surveyed 89 Knowledge of mother-to-child transmission of HIV Number of women that correctly identify all three means of vertical transmission Total number of women surveyed 90 Counselling coverage for the prevention of mother-to-child transmission of HIV Number of women that gave birth in the previous 24 months and received antenatal care reporting that they received counselling on HIV/AIDS during this care Total number of women that gave birth in the previous 24 months surveyed 91 Testing coverage for the prevention of mother-to-child transmission of HIV Number of women that gave birth in the previous 24 months and received antenatal care reporting that they received the results of an HIV test during this care Total number of women that gave birth in the previous 24 months surveyed 92 Age-mixing among sexual partners Number of women aged 15-24 years that had sex in the past 12 months with a partner who was 10 or more years older than they were Total number of sexually active women aged 15-24 surveyed 93 Security of tenure Number of household members living in urban households that lack formal documentation for their residence or that feel at risk of eviction Number of urban household members in households surveyed 94 Durability of housing Number of household members living in urban dwellings that are not considered durable Number of urban household members in households surveyed 95 Slum household Number of household members living in urban slums Number of household members in urban households surveyed 98 Unmet need for family planning Number of women that are currently married or in union that are fecund and want to space their births or limit the number of children they have and that are not currently using contraception Total number of women interviewed that are currently married or in union 99 Demand satisfied for family planning Number of women currently married or in union that are currently using contraception Number of women currently married or in union that have an unmet need for contraception or that are currently using contraception 92 INDICATOR NUMERATOR DENOMINATOR 100 Attitudes towards domestic violence Number of women that consider that a husband/partner is justified in hitting or beating his wife under at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses to have sex with him, (5) she burns the food Total number of women surveyed 101 Child disability Number of children aged 2-9 years with at least one of nine reported disabilities: (1) delay in sitting, standing or walking, (2) difficulty seeing, either in the daytime or at night, (3) appears to have difficulty hearing, (4) difficulty in understanding instructions, (5) difficulty walking or moving arms or has weakness or stiffness of limbs, (6) has fits, becomes rigid, loses consciousness, (7) does not learn to do things like other children his/her age, (8) cannot speak or cannot be understood in words, (9) appears mentally backward, dull or slow Total number of children aged 2-9 surveyed 93 APPENDIX F. QUESTIONNAIRES 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 Table HH.1: Results of household and individual interviews Numbers of households, women and children under 5 by results of the household, women's and under-five's interviews, and household, women's and under-five's response rates, Montenegro, 2005 Area Region Total Urban Rural South Central North Sampled households 1613 962 586 1166 823 2575 Occupied households 1578 916 580 1135 779 2494 Interviewed households 1490 868 542 1059 757 2358 Household response rate 94.4 94.8 93.4 93.3 97.2 94.5 Eligible women 1501 884 521 1096 768 2385 Interviewed women 1419 839 485 1045 728 2258 Women response rate 94.5 94.9 93.1 95.3 94.8 94.7 Women's overall response rate 89.3 89.9 87.0 89.0 92.1 89.5 Eligible children under 5 670 402 170 541 361 1072 Mother/Caretaker Interviewed 665 396 166 537 358 1061 Child response rate 99.3 98.5 97.6 99.3 99.2 99.0 Children's overall response rate 93.7 93.3 91.2 92.6 96.4 93.6 127 Table HH.2: Household age distribution by sex Percent distribution of the household population by five-year age groups and dependency age groups, and number of children aged 0-17 years, by sex, Montenegro, 2005 Sex Total Male Female Number Percent Number Percent Number Percent Age 0-4 321 7.3 314 6.9 635 7.1 5-9 400 9.1 374 8.2 775 8.6 10-14 379 8.6 324 7.1 704 7.8 15-19 332 7.5 355 7.8 687 7.6 20-24 339 7.7 351 7.7 690 7.7 25-29 351 7.9 340 7.4 691 7.7 30-34 299 6.8 326 7.1 626 7.0 35-39 305 6.9 320 7.0 625 7.0 40-44 332 7.5 280 6.1 611 6.8 45-49 290 6.6 300 6.6 590 6.6 50-54 279 6.3 286 6.3 565 6.3 55-59 205 4.6 237 5.2 441 4.9 60-64 156 3.5 183 4.0 339 3.8 65-69 170 3.8 200 4.4 370 4.1 70+ 261 5.9 381 8.3 643 7.1 Dependency age groups <15 1101 24.9 1013 22.2 2114 23.5 15-64 2887 65.3 2977 65.1 5865 65.2 65+ 431 9.8 581 12.7 1012 11.3 Age Children aged 0-17 1296 29.3 1234 27.0 2530 28.1 Adults 18+/Missing/DK 3123 70.7 3337 73.0 6460 71.9 Total 4419 100.0 4571 100.0 8991 100.0 128 Table HH.3: Household composition Percent distribution of households by selected characteristics, Montenegro, 2005 Weighted percent Number of households weighted Number of households unweighted Sex of household head Male 78.3 1846 1889 Female 21.7 512 469 Region South 26.1 616 542 Central 44.7 1055 1059 North 29.1 687 757 Area Urban 63.5 1497 1490 Rural 36.5 861 868 Number of household members 1 11.6 272 226 2-3 30.5 718 639 4-5 42.8 1009 1037 6-7 12.4 292 364 8-9 2.1 49 65 10+ .7 17 27 Ethnicity of household head Serbian 34.1 805 794 Montenegrin 41.5 979 951 Bosnian\Muslim 10.2 240 273 Albanian 2.7 65 65 Other 4.6 108 109 Missing 6.9 162 166 Wealth index quintiles Poorest 20.5 483 491 Second 19.6 461 480 Middle 19.2 453 463 Fourth 20.5 484 471 Richest 20.2 477 453 Total 100.0 2358 2358 At least one child aged < 18 years 51.5 2358 2358 At least one child aged < 5 years 20.5 2358 2358 At least one woman aged 15-49 years 68.1 2358 2358 129 Table HH.4: Women's background characteristics Percent distribution of women aged 15-49 years by background characteristics, Montenegro, 2005 Weighted percent Number of women weighted Number of women unweighted Region South 25.3 571 485 Central 45.4 1026 1045 North 29.3 661 728 Area Urban 63.5 1434 1419 Rural 36.5 824 839 Age 15-19 15.3 346 299 20-24 14.5 327 330 25-29 15.1 341 415 30-34 14.6 330 382 35-39 14.5 327 326 40-44 12.7 288 249 45-49 13.3 299 257 Marital/Union status Currently married/in union 59.9 1352 1492 Formerly married/in union 4.6 105 98 Never married/in union 35.5 801 668 Motherhood status Ever gave birth 61.1 1381 1526 Never gave birth 38.9 877 732 Education Primary or less 18.6 419 446 Secondary 63.9 1443 1432 University 17.5 395 380 Ethnicity of household head Serbian 31.3 707 704 Montenegrin 39.6 894 862 Bosnian\Muslim 11.9 270 304 Albanian 3.1 70 69 Other 5.4 122 126 Missing 8.7 196 193 Wealth index quintiles Poorest 17.9 404 425 Second 19.8 448 466 Middle 19.4 439 460 Fourth 21.6 487 466 Richest 21.3 480 441 Total 100.0 2258 2258 130 Table HH.5: Children's background characteristics Percent distribution of children under five years of age by background characteristics, Montenegro, 2005 Weighted percent Number of under-5 children weighted Number of under-5 children unweighted Sex Male 50.5 536 533 Female 49.5 525 528 Region South 20.9 222 166 Central 48.4 514 537 North 30.6 325 358 Area Urban 63.3 671 665 Rural 36.7 390 396 Age < 6 months 7.0 74 74 6-11 months 8.5 91 90 12-23 months 18.6 197 200 24-35 months 20.5 218 214 36-47 months 20.5 217 219 48-59 months 24.9 264 264 Mother's education Primary or less 23.2 246 251 Secondary 62.1 659 655 University 14.7 156 155 Ethnicity of household head Serbian 30.4 322 320 Montenegrin 39.0 413 409 Bosnian\Muslim 13.9 148 156 Albanian 3.3 35 31 Other 6.6 70 72 Missing 6.9 73 73 Wealth index quintiles Poorest 21.6 229 234 Second 20.6 219 234 Middle 20.1 214 217 Fourth 19.3 204 201 Richest 18.4 195 175 Total 100.0 1061 1061 131 Table NU.1: Child malnourishment Percentage of under-five children who are severely or moderately undernourished, Montenegro, 2005 Weight for age: % below -2 SD* Weight for age: % below - 3 SD Height for age: % below - 2 SD** Height for age: % below - 3 SD Weight for height: % below -2 SD*** Weight f
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