Nepal Multiple Indicator Cluster Survey 2010

Publication date: 2012

The Nepal Multiple Indicator Cluster Survey (NMICS) was carried out in 2010 by the Central Bureau of Statistics (CBS). Financial and technical support was provided by the United Nations Children’s Fund (UNICEF). MICS is an international household survey programme developed by UNICEF. The NMICS 2010 was conducted as part of the fourth global round of MICS (MICS4). MICS provides up-to-date information on the situation of children and women and measures key indicators that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. The main purpose of MICS 4 in Nepal is to support the government to generate statistically sound and comparable data for monitoring the situation of children and women for specified subregions in the Mid- and Far Western Regions of the country. These regions are inhabited by the most vulnerable populations, those affected by Nepal’s decade-long conflict, prone to natural disasters and disease outbreaks, and suffering from chronic food shortage. Although these regions have long been the development focus of the government and donor communities, an absence of data at the local level to support evidence-based planning and actions has persisted. Nepal Multiple Indicator Cluster Survey 2010 Mid- and Far Western Regions Final Report Central Bureau of Statistics UNICEF United Nations Children’s Fund May 2012 Copyright © May 2012 Government of Nepal, Central Bureau of Statistics/United Nations Children's Fund (UNICEF), 2012 Published by Government of Nepal Central Bureau of Statistics Thapathali Kathmandu, Nepal Tel: 977 1 4245947, 4229406 Website: www.cbs.gov.np United Nations Children’s Fund (UNICEF) United Nations House Pulchowk, Lalitpur Tel: 977 1 5523200 PO Box 1187 Kathmandu, Nepal Website: http://www. unicef.org/nepal Suggested citation: Central Bureau of Statistics, 2012. Nepal Multiple Indicator Cluster Survey 2010, Mid- and Far Western Regions, Final Report. Kathmandu: Central Bureau of Statistics and UNICEF Nepal. A child-friendly version of this report entitled Lives of Children and Women in the Mid- and Far Western Regions of Nepal 2010 has been produced by CBS and UNICEF Nepal. Both versions of NMICS 2010 can be downloaded from http://www.cbs.gov. np and http://www. unicef.org/nepal/5476.htm 5 Summary Table of Findings Nepal Multiple Indicator Cluster Survey (NMICS) and Millennium Development Goal (MDG) Indicators, Nepal, 2010 Topic MICS4 Indicator Number MDG Indicator Num ber Indicator Value NUTRITION Breastfeeding and infant feeding 2.4 Children ever breastfed 99.2 percent 2.5 Early initiation of breastfeeding 28.0 percent 2.6 Exclusive breastfeeding under six months 63.9 percent 2.7 Continued breastfeeding at one year 98.0 percent 2.8 Continued breastfeeding at two years 86.7 percent 2.9 Predominant breastfeeding under six months 80.1 percent 2.10 Duration of breastfeeding 31.5 months 2.11 Bottle feeding 5.2 percent 2.12 Introduction of solid, semi-solid or soft foods 62.6 percent 2.13 Minimum meal frequency 57.4 percent 2.14 Age-appropriate breastfeeding 76.1 percent Salt iodization 2.16 Iodized salt consumption 50.4 percent Vitamin A 2.17 Vitamin A supplementation (children under five) 90.1 percent Low birth weight 2.18 Low-birth-weight infants 26.1 percent 2.19 Infants weighed at birth 30.6 percent NMICS De-worming tablet coverage 72.8 percent CHILD HEALTH Vaccinations 3.1 Tuberculosis immunization coverage 88.8 percent 3.2 Polio immunization coverage 77.4 percent 3.3 Immunization coverage for diphtheria, pertussis and tetanus (DPT) 67.5 percent 3.4 4.3 Measles immunization coverage 83.4 percent NMICS Japanese encephalitis vaccination coverage 31.2 percent Tetanus toxoid 3.7 Neonatal tetanus protection 64.4 percent Care of illness 3.8 Oral rehydration therapy with continued feeding 47.4 percent 3.9 Care seeking for suspected pneumonia 51.1 percent 3.10 Antibiotic treatment of suspected pneumonia 56.1 percent NMICS Zinc tablet along with ORS during diarrhoea 21.7 percent Solid fuel use 3.11 Solid fuels 92.9 percent Malaria 3.16 Malaria diagnostics usage (finger or heel stick) 5.7 percent 3.17 Anti-malarial treatment of children under five the same or next day 0.2 percent 3.18 6.8 Anti-malarial treatment of children under five 0.5 percent WATER AND SANITATION Water and sanitation 4.1 7.8 Use of improved drinking water sources 82.8 percent 4.2 Water treatment 3.7 percent 4.3 7.9 Use of improved sanitation facilities 35.5 percent 4.4 Safe disposal of child's faeces 17.1 percent 4.5 Soap and water available at place for hand-washing 51.2 percent 4.6 Availability of soap in household 87.5 percent NMICS Distance between latrine and hand-washing place (within 10 paces) 25.9 percent NMICS 2010, Mid- and Far Western Regions 6 Topic MICS4 Indicator Number MDG Indicator Num ber Indicator Value REPRODUCTIVE HEALTH Contraception and unmet need 5.3 5.3 Contraceptive prevalence rate 52.4 percent 5.4 5.6 Unmet need 24.4 percent NMICS Experience of discrimination during menstruation (chaupadi) 19.4 percent Maternal and newborn health 5.5a 5.5b 5.5 Antenatal care coverage At least once by skilled personnel At least four times by any provider 45.0 percent 40.4 percent 5.6 Content of antenatal care 31.5 percent 5.7 5.2 Skilled attendant at delivery 28.7 percent 5.8 Institutional deliveries 29.8 percent 5.9 Caesarean section 2.8 percent NMICS Newborn care practices in non-institutional deliveries Dried before placenta was delivered Wrapped in a separate cloth Newborn first-time bathing practice (within one hour) 58.7 percent 88.4 percent 33.8 percent CHILD DEVELOPMENT Child development 6.1 Support for learning 70.6 percent 6.2 Father's support for learning 42.6 percent 6.3 Learning materials: children’s books 4.8 percent 6.4 Learning materials: playthings 55.2 percent 6.5 Inadequate care 50.7 percent 6.6 Early child development index 57.7 percent 6.7 Attendance in early childhood education 32.3 percent LITERACY AND EDUCATION Literacy and education 7.1 2.3 Literacy rate among young women 74.1 percent 7.2 School readiness 71.9 percent 7.3 Net intake rate in primary education 57.8 percent 7.4 2.1 Primary school net attendance ratio (adjusted) 73.1 percent 7.5 Secondary school net attendance ratio (adjusted) 55.6 percent 7.9 Gender parity index (primary school) 0.99 7.10 Gender parity index (secondary school) 0.90 CHILD PROTECTION Birth registration 8.1 Birth registration 41.9 percent Child labour 8.2 Child labour 44.3 percent 8.3 School attendance among child labourers 93.8 percent 8.4 Child labour among students 45.7 percent Child discipline 8.5 Violent discipline 83.0 percent Early marriage and polygyny 8.6 Marriage before the age of 15 years 15.7 percent 8.7 Marriage before the age of 18 years 59.9 percent 8.8 Young women aged 15–19 years currently married or in union 26.1 percent 8.9 Polygyny 3.6 percent 8.10a 8.10b Spousal age difference Women aged 15–19 years Women aged 20–24 years 4.9 percent 3.7 percent Domestic violence 8.14 NMICS Attitudes towards domestic violence Attitudes towards domestic violence (mother-in-law) 47.5 percent 62.0 percent NMICS Child grant 76.3 percent NMICS 2010, Mid- and Far Western Regions 7 Topic MICS4 Indicator Number MDG Indicator Num ber Indicator Value HIV/AIDS, SEXUAL BEHAVIOUR, AND ORPHANED AND VULNERABLE CHILDREN HIV/AIDS knowledge and attitudes 9.1 Comprehensive knowledge about HIV prevention 21.8 percent 9.2 6.3 Comprehensive knowledge about HIV prevention among young people 34.4 percent 9.3 Knowledge of mother-to-child transmission of HIV 34.0 percent 9.4 Accepting attitude towards people living with HIV 47.2 percent 9.5 Women who know where to be tested for HIV 44.5 percent 9.6 Women who have been tested for HIV and know the results 1.5 percent 9.8 HIV counselling during antenatal care 9.8 percent 9.9 HIV testing during antenatal care 5.0 percent MASS MEDIA AND USE OF INFORMATION/COMMUNICATION TECHNOLOGY Access to mass media MT.1 All three media at least once a week 5.3 percent Use of information/ communication technology MT.2 Used a computer 5.8 percent MT.3 Used the internet 2.3 percent TOBACCO AND ALCOHOL USE Tobacco use TA.1 Currently used any tobacco product 16.3 percent TA.2 Smoked a whole cigarette before the age of 15 years 5.8 percent Alcohol use TA.3 Had at least one drink of alcohol before the age of 15 years 6.5 percent TA.4 Currently used alcohol 9.5 percent SUBJECTIVE WELL-BEING SW.2 Very or somewhat happy 64.2 percent SW.3 Perceived a better life 39.2 percent 8 9 10 Foreword It is my great pleasure to acknowledge completion of the Nepal Multiple Indicator Cluster Survey (NMICS) 2010, which is a part of the fourth round of the global MICS household survey programme. This is the first time that a survey of this type that focuses on the situation of women and children in the country’s Mid- and Far Western Regions has been conducted exclusively by Nepal’s national government agencies. Our partnership with the Government of Nepal provided useful experience that can be fed into planning for subsequent surveys to monitor the situation of children and women. In particular, it has developed national capacity at the Central Bureau of Statistics (CBS) to more accurately monitor important indicators related to children and women in a variety of important areas including nutrition, child health, water and sanitation, reproductive health, child development, literacy and education, child protection, HIV and AIDS. I am delighted to note that NMICS has also helped to monitor some country-specific indicators such as discrimination against women during menstruation, attitudes toward domestic violence perpetrated by mothers-in-law, the child grant, and de-worming. I am confident that this new information will be invaluable for achieving the MDGs and other national goals with equity and in helping development workers to target their planning better in order to reduce disparity in the Mid- and Far Western Regions. While some NMICS findings are very encouraging, there are several findings that will require concerted action from all development partners in areas such as early marriage, discriminatory practices against women, violent child discipline, sanitation, and birth registration. Many issues emerging from the study will require further analysis using MICS4 data to understand the equity dynamics required to address them. I am delighted that the findings of NMICS are also being shared with children from the study area of the Mid- and Far Western Regions through a child-friendly version of the report. It was the decision of the Government of Nepal and UNICEF to disseminate the results of NMICS to children in these remote regions, who do not have access to digital or other media. It is very encourag ing that these child-friendly booklets are being provided to all schools in the 24 districts of the study regions. Children are not passive bystanders and should never be treated simply as helpless victims. By having the correct information, this will increase their capacity to engage actively in making their environment a better place for children and women. I am certain that this will provide them with information on how they can help to improve the situation of children and women in their own communities. I would like to thank the National Planning Commission for their guidance and the leadership provided to the NMICS process. I would also like to congratulate the Director General of CBS for the able leadership and professionalism of the CBS team in successfully carrying out this challenging survey. I also appreciate the great contribution made by the field team and express sincere tribute to Mrs Gaushara Khadka who lost her life in a road accident during the data collection in Dang. May her soul rest in peace. Hanaa Singer Country Representativ e UNICEF Nepal 11 12 Contents Summary Table of Findings. 5 Ack nowledgements . 8 Foreword .10 Preface .10 Contents .12 Executiv e Summary .13 Acronyms .22 I. Introduction .23 Background.23 Survey objectiv es .24 II. Sample and S urv ey Methodology .25 Sample design .25 Questionnaires.26 Tra ining and fieldwork .27 III. Sample Coverage and Characteristics of Households and Respondents .29 Sample coverage .29 Characteristics of households.29 Characteristics of female respondents aged 15–49 y ears and children under five.33 IV. Nutrition .37 Nutritional status .37 Breastfeeding and infant and y oung child feeding .37 Salt iodization .46 Children’s v itamin A supplementation .47 Low birth weight .49 De-worming .52 V. Child Health .54 Vaccinations.54 Japanese encephalitis .56 Neonatal tetanus protection .57 Oral rehydration treatment for diarrhoea .60 Care-seek ing and antibiotic treatment of pneumonia .68 Solid fuel use.72 Malaria .75 VI. Water and Sanitation .80 Use of improved drink ing water sources .80 Hand-washing at critical times . 100 VII. Reproductiv e Health . 102 Contraception . 102 Experience of discrimination during menstruation (chaupadi). 108 NMICS 2010, Mid- and Far Western Regions 13 Antenatal care . 109 Assistance at delivery . 113 Place of delivery . 117 Newborn care practices . 118 VIII. Child Dev elopment . 121 Early childhood education and learning . 121 IX. Literacy and Education . 131 Literacy among young women . 131 School readiness . 132 Primary and secondary school participation. 133 Self-reported literacy status of household members. 141 X. Child Protection. 143 Birth registration . 143 Child labour . 144 Child discipline . 149 Early marriage and polygyny . 151 Attitudes toward domestic violence . 160 Child grant . 163 XI. HIV and AI DS . 165 Knowledge about HIV transmission and misconceptions about HIV/AIDS . 165 Accepting attitudes towards people living with HIV/AI DS . 172 Knowledge of a place for HIV testing, and counselling and testing during antenatal care . 174 XII. Access to Mass Media and Use of Information/Communication Technology . 179 Access to mass media . 179 Use of information/communication technology . 180 XIII. Tobacco and Alcohol Use . 183 Ever and current use of tobacco . 183 First use of cigarettes and frequency of use . 186 XIV. Subjective well-being . 190 Appendix A. S ample Design . 196 Appendix B. List of Personnel I nv olved in the S urvey. 201 Appendix C. Estimates of Sampling Errors . 204 Appendix D. Data Quality Tables. 224 Appendix E. MICS 4 Indicators: Numerators and Denominators. 234 Appendix F. Questionnaires. 240 List of tables Table HH.1: Results of household, women's and under-five interv iews .29 Table HH.2: Household age distribution by sex .30 Table HH.3: Household composition .32 Table HH.4: Women’s background characteristics.34 NMICS 2010, Mid- and Far Western Regions 14 Table HH.5: Under-fives’ background characteristics.36 Table NU.1: Initia l breastfeeding .38 Table NU.2: Breastfeeding .40 Table NU.3: Duration of breastfeeding .42 Table NU.4: Age-appropriate breastfeeding .43 Table NU.5: Introduction of solid, semi-solid or soft food .44 Table NU.6: Minimum meal frequency .45 Table NU.7: Bottle-feeding .46 Table NU.8: Iodized sa lt consumption .47 Table NU.9: Children’s vitamin A supplementation .49 Table NU.10: Low birth weight .51 Table NU.11: De-worming of children .53 Table CH.1: Vaccinations in first y ear of life .55 Table CH.2: Vaccinations by background characteristics .56 Table CH.3: Vaccination against Japanese encephalitis .57 Table CH.4: Neonatal tetanus protection.59 Table CH.5: Oral rehy dration solution .62 Table CH.6: F eeding practices during diarrhoea .63 Table CH.7: Oral rehy dration therapy with continued feeding and other treatments .66 Table CH.8: Care-seeking for suspected pneumonia and antibiotic use during suspected pneumonia .69 Table CH.9: Care seeking of illness sy mptoms.71 Table CH.10: Solid fuel use .73 Table CH.11: Solid-fuel use by place of cooking .75 Table CH.12: Anti-malaria l treatment of children with anti-malaria l drugs.76 Table CH.13: Malaria diagnostics usage.79 Table WS.1: Use of improved water sources.81 Table WS.2: Household water treatment.83 Table WS.3: Time to source of drinking water.85 Table WS.4: Person collecting water .86 Table WS.5: Types of sanitation facilities .88 Table WS.6: Use and sharing of sanitation facilities.90 Table WS.7: Disposal of child’s faeces .92 Table WS.8: Use of improved water sources and improved sanitation facilities .94 Table WS.9: Water and soap at place for hand-washing .96 Table WS.10: Av ailability of soap .98 Table WS.11: Distance between latrine and place for hand-washing . 100 Table WS.12: Critica l times for hand-washing . 101 Table RH.1: Use of contraception. 103 Table RH.2: Unmet need for contraception . 106 Table RH.3: Experience of discrimination during menstruation . 109 Table RH.4: Antenatal care provider . 111 Table RH.5: Number of antenatal care vis its . 112 Table RH.6: Content of antenatal care. 113 Table RH.7: Assistance during delivery . 115 Table RH.8: Place of delivery . 118 Table RH.9: Newborn care practices in non-institutional deliv eries . 119 Table RH.10: First-time bathing of newborns. 120 Table CD.1: Early childhood education . 122 Table CD.2: S upport for learning . 124 Table CD.3: Learning materia ls . 126 NMICS 2010, Mid- and Far Western Regions 15 Table CD.4: I nadequate care. 128 Table CD.5: Early Child Development Index . 130 Table ED.1: Literacy among young women . 132 Table ED.2: S chool readiness . 133 Table ED.3: Primary school entry . 134 Table ED.4: Primary school attendance or higher. 135 Table ED.5: Secondary school attendance or higher . 137 Table ED.6: Education gender parity . 139 Table ED.7: S chool attendance . 140 Table ED.8: Self-reported literacy status of household members . 142 Table CP. 1: Birth reg istration . 144 Table CP. 2: Child labour . 146 Table CP. 3: Child labour and school attendance. 149 Table CP. 4: Child discipline . 151 Table CP. 5: Early marriage and polygy ny . 153 Table CP. 6: Trends in early marriage . 156 Table CP. 7: S pousal age difference. 158 Table CP. 8: Attitudes toward domestic v iolence . 161 Table CP. 9: Attitudes toward domestic v iolence . 163 Table CP. 10: Child grant . 164 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensiv e knowledge about HIV transmission . 166 Table HA.2: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensiv e knowledge about HIV transmission among young people . 169 Table HA.3: Knowledge of mother-to-child HIV transmission . 172 Table HA.4: Accepting attitudes toward people liv ing with HIV/AI DS . 174 Table HA.5: Knowledge of a place for HIV testing . 176 Table HA.6: HIV counselling and testing during antenatal care. 178 Table MT.1: Exposure to mass media . 180 Table MT.2: Use of computers and internet . 182 Table TA.1: Ever and current use of tobacco. 184 Table TA.2: Age at first use of cigarettes and frequency of use . 187 Table TA.3: Use of alcohol . 189 Table SW.1: Life satisfaction and happiness. 191 Table SW.2: Life satisfaction and happiness. 194 Table SW.3: Perception of a better life . 195 Table SD.1: Allocation of sample clusters (primary sampling units) to sampling strata. 197 Table SE. 1: I ndicators selected for sampling error calculations . 205 Table SE. 2: Sampling errors: Total sample . 206 Table SE. 3: Sampling errors: Urban areas . 208 Table SE. 4: Sampling errors: Rural areas. 210 Table SE. 5: Sampling errors: Mid-Western Mountains. 212 Table SE. 6: Sampling errors: Mid-Western Hills . 214 Table SE. 7: Sampling errors: Mid-Western Terai . 216 Table SE. 8: Sampling errors: Far Western Mountains . 218 Table SE. 9: Sampling errors: Far Western Hills . 220 Table SE. 10: Sampling errors: Far Western Terai . 222 Table DQ.1: Age distribution of household population . 224 Table DQ.2: Age distribution of eligible and interviewed women . 226 Table DQ.3: Age distribution of under-5s in household and under-5 questionnaires . 226 Table DQ.4: Women's completion rates by socio-economic characteristics of households . 227 NMICS 2010, Mid- and Far Western Regions 16 Table DQ.5: Completion rates for under-5 questionnaires by socio-economic characteristics of households . 228 Table DQ.6: Completeness of reporting. 229 Table DQ.7: Observation of places for hand-washing . 229 Table DQ.8: Observation of women’s health cards. 230 Table DQ.9: Observation of under-5s birth certificates. 231 Table DQ.10: Observation of vaccination cards . 231 Table DQ.11: Presence of mother in household and person interviewed for under-5 questionnaire . 232 Table DQ.12: Selection of children aged 2–14 years for the child discipline module . 232 Table DQ.13: School attendance by s ingle age . 233 List of figures Map 1: NMICS 2010 sample domains in the MFWR, Nepal .25 Figure HH.1: Age and sex distribution of household population .32 Figure NU.1: Percentage of last-born children who were first breastfed within one hour of birth and within one day of birth .39 Figure NU.2: Percentage of children under two by feeding pattern by age group.41 Figure NU.3: Percentage of infants weighing less than 2,500 grams at birth .52 Figure CH.1: Percentage of children aged 12–23 months who received the recommneded vaccinations by 12 months of age.55 Figure CH.2: Percentage of women with a live birth in the preceding 12 months who were protected against neonatal tetanus .60 Figure CH.3: Percentage of children under five with diarhoea in preceding two weeks who received ORS or increased fluids .68 Figure WS.1: Percentage of household members using an improved source of drinking water by subreg ion.82 Figure ED.1: Trends in school attendance for urban and rural household members aged 5–24 years . 141 Figure HA.1: Percentage of women who have comprehensive knowledge of preventing HIV transmission . 171 17 Executive Summary Summary of findings The Nepal Multiple Indicator Cluster Survey (NMICS) 2010 is a subnational survey of 7,372 women aged 15–49 years and 3,574 children under five from 6,000 households in the Mid- and Far Western Regions (MFWR) of Nepal. NMICS 2010 was implemented as part of the fourth round of the global MICS household survey programme with technical and financial support from UNICEF Nepal in collaboration with the Government of Nepal. The main purpose of NMICS 2010 is to support the government to generate statistically sound and comparable data for monitoring the situation of children and women in the MFWR of the country. NMICS 2010 covers topics related to nutrition, child health, water and sanitation, reproductiv e health, child development, literacy and education, child protection, HIV and AIDS, mass media and the use of information and communication technology, attitude towards domestic violence, the use of tobacco and alcohol, and life satisfaction. In addition, NMICS 2010 is the first survey in Nepal to provide baseline information on the prevalence of chaupadi (women who live in a separate house or animal shed during menstruation) in the MFWR and evidence on women’s life satisfaction. Nutrition Breastfeeding is nearly universal in the MFWR, with the median duration of any breastfeeding being 31.5 months and median duration for exclusive breastfeeding being relatively short at 4.0 months. Contrary to UNICEF and WHO recommendations, only around two in three (64 percent) children are exclusively breastfed for the first six months of life. The practice of introducing complementary food varies somewhat in these regions; however, around two in three (63 percent) children are provided with complementary food at 6–8 months of age. The continued practice of bottle-feeding is a concern because of possible contamination due to unsafe water and lack of hygiene in preparation. Overall, the use of bottle with a nipple is fairly low (five percent); however, this practice rises from three percent among children aged 0–5 months to seven percent among children aged 12–23 months. Nearly three fifths (57 percent) of children aged 6–23 months are receiving solid, semi-solid and soft foods the recommended minimum number of times a day. Child health Although immunization coverage in Nepal has improved over the past decade, only around three fifths (56 percent) of children in the MFWR have been fully immunized before their first birthday. Polio vaccines coverage is higher than other immunizations, as this vaccine is included as part of the national immunization days in Nepal. Almost nine in 10 (89 percent) children received BCG vaccination; 93 percent received the first polio dose but only 77 percent received the third; 86 percent received the first DPT dose but only 68 percent received the third; and 83 percent received the measles vaccine. In addition, nearly one third (31 percent) of children under five residing in the Terai of the MFWR were vaccinated against Japanese encephalitis. Eleven percent of children under five in the MFWR had had diarrhoea in the two weeks preceding the survey. Preventing dehydration due to diarrhoea by increasing fluid intake (oral rehydration solution (ORS)) and continuing to feed the child are important strategies for managing diarrhoea. Around half (47 percent) of children had received ORS with continued feeding. The government also recommends using zinc tablets with ORS during an episode of diarrhoea. Twenty-two percent of children with diarrhoea had received zinc tablets along with ORS. Seven percent of children aged 0–59 months in the MFWR were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these children, only half (51 percent) NMICS 2010, Mid- and Far Western Regions 18 were taken to health facilities or an appropriate healthcare provider, and 56 percent of those with fever received antibiotics. Almost no (0.2 percent) children with fever received anti-malarial drugs. NMICS 2010 gathered information on the use of solid fuels in the home as these increase the risks of suffering from acute respiratory illness, pneumonia, chronic obstructive lung disease and cancer, as well as tuberculosis, low birth weight, cataracts and asthma. Over nine in 10 (93 percent) household members used solid fuels for cooking in the MFWR. Water and sanitation Safe drinking water and proper sanitation and hygiene practices are basic necessities for good health. Improved drinking-water sources include piped water (into dwelling, compound, yard or plot, public tap/standpipe), tube well/borehole, protected well, protected spring, and rainwater collection/harvesting. More than four fifths (83 percent) of household members in the MFWR used an improved source of drinking water. Of household members who used an unimprov ed water source, only four percent use an appropriate water treatment method to make their drinking water safe. Some 46 percent of household members had an improved/unimproved drinking water source on premises, while 36 percent took less than 30 minutes to collect water from an improved/unimproved source and while 18 percent spent 30 minutes or more for this purpose. The majority (56 percent) of household members in the MFWR had no toilet facility. Some 36 percent were using an improved sanitation facility that was not shared. Safe disposal of a child’s faeces was practiced for only 17 percent of children aged 0–2 years. The incidence of diarrhoea and pneumonia in children under five could be significantly reduced by correct hand-washing practices with water and soap. Of households in the MFWR where a place for hand-washing was observed, over half (51 percent) had both water and soap present at the designated place. In 12 percent of households only water was available and in another 12 percent only soap was available. The remaining 25 percent of households had neither water nor soap available at the place designated for hand-washing. Around nine in 10 (88 percent) households had soap available somewhere in the dwelling. Around one quarter (26 percent) of households had a hand-washing place within 10 paces of their latrine. Reproductive health Current use of contraception was reported by 52 percent of women aged 15–49 years in the MFWR who were currently married or in a marital union. The most popular method was injectables/Dipo/Sangini (16 percent); this was followed by female sterilization (15 percent), male sterilization (seven percent), male condom (five percent) and the pill (five percent). Almost one quarter (24 percent) of women had an unmet need for contraception, with seven percent having an unmet need for spacing and 17 percent having an unmet need for limiting. Chaupadi is a harmful practice experienced by many women in the MFWR during their menstrual period, when they have to stay in a separate house or animal shed. This kind of living arrangement affects both women both physically and mentally. Almost one fifth (19 percent) of women aged 15– 49 had to stay in a separate house and 12 percent had to stay in an animal shed. Nepal’s antenatal care protocol provisions antenatal care visits in the fourth, sixth, eighth and ninth months of pregnancy under the focused safe motherhood programme in line with UNICEF and WHO recommendations. Coverage of antenatal care is relatively low in the MFWR, with only 45 percent of women aged 15–49 years who had a live birth during the two years preceding the survey receiving antenatal care at least once from a skilled provider (doctor, staff nurse or Auxiliary Nurse Midwife). Only two fifths (40 percent) had received at least four antenatal care visits from any provider. Furthermore, only 29 percent of women were delivered by skilled personnel (doctor, staff nurse or NMICS 2010, Mid- and Far Western Regions 19 Auxiliary Nurse Midwife), and almost the same percentage (30 percent) of deliveries took place in a health facility. The majority (95 percent) of women who received no antenatal care visits delivered at home; however, almost half (49 percent) of women who attended four or more antenatal care visits also delivered at home. In the two years preceding the survey, almost three fifths (59 percent) of women aged 15–49 years in the MFWR with a non-institutional live birth in the two years preceding the survey reported that their newborn was dried before the placenta was delivered and 88 percent reported that their newborn was wrapped in a separate cloth after drying. However, one third (34 percent) of women reported that their newborn was bathed within one hour of birth, and only 36 percent waited the recommended 24 hours before bathing their newborn. Child development Around one third (32 percent) of children aged 36–59 months in the MFWR were attending early childhood education at the time of the survey. In addition, 71 percent had engaged with an adult household member in four or more activities that promote learning and school readiness during the three days preceding the survey, with an average number of 4.4 activities. Some 43 percent of children had engaged with their father in one or more activities, with an average number of 0.8 activities. Only five percent of children under five in the MFWR lived in a household with at least three children’s books, and only one in 1,000 lived in a household with 10 or more children’s books. Some 55 percent had two or more types of playthings. Leaving children alone or in the presence of other young children is known to increase the risk of accidents. Around half (51 percent) of under- fives were left with inadequate care in the week preceding the survey, with 32 percent left alone and 42 percent left in the care of children aged less than 10 years. The Early Child Development Index (ECDI) represents the percentage of children who are developmentally on track in at least three of four domains (literacy–numeracy, physical, socio- emotional and learning). Some 58 percent of children aged 36–59 months in the MFWR were developmentally on track as indicated by the ECDI. The low level for literacy–numeracy (18 percent) might be attributed to limited access to early childhood education opportunities in these regions. Education and literacy Around three quarters (74 percent) of women aged 15–24 years in the MFWR were literate. Attendance in an organized early childhood education programme is important for the readiness of children for school. Seventy-two percent of children in the MFWR who were currently attending Grade 1 had attended preschool in the previous year. Some 73 percent of children of primary school age were attending primary school or higher. However, only 56 percent of children of secondary school age were attending secondary school or higher. The Gender Parity Index (GPI), which measures the school attendance ratio of girls to boys, was 0.99 at primary school level, indicating that girls and boys in the MFWR attend primary school at about the same rate. However, secondary school GPI dropped to 0.90, indicating that fewer girls than boys attend secondary school. Child protection Slightly more than two fifths (42 percent) of children under five had been birth registered with civil authorities in the MFWR, despite 73 percent of children having a mother/caretak er who knew how to register a birth. ‘Child labour’ is defined as work that exceeds a minimum number of hours, depending on the age of the child and the type of work. Overall, 44 percent of children aged 5–14 years in the MFWR were involved in child labour. Some 51 percent of children aged 5–11 years were involved in child labour NMICS 2010, Mid- and Far Western Regions 20 (at least one hour of economic work or 28 hours of domestic work) and 30 percent of children aged 12–14 years were involved in child labour (at least 14 hours of economic work or 28 hours of domestic work). Of children involved in child labour, over nine out of 10 (94 percent) were also attending school. Of children attending school, 46 percent were also involved in child labour. Overall, a very high proportion (83 percent) of children aged 2–14 years in the MFWR were subjected to at least one form of psychological or physical punishment by their mothers/caretakers or other household members, with 18 percent being subjected to severe physical punishment. In addition, 36 percent of respondents believed that a child needs to be physically punished. Some 16 percent of women aged 15–49 years in the MFWR first married or entered a marital union before their 15th birthday and 60 percent of women aged 20–49 years first married or entered a marital union before their 18th birthday. A low proportion (four percent) reported that they were living in a polygynous marriage or union. Domestic violence is also measured in NMICS 2010. Overall, 48 percent of women aged 15–49 years in the MFWR felt that a husband/partner is justified in hitting or beating his wife/partner for at least one of a variety of reasons, while 62 percent felt that a mother-in-law is justified in verbally abusing/threatening her daughter-in-law for at least one of a variety of reasons. NMICS 2010 also assessed the child grant status of children under five in the Karnali Zone (the Mid- Western Mountains), as the Government of Nepal has recently started a child grant scheme in this area. Almost 76 percent of eligible children had received the child grant. HIV and AIDS More than half (56 percent) of women aged 15–49 years in the MFWR had heard of AIDS, with younger women (15–24 years) reporting a higher rate of awareness. However, only 40 percent knew of two ways to prevent HIV transmission: 48 percent knew of having one faithful, uninfected sexual partner and 43 percent knew of using a condom for sex every time. Slightly more than one fifth (22 percent) of women had comprehensive knowledge of HIV transmission. Some 42 percent knew that a healthy looking person can have the AIDS virus; 35 percent knew that HIV cannot be transmitted by mosquito bites; 49 percent knew that HIV cannot be transmitted by supernatural means; 41 percent knew that HIV cannot be transmitted by sharing food with someone with AIDS. In total, 25 percent rejected two of the most common misconceptions about HIV transmission and knew that a healthy looking person can have the AIDS virus. Comprehensive knowledge about HIV/AIDS rises to 34 percent among young women (aged 15–24 years). Thirty-four percent of women aged 15–49 years in the MFWR and 48 percent of young women aged 15–24 years were able to correctly identify all three means of mother-to-child HIV transmission. Furthermore, of women who had heard of AIDS, 47 percent of those aged 15–49 and 53 percent of those aged 15–24 years expressed accepting attitudes towards people living with HIV. Although 45 percent of women aged 15–49 years in the MFWR knew where to be tested for HIV, only five percent have ever been tested and two percent were tested in the previous 12 months. Furthermore, less than two percent had been tested and told the result. Access to mass media and use of information/communication technology NMICS 2010 collected information from women aged 15–49 years on their exposure to mass media (newspapers, radio and television) and from women aged 15–24 years on their use of computers and the internet. Only five percent of women were exposed to all three types of media at least once a week. Radio appears to be most the accessible mass media (49 percent), followed by television (29 percent) and newspapers (eight percent). Six percent of young women had used a computer in the year preceding the survey and two percent had used the internet during the same period. NMICS 2010, Mid- and Far Western Regions 21 Tobacco and alcohol use Tobacco and alcohol use are known risk factors for many deadly diseases and harmful health conditions. Overall, one fifth (20 percent) of women aged 15–49 years in the MFWR reported having ever used a tobacco product and 16 percent currently used any tobacco product. Six percent of women had smoked a whole cigarette before the age of 15 years. Although 85 percent of women had never had an alcoholic drink, seven percent had had at least one drink of alcohol before the age of 15 years, and 10 percent had had at least one drink of alcohol on one or more days in the month preceding the survey. Subjective well-being NMICS 2010 asked young women aged 15–24 years in the MFWR to assess how satisfied they were with different areas of their life such as family, friendships, school, job, living environment and income. Some 91 percent were very or somewhat satisfied with their family life and friendships, 83 percent with their current job, 81 percent with school, self and life overall, 80 percent with their income, and 77 percent with their living environment. In total, 36 percent had life satisfaction (i.e., were very or somewhat satisfied with all facets of their life). Young women were also asked how happy they considered themselves to be. About two thirds (64 percent) reported that they were very or somewhat happy. Furthermore, 39 percent perceived a better life (i.e., they considered that their life had improved during the year preceding the survey and would continue to improve in the year subsequent to the survey). 22 Acronyms AIDS acquired immunodeficiency syndrome BCG Bacillus Calmette Guerin (Tuberculosis) CBS Central Bureau of Statistics DPT diphtheria, pertussis, tetanus ECDI Early Child Development Index GIS geographic information system GPI Gender Parity Index HIV human immunodeficiency virus IDD iodine deficiency disorders JE Japanese encephalitis MDG Millennium Development Goal MFWR Mid- and Far Western Regions MICS Multiple Indicator Cluster Survey NAR net attendance ratio NMICS Nepal Multiple Indicator Cluster Survey ORS oral rehydration solution ORT oral rehydration therapy ppm parts per million PSU primary sampling unit SPSS Statistical Package for Social Sciences UNGASS United Nations General Assembly Special Session UNICEF United Nations Children’s Fund USAID United States Agency for International Development VDC Village Development Committee WFFC World Fit for Children WHO World Health Organization 23 I. Introduction Background This report is based on data collected in 2010 for the first subnational Nepal Multiple Indicator Cluster Survey (NMICS) conducted by the Government of Nepal’s Central Bureau of Statistics (CBS) with technical and financial support from UNICEF. The survey, this time, was limited to the Mid- and Far Western Regions (MFWR) of Nepal and provides valuable information on the situation of children and women in these two development regions. It 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 for A World Fit For Children (WFFC), adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments were built 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 box below). A Commitme nt to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the WFFC 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.” (WFFC, 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.…” (WFFC, 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.” NMICS 2010 is intended, in large part, to fill the data gaps that have long existed for the MFWR. Over the years, Nepal has concentrated its development focus on the MFWR because of their higher level of extreme poverty and deprivation relative to the country’s other development regions. The results of NMICS 2010 will help in monitoring progress towards goals and targets emanating from international agreements, such as the Millennium Development Goals (MDGs) and WFFC, in these two development regions. Furthermore, NMICS 2010 has provided the Government of Nepal with useful experience that can be fed into planning for subsequent national surveys. In particular, it has developed national capacity at NMICS 2010, Mid- and Far Western Regions 24 the CBS in collecting data on important indicators related to children and women, including some country-specific indicators such as discrimination during menstruation, attitudes toward domestic violence perpetrated by mothers-in-law, the child grant, and de-worming. This survey has also generated information on indicators that are comparable with the ecological subregions defined in previous national surveys (e.g., the Nepal Demographic and Health Surveys). The results will contribute to monitoring progress made over the past decade on children’s and women’s issues. They will also help in identifying the regional and geographic disparities that exist within the country. This final report presents the results of the indicators and topics covered in the survey. Survey objectives The specific objectives of the NMICS 2010 are: • to provide up-to-date information for assessing the situation of children and women in the Mid- and Far Western Regions of Nepal; • to furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action; • to contribute to the improvement of data and monitoring systems at subnational levels in Nepal and to strengthen technical expertise in the design, implementation and analysis of such systems; and • to generate data on the situation of children and women that are required to identify vulnerable groups and identify disparities for policies and interventions. 25 II. Sample and Survey Methodology Sample design The sample for NMICS 2010 was designed to provide data on a large number of indicators related to the situation of children and women in each of the two development regions of Nepal’s MFWR, in urban and rural areas, and for the following six subregional domains (see Map 1). • Mid-Western Mountains • Mid-Western Hills • Mid-Western Terai 1 • Far Western Mountains • Far Western Hills • Far Western Terai Map 1: NMICS 2010 sample domains in the MFWR, Nepal Urban and rural areas within each region were identified as the main sampling strata and the sample was selected in two stages. Within each domain, 40 clusters (wards) were selected systematically with probability proportional to size, to yield a total of 240 wards. After a household listing was carried out within the selected wards, a systematic sample of 25 households was drawn from each ward. Smaller wards, where the number of households was less than 25, were grouped with adjoining wards to bring the total number of households to at least 25. Two adjoining wards were 1 The Terai lies in the northern part of the Indo-Gangetic plain, extending in Nepal nearly 800 km from east to west and 30– 40 km from north to south. NMICS 2010, Mid- and Far Western Regions 26 grouped together in nine clusters: one rural cluster each in Achham, Dolpa and Kailali and two rural clusters each in Baitadi, Bajhang and Humla. Similarly, in cases of large wards, especially in urban areas or municipalities, census enumeration blocks were used. Enumeration blocks were created by the GIS Section of the CBS for the 2011 population census by segmenting large wards. Of the 50 urban clusters in the survey, 22 were selected from segmented municipalities in the five districts of Banke, Dang, Kailali, Kanchanpur and Surkhet. Thus, a total of 6,000 households were selected for interviewing, of which 1,250 represented urban areas (municipalities) and 4,750 represented rural areas (Village Development Committees (VDCs)). The sample was stratified by regions and is not self-weighting. Sample weights were applied in the reporting of subregional results. A more detailed description of the sample design can be found in Appendix A. Questionnaires The standard MICS4 questionnaires were used and adapted to include several country-specific questions and modules. Three sets of questionnaires were used in the survey. (i) A household questionnaire used to collect information on all de jure household members (usual residents), the household, and the dwelling. (ii) A women’s questionnaire administered to all women aged 15–49 years living in each household. (iii) An under-fives’ questionnaire administered to mothers or caretakers of all children under five2 living in each household. The Household Questionnaire included the following modules. • Household listing form • Education • Water and sanitation • Household characteristics • Child labour • De-worming (Nepal-specific module) • Child discipline • Hand-washing • Salt iodization The Questionnaire for Individual Women included the following modules. • Woman’s background • Access to mass media and use of information communication technology • Desire for last birth • Maternal and newborn health 3 • Illness symptoms • Contraception • Unmet need • Attitudes towards domestic violence 4 (Nepal-specific module) 2 The terms ‘children under five’, ‘under-fives’, ‘children aged 0–4 years’, and ‘children aged 0–59 months’ are used interchangeably in this report. 3 Non-MICS standard questions were added to the questionnaire for women aged 15–49 years and asked to mothers who had given birth in a non-institutional setting in the two years preceding the survey in order to assess whether safe newborn care practices were adopted in the Mid- and Far Western Regions of Nepal. 4 Non-MICS standard questions were added to the questionnaire for women aged 15–49 years to assess their attitudes towards whether mothers-in-law are justified in verbally abusing or threatening their daughters-in-law. NMICS 2010, Mid- and Far Western Regions 27 • Marriage/union • HIV/AIDS • Tobacco and alcohol use • Life satisfaction The Questionnaire for Children Under Five was normally administered to mothers of under-fives; 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. • Age • Birth registration • Early childhood development • Breastfeeding • Care during illness • Malaria • Immunization • Child grant (Nepal-specific module) The questionnaires are based on the MICS4 model questionnaires 5 . From the MICS4 model English version, the questionnaires were translated into Nepali and two other local dialects, Tharu and Awadhi, which are widely spoken in the Terai. Questionnaires were pre-tested in the districts of Jumla (rural Mountains), Salyan (rural Hills) and Banke (urban Terai) during July 2010. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. However, due to political sensitivities regarding language issues, only the Nepali questionnaires were used to record data. An English version of the questionnaires used for NMICS 2010 is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in surveyed households for iodine content and observed the place used for hand-washing. Details and findings of these measurements are provided in the respective sections of the report. Training and fieldwork Field workers were contracted for three months. Of 60 personnel recruited, 12 were males and the rest were females. The field personnel recruited formed a heterogeneous group in terms of age, caste/ethnicity and education. An 11-day residentia l training course was held on 19–29 September 2010 in Banepa, Kavrepalanchok District, near to Kathmandu. Trainees were organized into three groups, each containing 20 personnel. Each group consisted of interviewers, data editors and supervisors. Training was conducted in three parallel sessions, and included lectures on interviewing techniques and understanding of the questionnaire contents as well as mock interviews between trainees to gain practice on asking questions. The residential mode of training gave participants a good opportunity to become familiar with each other before working as a team during data collection in the field. Data were collected by 12 field teams. Each team consisted of a supervisor, three female interviewers and a data editor. On average, each team collected data from 20 clusters (enumeration areas). In total, 60 people worked in the field over a period of about two and half months. Fieldwork began in October 2010 and concluded in December 2010. Data processing Data were entered using the CSPro software on four microcomputers by four data-entry operators and two data-entry supervisors. In order to ensure a high level of quality control, all questionnaires 5 The model MICS4 questionnaires can be found at www.childinfo.org NMICS 2010, Mid- and Far Western Regions 28 were double-entered and internal consistency checks were performed. Procedures and standard programmes developed under the global MICS4 programme and adapted to the Nepal questionnaires were used throughout. Data entry started in November 2010 and was completed in March 2011. Data were analysed using the Statistical Package for Social Sciences (SPSS) software programme, Version 18. The model syntax and tabulation plans developed by UNICEF were used for this purpose. 29 III. Sample Coverage and Characteristics of Households and Respondents Sample coverage Of the 6,000 households selected for the sample, 5,917 were found to be occupied. Of these, 5,899 were successfully interviewed, giving a household response rate of 99.7 percent. In interviewed households, 7,674 women (aged 15–49 years) were identified. Of these, 7,372 were successfully interviewed, yielding a response rate of 96.1 percent within interviewed households. In addition, 3,688 children under five were listed in the household questionnaire. Questionnaires were completed for 3,574 of these children, giving a response rate of 96.9 percent within interviewed households. Overall response rates of 95.8 percent and 96.6 percent are calculated for women’s and under-fives’ interviews, respectively (Table HH.1). Response rates for households, women and children under five were similar (above 95 percent) between urban/rural areas and across all subregions. Table HH.1: Results of household, women's and under-five interviews Numbers of households, women and children under five by results of the household, women's and under-fives’ interviews, and household, women's and under-fives’ response rates, MFWR, Nepal, 2010 Region Subregion Area Total M id -W e st e rn Fa r W e st e rn M id -W e st e rn M o u nt a in s M id -W e st e rn H ill s M id -W e st e rn T er a i Fa r W e st e rn M o u nt a in s Fa r W e st e rn H ill s Fa r W e st e rn T er a i U rb a n R ur a l No. of households Households sampled 3,000 3,000 1,000 1,000 1,000 1,000 1,000 1,000 1,250 4,748 6,000 Households occupied 2,964 2,953 991 989 984 973 991 989 1,232 4,685 5,917 Households interviewed 2,960 2,939 989 988 983 967 989 983 1,228 4,671 5,899 Household response rate 99.9 99.5 99.8 99.9 99.9 99.4 99.8 99.4 99.7 99.7 99.7 No. of wom en Women eligible 3,809 3,865 1,245 1,238 1,326 1,189 1,216 1,460 1,656 6,018 7,674 Women interviewed 3,671 3,701 1,202 1,198 1,271 1,138 1,174 1,389 1,582 5,790 7,372 Women’s response rate 96.4 95.8 96.5 96.8 95.9 95.7 96.5 95.1 95.5 96.2 96.1 Women’s overall response rate 96.2 95.3 96.4 96.7 95.8 95.1 96.4 94.6 95.2 95.9 95.8 No. of children under five Children under five eligible 1,872 1,816 835 586 451 641 629 546 588 3,100 3,688 Children under five mother/ caretaker interviewed 1,817 1,757 817 569 431 624 609 524 561 3,013 3,574 Under-fives’ response rate 97.1 96.8 97.8 97.1 95.6 97.3 96.8 96.0 95.4 97.2 96.9 Under-fives’ overall response rate 96.9 96.3 97.6 97.0 95.5 96.7 96.6 95.4 95.1 96.9 96.6 Characteristics of households The 2011 population census estimated 26.6 million people are living in Nepal. The sex ratio is estimated to be 94.4 (males per 100 females) and the household size is recorded at 4.7 members. The 2011 census also shows that the Terai constitutes 50.2 percent of the total population, while the Hills constitute 43.1 percent and the Mountains 6.8 percent. Seventeen percent of the total population resides in urban areas. The weighted age and sex distribution of the surveyed population is provided in Table HH.2. In the 5,899 households interviewed, 31,260 household members were listed. Of these, 15,053 were males and 16,206 were females. NMICS 2010, Mid- and Far Western Regions 30 Table HH.2 shows the distribution by age and sex of the surveyed population. Some 11 percent of the surveyed population was aged 0–4 years (under-fives) (12 percent male and 10 percent female), 40 percent was aged 0–14 years (41 percent male and 38 percent female) and 46 percent was aged 0–17 years (49 percent male and 44 percent female). The percentage of the population aged 65 years and above was four percent. The total dependency rate, typically measured as the proportion of the total population outside the economically active age (15–64 years), was 57 percent (55 percent male and 58 percent female). The average household size was 5.3, which is slightly higher than the national average of 4.7. Table HH.2: Household age distribution by sex Frequency and percentage of household population by sex and by five-year age groups, dependency age groups, and child (aged 0–17 years) and adult populations (aged 18+ years), MFWR, Nepal, 2010 Male Fem ale Total No. Percent No. Percent No. Percent Age 0–4 years 1,796 11.9 1,692 10.4 3,489 11.2 5–9 years 2,259 15.0 2,154 13.3 4,413 14.1 10–14 years 2,141 14.2 2,326 14.4 4,468 14.3 15–19 years 1,742 11.6 1,613 10.0 3,356 10.7 20–24 years 1,078 7.2 1,486 9.2 2,565 8.2 25–29 years 1,039 6.9 1,296 8.0 2,335 7.5 30–34 years 822 5.5 1,042 6.4 1,864 6.0 35–39 years 755 5.0 903 5.6 1,658 5.3 40–44 years 643 4.3 841 5.2 1,484 4.7 45–49 years 649 4.3 606 3.7 1,255 4.0 50–54 years 525 3.5 688 4.2 1,213 3.9 55–59 years 540 3.6 494 3.0 1,034 3.3 60–64 years 457 3.0 489 3.0 946 3.0 65–69 years 313 2.1 275 1.7 587 1.9 70–74 years 172 1.1 171 1.1 343 1.1 75–79 years 76 0.5 59 0.4 136 0.4 80–84 years 29 0.2 45 0.3 73 0.2 85+ years 14 0.1 18 0.1 33 0.1 Missing/don’t know 1 0.0 7 0.0 8 0.0 Dependency age groups 0–14 years 6,197 41.2 6,173 38.1 12,370 39.6 15–64 years 8,251 54.8 9,459 58.4 17,709 56.7 65+ years 604 4.0 568 3.5 1,172 3.8 Missing/don’t know 1 0.0 7 0.0 8 0.0 Child and adult populations Children aged 0–17 years 7,311 48.6 7,156 44.2 14,468 46.3 Adults aged 18+ years 7,741 51.4 9,043 55.8 16,784 53.7 Missing/don’t know 1 0.0 7 0.0 8 0.0 Total 15,053 100.0 16,206 100.0 31,260 100.0 NMICS 2010, Mid- and Far Western Regions 31 Figure HH.1 shows the age and sex distribution of household members in a population pyramid. The population pyramid has odd ‘spikes’ for females aged 10–14 years and 50–54 years. This unexpected age pattern is likely to be caused by heaping on women aged 50 years (as data quality tables suggest), as well as the possibility that some interviewers might have tried to avoid conducting interviews with all women by recording the ages of some women to be outside the eligibility age range, i.e., 15–49 years. Tables HH.3 to HH.5 provide basic information on households, female respondents aged 15–49, and children under five by presenting the unweighted as well as the weighted numbers. Information on the basic characteristics of households, women and children under five interviewed in the survey is essential for interpretation of the findings presented later in the report and can also provide an indication of the representativeness of the survey. The remaining tables in this report are presented with only weighted numbers. See Appendix A for more details about the weighting. Tables HH.3 provides basic background information on the households surveyed. These background characteristics are used in subsequent tables in this report; these figures are also intended to show the numbers of observations by major categories of analysis used in the report. Table HH.3 provides information on composition of households by region, subregion, sex of household head, area, number of household members, and education6 of household head. Some 56 percent of households were located in the Mid-Western Region and 44 percent in the Far Western Region. By subregion, 29 percent were in the Mid-Western Hills, 22 percent in the Far Western Terai, 22 percent in the Mid-Western Terai, 14 percent in the Far Western Hills, seven percent in the Far Western Mountains and six percent in the Mid-Western Mountains. The total weighted and unweighted numbers of households are equal, since sample weights were normalized (see Appendix 6 Unless otherwise stated, ‘education’ refers to educational level attained by the respondent, when used as a background variable in this report. The categories for education are as follows: no education = None, Grades 1–5 = Primary, and Grade 6 and above = Secondary +. 8 6 4 2 0 2 4 6 8 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Percent Ag e gr o u p Figure HH.1: Age and sex distribution of household population, MFWR, Nepal, 2010 Females Males NMICS 2010, Mid- and Far Western Regions 32 A). However, it should be noted here that the weighted numbers for the Mid-Western Mountains and Far Western Mountains are much lower than the unweighted numbers due to oversampling in these two subregions. Around four fifths (80 percent) of surveyed households were headed by a male. Most (89 percent) households were located in rural areas and 61 percent had five or more members. Almost half (49 percent) of household heads were without formal education. Some 45 percent of households had at least one child under five, 87 percent had at least one child under 18, and 90 percent had at least one eligible woman aged 15–49 years. The weighted average household size was estimated to be 5.3. Table HH.3: Household composition Percentage and frequency of households by selected characteristics, MFWR, Nepal, 2010 Weighted percent No. of households Weighted Unweighted Region Mid-Western 56.4 3,325 2,960 Far Western 43.6 2,574 2,939 Subregion Mid-Western Mountains 5.8 344 989 Mid-Western Hills 28.9 1,703 988 Mid-Western Terai 21.7 1,278 983 Far Western Mountains 7.4 438 967 Far Western Hills 14.2 836 989 Far Western Terai 22.0 1,300 983 Sex of household head Male 79.8 4,708 4,790 Female 20.2 1,191 1,109 Area Urban 10.9 645 1,228 Rural 89.1 5,254 4,671 Number of household m em bers 1 2.4 140 148 2 6.5 381 357 3 12.3 727 687 4 18.0 1,061 1,036 5 20.2 1,189 1,143 6 16.3 963 981 7 10.7 632 668 8 5.5 325 354 9 3.3 197 222 10+ 4.8 284 303 Education of household head None 49.0 2,892 2,902 Primary 22.0 1,299 1,173 Secondary + 28.8 1,696 1,808 Missing/don’t know 0.2 12 16 Total 100.0 5,899 5,899 Households with at least: One child aged 0–4 years 44.7 5,899 5,899 One child aged 0–17 years 87.5 5,899 5,899 One woman aged 15–49 years 90.4 5,899 5,899 Mean household size 5.3 5,899 5,899 NMICS 2010, Mid- and Far Western Regions 33 Characteristics of female respondents aged 15–49 years and children under five Tables HH.4 and HH.5 provide information on the background characteristics of female respondents aged 15–49 years and children under five. In both tables, the total weighted and unweighted numbers of households are equal, since sample weights have been normalized (standardized). However, the weighted numbers for the Mid-Western Mountains and Far Western Mountains are much lower than the unweighted numbers due to oversampling in these two subregions. In addition to providing 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 subsequent tabulations in this report. Table HH.4 provides information on female respondents aged 15–49 years by region, subregion, urban/rural area, age, marital status, motherhood status, births in last two years, education and wealth index quintile 7 . Of total female respondents aged 15–49 years, 55 percent were living in the Mid-Western Region and 45 percent were living in Far Western Region. Twenty-seven percent were in the Mid-Western Hills, followed by the Far Western Terai (25 percent), Mid-Western Terai (22 percent), Far Western Hills (13 percent), Far Western Mountains (seven percent) and Mid-Western Mountains (six percent). However, the weighted numbers for the Mid-Western Mountains and Far Western Mountains are much lower than the unweighted numbers due to oversampling in these two subregions. Almost 89 percent of female respondents were from rural areas compared to only 11 percent from urban areas. The 15–19-years age group had the largest proportion of women (21 percent), followed by the 20– 24-years age group (19 percent), 25–29-years age group (17 percent), 30–34 years-age group (14 percent), 35–39-years age group (12 percent), 40–44-years age group (11 percent) and 45–49-years age group (eight percent). A large proportion of surveyed women (77 percent) were married or in a marital union and about one fifth (20 percent) had never been married. Almost three quarters (73 percent) had given birth at least once in their lifetime, and 17 percent had given birth at least once in the two years preceding the survey. The majority of female respondents (55 percent) had never been to school, while 14 percent had completed primary education, and 31 percent had completed secondary or higher education. 7 Principal components analysis was performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth to assign weights (factor scores) to each of the household assets. Each household was then assigned a wealth score based on these weights and the assets owned by the household. The surveyed household population was then ranked according to the wealth score for each household, and was divided into five equal parts (quintiles) from lowest (poorest) to highest (richest). The factors/assets used in these calculations were as follows: source of drinking water, type of sanitation facility, persons per sleeping room, type of floor, type of roof, type of wall, type of cooking fuel, assets in households (electricity, radio, television, non-mobile telephone, refrigerator, improved cooking stove (ICS), table, chair, bed/cot, sofa, wardrobe, computer, wall clock, electric fan, dhiki/jato , microwave oven and washing machine) and assets of household members (watch, mobile phone, bicycle/rickshaw, motor cycle/scooter, animal-drawn cart, car/truck/bus/jeep, tractor, boat, rent, agricultural land, area of agricultural land, livestock and ownership of bank account.). The wealth index is assumed to capture underlying long-term wealth through information on household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular dataset they are based on. Further information on the construction of the wealth index can be found in: Filmer, D. and Pritchett, L., 2001. Estimating wealth effects without expenditure data – or tears: an application to educational enrolments in states of India. Demography 38(1): 115–132; Gwatkin, D.R., Rutstein, S., Johnson, K., Pande, R. and Wagstaff. A., 2000. Socio-Economic Differences in Health, Nutrition, and Population. HNP/Poverty Thematic Group, Washington, DC: World Bank; Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro. NMICS 2010, Mid- and Far Western Regions 34 Some 17 percent of female respondents were residing in households in the poorest quintile, while around 22 percent were living in households in the richest quintile. Table HH.4: Women’s background characteristics Percentage and frequency of women aged 15–49 years by selected characteristics, MFWR, Nepal, 2010 Weighted percent No. of wom en aged 15–49 years Weighted Unweighted Region Mid-Western 54.7 4,036 3,671 Far Western 45.3 3,336 3,701 Subregion Mid-Western Mountains 5.5 408 1,202 Mid-Western Hills 27.1 1,998 1,198 Mid-Western Terai 22.1 1,630 1,271 Far Western Mountains 6.9 508 1,138 Far Western Hills 13.0 961 1,174 Far Western Terai 25.3 1,867 1,389 Area Urban 11.5 848 1,582 Rural 88.5 6,524 5,790 Age 15–19 years 20.5 1,511 1,485 20–24 years 18.8 1,387 1,346 25–29 years 16.7 1,235 1,240 30–34 years 13.5 994 987 35–39 years 11.7 861 917 40–44 years 10.9 802 813 45–49 years 7.9 582 584 Marital/union status Currently married/in union 77.4 5,706 5,757 Widowed 2.3 166 179 Divorced/separated 0.4 31 18 Never married/in union 19.9 1,469 1,408 Motherhood status Ever gave birth 72.8 5,365 5,422 Never gave birth 27.2 2,007 1,950 Births in last two years Had a birth in last two years 17.2 1,265 1,339 Had no birth in last two years 82.8 6,107 6,033 Education None 54.8 4,042 4,202 Primary 14.1 1,036 956 Secondary + 31.1 2,291 2,211 Missing/don’t know 0.0 4 3 Wealth index quintile Poorest 16.7 1,230 1,629 Second 19.2 1,412 1,487 Middle 20.6 1,519 1,320 Fourth 21.6 1,594 1,302 Richest 21.9 1,618 1,634 Total 100.0 7,372 7,372 Background characteristics for children under five are presented in Table HH.5; these include distribution by region, subregion, sex, urban/rural area, age, mother’s education and wealth index quintile. NMICS 2010, Mid- and Far Western Regions 35 Some 56 percent of children under five were living in the Mid-Western Region and 44 percent were living in the Far Western Region. By subregion, almost one third (30 percent) were living in the Mid- Western Hills, 21 percent in the Far Western Terai, 17 percent in the Mid-Western Terai, 16 percent in the Far Western Hills, and eight percent each in the Mid-Western Mountains and Far Western Mountains. Slightly more than half (51 percent) were male and the remainder (49 percent) were female. Over 91 percent were living in rural areas, while nine percent were living in urban areas. By age group, 10 percent were younger than six months, 10 percent are aged 6–11 months, 18 percent were aged 12–23 months, 20 percent were aged 24–35 months, 23 percent were aged 36– 47 months and 21 percent were aged 48–59 months. Around two thirds (60 percent) of mothers/caretak ers of children under five had never received any formal education, 16 percent had primary education and 24 percent had at least secondary education. In terms of wealth quintile, slightly more than one fourth (26 percent) of children under five were living in the poorest households, while 15 percent were living in the richest households. NMICS 2010, Mid- and Far Western Regions 36 Table HH.5: Under-fives’ background characteristics Percentage and frequency of children aged 0–4 years by selected characteristics, MFWR, Nepal, 2010 Weighted percent No. of children aged 0–4 years Weighted Unweighted Region Mid-Western 55.5 1,984 1,817 Far Western 44.5 1,590 1,757 Subregion Mid-Western Mountains 8.4 302 817 Mid-Western Hills 30.3 1,082 569 Mid-Western Terai 16.8 600 431 Far Western Mountains 8.4 300 624 Far Western Hills 15.5 553 609 Far Western Terai 20.6 737 524 Sex Male 51.5 1,840 1,843 Female 48.5 1,734 1,731 Area Urban 8.7 312 561 Rural 91.3 3,262 3,013 Age 0–5 months 9.5 339 319 6–11 months 9.8 350 355 12–23 months 17.5 626 622 24–35 months 20.0 714 726 36–47 months 22.5 803 831 48–59 months 20.8 743 721 Mother’s education None 60.1 2,148 2,323 Primary 16.2 579 479 Secondary+ 23.7 846 770 Missing/don’t know 0.0 1 2 Wealth index quintile Poorest 25.9 927 1,111 Second 22.5 804 848 Middle 19.8 709 634 Fourth 17.1 611 497 Richest 14.6 523 484 Total 100.0 3,574 3,574 Mother’s education refers to educational attainment of mothers and caretakers of children under five 37 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 are only mildly or moderately malnourished—showing no outward sign of their vulnerability. One of the MDGs is to halve the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist the MDG on reducing child mortality. Breastfeeding and infant and young child feeding Breastfeeding in the first years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. WHO/UNICEF provide the following feeding recommendations. • Exclusive breastfeeding for first six months of life • Continued breastfeeding for two years or more • Safe, appropriate and adequate complementary foods beginning at six months of age • Frequency of complementary feeding: two times per day for 6–8-month-olds; three times per day for 9–11-month-olds It is also recommended that breastfeeding be initiated within one hour of birth. The indicators related to recommended child feeding practices are as follows. • Early initiation of breastfeeding (within 1 hour of birth) • Exclusive breastfeeding rate (< 6 months) • Predominant breastfeeding (< 6 months) • Continued breastfeeding rate (at 1 year and at 2 years) • Duration of breastfeeding • Age-appropriate breastfeeding (0–23 months) • Introduction of solid, semi-solid and soft foods (6–8 months) • Minimum meal frequency (6–23 months) • Milk feeding frequency for non-breastfeeding children (6–23 months) • Bottle feeding (0–23 months) Table NU.1 provides information on the proportion of last-born children in the two years preceding the survey who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed. Some 99 percent of surveyed children were breastfed at some stage. However, only 28 percent of babies in the MFWR were breastfed for the first time within one hour of birth, despite this being an important step in the management of lactation and the establishment of a physical and emotional relationship between the mother and baby. Some 90 percent of surveyed children had started breastfeeding within one day of birth. Only seven percent had received a prelacteal feed. NMICS 2010, Mid- and Far Western Regions 38 Table NU.1: Initial breastfeeding Percentage of last-born children in the two years preceding the survey who were ever breastfed, were breastfed within one hour of birth and within one day of birth, and who received a prelacteal feed, MFWR, Nepal, 2010 Percent ever breastfed [1] Percent who were first breastfed: Percent who received a prelacteal feed No. of last-born children in two years preceding the survey Within one hour of birth [2] Within one day of birth Region Mid-Western 99.1 23.8 87.5 7.5 687 Far Western 99.3 33.1 92.5 6.0 578 Subregion Mid-Western Mountains 98.8 45.4 92.3 5.4 101 Mid-Western Hills 98.9 23.6 91.9 5.7 373 Mid-Western Terai 99.5 13.9 77.4 11.8 213 Far Western Mountains 100.0 45.0 94.0 6.7 104 Far Western Hills 98.2 27.6 85.9 4.5 198 Far Western Terai 99.8 32.5 96.7 6.9 275 Area Urban 98.7 32.2 89.1 15.1 120 Rural 99.2 27.6 89.9 6.0 1,144 Months since birth 0–11 months 98.9 28.3 88.9 7.9 642 12–23 months 99.5 27.7 90.5 5.4 584 Assistance at delivery Skilled attendant 98.5 32.5 88.5 9.3 411 Traditional birth attendant 99.4 26.9 90.2 5.9 773 Other/missing 100.0 16.4 92.2 3.5 80 Place of delivery Government health facility 98.2 34.0 87.7 9.7 338 Private sector health facility (100.0) (23.1) (97.8) (13.3) 39 Home 99.5 26.1 90.4 5.6 873 Mother’s education None 99.5 30.8 87.9 6.4 699 Primary 98.1 21.6 89.3 4.9 230 Secondary + 99.4 26.7 94.0 9.0 335 Wealth index quintile Poorest 99.6 26.6 91.5 3.1 321 Second 98.7 29.8 88.9 8.4 285 Middle 99.0 28.0 89.4 5.9 255 Fourth 98.8 31.0 86.3 7.5 214 Richest 99.8 24.5 92.7 11.4 188 Total 99.2 28.0 89.8 6.8 1,265 [1] MICS Indicator 2.4 [2] MICS Indicator 2.5 Figures in parenthesis indicate that the percentage is based on denominators of 25–49 unweighted cases 15 cases with missing ‘place of delivery’ not shown Table NU.1 indicates that the practice of breastfeeding within one day of birth is nearly universal in all regions except the Mid-Western Terai (77 percent), and for all other background characteristics. However, there were variations by background characteristic in the initiation of breastfeeding within one hour of birth. Only 24 percent of newborns in the Mid-Western Region were breastfed within one hour of birth compared to 33 percent in the Far Western Region. Subregionally, the highest proportion was in the Mid-Western Mountains (45 percent) and the lowest proportion was in the Mid-Western Terai (14 percent). There was little variation by urban/rural area or months since birth. NMICS 2010, Mid- and Far Western Regions 39 Newborns who were delivered by a skilled assistant (33 percent) were more likely to be breastfed within one hour of birth than those delivered by a traditional birth attendant (27 percent) or by others (16 percent). Newborns who were delivered in a government health facility (34 percent) were more likely to breastfeed within one hour than those who were delivered at home (26 percent). Mother’s education level and household wealth status showed uneven variations and no significant trend could be observed. Figure NU.1 illustrates the large differences in the percentage of newborns who were breastfed within one hour of birth and the percentage breastfed within one day. In addition, there was considerable variation by subregion. Table NU.2 shows breastfeeding status; this is based on children’s consumption of food and fluids in the 24 hours prior to the interview as reported by mothers/caretakers. Exclusively breastfed refers to infants who received only breastmilk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life, as well as the continued breastfeeding of children at one year of age (i.e., for children aged 12–15 months) and at two years of age (i.e., for children aged 20–23 months). Some 64 percent of children aged less than six months in the MFWR were exclusively breastfed, a level considerably lower than that recommended. However, 80 percent were predominantly breastfed. At one year of age, 98 percent of children were still being breastfed and, at two years of age, 87 percent were still being breastfed. It should be noted that sample sizes were small; therefore, variations by background characteristic must be viewed with caution. Data suggest that more educated mothers (secondary and above) were less likely than other mothers to exclusively breastfeed their children for the first six months of life. No clear pattern on breastfeeding could be observed by wealth quintile; however, the poorest quintile (71 percent) and the fourth quintile (72 percent) had the highest levels and the second quintile (54 percent) had the lowest. Variations by background characteristic for predominantly breastfed, continued breastfeeding at one year of age and continued breastfeeding at two years of age have not been highlighted because of the small sample sizes. 92 92 77 94 86 97 89 90 90 45 24 14 45 28 33 32 28 28 0 20 40 60 80 100 Pe rc en t Figure NU.1 Percentage of last-born children w ho were first breastfed w ithin one hour and within one day of birth, MFWR, Nepal, 2010 With in o ne da y With in o ne ho ur NMICS 2010, Mid- and Far Western Regions 40 Table NU.2: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, MFWR, Nepal, 2010 Children aged 0–5 months Children aged 12–15 m onths Children aged 20–23 m onths Percent exclusively breastfed [1] Percent predomin- antly breastfed [2] No. of children Percent breastfed (continued breastfeeding at 1 year) [3] No. of children Percent breastfed (continued breastfeeding at 2 years) [4] No. of children Region Mid-Western 65.0 82.1 194 96.3 133 83.8 92 Far Western 62.3 77.6 144 100.0 106 89.7 93 Subregion Mid-Western Mountains 49.1 68.2 25 (95.9) 16 (97.1) 12 Mid-Western Hills (65.3) (80.8) 105 (95.5) 78 (87.3) 40 Mid-Western Terai (70.6) (89.5) 64 (98.2) 40 (76.3) 40 Far Western Mountains 54.5 71.5 28 (100.0) 21 * 10 Far Western Hills 54.0 73.0 51 (100.0) 33 (90.6) 30 Far Western Terai (72.2) (83.7) 65 (100.0) 53 (89.8) 53 Sex Male 62.4 77.1 172 96.8 134 89.0 80 Female 65.4 83.2 167 99.4 105 85.0 106 Area Urban (67.4) (85.0) 22 (97.0) 24 (95.5) 25 Rural 63.6 79.8 317 98.1 216 85.4 161 Mother’s education None 66.0 83.6 187 95.6 112 85.3 94 Primary 68.9 82.9 74 (100.0) 50 (88.3) 36 Secondary+ 54.0 69.3 78 100.0 78 88.0 55 Wealth index quintile Poorest 70.5 87.8 89 92.0 53 (97.1) 46 Second 53.5 75.3 85 99.3 53 (67.0) 30 Middle 62.0 72.7 69 (100.0) 48 (99.5) 38 Fourth 71.5 85.8 59 (99.3) 40 (77.8) 40 Richest (62.8) (77.4) 35 100.0 46 (86.4) 30 Total 63.9 80.1 339 98.0 240 86.7 185 [1] MICS Indicator 2.6 [2] MICS Indicator 2.9 [3] MICS Indicator 2.7 [4] MICS Indicator 2.8 Figures in parenthesis indicate that the percentage is based on denominators of 25–49 unweighted cases * An asterisk indicates that the percentage or proportion is calculated on fewer than 25 unweighted cases One case with missing ‘mother’s education’ not shown NMICS 2010, Mid- and Far Western Regions 41 Figure NU.2 shows the pattern of breastfeeding by child’s age in months. Even at the earliest ages, the majority of children in the MFWR received liquids or foods other than breastmilk. By the age of six months, the percentage of children exclusively breastfed was below 18 percent. However, at two years of age the majority of children (over 80 percent) were still receiving breastmilk along with other foods. Table NU.3 shows the median duration of breastfeeding by selected background characteristics. Among children aged less than three years in the MFWR, the median duration was 31.5 months for any breastfeeding, 4.0 months for exclusive breastfeeding, and 5.8 months for predominant breastfeeding. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 -1 2 -3 4 -5 6 -7 8 -9 1 0 -1 1 1 2 -1 3 1 4 -1 5 1 6 -1 7 1 8 -1 9 2 0 -2 1 2 2 -2 3 Age in months Figure NU.2 Percent distribution of children under age 2 by feeding pattern by age group, MFWR, Nepal, 2010 Exclusively breastfed Breastfed and plain water only Breastfed and non- milk liquids Breastfed and ot her milk/ formula Breastfed and ot her foods Not brea stfed NMICS 2010, Mid- and Far Western Regions 42 Table NU.3: Duration of breastfeeding Median duration (in months) of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children aged 0–35 months, MFWR, Nepal, 2010 Median duration (in m onths) of No. of children aged 0–35 months Any breastfeeding [1] Exclusive breastfeeding Predominant breastfeeding Region Mid-Western ≥36.0 3.7 5.0 1,127 Far Western ≥36.0 3.7 5.0 902 Subregion Mid-Western Mountains 33.6 2.4 4.3 170 Mid-Western Hills ≥36.0 3.6 4.7 608 Mid-Western Terai ≥36.0 4.4 5.7 349 Far Western Mountains ≥36.0 3.0 4.1 170 Far Western Hills ≥36.0 2.9 4.3 321 Far Western Terai ≥36.0 4.7 5.8 411 Sex Male ≥36.0 3.5 4.8 1,020 Female ≥36.0 3.9 5.2 1,009 Area Urban 34.4 3.8 4.8 172 Rural ≥36.0 3.7 5.0 1,857 Mother’s education None ≥36.0 3.7 5.1 1,137 Primary ≥36.0 4.7 5.8 363 Secondary+ ≥36.0 2.8 4.0 529 Wealth index quintile Poorest ≥36.0 3.9 4.9 519 Second ≥36.0 2.9 5.1 459 Middle ≥36.0 3.5 4.7 403 Fourth ≥36.0 4.7 6.1 354 Richest ≥36.0 3.7 4.7 293 Median ≥36.0 3.7 5.0 2,029 Mean for all children (0–35 months) 31.5 4.0 5.8 2,029 [1] MICS Indicator 2.10 The adequacy of infant feeding for children aged less than 24 months is shown in Table NU.4. Different criteria for adequate feeding were used depending on the age of the child. For infants aged 0–5 months, exclusive breastfeeding is considered adequate; while infants aged 6–23 months are considered to be adequately fed if they are receiving breastmilk and solid, semi-solid or soft foods. About two thirds (64 percent) of infants aged 0–5 months in the MFWR were found to be appropriated breastfed, while 80 percent of children aged 6–23 months were appropriately breastfed. Of all children aged 0–23 months, 76 percent were appropriately breastfed. There was little variation by most background characteristics in the percentage of children aged 0– 23 months who were being appropriately breastfed. However, subregionally, the highest percentage was in the Mid-Western Hills and Mid-Western Mountains (both 80 percent) and the lowest was in the Far Western Mountains (68 percent). In addition, children in urban areas (82 percent) were more likely to be appropriately breastfed than their rural counterparts (76 percent). The range by wealth quintile was from 71 percent of children in the second quintile to 83 percent in the richest quintile. NMICS 2010, Mid- and Far Western Regions 43 Table NU.4: Age-appropriate breastfeeding Percentage of children aged 0–23 months who were appropriately breastfed during the day preceding the survey, MFWR, Nepal, 2010 Children aged 0–5 months Children aged 6–23 months Children aged 0–23 m onths Percent exclusively breastfed [1] No. of children Percent currently breastfeeding and receiving solid, semi-solid or soft foods No. of children Percent appropriately breastfed [2] No. of children Region Mid-Western 65.0 194 84.6 523 79.3 717 Far Western 62.3 144 75.5 454 72.3 598 Subregion Mid-Western Mountains 49.1 25 80.3 80 72.9 105 Mid-Western Hills 65.3 105 86.0 282 80.4 387 Mid-Western Terai (70.6) 64 84.3 160 80.4 225 Far Western Mountains 54.5 28 73.0 80 68.1 108 Far Western Hills 54.0 51 77.6 155 71.8 206 Far Western Terai (72.2) 65 75.0 218 74.3 284 Sex Male 62.4 172 79.5 483 75.0 655 Female 65.4 167 81.2 493 77.2 660 Area Urban (67.4) 22 85.9 94 82.3 116 Rural 63.6 317 79.8 883 75.5 1,199 Mother’s education None 66.0 187 78.9 536 75.6 724 Primary 68.9 74 78.2 163 75.3 237 Secondary+ 54.0 78 84.7 277 77.9 354 Wealth index quintile Poorest 70.5 89 80.1 241 77.5 331 Second 53.5 85 78.5 215 71.4 300 Middle 62.0 69 77.9 195 73.7 264 Fourth 71.5 59 79.7 168 77.5 227 Richest (62.8) 35 87.3 157 82.8 192 Total 63.9 339 80.4 976 76.1 1,315 [1] MICS Indicator 2.6 [2] MICS Indicator 2.14 Figures in parenthesis indicate that the percentage is based on denominators of 25–49 unweighted cases Adequate complementary feeding of children from six months to two years of age is particularly important for growth and development and the prevention of undernutrition. Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary foods that help to meet nutritional requirements when breastmilk is no longer sufficient. This requires that for breastfed children two or more meals of solid, semi-solid or soft foods are needed if they are 6–8 months old, and three or more meals if they are 9–23 months old. For children aged 6–23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. Among all children aged 6–8 months in the MFWR who were currently breastfeeding or non- breastfeeding, slightly more than three fifths (63 percent) were receiving solid, semi-solid, or soft foods (Table NU.5). Although the sample sizes were small and so figures should be viewed with caution, 76 percent of children in the Mid-Western Region were receiving solid, semi-solid, or soft NMICS 2010, Mid- and Far Western Regions 44 foods compared to only 50 percent in the Far Western Region. There was little variation by gender or urban/rural area. Table NU.5: Introduction of solid, semi-solid or soft food Percentage of infants aged 6–8 months who received solid, semi-solid or soft foods during the day preceding the survey, MFWR, Nepal, 2010 Currently breastfeeding All (currently breastfeeding + non-breastfeeding) Percent receiving solid, semi-solid or soft foods No. of children aged 6–8 months Percent receiving solid, semi-solid or soft foods [1] No. of children aged 6–8 months Region Mid-Western 74.6 93 74.5 94 Far Western 49.8 90 50.1 90 Sex Male 63.4 90 63.6 92 Female 61.5 93 61.5 93 Area Urban * 14 * 14 Rural 63.1 169 63.2 170 Total 62.5 183 62.6 184 [1] MICS Indicator 2.12 Other background characteristics are not shown because the numbers of unweighted observations were lower than 50 Information on children currently not breastfeeding is not shown due to only one case in this category Table NU.6 presents the proportion of children aged 6–23 months who received semi-solid or soft foods the minimum number of times or more during the day before the interview according to breastfeeding status. The minimum number of times or minimum meal frequency8 for different age groups is generally defined as a proportion of breastfed and non-breastfed children aged 6–23 months who receive solid, semi-solid, or soft foods or milk feeds the minimum number of times or more9. The recommended minimum meal frequencies are as follows. • Two times for breastfed infants aged 6–8 months • Three times for breastfed children aged 9–23 months • Four times for non-breastfed children aged 6–23 months Overall, nearly three fifths (57 percent) of all children aged 6–23 months (both currently breastfeeding and non-breastfeeding) in the MFWR were receiving solid, semi-solid and soft foods the minimum number of times a day. Regionally, 66 percent of children in the Mid-Western Region compared to 47 percent in the Far Western Region were receiving the recommended minimum meal frequency, and subregionally, the highest percentage was in the Mid-Western Hills (71 percent) and the lowest percentage was in the Far Western Terai (45 percent). Interestingly for Nepal, there was little variation by gender. Children aged 9–11 months (39 percent) were least likely to receive the recommended minimum number of meals a day. Some 71 percent of children in urban areas received the recommended minimum compared to 56 percent of rural children. There was little variation by mother’s education or household wealth quintile. 8 Among currently breastfeeding children aged 6–8 months, minimum meal frequency is defined as children who also received solid, semi-solid or soft foods two times or more. Among currently breastfeeding children aged 9–23 months, receipt of solid, semi-solid or soft foods at least three times constitutes minimum meal frequency. For non-breastfeeding children aged 6–23 months, minimum meal frequency is defined as children receiving solid, semi-solid or soft foods, and milk feeds, at least four times during the previous day. 9 USAID, AED, UCDAVIS, IFPRI, UNICEF and WHO, 2008. Indicators for Assessing Infant and Young Child Feeding Practices. Part 1: Definitions . Geneva: WHO. NMICS 2010, Mid- and Far Western Regions 45 Among currently breastfeeding children aged 6–23 months in the MFWR, nearly three fifths (57 percent) were receiving solid, semi-solid and soft foods the minimum number of times. Table NU.6: Minimum meal frequency Percentage of children aged 6–23 months who received solid, semi-solid or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the day preceding the survey, MFWR, Nepal, 2010 Currently breastfeeding All (currently breastfeeding + non-breastfeeding) Percent receiving solid, semi-solid and soft foods the minimum number of times No. of children aged 6–23 months Percent with minimum meal frequency [1] No. of children aged 6–23 months Region Mid-Western 66.4 494 66.3 523 Far Western 45.8 435 47.1 454 Subregion Mid-Western Mountains 54.3 77 54.8 80 Mid-Western Hills 71.1 270 71.4 282 Mid-Western Terai 64.3 147 63.1 160 Far Western Mountains 47.7 76 48.7 80 Far Western Hills 48.5 148 50.0 155 Far Western Terai 43.2 211 44.5 218 Sex Male 56.3 460 57.1 483 Female 57.3 469 57.6 493 Age 6–8 months 50.2 183 50.2 184 9–11 months 36.7 159 39.1 166 12–17 months 60.0 351 60.5 360 18–23 months 70.7 236 69.7 266 Area Urban 70.7 91 70.5 94 Rural 55.2 838 56.0 883 Mother’s education None 54.3 509 54.4 536 Primary 56.5 155 57.5 163 Secondary+ 61.7 265 63.3 277 Wealth index quintile Poorest 55.5 230 56.9 241 Second 58.6 199 59.4 215 Middle 58.8 192 58.4 195 Fourth 50.8 157 51.9 168 Richest 59.8 151 60.1 157 Total 56.8 929 57.4 976 [1] MICS Indicator 2.13 One case with missing ‘mother’s education’ not shown Information on children ‘currently not breastfeeding’ is not shown due to only 47 cases in this category The continued practice of bottle-feeding is a concern because of possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.7 shows that five percent of children aged 0–23 months in the MFWR were being fed using a bottle with a nipple. There was little variation by region, gender, urban/rural area or mother’s education. The practice of bottle-feeding was highest in the Mid-Western Hills (seven percent) compared to the other subregions. A low proportion of children aged less than six months (three percent) were bottle fed. The practice of bottle feeding was lowest for the poorest quintile (one percent) and highest for the richest quintile (nine percent). NMICS 2010, Mid- and Far Western Regions 46 Table NU.7: Bottle-feeding Percentage of children aged 0–23 months who were fed using a bottle with a nipple during the day preceding the survey, MFWR, Nepal, 2010 Percent fed using a bottle with a nipple [1] No. of children aged 0–23 months Region Mid-Western 5.8 717 Far Western 4.4 598 Subregion Mid-Western Mountains 3.9 105 Mid-Western Hills 6.5 387 Mid-Western Terai 5.3 225 Far Western Mountains 2.6 108 Far Western Hills 2.7 206 Far Western Terai 6.4 284 Sex Male 3.7 655 Female 6.6 660 Age 0–5 months 2.5 339 6–11 months 5.3 350 12–23 months 6.6 626 Area Urban 6.3 116 Rural 5.1 1,199 Mother’s education None 4.6 724 Primary 5.6 237 Secondary+ 6.0 354 Wealth index quintile Poorest 1.2 331 Second 5.9 300 Middle 7.1 264 Fourth 4.2 227 Richest 9.2 192 Total 5.2 1,315 [1] MICS Indicator 2.11 Salt iodization Iodine deficiency disorders (IDD) are the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. IDD also increase the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD take their greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The international goal was to achieve sustainable elimination of iodine deficiency by 2005. The indicator for this is the percentage of households consuming adequately iodized salt (≥15 parts per million (ppm)). In Nepal, three major subnational surveys (1965, 1979–82 and 1985–86) found a high prevalence of IDD. This provided an impetus for the establishment of the national IDD programme in 1998. The primary intervention implemented in Nepal to control IDD is the universal iodization of all edible salts. Other strategies include advocacy at national and district levels, mass media campaigns to promote the use of packet iodized salt with the ‘two-child logo’, demand creation for crushed salt NMICS 2010, Mid- and Far Western Regions 47 and other varieties of packed salt, and awareness-rais ing among health workers and the general public. In all surveyed households, salt used for cooking was analysed for iodine content using salt test kits that identified the presence of potassium iodate. Table NU.8 shows that very small proportion of households (0.2 percent) in the MFWR had no salt available. In half of interviewed households (50 percent), salt was found to be adequately iodized, i.e., containing 15 ppm or more of iodine. Some 55 percent of households in the Mid-Western Region had adequately salt compared to 44 percent in the Far Western Region. Use of adequately iodized salt was highest in the Mid-Western Terai (63 percent) and lowest in the Far Western Hills (34 percent). Almost three quarters (74 percent) of urban households were found to be using adequately iodized salt compared to 48 percent in rural areas. The use of adequately iodized salt showed wide variation by wealth quintile from 31 percent for the poorest households to 82 percent for the richest households. Table NU.8: Iodized salt consumption Percentage of households by consumption of iodized salt, MFWR, Nepal, 2010 Percent in which salt was tested No. of households Percent of household with: Total No. of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 ppm >0 and <15 ppm 15+ ppm [1] Region Mid-Western 99.8 3,325 0.1 22.4 22.4 55.1 100.0 3,323 Far Western 99.5 2,574 0.3 30.1 25.2 44.3 100.0 2,569 Subregion Mid-Western Mountains 100.0 344 0.0 17.7 29.1 53.3 100.0 344 Mid-Western Hills 99.7 1,703 0.2 25.2 25.3 49.4 100.0 1,701 Mid-Western Terai 99.9 1,278 0.0 20.0 16.9 63.2 100.0 1,277 Far Western Mountains 99.5 438 0.3 37.1 20.5 42.2 100.0 437 Far Western Hills 99.7 836 0.3 30.4 34.9 34.4 100.0 836 Far Western Terai 99.3 1,300 0.4 27.7 20.5 51.5 100.0 1,296 Area Urban 98.9 645 0.9 9.6 15.8 73.8 100.0 644 Rural 99.8 5,254 0.1 27.8 24.6 47.5 100.0 5,248 Wealth index quintile Poorest 99.7 1,241 0.2 34.6 34.4 30.8 100.0 1,240 Second 99.9 1,239 0.1 33.6 29.5 36.8 100.0 1,238 Middle 99.6 1,178 0.4 29.2 25.6 44.8 100.0 1,178 Fourth 99.6 1,127 0.3 19.6 18.8 61.4 100.0 1,125 Richest 99.6 1,114 0.2 9.9 7.9 82.1 100.0 1,111 Total 99.7 5,899 0.2 25.8 23.6 50.4 100.0 5,892 [1] MICS Indicator 2.16 Children’s vitamin A supplementation Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, NMICS 2010, Mid- and Far Western Regions 48 vitamin A deficiency is moderately prevalent in the developing world and particularly in countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by 2000. This goal was endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly’s Special Session on Children in 2002. The critical role of vitamin A in child health and immune function also makes control of this deficiency a primary component of child survival efforts, and therefore, critical to the achievement of the fourth MDG to reduce under-five mortality by two thirds between 1990 and 2015. For countries with vitamin A deficiency problems, current international recommendations call for high-dose vitamin A supplementation every four to six months, targeted at all children aged 6–59 months living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a safe, cost-effectiv e, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers who are breastfeeding helps protect their children during the first months of life and helps to replenish the mother’s stores of vitamin A, which are depleted during pregnancy and lactation. For countries with vitamin A supplementation programmes, the definition of the indicator is the percentage of children aged 6–59 months receiving at least one high-dose vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, Nepal’s Ministry of Health and Population recommends that children aged 6–11 months be given one vitamin A capsule (100,000 IU) and children aged 12–59 months be given a vitamin A capsule (200,000 IU) every six months. It also recommends that mothers take a vitamin A supplement within eight weeks of giving birth due to increased vitamin A requirements during pregnancy and lactation. In the six months preceding the survey, nine in 10 (90 percent) children aged 6–59 months in the MFWR had received a high-dose vitamin A supplement (Table NU.9). There was little variation by region, gender, urban/rural area, mother’s education or wealth quintile. Vitamin A supplementation coverage was lowest in the Far Western Terai (84 percent) compared to other subregions. Only 73 percent of children aged 6–11 months had received vitamin A supplementation in the six months preceding the survey compared to over 90 percent of all older children. NMICS 2010, Mid- and Far Western Regions 49 Table NU.9: Children’s vitamin A supplementation Percentage of children aged 6–59 months by receipt of a high-dose vitamin A supplement in the six months preceding the survey, MFWR, Nepal, 2010 Percent who received vitam in A according to: Percent who received vitamin A during the six months preceding the survey [1] No. of children aged 6–59 months Child health book/card/ vaccination card Mother’s report Region Mid-Western 0.9 92.2 92.3 1,790 Far Western 1.2 87.2 87.2 1,445 Subregion Mid-Western Mountains 0.3 93.1 93.1 277 Mid-Western Hills 0.0 93.7 93.7 978 Mid-Western Terai 2.9 89.0 89.4 536 Far Western Mountains 1.7 91.7 91.7 272 Far Western Hills 0.0 89.0 89.0 502 Far Western Terai 1.9 84.1 84.1 671 Sex Male 1.2 89.9 90.1 1,668 Female 0.8 90.1 90.1 1,568 Area Urban 0.7 89.1 89.1 290 Rural 1.1 90.1 90.2 2,945 Age 6–11 months 0.8 73.3 73.3 350 12–23 months 3.4 91.0 91.0 626 24–35 months 0.3 91.6 91.9 714 36–47 months 0.9 91.5 91.5 803 48–59 months 0.0 93.9 93.9 743 Mother’s education None 1.1 89.3 89.3 1,961 Primary 1.2 90.4 90.9 505 Secondary+ 0.7 91.7 91.7 768 Wealth index quintile Poorest 0.1 87.8 87.8 838 Second 1.1 94.7 94.7 719 Middle 1.6 87.3 87.3 640 Fourth 1.8 91.3 91.3 552 Richest 0.9 88.9 89.4 487 Total 1.0 90.0 90.1 3,235 [1] MICS Indicator 2.17 One case with missing ‘mother’s education’ not shown 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 g) 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. NMICS 2010, Mid- and Far Western Regions 50 In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have most impact: the mother’s poor nutritional status before conception, her short stature (due mostly to under-nutrition and infections during her childhood), and poor nutrition during pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. Cigarette smoking during pregnancy is also a leading cause of low birth weight, especially in the industria lized world. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2,500 g 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 birth 10 . Table NU.10 shows that 26 percent of last-born children in the two years preceding the survey in the MFWR were estimated to weigh less than 2,500 g at birth. There was little variation by region, subregion or urban/rural area. Mother’s education and household wealth status affected the prevalence of low birth weight: 28 percent of children whose mother had no education were estimated to have had low birth weight compared to 22 percent of children whose mother had at least secondary education, and 28 percent of children from the poorest quintile were estimated to have had low birth weight compared to 21 percent of children from the richest quintile. Some 31 percent of last-born children in the MFWR were weighed at birth (Table NU.10). This corresponds to the approximately three in 10 deliveries that take place in institutions. The majority of births in the MFWR take place at home, where the practice of weighing babies is not common. Inaccessibility to health institutions, particularly in the Hills and Mountains, together with lack of human resources and equipment limit use of institutional delivery services. There was substantial variation in weighing at birth by background characteristics. Subregionally, variation ranged from 48 percent on the Far Western Terai to 11 percent in the Far Western Mountains. Urban children (53 percent) were much more likely to be weighed at birth than rural children (28 percent). Children whose mother had no education (20 percent) were less likely to be weighed at birth compared to children whose mother had primary education (33 percent) and children whose mother had at least secondary education (51 percent). Wealth quintile strongly affected the likelihood of being weighed at birth: only seven of children from the poorest quintile were weighed compared to 70 percent of children from the richest quintile. 10 For a detailed description of the methodology, see Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E., 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization , 74(2), 209–16. NMICS 2010, Mid- and Far Western Regions 51 Table NU.10: Low birth weight Percentage of last-born children in the two years preceding the survey that are estimated to have weighed below 2,500 g at birth and percentage of live births weighed at birth, MFWR, Nepal, 2010 Percent of live births: No. of last-born children in two years preceding survey Below 2,500 g [1] Weighed at birth [2] Region Mid-Western 25.5 28.9 687 Far Western 26.8 32.6 578 Subregion Mid-Western Mountains 26.4 13.9 101 Mid-Western Hills 26.3 22.4 373 Mid-Western Terai 23.8 47.5 213 Far Western Mountains 28.2 10.5 104 Far Western Hills 27.9 22.9 198 Far Western Terai 25.5 47.9 275 Area Urban 23.6 52.9 120 Rural 26.4 28.2 1,144 Education None 28.3 19.8 699 Primary 25.9 33.0 230 Secondary + 21.7 51.4 335 Wealth index quintile Poorest 28.1 6.8 321 Second 27.1 22.9 285 Middle 28.6 24.8 255 Fourth 23.7 48.9 214 Richest 20.5 70.0 188 Total 26.1 30.6 1,265 [1] MICS Indicator 2.18 [2] MICS Indicator 2.19 NMICS 2010, Mid- and Far Western Regions 52 Figure NU.3 shows the correlation between wealth quintile and low birth weight. De-worming NMICS 2010 inserted a country-specific module on de-worming into the household questionnaire. Information was collected for each household member aged 6–11 years on whether they had received a de-worming tablet in the year preceding the survey. Table NU.11 shows that nearly three quarters (73 percent) of children aged 6–11 years in the MFWR had received a de-worming tablet in the year preceding the survey. Some 66 percent of children in Mid-Western Region had received a de-worming tablet compared to 82 percent in the Far Western Region. Subregionally, the highest proportion was in the Far Western Hills (86 percent) and the lowest proportion was in the Mid-Western Terai (59 percent). There was little variation by gender, urban/rural area, mother’s education or wealth quintile. 28 27 29 24 21 26 0 5 10 15 20 25 30 35 Poorest Second Middle Fourth Richest Total Pe rc en t Wealth quintiles Figure NU.3 Percentage of infants w eighing less than 2500 grams at birth, MFWR, Nepal, 2010 NMICS 2010, Mid- and Far Western Regions 53 Table NU.11: De-worming of children Percentage of children aged 6–11 years by receipt of de-worming tablet in the year preceding the survey, MFWR, Nepal, 2010 Percent by receipt of de-worming tablet in year preceding survey Total No. of children aged 6–11 years Yes No Don’t know Region Mid-Western 65.6 30.7 3.7 100.0 2,863 Far Western 81.8 16.0 2.2 100.0 2,282 Subregion Mid-Western Mountains 73.6 23.7 2.8 100.0 371 Mid-Western Hills 67.9 28.2 4.0 100.0 1,520 Mid-Western Terai 59.0 37.3 3.8 100.0 972 Far Western Mountains 77.6 20.8 1.6 100.0 453 Far Western Hills 86.0 11.8 2.1 100.0 828 Far Western Terai 80.1 17.3 2.6 100.0 1,002 Sex Male 72.0 24.5 3.5 100.0 2,588 Female 73.6 23.8 2.6 100.0 2,557 Area Urban 71.8 24.4 3.8 100.0 473 Rural 72.9 24.1 3.0 100.0 4,673 Mother’s education None 71.6 25.1 3.3 100.0 4,000 Primary 76.7 21.6 1.6 100.0 546 Secondary+ 76.9 20.3 2.7 100.0 593 Wealth index quintile Poorest 70.4 25.8 3.8 100.0 1,281 Second 70.2 27.0 2.7 100.0 1,118 Middle 72.7 23.6 3.7 100.0 1,068 Fourth 76.0 22.8 1.2 100.0 885 Richest 76.7 19.8 3.5 100.0 794 Total 72.8 24.2 3.1 100.0 5,145 54 V. Child Health Vaccinations The aim of 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. However, worldwide there are still 27 million children overlooked by routine immunization and, as a result, vaccine-preventable diseases cause more than two million deaths every year. The WFFC goal is to ensure that full immunization of children aged less than one year reaches 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. The Ministry of Health and Population in Nepal follows the UNICEF and WHO guidelines on vaccinations. Accordingly, by the age of 12 months, each 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. Mothers in the survey were asked to provide vaccination cards for children under five. Interviewers copied vaccination information from the cards on to the NMICS 2010 questionnaire. Overall, about one fifth (21 percent) of children had vaccination cards. If the child did not have a card, the mother was asked to recall whether or not the child had received each vaccination and, for DPT and polio, how many times. For children without vaccination cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards. Only children old enough to be fully vaccinated were counted, i.e., those aged 12–23 months. Table CH.1 shows the percentage of children aged 12–23 months in the MFWR who were vaccinated at any time before the survey according to the vaccination card or the mother’s report as well as those who were vaccinated before their first birthday, as recommended. Some 89 percent had received a BCG vaccination by the age of 12 months. Similarly, 93 percent had received Polio 1 by the age of 12 months, but this declines to 77 percent for the third dose. The first dose of DPT was given to 86 percent of children, but declined to 81 percent for the second dose and 68 percent for the third dose. Coverage for measles vaccine was 83 percent. As a result, the percentage of children who had all the recommended vaccinations by their first birthday was 56 percent. NMICS 2010, Mid- and Far Western Regions 55 Table CH.1: Vaccinations in first year of life Percentage of children aged 12–23 months immunized against childhood diseases at any time before the survey and before their first birthday, MFWR, Nepal, 2010 Percent vaccinated any time before survey according to: Percent vaccinated by 12 months of age Vaccination card Mother’s report Either BCG [1] 21.2 70.9 92.2 88.8 Polio 1 20.9 74.3 95.2 93.2 2 20.8 71.0 91.7 89.8 3 [2] 20.6 60.0 80.6 77.4 DPT 1 20.7 67.3 88.1 86.2 2 20.6 62.3 82.9 81.1 3 [3] 20.5 49.9 70.3 67.5 Measles [4] 20.1 71.4 91.5 83.4 All vaccinations 20.3 44.3 64.6 55.7 No vaccinations 0.0 4.6 4.6 4.6 Number of children aged 12–23 months 626 626 626 626 [1] MICS Indicator 3.1 [2] MICS Indicator 3.2 [3] MICS Indicator 3.3 [4] MICS Indicator 3.4; MDG Indicator 4.3 Figure CH.1 shows the percentage of children aged 12–23 months in the MFWR who had received each recommended vaccine by the age of 12 months. 89 86 81 68 93 90 77 83 56 0 10 20 30 40 50 60 70 80 90 100 BCG DPT1 DPT2 DPT3 Polio1 Polio2 Polio3 Measles All Pe rc en t Figure CH.1 Percentage of children aged 12-23 months who receiv ed the recommended v accinations by 12 months, MFWR, Nepal, 2010 NMICS 2010, Mid- and Far Western Regions 56 Table CH.2 shows vaccination coverage rates among children aged 12–23 months by background characteristic. The figures indicate children receiving vaccinations at any time up to the date of the survey, and are based on information from both vaccination cards and mothers’/caretakers’ reports. There was little variation by region or gender. Full immunization coverage was highest in the Mid- Western Terai (76 percent) and lowest in the Mid-Western Mountains (46 percent). Children living in urban areas (58 percent) were less likely than those in rural areas (65 percent) to receive all vaccinations, and children whose mother had no education (57 percent) were less likely to receive all vaccinations than children whose mother had a primary education (75 percent) or secondary education (73 percent). The likelihood of receiving all vaccinations increases with the wealth status of the household from 60 percent in the poorest quintile to 73 percent in the richest quintile. Table CH.2: Vaccinations by background characteristics Percentage of children aged 12–23 months currently vaccinated against childhood diseases, MFWR, Nepal, 2010 Percent of children who received: Percen t with vaccin- ation card seen No. of child- ren aged 12–23 months BCG Polio DPT Mea- sles None All 1 2 3 1 2 3 Region Mid-Western 91.3 95.4 91.5 79.8 88.0 83.1 68.3 92.5 4.3 62.3 12.4 334 Far Western 93.1 95.0 92.0 81.5 88.2 82.6 72.8 90.3 4.8 67.3 30.8 292 Subregion Mid-Western Mountains 93.7 95.1 90.6 65.0 90.9 82.8 59.2 89.0 3.3 45.5 6.1 52 Mid-Western Hills 88.8 95.2 92.4 81.4 87.0 81.4 69.2 92.5 4.7 65.9 6.4 171 Mid-Western Terai 94.1 95.8 90.6 84.3 88.2 86.1 71.1 94.2 4.2 64.5 24.7 111 Far Western Mountains 91.0 96.1 93.8 75.7 87.9 83.6 72.3 92.3 3.0 65.0 21.8 51 Far Western Hills 93.4 94.7 90.2 75.7 85.3 73.7 59.0 88.4 5.3 54.5 7.4 97 Far Western Terai 93.7 94.8 92.5 87.5 90.0 87.9 81.6 90.9 5.2 76.0 49.8 144 Sex Male 89.9 95.0 90.0 80.8 86.8 81.8 68.8 91.5 4.8 64.6 22.9 318 Female 94.5 95.5 93.4 80.3 89.4 84.0 71.9 91.5 4.3 64.5 19.1 308 Area Urban 89.2 90.1 86.3 83.2 82.7 80.5 62.7 85.8 9.6 57.9 32.8 65 Rural 92.5 95.8 92.3 80.3 88.7 83.2 71.2 92.2 4.0 65.3 19.6 561 Mother’s education None 88.1 93.4 88.8 74.8 83.9 78.2 63.9 89.1 6.2 57.1 16.3 341 Primary 98.2 98.2 94.8 90.8 91.8 89.5 79.3 92.4 1.8 74.6 21.1 106 Secondary+ 96.3 96.9 95.3 85.3 93.4 87.9 76.9 95.4 3.1 72.9 30.0 178 Wealth index quintile Poorest 91.5 98.4 95.9 79.2 88.7 77.1 63.3 94.2 1.3 59.8 7.5 144 Second 90.1 92.7 90.2 77.2 80.7 73.4 60.8 88.9 6.6 54.7 12.1 137 Middle 89.0 91.5 86.5 75.4 87.0 84.3 70.0 83.8 8.4 61.5 18.1 131 Fourth 96.5 96.6 93.4 86.7 96.3 96.3 86.0 96.6 3.4 79.0 32.1 111 Richest 95.3 97.1 92.8 87.2 89.9 87.5 76.4 95.4 2.9 72.8 43.5 103 Total 92.2 95.2 91.7 80.6 88.1 82.9 70.3 91.5 4.6 64.6 21.0 626 Japanese encephalitis Japanese encephalitis (JE) is seasonally endemic to the Terai. The first outbreak of JE in Nepal was reported in 1978. Since then, JE infection has been reported in animal reservoirs and in humans throughout the Terai. It has also been reported outside the Terai and in the Kathmandu valley. In recent years, the Ministry of Health and Population has introduced public health interventions, NMICS 2010, Mid- and Far Western Regions 57 including mass immunization campaigns for children aged 1–15 years, in known JE-endemic areas. To assess coverage of JE vaccination, this Nepal-specific indicator was added to NMICS 2010. Only the mothers/caretakers of children aged 12–59 months in the Terai of the MFWR (Dang, Banke, Bardiya, Kailali and Kanchanpur) were asked whether their child had received the JE vaccination. If possible, mothers/caretakers were asked to show the vaccination card that was provided separately when the JE vaccine was given to children. Table CH.3 shows that seven percent of children aged 12–59 months in the Terai had been vaccinated for JE at some time, according to vaccination cards observed by interviewers during the survey. In addition, the mothers/caretakers of 24 percent of children recalled that their child had received a JE vaccination. Combining the two indicates that 31 percent of children had ever been vaccinated for JE. Subregionally, 27 percent of children in the Mid-Western Terai had been vaccinated compared to 35 percent in the Far Western Terai. There is little variation by gender. Urban children (40 percent) were more likely to be vaccinated than rural children (29 percent). The likelihood of being vaccinated against JE increased with the level of mother’s education and household wealth status from 25 percent for children whose mother had no education to 43 percent for children whose mother had at least secondary education, and from five percent for children in the poorest quintile to 43 percent for children in the richest quintile. Table CH.3: Vaccination against Japanese encephalitis Percentage of children aged 12–59 months currently vaccinated against Japanese encephalitis, Terai subregions of MFWR, Nepal, 2010 Percent vaccinated for Japanese encephalitis any time before survey according to: Total No. of children aged 12–59 months Vaccination card Mother’s report Either Subregion Mid-Western Terai 2.2 24.3 26.5 100.0 487 Far Western Terai 11.6 23.5 35.0 100.0 597 Sex Male 7.5 25.1 32.6 100.0 565 Female 7.2 22.5 29.7 100.0 519 Area Urban 7.2 33.3 40.4 100.0 208 Rural 7.4 21.6 29.0 100.0 876 Mother’s education None 5.5 19.5 24.9 100.0 606 Primary 10.6 25.1 35.7 100.0 158 Secondary + 10.1 33.0 43.1 100.0 298 Wealth index quintile Poorest 0.0 5.2 5.2 100.0 63 Second 1.2 12.1 13.3 100.0 113 Middle 9.4 16.6 26.0 100.0 239 Fourth 10.6 22.7 33.4 100.0 307 Highest 6.5 36.5 43.0 100.0 361 Total 7.4 23.8 31.2 100.0 1,084 Neonatal tetanus protection The aim of MDG 5 is to reduce the maternal mortality ratio by three quarters between 1990 and 2015, with one of the strategies being to eliminate maternal tetanus. In addition, there is a goal is to reduce the incidence of neonatal tetanus to less than one case per 1,000 live births in every administrative district. One of the WFFC goals was to eliminate maternal and neonatal tetanus by 2005. NMICS 2010, Mid- and Far Western Regions 58 To prevent maternal and neonatal tetanus, all pregnant women should receive at least two doses of the tetanus toxoid vaccine. However, if a woman does not receive two doses of the vaccine during pregnancy, she (and her newborn) is also considered to be protected if the one of following circumstances applies. • She has received at least two doses of tetanus toxoid vaccine, the last within the prior three years • She has received at least three doses, the last within the prior five years • She has received at least four doses, the last within the prior 10 years • She has received at least five doses during her lifetime Table CH.4 shows the tetanus protection status of women aged 15–49 years in the MFWR who had a live birth in the two years preceding the survey. Around two thirds (64 percent) were found to be protected against neonatal tetanus. There was little variation by region or urban/rural area. Subregionally, the highest percentage was in the Far Western Hills (70 percent) and the lowest was in the Mid-Western Mountains (57 percent). The likelihood of protection against neonatal tetanus increased with a woman’s level of education and household wealth status. Only 54 percent of women with no education were protected compared to 79 percent of women with at least secondary education. Only 53 percent of women from the poorest quintile were protected compared to 76 percent of women in the richest quintile. NMICS 2010, Mid- and Far Western Regions 59 Table CH.4: Neonatal tetanus protection Percentage distribution of women aged 15–49 years with a live birth in the two years preceding the survey protected against neonatal tetanus, MFWR, Nepal, 2010 Percent who received at least 2 doses during last pregnancy Did not receive 2 or m ore doses during last pregnancy but received: Protected against tetanus [1] No. of women with a live birth in last 2 years 2 doses, the last within 3 years 3 doses, the last within 5 years 4 doses, the last within 10 years 5 or more doses during lifetime Region Mid-Western 56.4 5.3 0.0 0.0 0.0 61.6 687 Far Western 59.8 7.9 0.1 0.0 0.0 67.7 578 Subregion Mid-Western Mountains 54.7 2.2 0.0 0.0 0.0 56.8 101 Mid-Western Hills 53.9 5.8 0.0 0.0 0.0 59.7 373 Mid-Western Terai 61.5 5.9 0.0 0.0 0.0 67.3 213 Far Western Mountains 59.4 2.5 0.4 0.0 0.0 62.3 104 Far Western Hills 62.3 7.6 0.0 0.0 0.0 69.9 198 Far Western Terai 58.1 10.2 0.0 0.0 0.0 68.3 275 Area Urban 59.0 9.9 0.0 0.0 0.0 68.9 120 Rural 57.8 6.1 0.0 0.0 0.0 64.0 1,144 Education None 48.9 4.8 0.1 0.0 0.0 53.7 699 Primary 64.5 10.6 0.0 0.0 0.0 75.2 230 Secondary + 72.3 7.1 0.0 0.0 0.0 79.4 335 Wealth index quintile Poorest 48.8 4.2 0.1 0.0 0.0 53.1 321 Second 52.9 8.6 0.0 0.0 0.0 61.5 285 Middle 58.5 4.8 0.0 0.0 0.0 63.3 255 Fourth 68.4 8.5 0.0 0.0 0.0 76.9 214 Richest 68.4 7.1 0.0 0.0 0.0 75.6 188 Total 57.9 6.5 0.0 0.0 0.0 64.4 1,265 [1] MICS Indicator 3.7 NMICS 2010, Mid- and Far Western Regions 60 Figure CH.2 shows the protection of women against neonatal tetanus by major background characteristics. Oral rehydration treatment for diarrhoea Diarrhoea is the second highest cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration through the 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 57 60 67 62 70 68 69 64 54 75 79 53 61 63 77 76 65 0 10 20 30 40 50 60 70 80 90 Mid -Western Mountains Mid -Western Hills Mid- Western Terai Far -Western Mountains Far- Western Hills Far- Western Terai Urban Rural Mother's Educat ion None Primary Secondary + Poorest Second Middle Fourth Richest Total Percent Figure CH.2 Percentage of women with a live birth in the last 12 months w ho are protected against neonatal tetanus, MFWR, Nepal, 2010 NMICS 2010, Mid- and Far Western Regions 61 deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The WFFC gave a specific goal of reducing death due to diarrhoea among children under five by half between 2000 and 2010, and it also called for a reduction in the incidence of diarrhoea by 25 percent. Reducing deaths from diarrhoea would also significantly impact the MDG on reducing by two thirds the mortality rate among children under five between 1990 and 2015. The indicators used are as follows. • Prevalence of diarrhoea • Oral rehydration therapy (ORT) • Home management of diarrhoea • ORT with continued feeding In the NMICS 2010 questionnaire, mothers (or caretakers) were asked to report whether their child had had diarrhoea in the two weeks preceding the survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Table CH.5 shows that 11 percent of children under five in the MFWR had had diarrhoea in the two weeks preceding the survey. There was little variation by region or gender. Subregionally, the prevalence of diarrhoea was highest among children living in the Far Western Hills (18 percent) and lowest for those in the Far Western Terai (four percent). Urban children (seven percent) were less likely than rural children (12 percent) to have diarrhoea. Children aged 12–23 months (13 percent) were more likely than other children to have diarrhoea; this is the peak weaning period. Children aged 48–59 months (eight percent) were the least likely. Mother’s education and household wealth status affected the likelihood of children having diarrhoea. Children whose mother had no education (13 percent) were more likely than children whose mother had primary (11 percent) or at least secondary education (eight percent) to have diarrhoea. Children in the lowest two wealth quintiles (15 percent) were more likely than other to have diarrhoea, with those in the richest quintile (six percent) least likely. Table CH.5 also shows the percentage of children receiving ORT (recommended liquids) during the episode of diarrhoea. About three fifths (58 percent) of children in the MFWR received ORS (Navjeevan or Jeevanjal powder mixed in water) during their diarrhoeal episode and slightly more than one fifth (22 percent) of children received a zinc tablet along with ORS. Some variations by background characteristic were noticeable; however, sample sizes were small, so these should be viewed with caution. Male children (26 percent) were more likely than female children (17 percent) and urban children (30 percent) were more likely than rural children (21 percent) to receive a zinc tablet along with ORS during an episode of diarrhoea. Children aged under one were the least likely to receive recommended liquids (32 percent) and least likely to receive a zinc tablet (six percent). Variations subregionally, by mother’s education and by household wealth status showed no obvious or no reliable trends. NMICS 2010, Mid- and Far Western Regions 62 Table CH.5: Oral rehydration solution Percentage of children aged 0–59 months with diarrhoea in the preceding two weeks, and treatment with ORS, MFWR, Nepal, 2010 Percent with diarrhoea in two weeks preceding survey No. of children aged 0–59 months Percent with diarrhoea who received: No. of children aged 0–59 months with diarrhoea in two weeks preceding survey ORS (Navjeevan/ Jeevanjal powder mixed in water) Zinc tablet along with ORS Region Mid-Western 12.7 1,984 51.4 22.1 252 Far Western 9.4 1,590 68.2 21.1 149 Subregion Mid-Western Mountains 17.4 302 68.4 32.3 53 Mid-Western Hills 11.3 1,082 41.8 18.8 122 Mid-Western Terai 12.9 600 55.0 20.2 78 Far Western Mountains 6.5 300 (53.9) (13.6) 20 Far Western Hills 18.4 553 68.0 16.8 102 Far Western Terai 3.8 737 (79.3) (42.0) 28 Sex Male 11.4 1,840 60.6 26.0 210 Female 11.0 1,734 54.4 17.0 191 Area Urban 7.2 312 61.2 30.2 22 Rural 11.6 3,262 57.5 21.2 379 Age 0–11 months 11.6 689 31.9 5.5 80 12–23 months 13.1 626 64.5 16.3 82 24–35 months 12.0 714 57.7 17.6 86 36–47 months 11.5 803 73.6 36.8 92 48–59 months 8.2 743 58.1 33.0 61 Mother’s education None 12.6 2,148 54.9 23.0 271 Primary 11.2 579 64.0 13.8 65 Secondary 7.7 846 62.7 24.2 65 Wealth index quintile Poorest 14.5 927 51.1 18.2 134 Second 14.9 804 55.1 20.0 120 Middle 9.0 709 67.5 27.6 63 Fourth 8.6 611 (77.1) (25.0) 53 Richest 5.9 523 (42.4) (25.4) 31 Total 11.2 3,574 57.7 21.7 401 Figures in parenthesis indicate that the percentage is based on denominators of 25–49 unweighted cases Table CH.6 shows the percentage of children aged 0–59 months in the MFWR with diarrhoea in the two weeks preceding the survey who were given liquids and food during their episode. One quarter (25 percent) drank more liquids than usual while 36 percent drank the same amount. Some 37 percent ate somewhat less food, 33 percent ate the same amount of food, and seven percent ate much less. Children in the Far Western Region were much more likely than those in the Mid-Western Region to be given much less to drink and eat, and much less likely to be given to drink and eat. Given the sample sizes, variations by background characteristic showed no obvious or reliable trends. Generally, drinking more liquids during diarrhoea was more common than eating more food. Table CH.6: Feeding practices during diarrhoea Percentage of children aged 0–59 months with diarrhoea in the two weeks preceding the survey by amount of liquids and food given during the episode of diarrhoea, MFWR, Nepal, 2010 Percent with diarr- hoea in two weeks prece- ding survey No. of children aged 0–59 months Drinking practices during diarrhoea Total Eating practices during diarrhoea: Total No. of children aged 0–59 months with diarr- hoea in two weeks prece- ding survey Given much less to drink Given some- what less to drink Given about the same to drink Given more to drink Given nothing to drink Missing / don’t know Given much less to eat Given some- what less to eat Given about the same to eat Given more to eat Stopped food Never been given food Missing/ don’t know Region Mid-Western 12.7 1,984 1.9 23.3 42.5 28.9 2.6 0.9 100.0 2.7 35.8 38.6 13.5 5.3 2.5 1.6 100.0 252 Far Western 9.4 1,590 18.3 36.6 23.5 17.3 3.4 0.8 100.0 14.2 38.9 24.4 9.1 12.0 0.7 0.8 100.0 149 Subregion Mid-Western Mountains 17.4 302 4.7 18.8 37.8 34.0 1.1 3.5 100.0 4.9 44.4 28.0 8.6 10.1 1.9 2.1 100.0 53 Mid-Western Hills 11.3 1,082 0.0 19.5 43.3 33.9 3.0 0.3 100.0 0.0 23.7 46.1 20.6 5.7 1.5 2.5 100.0 122 Mid-Western Terai 12.9 600 2.9 32.3 44.4 17.5 2.9 0.0 100.0 5.4 49.0 34.0 5.6 1.5 4.5 0.0 100.0 78 Far Western Mountains 6.5 300 20.8 41.0 31.3 2.1 4.8 0.0 100.0 * * * * * * * 100.0 20 Far Western Hills 18.4 553 17.4 41.5 17.4 18.5 4.1 1.1 100.0 18.7 39.5 17.4 10.3 13.0 0.0 1.1 100.0 102 Far Western Terai 3.8 737 20.1 15.9 40.2 23.9 0.0 0.0 100.0 * * * * * * * 100.0 28 Sex Male 11.4 1,840 9.0 29.7 38.3 20.1 1.6 1.2 100.0 9.0 39.1 32.6 11.2 6.6 0.7 0.9 100.0 210 Female 11.0 1,734 6.9 26.7 32.3 29.5 4.3 0.4 100.0 4.8 34.6 34.1 12.6 9.1 3.0 1.8 100.0 191 Area Urban 7.2 312 5.9 31.6 35.1 23.2 2.6 1.6 100.0 8.0 41.0 29.8 8.6 8.8 2.2 1.6 100.0 22 Rural 11.6 3,262 8.1 28.0 35.5 24.7 2.9 0.8 100.0 6.9 36.7 33.5 12.1 7.7 1.8 1.3 100.0 379 Age 0–11 months 11.6 689 8.7 23.2 42.4 20.2 5.5 0.0 100.0 9.1 18.3 45.2 9.6 10.2 7.6 0.0 100.0 80 12–23 months 13.1 626 5.3 28.1 36.3 27.2 1.8 1.4 100.0 3.5 42.6 25.7 18.2 5.0 0.4 4.6 100.0 82 24–35 months 12.0 714 9.1 25.8 30.4 32.0 1.8 0.9 100.0 10.3 43.6 28.7 7.6 8.9 0.0 0.9 100.0 86 36–47 months 11.5 803 10.2 40.1 27.0 21.0 0.9 0.8 100.0 7.5 40.6 27.4 14.0 9.4 1.0 0.0 100.0 92 48–59 months 8.2 743 5.8 20.5 45.0 21.9 5.6 1.2 100.0 3.1 38.8 43.4 9.1 4.3 0.0 1.2 100.0 61 Cont’d Table CH.6: Feeding practices during diarrhoea Percentage of children aged 0–59 months with diarrhoea in the two weeks preceding the survey by amount of liquids and food given during the episode of diarrhoea, MFWR, Nepal, 2010 Percent with diarr- hoea in two weeks prece- ding survey No. of children aged 0–59 months Drinking practices during diarrhoea Total Eating practices during diarrhoea: Total No. of children aged 0–59 months with diarr- hoea in two weeks prece- ding survey Given much less to drink Given some- what less to drink Given about the same to drink Given more to drink Given nothing to drink Missing / don’t know Given much less to eat Given some- what less to eat Given about the same to eat Given more to eat Stopped food Never been given food Missing/ don’t know Mother’s education None 12.6 2,148 6.8 33.6 38.3 17.1 3.2 1.0 100.0 6.8 40.4 36.4 5.8 7.8 1.9 0.8 100.0 271 Primary 11.2 579 8.2 18.9 24.7 47.7 0.0 0.6 100.0 3.0 29.5 21.3 30.3 11.2 0.0 4.7 100.0 65 Secondary 7.7 846 12.6 15.4 34.2 32.7 4.5 0.6 100.0 11.7 29.7 32.4 18.8 4.2 3.3 0.0 100.0 65 Wealth index quintile Poorest 14.5 927 7.8 35.8 35.1 17.0 4.1 0.3 100.0 5.4 44.2 35.9 5.4 7.3 1.4 0.3 100.0 134 Second 14.9 804 6.0 22.8 41.6 28.3 0.4 0.9 100.0 6.9 27.2 40.7 15.3 6.4 2.6 0.9 100.0 120 Middle 9.0 709 9.4 31.6 28.6 26.3 2.4 1.7 100.0 10.5 42.8 25.4 9.8 10.3 0.0 1.1 100.0 63 Fourth 8.6 611 9.7 25.3 39.5 21.6 3.2 0.7 100.0 5.8 37.1 25.8 19.2 10.3 0.9 0.7 100.0 53 Richest 5.9 523 11.2 14.7 19.9 45.0 7.9 1.2 100.0 (8.4) (30.4) (22.3) (18.6) (5.6) (6.0) (8.7) 100.0 31 Total 11.2 3,574 8.0 28.2 35.4 24.6 2.9 0.8 100.0 7.0 36.9 33.3 11.9 7.8 1.8 1.3 100.0 401 Figures in parenthesis indicate that the percentage is based on denominators of 25–49 unweighted cases An asterisk indicates that the percentage or proportion is calculated on fewer than 25 unweighted cases NMICS 2010, Mid- and Far Western Regions 65 Table CH.7 shows the percentage of children aged 0–59 months in the MFWR with diarrhoea in the two weeks preceding the survey who received oral rehydration therapy with continued feeding, and the percentage of children with diarrhoea who received other treatments. Overall, 68 percent of children with diarrhoea received ORS or increased fluids. Combining information in Tables CH.5 and CH.6 indicates that 47 percent of children received both ORS and continued feeding, as is the recommendation. There was little variation in the correct home management of diarrhoea by region, gender, urban/rural area, mother’s education or household wealth status; or sample sizes were too small to be reliable. Subregionally, the highest percentage of children receiving ORS with continued feeding was in the Far Western Terai (73 percent) and the lowest was in the Mid-Western Hills (40 percent). Children aged 0–11 months (26 percent) were less likely than other children to receive ORS with continued feeding. Table CH.7: Oral rehydration therapy with continued feeding and other treatments Percent of children aged 0–59 months with diarrhoea in the two weeks preceding the survey who received oral rehydration therapy with continued feeding or other treatments, MFWR, Nepal, 2010 Percent with diarrhoea who received Percent with diarrhoea who received other treatment Not given any treatment or drug No. of children aged 0–59 months with diarrhoea ORS or increased fluids ORS with continued feeding [1] Pill or syrup: Injection: Home remedy/ herbal medicine Other Antibiotic Zinc Other Unknown Antibiotic Unknown Region Mid-Western 64.9 45.5 4.6 7.0 .9 5.2 0.8 3.0 3.3 1.3 26.9 252 Far Western 71.8 50.5 0.5 1.0 1.1 4.4 0.0 0.0 3.7 1.1 23.5 149 Subregion Mid-Western Mountains 77.8 53.8 2.0 5.0 0.0 0.9 0.8 0.0 7.7 2.1 17.9 53 Mid-Western Hills 58.5 39.8 7.1 4.6 1.9 5.8 0.0 6.2 3.5 0.3 31.7 122 Mid-Western Terai 66.2 48.9 2.5 12.2 0.0 7.1 2.2 0.0 0.0 2.1 25.6 78 Far Western Mountains * * * * * * * * * * * 20 Far Western Hills 72.9 46.3 0.3 1.5 1.5 3.6 0.0 0.0 5.5 0.0 22.7 102 Far Western Terai 80.8 73.0 0.0 0.0 0.3 7.5 0.0 0.0 0.0 4.2 15.1 28 Sex Male 67.8 50.0 1.4 6.9 1.7 1.3 0.0 0.0 3.4 1.3 26.3 210 Female 67.1 44.5 4.9 2.5 0.2 8.9 1.1 4.0 3.6 1.1 25.0 191 Area Urban 66.6 49.1 2.6 4.7 1.6 5.0 0.0 0.0 0.0 1.9 27.7 22 Rural 67.5 47.3 3.1 4.8 0.9 4.9 0.6 2.0 3.7 1.2 25.5 379 Age 0–11 months 49.1 26.2 4.8 2.6 0.1 7.1 0.0 0.0 10.2 0.6 34.3 80 12–23 months 70.5 56.3 5.9 5.0 2.8 4.3 2.0 9.3 0.0 2.1 22.3 82 24–35 months 71.4 42.6 0.0 1.9 0.0 9.9 0.0 0.0 3.3 0.4 24.0 86 36–47 months 79.1 59.2 3.5 1.6 0.3 0.0 0.0 0.0 1.8 0.0 19.1 92 48–59 months 64.4 51.8 0.7 16.1 2.1 3.2 0.7 0.0 2.2 3.7 30.9 61 Mother’s education None 61.8 44.0 2.8 4.1 0.1 4.8 0.8 0.0 2.8 1.1 31.9 271 Primary 83.4 55.0 7.3 3.0 2.0 7.0 0.0 11.7 5.4 0.0 11.0 65 Secondary 75.3 53.6 0.0 9.5 3.7 3.0 0.0 0.0 4.5 2.6 14.3 65 Cont’d Table CH.7: Oral rehydration therapy with continued feeding and other treatments Percent of children aged 0–59 months with diarrhoea in the two weeks preceding the survey who received oral rehydration therapy with continued feeding or other treatments, MFWR, Nepal, 2010 Percent with diarrhoea who received Percent with diarrhoea who received other treatment Not given any treatment or drug No. of children aged 0–59 months with diarrhoea ORS or increased fluids ORS with continued feeding [1] Pill or syrup: Injection: Home remedy/ herbal medicine Other Antibiotic Zinc Other Unknown Antibiotic Unknown Wealth index quintile Poorest 57.4 43.0 0.5 0.5 0.9 4.0 0.0 0.0 4.0 0.7 35.9 134 Second 68.4 45.7 5.0 5.2 1.9 0.4 0.0 6.3 3.5 0.4 25.6 120 Middle 76.4 51.7 1.2 9.1 0.0 7.5 0.0 0.0 4.0 2.6 18.2 63 Fourth (78.2) (65.2) (0.5) (4.7) (0.5) (10.9) (0.8) (0) (0) (0.7) 13.9 53 Richest (70.9) (33.1) (15.1) (13.6) (0.3) (10.7) (5.5) (0) (6.0) (4.5) (16.9) 31 Total 67.5 47.4 3.1 4.8 1.0 4.9 0.5 1.9 3.5 1.2 25.7 401 [1] MICS Indicator 3.8 Figures in parenthesis indicate that the percentage is based on denominators of 25–49 unweighted cases * An asterisk indicates that the percentage or proportion is calculated on fewer than 25 unweighted cases NMICS 2010, Mid- and Far Western Regions 68 Figure CH.3 shows the percentage of children under five in the MFWR with diarrhoea in the two weeks preceding the survey who received ORS or increased fluids by background characteristic. Care-seeking and antibiotic treatment of pneumonia Pneumonia is a leading cause of death in children and the use of antibiotics in under-fiv es with suspected pneumonia is a key intervention. The WFFC goal is to reduce deaths due to acute respiratory infections by one third. Children with suspected pneumonia are those who have an illness with a cough accompanied by rapid or difficult breathing and whose symptoms are not due to a problem in the chest or a blocked nose. The indicators used are as follows. • Prevalence of suspected pneumonia • Care-seeking for suspected pneumonia • Antibiotic treatment for suspected pneumonia • Knowledge of the danger signs of pneumonia Table CH.8 presents information on the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. Seven percent of children aged 0–59 months in the MFWR were reported to have had symptoms of pneumonia during the two weeks preceding the survey. Of these, 51 percent were taken to an appropriate provider. About one third (32 percent) were taken to public sector health institutions (hospital: nine percent, primary healthcare centre: seven percent, and health post/sub health post: 16 percent). Around six percent received treatment from a Female Community Health Volunteer. Some 34 percent received treatment from private hospitals, clinics or pharmacies. Home remedies were given to nine percent of children and two percent visited a traditional healer. There was little variation by background characteristic. 68 67 78 58 66 73 81 67 68 62 83 75 67 0 10 20 30 40 50 60 70 80 90 100 Pe rc en t Figure CH.3 Percentage of children under age 5 with diarrhoea who received oral rehydration treatment, MFWR, Nepal, 2010 Table CH.8: Care-seeking for suspected pneumonia and antibiotic use during suspected pneumonia Percentage of children aged 0–59 months with suspected pneumonia in the two weeks preceding the survey who were taken to a health provider and percentage of children who were given antibiotics, MFWR, Nepal, 2010 Percent with suspected pneu- monia in two weeks preceding survey No. of children aged 0–59 months Percent with suspected pneumonia who were taken to: Any appro- priate provider [1] Percent with suspected pneumonia who received antibiotics in two weeks preceding survey [2] No. of children aged 0–59 months with suspected pneumonia in two weeks pre- ceding survey Public source Private source Other source G o v e r n m e n t h o s p i t a l P r i m a r y h e a l t h c a r e c e n t r e H e a l t h p o s t / s u b h e a l t h p o s t V i l l a g e H e a l t h W o r k e r M o b i l e / o u t r e a c h c l i n i c F e m a l e C o m m u n i t y H e a l t h V o l u n t e e r P r i v a t e h o s p i t a l / c l i n i c P r i v a t e p h a r m a c y R e l a t i v e / f r i e n d S h o p H o m e r e m e d y T r a d i t i o n a l h e a l e r ( d h a m i / j h a k r i ) Region Mid-Western 7.0 1,984 5.6 2.2 20.9 1.9 2.5 5.7 18.3 15.8 0.2 .0 5.8 1.7 51.3 57.3 139 Far Western 7.6 1,590 12.6 11.8 10.5 0.2 1.4 5.4 20.6 13.9 1.1 1.1 11.8 1.6 50.8 54.6 120 Subregion Mid-Western Mountains 5.0 302 11.5 3.7 28.9 6.4 0.0 9.4 3.2 12.9 1.9 0.0 0.0 0.0 53.6 (47.7) 15 Mid-Western Hills 7.6 1,082 5.3 3.0 21.5 0.0 4.3 4.8 16.6 17.9 0.0 0.0 4.0 0.0 50.6 (64.9) 82 Mid-Western Terai 7.0 600 4.0 0.0 16.7 4.0 0.0 6.2 27.2 12.9 0.0 0.0 11.4 5.5 52.0 (45.8) 42 Far Western Mountains 2.1 300 7.4 0.0 43.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 6.6 0.0 50.5 * 6 Far Western Hills 11.6 553 9.7 17.9 10.1 0.4 0.0 10.1 13.6 7.4 0.0 0.0 10.4 3.1 47.3 52.8 64 Far Western Terai 6.8 737 17.0 5.4 7.0 0.0 3.3 0.0 32.1 23.9 2.7 2.7 14.2 0.0 55.4 (59.4) 50 Sex Male 7.3 1,840 8.7 7.4 15.1 1.9 1.2 2.8 24.8 15.1 0.2 0.0 6.8 1.5 55.8 59.3 135 Female 7.2 1,734 9.0 5.8 17.1 0.3 2.8 8.5 13.5 14.7 1.1 1.1 10.5 1.8 46.0 52.5 124 Area Urban 7.6 312 3.7 1.1 5.2 1.1 0.0 2.0 47.8 23.3 0.0 0.0 1.2 0.0 58.1 (64.1) 24 Rural 7.2 3,262 9.4 7.2 17.2 1.1 2.2 5.9 16.5 14.1 0.7 0.6 9.3 1.8 50.4 55.2 236 Age 0–11 months 8.4 689 18.5 2.3 25.8 0.0 0.0 2.7 11.5 8.2 0.5 0.0 10.4 1.7 52.3 (54.7) 58 12–23 months 8.8 626 6.7 6.7 18.5 0.3 0.0 8.1 15.5 22.4 2.5 0.0 13.9 4.2 44.5 (62.6) 55 24–35 months 8.2 714 0.8 6.1 13.9 0.4 8.8 2.9 26.6 19.5 0.0 2.3 8.5 0.0 54.5 63.6 59 36–47 months 7.0 803 10.4 9.0 12.7 1.4 0.0 4.3 15.6 10.6 0.0 0.0 6.2 1.8 49.1 42.1 56 48–59 months 4.2 743 7.2 11.2 4.0 5.3 0.0 13.6 33.8 13.4 0.0 0.0 0.0 0.0 57.8 (58.1) 31 Cont’d Table CH.8: Care-seeking for suspected pneumonia and antibiotic use during suspected pneumonia Percentage of children aged 0–59 months with suspected pneumonia in the two weeks preceding the survey who were taken to a health provider and percentage of children who were given antibiotics, MFWR, Nepal, 2010 Percent with suspected pneu- monia in two weeks preceding survey No. of children aged 0–59 months Percent with suspected pneumonia who were taken to: Any appro- priate provider [1] Percent with suspected pneumonia who received antibiotics in two weeks preceding survey [2] No. of children aged 0–59 months with suspected pneumonia in two weeks pre- ceding survey Public source Private source Other source G o v e r n m e n t h o s p i t a l P r i m a r y h e a l t h c a r e c e n t r e H e a l t h p o s t / s u b h e a l t h p o s t V i l l a g e H e a l t h W o r k e r M o b i l e / o u t r e a c h c l i n i c F e m a l e C o m m u n i t y H e a l t h V o l u n t e e r P r i v a t e h o s p i t a l / c l i n i c P r i v a t e p h a r m a c y R e l a t i v e / f r i e n d S h o p H o m e r e m e d y T r a d i t i o n a l h e a l e r ( d h a m i / j h a k r i ) Mother’s education None 7.6 2,148 9.3 6.5 17.2 1.5 2.1 4.5 17.6 11.3 0.2 0.8 9.3 0.6 52.0 51.9 164 Primary 7.5 579 8.9 12.8 9.2 0.6 3.7 12.6 22.9 10.8 0.0 0.0 5.3 5.3 58.0 (76.9) 44 Secondary 6.1 846 7.3 1.9 18.1 0.3 0.0 3.0 22.0 29.9 2.6 0.0 8.8 1.9 42.5 (51.8) 52 Wealth index quintile Poorest 6.4 927 1.1 8.1 19.9 0.7 5.9 4.1 11.9 6.1 0.5 0.0 14.5 1.7 45.5 45.9 60 Second 8.0 804 13.2 8.6 9.9 1.0 0.0 8.6 19.9 7.3 2.1 0.0 3.2 1.5 52.7 45.8 64 Middle 9.5 709 11.1 6.7 20.1 0.0 0.0 7.4 15.8 23.5 0.0 0.0 6.2 3.4 49.9 61.7 67 Fourth 7.4 611 13.8 5.1 21.9 0.4 0.0 1.0 25.3 23.6 0.0 0.0 16.1 0.0 58.2 (71.9) 45 Richest 4.3 523 0.4 0.0 0.0 7.4 7.2 4.2 35.9 17.2 0.0 5.9 0.0 0.0 50.8 (63.7) 23 Total 7.3 3,574 8.8 6.6 16.1 1.1 2.0 5.6 19.3 14.9 0.6 0.5 8.5 1.6 51.1 56.1 259 [1] MICS Indicator 3.9 [2] MICS Indicator 3.10 Figures in parenthesis indicate that the percentage is based on denominators of 25–49 unweighted cases * An asterisk indicates that the percentage or proportion is calculated on fewer than 25 unweighted cases One case with missing ‘mother’s education’ not shown NMICS 2010, Mid- and Far Western Regions 71 Some 56 percent of under-fives in the MFWR with suspected pneumonia had received an antibiotic during the two weeks preceding the survey (Table CH.8). There was little variation by background characteristic or sample sizes were too small to show reliable trends. Mothers’ knowledge of the danger signs of pneumonia is an important determinant in care-seeking behaviour. Information on care-seeking behaviour is presented in Table CH.9. Overall, six percent of mothers/caretak ers knew of the two danger signs of pneumonia—fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility was fever (89 percent); this was followed by ‘becomes sicker’ (39 percent). Some 19 percent of mothers/caretakers identified ‘fast breathing’ and 22 percent identified ‘has difficulty breathing’ as symptoms requiring children to be taken to a healthcare provider immediately. There was little variation by background characteristic in mothers/caretakers knowledge of the two danger signs of pneumonia. Table CH.9: Care seeking of illness symptoms Percentage of mothers and caretakers of children aged 0–59 months by symptoms that would cause them to take the child immediately to a health facility, and percentage of mothers who recognize fast and difficult breathing as signs for seeking care immediately, MFWR, Nepal, 2010 Percent of mothers/caretakers of children aged 0–59 months who think that a child should be taken immediately to a health facility if the child: Mothers / care- takers who recog- nized the two danger signs of pneu- monia No. of mothers/ care- takers of children aged 0–59 months Is not able to drink or breast- feed Becomes sicker Develops a fever Has fast breathin g Has difficulty breathin g Has blood in stool Is drinking poorly Has other symp- toms Region Mid-Western 16.5 39.6 91.9 18.8 21.2 12.6 8.2 34.6 5.0 1,463 Far Western 25.8 37.1 85.7 19.6 23.7 11.9 5.5 35.3 7.5 1,166 Subregion Mid-Western Mountains 22.6 36.8 84.8 16.2 17.6 14.6 9.9 30.9 5.7 212 Mid-Western Hills 11.4 38.4 95.2 16.0 19.2 11.8 10.7 40.7 3.6 801 Mid-Western Terai 22.5 43.0 89.4 25.0 26.4 13.2 2.9 25.4 7.2 450 Far Western Mountains 9.0 38.9 83.2 27.3 18.3 4.3 2.7 40.7 8.8 216 Far Western Hills 31.6 36.3 81.9 19.3 18.3 9.7 10.9 41.3 7.2 395 Far Western Terai 28.2 37.0 89.3 16.7 29.6 16.5 2.8 29.0 7.2 555 Area Urban 24.2 26.4 90.4 20.4 24.2 18.0 4.0 33.8 8.1 232 Rural 20.2 39.6 89.0 19.0 22.1 11.8 7.3 35.0 5.9 2,397 Education None 20.4 38.4 87.4 18.6 20.5 11.9 7.0 34.7 5.4 1,554 Primary 17.9 38.7 92.5 17.2 28.1 10.9 8.6 37.3 6.5 431 Secondary + 22.8 38.5 91.1 21.9 22.9 14.4 5.8 33.8 7.7 643 Wealth index quintile Poorest 16.4 33.6 86.2 14.8 15.3 7.8 8.2 43.0 3.9 667 Second 18.7 34.8 91.0 19.7 21.1 11.4 10.3 36.7 5.8 567 Middle 23.4 43.1 90.4 18.3 25.2 14.1 5.8 31.2 6.1 520 Fourth 24.4 40.8 88.9 23.4 27.2 13.7 4.9 31.5 8.3 472 Richest 22.1 43.1 90.0 21.8 26.1 17.2 4.3 27.8 7.6 403 Total 20.6 38.5 89.1 19.1 22.3 12.3 7.0 34.9 6.1 2,629 NMICS 2010, Mid- and Far Western Regions 72 Solid fuel use More than three billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, such as cooking and heating. Cooking and heating with solid fuels with traditional cooking stoves leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is pollution from the 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 obstructiv e lung disease and cancer, and possibly of tuberculosis, low birth weight, cataracts and asthma. The main indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. Overall, nearly 93 percent of all household members in the MFWR used solid fuels for cooking (Table CH.10). Use of solid fuels was common among household members across all subregions, although it was a little lower in the Terai than the Hills and Mountains. It was almost universal in rural areas (95 percent) compared to urban areas (74 percent). It was also higher in households whose household head had no education (97 percent) compared to households whose household head had at least secondary education (86 percent). Although household members in the four poorest wealth quintiles had similar levels of use, at 99 percent, households in the richest quintile had strikingly lower use, at only 66 percent. Most household members use firewood (92 percent) for cooking purposes; this was followed by liquefied petroleum gas (LPG) (four percent) and biogas (three percent). Table CH.10: Solid fuel use Percentage of household members according to type of cooking fuel used by the household, and percentage of household members living in households using solid fuels for cooking, MFWR, Nepal, 2010 Percent household members in households using: No. of household members Electricity Liquefied petroleum gas (LPG) Biogas Kerosene Solid fuels Other No food cooked in household Total Solid fuels for cooking [1] Wood Straw, shrubs, grass Animal dung/ briquette Agricultural crop residue Region Mid-Western 0.0 4.7 2.1 0.2 91.8 0.0 0.6 0.1 0.4 0.0 100.0 92.5 17,155 Far Western 0.2 1.9 4.2 0.2 92.9 0.0 0.1 0.3 0.3 0.0 100.0 93.3 14,105 Subregion Mid-Western Mountains 0.0 0.0 0.0 0.1 99.9 0.0 0.0 0.0 0.0 0.0 100.0 99.9 2,033 Mid-Western Hills 0.0 4.0 0.4 0.3 94.9 0.1 0.4 0.0 0.0 0.0 100.0 95.3 8,559 Mid-Western Terai 0.0 7.2 5.1 0.2 85.3 0.0 1.1 0.2 0.9 0.0 100.0 86.6 6,564 Far Western Mountains 0.0 0.0 0.1 0.1 99.6 0.1 0.0 0.0 0.0 0.0 100.0 99.7 2,438 Far Western Hills 0.0 0.3 0.1 0.2 99.4 0.0 0.0 0.0 0.0 0.0 100.0 99.4 4,339 Far Western Terai 0.4 3.5 7.9 0.1 86.8 0.0 0.1 0.5 0.5 0.0 100.0 87.5 7,327 Area Urban 0.2 18.2 6.7 0.3 72.1 0.0 0.7 0.7 1.1 0.1 100.0 73.5 3,376 Rural 0.1 1.7 2.6 0.2 94.8 0.0 0.3 0.1 0.2 0.0 100.0 95.2 27,884 Education of household head None 0.1 0.8 1.9 0.1 96.1 0.0 0.5 0.2 0.3 0.0 100.0 96.8 15,094 Primary 0.0 3.1 2.9 0.3 92.6 0.0 0.6 0.0 0.5 0.0 100.0 93.2 7,287 Secondary + 0.3 8.3 5.1 0.3 85.7 0.0 0.0 0.2 0.2 0.0 100.0 85.9 8,782 Wealth index quintile Poorest 0.0 0.0 0.0 0.0 100.0 0.0 0.0 0.0 0.0 0.0 100.0 100.0 6,252 Second 0.0 0.0 0.0 0.2 99.6 0.0 0.2 0.0 0.0 0.0 100.0 99.8 6,253 Middle 0.0 0.0 0.0 0.5 98.0 0.0 1.4 0.2 0.0 0.0 100.0 99.5 6,254 Fourth 0.1 0.1 0.8 0.0 98.3 0.1 0.1 0.3 0.0 0.0 100.0 98.9 6,251 Richest 0.4 17.2 14.4 0.2 65.7 0.0 0.2 0.3 1.6 0.0 100.0 66.2 6,250 Total 0.1 3.5 3.1 0.2 92.3 0.0 0.4 0.2 0.3 0.0 100.0 92.9 31,260 [1] MICS Indicator 3.11 97 cases with missing ‘education of household head’ not shown NMICS 2010, Mid- and Far Western Regions 74 Solid-fuel use on its own is a poor proxy for indoor air pollution, since the concentration of pollutants differs when the same fuel is burnt in different types of stove or fire. Use of closed stoves with chimneys minimizes indoor air pollution, while an open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. Solid-fuel use by place of cooking for household members in the MFWR is shown in Table CH.11. Some 46 percent of household members used a separate room as a kitchen, but another 46 percent used any place in the house for cooking. A low proportion of household members used a separate building (seven percent) and only one percent cooked outdoors. There was little variation in the use of a separate kitchen by region or urban/rural area. Subregionally, the highest percentage was in the Mid-Western Hills (53 percent) and lowest was in the Far Western Mountains (30 percent). Having a separate kitchen had a positive correlation with the level of education of the household head and with the economic status of the household. In households where the household head had at least secondary education, households members were more likely to cook in a separate kitchen than in households where the household head had no education (56 percent compared to 40 percent). In households in the richest quintile, households members were more likely to cook in a separate kitchen than in households in the poorest quintile (64 percent compared to 24 percent). The practice of cooking elsewhere in the house was most common in the Far Western Mountains (68 percent), in rural areas (47 percent) and in households in the poorest quintile (75 percent). NMICS 2010, Mid- and Far Western Regions 75 Table CH.11: Solid-fuel use by place of cooking Percentage of household members in households using solid fuels by place of cooking, MFWR, Nepal, 2010 Place of cooking: Total No. of household members using solid fuels for cooking In a separate room used as kitchen Elsewhere in the house In a separate building Outdoors Other Missing Region Mid-Western 49.4 42.2 7.5 1.0 0.0 0.0 100.0 15,875 Far Western 42.3 49.4 6.6 1.6 0.0 0.0 100.0 13,158 Subregion Mid-Western Mountains 38.4 60.6 0.8 0.2 0.1 0.0 100.0 2,030 Mid-Western Hills 53.4 43.3 2.7 0.6 0.0 0.0 100.0 8,160 Mid-Western Terai 47.4 34.0 16.8 1.7 0.0 0.1 100.0 5,685 Far Western Mountains 30.0 68.3 1.5 0.2 0.0 0.0 100.0 2,431 Far Western Hills 35.2 61.2 3.3 0.2 0.0 0.0 100.0 4,315 Far Western Terai 51.7 34.4 10.8 3.1 0.1 0.0 100.0 6,412 Area Urban 49.9 27.0 19.0 3.9 0.2 0.0 100.0 2,482 Rural 45.8 47.2 6.0 1.0 0.0 0.0 100.0 26,551 Education of household head None 39.5 52.1 6.7 1.6 0.0 0.0 100.0 14,610 Primary 49.0 45.1 5.2 0.7 0.0 0.0 100.0 6,791 Secondary + 56.3 33.0 9.6 1.0 0.0 0.0 100.0 7,544 Wealth index quintile Poorest 24.0 74.9 0.7 0.3 0.0 0.1 100.0 6,252 Second 42.0 56.3 1.3 0.3 0.0 0.0 100.0 6,238 Middle 49.3 45.5 3.8 1.3 0.0 0.0 100.0 6,223 Fourth 57.5 28.0 11.9 2.6 0.1 0.0 100.0 6,182 Richest 64.2 10.7 23.1 2.0 0.0 0.0 100.0 4,137 Total 46.2 45.5 7.1 1.3 0.0 0.0 100.0 29,033 88 cases with missing ‘education of household head’ not shown Malaria Malaria contributes to anaemia in children. In areas where malaria is common, international recommendations suggest treating any fever in children as if it were malaria and immediately giving the child a full course of recommended anti-malarial tablets. Children with severe malaria symptoms, such as fever or convulsions, should be taken to a health facility. In addition, children recovering from malaria should be given extra liquids and food and, for younger children, should continue breastfeeding. USAID has promoted malaria control programmes in Nepal since 1954. In 1993, WHO initiated the Global Malaria Control Strategy to focus on problem areas. Areas with a high incidence of malaria in Nepal were identified, and 12 priority districts in the forest area, foothills and inner Terai were targeted for focused initiatives under the Roll Back Malaria Strategy. Currently, malaria control activities are in place in 65 of the country’s 75 districts. Questions on the prevalence and treatment of fever were asked of mothers/caretakers of all children under five. About one fifth (19 percent) of children were ill with fever in the two weeks preceding the survey (Table CH.12). There was little variation by region, gender, mother’s education or wealth quintile. Differences in fever prevalence across subregions were large, ranging from six percent in the Far Western Mountains to 29 percent in the Mid-Western Terai. Fever prevalence declined with age and peaked at 12–23 months (22 percent). Table CH.12: Anti-malarial treatment of children with anti-malarial drugs Percentage of children aged 0–59 months with fever in the two weeks preceding the survey who received anti-malarial drugs, MFWR, Nepal, 2010 Percent who had a fever in two weeks pre- ceding survey No. of children aged 0–59 months Percent with a fever in two weeks preceding survey who were treated with: Percent who took an anti- malarial drug on same or next day [2] No. of children with fever in two weeks pre- ceding survey Anti-malarial Other medications Don’t know SP/ Fansidar Chloro- quine Armodi- aquine Quinine Arte- misnin- based combin- ations Other anti- malarial Any anti- malarial drug [1] Paracet- amol/ Panadol/ Acet- amino- phan Aspirin Ibu- profen Other Region Mid-Western 19.3 1,984 0.0 0.1 0.0 0.0 0.2 0.4 0.6 15.6 0.0 0.1 1.8 4.8 0.2 382 Far Western 18.6 1,590 0.0 0.0 0.0 0.0 0.0 0.3 0.3 5.9 0.4 0.0 3.0 12.0 0.1 295 Subregion Mid-Western Mountains 13.7 302 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4.5 0.0 1.3 1.8 3.8 0.0 41 Mid-Western Hills 15.2 1,082 0.0 0.0 0.0 0.0 0.0 0.9 0.9 10.5 0.0 0.0 0.3 3.9 0.0 165 Mid-Western Terai 29.3 600 0.0 0.2 0.0 0.0 0.3 0.0 0.5 23.1 0.0 0.0 3.3 5.9 0.5 176 Far Western Mountains 5.7 300 (0.0) (0) 0.0 0.0 (0) (5.1) (5.1) (5.4) (0) (0) (0) (2.8) (2.4) 17 Far Western Hills 28.4 553 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5.3 0.8 0.0 1.7 19.0 0.0 157 Far Western Terai 16.4 737 0.0 0.0 0.0 0.0 0.0 0.0 0.0 6.7 0.0 0.0 5.1 4.1 0.0 121 Sex Male 18.0 1,840 0.0 0.1 0.0 0.0 0.2 0.1 0.4 9.0 0.4 0.0 1.5 4.4 0.3 331 Female 20.0 1,734 0.0 0.0 0.0 0.0 0.0 0.5 0.5 13.6 0.0 0.2 3.2 11.2 0.1 347 Area Urban 27.2 312 0.0 0.3 0.0 0.0 0.7 0.0 1.0 13.7 0.0 0.0 6.7 6.9 1.0 85 Rural 18.2 3,262 0.0 0.0 0.0 0.0 0.0 0.4 0.4 11.1 0.2 0.1 1.7 8.1 0.1 593 Age 0–11 months 19.5 689 0.0 0.0 0.0 0.0 0.0 1.1 1.1 9.3 1.0 0.0 3.3 8.1 0.0 134 12–23 months 22.4 626 0.0 0.0 0.0 0.0 0.0 0.0 0.0 9.3 0.0 0.0 0.1 7.2 0.0 140 24–35 months 20.5 714 0.0 0.0 0.0 0.0 0.0 0.3 0.3 11.3 0.0 0.4 1.8 8.8 0.0 146 36–47 months 16.7 803 0.0 0.0 0.0 0.0 0.0 0.0 0.0 16.5 0.0 0.0 3.1 9.0 0.0 134 48–59 months 16.6 743 0.0 0.2 0.0 0.0 0.5 0.3 1.1 10.6 0.0 0.0 3.6 6.3 1.1 123 Mother’s education None 19.2 2,148 0.0 0.0 0.0 0.0 0.1 0.2 0.4 10.9 0.0 0.1 2.2 9.5 0.2 413 Primary 22.2 579 0.0 0.0 0.0 0.0 0.0 1.1 1.1 9.0 0.0 0.0 0.9 6.6 0.0 128 Secondary 16.2 846 0.0 0.2 0.0 0.0 0.0 0.0 0.2 15.0 1.0 0.0 4.2 4.4 0.2 137 Cont’d Table CH.12: Anti-malarial treatment of children with anti-malarial drugs Percentage of children aged 0–59 months with fever in the two weeks preceding the survey who received anti-malarial drugs, MFWR, Nepal, 2010 Percent who had a fever in two weeks pre- ceding survey No. of children aged 0–59 months Percent with a fever in two weeks preceding survey who were treated with: Percent who took an anti- malarial drug on same or next day [2] No. of children with fever in two weeks pre- ceding survey Anti-malarial Other medications Don’t know SP/ Fansidar Chloro- quine Armodi- aquine Quinine Arte- misnin- based combin- ations Other anti- malarial Any anti- malarial drug [1] Paracet- amol/ Panadol/ Acet- amino- phan Aspirin Ibu- profen Other Wealth index quintile Poorest 17.5 927 0.0 0.0 0.0 0.0 0.0 1.2 1.2 9.3 0.0 0.3 1.5 13.0 0.0 163 Second 18.6 804 0.0 0.0 0.0 0.0 0.4 0.0 0.4 9.3 0.0 0.0 1.7 9.9 0.4 150 Middle 19.5 709 0.0 0.0 0.0 0.0 0.0 0.3 0.3 16.2 1.0 0.0 0.9 9.1 0.3 138 Fourth 20.4 611 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5.9 0.0 0.0 3.7 2.1 0.0 125 Richest 19.7 523 0.0 0.3 0.0 0.0 0.0 0.0 0.3 17.9 0.0 0.0 4.9 2.6 0.3 103 Total 19.0 3,574 0.0 0.0 0.0 0.0 0.1 0.3 0.5 11.4 0.2 0.1 2.3 7.9 0.2 678 [1] MICS Indicator 3.18; MDG Indicator 6.8 [2] MICS Indicator 3.17 Figures in parenthesis indicate that the percentage is based on denominators of 25–49 unweighted cases One case with missing ‘mother’s education’ not shown NMICS 2010, Mid- and Far Western Regions 78 Mothers were asked to report all of the medicines given to a child to treat fever, including both medicines given at home and medicines given or prescribed at a health facility. Overall, less than one percent (0.5 percent) of children with fever were treated with an ‘appropriate’ anti-malarial drug, and only 0.2 percent received anti-malaria l drugs within 24 hours of the onset of symptoms. Table CH.13 provides information on children aged 0–59 months in the MFWR who had a fever in the two weeks preceding the survey and who received a finger or heel stick for malaria testing. Overall, six percent of children had a finger or heel stick. There was little variation by region, urban/rural area or mother’s education. Subregionally, the highest proportion of children receiving a finger or heel stick was in the Mid-Western Terai (nine percent) and the lowest was in the Far Western Terai (two percent). Boys (eight percent) were more likely than girls (four percent) to have a finger or heel stick. Only two percent of children aged 12–23 months received a finger or heel stick. There was no obvious trend by wealth quintile, although children from the second quintile (10 percent) were most likely to receive a finger or heel stick and children from the poorest quintile (three percent) were least likely. NMICS 2010, Mid- and Far Western Regions 79 Table CH.13: Malaria diagnostics usage Percentage of children aged 0–59 months who had a fever in the two weeks preceding the survey and who had a finger or heel stick for malaria testing, MFWR, Nepal, 2010 Percent who had a finger or heel stick [1] No. of children aged 0–59 months with fever in two weeks preceding survey Region Mid-Western 7.2 382 Far Western 3.7 295 Subregion Mid-Western Mountains 6.6 41 Mid-Western Hills 5.7 165 Mid-Western Terai 8.8 176 Far Western Mountains (5.5) 17 Far Western Hills 4.9 157 Far Western Terai 2.0 121 Sex Male 7.8 331 Female 3.7 347 Area Urban 4.0 85 Rural 5.9 593 Age 0–11 months 6.2 134 12–23 months 1.9 140 24–35 months 8.3 146 36–47 months 5.3 134 48–59 months 6.6 123 Mother’s education None 5.7 413 Primary 4.3 128 Secondary 6.9 137 Wealth index quintile Poorest 3.3 163 Second 9.7 150 Middle 4.1 138 Fourth 4.5 125 Richest 7.2 103 Total 5.7 678 [1] MICS Indicator 3.16 Figures in parenthesis indicate that the percentage is based on denominators of 25–49 unweighted cases 80 VI. Water and Sanitation Safe drinking water and proper sanitation and hygiene practices are basic necessities 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 from long distances. Proper sanitation and hygiene can significantly reduce the incidence of diseases such as diarrhoea, polio and acute respiratory infections. The MDG target is to reduce the proportion of people without sustainable access to safe drinking water and basic sanitation by half between 1990 and 2015. The WFFC 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 Government of Nepal’s national goal is to achieve universal coverage of water supply and sanitation services by 2017. Indicators used for water, sanitation and hygiene in NMICS 2010 are as follows. • Use of improved source of drinking water • Use of appropriate water treatment method • Time taken to collect drinking water from source • Person collecting drinking water • Use of improved sanitation facilities • Sanitary disposal of child’s faeces • Presence of water and soap at place for hand-washing • Distance between latrine and hand-washing place For more details on water and sanitation and to access some reference documents, please visit the UNICEF Childinfo website http://www.childinfo.org/wes.html. Use of improved drinking water sources Table WS.1 shows the proportion of the population by source of drinking water. Improved sources include piped water (into dwelling, compound, yard or plot, public tap/standpipe), tube well/borehole, protected well, protected spring, and rainwater collection/harvesting. Unimprov ed sources include unprotected well, unprotected spring, tanker or truck, and surface water. Bottled water is considered an improved water source only if the household is uses water from an improved source for other purposes such as cooking and personal hygiene. Overall, 83 percent of the population in the MFWR used an improved source of drinking water. There was little variation by region or education of household head. Subregionally, the highest proportion was in the Far Western Terai (99 percent) and the lowest proportion was in the Far Western Mountains (70 percent). The urban population (91 percent) was more likely to use an improved source of drinking water than the rural population (82 percent). The use of an improved source of drinking water was positively associated with the economic status of the household. People living in the richest households (96 percent) were more likely to use an improved source of drinking water than people in the poorest households (64 percent). About one third (30 percent) of the population in the MFWR used public tap/standpipe as an improved source; this was followed by tube well/handpump without a platform (17 percent) and tube well/handpump with a platform (16 percent). Some one in 10 (10 percent) use an unprotected spring for drinking water (an unimproved source). Table WS.1: Use of improved water sources Percentage of household population according to main source of drinking water and percentage of household population using improved drinking water sources, MFWR, Nepal, 2010 Percent according to main source of drinking water who are using: Total Percent using improv- ed source of drinking water [1] No. of house- hold mem- bers Improved source: Unimproved source: Piped water: Tube well, hand- pump without plat- form Tube well, hand- pump with plat- form Pro- tected well Pro- tected spring Rain- water collec- tion/ harvest- ing Unpro- tected well Unpro- tected spring Tanker/ truck Surface water Bottled water Other Into dwelling Into com- pound, yard or plot To neigh- bours Public tap/ stand- pipe Region Mid-Western 2.3 10.5 2.0 33.0 11.0 11.2 3.0 7.2 0.0 3.1 10.4 0.0 5.3 0.1 0.9 100.0 80.2 17,155 Far Western 0.9 5.5 3.1 25.8 23.9 21.0 0.3 5.4 0.0 0.3 9.1 0.0 4.0 0.1 0.5 100.0 86.1 14,105 Subregion Mid-Western Mountains 0.2 3.8 1.0 55.8 0.0 0.0 0.1 20.9 0.0 0.3 7.7 0.0 10.0 0.0 0.3 100.0 81.8 2,033 Mid-Western Hills 3.3 13.9 2.5 47.1 0.0 0.4 0.6 8.7 0.0 1.3 15.5 0.0 6.5 0.0 0.2 100.0 76.5 8,559 Mid-Western Terai 1.6 8.1 1.6 7.7 28.8 28.7 6.9 1.1 0.0 6.4 4.6 0.0 2.3 0.2 2.0 100.0 84.5 6,564 Far Western Mountains 0.6 11.6 1.6 46.7 0.0 0.0 0.4 8.6 0.1 0.8 19.4 0.2 9.5 0.1 0.3 100.0 69.7 2,438 Far Western Hills 1.4 5.5 7.9 46.4 0.0 0.0 0.2 12.4 0.0 0.2 18.6 0.0 7.4 0.0 0.0 100.0 73.8 4,339 Far Western Terai 0.8 3.4 0.7 6.7 46.0 40.4 0.3 0.3 0.0 0.2 0.1 0.0 0.1 0.2 0.9 100.0 98.6 7,327 Area Urban 5.6 12.0 3.5 8.7 13.1 38.8 5.2 4.5 0.0 3.5 2.5 0.0 1.2 0.6 0.8 100.0 91.3 3,376 Rural 1.2 7.8 2.4 32.3 17.3 12.8 1.4 6.6 0.0 1.6 10.7 0.0 5.1 0.0 0.7 100.0 81.8 27,884 Education of household head None 1.0 6.6 2.5 31.1 17.8 12.6 1.8 6.9 0.0 2.1 11.5 0.0 5.1 0.0 1.0 100.0 80.2 15,094 Primary 1.3 7.1 2.5 28.5 19.6 16.4 1.7 5.3 0.0 1.9 9.7 0.0 5.2 0.0 0.7 100.0 82.4 7,287 Secondary + 3.2 11.7 2.4 28.8 12.9 20.3 1.8 6.5 0.0 1.3 6.9 0.0 3.7 0.2 0.2 100.0 87.6 8,782 Missing/don’t know 1.6 29.0 1.8 13.2 10.3 14.8 0.0 3.7 0.0 2.1 16.6 0.0 6.9 0.0 0.0 100.0 74.4 97 Wealth index quintile Poorest 0.0 1.3 2.3 47.6 0.9 0.0 0.1 11.2 0.0 1.1 25.2 0.0 10.1 0.0 0.2 100.0 63.5 6,252 Second 0.5 5.1 4.8 46.0 6.3 2.5 1.0 10.7 0.0 1.7 13.4 0.0 7.1 0.0 0.8 100.0 76.9 6,253 Middle 0.5 10.1 2.4 29.6 21.4 14.7 1.8 5.7 0.0 3.0 6.2 0.1 3.1 0.0 1.4 100.0 86.2 6,254 Fourth 0.9 9.4 2.3 18.7 36.3 18.4 2.2 3.1 0.0 1.7 2.9 0.0 3.2 0.0 0.9 100.0 91.2 6,251 Richest 6.5 15.4 0.7 7.1 19.2 42.5 3.7 1.3 0.0 1.7 1.3 0.0 0.0 0.3 0.3 100.0 96.3 6,250 Total 1.7 8.2 2.5 29.8 16.8 15.6 1.8 6.4 0.0 1.8 9.8 0.0 4.7 0.1 0.7 100.0 82.8 31,260 [1] MICS Indicator 4.1; MDG Indicator 7.8 NMICS 2010, Mid- and Far Western Regions 82 Figure WS.1 shows the percentage of household members using an improved source of drinking water by subregion. Figure WS.1: Percentage of household members using improved source of drinking water by subregion, MFWR, Nepal, 2010 Information on use of in-house water treatment is presented in Table WS.2. Households were asked about ways they may be treating water at home to make it safer to drink—boiling, adding bleach or chlorine, using a water filter and using solar disinfection were considered appropriate treatments for drinking water. The table shows water treatment by all households and the percentage of household members living in households using unimproved water sources but using an appropriate water treatment method. Overall, a very low proportion (four percent) of households in the MFWR who were using an unimprov ed water source also used an appropriate method to treat their drinking water. Subregionally, use of a household-level water treatment method was highest in the Mid-Western Terai (nine percent) and lowest in the Far Western Mountains (0.2 percent). Urban households (22 percent) were much more likely to use an appropriate water treatment method than rural households (three percent). The education level of the household head had a limited effect on the use an appropriate method of water treatment: only three percent of households whose head had no education used in-house water treatment compared to six percent of households whose head has at least secondary education. However, household wealth status greatly affected the use an appropriate method of water treatment: only two percent of households from the poorest quintile used in-house water treatment compared to 30 percent of households from the richest quintile. Boiling (three percent) was the most common form of treatment, followed by use of a water filter (three percent) and straining through a cloth (three percent). 82 77 85 70 74 99 0 10 20 30 40 50 60 70 80 90 100 Mid-Wes tern Mountains Mid-Western Hills Mid-Wes tern Terai Far-Western Mountains Far-Western Hills Far-Western Terai P er ce nt a g e Subregions Table WS.2: Household water treatment Percentage of household population by drinking water treatment method used in the household and, for household members living in households where an unimproved drinking water source is used, the percentage who are using an appropriate treatment method, MFWR, Nepal, 2010 Water treatment method used in the household No. of household members Percent using unimproved drinking water source and using an appropriate water treatment method [1] No. of household members in households using unimproved drinking water source None Boil Add bleach/ chlorine Strain through a cloth Use water filter Solar disinfection Let it stand and settle Other Don’t know Region Mid-Western 87.3 4.0 1.5 5.0 4.6 0.1 0.7 0.3 0.0 17,155 5.0 3,391 Far Western 96.8 2.2 0.3 0.1 1.0 0.0 0.0 0.1 0.0 14,105 1.5 1,964 Subregion Mid-Western Mountains 93.0 5.1 0.3 0.3 0.8 0.0 0.0 0.7 0.2 2,033 5.2 370 Mid-Western Hills 90.1 2.8 0.9 1.9 4.9 0.0 0.8 0.4 0.0 8,559 3.2 2,014 Mid-Western Terai 81.9 5.1 2.5 10.6 5.3 0.1 0.7 0.1 0.0 6,564 8.6 1,007 Far Western Mountains 99.2 0.7 0.1 0.0 0.1 0.0 0.0 0.0 0.0 2,438 0.2 738 Far Western Hills 94.5 4.4 1.0 0.1 0.7 0.0 0.1 0.1 0.0 4,339 2.2 1,137 Far Western Terai 97.4 1.4 0.0 0.1 1.5 0.0 0.0 0.1 0.0 7,327 2.2 89 Area Urban 79.8 6.8 2.6 6.3 10.0 0.3 0.1 0.5 0.0 3,376 21.9 271 Rural 93.0 2.7 0.8 2.4 2.1 0.0 0.4 0.2 0.0 27,884 2.8 5,084 Education of household head None 95.0 1.7 0.5 2.3 0.9 0.0 0.1 0.2 0.0 15,094 2.6 2,981 Primary 91.0 2.8 0.7 3.7 2.2 0.0 0.9 0.1 0.0 7,287 4.3 1,279 Secondary + 86.3 5.9 1.9 3.0 7.1 0.1 0.3 0.3 0.0 8,782 6.2 1,069 Missing/don’t know 90.9 9.1 0.0 0.0 9.1 0.0 0.0 0.0 0.0 97 0.0 25 Wealth index quintile Poorest 96.9 1.3 0.0 1.2 0.1 0.0 0.4 0.3 0.0 6,252 2.3 2,284 Second 95.4 1.7 0.4 2.6 0.2 0.0 0.6 0.1 0.0 6,253 1.9 1,445 Middle 95.0 1.5 0.9 2.4 0.5 0.0 0.2 0.0 0.0 6,254 4.9 865 Fourth 90.5 3.5 0.8 4.3 2.1 0.0 0.4 0.3 0.0 6,251 2.6 551 Richest 80.3 7.9 2.6 3.5 12.0 0.2 0.3 0.4 0.0 6,250 30.1 209 Total 91.6 3.2 1.0 2.8 3.0 0.0 0.4 0.2 0.0 31,260 3.7 5,354 [1] MICS Indicator 4.2 Respondents may have reported more than one method of water treatment NMICS 2010, Mid- and Far Western Regions 84 Table WS.3 presents information on the amount of time taken for a round trip to collect water and Table WS.4 records the person who usually collects it. Data on the number of trips made in one day were not collected. For household members in the MFWR using an improved source of drinking water, 43 percent had access to it on premises, 31 percent took less than 30 minutes to collect it, and 10 percent spent 30 minutes or more. For household members using an unimproved source of drinking water, one percent had it on premises, seven percent took less than 30 minutes to collect it and nine percent took 30 minutes or more. Households in the Mid-Western Region were less likely than those in the Far Western Region to have either an improved or unimproved water source on premises, and were more likely to spend longer collecting water from an outside source. Subregionally, there was much variation but generally those in the Hills and Mountains were less likely than those in the Terai to have water on premises and more likely to spend longer collecting it. More time was spent collecting water in rural areas than in urban areas, where 72 percent of households had an improved water source on premises. The education level of the household head had a limited association with time spent collecting water, although households with a head who had at secondary education were more likely than other households to have water on the premises. Members of poorer households were more likely than members of richer households to have no access to water on the premises and to spend a longer time collecting it from outside. Only five percent of households from the poorest quintile had an improved water source on premises compared to 86 percent from the richest quintile. NMICS 2010, Mid- and Far Western Regions 85 Table WS.3: Time to source of drinking water Percentage of household population according to time to go to source of drinking water, collect water and return, for users of improved and unimproved drinking water sources, MFWR, Nepal, 2010 Time to source of drinking water Total No. of house- hold members Users of improved drinking water sources Users of unimproved drinking water sources Water on premises Less than 30 minutes 30 minutes or more Missing/ don’t know Water on premises Less than 30 minutes 30 minutes or more Region Mid-Western 39.3 29.8 11.2 0.0 1.6 8.0 10.2 100.0 17,155 Far Western 51.8 26.8 7.4 0.0 0.5 6.1 7.4 100.0 14,105 Subregion Mid-Western Mountains 6.8 45.1 29.9 0.0 0.3 6.6 11.3 100.0 2,033 Mid-Western Hills 24.9 36.8 14.8 0.0 0.9 7.2 15.4 100.0 8,559 Mid-Western Terai 68.1 15.8 0.8 0.0 2.8 9.3 3.2 100.0 6,564 Far Western Mountains 17.2 38.1 14.4 0.0 0.4 7.8 22.1 100.0 2,438 Far Western Hills 18.0 45.1 10.7 0.0 0.5 14.5 11.2 100.0 4,339 Far Western Terai 83.4 12.1 3.1 0.1 0.5 0.6 0.2 100.0 7,327 Area Urban 74.8 13.9 3.2 0.0 1.9 4.3 1.9 100.0 3,376 Rural 41.3 30.2 10.3 0.0 1.0 7.5 9.8 100.0 27,884 Education of household head None 40.8 28.0 11.4 0.0 1.1 9.5 9.2 100.0 15,094 Primary 44.8 28.7 8.9 0.1 1.4 5.5 10.6 100.0 7,287 Secondary + 51.9 29.0 6.9 0.0 0.7 4.4 7.0 100.0 8,782 Missing/don’t know 57.6 13.2 3.7 0.0 2.1 6.9 16.6 100.0 97 Wealth index quintile Poorest 7.5 37.3 18.7 0.0 0.5 15.5 20.5 100.0 6,252 Second 20.3 41.3 15.2 0.1 0.9 9.6 12.7 100.0 6,253 Middle 44.5 32.4 9.2 0.0 1.5 6.3 6.0 100.0 6,254 Fourth 65.8 22.3 3.1 0.0 1.2 3.0 4.6 100.0 6,251 Richest 86.6 8.8 1.3 0.0 1.3 1.2 0.8 100.0 6,250 Total 44.9 28.4 9.5 0.0 1.1 7.1 8.9 100.0 31,260 Table WS.4 shows that 59 percent of households in the MFWR do not have drinking water on the premises. Households in the Mid-Western Region were more likely than households in the Far Western Region to have no drinking water on the premises (63 percent compared to 53 percent). Households in the Mid-Western Mountains (94 percent) showed the highest proportion without a source of drinking water on the premises and households in the Far Western Terai (19 percent) showed the lowest proportion. Households in rural areas (62 percent) were more likely than those in urban areas (28 percent) to have no source of drinking water on the premises. Households with heads with no education and those in poorer wealth quintiles were more likely than others to have no source of drinking water on the premises. In households without a source of drinking water on the premises, usually an adult female (91 percent) collected it. This was followed by an adult male (four percent), female child (four percent) and male child (one percent). Children in urban areas (seven percent for girls and two percent for boys) were more likely than children with other background characteristics to collect water. Female children in the richest quintile (five percent) were more likely than children in other wealth quintiles to collect water. NMICS 2010, Mid- and Far Western Regions 86 Table WS.4: Person collecting water Percentage of households without drinking water on the premises, and percentage of households without drinking water on premises according to the person usually collecting drinking water used in the household, MFWR, Nepal, 2010 Percent households without drinking water on premises No. of households Person usually collecting drinking water in households without a source on the premises Total No. of households without drinking water on premises Adult woman (aged 15+ years) Adult man (aged 15+ years) Female child (aged under 15) Male child (aged under 15) Region Mid-Western 62.7 3,325 90.3 4.1 4.6 1.0 100.0 2,084 Far Western 53.2 2,574 93.0 3.8 2.4 0.8 100.0 1,369 Subregion Mid-Western Mountains 94.1 344 89.1 4.4 4.4 2.1 100.0 324 Mid-Western Hills 77.4 1,703 91.4 3.3 4.3 1.0 100.0 1,317 Mid-Western Terai 34.6 1,278 88.0 6.3 5.5 0.1 100.0 442 Far Western Mountains 83.7 438 94.0 3.8 1.8 0.5 100.0 367 Far Western Hills 89.8 836 92.9 4.0 2.4 0.7 100.0 751 Far Western Terai 19.3 1,300 91.7 3.2 3.4 1.6 100.0 251 Area Urban 27.7 645 85.8 5.3 6.6 2.3 100.0 179 Rural 62.3 5,254 91.7 3.9 3.6 0.9 100.0 3,274 Education of household head None 63.7 2,892 90.3 4.3 4.2 1.2 100.0 1,841 Primary 59.2 1,299 92.7 2.5 3.6 1.2 100.0 769 Secondary + 49.4 1,696 92.3 4.7 2.8 0.2 100.0 837 Wealth index quintile Poorest 94.7 1,241 90.8 4.2 3.9 1.1 100.0 1,176 Second 83.5 1,239 90.7 4.7 3.4 1.2 100.0 1,035 Middle 56.5 1,178 93.2 2.4 3.9 0.4 100.0 665 Fourth 37.8 1,127 92.4 3.5 3.4 0.8 100.0 426 Richest 13.5 1,114 89.4 5.1 5.1 0.4 100.0 151 Total 58.5 5,899 91.4 4.0 3.7 0.9 100.0 3,453 Five cases with missing ‘education of household head’ not shown Use of improved sanitation facilities Inadequate disposal of human excreta and lack of personal hygiene are associated with a range of diseases including diarrhoeal diseases and polio. An improved sanitation facility is defined as one that hygienically separates human excreta from human contact. Improved sanitation can reduce diarrheal diseases by more than one third, and can significantly lessen the adverse health impacts of other disorders responsible for death and disease among millions of children in developing countries. Improved sanitation facilities for excreta disposal include flush/pour to a piped sewer system, septic tank or pit latrine; ventilated improved pit latrine; pit latrine with slab; or composting toilet. Table WS.5 shows the proportion of household members in the MFWR using each type of sanitation facility. The majority (56 percent) had no toilet facility. This was followed by an improved toilet facility with flush to septic tank (19 percent), improved toilet facility with flush to pit latrine (12 percent), improved pit latrine with slab (seven percent), and unimproved pit latrine without slab (two percent). The highest proportion of households with no toilet facility was in the Far Western Mountains (76 percent) and the lowest proportion was in the Mid-Western Terai (49 percent). Urban households (31 percent) were less likely than rural households (59 percent) to have no toilet facility. Households NMICS 2010, Mid- and Far Western Regions 87 whose head had no education (62 percent) or primary education (61 percent) were much more likely than households whose head had at least secondary education (40 percent) to have no toilet facility. Households in the poorest quintile (85 percent) were over three times more likely than those in the richest quintile (19 percent) to have no toilet. Toilet facility with a flush to septic tank were most common in households of the Mid-Western Region (23 percent), of the Mid-Western Terai (28 percent), in urban areas (53 percent), whose head had at least secondary education (33 percent) and in the richest quintile (52 percent). Only six percent of households in the Far Western Mountains, 15 percent of households in rural areas, and two percent of households in the poorest quintile had a toilet facility with a flush to septic tank. Table WS.5: Types of sanitation facilities Percentage of household population according to type of toilet facility used by the household, MFWR, Nepal, 2010 Percent according to type of toilet facility used Open defecation (no facility, bush, field) Total No. of household members Improved sanitation facility Unimproved sanitation facility Flush to: Ventilated improved pit latrine (VIP) Pit latrine with slab Composting toilet Flush/pour to some- where else Pit latrine without slab/ open pit Bucket Other Piped sewer system Septic tank Pit latrine Region Mid-Western 0.4 22.7 13.1 0.3 6.2 1.0 0.1 2.3 0.0 0.1 53.8 100.0 17,155 Far Western 2.3 15.5 10.3 0.9 8.4 2.4 0.4 1.6 0.0 0.2 57.9 100.0 14,105 Subregion Mid-Western Mountains 0.3 15.0 19.8 0.4 13.3 0.1 0.1 1.5 0.0 0.1 49.6 100.0 2,033 Mid-Western Hills 0.3 20.7 15.0 0.3 4.4 0.1 0.0 0.7 0.0 0.0 58.4 100.0 8,559 Mid-Western Terai 0.6 27.6 8.6 0.2 6.3 2.4 0.1 4.6 0.1 0.3 49.1 100.0 6,564 Far Western Mountains 0.1 5.6 7.7 0.1 10.2 0.0 0.0 0.8 0.0 0.0 75.5 100.0 2,438 Far Western Hills 2.0 17.3 17.9 0.7 5.6 0.0 1.2 1.6 0.0 0.0 53.8 100.0 4,339 Far Western Terai 3.3 17.8 6.7 1.3 9.5 4.7 0.1 1.8 0.0 0.3 54.5 100.0 7,327 Area Urban 2.4 52.9 4.6 0.5 4.4 2.0 0.3 1.6 0.1 0.4 30.8 100.0 3,376 Rural 1.1 15.4 12.8 0.6 7.5 1.6 0.2 2.0 0.0 0.1 58.7 100.0 27,884 Education of household head None 1.1 14.0 11.5 0.6 6.6 1.4 0.2 2.1 0.0 0.2 62.2 100.0 15,094 Primary 0.9 14.7 10.7 0.6 8.4 1.0 0.2 1.9 0.0 0.1 61.4 100.0 7,287 Secondary + 1.9 32.6 13.4 0.5 7.3 2.5 0.3 1.8 0.0 0.1 39.7 100.0 8,782 Missing/don’t know 0.0 26.2 12.0 0.0 2.5 0.0 0.0 0.0 0.0 0.0 59.4 100.0 97 Wealth index quintile Poorest 0.0 2.0 6.9 0.1 4.7 0.0 0.3 0.5 0.0 0.0 85.4 100.0 6,252 Second 0.5 9.6 12.1 0.3 9.2 0.0 0.2 1.0 0.0 0.0 67.1 100.0 6,253 Middle 1.2 12.5 14.8 0.7 7.2 0.4 0.3 2.4 0.0 0.2 60.4 100.0 6,254 Fourth 1.3 21.2 13.3 1.4 10.7 1.3 0.1 3.4 0.0 0.5 46.8 100.0 6,251 Richest 3.4 51.9 12.1 0.3 4.2 6.4 0.3 2.5 0.1 0.1 18.6 100.0 6,250 Total 1.3 19.4 11.9 0.6 7.2 1.6 0.2 2.0 0.0 0.2 55.7 100.0 31,260 NMICS 2010, Mid- and Far Western Regions 89 Access to proper basic sanitation is measured by the proportion of the population using an improved sanitation facility. The MDGs and WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation classify households as using an improved sanitation facility if it is an acceptable type of toilet and is not shared (i.e., an improved sanitation facility is not acceptable if it is shared by two or more households). Table WS.6 shows that 36 percent of the household population in the MFWR were using an improved sanitation facility that was not shared. Some five percent of households were using an improved toilet facility that was shared by five or fewer households. There was little variation in the use of an improved sanitation facility that was not shared by region. Subregionally, the highest proportion was in the Mid-Western Mountains (46 percent) and the lowest proportion was in the Far Western Mountains (22 percent). Urban households (56 percent) were more likely to use an unshared improved toilet than rural households (33 percent). Households whose head had at least secondary education (49 percent) were more likely to use an unshared improved toilet than those whose head had a primary education (29 percent) or no education (31 percent). Households in the richest quintile (64 percent) were much more likely to use an unshared improved toilet than those in the poorest quintile (13 percent). Table WS.6: Use and sharing of sanitation facilities Percentage of household population by use of private and public sanitation facilities and use of shared facilities, by users of improved and unimproved sanitation facilities, MFWR, Nepal, 2010 Users of improved sanitation facilities Users of unimproved sanitation facilities Open defecation (no facility, bush field, etc.) Total No. of household members Not shared [1] Public facility Shared by: Not shared Public facility Shared by: 5 households or fewer More than 5 households 5 households or fewer More than 5 households Region Mid-Western 36.8 0.2 5.7 0.6 2.2 0.0 0.3 0.1 53.8 100.0 17,155 Far Western 33.9 0.1 5.0 1.0 1.8 0.0 0.4 0.0 57.9 100.0 14,105 Subregion Mid-Western Mountains 46.2 0.3 1.6 0.4 1.5 0.0 0.0 0.1 49.6 100.0 2,033 Mid-Western Hills 35.2 0.1 4.9 0.2 0.7 0.0 0.0 0.0 58.4 100.0 8,559 Mid-Western Terai 36.0 0.4 8.1 1.1 4.2 0.0 0.7 0.3 49.1 100.0 6,564 Far Western Mountains 22.4 0.1 1.2 0.0 0.8 0.0 0.0 0.0 75.5 100.0 2,438 Far Western Hills 41.1 0.0 2.3 0.0 2.8 0.0 0.0 0.0 53.8 100.0 4,339 Far Western Terai 33.5 0.1 7.9 1.9 1.5 0.0 0.7 0.0 54.5 100.0 7,327 Area Urban 55.9 0.3 9.8 0.8 1.8 0.0 0.5 0.1 30.8 100.0 3,376 Rural 33.0 0.1 4.9 0.7 2.0 0.0 0.3 0.1 58.7 100.0 27,884 Education of household head None 30.7 0.2 4.0 0.2 2.3 0.0 0.2 0.1 62.2 100.0 15,094 Primary 29.2 0.0 6.0 1.1 1.8 0.0 0.3 0.2 61.4 100.0 7,287 Secondary + 49.0 0.1 7.4 1.3 1.8 0.0 0.4 0.0 39.7 100.0 8,782 Missing/don’t know 40.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 59.4 100.0 97 Wealth index quintile Poorest 13.2 0.0 0.5 0.0 0.8 0.0 0.0 0.0 85.4 100.0 6,252 Second 28.8 0.1 2.6 0.1 1.1 0.0 0.0 0.0 67.1 100.0 6,253 Middle 32.5 0.0 3.3 0.6 2.3 0.0 0.3 0.4 60.4 100.0 6,254 Fourth 38.9 0.5 8.3 1.5 3.3 0.0 0.7 0.0 46.8 100.0 6,251 Richest 64.2 0.1 12.1 1.4 2.5 0.0 0.5 0.0 18.6 100.0 6,250 Total 35.5 0.1 5.4 0.7 2.0 0.0 0.3 0.1 55.7 100.0 31,260 [1] MICS Indicator 4.3; MDG Indicator 7.9 NMICS 2010, Mid- and Far Western Regions 91 Disposal of child’s faeces is considered to be safe if the child itself is using an improved toilet facility (toilet/ latrine) or the stool is disposed of down an improved toilet facility. Table WS.7 shows that less than one fifth (17 percent) of children aged 0–2 years in the MFWR had their faeces disposed of safely. There was little variation by region. Subregionally, the highest proportion was in the Far Western Hills (21 percent) and the lowest was in the Far Western Mountains (10 percent). Children in urban areas (37 percent) were more likely to have their faeces disposed of safely than those in rural areas (15 percent). There is positive relationship between mother’s education and household wealth status: children whose mother had at least secondary education (33 percent) were more likely to have their faeces disposed of safely than other children, and children in the richest quintile (44 percent) were nearly 13 times more likely to have their faeces disposed of safely than those in the poorest quintile (three percent). Table WS.7: Disposal of child’s faeces Percentage of children aged 0–2 years according to place of disposal of child’s faeces, and percentage of children aged 0–2 years whose stools were disposed of safely the last time the child passed stools, MFWR, Nepal, 2010 Place of disposal of child’s faeces Total Percent of children whose stools were disposed of safely [1] No. of children aged 0–2 years Child used toilet/latrine Put/rinsed into toilet or latrine Put/rinsed into drain or ditch Thrown into garbage (solid waste) Buried Left in open places Other Don’t know/ missing Region Mid-Western 1.2 17.2 5.8 43.0 0.9 29.8 2.0 0.0 100.0 18.4 1,127 Far Western 1.2 14.3 9.1 44.5 0.4 28.6 1.6 0.3 100.0 15.5 902 Subregion Mid-Western Mountains 1.1 16.4 5.5 35.1 2.1 34.6 5.1 0.2 100.0 17.5 170 Mid-Western Hills 1.2 16.2 5.2 43.2 0.4 32.5 1.3 0.0 100.0 17.3 608 Mid-Western Terai 1.4 19.5 7.0 46.6 1.1 22.9 1.6 0.0 100.0 20.8 349 Far Western Mountains 0.8 9.4 5.8 26.5 0.0 53.6 3.6 0.3 100.0 10.2 170 Far Western Hills 1.7 19.5 4.7 33.8 0.7 38.8 0.0 0.8 100.0 21.2 321 Far Western Terai 1.0 12.3 13.9 60.3 0.3 10.1 2.1 0.0 100.0 13.3 411 Area Urban 3.7 33.6 13.8 25.8 0.1 19.3 3.5 0.2 100.0 37.3 172 Rural 1.0 14.3 6.7 45.3 0.7 30.2 1.7 0.2 100.0 15.3 1,856 Mother’s education None 0.9 10.8 7.0 39.4 0.8 39.1 1.8 0.2 100.0 11.7 1,136 Primary 1.1 10.0 8.4 57.7 0.6 20.8 1.1 0.3 100.0 11.0 363 Secondary + 2.0 31.0 7.0 43.4 0.3 14.0 2.4 0.0 100.0 32.9 529 Wealth index quintile Poorest 0.5 2.9 3.9 40.8 0.7 49.4 1.7 0.1 100.0 3.4 519 Second 1.1 11.0 6.8 40.7 0.7 36.1 2.9 0.6 100.0 12.1 459 Middle 0.7 15.2 9.4 51.4 0.3 22.6 0.4 0.0 100.0 15.9 403 Fourth 1.9 21.1 9.1 50.7 0.3 15.6 1.2 0.1 100.0 23.0 354 Richest 2.4 41.6 8.9 34.2 1.3 8.6 3.0 0.0 100.0 44.0 293 Total 1.2 15.9 7.3 43.7 0.6 29.3 1.8 0.2 100.0 17.1 2,028 [1] MICS Indicator 4.4 NMICS 2010, Mid- and Far Western Regions 93 In 2008, the Joint Monitoring Programme developed a new way of presenting access figures 11 by disaggregating and refining data on drinking water and sanitation to reflect them in a ‘ladder’ format. This allows disaggregated analysis of trends in a three-rung ladder for drinking water and a four-rung ladder for sanitation. For drinking water, this gives two rungs for improved sources (piped into dwelling, plot or yard , and others) and one rung for unimproved. For sanitation, this gives one rung for improved sanitation and three rungs for unimprov ed (shared improved facilities, unimprov ed facilities, and no facilities). Table WS.8 presents information on household population for drinking water and sanitation ladders. It also shows the percentage of household members using an improved source of drinking water as well as a sanitary means of excreta disposal. One third (33 percent) of household members in the MFWR reported using an improved source of drinking water and improved sanitation facility. Some 29 percent of household in the Mid-Western Region and 23 percent in the Far Western Region used both improved drinking water source and sanitation facility. About two fifths (41 percent) of households in the Mid-Western Mountains used both compared to only 18 percent of households in the Far Western Mountains. Urban households (52 percent) were more likely to use both than rural households (30 percent). Households whose head had at least secondary education (46 percent) were more likely to use both than households whose head had primary education (27 percent) or no education (28 percent). Households in the richest quintile (62 percent) were almost six times more likely to use both improved drinking water source and sanitation facility than those in the poorest quintile (11 percent). 11 WHO/UNICEF Joint Monitoring Programme, 2008. MDG Assessment Report. http://www.wssinfo.org/download?id_document=1279 Table WS.8: Use of improved water sources and improved sanitation facilities Percentage of household population using both improved drinking water sources and improved sanitation facilities, MFWR, Nepal, 2010 Percentage of household population: No. of households Using improved sources of drinking water [1] Unimproved drinking water Total Improved sanitation [2] Unimproved sanitation Total Improved drinking water source and improved sanitation Piped into dwelling, plot or yard Other improved Shared improved facilities Unimproved facilities Open defecation Region Mid-Western 12.8 67.4 19.8 100.0 36.8 6.8 2.5 53.8 100.0 28.6 17,155 Far Western 6.4 79.7 13.9 100.0 33.9 6.0 2.2 57.9 100.0 23.0 14,105 Subregion Mid-Western Mountains 4.0 77.8 18.2 100.0 46.2 2.6 1.6 49.6 100.0 41.1 2,033 Mid-Western Hills 17.2 59.2 23.5 100.0 35.2 5.7 0.7 58.4 100.0 32.3 8,559 Mid-Western Terai 9.7 74.8 15.5 100.0 36.0 9.6 5.2 49.1 100.0 33.1 6,564 Far Western Mountains 12.2 57.5 30.3 100.0 22.4 1.2 0.8 75.5 100.0 18.4 2,438 Far Western Hills 6.8 67.0 26.2 100.0 41.1 2.3 2.8 53.8 100.0 35.1 4,339 Far Western Terai 4.2 94.4 1.4 100.0 33.5 9.8 2.2 54.5 100.0 33.1 7,327 Area Urban 17.6 73.7 8.7 100.0 55.9 10.8 2.5 30.8 100.0 51.5 3,376 Rural 9.0 72.8 18.2 100.0 33.0 5.9 2.4 58.7 100.0 30.3 27,884 Education of household head None 7.5 72.7 19.8 100.0 30.7 4.6 2.6 62.2 100.0 27.6 15,094 Primary 8.4 74.0 17.6 100.0 29.2 7.1 2.3 61.4 100.0 26.8 7,287 Secondary + 14.9 72.7 12.4 100.0 49.0 9.2 2.1 39.7 100.0 45.9 8,782 Missing/don’t know 30.6 43.9 25.6 100.0 40.6 0.0 0.0 59.4 100.0 38.5 97 Wealth index quintile Poorest 1.3 62.2 36.5 100.0 13.2 .6 0.8 85.4 100.0 11.0 6,252 Second 5.6 71.3 23.1 100.0 28.8 2.9 1.1 67.1 100.0 25.5 6,253 Middle 10.6 75.6 13.8 100.0 32.5 4.2 2.9 60.4 100.0 28.1 6,254 Fourth 10.2 81.0 8.8 100.0 38.9 10.4 4.0 46.8 100.0 36.0 6,251 Richest 21.8 74.5 3.7 100.0 64.2 14.2 3.0 18.6 100.0 62.3 6,250 Total 9.9 72.9 17.2 100.0 35.5 6.4 2.4 55.7 100.0 32.6 31,260 [1] MICS Indicator 4.1; MDG Indicator 7.8 [2] MICS Indicator 4.3; MDG Indicator 7.9 NMICS 2010, Mid- and Far Western Regions 95 Hand-washing Hand-washing with water and soap is the most cost-effective health intervention to reduce the incidence of both diarrhoea and acute respiratory infections in children under five. It is most effective when done using water and soap and after using a toilet or cleaning a child, before eating or handling food, and before feeding a child. Monitoring correct hand-washing behaviour at these critical times is challenging. When direct observation is not practicable, a reliable alternative to self- reported behaviour is assessing the likelihood that correct hand-washing takes place by observing if a household has a specific place where people most often wash their hands and observing if water and soap (or other local cleansing materials) are present at that specific place. Table WS.9 shows that 94 percent of households in the MFWR had a specific place for hand-washing. Some five percent of households could not indicate a specific place and less than one percent (0.3 percent) did not give permission to see the place used for hand-washing. Of those households where a place for hand-washing was observed, over half (51 percent) had both water and soap present at the designated place. In 12 percent of households only water was available and in another 12 percent only soap was available. The remaining 25 percent of households had neither water nor soap available at the place designated for hand-washing. Of households with an observed hand-washing place, some 48 percent in the Mid-Western Region and 55 percent in the Far Western Region had both soap and water available. The highest proportion of households with both soap and water available was in the Far Western Terai (73 percent) and the lowest was in the Mid-Western Mountains (27 percent). Urban households (82 percent) were much more likely than rural households (47 percent) to have both available. The education of the household head and household wealth status were positive associated availability of soap and water. Households whose head had at least secondary education (64 percent) were more likely to have both soap and water available than households whose head had primary education (50 percent) or no education (44 percent). Households in the richest quintile (91 percent) were six times more likely to have water and soap in than those in the poorest quintile (15 percent). Table WS.9: Water and soap at place for hand-washing Percentage of households where place for hand-washing was observed and percentage of households by availability of water and soap at place for hand-washing, MFWR, Nepal, 2010 Percent where place for hand- washing observed Percent where place for hand-washing not observed: Total No. of households Percent where place for hand-washing observed, and: Total No. of households where place for hand- washing observed Not in dwelling/ plot/yard No permission to see Other reasons Water and soap available [1] Water available, soap not available Water not available, soap available Water and soap not available Region Mid-Western 92.8 6.6 0.2 0.4 100.0 3,325 48.4 8.8 13.0 29.8 100.0 3,085 Far Western 95.0 3.6 0.5 0.9 100.0 2,574 54.8 16.4 10.1 18.8 100.0 2,44

View the publication