Pakistan - Multiple Indicator Cluster Survey - 2011

Publication date: 2011

PUNJAB (A province of Pakistan) Provincial Report Volume - 1 Multiple Indicator Cluster Survey (MICS) Punjab 2011 Monitoring the situation of children and women U N D P unicef The Multiple Indicator Cluster Survey (MICS) Punjab was carried out in 2011 by Bureau of Statistics, Government of the Punjab in collaboration with United Nations Children‘s Fund (UNICEF) and United Nations Development Programme (UNDP). The major financing was provided by Government of the Punjab through Annual Development Programme and the technical support was provided by the UNICEF and UNDP. MICS is an international household survey programme developed by UNICEF. The MICS Punjab, 2011 was conducted as part of the fourth global round of MICS surveys (MICS4). It 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. Additional information on the global MICS project may be obtained from www.childinfo.org. The final report consists of 37 volumes of which this is the first. All volumes of the report are available at www.bos.gop.pk and www.pndpunjab.gov.pk. Suggested Citation: Bureau of Statistics, Planning and Development Department, Government of the Punjab, Multiple Indicator Cluster Survey, Punjab 2011. M I C S P U N J A B 2 0 1 1 ii Social sector has remained a priority area for the Government of Punjab and development outlays for this sector have grown manifold over the last five years. Government of the Punjab along with the National/ International partners is committed to attain the Millennium Development Goals (MDGs) vis-a-vis education, health, water supply & sanitation and poverty. This would require not only provision of adequate resources but also a very robust system for ascertaining the area specific needs, efficient use of resources and regular monitoring of the results and impacts. Towards this end, Government of Punjab conducted first district based Multiple Indicator Cluster Survey (MICS) in 2003-04. This survey provided benchmark for a number of indicators at district level that created a culture for using data for planning purposes. For the first time in the history of Pakistan, raw data was shared with academia, research organizations and development partners. The same was done with the second round of MICS Punjab, 2007-08. These surveys proved to be the most important tools in determining government budgetary outlays, particularly for the social sector. Besides, international papers, more than a dozen students have completed their M. Phil theses by using MICS data. MICS Punjab, 2007-08 was based on 70 indicators. The usage of information generated by the survey pointed to the need for further improvements in the scope and coverage of selected indicators in the third round of MICS. Therefore, scope of MICS Punjab, 2011 was expanded to more than 100 indicators. MICS Punjab, 2011 was the biggest survey in the history of Punjab in terms of indicators and sample size. This posed great challenge in terms of logistics and management. It is a matter of immense satisfaction that the survey has been completed within a stipulated time period. The results of MICS Punjab, 2011 describe progress made on key social indicators since 2007-08. They also provide a baseline for a number of newly included social indicators. Planning & Development Department, UNICEF, UNDP and other stakeholders at the provincial and district level richly deserve all the credit for coming up with an excellent report. Special credit goes to Bureau of Statistics Punjab for their untiring efforts and hard work. Third round of MICS allows the provincial government and districts to monitor their respective status of human and social development with precise data on a variety of key indicators. It will assist the decision-makers to move towards new avenues of human and social development. I am confident that this report will prove to be a valuable source for planning efforts of Government of Punjab and development partners, and a reference for academia and research organizations. JAVAID ASLAM Chairman, Planning and Development Board, Punjab Dated: 2nd September, 2012 FOREWORD M I C S P U N J A B 2 0 1 1 iii M I C S P U N J A B 2 0 1 1 The Multiple Indicator Cluster Survey (MICS) Punjab 2011 is the result of devoted efforts of different departments and organisations. It was funded through the Punjab Annual Development Programme, UNICEF and UNDP. The survey and its analysis was conducted by the Bureau of Statistics, Punjab with technical support of Global MICS Team. Pakistan Bureau of Statistics provided the sample design. The survey tools, design and data was reviewed and cleared by the regional and headquarter offices of UNICEF. Each individual, department and organisation involved in MICS Punjab, 2011 deserve praise and recognition. Chairman, Planning and Development (P&D) Board (who heads the Provincial Steering Committee of MICS) and Secretary P&D Department extended their fullest support throughout the process. Mr. Shamim Rafique, DG, BOS and his team deserve special appreciation as they made possible timely completion of MICS Punjab, 2011. Keen interest and contribution made by the members of the Steering Committee, Technical and Planning & Coordination groups are also acknowledged. The services of Mr. Khalid Sultan, Focal Person from P&D Department, in coordinating MICS Punjab, 2011 are commendable. Muhammad Akram Rana (PME officer, UNICEF, Lahore), Ehsan_ul_Haq (M&E specialist, UNICEF, Islamabad), M. Zaman Watto (UNDP, Lahore) and Rana M. Sarwar (Consultant on MICS, UNDP) played active role in the MICS Punjab, 2011. Special thanks are due to the contributors from UNICEF (ROSA office and global MICS desk) for their technical guidance. Contribution of Pakistan Bureau of Statistics for providing sample design and listing, and M/S Eycon (Pvt.) Ltd. for data management support is duly acknowledged. The fieldwork of this survey was a mammoth task; however, it was adequately and adeptly catered for by the Regional Supervisors, Team Supervisors, Editors, Measurers and Field Interviewers. Consequently, it was completed in record time and with no major operational issue. The entire field team deserves appreciation. All district governments and administrative departments provided valuable support through services of their staff and facilitation in field work. Communities, local leadership and members of the sampled households devoted their time and resources. They need to be applauded for their confidence in sharing personal information and enriching this survey. The information provided by them remains in trust and will not be used for any purposes other than their own benefit. ARIF ANWAR BALOCH Chief Economist Dated: 2nd September, 2012 Planning and Development Board, Punjab ACKNOWLEDGEMENT iv S U M M A R Y T A B L E O F F I N D I N G S SUMMARY TABLE OF FINDINGS v Multiple Indicator Cluster Survey (MICS) and Millennium Development Goals (MDGs) Indicators, Punjab, 2011 TOPIC INDICATOR NO INDICATOR VALUE MICS Punjab, 2011 MDG CHILD MORTALITY Child mortality 1.1 4.1 Under-five mortality rate 104 per thousand LB 1.2 4.2 Infant mortality rate 82 per thousand LB NUTRITION Nutritional status 2.1a 1.8 Underweight prevalence (moderate & severe) percent 2.1b Underweight prevalence (severe) percent 2.2a Stunting prevalence (moderate & severe) percent 2.2b Stunting prevalence (severe) 15 percent 2.3a Wasting prevalence (moderate & severe) 16 percent 2.3b Wasting prevalence (severe) 4.4 percent Breastfeeding and infant feeding 2.4 Children ever breastfed 95 percent 2.5 15 percent 2.6 22 percent Continued breastfeeding rate at percent 2.7 68 percent 2.8 34 percent 2.9 52 percent 2.10 Median duration of any breastfeeding 18 months 2.11 54 percent 2.12 Introduction of solid, semi-solid or soft foods 38 percent 2.13 42 percent 2.14 35 percent 2.15 86 percent Salt iodization 2.16 Iodized salt consumption 34 percent Vitamin A 2.17 73 percent Weight at birth 2.18 28 percent 2.19 Infants weighed at birth 10 percent CHILD HEALTH Immunization 3.1 74 percent 3.2 Polio immunization coverage (Polio 3) 70 percent 3.3 Immunization coverage 55 percent 3.4 4.3 Measles immunization coverage 64 percent Tetanus toxoid 3.7 Neonatal tetanus protection 75 percent Care of illness 3.8 Oral rehydration therapy with continued feeding 30 percent Use of Oral Rehydration Therapy (ORT) 40 percent 3.9 Care seeking for suspected pneumonia 77 percent Solid fuel use 3.11 Solid fuel used 66 percent Tuberculosis immunization coverage (BCG) Low-birth weight infants Vitamin A supplementation (children under 3) Milk feeding frequency for non-breastfed children (6-23) months Age-appropriate breastfeeding Minimum meal frequency (6-23) months Bottle feeding (0-23) months - 20–23 months (2 year) - 12–15 months (1 year) Exclusive breastfeeding rate under 6 months Early initiation of breastfeeding 36 11 33 Predominant breastfeeding under 6 months TOPIC INDICATOR NO. INDICATOR VALUE MICS Punjab, 2011 MDG WATER & SANITATION Water and sanitation 4.1 7.8 Use of improved drinking water sources 94 percent 4.2 Water treatment 3.6 percent 4.3 7.9 Use of improved sanitation 72 percent 4.5 Place for hand washing (water & soap available) 77 percent 4.6 Availability of soap (anywhere in the dwelling) 95 percent REPRODUCTIVE HEALTH1 Contraception & unmet needs 5.1 5.4 Adolescent birth rate (for women aged 15-19) 30 per 1,000 5.2 Early childbearing 14 percent 5.3 5.3 Contraceptive prevalence 35 percent 5.4 5.6 Unmet need for contraception 17 percent Maternal and newborn health 5.5a 5.5 Antenatal care (at least once by skilled personnel) 74 percent 5.5b Antenatal care (at least four times by any provider) 40 percent 5.6 Content of antenatal care (Blood pressure, urine & blood tested) 41 percent 5.7 5.2 Skilled attendant at delivery 59 percent 5.8 Institutional deliveries 53 percent 5.9 Caesarean section 18 percent LITERACY AND EDUCATION Literacy and education 7.1 2.3 Literacy rate among young women 66 percent Literacy rate 10+ years 60 percent Literacy rate 15+ years 57 percent Adult literacy rate 15–24 years 74 percent 7.2 School readiness 79 percent 7.3 Net intake rate in primary education (5 years) 26 percent 7.4 2.1 Primary school net attendance ratio (5–9 years) 59 percent 7.5 Secondary school net attendance ratio 40 percent 7.6 2.2 Children reaching last grade of primary 97 percent 7.7 Primary completion rate 78 percent 7.8 Transition rate to secondary school 94 percent 7.9 3.1 Gender parity index (primary school) 0.95 ratio 7.10 3.1 Gender parity index (secondary school) 0.94 ratio CHILD PROTECTION Birth registration 8.1 Birth registration 77 percent Child labour 8.2 Child labour (5-14 years) 11 percent 8.3 School attendance among child labourers (5-14 years) 53 percent 8.4 Child labour among students (5-14 years) 7.7 percent Early marriage 8.6 Marriage before age 15 5.7 percent 8.7 Marriage before age 18 23 percent 8.8 Young women aged 15-19 years currently married 8.5 percent MICS Punjab indicators for women aged 15-49 years are presented for ever-married women only while the standard MICS (and MDG ) indicators are calculated for all women. 1 S U M M A R Y T A B L E O F F I N D I N G Svi SUMMARY TABLE OF FINDINGS S U M M A R Y T A B L E O F F I N D I N G S vii Human Immunodeficiency Virus Acquired Immune Deficiency Syndrome SUMMARY TABLE OF FINDINGS TA B L E O F C O N T E N T Sviii iii iv v xi xiii xiv xv 1 1 1 3 3 3 4 4 5 6 6 7 7 8 8 8 10 12 12 14 14 16 19 19 5.5. Low Birth Weight . 20 6. CHILD HEALTH . 22 6.1. Vaccinations . 22 6.2. Neonatal Tetanus Protection . 24 6.3. Oral Rehydration Treatment . 24 6.4. Care Seeking and Antibiotic Treatment for Suspected Pneumonia . 26 6.5. Solid Fuels . 27 7. WATER AND SANITATION . 29 7.1. Use of Improved Water Sources . 29 7.2. Use of Improved Sanitation Facilities . 31 7.3. Handwashing . 32 8. REPRODUCTIVE HEALTH . 34 8.1. Fertility . 34 8.2. Unwilling Pregnancy . 35 8.3. Contraception . 35 8.4. Contraceptive Dropout. 37 8.5. Unmet Need . 37 8.6. Antenatal Care . 38 8.7. Assistance at Delivery . 40 8.8. Caesarean Section . 41 8.9. Place of Delivery . 41 8.10. Postnatal Care . 42 9. LITERACY AND EDUCATION . 43 9.1. Literacy . 43 9.2. Literacy Rate (10+ years) . 43 9.3. Literacy Rate (15+ years) . 44 9.4. Adult Literacy Rate (15–24 years) . 44 9.5. Literacy among Young Women . 45 9.6. School Readiness . 45 9.7. Net Intake Rate in Primary Education . 45 9.8. Primary School Net Attendance Ratio . 46 9.9. Primary School Gross Attendance Ratio . 46 9.10. Secondary School Net Attendance Ratio . 47 9.11. Out of School Children .47 TA B L E O F C O N T E N T S ix TA B L E O F C O N T E N T S 9.12. Children Reaching Last Grade of Primary . 47 9.13. Primary Completion Rate & Transition Rate to Secondary School. 47 9.14. Gender Parity Index . 48 9.15. Public and Private Net Primary Attendance Rate . 48 9.16. Preschool Attendance . 49 10. CHILD PROTECTION . 50 10.1. Birth Registration . 50 10.2. Child Labour . 50 10.3. Student Labourers and Labourer Students . 51 10.4. Early Marriage . 51 11. HIV / AIDS. 54 11.1. Knowledge about HIV Transmission and Misconceptions . 54 11.2. Accepting Attitudes towards People Living with HIV/AIDS . 55 12. ADULT HEALTH AND HEALTH CARE . 57 12.1. Reported Chronic Cough, Tuberculosis and Hepatitis . 57 12.2. Care Provided by Lady Health Worker . 57 13. SOCIO ECONOMIC DEVELOPMENT . 58 13.1. Household Characteristics . 58 13.2. Housing . 58 13.3. Household Possessions and Utilities . 59 13.4. Remittances and Cash Donations . 60 13.5. Social Benefits, Subsidies and Family Support Programmes . 60 13.6. Unemployment . 61 ANNEXURE-I MICS4 DATA PROCESSING SYSTEM . 62 STATISTICAL TABLES . 63 APPENDIX-A (SAMPLE DESIGN) . 275 APPENDIX-B (ESTIMATES OF SAMPLING ERRORS) . 286 APPENDIX-C (DATA QUALITY TABLES) . 301 APPENDIX-D (PUNJAB MICS4 INDICATORS) . 320 x xiL I S T O F F I G U R E S Figure HH.1A: Age and sex distribution of household population MICS Punjab, 2007-08 . 9 Figure HH.1B: Age and sex distribution of household population MICS P unjab, 2011 . 9 Figure CM.1: Under-five mortality rate by background characteristics MICS Punjab, 2011 . 13 Figure NU.1: Percentage of children under-5 who were undernourished MICS Punjab, 2011 . 15 Figure NU.2: Percentage of underweight children (moderately or severally) under-5 by area of . residence and wealth index quintile MICS Punjab, 2011. . 16 Figure NU.3: Percent distribution of children under 2 years by feeding pattern by age group MICS Punjab, 2011 . . . . 17 Figure NU.4: Consumption of adequately iodized salt MICS Punjab, 2011 . 19 Figure NU.5: Percentage of low birth weight children by area of residence, wealth quintile and mother's education MICS Punjab, 2011 . . . 21 Figure CH.1: Percentage of children aged 12-23 months who received the recommended vaccinations by 12 months MICS Punjab, 2011 . . . 23 Figure CH.2: Percentage of women protected against tetanus by area of residence, wealth quintile and mother education MICS Punjab, 2011 . . 24 Figure CH.3: Drinking and eating practices of the children under 5 years during the episodes of diarrhoea MICS Punjab, 2011 . . . 26 Figure CH.4: Percentage distribution of household using solid fuel by area of residence and wealth quintiles MICS Punjab, 2011 . . . 27 Figure CH.5: Utilization of solid fuel by place of cooking MICS Punjab, 2011 . 28 Figure WS.1: Percentage distribution of household members by source of drinking water MICS Punjab, 2011 . . . . 30 Figure WS.2: Use of appropriate water treatment by area of residence, education of head of household and wealth quintiles MICS Punjab, 2011 . . 30 Figure WS.3: Percentage of household population using improved sanitation facility by area of residence, education of head and wealth quintiles MICS Punjab, 2011 . 31 Figure WS.4: Percentage of household population using improved drinking water sources and improved sanitation facility (not shared) by area of residence MICS Punjab, 2011 . 32 Figure WS.5: Availability of both water and soap at the place of hand washing MICS Punjab, 2011 . 33 Figure WS.6: Availability of soap in observed households MICS Punjab, 2011. 33 Figure RH.1: Comparison of fertility rates, MICS Punjab . . 34 Figure RH.2: Percentage of ever-married women aged 20-24 who had a live birth before age 18 by area of residence, wealth quintiles and women education MICS Punjab, 2011 35 Figure RH.3: Percentage of currently married women aged 15-49 years who were using (or whose husband were using) a contraceptive method MICS Punjab, 2011 . 36 Figure RH.4: Contraceptive utilization of currently married women aged 15-49 years by method MICS Punjab, 2011 . . . . 36 LIST OF FIGURES . LIST OF FIGURES L I S T O F F I G U R E Sxii Figure RH.5: Percentage of currently married women aged 15-49 years who were using (or whose husband were using) a contraceptive method by area of residence, number of living children and wealth quintiles MICS Punjab, 2011 . . 37 Figure RH.6: Percent distribution of women aged 15-49 years (ever married) received antenatal care MICS Punjab, 2011 . . . . 39 Figure RH.7: Percentage of women aged 15-49 years (ever-married) had skilled assistance during delivery by area of residence, women education and wealth quintiles MICS Punjab, 2011 . 40 Figure RH.8: Caesarean section by area of residence, mother's education and wealth quintiles MICS Punjab, 2011 . . . . 41 Figure RH.9: Place of delivery by area of residence, antenatal visits and wealth quintiles MICS Punjab, 2011 . . . . 41 Figure ED.1: Literacy rate 10+ years by sex and area of residence MICS Punjab, 2011 . 43 Figure ED.2: Literacy rate 10+ years by education of the head and wealth quintiles MICS Punjab, 2011 . 44 Figure ED.3: Literacy rate (15+) by age groups and sex MICS Punjab, 2011 . 44 Figure ED.4: Adult literacy rate by area of residence, education of the head and wealth quintiles MICS Punjab, 2011 . . . . 45 Figure ED.5: Primary school attendance rates by area of residence, mother‘s education and wealth quintiles MICS Punjab, 2011 . . . 46 Figure ED.6: Secondary school NAR, secondary school age children attending primary school and secondary school children out of school MICS Punjab, 2011 . 47 Figure ED.7: Gender Parity Index (GPI) of primary and secondary school by wealth quintiles MICS Punjab, 2011 . . . . 48 Figure ED.8: Gender Parity Index (GPI) of primary and secondary by area of residence MICS Punjab, 2011 . . . . 48 Figure ED.9: Public and private net primary attendance rates by wealth quintiles MICS Punjab, 2011 . . . . . 48 Figure CP.1: Birth registration by area of residence and divisions MICS Punjab, 2011 . 50 Figure CP.2: Marriage before age 15 years by area of residence, mother's education and wealth quintiles MICS Punjab, 2011 . . . 53 Figure CP.3: Percentage of women married before the age 15 years by women age groups MICS Punjab, 2011 . . . . 53 Figure HA.1: Percentage of women aged 15-49 years (ever married) with comprehensive knowledge of HIV/ AIDS by background characteristics MICS Punjab, 2011 . 55 Figure HA.2: Percentage of women aged 15-49 years (ever married) who knew all three means of HIV/ AIDS transmission from mother to child by background characteristics MICS Punjab, 2011 . . . . 55 Figure HA.3: Accepting attitudes of women aged 15-49 (ever married) toward people living with HIV/AIDS MICS Punjab, 2011 . . . 56 L I S T O F F I G U R E S LIST OF FIGURES xiii Figure HC.1: Percentage distribution of households by household members MICS Punjab, 2011 . 58 Figure HC.2: Percentage of households had "pacca" floor by area of residence, wealth quintiles and education of the head MICS Punjab, 2011. . 58 Figure HC.3: Percentage household having "pacca" roofs by area of residence, wealth quintiles and education of the head MICS Punjab, 2011 . . 59 Figure HC.4: Ownership of houses, agriculture land and livestock by area of residence MICS Punjab, 2011 . . . . 59 LIST OF TABLES Table SD.1A: Sample size and allocation (households) . . 3 Table HH.1A: Results of household, women's and under-5 interviews . 8 Table CM.1: Children ever born, children surviving and proportion dead . 12 Statistical Tables . . . 63 A B B R E V I A T I O N S AIDS Acquired Immune Deficiency Syndrome BCG Bacillus Calmette Guérin BOS Bureau of Statistics CSPro Census and Survey Processing System DPT Diphtheria, Pertussis and Tetanus EPI Expanded Programme on Immunization GAR Gross Attendance Rate UNGASS UN General Assembly‘s Special Session (on HIV/ AIDS) GPI Gender Parity Index HIV Human Immunodeficiency Virus HU Housing Unit IMR Infant Mortality Rate IUD Intrauterine Device LB Live births LHV Lady Health Visitor LHW Lady Health Worker MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS4 The fourth round of the Multiple Indicator Cluster Surveys NAR Net Attendance Rate ORS Oral Rehydration Solution ORT Oral Rehydration Therapy PBS Pakistan Bureau of Statistics P&D Planning and Development PENTA Combination of 5 Vaccines (Diphtheria, Pertussis, Tetanus, Haemophilu influenzae B (HIB) and Hepatitis B) PME Programme Monitoring and Evaluation PDD Planning and Development Department PPM Parts Per Million PSUs Primary Sampling Units ROSA Regional Office for South Asia - UNICEF SBA Skilled Birth Attendant SPSS Statistical Package for Social Sciences SSUs Secondary Sampling Units STIs Sexually Transmitted Infections TBAs Traditional Birth Attendants TFR Total Fertility Rate U5MR Under 5 Mortality Rate UN United Nations UNICEF United Nations Children's Fund UNDP United Nations Development Programme WFFC World Fit For Children WHO World Health Organisation xiv ABBREVIATIONS E X E C U T I V E S U M M A R Y xv EXECUTIVE SUMMARY MICS Punjab, 2011 provides representative household survey estimates regarding more than 100 indicators vis-a-vis province, area of residence (major cities, other urban and rural),9 divisions, 36 districts and 150 tehsils/towns. Results are also categorised with respect to gender, background characteristics of households, wealth quintiles. In some cases age group division is also given including the situation of mother and child in the province. It was one of the largest surveys in the history of Pakistan with a sample size of 102,545 households and an exceptional response rate of 97 percent. The survey report has 37 volumes. Volume-I comprises main report with technical appendices. The remaining 36 volumes, one for each district, present results up to tehsil level. The survey was planned, designed and implemented by Punjab Bureau of Statistics. The sample design and listing was provided by Pakistan Bureau of Statistics formerly known as Federal Bureau of Statistics, Pakistan.Technical input was obtained from global desk on MICS4, UNICEF. Fieldwork was carried out from July to December 2011. Findings reveal the significant variations in most of the indicators with respect to location, gender, household characteristics, administrative units and wealth quintiles. Major findings of the survey are summarized below: Under-five child mortality rate was estimated at 104 deaths per 1,000 live births and the Infant mortality rate at 82 deaths per 1,000 live births. Thirty-three percent of children under 5 were moderately or severely underweight. Thirty-six percent were moderately or severely stunted (i.e. too short for their age) and 16 percent were severely or moderately wasted (i.e. too thin for their height). Twenty-two percent of children aged 0–5 months were exclusively while 52 percent were predominately breastfed. Sixty-eight percent of the children aged 12-15 months were continuously breastfed at 1 year while 34 percent of children aged 20-23 months were continuously breastfed at 2 years. Thirty-four percent of the households were found to be using adequately iodized salt. In the 6 months preceding the survey, 73 percent of children aged 6–35 months received a high dose of Vitamin A supplement. Sixteen percent of children under 5 had diarrhoea in the 2 weeks preceding the survey. Out of them 40 percent of the children were given Oral Rehydration Therapy (ORT) whereas 14 percent were untreated. Three percent of the children had suspected pneumonia, 77 percent of them were taken to any appropriate health provider. Almost two third of the households (urban 17; rural 86) used solid fuels for cooking. High rate was largely due to use of wood for cooking purposes (39 percent). INFANT AND UNDER-FIVE CHILD MORTALITY NUTRITIONAL STATUS BREASTFEEDING SALT IODISATION VITAMIN A SUPPLEMENTS DIARRHOEA/ ORT AND PNEUMONIA SOLID FUEL USE E X E C U T I V E S U M M A R Y EXECUTIVE SUMMARY xvi WATER AND SANITATION FERTILITY CONTRACEPTION ANTENATAL CARE AND ASSISTANCE AT DELIVERY LITERACY EDUCATION CHILD LABOUR BIRTH REGISTRATION Eighty-nine percent of the population had access to improved drinking water sources at their premises, 6 percent within the travelling time of half an hour and 3.7 percent at more than half an hour. Ninety-four percent were using improved sources of drinking water. Major improved sources were motorized pump (41 percent), hand pump (34 percent) and piped water (15 percent). Overall, 72 percent of the population (urban 92 percent; rural 64 percent) were using improved sanitation facilities with majority using flush toilets connected to septic tanks (42 percent) followed by sewerage systems (20 percent). Fertility rate was estimated at 3.6 children per woman aged 15-49 years. Current use of contraceptives was reported by 35 percent. Contraceptive use rose from 19 percent amongst women with one living child to 49 percent for women with four or more living children. Seventy-four percent women received antenatal care from a medical doctor, nurse, midwife or Lady Health Visitor (LHV) at least once during their pregnancy. Fifty-nine percent of deliveries were attended by Skilled Birth Attendants (SBAs) (a doctor, nurse, certified midwife or LHV) while 38 percent received postnatal care from SBA. Thirty-eight percent of all deliveries (rural 44 percent, urban 22 percent) were attended by Traditional Birth Attendants (TBAs). Sixty percent of the population aged 10 years and above was literate, with differentials between males (68 percent) and females (51 percent). The adult literacy rate among population aged 15–24 years was 74 percent (male 78 percent; female 70 percent). The net intake rate was 26 percent for children aged 5 years, rising to 44 percent for children aged 6 years, indicating that most children start primary school late. The Net Attendance Rate (NAR), i.e. children aged 5–9 years who attend primary or secondary school, was 59 percent, whereas Gross Attendance Rate (GAR) was 89 percent. Fifty-nine percent of children aged 5-9 years were attending government schools while 41 percent were going to private schools. In case of secondary school-aged children (10–14 years), 40 percent were attending secondary school, with a low percentage in rural areas (35 percent) as compared to urban (53 percent). The Gender Parity Index (GPI) was 0.95 for primary school and 0.94 for secondary school, showing that more boys attend school than girls. GPI was low in rural areas, 0.92 for primary and 0.85 for secondary school. Eleven percent of the children aged 5–14 years were involved in child labour with significant variation across gender, areas of residence, districts and wealth quintile. Children, who work, were less likely to participate in school (7.7 percent) whereas the percentage of child labourers who were attending school was 53. The births of percent of children under 5 years of age were registered.77 EXECUTIVE SUMMARY xviiE X E C U T I V E S U M M A R Y PREVALENCE OF COUGH, TUBERCULOSIS AND HEPATITIS LADY HEALTH WORKER COVERAGE KNOWLEDGE OF PREVENTING HIV / AIDS UNEMPLOYMENT OWNERSHIP OF ASSETS REMITTANCES AND CASH DONATIONS Almost two percent of the population reported chronic cough (a cough lasting at least 3 weeks preceding the survey).The diagnosed tuberculosis and hepatitis during last one year was 0.4 percent and 1.2 percent, respectively. About half (48 percent) of women aged 15-49 years reported visit by Lady Health Worker (LHW). Twenty-seven percent of married women aged 15–49 years had heard of HIV/AIDS (major cities 54 percent; other urban 47 percent; rural 18 percent).Only 7.8 percent rejected the two most common misconceptions and knew that a healthy looking person could have the AIDS virus. Only 4.3 percent had comprehensive knowledge about the disease. Twenty-two percent of women aged 15-49 years (ever married) knew that HIV can be transmitted from mother to child. Almost three percent of people over 15 years of age were unemployed. The rate was same in urban and rural areas. Eighty-six percent of the population owned a house, 34 percent agricultural land and 48 percent livestock. As expected, ownership of agricultural land and livestock was higher amongst the rural population. Slightly more than seven percent of the households received remittances from within the country and 4.7 percent from abroad. 1.1. Background This report is based on Multiple Indicator Cluster Survey, Punjab 2011 (MICS Punjab, 2011), conducted from July to December 2011 by the Bureau of Statistics (BOS), Planning and Development Department (PDD), Government of the Punjab. The survey provides valuable insight into the situation of children and women in Punjab. It was aimed to cater for the need to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration (adopted by all 191 United Nations (UN) Member States in September 2000) and the Plan of Action of A World Fit For Children (WFFC) (adopted by 189 Member States at the UN Special Session on Children in May 2002). Both commitments build upon promises made by the international community at the 1990 World Summit for Children. Punjab is committed to improve the welfare of its people particularly those who are vulnerable to socio economic hardships. MICS Punjab, 2011 is a household survey intended to assist the Government of Pakistan/ Punjab in planning and monitoring social service delivery and other indicators of development. The survey fills gaps in essential data and provides latest information with respect to province, divisions, districts and tehsils. Its findings will ultimately feed into government programmes for sustainable development and poverty alleviation. As a signatory, Pakistan is committed to improve the situation of all its citizens, especially women and children, and to report upon progress made in the years since these agreements. The MICS Punjab, 2011 report shall play an important role in monitoring progress towards attaining goals and targets set in international agreements. The value of this survey goes far beyond generating data for international reporting. To formulate and achieve goal-oriented plans, it is essential that resources are distributed based on rational and appropriate objectives at the provincial, district and tehsil level. The MICS Punjab, 2011 will meet the data needs of policy makers, managers, researchers and academia. It is a collaborative effort of Government of the Punjab, United Nations Children's Fund (UNICEF) and United Nations Development Programme (UNDP). The survey was coordinated and supervised by the Steering Committee, Technical, Planning and Coordination Groups chaired by the Chairman and Chief Economist, Planning and Development (P&D) Board, respectively. These groups comprised key technical staff of the line departments, UNICEF and UNDP. Operational responsibility, such as development of survey tools, training, field operation and draft report, was of BOS, Punjab. The report was approved by the Steering Committee chaired by the Chairman P&D Board, comprising all secretaries of Social Sector Departments. This final report presents the results of the indicators and topics covered in the survey. 1.2. Survey Objectives The primary objectives of the MICS Punjab, 2011 are to:- provide up-to-date information for assessing the situation of children and women in Punjab, including the identification of vulnerable groups/ disparities and formulation of policies and interventions I N T R O D U C T I O N1 INTRODUCTION 1 2I N T R O D U C T I O N furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other international commitments as a basis for future action contribute to the improvement of data and monitoring systems in Punjab and to strengthen technical expertise in the design, implementation, and analysis of such systems update snapshots of social development provide data for time series analysis and to ascertain achievements compared to previous MICS surveys provide benchmark position for new indicators and to develop strong advocacy tools provide up-to-date data for social sector researchers/ academia 3 2.1. Sample Design The sample for the MICS Punjab, 2011 was designed by Pakistan Bureau of Statistics (PBS), to provide estimates on a large number of indicators on the situation of women and children including the socio-economic indicators at the provincial level for 9 divisions, 36 districts, 150 tehsils /towns, major cities, other urban and rural areas. The sample design was reviewed for adequacy and soundness by international consultants engaged by UNICEF Pakistan. Sample size summarized district-wise is presented in Table SD.1A. The sample was selected in two stages. Within each of the 287 sampling domains4, Enumeration Areas (EA) (enumeration blocks in urban areas or village/ mouzas/ dehs in rural areas) were selected with probability proportional to size. Prior to the survey implementation, a complete listing of households in all the selected EAs was conducted. Based on the total number of households in each EA a systematic sample of 12 households in urban and 16 households in rural areas was randomly drawn. This formed the second stage of sampling. In selected households, all females aged 15-49 years and children under five years were identified for individual interviews. The total sample size for the survey was 102,0485 households. The sample was not self-weighting and sample weights were used to report results. A more detailed description of the sample design can be found in Appendix A. 2.2. Finalization of Indicators The fourth round of the Multiple Indicator Cluster Surveys (MICS4) being a standard methodology has limited space for additional indicators but is flexible enough to adapt indicators to local environments. The Technical Group followed a comprehensive plan for the finalization of list of indicators for the MICS Punjab, 2011. It was Table SD.1A: Sample size and allocation (households) Sr. No. District Households Major City Other Urban Rural Total Total 10044 31812 60192 102048 1 Bahawalpur 288 1212 2688 4188 2 Bahawalnagar - 1176 1872 3048 3 RY Khan - 1488 2512 4000 4 DG Khan - 648 1152 1800 5 Layyah - 528 1504 2032 6 Muzaffargarh - 1224 1936 3160 7 Rajanpur - 576 1296 1872 8 Faisalabad 1740 1416 3184 6340 9 Chiniot - 624 1040 1664 10 Jhang - 876 2048 2924 11 TT Singh - 888 1248 2136 12 Gujranwala 852 1296 2656 4804 13 Gujrat - 972 1584 2556 14 Hafizabad - 528 736 1264 15 Mandi Bahaudin - 684 1072 1756 16 Narowal - 816 1600 2416 17 Sialkot 396 888 2160 3444 18 Lahore 4140 - 1344 5484 19 Kasur - 1260 1840 3100 20 Nankana - 972 1472 2444 21 Okara - 1020 1600 2620 22 Sheikhupura - 1308 1824 3132 23 Multan 1560 504 1936 4000 24 Khanewal - 1188 1728 2916 25 Lodhran - 708 1024 1732 26 Pakpattan - 696 1056 1752 27 Sahiwal - 744 1136 1880 28 Vehari - 1032 1520 2552 29 Attock - 1284 1584 2868 30 Chakwal - 612 1600 2212 31 Jhelum - 744 1456 2200 32 Rawalpindi 588 1092 3056 4736 33 Sargodha 480 1032 2192 3704 34 Bhakkar - 660 1456 2116 35 Khushab - 552 1120 1672 36 Mianwali - 564 960 1524 4 5 The number of all combinations of tehsils/ towns by area of residence (rural, major cities, other urban) is equal to 287 (see Table SD.1 in Appendix A). Total sample size determined by PBS was 102,048 households. However, due to UNICEF policy (of interview in all households in the selected structure if there was only one in listing but more than one household were found at the time of survey) total sample size achieved at the end of the survey was 102,545. The results presented in the report and subsequent district reports are based on this sample size. S A M P L E A N D S U R V E Y M E T H O D O L O G Y S S M AMPLE AND URVEY ETHODOLOGY 2 4 decided by the Technical Group to hold sectoral consultations with key social sector departments and development partners. After sectoral discussions, one day ‘Information Needs Assessment Workshop‘ was conducted and the proposed indicators were discussed in the technical sessions. The recommendations of the Workshop were fine-tuned in BOS Punjab and Steering Committee approved the final list of indicators (Appendix-D). 2.3. Questionnaires Questionnaires for the MICS Punjab, 2011 were based on MICS4 set of following three model Questionnaires6, modified/customised to local conditions and to accommodate additional indicators approved by the Steering Committee. 1. A Household Questionnaire which was used to collect information on all de jure household members (usual residents), the household, and the dwelling 2. A Women Questionnaire administered in each household to all women aged 15-49 years 3. A Child Questionnaire administered to mothers or caretakers for all children under 5 years living in the household The Questionnaires included the following modules: Household Questionnaire Woman Questionnaire Child Questionnaire Household information panel (HH) Woman information panel (WM) Under 5 child information panel (UF) Household Listing (HL) Woman‘s Background (WB) Age (AG) Education (ED) Marriage (MA) Birth Registration (BR) Water and Sanitation (WS) Child Mortality (CM) Breast Feeding (BF) Household Characteristics (HC) Desire for last Birth (DB) Care of illness (CA) *Remittances and Zakat (RZ) Maternal and New born health (MN) Immunization (IM) *Pension benefits (PB) Illness Symptoms (IS) Anthropometry (AN) *Safety Nets (SN) Contraception (CP) Child Labour (CL) Unmet Need (UN) Hand Washing (HW) HIV/AIDS (HA) Salt Iodization (SI) *Employment (EM) *Household Expenditures (HE) *Non-MICS4 Module 2.4. Pretesting The Questionnaires were translated from English to Urdu language for data collection and again retranslated into English for Regional Office for South Asia (ROSA), UNICEF and Global MICS team, New York. The Questionnaires were pretested in Southern, Central and Northern zones of the Punjab. One District/ Tehsil was selected randomly and within the Tehsil, one urban site (12 households) and one rural site (16 households) called cluster, was enumerated as per guidelines of MICS4 methodology. 6 The model MICS4 questionnaires can be found at www.childinfo.org S A M P L E A N D S U R V E Y M E T H O D O L O G Y S A M P L E A N D S U R V E Y M E T H O D O L O G Y5 The pretesting teams tested the salt used for cooking in the households for iodine content, observed the structure of walls, floors and roofs, saw places for handwashing, and measured weights and heights of children aged under 5 years. In the light of findings of the pretesting, questionnaires were improved and finalized. 2.5. Training and Fieldwork To manage huge fieldwork operation while assuring quality and proper supervision, the province was divided into ten regions of 3–5 districts: Bahawalpur, DG Khan, Faisalabad, Gujranwala, Lahore I, Lahore II, Multan, Rawalpindi, Sahiwal and Sargodha. Ten senior officers of BOS were designated as regional supervisors - one for each region. They were responsible for all aspects of the field work in their respective regions. Seventy-five field teams were constituted each comprising 7 members in urban and 9 in rural areas. In addition more than 300 staff was deployed for preparing listings of the households in the selected clusters. Detail of total staff deployed in the survey is given as under: Workforce Required Number Household Listers 335 Regional Supervisors 10 Team Supervisors 75 Field Editors 75 Male Interviewers 166 Female Interviewers 166 Female Measurers 75 Training was undertaken as per standard protocols of MICS4 methodology. Following standardised material was used during the trainings to bring understanding, knowledge and skills of all the trainees at the same level: - Interviewer‘s Manual - Supervisor‘s/Editor‘s Manual - Instructions for Measurers - GPS Guide lines Due to large number of trainees, manageable groups of trainees were made and field work trainings were organized at Multan, Faisalabad, Rawalpindi and Lahore. Each training venue was chosen according to size of groups of trainees. In addition to standard training of field staff, Regional Supervisors, Team Supervisors, Measurers and Editors were given special trainings related to their specific duties. Two hours sessions for this purpose were held in the evening after standard training sessions. Following trainings were organized to train the workforce for the survey: Training Type/ Purpose Duration Trainers Listing 2 days Experienced officers of PBS Training of Trainers (TOT) 7 days Technical officers who prepared the questionnaire along with Professional Trainers Training of Supervisors/ Editors/ Interviewers/ Measurers 14 days Master Trainers along with Professional Trainers Training of Measurers (Anthropometric measurements) 3 days Nutrition Specialists S A M P L E A N D S U R V E Y M E T H O D O L O G Y 6 As part of training, master trainers carried out mock interviews during the training. During the training two days were assigned for field work of supervisors, editors, interviewers and measurers. They were taken to nearby areas, not selected for the survey, and were involved in real time interviews, editing and measurements. Seventy-five Team Supervisors led the interviewers‘ teams. Each team comprised two male & two female interviewers in urban areas and three males & three females in rural areas along with one exclusive measurer and field editor. A twelve-seater air conditioned vehicle was provided to each team for field travel. The male interviewers were responsible for locating sampled households, introduction and administering the Household Questionnaire. The female interviewers administered the women and children Questionnaires to eligible women and mothers or caretakers of children. The Measurers performed the anthropometric measurements on children. Team Supervisors ensured that the visited household was one identified through the sampling process. The Field Editor ensured finalization of Questionnaires both in terms of completeness and accuracy before the team left the surveyed cluster. 2.6. Monitoring of Field Work The monitoring of field work for quality data collection included conventional as well as innovative methods. Under the conventional method all the participating organizations carried out monitoring including Chairman, Chief Economist, P&D board, Focal person PDD, Manager UNDP & Programme Monitoring and Evaluation (PME) officer, UNICEF, Director General and senior staff of BOS and National consultant on MICS. All these monitoring activities were coordinated at BOS and it was ensured that each field team is visited more than once by the monitors. Besides, UNDP also deputed third party monitors. All the monitors submitted reports at the end of their visits based on which instructions were issued to the field teams. In MICS Punjab, 2011 Global Positioning System (GPS) was also used to monitor the movement of field teams. Each team supervisor was given a GPS device through which they sent GPS coordinates at headquarter both at the time of entering and leaving the cluster. This system enabled BOS to monitor the field teams that they visited the cluster. Moreover, arriving and leaving time of the teams was noted, through which their stay in the cluster could be evaluated. The team supervisor was responsible to forward information on eligible children, women, anthropometry and response level through SMS. This data proved to be very useful in evaluating the performance of field teams. In order to assure quality of data, a team was inducted by the UNICEF. The quality assurance team monitored presence of members of the field teams. They also reviewed the filled questionnaires received from the field and reported to the BOS regarding quality of editing (completeness and accuracy). In the light of these observations the field teams were issued necessary instruction to improve the data quality. 2.7. Data Processing and Analysis The data entry and cleaning operation was organized at a central location i.e. Lahore under the supervision of a qualified data management organization. Data were entered using Census and Survey Processing System (CSPro). In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programmes developed under the global MICS4 programme and adapted to the MICS Punjab, Questionnaire were used throughout. The procedures followed for ensuring double data entry and cleaning is depicted in the Flow Chart at Annexure-I. Data processing began almost simultaneously with data collection and was completed within 15 days of completion of field work. Data were analysed using the Statistical Package for Social Sciences (SPSS) software, and the model syntax and tabulation plans developed by UNICEF. The data management team produced data quality tables on weekly basis which were shared with BOS on each Friday and discussed on each Saturday. The quality tables included descriptive statistics on key variables for each team based on number of questionnaires entered up to that time. In the light of performance shown by the teams in the quality tables instructions were immediately issued to the teams performing below average. Moreover, to enhance data quality, other corrective steps were also taken including reshuffling of team(s) member(s) reporting inadequately and arranging additional trainings in the field where felt necessary. Initial analysis, for cleaning purpose, was carried out by examining frequency distribution of all variables and looking at possible errors in data entry and otherwise. Dummy tables reflecting cross-tables between dependent and independent variables were generated focusing on presenting frequencies and simple bivariate tables. Finally, data was exported from CSPro to SPSS software tabulation programme for construction of analysis files (comprising HH: Household, HL: Household listing, WM: Women and CH: Children); production of tabulations; analysis of sampling errors/ confidence intervals; and production of datasets and tabulations for report writing. 2.8. International Review MICS Punjab, 2011 is 3rd round of MICS in Punjab based on MICS4 methodology. All stages of the survey were closely monitored by the ROSA and global MICS team New York. Before start of survey, ROSA reviewed the sample design, survey tools and trainings through international consultants. The software used for data entry and analysis was adopted from the MICS4 recommended methodology which was also reviewed by the national /international consultants. The data files, syntax files and tabulations were shared with ROSA and global MICS team New York. The data and software review inputs received from these organizations were addressed before the finalization of the report. 2.9. Organisation of the Report The report for MICS Punjab, 2011 consists of 37 volumes. Volume-I presents results at the provincial, divisional and district levels. Technical aspects of the Survey are described in the appendices. The remaining volumes provide disaggregated data vis-a-vis tehsil for each of the 36 districts of the province. S A M P L E A N D S U R V E Y M E T H O D O L O G Y7 3.1. Sample Coverage All 7,250 sampled clusters were successfully surveyed. Out of 102,545 households selected for the survey, 97,995 were found to be occupied. 95,238 were successfully interviewed with a response rate of 97 percent. In interviewed households, 150,814 women aged 15–49 years were identified and 137,938 were successfully interviewed, i.e. response rate of 92 percent. Of the 74,126 children under 5 years listed in household questionnaires, 66,666 child questionnaires were answered with a response rate of 90 percent. The overall response rates for women and children under-five were 89 and 87 percent respectively (Table HH.1A). Table HH.1A: Results of household, women and under-5 interviews Rural All Urban Major Cities Other Urban Total Households Sampled 60,498 42,047 10,281 31,766 102,545 Occupied 58,037 39,958 9,713 30,245 97,995 Interviewed 56,863 38,375 9,032 29,343 95,238 Household response rate 98.0 96.0 93.0 97.0 97.2 Women (15-49) years Eligible 87,616 63,198 14,819 48,379 150,814 Interviewed 80,159 57,779 13,406 44,373 137,938 Women's response rate 91.5 91.4 90.5 91.7 91.5 Women‘s overall response rate 89.6 87.8 84.1 89.0 88.9 Children under 5 years Eligible 45,993 28,133 6,622 21,511 74,126 Mothers/caretakers interviewed 41,517 25,149 5,832 19,317 66,666 Under-5's response rate 90.3 89.4 88.1 89.8 89.9 Under-5‘s overall response rate 88.4 85.9 81.9 87.1 87.4 3.2. Characteristics of Households The weighted age and sex distribution of the survey population is provided in Table HH.2. This distribution is also used to produce the population pyramid in Figure HH.1. In the 95,238 households successfully interviewed, 597,462 household members were listed. Of these, 302,222 (51 percent) were males 295,240 (49 percent) were females The average household size was 6.3 close to 6.5 and 6.6 as per in MICS Punjab, 2007-08 and 2003–04, respectively (Table HC.10) The mean number of persons per room was 3.7, as in previous rounds of MICS Punjab (Tables HC.10) The largest age cohort was the 5–9 age group (13%), which decreased with each subsequent 5- years interval following the pattern of MICS Punjab, 2007-08. The preceding age group 0-4 also decreased indicating fall in population growth rate. The population of the province was 8S A M P L E C O V E R A G E S C C H R AMPLE OVERAGE AND HARACTERISTICS OF OUSEHOLDS AND ESPONDENTS 3 S A M P L E C O V E R A G E9 relatively young, with a median age of 20 years, i.e., half the population was below 20 years of age. Single-year age distribution showed a constant decline in population size in each year after age 20; however, problem of age heaping was prevalent after every 5 years of age (Table DQ.1 in Appendix C). In MICS Punjab, 2011, particular efforts were made to minimise age reporting errors by training interviewers in age probing techniques. Reference calendars of major local/national events were also provided to assist in determining approximate age of respondents who could not provide accurate age or date of birth. Resultantly, errors in recording ages and date of births were controlled to a great extent. The result of the efforts to manage age reporting errors can be observed from pyramids of MICS Punjab, 2007-08 and MICS Punjab, 2011. As with other surveys, MICS Punjab, 2007–08 showed concentration of women aged 50–54 years (Figure HH.1A), but this position was not in MICS Punjab, 2011 (FigureHH.1B). The position was the same for children 0-4 years and 5- 14 years. Single year age distribution in Table DQ.1 showed a leap from age 49 to 50 for women. This was not pronounced at 4–5 year boundary, for children under 5 years of age. Table DQ.1 shows a common error of "digit preference" that produces age heaping at ages ending in 0 and 5, due to a common problem of misreporting age universally which was observed in MICS Punjab, 2011, the 1998 census and other surveys. The 0–14 age group made up about 38 percent of the total population, while the population aged 65 years and above constituted 4.6 percent only. The share of economically active population (15–64 years) was 58 percent of the Punjab's total population (Table HH.2). The broad age structure was comparable to that reported in the MICS Punjab, 2007–08: the overall dependency ratio was almost same at 73 percent (Table HH.2). The year of birth was asked from all interviewed women yet about 4 percent did not report the exact month and year of birth (Table DQ.6 in Appendix C). This should be taken into consideration in results interpretation. Only about 0.4 percent of children under 5 had both month and year unreported, while for 2 percent the month of birth was not reported. Tables HH.3 - HH.5 provide basic information on the households, female respondents aged 15-49 years and children under-5 by presenting their unweighted as well as the weighted numbers. Information on basic characteristics of households, women, and children under-5 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 Figure HH.1B: Age and Sex Distribution of Household Population MICS Punjab, 2011 Females Males 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 Figure HH.1A: Age and sex distribution of household population MICS Punjab, 2007-08 Females Males 10 interviewed in the survey is essential for the interpretation of findings presented later in the report and also can provide an indication of the representativeness of the survey. The remaining tables in this report are presented only with weighted numbers. See Appendix A for more details about the weighting. Within households, sex of the household head, area of residence, division, district, number of household members and education of the head of the household are shown in Table HH.5. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show number of observations by major categories of analysis in the report. Since sample weights were normalized, the weighted and un-weighted number of households was equal. (Appendix A). The table also shows proportions of households with at least one child under 18, at least one child under 5 and at least one eligible woman aged 15-49 years. The table shows the weighted average household size estimated by the survey as well. Ninety-two percent males were head of households as compared to 95 percent in MICS Punjab, 2007-08. A small proportion of households (8 percent) in the Punjab were headed by females. At provincial level, about 71 percent of households were in rural areas, while the rest were in urban. District distribution of households generally followed the pattern of MICS Punjab, 2007-08. More than half of households (58 percent as compared to 56 percent in MICS Punjab, 2007-08) had 4 to 7 members reflecting large family size. One-member households were at about 1.2 percent. Out of total households interviewed, 47 percent had at least one child under 5 years and 92 percent had at least one woman aged 15–49 years. 3.3. Characteristics of Respondents Tables HH.4 and HH.5 provide information on background characteristics of female respondents aged 15–49 years and children under 5 years of age. In addition these tables show number of observations in each background category. Table HH.4 provides background characteristics of female respondents 15–49 years of age, and shows information on area of residence, district, age, marital status, motherhood status, education7 and wealth quintiles8. Women aged 15-49 years constituted 50 percent of total women population. Out of this age group of women: 42 percent had not received any form of education; 18 percent had primary education; 7 Unless otherwise stated, "education" refers to educational level attended by the respondent throughout this report when it is used as a background variable. 8 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 that household. The survey household population was then ranked according to the wealth score of the household they are living in, and was finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). The assets used in these calculations were as follows: number of rooms for sleeping per member; material used for floor, roof and wall of dwelling; type of cooking fuel; electricity; gas; radio; television; cable television; mobile and non-mobile phone; computer; internet access; refrigerator; air conditioner; washing machine; cooler; microwave; sewing machine; iron; water filter; motorised pump; watch; bicycle; motorcycle/scooter; animal-drawn cart; car or truck; source of drinking water and type of sanitation facility. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Filmer, D. and Pritchett, L., 2001. “Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India”. Demography 38(1): 115-132. Gwatkin, D.R., Rutstein, S., Johnson, K. , Pande, R. and Wagstaff. A., 2000. Socio-Economic Differences in Health, Nutrition, and Population. HNP/Poverty Thematic Group, Washington, DC: World Bank. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro. S A M P L E C O V E R A G E 62 percent were found to be ever married; 11 26 percent had middle or secondary education; and All were generally evenly distributed across wealth quintiles. Some background characteristics of children under 5 years of age are presented in Table HH.5. These include distribution of children by sex, area of residence, district, age in months, mothers' or caretakers' education and wealth quintiles. The percentage of male children under 5 was 51, against 49 for female children. Seventy-three percent of these resided in rural areas. Smaller groups comprised of children aged 0–5 months (10 percent) and 6–11 months (11 percent). The proportion of older children was higher and almost equally distributed, at about 20 percent in each age group. Majority of the children under 5 years (52 percent) had mothers with no education followed by 18 percent having primary education. Mothers with higher education than primary were about 10 percent in each level (Table HH.5). S A M P L E C O V E R A G E C MHILD ORTALITY 4 C H I L D M O R T A L I T Y 12 One of the overarching targets of the Millennium Development Goals (MDGs) and WFFC is reduction in infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Measuring childhood mortality may seem easy, but attempts using direct questions, such as “Has anyone in this household died in the last year? give inaccurate results. Using direct measures of child mortality from birth histories is ” time consuming, expensive, and requires greater attention. Alternatively, indirect methods developed to measure child mortality produce robust estimates that are comparable with the ones obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing techniques. The infant mortality rate is the probability of dying before first birthday. The under-five mortality rate is the probability of dying before the fifth birthday. In MICS surveys, infant and under five mortality rates are calculated based on an indirect estimation technique known as the Brass method9. The data used in the estimation are: the mean number of children ever born for five year age groups of women from age 15 to 49 years, and the proportion of these children who are dead, also for five-year age groups of women (Table CM.1). The technique converts the proportions of dead among children of women in each age group into probabilities of dying by taking into account the approximate length of exposure of children to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in Pakistan, the East model life table was selected as most appropriate on the recommendation of global MICS team. In MICS Punjab, 2003-04 and 2007- 08, South model life tables were used for estimation of child mortalities. Table CM.1: Children ever born, children surviving and proportion dead Mean and total numbers of children ever born, children surviving and proportion dead by age of women, MICS Punjab, 2011. Children ever born Children surviving Proportion dead Number of women Mean Total Mean Total Punjab 2.21 304,410 1.97 271,311 0.109 137,938 Age 15-19 0.04 1,336 0.04 1,203 0.099 31,519 20-24 0.53 14,728 0.49 13,394 0.091 27,588 25-29 1.79 40,552 1.63 36,832 0.092 22,627 30-34 3.25 55,807 2.93 50,257 0.100 17,173 35-39 4.35 65,799 3.89 58,866 0.105 15,132 40-44 5.07 66,973 4.47 59,078 0.118 13,213 45-49 5.54 59,215 4.84 51,680 0.127 10,687 Punjab 2.21 304,410 1.97 271,311 0.109 137,938 4.1. Infant and Under-Five Mortality Rates Table CM.2 provides estimates of child mortality. The infant mortality rate was estimated at 82 per thousand live births (LB), while the Under 5 Mortality Rate (U5MR) was around 104 per thousand. Infant Mortality Rate (IMR) and U5MR among male children was 89 and 111 respectively, while in female children was 75 and 97 respectively. 9 United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations publica tion, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Pop Division. United Nations, 1990b. Step-by-step Guide to the Estimation of Child Mortality. New York, UN. C H I L D M O R T A L I T Y13 Infant and under-five mortality rates were highest in rural areas with former at 90 deaths per thousand LB and latter at 115. In all urban areas these were 61 and 73 respectively which were lower than the rural areas by 33 and 37 percent respectively. Mortality was lower in major cities compared to other urban areas. The probability of dying amongst children in the highest wealth quintile was considerably lower than the provincial average (Table CM.2). A sharp negative association existed between child mortality and mother's education. With each increment in mothers' education, the probability of children dying decreased. Under-five mortality rates rose from 43 per 1,000 LB for mothers with higher education to 127 per 1,000 LB for mothers without any education. Similar differences in mortality rates were found in terms of wealth quintile. Children in the lowest wealth quintile had almost thrice the under- five mortality rates compared to those in the highest. The probability of dying among children in the top wealth quintile was almost 50 percent lower than the provincial estimates. Among divisions, IMR and U5MR were the lowest in Rawalpindi (IMR 58; U5MR 69) and the highest in Sahiwal (IMR 109; U5MR 143). Similarly, the variations among districts were also observed. Rawalpindi district again had the lowest mortality rates (IMR 51; U5MR 60) compared to Pakpattan district which had the highest (IMR 130; U5MR 173) (Table CM.2). 51 82 102 126 142 43 62 77 91 127 97 111 84 62 73 115 104 0 40 80 120 160 Highest Fourth Middle Second Lowest Wealth quintiles Higher Secondary Middle Primary None Mother's education Female Male Sex Other urban Major cities All Urban Rural Area of residence Punjab Under five mortalities per 1,000 Figure CM.1: Under-five mortality rate by background characteristics MICS Punjab, 2011 N U T R I T I O N 14 5.1. Nutritional Status Children‘s nutritional status is a reflection of their overall health. When children have access to adequate food supply, not exposed to repeated illness, and well cared for, they reach their growth potential and considered well nourished. Malnutrition is associated with more than half of all children's deaths worldwide. Undernourished children are more likely to die from common childhood illnesses, and those who survive are subject to recurring sicknesses like diarrhoeal diseases, respiratory infections and faltering growth. Three-quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished, showing no outward sign of their vulnerability. The MDG target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015, and the WFFC goal is to reduce the prevalence of malnutrition among children under 5 years of age by at least one-third between 2000–2010, with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the World Health Organisation (WHO) growth standards10. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight- for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In MICS, weights and heights of all children under 5 years of age were measured using anthropometric equipment recommended by UNICEF (www.childinfo.org). Findings in this section are based on the results of these measurements taken by the measurers especially deployed for this purpose. Table NU.1 shows percentages of children classified into each of the above described categories, based on the anthropometric measurements. Additionally, the table includes percentage of children who were overweight that takes into account those children whose 10 http://www.who.int/childgrowth/standards/second_set/technical_report_2.pdf NUTRITION 5 N U T R I T I O N15 weight for height was above 2 standard deviations from the median of the reference population, and mean z-scores for all three anthropometric indicators. Children whose full birth date (month and year) were not obtained, and children whose measurements were outside a plausible range were excluded from Table NU.1. Children were excluded from one or more of the anthropometric indicators when their weights and heights had not been measured, whichever applicable. For example, if a child had been weighed but his/her height was not been measured, the child was included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality Tables DQ.6 and DQ.7. Thirty-three percent of children under 5 years in Punjab were moderately or severely underweight and 11 percent were classified as severely underweight (Table NU.1). The proportion of children under 5 years moderately or severely underweighted was slightly less than that reported in MICS Punjab, 2007–08 (34 percent), and was considered to be very high: in a well-nourished population only 2.3 percent of children fall below minus 2 standard deviations and only 0.1 percent fall below minus 3 standard deviations. About 1 out of 3 children (36 percent) were severely or moderately stunted or too short for their age and 15 percent were severely stunted. This result showed an improvement over MICS Punjab, 2007- 08, 42 percent and 23 percent respectively. Sixteen percent of children were severely or moderately wasted and four percent severely wasted. Gender differentials are small. Children in rural areas are more likely to be underweight and stunted than other children. In major cities they are least likely to be underweight or stunted. Stunting rose sharply from the age group of 12– 23 month and then levels off for older ages (Figure NU.1). The underweight prevalence was higher in the age group of 12–35 months compared to younger and older children. Results indicate that the child's nutritional status was strongly correlated with the mother's education: children whose mothers had higher education were least likely to be underweight and stunted. Underweight and stunting figures for children from households in the lowest wealth quintile significantly exceeded the province average. Figure NU.2 showed the underweight prevalence among children under age five. Wasting varies slightly by mother’s education and wealth quintiles. 31 30 35 35 33 30 20 25 39 43 41 36 27 22 19 14 11 10 0 5 10 15 20 25 30 35 40 45 < 6 6-11 12-23 24-35 36-47 48-59 Age in months Figure NU.1: Percentage of children under-5 who were undernourished MICS Punjab, 2011 Underweight Stunting Wasting N U T R I T I O N 16 5.2. Breastfeeding and Infant and Young Child Feeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for first six months; • Continued breastfeeding for two years or more; • Safe, appropriate and adequate complementary foods beginning at 6 months; and • Frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day for 9-11 month olds. It is also recommended that breastfeeding be initiated within one hour of birth. The indicators related to recommended child feeding practices are as follows: • Children ever breastfed; • Early initiation of breastfeeding (within 1 hour of birth); • Exclusive breastfeeding rate (< 6 months); • Continued breastfeeding rate (at 1 year and at 2 years); • Predominant breastfeeding (< 6 months); • 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); • Vitamin A supplementation (children under age 3); • Low-birth weight infants; and • Infants weighed at birth. Table NU.2 shows proportion of children born 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 33 26 35 45 38 31 27 19 0 10 20 30 40 50 60 Punjab Urban Rural Lowest Second Middle Fourth Highest Area of residence and Wealth quintiles Figure NU.2: Percentage of underweight children (moderately or severally) under-5 by area of residence and wealth index quintile MICS Punjab, 2011 17 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Age groups Figure NU.3: Percent distribution of children under 2 years by feeding pattern by age group MICS Punjab, 2011 Breastfed and complementary foods Breastfed and other milk/ formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed those who received a prelacteal feed. Though a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 15 percent of babies were breastfed for the first time within one hour of birth. Fifty percent of newborns started breastfeeding within one day of birth. Early initiation had no association with women‘s education and wealth quintiles. WHO and UNICEF recommend exclusive breastfeeding for first 6 months of life starting within an hour after birth, followed by appropriate and adequate complementary breastfeeding for the first 2 years of life as an economical and safe means of protecting children from infection and providing them with an ideal source of nutrients. In Table NU.3, breastfeeding status was based on reports of mothers/caretakers of children‘s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements or medicines) and predominately breastfed infants received breast milk and certain fluids (water based drinks, fruit juices, Oral Rehydration Solution (ORS), Ritual fluids, vitamins, mineral supplements or medicines). The table shows exclusive and predominant breastfeeding of infants during the first 6 months of life, as well as continued breastfeeding at 12–15 and 20–23 months of age. More than half of children below 6 months of age were predominately breastfed (52 percent), while a near to one fourth of children were exclusively breastfed (22 percent). The percentage of exclusively breastfed children was same for both urban and rural (22 percent). By age 12-15 months, 68 percent of children were still being breastfed and by age 20-23 months, such children were 34 percent. Girls were slightly more likely to be exclusively and predominately breastfed than boys. Figure NU.3 shows the detailed pattern of breastfeeding by the child's age in months. Even at earlier ages, a quarter of children received liquids or foods other than breast milk, with almost only two-thirds of children under 1 month exclusively breastfed. The percentage of exclusive breastfeeding decreased by age. A small percentage of older children were still exclusively breastfed, even at age 22–23 months. About 25 percent children of this age were receiving breast milk and complementary feeding. N U T R I T I O N Adequately fed infants under 1 year of age included infants aged 0–5 months who were exclusively breastfed and infants aged 6–11 months who were breastfed and ate solid or semi- solid foods the appropriate number of times the day before the survey. Table NU.4 shows median duration of breastfeeding by selected background characteristics. Among children under age 3 years, the median duration was 18 months for any breastfeeding, 0.6 months for exclusive and 2.4 months for predominant breastfeeding. The adequacy of infant feeding in children under 24 months is provided in Table NU.5. Different criteria of adequate feeding were used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding was considered as adequate feeding, while infants aged 6-23 months were considered to be adequately fed if they were receiving breastmilk and solid, semi-solid or soft food. As a result of these feeding patterns, only 39 percent of children aged 6-23 months were being adequately fed. Adequate feeding among all infants aged 0-5 months dropped to 22 percent. Thirty-five percent of the children aged 0-23 months were appropriately breastfed which was close to the percentage observed for area of residence, mothers‘ education and wealth quintiles. Adequate complementary feeding of children from 6 months to two years of age is particularly important for growth and development and the prevention of undernutrition. Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary foods that help meet nutritional requirements when breastmilk is no longer sufficient. This requires that for breastfed children, two or more meals of solid, semi-solid or soft foods are needed if they are six to eight months old, and three or more meals if they are 9-23 months of age. For children 6-23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. Overall, 38 percent of infants aged 6-8 months received solid, semi-solid, or soft foods (Table NU.6). This percentage was higher in urban 47 as against 35 in rural. Among currently breastfeeding infants this percentage was 37 while it was 47 for infants currently not breastfed. It may be good to note the differences between wealth quintiles for infants aged 6-8 months who received solid, semi-solid and soft foods (Lowest 30 percent versus highest 46 percent). Table NU.7 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 or night preceding the interview by breastfeeding status (see the note in Table NU.7 for a definition of minimum number of times for different age groups). Overall, more than 42 percent of the children aged 6-23 months were receiving solid, semi-solid and soft foods the minimum number of times. A slightly higher percentage of children in urban (48 percent) were achieving the minimum meal frequency compared to rural areas (40 percent). Among currently breastfeeding children aged 6-23 months, 19 percent were receiving solid, semi-solid and soft foods the minimum number of times and this proportion was slightly higher among males (19 percent) compared to females (18 percent). Among non-breastfeeding children, 84 percent were receiving solid, semi-solid and soft foods or milk feeds 4 times or more. The continued practice of bottle-feeding is a matter of concern because of possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.8 shows that bottle-feeding was prevalent in Punjab: 54 percent of children under 6 months were fed using a bottle with a nipple. The bottle feeding was slightly higher in urban (61 percent) compared to rural areas (51 percent). Bottle feeding was higher both in the highest wealth quintile (65 percent) and the mothers with higher education (68 percent). N U T R I T I O N 18 19 5.3. Salt Iodization Iodine Deficiency Disorder is 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, and takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability and impaired work performance. It also increases risk of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. In this survey, the indicator is percentage of households consuming adequately iodized salt greater than or equal to 15 Parts Per Million (PPM). Salt used for cooking was tested for iodine content in 99 percent of surveyed households using salt test kits for presence of potassium iodide. As Table NU.9 shows, a very small proportion of households (0.6 percent) had no salt available at the time of survey. Salt was adequately iodized in 34 percent of households (Figure NU.4): 29 percent higher as compared to MICS Punjab, 2007– 08. Consumption of adequately iodized salt varied greatly among districts, area of residence and wealth quintiles. Use of iodized salt was lowest in Rajanpur district (17 percent) and highest in Gujrat (55 percent). Forty-one percent of urban households were found to be using adequately iodized salt as compared to 31 percent in rural. Use of iodized salt by the richest and the poorest households was at 51 percent and 24 percent respectively. 5.4. 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 vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in developing world and particularly in countries with 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 the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly's Special Session on Children in 2002. The critical role of vitamin A in child health and immune function makes control of deficiency a primary component of child survival efforts, and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. For countries where vitamin A deficiency is common, current international recommendations call for high-dose supplementation every 4–6 months for all children aged 6–59 months living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a Not Iodized (0 PPM) 42% 0< PPM <15 24% 15+ PPM 34% No salt <1% Figure NU.4: Consumption of adequately iodized salt MICS Punjab, 2011 N U T R I T I O N 20 safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers helps protect their children during the first months of life and helps to replenish the mother's own stores of vitamin A which are depleted during pregnancy and lactation. Under Pakistan's National Health Policy 2001 vitamin A supplements are to be provided annually to all children aged 6-59 months on National Immunisation Days through the Expanded Programme on Immunization (EPI) network. This survey uses as an indicator the percentage of children 6–35 months of age who receive at least one high-dose vitamin A supplement in the preceding 6 months. MICS Punjab, 2011 found that about 73 percent of children aged 6–35 months11 received at least one high dose of vitamin A supplements during the 6 months before the interview (Table NU.10) as compared to 79 percent for children aged 6-59 months in MICS Punjab, 2007–08. In the 6 months preceding the survey, children aged 6–11 months had least coverage (62 percent) compared with older children aged 24-35 months who received the supplement (76 percent). 5.5. Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have most impact: mother's poor nutritional status before conception, 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. 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 majority of newborns are not delivered in facilities. Those who were born at facility 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 so, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, percentage of births was estimated from two items in the questionnaire: the mother‘s assessment of the child‘s size at 11 MICS Punjab, 2011 collected this information only from children age less than 36 months, while the standard MICS questionnaire presents this information for children age 6-59 months. N U T R I T I O N 21 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 birth12. Overall, 10 percent of children were weighed at birth out of which 28 percent were weighed less than 2500 grams (Table NU.11). The percentage of low birth weight does not vary much by area of residence, mother‘s education or wealth quintiles (Figure NU.5). 12 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. 28 27 29 29 28 27 26 25 30 30 28 27 26 0 10 20 30 40 50 Area of residence, Mother education and Wealth quintiles Figure NU.5: Percentage of low birth weight children by area of residence, wealth quintile and mother's education MICS Punjab, 2011 N U T R I T I O N 6.1. Vaccinations No public health tool has been as successful and cost-effective as immunisation at saving lives, particularly among the world‘s children. However, creating awareness about the benefits of immunization is critical. For that reason, focused advocacy—an effort to influence policy and decision-makers—and communication efforts on the importance of immunization are key components in the fight against immunization of preventable diseases. The Millennium Development Goal 4 (MDG 4) is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this regard. Immunizations have saved lives of millions of children in the three decades since the launch of the EPI in 1974. Worldwide there are still 27 million children overlooked by routine immunization. As a result, vaccine-preventable diseases cause more than 2 million deaths every year. WFFC goal is to ensure full immunization of children under one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. In accordance with the Health Department guidelines, a child should receive a Bacillus Calmette Guérin (BCG) vaccination to protect him/her against tuberculosis, three doses of PENTA13 to protect against diphtheria, pertussis, tetanus, Haemophilu Influenzae B (HIB), Hepatitis B and three doses of Polio vaccine (with one zero dose at birth) by the age of 12 months. Measles vaccine should be administered by the age of 9 and 15 months. This is in accordance with the UNICEF and WHO guidelines that a child should receive a BCG vaccination to protect against childhood tuberculosis, three doses of PENTA to protect against diphtheria, pertussis, tetanus, HIB and Hepatitis B, three doses of polio vaccine, and measles vaccination by the age of 12 to 15 months14. Information on vaccination coverage was collected for all children under three years of age. All mothers or caretakers were asked to provide vaccination cards. If the vaccination card for a child was available, interviewers copied vaccination information from the cards onto the MICS questionnaire. If no vaccination card was available for the child, the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccinations., and for Polio, PENTA and Hepatitis B, how many doses were received. The final vaccination coverage estimates were based on both information obtained from the vaccination card and the mother‘s report of vaccinations received by the child. The percentage of children aged 12-23 months who had received each of the specific vaccinations by source of information (vaccination card and mother‘s recall) is shown in Table CH.1. The denominator for the table is comprised of children aged 12-23 months so that only children who were old enough to be fully vaccinated were counted. In the first three columns of the table, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother‘s report. In the last column, 13 Combination of 5 Vaccines (Diphtheria, Pertussis, Tetanus, Haemophilias influenza B (HIB) and Hepatitis B) 14 MICS Punjab, 2011 collected vaccination information only from children age less than 36 months, while the standard MICS questionnaire collects the same information for children aged under five. C H I L D H E A L T H 22 C HHILD EALTH 6 C H I L D H E A L T H 23 only those children who were vaccinated before their first birthday, as recommended, are included. 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. Seventy-four percent of the children aged 12-23 months received a BCG vaccination by the age of 12 months and the first dose of PENTA was given to 68 percent. The percentage declined marginally for subsequent doses of PENTA to 64 percent for the second dose, and 54 percent for the third dose (Figure CH.1). Similarly, 77 percent of children received Polio 1 by age of 12 months and this declined to 68 percent by the third dose. The coverage for measles vaccine by 12 months was higher than the third dose coverage of PENTA, at 60 percent. The percentage of children who had received all the recommended vaccinations by their first birthday was only 43 percent in MISC Punjab, 2011. The proportion of children not receiving any type of vaccination was 20 percent. Table CH.2 presents vaccination coverage estimates among children aged 12-23 months by background characteristics; area of residence, sex of the child, mother education and wealth quintiles. Overall, only 35 percent of children had vaccination cards. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and were based on information from both the vaccination cards and mothers‘/caretakers‘ reports. The coverage of BCG and Polio1 was higher than that of other vaccinations. However, the coverage of Polio3 and PENTA3 dropped by 4 percent and 9 percent compared to Polio2 and PENTA2 respectively. Measles vaccination was received by only 65 percent of children aged 12-23 months. Overall, 47 percent of children aged 12-23 months who were fully vaccinated, they received BCG, 3 doses of Diphtheria, Pertussis and Tetanus (DPT), 3 doses of Polio and measles vaccines. Immunization coverage among girls was slightly higher than that of boys. It would be interesting to note the differences in all vaccine coverage between rural (45 percent) versus 74 77 74 68 68 64 54 60 43 0 20 40 60 80 100 Vaccination Figure CH.1: Percentage of children aged 12-23 months who received the recommended vaccinations by 12 months MICS Punjab, 2011 24 urban (52 percent), mothers with no education (39 percent) versus with higher education (59 percent) and wealth quintiles (33 percent in lowest versus 58 percent in highest). 6.2. Neonatal Tetanus Protection One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy being to eliminate maternal tetanus. Another goal is to reduce the incidence of neonatal tetanus to less than 1 case of neonatal tetanus per 1000 live births in every district. WFFC goal is to eliminate maternal and neonatal tetanus by 2005. Prevention of maternal and neonatal tetanus requires that all pregnant women receive at least two doses of tetanus toxoid vaccine. However, if women have not received two doses of the vaccine during pregnancy, they (and their newborn) are considered to be protected if the following conditions are met: Received at least two doses of tetanus toxoid vaccine, the last within the prior 3 years; Received at least 3 doses, the last within last 5 years; Received at least 4 doses, the last within 10 years; Table CH.3 shows protection status from tetanus of women who had a live birth within last two years. Seventy-five percent of the women were found to be protected against tetanus, rural 72 percent and urban 82 percent. Differentials in neonatal tetanus protection coverage were observed in women education and wealth quintiles. Women with no education were less likely to be protected (65 percent) compared to women with high education (91 percent) (Figure CH.2). Disparities existed among districts, the lowest in DG Khan (48 percent) and Rajanpur (52 percent) and the highest in Sialkot (94 percent), Gujrat and Gujranwala (89 percent). 6.3. Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from body in liquid stools. Management of diarrhoea either through 75 82 72 65 80 82 89 91 61 69 76 82 89 0 20 40 60 80 100 Area of residence, Wealth index quintiles and Mothers' education Figure CH.2: Percentage of women protected against tetanus by area of residence, wealth quintile and mother education MICS Punjab, 2011 C H I L D H E A L T H 25 ORS or a Recommended Home Fluid (RHF) can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals are to: 1) reduce by one half the deaths due to diarrhoea among children under five by 2010 compared to 2000 (WFFC); 2) reduce by two thirds the mortality rate among children under five by 2015 compared to 1990 (Millennium Development Goals); 3) reduce incidence of diarrhoea by 25 percent; In the MICS Punjab, 2011, prevalence of diarrhoea was estimated by asking mothers or caretakers whether their child under age five years had an episode of diarrhoea in the two weeks prior to the survey. In cases where mothers reported that the child had diarrhoea, a series of questions were asked about the treatment of the illness, including what the child had to drink and eat during the episode and whether that was more or less than the child usually drank and ate. The indicators are: Prevalence of diarrhoea Oral rehydration therapy (ORT) Home management of diarrhoea (ORT or increased fluids) and continued feeding Overall, 16 percent of under five children had diarrhoea in the two weeks preceding the survey (Table CH.4), which was higher as compared to MICS Punjab, 2007-08 (8 percent). This increase may be attributed to summer timing of the survey because in summer diarrhoea outbreaks are usually high. Peak prevalence of diarrhoea occurred amongst children aged less than 12 months and between 12-23 months (22 and 23 percent respectively). Prevalence was higher in rural (17 percent) than in urban areas (14 percent). Diarrhoea among children under 5 was negatively associated with wealth quintiles: higher prevalence in lowest quintile and lower in the highest quintile. The same relation was seen for education of the mother. Table CH.4 also shows percentage of children receiving various types of recommended liquids during episode of diarrhoea. Since mothers were able to name more than one type of liquid, the percentages do not necessarily add to 100. About 29 percent received fluids from ORS packets or pre-packaged ORS fluids and 8 percent received recommended homemade fluids. Children of mothers with no education were less likely to receive oral rehydration treatment than other children. Approximately 34 percent of children with diarrhoea received one or more of the recommended home treatments (i.e. ORS or any recommended homemade fluid). Disparities existed among area of residence, rural (33 percent) and urban (38 percent). Only 10 percent of under five children with diarrhoea drank more than usual while 79 percent drank the same or less (Table CH.5). Seventy-eight percent ate somewhat less, same or more (continued feeding) and remaining 22 percent ate much less or nil. Figure CH.3 showed the drinking and eating practices of under 5 children during the episodes of diarrhoea. C H I L D H E A L T H 26 Table CH.6 provides proportion of children aged 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and percentage of children with diarrhoea who received other treatments. Overall, 36 percent of children with diarrhoea received ORS or increased fluids and 40 percent ORT (ORS or recommended homemade fluids or increased fluids). Combining the information in Table CH.5 with that in Table CH.4 on oral rehydration therapy, it was observed that 30 percent of children received ORT and, at the same time, feeding was continued, as is the recommendation. There were significant differences in home management of diarrhoea by background characteristics. In rural areas, only 29 percent received ORT and continued feeding, as compared to 34 percent in urban areas. This practice showed a positive correlation with mother‘s education and wealth quintiles. Highest ORT and continued feeding use was in D.G Khan District (56 percent) and lowest was in R.Y Khan (17 percent). 6.4. Care Seeking and Antibiotic Treatment for Suspected Pneumonia Pneumonia is the leading cause of death in children. Use of antibiotics in under 5 years with suspected pneumonia is a key intervention. WFFC goal is to reduce by one-third the deaths due to acute respiratory infections. In MICS Punjab, 2011 prevalence of suspected pneumonia was estimated by asking mothers or caretakers whether their child under age five had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were due to a problem in chest or problem in the chest accompanied by a blocked nose. Table CH.7 presents prevalence of suspected pneumonia and, if care was sought outside home, the site of care. Only 3 percent of children aged 0-59 months were reported to have symptoms of pneumonia during the two weeks preceding the survey. Of these 77 percent were taken to an appropriate provider (Figure CH.5). Prevalence of pneumonia dropped from 3.9 percent in infants (0–11 months) to 2.5 percent in children (48–59 months). The percentage of children taken to appropriate providers varied with area of residence with higher percentage (82 percent) in urban compared to rural areas (76 percent). Percentages remained almost constant for mother's education and wealth quintiles. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.8. Mother‘s knowledge of the danger signs is an important determinant of care-seeking behaviour. About 7 percent women know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptoms for taking a child to a health facility were ‘develops a fever‘ (78 percent), ‘fast breathing‘ (17 percent) and ‘difficult 8.9 30.3 49.1 10.3 1.1 11.6 30.2 44.5 3.0 10.5 0.0 10.0 20.0 30.0 40.0 50.0 60.0 Much less Somewhat less About same More Nothing Drinking and Eating habbits Figure CH.3: Drinking and eating practices of the children under 5 years during the episodes of diarrhoea MICS Punjab, 2011 Drink Eat C H I L D H E A L T H 27 breathing‘ (15 percent). No variations existed among area of residence, but districts varied markedly. 6.5. Solid Fuels More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is that harmful products of incomplete combustion including carbon monoxide (CO), polyaromatic hydrocarbons, sulphur dioxide (SO2) and other toxic elements, increase risk of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts and asthma. The primary indicator is proportion of the population using solid fuels as the primary source of domestic energy for cooking. Here primary indicator is proportion of the population using solid fuels, including wood, charcoal, crop residue and dung as the primary source of domestic energy for cooking. Overall 66 percent of households were found using solid fuels for cooking (Table CH.9). The use of wood was especially common (39 percent) followed by Animal dung (16 percent). Use of solid fuels was low in urban (17 percent) and high in rural areas (86 percent). It was especially low in major cities (5 percent) compared to other urban areas (30 percent). Differentials with respect to household wealth quintile and education of the household head were also significant. Households in the highest wealth quintile were much less likely to use solid fuels (3.2 percent) compared to 100 percent in the lowest wealth quintile (Figure CH.6). Lahore district showed the lowest proportion of households using solid fuel (12 percent) whereas the highest percentage was observed in Rajanpur and Bhakkar (98 percent) (Table CH.9). Solid fuel use alone was a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while open stove or fire with no chimney or hood means that there is no protection from the harmful effects of solid fuels. Solid fuel use by place of cooking is depicted in Table CH.10. 66 86 17 100 98 86 43 3 0 20 40 60 80 100 Figure CH.4: Percentage distribution of household using solid fuel by area of residence and wealth quintiles MICS Punjab, 2011 C H I L D H E A L T H 28 Twenty-one percent of the households used solid fuel in a separate room used as a kitchen and 75 percent were using the place which was located elsewhere in the house. Figure CH.5 shows the utilization of solid fuel by place of cooking. In a separate room used as kitchen 21% Elsewhere in the house 75% Outdoors / open place 3% Other / Missing 1% Figure CH.5: Utilization of solid fuel by place of cooking MICS Punjab, 2011 C H I L D H E A L T H W SATER AND ANITATION 7 W A T E R A N D S A N I T A T I O N29 Safe drinking water is a necessity and a basic human right. Unsafe drinking water can be a significant carrier of diarrhoea and other diseases such as cholera, typhoid and dysentery. Drinking water can also be polluted with chemicals, physical and microbiological contaminants which may have harmful effects on human health. In addition, access to drinking water may be particularly important for women and children who often bear the primary responsibility for carrying water, particularly in rural areas. MDG target is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation, while WFFC calls for reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The following indicators were covered in MICS Punjab, 2011: Water • Use of improved drinking water sources; • Use of adequate water treatment method; • Time to source of drinking water; and • Person collecting drinking water. Sanitation • Use of improved sanitation facilities; and • Sanitary disposal of child‘s faeces. This survey also collects information on availability of facilities and conditions for handwashing. The following aspects were covered: • Place for handwashing; • Availability of soap in household. 7.1. Use of Improved Water Sources Distribution of population by main source of drinking water is shown in Table WS.1 and Figure WS.1. Improved sources of drinking water include piped water (into dwelling, compound, yard or plot, to neighbour, public tap/standpipe), hand pump, motorised pump, tubewell /borehole or turbine, protected well and spring. Rainwater is not considered as improved source since animals also drink water from the same source. Bottled water is considered as an improved water source only if the household is using an improved water source for handwashing and cooking. Overall, 94 percent of the population was using an improved source of drinking water – 88 percent in urban areas and 96 percent in rural. People of Punjab rely primarily on motorised pumps (41 percent) and hand pumps 34 percent. Other sources were piped water (15 percent) and public taps or standpipes (3 percent) (Figure WS.1). It may be noted that motorised pump connected to a main water source (borehole or water supply pipeline), might have depressed responses to the use of piped water. This was particularly important in urban areas where most households reported motorised pumps connected to a piped water source. This may have contributed to the low reported rate of 15 percent use of piped water as households may report motorised pumps which were installed on water supply pipelines or underground storage inside dwellings used to store drinking water from pipelines. Water supply from tankers and carts accounting for just over 2 percent were the main unimproved source of drinking water and were mostly found in major cities. The largest users of this source were in Faisalabad district (19 percent). W A T E R A N D S A N I T A T I O N 30 Eighty-six percent of the population residing in major cities had access to improved water sources: piped water (47 percent) and motorised pump (27 percent), while in other urban areas more than half used motorised pumps, and use of hand pump and piped water were 15 and 18 percent, respectively. In most of the districts, 90 percent of the population had access to improved sources of drinking water. Only four districts, Faisalabad (80 percent), DG Khan (85 percent), Rajanpur and Rawalpindi (87 percent) had less than 90 percent. Water treatment method used by households is presented in Table WS.2. Households were asked about ways through which they treated water at home to make it safer for drinking. Boiling water, adding bleach or chlorine, using a water filter, and using solar disinfection are considered as proper treatment of drinking water. The table shows water treatment by all households. About 7 percent of them were using appropriate water treatment methods. Boiling (3.9 percent) and water filter (1.7 percent) were the most common methods used for treatment. Figure WS.2 shows percentage of household members using unimproved drinking water sources and an appropriate water treatment method. Use of appropriate water treatment methods varied by area of residence with the highest percentage occurring in major cities (5.3 percent), followed by all urban areas (4.9 percent) and under 2 percent in rural areas. Appropriate water treatment was associated with households whose heads had higher education (8.2 percent) and with households in the highest wealth quintile (6.3 percent). Significant variations existed across districts. People in Lahore had the highest use of appropriate water treatment (12.7 percent) mostly boiling (22 percent) or filtration (8 percent) followed by Gujranwala (12 percent). Other districts ranged from 8 percent to under 1 percent with the lowest usage in Bahawalpur and Muzaffargarh. Piped into dwelling 12% Piped into compound, yard or plot 2% Piped to neighbour 1% Public tap / standpipe 3%Tube well 1% Hand pump (tap) 34% Motorized pump (dunky / turbine) 41% Protected well 1% Protected spring 0%Bottled water (mineral) 0% Un-improved 6% Figure WS.1: Percentage distribution of household members by source of drinking water MICS Punjab, 2011 6.3 2.6 1.0 0.9 1.1 8.2 4.7 2.3 2.7 1.5 1.8 4.9 3.6 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Highest Fourth Middle Second Lowest Wealth quintiles Higher Secondary Middle Primary None Education of head Rural Urban Area of residence Punjab Percent Figure WS.2: Households using unimproved drinking water and using appropriate water treatment by area of residence, education of head of household and wealth quintiles MICS Punjab, 2011 The amount of time taken to obtain water is presented in Table WS.3 and the person who usually collected the water in Table WS.4. Note that these results refer to one roundtrip from home to drinking water source and back. Information on the number of trips made in one day was not collected. Table WS.3 shows that in 89 percent of households, the drinking water source was on their premises. However, regional variations revealed that less households in Faisalabad (74 percent), Rajanpur (75 percent), Rawalpindi (77 percent) and DG Khan (78 percent) had water on their premises. For 6 percent of all households, it takes less than 30 minutes to get to the water source and bring water, while 3.7 percent spend 30 minutes or more for this purpose. The households spending 30 minutes or more to fetch water were 15 percent in Rajanpur and DG Khan compared with 8 percent in Faisalabad and RY Khan. Table WS.4 shows that in 44 percent of households, an adult male was usually the person collecting water followed by an adult female (38 percent), when the source of drinking water was not on the premises. Only in 7 percent of the cases, female or male children under age 15 collected water. Proportion of missing was 11 percent i.e., who did not respond to the question. In the highest wealth quintile higher proportion of adult males was collecting water (64 percent) as compared to the lowest wealth quintile where more adult females were performing this activity (67 percent). 7.2. Use of Improved Sanitation Facilities Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases including diarrhoeal diseases and polio. An improved sanitation facility is defined as the one that hygienically separates human excreta from human contact. Improved sanitation can reduce diarrheal disease by more than a third, and can significantly lessen 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 or pour flush to a piped sewer system, septic tank, or pit latrine; ventilated improved pit latrine, pit latrine with slab, and use of a composting toilet. Seventy-two percent of the population of Punjab was living in households using improved sanitation facilities (Table WS.5). This percentage was 92 in urban and 64 percent in rural areas. Flush toilets piped to sewerage system was the most common sanitation facility in major cities (81 percent) whereas flush to septic tank was most common in both rural (46 percent) and other urban (52 percent). No facility, bush or field (i.e unimproved facilities) were most common in rural areas (32 percent). Table indicates that use of improved sanitation facilities had a strong positive correlation with education of the head of the household and wealth quintiles (Figure WS.3). Districts where residents were least likely to use improved sanitation facilities included Rajanpur (33 percent), DG Khan (42 percent), Multan (45 percent), Muzaffargarh (46 percent), Chiniot (47 percent) and Jhang (48 percent). 97 94 88 66 16 93 87 80 72 59 64 92 72 0 20 40 60 80 100 Highest Fourth Middle Second Lowest Wealth quintiles Higher Secondary Middle Primary None Education of head Rural Urban Area of residence Punjab Percent Figure WS.3: Percentage of household population using improved sanitation facility by area of residence, education of head and wealth quintiles MICS Punjab, 2011 W A T E R A N D S A N I T A T I O N31 The MDGs and the WHO / UNICEF Joint Monitoring Programme for Water Supply and Sanitation classify households as using an unimproved sanitation facility if they are using otherwise acceptable sanitation facilities but sharing a facility between two or more households or using a public toilet facility. As shown in Table WS.6, 72 percent of the household population was using an improved sanitation facility. Use of ‘not shared‘ facility was more common among households with improved facility (single as well as shared). Only 9 percent of them used an improved facility that was shared with other households; rural 9.3 percent and urban 8.4 percent. Open defecation was 23 percent, mostly found in rural areas (32 percent) and in lowest wealth quintile (82 percent). Safe disposal of a child‘s faeces means disposing of stool, using a toilet or by rinsing into a toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table WS.7. The faeces of 66 percent children were disposed of safely with considerable variation among rural (57 percent) and urban (91 percent). This percentage was noticeably low for the lowest wealth quintile (17 percent) compared to the highest wealth quintile (92 percent). Mother‘s education followed a similar pattern. Table WS.8 shows that 58 percent of the household members in Punjab were using improved sources of drinking water and improved sanitation facilities. There was considerable variation among rural (52 percent) and urban (74 percent). Figure WS.4 shows the percentage of household population using improved drinking water sources and improved sanitation (not shared) and both improved water sources and sanitation by area of residence. Districts varied markedly for the households that had both improved drinking water and improved sanitation (DG Khan 21 percent versus Lahore 85 percent). 7.3. Handwashing Handwashing with water and soap is the most cost effective health intervention to reduce both incidence of diarrhoea and pneumonia in children under five. It is most effective when done using water and soap after visiting 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. A reliable alternative to observations or self-reported behaviour is assessing the likelihood that correct hand washing behaviour 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 a specific place for handwashing. The survey used observational method to confirm the following relating to handwashing practices: i. Place of hand washing; ii. Presence of water; and 96 54 52 88 84 74 94 63 58 0 20 40 60 80 100 Improved water sources Improved sanitation (Not shared) Improved water sources and sanitation Water & Sanitation categories Figure WS.4: Percentage of household population using improved drinking water sources and improved sanitation facility (not shared) by area of residence MICS Punjab, 2011 Rural Urban Punjab W A T E R A N D S A N I T A T I O N 32 33 iii. Presence of soap or any other cleaning material. In Punjab, 97 percent of the households with a specific place for hand washing were observed, while 1.1 percent could not indicate a specific place and 1.7 percent did not give a permission to see the place used for handwashing (Table WS.9). Of those households where a place for handwashing was observed, more than two-thirds, (77 percent) had both water and soap present at the specific place. Availability of water and soap was positively correlated with wealth quintiles. Figure WS.5 shows the disparities between wealth quintiles and area of residence. Variations were also observed among districts. Availability of both water and soap was low in DG Khan (36 percent), RY Khan (54 percent) and Jhang (55 percent), whereas high in Gujrat (96 percent), Hafizabad, Gujranwala and Lahore (94 percent). In 19 percent of the households only water was available at the specific place, while in 1.1 percent the place only had soap but no water. The remaining 2.5 percent of households had neither water nor soap available at the designated place for hand washing. In 95 percent of the households either the soap was observed (78 percent) or shown (17 percent) to the interviewer (Table WS.10) (Figure WS.6). 98 93 85 68 43 71 92 77 0 20 40 60 80 100 Highest Fourth Middle Second Lowest Wealth quintiles Rural Urban Area of residence Punjab Percent Figure WS.5: Availability of both water and soap at the place of hand washing MICS Punjab, 2011 Soap observed 78% Soap shown 17% No soap in household / Not shown 5% Figure WS.6: Availability of soap in observed households MICS Punjab, 2011 W A T E R A N D S A N I T A T I O N R E P R O D U C T I V E H E A L T H 35 Childbearing early in life carry significant risks for young people all around the world. Table RH.2 presents some early childbearing indicators for ever-married women aged 15-19 and 20- 24 years (ever married) while Table RH.3 presents the trends for early childbearing. As shown in Table RH.2, 37 percent of women aged 15-19 years had already had a birth, 22 percent were pregnant with their first child, 60 percent had begun childbearing and 3.6 percent had a live birth before age 15. Fourteen percent of the women in age group of 20-24 years reported that they had a live birth before age 18. The disparities among area of residence, mother education and wealth quintiles are presented in Figure RH.2. The percentage for ever-married women aged 15-19 years who had a live birth and was pregnant with first child and had begun childbearing was higher in comparison to the percentage of ever married women aged 20-24 years who had a live birth before the age of 18 years. 8.2. Unwilling Pregnancy 8.3. Contraception Appropriate family planning is important for the health of women and children. It can be guaranteed by: 1. Preventing pregnancies that are too early or too late; 2. Extending / spacing the period between births; and 3. Limiting the number of children. WFFC goal is to ensure access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many i.e., unwanted pregnancies. 3 7 11 13 19 8 9 11 18 21 15 11 14 0 5 10 15 20 25 Higher Secondary Middle Primary None/ preschool Women Education Highest Fourth Middle Second Lowest Wealth quintiles Rural Urban Area of residence Punjab Percent Figure RH.2: Percentage of ever-married women aged 20-24 who had a live birth before age 18 by area of residence, wealth quintiles and women education MICS Punjab, 2011 In MICS Punjab, 2011 most pregnant women reported that they wanted to have children when they got pregnant (91 percent), while 7.9 percent did not want to get pregnant. Out of these unwilling pregnant women, 39 percent wanted child and 53 percent did not want child (Table RH.12).Unwilling pregnancy did not vary much among urban and rural areas. It increased with the number of living children: increasing from 0.3 percent for women with no living children to 21 percent for women who had four or more. There was no clear trend to correlate with wealth quintiles and women education. Narowal had the smallest percentage (0.5 percent) of unwilling pregnancies while Mandi Bahaudin had the largest (17 percent). R E P R O D U C T I V E H E A L T H 36 Current use of contraception was defined as the proportion of women who reported that they were using a family planning method at the time of interview. Only women 15-49 years who were married at the time of survey were asked questions in this regard. Current use of contraception was reported by 35 percent of women (currently married) or their husbands (Table RH.4) which was high as compared to 32 percent in MICS Punjab, 2007–08. More women were using modern methods (29 percent) than traditional methods (6.3 percent). With 11 percent usage, the most popular method was female sterilisation (Figure RH.3) followed by condom (8.3 percent) and Intrauterine Devices (IUDs) (3.5 percent). It would be interesting to note that female sterilization (11 percent) was higher than male sterilization by only 0.1 percent. Current contraceptive use was higher in urban (43 percent) than in rural areas (32 percent). Condom was the most popular method in urban areas (13 percent) followed by female sterilisation (12 percent), while in rural areas female sterilisation was followed by condom (7 percent). Younger women were less likely to use contraception than older women. Only about 8.2 percent of married women aged 15–19 years were currently using any method of contraception. This was expected in a society where young women were anxious to get pregnant as soon as they marry. This percentage increased by age until it reached 46 percent for women 40-44 years old and decreased for women aged 45–49 years (37 percent). Figure RH.4 displays the use of modern and traditional contraceptives by women's age. Modern contraceptive methods were more commonly used than traditional methods across all age groups except 15-19 years. Use of traditional methods was nearly constant for women aged 20 to 44 years. Not using any method 65% Female sterilization 11% IUD 4% Injectables 3% Pill 2% Condom 8% Lactational amenorrhoea method (LAM) 3% Withdrawal 3% Other / implants / male sterilization 1% Figure RH.3: Percentage of currently married women aged 15-49 years who were using (or whose husband were using) a contraceptive method MICS Punjab, 2011 4 7 7 7 7 6 44 13 22 32 38 40 33 92 80 71 61 55 54 63 0 20 40 60 80 100 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age groups Figure RH.4: Contraceptive utilization of currently married women aged 15-49 years by method MICS Punjab, 2011 No method Modern method Traditional method 37 Contraceptive prevalence was associated with women education. Contraceptive users with no education were more likely to use female sterilisation, while with higher education; they were most likely to use condoms. Women in the highest wealth quintile were more likely to use contraceptive methods compared to other women. The largest proportion of women using traditional methods was in the highest wealth quintile (8 percent). Use of any contraceptive method was low when the woman had no living children (1 percent). The greater the number of living children a woman had the more likely was the use contraceptives. The use of contraceptive rose from 19 percent for women with 1 living children to 49 percent for women with four or more children (Figure RH.5). Differentials existed in current use of contraception across 36 districts. Women in Gujranwala District had the highest contraceptive prevalence (47 percent) while Bhakkar and DG Khan had the lowest (22 percent). 8.4. Contraceptive Dropout Slightly more than seven percent of women had used contraceptives in the past but were not currently using. They are defined as ‘dropouts‘. Table RH.4A presents the percentage of non- pregnant women who were not using any contraceptive method (dropout). The dropout was higher in urban (7.6 percent) compared to rural (6.9 percent). The dropouts were highest in Bahawalnagar followed by Narowal, Chakwal and Gujrat (Table RH.4A). 8.5. Unmet Need Unmet need for contraception refers to fecund women who were not using any method of contraception, but who wish to postpone the next birth (spacing) or who wish to stop childbearing altogether (limiting). Unmet need was identified in MICS Punjab, 2011 by using a set of questions eliciting current behaviours and preferences pertaining to contraceptive use, fecundity, and fertility preferences. Table RH.5 shows the levels of met need, unmet need and the demand for contraception satisfied. Unmet need for spacing is defined as the percentage of women who are not using a method of contraception and are not pregnant and not postpartum amenorrheic15 and are fecund16 and say they want to wait two or more years for their next birth or 15 A women is postpartum amenorrheic if she had a birth in last two years and is not currently pregnant, and her menstrual period has not returned since the birth of the last child. 16 A women is considered infecund if she is neither pregnant nor postpartum amenorrheic, and 43 37 35 33 28 1 19 31 43 49 32 43 35 0 10 20 30 40 50 60 Highest Fourth Middle Second Lowest Wealth quintiles 0 1 2 3 4+ No. of living children Rural Urban Area of residence Punjab Percent Figure RH.5: Percentage of currently married women aged 15-49 years who were using (or whose husband were using) a contraceptive method by area of residence, number of living children and wealth quintiles MICS Punjab, 2011 R E P R O D U C T I V E H E A L T H 38 are not pregnant and not postpartum amenorrheic and are fecund and unsure whether they want another child or are pregnant and say that pregnancy was mistimed: would have wanted to wait or are postpartum amenorrheic and say that the birth was mistimed: would have wanted to wait Unmet need for limiting is defined as percentage of women who are not using a method of contraception and are not pregnant and not postpartum amenorrheic and are fecund and say they do not want any more children or are pregnant and say they do not want to have a child or are postpartum amenorrheic and say that they did not want the birth Total unmet need for contraception is the sum of unmet need for spacing and limiting. Seventeen percent of women confirmed the unmet need for contraception spacing (8.9 percent) and limiting (8.2 percent). Met need for limiting includes women who were using (or whose partner is using) a contraceptive method and who want no more children, are using male or female sterilization or declare themselves as infecund. Met need for spacing includes women who are using (or whose partner is using) a contraceptive method and who want to have another child or are undecided whether to have another child. The total of met need for spacing and limiting ads up to the total met need for contraception. Thirty-five percent of the women confirmed the met need of contraception for spacing (10 percent) and limiting (25 percent). Using information on contraception and unmet need, the percentage of demand for contraception satisfied is also estimated from the MICS data. The percentage of demand satisfied is defined as the proportion of women currently married who are currently using contraception, of the total demand for contraception. The total demand for contraception includes women who currently have an unmet need (for spacing or limiting), plus those who are currently using contraception. Overall demand for contraception satisfied found to be 67 percent with notable variation among rural (65 percent) and urban (73 percent). Total met need was higher than the total unmet need for family planning (Table RH.5). Unmet need was high (17 percent) among rural women and in those with higher and secondary education (19 percent). Unmet need did show reverse correlation with wealth quintiles, higher 19 percent in the lowest wealth quintile and lowest 15 percent in the highest wealth quintile. 8.6. Antenatal Care Antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. Better understanding of foetal growth and development and its relationship to the mother's health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about (1a) has not had menstruation for at least six months, or (1b) never menstruated, or (1c) her last menstruation occurred before her last birth, or (1d) in menopause/has had hysterectomy OR (2) She declares that she has had hysterectomy, or that she has never menstruated or that she is menopausal, or that she has been trying to get pregnant for 2 or more years without result in response to questions on why she thinks she is not physically able to get pregnant at the time of survey OR (3) She declares she cannot get pregnant when asked about desire for future birth OR (4) She has not had a birth in the preceding 5 years, is currently not using contraception and is currently married and was continuously married during the last 5 years preceding the survey R E P R O D U C T I V E H E A L T H 39 the risks of labour and delivery, it may provide the route for ensuring that pregnant women do, in practice, deliver with the assistance of Skilled Birth Attendant (SBA). The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life-saving for both the mother and infant. Prevention and treatment of malaria among pregnant women, management of anaemia during pregnancy and treatment of Sexually Transmitted Infections (STIs) can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women's nutritional status and prevent infections (e.g., malaria and STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content of antenatal care visits, which include: Blood pressure measurement Urine testing for bateriuria and proteinuria Blood testing to detect syphilis and severe anaemia Weight/height measurement (optional) The type of personnel providing antenatal care to women aged 15-49 years who gave birth in the two years preceding the survey is presented in Table RH.6. The result shows that a relatively small percentage of women did not receive antenatal care. Coverage of antenatal care by SBA was 74 percent which showed a significant increase compared to MICS Punjab, 2007–08 (53 percent). The survey showed that mainly doctors provided antenatal care in the Punjab (59 percent) (Figure RH.6), whereas only 5.1 percent of women received antenatal care from traditional birth attendant, i.e., non-skilled personnel. It was substantially low as compared to MICS Punjab, 2007-08 (26 percent). Nineteen percent of women did not receive any antenatal care during pregnancy which was almost the same as in MICS Punjab, 2007-08. Antenatal care coverage by SBA was 17 percent higher in urban areas compared to rural. Major cities had the highest rate of antenatal care by SBA (91 percent). Younger women were more likely to seek antenatal care than older ones. Antenatal care increased markedly by women's education and wealth quintiles. In the lowest wealth quintile, the percentage of women receiving antenatal care was 51 percent, rising to 78 percent in the middle and 94 percent in the highest. Number of women receiving antenatal care also varied by districts; Gujrat and Jhelum 91 percent, Rajanpur 48 percent, DG Khan 51 percent and Kasur 53 percent. No antenatal care 19% LHW 1% Traditional birth attendant 5% Other/missi ng 1% Doctor 59% Nurse / Midwife 12% LHV 3% Other 74% Figure RH.6: Percent distribution of women aged 15-49 years (ever married) received antenatal care MICS Punjab, 2011 R E P R O D U C T I V E H E A L T H 40 Table RH.7 shows number of antenatal care visits during the last pregnancy preceding two years of the survey. Forty-one percent of the women had four or more visits for antenatal care with significant variations among rural (32 percent) and urban (63 percent). In the lowest wealth quintile the percentage of women with 4 or more visits was 15 percent, rising to 37 percent in the middle quintile and 78 percent in the highest. Similar pattern was observed for women‘s education. The types of services pregnant women received during antenatal care are shown in Table RH.8. Among those who had a live birth during the two years preceding the survey, 45 percent reported that a blood sample was taken during antenatal care visits, 67 percent told that their blood pressure was checked, 52 percent indicated that urine specimen was taken and 39 percent said that weights were measured. All four (Blood pressure measured, urine specimen, blood test taken and Weight taken) were reported by 32 percent of the women, whereas the first three (Blood pressure measured, urine specimen and blood test taken) were performed for 41 percent. In the lowest wealth quintile the percentage of women with all 4 tests measured was 6.4 percent, rising to 28 percent in the middle and 73 percent in the highest wealth quintile. 8.7. Assistance at Delivery Three quarters of all maternal deaths occur during delivery and immediate post-partum period. The single most critical intervention for safe motherhood is to ensure that a competent health worker, with midwifery skills, is present at every birth, and transport is available to a referral facility for obstetric care in case of emergency. WFFC goal is to ensure that women have ready and affordable access to SBA. The indicators are proportion of births with SBA and proportion of institutional deliveries. Presence of SBA at delivery indicator is also used to track progress toward the Millennium Development target of reducing the maternal mortality rate by three quarters between 1990 and 2015. MICS included a number of questions to assess the proportion of births attended by a SBA. About 59 percent of births occurring in the two years preceding the survey were delivered by SBA (Table RH.9) with significant difference between rural 52 percent and urban 75 percent. This percentage was highest in Lahore 82 and the lowest in Rajanpur 17. The more educated a woman, the more likely she was to have delivery with the assistance of a SBA. Figure RH.7 shows the skilled assistance at delivery by background characteristics. Medical doctors assisted 45 percent of births while nurses or midwifes 11 percent, Lady Health Visitors (LHVs) 3 percent, Lady Health Workers 1 percent and relatives/friends 2 percent. Thirty-eight percent of births were delivered with assistance of Traditional Birth 89 71 59 46 33 92 82 73 61 42 52 75 59 0 20 40 60 80 100 Highest Fourth Middle Second Lowest Wealth quintiles Higher Secondary Middle Primary None Women education Rural Urban Area of residence Punjab Percent Figure RH.7: Percentage of women aged 15-49 years (ever- married) had skilled assistance during delivery by area of residence, women education and wealth quintiles MICS Punjab, 2011 R E P R O D U C T I V E H E A L T H 41 S O C I O E C O N O M I C D E V E L O P M E N T Attendants (TBAs) which was considerably low as compared to MICS Punjab, 2007-08 (55 percent). Women aged 20–34 were more likely to be assisted by SBA. Women with less than primary education were more likely to deliver with assistance of a traditional birth attendant, while more educated women tended to get assistance from doctors. Women in the highest wealth quintile were more likely to be assisted by SBA (89 percent) than in the lowest wealth quintile who was mainly assisted by TBAs (62 percent). The women assisted during delivery by SBA were 82 percent in Lahore, 80 percent in Jhelum and 79 percent in Rawalpindi. Women in Rajanpur district were the least likely to have deliveries assisted by SBA (17 percent). Here, 73 percent of the women were assisted by TBAs. 8.8. Caesarean Section A Caesarean section, is a surgical procedure in which one or more incisions are made through mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus. The question about caesarean was asked from women 15-49 years (ever married) who had a live birth preceding two years of date of survey. Eighteen percent of the births preceding the survey were delivered by caesarean section with prominent disparities among area of residence, women education and wealth quintiles (Table RH.9 and Figure RH.8). 8.9. Place of Delivery Increasing proportion of births delivered in health facilities is an important factor in reducing health risks for both the mother and the baby. Proper medical attention and hygienic conditions during delivery can reduce the risks of complications and infection that can cause morbidity and mortality to either the mother or the baby. Table RH.10 presents the percent distribution of women aged 15- 49 (ever married), who had a live birth in the two years preceding the survey by place of delivery and the percentage of births delivered in a health facility, according to background characteristics. 18 15 25 10 18 22 29 36 7 11 17 24 33 0 10 20 30 40 Background variables Figure RH.8: Caesarean section by area of residence, mother's education and wealth quintiles MICS Punjab, 2011 77 45 20 86 66 53 40 29 47 71 53 0 20 40 60 80 100 4+ visits 1-3 visits None Antenatal care visits Highest Fourth Middle Second Lowest Wealth quintiles Rural Urban Area of residence Punjab Percent Figure RH.9: Place of delivery by area of residence, antenatal visits and wealth quintiles MICS Punjab, 2011 R E P R O D U C T I V E H E A L T H 42 Fifty-four percent of births were delivered in a health facility; 17 percent in public sector and 37 percent in private sector facilities. Almost half (46 percent) occur at home. By age, women aged 20-34 years were more likely to deliver in a health facility (55 percent). Women in urban areas were more likely to deliver in a health facility compared to their rural counterparts (71 percent compared with 47 percent). Rawalpindi and Lahore districts had the highest proportion of institutional deliveries (79 percent each), followed by Jhelum (73 percent), while Rajanpur had the lowest proportion (16 percent). Women with higher education were more likely to deliver in a health facility than women with less or no education. The proportion of births occurring in a health facility increased steadily with increasing wealth quintile, from 29 percent in the lowest wealth quintile to 86 percent in the highest (Figure RH.9). The majority of women who received no antenatal care services delivered at home (77 percent). 8.10. Postnatal Care Care following delivery is very important for both mother and child, particularly if the birth is not assisted by SBA. It is generally recommended that mothers receive the first postnatal check-up within two days of delivery in order to detect problems that may lead to maternal death. Postnatal care coverage by a skilled personnel was 38 percent (Table RH.10A) with significant variations among rural (32 percent) and urban (53 percent). As expected, the percentage of women receiving postnatal care increased markedly by women's education. The percentage of women receiving postnatal care rose from 19 percent in the lowest wealth quintile to 37 percent in middle, and 65 percent in the highest. Forty-four percent of women did not receive any postnatal care after birth. The number of women receiving postnatal care varied by districts, with the highest in Sahiwal District (57 percent), followed by Lahore, Gujranwala, Rawalpindi and Chakwal between 50– 55 percent. Postnatal care was least in Rajanpur (17 percent), Muzaffargarh (18 percent) and Bahawalnagar (19 percent). The maximum postnatal care provided by TBAs were found in Rajanpur (53 percent) followed by Vehari (38 percent). R E P R O D U C T I V E H E A L T H L EITERACY AND DUCATION 9 L I T E R A C Y A N D E D U C A T I O N43 Universal access to basic education and achievement of primary education worldwide is one of the most important goals of the Millennium Development and WFFC. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour, sexual exploitation, promoting human rights and democracy, protecting environment, and influencing population growth. MICS Punjab, 2011 covered the following indicators: Literacy Literacy rate (10+ years) Literacy rate (15+ years) Adult literacy rate (15-24 years) Literacy among young women Education School readiness Net intake rate in primary education Primary school net attendance ratio Secondary school net attendance ratio Children reaching last grade of primary Primary completion rate Transition rate to secondary school Gender parity index (primary school) Gender parity index (secondary school) 9.1. Literacy Literacy is an important indicator for monitoring progress towards universal education. It was assessed in MICS Punjab, 2011 by asking the respondent whether each household member had the ability to read and write with understanding in any language from a list of languages (Urdu, English, Punjabi, Saraiki and others), but excluding Quranic reading if this was the only response. Literacy rate 10+ years, 15+ years and 15-24 years were derived from the survey specific questions and were not the part of MICS4 standard questionnaires. 9.2. Literacy Rate (10+ years) Literacy rate amongst household members above 10 years of age is presented in Table ED.10A. More than half (60 percent) of the Punjab population 10+ years was literate, with a clear difference between males (68 percent), females (51 percent), rural (53 percent), urban (75 percent) and major cities (77 percent) (Figure ED.1). Gender disparities also existed by area of residence. In rural areas 63 percent males were literate as compared to only 43 percent females. Gender gap was slightly narrower in major cities (males 80 percent; females 74 percent) and in other urban areas (males 78 percent; females 66 60 68 51 53 75 77 0 20 40 60 80 100 Figure ED.1: Literacy rate 10+ years by sex and area of residence MICS Punjab, 2011 L I T E R A C Y A N D E D U C A T I O N 44 percent). In MICS Punjab, 2003-04 literacy rate of Punjab was 54 percent, which increased to 59 percent in MICS Punjab, 2007-08 and 60 percent in MICS Punjab, 2011. Literacy for 10+ years decreased with the increasing age since the older population was less literate than the younger. However a positive correlation of literacy rate (10+ years) with the education of household head and wealth quintiles was observed as expected. Literacy rate increased sharply from lowest wealth quintile (27 percent) to highest (85 percent) (Figure ED.2). Similarly, literacy rate markedly increased with education level of the head of the household from 37 percent (No education) to 89 percent (Higher education). Among districts Rawalpindi (78 percent), Jhelum and Lahore (73 percent), and Gujranwala (72 percent) were at the top of the list with rates of literacy (10+ years), significantly higher than the provincial average, while Rajanpur (33 percent), DG Khan (42 percent) and Muzaffargarh (42 percent) were at bottom with rates considerably lower than the provincial average. 9.3. Literacy Rate (15+ years) Table ED.10B shows the literacy rate (15+ years). More than half (57 percent) of the population aged 15 years and above was literate; with the disparity between males (66 percent) and females (47 percent). Variations in literacy (15+ years) were similar to those in literacy (10+ years), with lower rate in rural areas (49 percent) particularly for females (38 percent). Gender gap was slightly narrower in major cities and in other urban areas. The district variations in literacy rate amongst 15+ years were similar to those amongst 10+ years. Figure ED.3 shows gender gap in adult literacy with respect to the age. 9.4. Adult Literacy Rate (15–24 years) Adult literacy rate of 15–24 years also termed as youth literacy rate is presented in Table ED.10C. Overall youth literacy rate was 74 percent, amongst males 78 percent and females 70 percent. Gender disparities also existed by area of residence, 75 percent of males were literate as compared to 62 percent of rural females. However, there was only a slight variation among other urban (84 percent) and major cities (87 percent). 0 20 40 60 80 100 Figure ED.3: Literacy rate (15+) by age groups and sex MICS Punjab, 2011 Males Females 85 71 62 47 27 89 82 75 65 37 60 0 20 40 60 80 100 Highest Fourth Middle Second Lowest Wealth quintiles Higher Secondary Middle Primary None Education of the head Punjab Percent Figure ED.2: Literacy rate 10+ years by education of the head and wealth quintiles MICS Punjab, 2011 45 The adult literacy rate had a positive association with the wealth quintiles. Amongst males, the highest wealth quintile had a literacy rate of 94 percent as compared to 38 percent in the lowest. In case of females it was 95 percent as compared to 24 percent for highest and lowest quintiles respectively. Distribution of adult literacy by wealth quintiles is presented in Figure ED.4. The younger population, aged 15–19 years was slightly more literate (76 percent) than those aged 20–24 years (72 percent). 9.5. Literacy among Young Women One of the WFFC goals is to assure adult literacy. Adult literacy is also an MDG indicator, relating to both men and women. This section presents results using data from “Individual women‘s questionnaire.” Literacy rates presented in section 9.4 should not be mixed with this indicator. The results in this section are based on females aged 15-24 years. Literacy was assessed on the ability of the respondent to read a short simple statement or school attendance. Percentage of women aged 15-24 years who were literate is presented in Table ED.1. The literacy rate among young women was 66 percent in Punjab which varied by place of residence (58 percent in rural & 84 percent in urban). Literacy among young women showed a positive association with wealth quintiles. Literacy was only 20 percent in the lowest wealth quintile and 94 percent in the highest. 9.6. School Readiness Attendance to pre-school education in an organised learning or child education programme is important for the readiness of children to school. Table ED.2 shows the proportion of children in the first grade of primary school who attended pre-school the previous year. Overall, 79 percent of children who currently attended the first grade of primary school (regardless of age) attended pre-school the previous year. The value of indicator for rural areas was 77 percent and 85 percent for urban areas. The percentage of children attending first grade who attended pre-school in previous year has shown a positive correlation with wealth quintiles. The value was high 87 percent for highest wealth quintile as compared to 70 percent in the lowest wealth quintile. Disparities existed among districts: Chiniot, Jhang, Nankana Sahib, Gujrat and Vehari were on the top and DG Khan (42 percent) followed by Muzaffargarh (27 percent) were at the bottom. 9.7. Net Intake Rate in Primary Education Under the Punjab education system, the age of entry to primary school is 5 years. Since many children enter later, this survey also considered entry age of 6 years. Of 5-year-old, 26 percent (Table ED.3) were in grade 1 or higher, and of 6-years-old 44 percent were in grade 1 or higher, with only a narrow gender gap. These rates vary by area of residence, higher urban 94 87 79 63 38 96 92 85 76 58 69 85 74 0 20 40 60 80 100 120 Highest Fourth Middle Second Lowest Wealth quintiles Higher Secondary Middle Primary None Education of the head Rural Urban Punjab Area of residence Percent Figure ED.4: Adult literacy rate by area of residence, education of the head and wealth quintiles MICS Punjab, 2011 L I T E R A C Y A N D E D U C A T I O N children aged 5 and 6 years entered Grade 1 than rural children. A positive correlation with the mother's education was observed: for children aged 5 and 6 years the highest rates were observed for children whose mothers had higher education: 38 percent for entry at age 5 and 70 percent for entry at age 6. 9.8. Primary School Net Attendance Ratio Table ED.4 presents Net Attendance Rate (NAR) of primary school, i.e., number of primary school-aged children (5–9 years) who were attending primary or secondary school as a percentage of the total number of children in that age group. Overall, more than half of children of primary school age were attending primary school (59 percent). It represents an increase from the MICS Punjab, 2007–08 (53 percent). Boys had a slightly higher NAR (61 percent) compared to girls (58 percent). In urban areas, 69 percent of primary school-aged children attended school compared to only 56 percent in rural areas. This disparity was more pronounced for girls (urban 70 percent; rural 54 percent) compared to boys (urban 69 percent; rural 58 percent). Attendance rate was lowest for children of 5 years (27 percent). This may be due to the fact that many children enter school at age 6 rather than age 5. School attendance of children aged 5-9 years increased with mother‘s education: higher education 79 percent; secondary 77 percent; middle 74 percent; primary 71 percent and no education 51 percent. Children in the highest wealth quintile were twice as likely to attend primary school (highest 77 percent; lowest 36 percent) (Figure ED.5). 9.9. Primary School Gross Attendance Ratio Table ED.4B presents the Gross Attendance Rate (GAR) for primary school, which considers the number of children of all ages who were attending primary or secondary school as a percentage of the total number of children of primary school age (5–9 years). The GAR at the primary level in the Punjab was 89 percent. The rates varied by sex, area of residence, mother's education, wealth index, division and district. Boys had a higher rate (93 percent) than girls (84 percent) and urban areas had higher rate (99 percent) than rural areas (86 percent). Thus more boys than girls and more urban children than rural (of all ages) attended primary school. Gross primary attendance rate increased sharply with the wealth quintiles, from 59 percent in the lowest wealth quintile to 102 percent in the highest. Districts also vary markedly, 59 percent in DG Khan and 115 percent in Mandi Bahaudin compared with 100 percent in Sargodha. Comparing GAR (89 percent) with the NAR (59 percent) indicates that many children in primary school at the time of the survey were overage. This was consistent across background characteristics. 77 72 67 56 36 79 77 74 71 50 56 69 59 0 20 40 60 80 100 Highest Fourth Middle Second Lowest Wealth quintiles Higher Secondary Middle Primary None/ preschool Mother education Rural Urban Area of residence Punjab Percent Figure ED.5: Primary school attendance rates by area of residence, mother‘s education and wealth quintiles MICS Punjab, 2011 L I T E R A C Y A N D E D U C A T I O N 46 47 9.10. Secondary School Net Attendance Ratio Secondary school NAR is presented in Table ED.5. Only 40 percent of children of appropriate age (10–14 years) attended middle or secondary school. The remaining 60 percent were either out of school or in primary school. Secondary school net attendance rate was higher for boys (41 percent) than girls (39 percent). Net attendance rate was low in rural areas (35 percent), for children aged 10 years (15 percent), for children of mothers with no education (29 percent) and children in the lowest wealth quintile (14 percent). 9.11. Out of School Children Thirty-one percent of children of secondary school age were in primary school, and 29 percent out of school (Figure ED.6). The middle/secondary NAR was greater for boys than girls. Secondary school-aged rural children (33 percent) were out of school compared to urban children (20 percent). Disparities also existed between districts. Hafizabad had the highest percentage (41 percent) of children of secondary school age who were still in primary school compared to 24 percent in Attock district. 9.12. Children Reaching Last Grade of Primary The percentage of children entering first grade who eventually reached the last grade of primary school is presented in Table ED.6. Of all children starting grade one, the majority of them (97 percent) eventually reached the last grade. Notice that this number excluded children that repeat grades and that eventually moved up to reach last grade. This indicator was consistent with respect to background characteristics. 9.13. Primary Completion Rate & Transition Rate to Secondary School Primary school completion rate and transition rate to secondary education are presented in Table ED.7. Primary completion rate is ratio of the total number of students, regardless of age, entering the last grade of primary school for the first time, to the number of children of the primary graduation age at the beginning of the current (or most recent) school year. At the moment of the survey, the primary school completion rate was 78 percent with notable variation among rural 74 percent and urban 91 percent. The primary school completion rate was lowest in the lowest wealth quintile (44 percent) and increased sharply for the higher quintiles. Ninety-four percent of the children that completed successfully the last grade of primary school were found at the moment of the survey to be attending the first grade of secondary school. Similar results were observed with respect to the background characteristics. 40 41 38 52 35 31 34 28 28 32 29 25 34 20 33 0 20 40 60 80 100 Punjab Male Female Urban Rural Figure ED.6: Secondary school NAR, secondary school age children attending primary school and secondary school children out of school MICS Punjab, 2011 Out of school In primary school NAR L I T E R A C Y A N D E D U C A T I O N L I T E R A C Y A N D E D U C A T I O N 48 9.14. Gender Parity Index Ratio of girls to boys attending primary and secondary education is provided in Table ED.8. These ratios are better known as Gender Parity Index (GPI). Notice that the ratios included were obtained from net attendance ratios rather than gross attendance ratios. The table shows that gender parity for primary school was 0.95, indicating that more boys attended primary school than girls. However, the indicator dropped slightly to 0.94 for secondary education indicating that there were 94 girls for every 100 boys attending secondary school. The disadvantage of girls was particularly pronounced among children living in the poorest households and rural areas (Figure ED.7 & ED.8). More girls than boys were attending primary and secondary schools in urban area (1.02 and 1.10 for primary and secondary respectively). While in rural areas the parity index for primary school was 0.92 and 0.85 for secondary school. Table ED.8 shows that out of 36 districts, 11 had a primary school gender parity level of more than one, 9 districts had secondary school gender parity more than one. Rajanpur, Jhang and Mianwali had the lowest Gender Parity Index (less than 0.60) for secondary school as compared to Mandi Bahaudin (1.35). Gender Parity Index for primary school was more than one in Lahore, Vehari, Rawalpindi, Faisalabad, Gujranwala, Jhang, Sheikhupura, Narowal, Sialkot, Jhelum and Gujrat. For secondary school, Gender Parity Index was more than 1 in Narowal, Bahawalpur, Faisalabad, Lahore, Jhelum, Gujrat, Sialkot, Gujranwala and Mandi Bahaudin. It reflects that more girls than boys attended school in these districts. 9.15. Public and Private Net Primary Attendance Rate Table ED.14 calculated from a survey specific questions which were not included in the MICS4 standard questionnaires, shows the distribution of children aged 5–9 years attending public/private types of primary schools. In the surveyed households, 59 percent attended government schools and 41 percent private. In rural areas, more children attended government schools (68 percent) than private (32 percent). Mothers with middle or higher education were 88 11 78 21 63 37 46 54 24 76 0 20 40 60 80 100 Pubic Private Figure ED.9: Public and private net primary attendance rates by wealth quintiles MICS Punjab, 2011 Lowest Second Middle Fourth Highest 0.92 0.85 1.03 1.081.02 1.13 0.00 0.20 0.40 0.60 0.80 1.00 1.20 Primary Secondary Figure ED.8: Gender Parity Index (GPI) of primary and secondary by area of residence MICS Punjab, 2011 Rural Major city Other urban 0.73 0.39 0.92 0.74 1.00 0.971.02 1.09 1.03 1.07 0.00 0.20 0.40 0.60 0.80 1.00 1.20 Primary Secondary Figure ED.7: Gender Parity Index (GPI) of primary and secondary school by wealth quintiles MICS Punjab, 2011 Lowest Second Middle Fourth Highest 49 more likely to send their children to private schools than those with primary or no education. As expected, the type of school was strongly correlated with the wealth quintiles. The type of school also varied markedly by district: more children attend private than government schools in Lahore (65 percent), Gujranwala (61 percent), Sialkot (57 percent), Faisalabad (56 percent), Sheikhupura (52 percent) and Rawalpindi districts (52 percent). 9.16. Preschool Attendance Thirty percent of children aged 3–4 years were found attending preschool, with comparable attendance for boys (31 percent) and girls (29 percent) (Table ED.9). In urban areas preschool attendance was almost double than in rural areas. A much higher percentage of children aged 4 years attended preschool (41 percent) compared to those aged 3 years (19 percent). Preschool attendance increased markedly with mother's education and wealth quintiles. Large variations were observed among districts: under 10 percent of children aged 3–4 years in Rajanpur and Lodhran attending preschool compared to more than 41 percent in Lahore, Gujranwala, Sialkot, Attock, Mandi Bahaudin, Gujrat, Rawalpindi and Jhelum. L I T E R A C Y A N D E D U C A T I O N C PHILD ROTECTION 10 C H I L D P R O T E C T I O N 50 10.1. Birth Registration The International Convention on the Rights of the Child states that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. The WFFC states the goal to develop systems to ensure the registration of every child at or shortly after birth, and fulfil his or her right to acquire a name and a nationality, in accordance with national laws and relevant international instruments. The indicator is the percentage of children under 5 years of age whose birth is registered. Births of 77 percent of children under five years had been registered (Table CP.1). Registration rates were 11 percent higher in urban areas compared to rural. There were no significant variations across gender. Birth registration was the lowest among infants under one year old (71 percent) and amongst children of women with no/preschool education (67 percent). Families in the highest wealth quintile were more likely to register their births (92 percent). Regional differences were also observed: DG Khan and Bahawalpur Divisions had the lowest birth registration rates (40 percent and 55 percent respectively) while Gujranwala and Rawalpindi had the highest (90 percent or more) (Figure CP.1). 10.2. Child Labour Article 32 of the Convention on the Rights of the Child states: "States Parties recognize the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child's education, or to be harmful to the child's health or physical, mental, spiritual, moral or social development." The WFFC mentions nine strategies to combat child labour, and the MDGs call for the protection of children against exploitation. In MICS Punjab, 2011 questionnaire, a number of questions addressed issue of child labour, that is, children 5-14 years of age involved in labour activities. A child is considered to be involved in child labour activities at the moment of the survey if involved during the week preceding the survey: Ages 5-11: at least one hour of economic work or 28 hours of domestic work per week. Ages 12-14: at least 14 hours of economic work or 28 hours of domestic work per week. Economic activities include: Paid or unpaid work for someone who is not a member of the household as well as work for a family farm or business. 94 90 88 88 85 85 69 55 40 74 85 77 0 20 40 60 80 100 Gujranwala Rawalpindi Lahore Faisalabad Sargodha Sahiwal Multan Bahawalpur D.G.Khan Divisions Rural Urban Area of residence Punjab Percent Figure CP.1: Birth registration by area of residence and divisions MICS Punjab, 2011 C H I L D P R O T E C T I O N51 Domestic work includes household chores like collecting firewood, fetching water, cooking, cleaning, looking after animals or livestock, or caring for children. This definition allows differentiation between child labour and child work to identify the type of work that should be eliminated. As such, the estimate provided here is a minimum of the prevalence of child labour since some children may be involved in hazardous labour activities for a number of hours that could be less than the numbers specified in the criteria explained above. Table CP.2 presents the results of child labour by the type of work. Percentages do not add up to the total rate of child labour as children may be involved in more than one type of work. MICS Punjab, 2011 estimated that about 11 percent of children aged 5–14 years were involved in child labour including household chores. The child labour among the age group of 5-11 years was slightly lower at 10 percent as compared to 12 percent in the age group of 12-14 years. A higher percentage of rural children (13 percent) were engaged in child labour compared to urban children (5.4 percent). More boys were involved in child labour (12 percent) as compared to girls (9.4 percent). Children's involvement in labour decreased as mothers' education increased: involvement was the highest for children of mothers with no education (14 percent). Majority of these children were working for the family business. Children in the lowest wealth quintile had the highest labour rate (21 percent) with most working for family business. Notable variation among district existed, highest in Okara, Rajanpur and Vehari (over 20 percent), lowest in Rawalpindi and Jhelum (less than 4 percent). 10.3. Student Labourers and Labourer Students Table CP.3 presents the percentage of children aged 5-14 years attending school who were involved in child labour (referred to as "student labourers") and percentage of children aged 5-14 years involved in child labour who were attending school (referred to as "labourer students"). Seventy-five percent of the children 5-14 years of age attending school, 7.7 percent were also involved in child labour activities. More rural children (10 percent) were student labourers compared to urban children (3.5 percent). More were boys (9.4 percent) than girls (5.7 percent). There was higher proportion of student labourers in 5–11 year age group (8.7 percent) than in 12–14 year age group (5.2 percent), and the percentage decreased with the increase in mother's education and wealth quintiles. Out of 11 percent of the children who were involved in child labour, 53 percent of them were also attending school: these were termed as labourer students. There were slightly more labourer students in urban (55 percent) than rural areas (53 percent). Labourer students were also more prevalent in the 5–11 year age group (65 percent) than in 12–14 years (29 percent). Child labourers who belonged to higher wealth quintiles or whose mothers had higher education were more likely to attend school. Mandi Bahaudin, Rawalpindi and Sialkot had the highest percent of labourer students (above 80 percent) while Rajanpur, Hafizabad, Bahawalpur, DG Khan and Multan had the lowest (31-37 percent). 10.4. Early Marriage Marriage before the age of 18 is a reality for many young girls. According to UNICEF‘s worldwide estimates, over 64 million women aged 20-24 years were married before the age of 18. Factors that influence child marriage rates include: state of the country's civil registration system, which provides proof of age for children; existence of an adequate legislative C H I L D P R O T E C T I O N 52 framework with an accompanying enforcement mechanism to address cases of child marriage and existence of customary or religious laws that condone the practice. In many parts of the world parents encourage marriage of their daughters while they are still children hoping that the marriage will benefit them both financially and socially, while also relieving financial burdens on the family. In fact, child marriage is a violation of human rights, compromising development of girls and often resulting in early pregnancy and social isolation, with little education and poor vocational training reinforcing the gendered nature of poverty. The right to 'free and full' consent to a marriage is recognized in the Universal Declaration of Human Rights - with the recognition that consent cannot be 'free and full' when one of the parties involved is not sufficiently mature to make an informed decision about a life partner. The Convention on the Elimination of all Forms of Discrimination against Women mentions the right to protection from child marriage in article 16, which states: "The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage. While marriage is not considered " directly in the Convention on the Rights of the Child, child marriage is linked to other rights - such as the right to express their views freely, the right to protection from all forms of abuse, and the right to be protected from harmful traditional practices - and is frequently addressed by the Committee on the Rights of the Child. Other international agreements related to child marriage are the Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages and the African Charter on the Rights and Welfare of the Child and the Protocol to the African Charter on Human and People's Rights on the Rights of Women in Africa. Child marriage was also identified by the Pan-African Forum against the Sexual Exploitation of Children as a type of commercial sexual exploitation of children. Young married girls are a unique, though often invisible, group required to perform heavy amounts of domestic work, under pressure to demonstrate fertility and responsible for raising children while still children themselves. Married girls and child mothers face constraints in decision-making and life choices. Boys are also affected by child marriage but the issue impacts girls in far larger numbers and with more intensity. Research suggests that many factors interact to place a child at risk of marriage. Poverty, protection of girls, family honour and provision of stability during unstable social periods are considered as significant factors in determining a girl‘s risk of becoming married while still being a child. Women who are married at younger ages were more likely to believe that it is sometimes acceptable for a husband to beat his wife and were more likely to experience domestic violence. Age gap between partners is thought to contribute to these abusive power dynamics and to increase the risk of untimely widowhood. Women who are married before the age of 18 tend to have more children than those who marry later in life. Pregnancy related deaths are known to be a leading cause of mortality among married girls, particularly among the youngest of this cohort. In many parts of the province of Punjab, parents encourage marriage of their daughters while they are still children in hopes that marriage will lightened their responsibility or due to social /cultural customs. Two of the indicators are to estimate the percentage of women married before 15 years of age and percentage married before 18 years of age. The percentage of women married at various ages is provided in Table CP.5. About one in eleven young women aged 15-19 years was currently married (8.5 percent). This proportion varied between urban (5.2 percent) and rural (9.9 percent) and was negatively correlated to women‘s education and wealth quintiles. Women with no education were more likely to experience early marriage. Nineteen percent of 53 the women aged 15-19 years with no education were currently married. This percentage decreased gradually with the increase in education of the women. About 6 percent of the girls were married before the age of 15 years. This percentage was higher in rural (6.5 percent) as compared with urban (3.9 percent). The relationship was observed with wealth quintiles and women education. Women in highest wealth quintile and higher education had the lowest (3 percent and 0.4 percent respectively) whereas women in the lowest wealth quintile and no education had the highest (11 percent and 10 percent respectively) marriages before the age of 15 years (Figure CP.2). A high level of early marriages was observed in Muzaffargarh district (20 percent) before age 15 years. Twenty-three percent of the women were married before 18 years with considerable disparities among rural (25 percent) and urban (18 percent). Similar relation with women education and wealth quintiles was observed as was found in under 15 years marriages. Table CP.6 presents the proportion of women who were first married before age 15 and 18 by area of residence and age groups. The percentage of women married before age of both 15 and 18 years were higher in the rural as compared to urban areas. Figure CP.3 shows an interesting cultural change in the society. In past years the percentage of early marriages was higher which decreased gradually over time in both rural and urban areas. The percentage of under 15 years marriages was around 9 percent in the age groups of (45-49, 40-44, & 35-39), which has decreased gradually to only 1.6 percent in the age group of 15-19 years. Figure CP.3 also demonstrates the fact that early age marriages were more pronounced in rural areas as compared to urban. 5.7 6.5 3.9 10.4 4.5 2.8 1.3 0.4 10.5 7.2 5.0 3.9 3.0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Figure CP.2: Marriage before age 15 years by area of residence, mother's education and wealth quintiles MICS Punjab, 2011 0.0 2.0 4.0 6.0 8.0 10.0 12.0 15-1920-2425-2930-3435-3940-4445-49 Age groups Figure CP.3: Percentage of women married before the age 15 years by women age groups MICS Punjab, 2011 Punjab Rural Urban C H I L D P R O T E C T I O N H AIV / IDS 11 H I V / A I D S 54 11.1. Knowledge about HIV Transmission and Misconceptions One of the most important prerequisites for reducing the rate of HIV infection is accurate knowledge of how HIV is transmitted and strategies for preventing transmission. Correct information is the first step towards raising awareness and giving young people the tools to protect themselves from the infection. Misconceptions about HIV are common and can confuse young people and hinder prevention efforts. Different regions are likely to have variations in misconceptions although some appear to be universal (for example that sharing food can transmit HIV or mosquito bites can transmit HIV). The UN General Assembly Special Session on HIV/AIDS (UNGASS) called on governments to improve the knowledge and skills of young people to protect themselves from HIV. The indicators to measure this goal as well as the MDG of reducing HIV infections by half include improving the level of knowledge of HIV and its prevention, and changing behaviours to prevent further spread of the disease. HIV modules were administered to ever married women 15-49 years of age. One indicator which is both an MDG and UNGASS indicator is the percentage of young women who have comprehensive and correct knowledge of HIV prevention and transmission. In MICS Punjab, 2011 all ever married women who had heard of AIDS were asked whether they knew of the two main ways of preventing HIV transmission – having only one faithful uninfected partner and using a condom every time. The results are presented in Table HA.1. In Punjab, more than one fourth of the interviewed women (27 percent) had heard of AIDS. Eighteen percent of women knew of having one faithful uninfected sex partner and 14 percent knew of using a condom every time as main ways of preventing HIV transmission. Eleven percent of women knew both ways and only 4.3 percent had the comprehensive knowledge. Table HA.1 also provides information on whether women knew that HIV could not be transmitted by sharing food with someone with AIDS, about 15 percent agreed to this statement. Of the interviewed women, only 7.8 percent rejected the two most common misconceptions and knew that a healthy-looking person can be infected. Twenty one percent of women considered that HIV cannot be transmitted through supernatural means, whereas 17 percent believed so through mosquito bites. Eighteen percent thought that a healthy- looking person can be infected. The results for women aged 15-24 years (ever married) are separately presented in Table HA.2. Twenty-five percent of them had heard about AIDS. Only 10 percent knew both main ways of preventing HIV transmission, 17 percent of women aged 15-24 years (ever married) knew that a healthy looking person can have the AIDS virus. About seven percent rejected the two most common misconceptions along with the knowledge that a healthy looking person can have the AIDS virus. About 4 percent women of this age group (ever married) had the comprehensive knowledge of AIDS. The level of comprehensive knowledge was found higher in urban areas (7.2 percent), women with higher education (21 percent) and the women living in the highest wealth quintile (11 percent). Women who had comprehensive knowledge about HIV prevention included those who knew of the two main ways of HIV prevention, who understood that a healthy looking person could have the AIDS virus, and who rejected the two most common misconceptions. H I V / A I D S55 Tables HA.1 and HA.2 also present the percentage of women with comprehensive knowledge. This knowledge was fairly low although there were differences by area of residence and women‘s education. Overall, 4.3 percent of women were found to have comprehensive knowledge, which was higher in urban areas (8.4 percent) compared to rural (2.6 percent). As expected, the percentage of women with comprehensive knowledge increased with the woman‘s education: highest 23 percent for women having high education (Figure HA.1). Knowledge of mother-to-child transmission of HIV is also an important first step for women to seek HIV testing when they are pregnant to avoid infection in the baby. Women should know that HIV can be transmitted during pregnancy, during delivery, and through breastfeeding. The level of knowledge among ever married women aged 15-49 years concerning mother-to-child transmission is presented in Table HA.3. Overall, 22 percent of women knew that HIV could be transmitted from mother to child with sharp differentials among rural (15 percent) and urban (39 percent). The knowledge increased sharply with the increase in woman‘s education and wealth quintiles. The percentage of women who knew all three means of mother-to-child transmission was 14 percent, while 5 percent did not know of any specific mean. The percentage varied greatly by area of residence, women‘s education and wealth quintiles (Figure HA.2). The percentage was highest in Gujranwala division (23 percent) and lowest in D.G. Khan (6.5 percent). 11.2. Accepting Attitudes towards People Living with HIV/AIDS The indicators on attitudes toward people living with HIV measure stigma and discrimination in the community. Stigma and discrimination are low if respondents report an accepting attitude on the following four questions: 1. would care for family member sick with AIDS; 2. would buy fresh vegetables from a vendor who is HIV positive; 3. thinks that a female teacher who is HIV positive should be allowed to teach in school; and 12.2 5.2 2.7 0.9 0.2 23.3 12.0 5.8 1.9 0.3 2.6 8.4 4.3 0 5 10 15 20 25 Highest Fourth Middle Second Lowest Wealth quintiles Higher Secondary Middle Primary None Women's education Rural Urban Area of residence Punjab Percent Figure HA.1: Percentage of women aged 15-49 years (ever married ) with comprehensive knowledge of HIV/ AIDS by background characteristics MICS Punjab, 2011 32 20 12 5 2 48 36 25 13 3 10 25 14 0 10 20 30 40 50 Highest Fourth Middle Second Lowest Wealth quintiles Higher Secondary Middle Primary None Women's education Rural Urban Punjab Percent Figure HA.2: Percentage of women aged 15-49 years (ever married) who knew all three means of HIV/ AIDS transmission from mother to child by background characteristics MICS Punjab, 2011 56 4. would not want to keep HIV status of a family member a secret. Table HA.4 presents the attitudes of women towards people living with HIV/AIDS. In Punjab 97 percent of women who had heard of AIDS agree with at least one accepting attitude. The most common discriminative attitude was “not being willing to buy fresh vegetables from a shopkeeper with HIV/AIDS“ (43 percent). Thirty-nine percent of the women express accepting attitudes on all four indicators with noticeable variation among rural (41 percent) and urban (37 percent). More educated women and those from the highest quintile had more accepting attitudes than the ones with lower education and a poorer wealth status. Willing to care for a family member with the AIDS virus Would buy fresh vegetables from a shopkeeper who has the AIDS virus Believe that a female teacher with the AIDS virus and is not sick should be allowed to continue teaching Would not want to keep secret that a family member got infected with the AIDS virus Agree with at least one accepting attitude Express accepting attitudes on all four indicators 91 57 63 74 97 39 0 20 40 60 80 100 Figure HA.3: Accepting attitudes of women aged 15-49 (ever married) toward people living with HIV/AIDS MICS Punjab, 2011 H I V / A I D S A H H C DULT EALTH AND EALTH ARE 12 A D U L T H E A L T H A N D H E A L T H C A R E57 The findings presented in this chapter are based on the questions / modules specifically included in MICS Punjab, 2011 questionnaire that was not the part of the MICS4 standard questionnaire. 12.1. Reported Chronic Cough, Tuberculosis and Hepatitis Chronic Cough Table HC.1 presents responses to questions in Household Questionnaire about chronic cough, tuberculosis and hepatitis. A recent chronic cough is suggestive but not diagnostic of tuberculosis. The population reporting cough for more than last three week was 2.2 percent. Results slightly vary between urban (1.5 percent) and rural (2.5 percent). The highest percentage of reports came from the lowest wealth quintile (3.1 percent) and the lowest from the highest (1.1 percent). Hafizabad District had the highest percentage (9.6 percent) followed by Bahawalnagar (7.9 percent), Rajanpur (6.5 percent), Mianwali (5.5 percent) and Muzaffargarh (4.6 percent). Tuberculosis About 1 in 250 (0.4 percent) of the surveyed population reported diagnosis of tuberculosis in the past year, compared to the MICS Punjab, 2007–08 result of about 1 in 333. No differences were observed by gender and area of residence (rural or urban) while lower percentages were observed amongst progressively more educated respondents and those belonging to higher wealth quintiles. Districts Rajanpur (1.6 percent) and Multan (0.9 percent) had the largest population diagnosed with tuberculosis. Hepatitis About 1 in 85 (1.2 percent) of the surveyed population reported diagnosis of hepatitis in the past year (Table HC.1). In rural areas, more people reported a diagnosis (1.2 percent) than in urban areas (1 percent). Among urban areas, major cities (0.9 percent) and other urban (1.1 percent) reported a diagnosis of hepatitis. There were significant variations among districts ranging from 0.4 percent in Bhakkar to 3.0 percent in Hafizabad and 2.9 percent in Rajanpur. 12.2. Care Provided by Lady Health Worker Forty-eight percent of the women aged 15–49 years reported a visit by a Lady Health Worker (LHW) in the month preceding the survey: rural 52 percent and urban 37 percent (Table HC.2). About 47 percent of households in the lowest wealth quintile compared to 38 percent in the highest reported visit of LHW. Between districts, the lowest visits occurred in Lahore, Faisalabad and Attock (less than 27 percent). S O C I O E C O N O M I C D E V E L O P M E N T 58 13.1. Household Characteristics In the survey it was found that overall 86 percent of the household population was living in their own houses. This percentage was higher in rural areas (90 percent) as compared to urban (78 percent) (Table HC.9A). In major cities 18 percent of population was living in rented houses. Interestingly, wealth index had no relation with ownership status of the households. Table HC.16 provides information on the type of houses. Overall, 76 percent of the households were living in independent houses/ compounds and 22 percent in a part of a large sublet unit. In the lowest wealth quintile, 2.1 percent of the households were living in a part of a house or compound. Table HC.10 provides information on the percent distribution of households by household members, 13.2. Housing 1.2 13.4 27.7 30.5 16.2 10.9 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 1 2-3 4-5 6-7 8-9 10+ Household members Figure HC.1: Percentage distribution of households by household members MICS Punjab, 2011 100 96 70 27 4 90 78 67 56 41 44 92 58 0 20 40 60 80 100 Highest Fourth Middle Second Lowest Wealth quintiles Higher Secondary Middle Primary None Education of the head Rural Urban Area of residence Punjab Percent Figure HC.2: Percentage of households had "pacca" floor by area of residence, wealth quintiles and education of the head MICS Punjab, 2011 S E DOCIO CONOMIC EVELOPMENT 13 mean household size and mean number of persons per room. The mean household size was 6.3 persons. There were 1.2 percent households with one member and 11 percent had 10 or more members (Figure HC.1). The highest proportion of the households (31 percent) had 6 to 7 members. Mean number of persons per room were 3.7 which was same as in MICS Punjab, 2007-08. There were no disparities among urban and rural areas. Information on materials used to construct floor, roof and walls of houses collected in the survey is given in Tables HC.7A, HC.7B and HC.7C. Fifty-eight percent of the households had “pacca” or finished floor and 42 percent “Katch” or rudimentary floor (Table HC.7A). This percentage varied markedly by area of residence, 92 percent in urban and 44 percent in rural. The percentage of “Pacca” floor was positively correlated with the education of the head and wealth quintals (Figure HC.2). More houses had“pacca” roofs (76 percent) than “pacca” floors, with noticeable variation among rural (71 percent) and urban (90 percent). Houses in the higher wealth quintiles were more likely to have “pacca”roofs. The relation of “pacca” roof with the education of the head and wealth quintiles is depicted in Figure HC.3. S O C I O E C O N O M I C D E V E L O P M E N T59 Seventy-four percent of the households had “pacca’’ walls. Urban houses were more likely to have pacca walls (96 percent) than rural (65 percent). Houses in the higher wealth quintiles were more likely to have pacca walls (Table HC.7C). Type of floor, roof and walls varied greatly by district and was directly influenced by degree of urbanization. Percentage of households having pacca floor were low in Layyah (19 percent), Rajanpur (20 percent), Muzaffargarh & DG Khan (27 percent each) and high in Gujrat, Jhelum, Rawalpindi and Lahore (more than 85 percent). Almost similar patterns were observed in pacca roofs and walls. 13.3. Household Possessions and Utilities Information on household possessions, utilities and ownership of durable goods is shown in Table HC.8A and HC.8B. The survey results showed that 94 percent households had electricity, 31 percent had gas, 6 percent had radio, 11 percent had computer and, 64 percent had TV. More people had the facility of mobile phone (87 percent) than land line telephones (7 percent). Sixty percent used motorised pumps. A high percentage of the population (89 percent) used more than three utilities. About 52 percent owned a watch, significantly low as compared to 90 percent in MICS Punjab, 2007- 08. Forty-one percent owned a bicycle, 38 percent a motorcycle or scooter and only 5 percent car or other vehicles, while 14 percent owned animal cart. About 94 percent owned at least one of these possessions. Information about ownership of agricultural land and livestock are presented in Table HC.9A. Thirty-four percent owned agricultural land and 48 percent owned livestock, while 91 percent of the households had house, land or livestock. Ownership of agricultural land and livestock was mostly within the rural population (Figure HC.4). Ownership status differed greatly by background variables. The findings presented in the following sections for Remittances and Cash Donations, Social benefits and Unemployment are based on the questions / modules specifically included in MICS Punjab, 2011 questionnaire that were not the part of the MICS4 standard questionnaire. 98 89 82 70 45 71 90 76 0 20 40 60 80 100 Highest Fourth Middle Second Lowest Wealth quintiles Rural Urban Area of residence Punjab Percent Figure HC.3: Percentage household having "pacca" roofs by area of residence, wealth quintiles and education of the head MICS Punjab, 2011 90 44 63 95 78 9 11 81 0 20 40 60 80 100 Own a house Own agricluture land Own livestock Ownership of assets (House, land or livestock) Figure HC.4: Ownership of houses, agriculture land and livestock by area of residence MICS Punjab, 2011 Rural Urban 60 13.4. Remittances and Cash Donations Remittances Respondents were asked whether the household received (from within the country and/ or overseas) any remittance (in cash) during the last year. Slightly more than 7 percent of them reported yes‘ from within the country ‘ (Table HC.11A) with differentials among urban (3.2 percent) and rural (9.1 percent). Households in the second, middle and fourth wealth quintiles were more likely to receive remittances compared to those in the lower and higher wealth quintiles. Half of the households received remittances below Rs. 60,000 per year. Table HC.11B shows the data on remittances received from abroad. Almost 5 percent households received remittances from abroad out of which half received below Rs. 150,000 per year. Cash donations Only 1.5 percent of households received cash donations through zakat or other means during the year preceding the survey (Table HC.12). Among these half of the households received less than Rs. 10,000 per year and the other half more than Rs. 10,000. There were less than one percent households in the highest wealth quintile receiving cash donations as compared to 2.1 percent in the lowest. However, this result was based on small number of responses. 13.5. Social Benefits, Subsidies and Family Support Programmes Only 7.3 percent of the population was receiving pension benefits (Table HC.13). Major source among the pension beneficiaries was Government (93 percent). Education of head of the household and wealth status was strongly associated with pension benefits. Of households where the head had higher education, 16 percent received pension benefits compared to 3 percent where the head had no education. Thirteen percent of households in the highest wealth quintile received pension benefits compared to only 1.2 percent in the lowest. Variations were observed between districts, ranging from 1 percent in Rajanpur to a striking 32 percent in Chakwal. Almost seven percent of households got benefits from government schemes of social protection such as the subsidies on food, Benazir Income Support Programme (BISP) and Wattan Card (Table HC.14A). More rural households (7.5 percent) benefit from these initiatives than urban (4.1 percent). Large variations existed among households in Rajanpur and Muzaffargarh showing the highest percentages (39 percent & 33 percent respectively) and Lodhran (0.4 percent), Narowal (0.8 percent), Khanewal (1.3 percent), Lahore, Sheikhupura and Sialkot districts (2 percent each) showing the lowest. Table HC.14B shows that about 14 percent of households purchased goods from government utility stores. Of this, majority (78 percent) rarely used these stores and only 21 percent visited them regularly. More households in urban areas (23 percent) purchased goods from government utility stores than in rural (10 percent). Disparities were also observed among districts: more households in Chakwal (38 percent), Rawalpindi (35 percent), Jhelum (33 percent) and Khushab (29 percent) purchased goods from government utility stores than other districts. About 24 percent of households thought that the government initiatives were benefiting the low income group. S O C I O E C O N O M I C D E V E L O P M E N T 61 13.6. Unemployment Employment comprises all 15 plus aged persons who worked at least one hour during the reference period (one week prior to the date of interview) and were either paid employed or self-employed. Persons employed on permanent/regular footings, who had not worked for any reason during the reference period, are also treated as employed, regardless of the duration of the absence or whether workers continued to receive a salary during the absence. Unemployment rate is the percentage of those in active labour force who are unemployed and seeking jobs. In MICS Punjab, 2011 information on employment status was extracted from data collected on sources of income for those 15 years or older. Active labour force consists of government and private sector employees, self-employed, labourers, those working in agriculture, livestock, poultry and fishery etc. About 3 percent of the population aged 15 years or older were unemployed, with 2.9 percent unemployed in rural areas and 3.1 percent in urban (Table HC.5). Most unemployed adults (12 percent) were in the age group of 15–19 years. Differentials according to wealth quintiles revealed that a higher percentage of the population in the middle wealth quintile were unemployed and seeking jobs than in the lowest. District wise variation was high, with unemployment rates ranging from 0.9 percent in Narowal and Jhelum to 6.3 percent in Lodhran. S O C I O E C O N O M I C D E V E L O P M E N T ANNEXURE - I 62 No No Yes Yes Yes No Yes No Data -en try opera tor 2 Verifica tion Data -processing supervisor Check data with entry-in-batch Correct Main Data File Data -processing supervisor Data -en try opera tor 1 Entry-in-batch OK? Investigate Errors Data -processing supervisor Main D ata Entry Data -en try opera tor 1 Structu re Check Data -processing supervisor Structure OK? Verifica tion Data Entry Determine Correct Values Data -en try opera tors 1 & 2 Secondary Ed iting Data -processing supervisor Inconsistencies? Differences? Back-up Raw Data File Data -processing supervisor Correct Raw Data File Data -processing supervisor Resolve Inconsistencies Secondary Editor Back-up Final Data File Data -processing supervisor Correct Main Data File Data -en try opera tor 1 Investigate Errors Data -processing supervisor Correct Both Data Files Data -en try opera tors 1 & 2 MICS4 DATA PROCESSING SYSTEM ANNEXURE-I STATISTICAL TABLES S T A T I S T I C A L T A B L E S 63 STATISTICAL TABLES HOUSEHOLD (HH) Table HH.1: Households and individuals interviewed . 66 Table HH.2: Household population distribution by age group and sex . 70 Table HH.3: Household composition . 71 Table HH.4: Women's background characteristics . 73 Table HH.5: Children's background characteristics . 75 CHILD MORTALITY (CM) Table CM.2: Child mortality . 77 NUITRITION (NU) Table NU.1: Nutritional status of children . 79 Table NU.2: Initial breastfeeding . 81 Table NU.3: Breastfeeding . 83 Table NU.4: Duration of breastfeeding . 86 Table NU.5: Age-appropriate breastfeeding . 88 Table NU.6: Introduction of solid, semi-solid or soft food . 90 Table NU.7: Minimum meal frequency . 92 Table NU.8: Bottle feeding . 94 Table NU.9: Iodized salt consumption. 96 Table NU.10: Children's vitamin A supplementation . 98 Table NU.11: Low birth weight infants. 100 CHILD HEALTH (CH) Table CH.1: Vaccinations in first year of life . 102 Table CH.2: Vaccinations by background characteristics . 103 Table CH.3: Neonatal tetanus protection . 106 Table CH.4: Oral rehydration solutions and recommended homemade fluids . 108 Table CH.5: Feeding practices during diarrhoea . 110 Table CH.6: Oral rehydration therapy with continued feeding and other treatments . 114 Table CH.7: Care seeking for suspected pneumonia and antibiotic use during suspected pneumonia . 117 Table CH.8: Knowledge of the two danger signs of pneumonia . 120 Table CH.9: Solid fuel use . 123 Table CH.10: Solid fuel use by place of cooking . 126 WATER & SANITATION (WS) Table WS.1: Use of improved water sources . 128 Table WS.2: Household water treatment . 131 Table WS.3: Time to source of drinking water . 134 Table WS.4: Person collecting water . 136 Table WS.5: Types of sanitation facilities . 139 S T A T I S T I C A L T A B L E S64 Table WS.6: Use and sharing of sanitation facilities . 142 Table WS.7: Disposal of child's faeces . 145 Table WS.8: Drinking water and sanitation ladders . 148 Table WS.9: Water and soap at place for handwashing . 150 Table WS.10: Availability of soap . 153 REPRODUCTIVE HEALTH (RH) Table RH.1: Adolescent birth rate and total fertility rate . 156 Table RH.2: Early childbearing . 158 Table RH.3: Trends in early childbearing . 160 Table RH.4: Use of contraception . 162 Table RH.4A: Women who ever used but are not currently using contraceptive method . 164 Table RH.5: Unmet need for contraception . 166 Table RH.6: Antenatal care provider . 168 Table RH.7: Number of antenatal care visits . 170 Table RH.8: Content of antenatal care . 172 Table RH.9: Assistance during delivery . 174 Table RH.10: Place of delivery . 177 Table RH.10A: Postnatal care provider . 179 Table RH.12: Unwilling pregnancy . 181 EDUCATION (ED) Table ED.1: Literacy among young women . 183 Table ED.2: School readiness . 185 Table ED.3: Age of primary school entry (adjusted net intake rate in primary education) . 187 Table ED.4: Primary school attendance . 189 Table ED.4B: Primary school gross attendance ratio (5-9 years) . 191 Table ED.5: Secondary school attendance . 193 Table ED.6: Children reaching last grade of primary school . 195 Table ED.7: Primary school completion and transition to secondary school . 197 Table ED.8: Education gender parity index (GPI) . 199 Table ED.9: Pre-school attendance . 201 Table ED.10A: Literacy rate 10+ by sex and number of household members . 203 Table ED.10B: Literacy rate 15+ by sex and number of household members . 205 Table ED.10C: Table ED.10C: Literacy rate 15-24 . 207 Table ED.14: Public and private primary school attendance rate . 209 CHILD PROTECTION (CP) Table CP.1: Birth registration . 211 Table CP.2: Child labour . 213 Table CP.3: Child labour and school attendance . 217 Table CP.5: Early marriage . 219 Table CP.6: Trends in early marriage . 221 HIV/ AIDS (HA) Table HA.1: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission . 222 Table HA.2: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission among young people . 225 Table HA.3: Knowledge of mother-to-child HIV transmission . 228 Table HA.4: Accepting attitudes toward people living with HIV/AIDS . 230 HOUSEHOLD CHARATERISTICS (HC) Table HC.1: Prevalence of Cough, TB and Hepatitis . 232 Table HC.2: Care provided by Lady Health Worker (LHW) . 234 Table HC.5: Un-employment rate 15 years and above . 236 Table HC.6: Percentage of family members working outside Village / Town/ Province/ Overseas, MICS Punjab, 2011 . 238 Table HC.7A: Main material of the floor, MICS Punjab, 2011 . 240 Table HC.7B: Main material of the roof, MICS Punjab, 2011 . 242 Table HC.7C: Main material of the walls, MICS Punjab, 2011 . 244 Table HC.8A: Household possessions . 246 Table HC.8B: Household utilities . 249 Table HC.9A: House ownership . 252 Table HC.10: Household size and mean household size, MICS Punjab, 2011 . 254 Table HC.11A: Receiving remittance from Pakistan . 256 Table HC.11B: Receiving remittance from Abroad . 258 Table HC.12: Received zakat/donations . 260 Table HC.13: Pension Benefits . 263 Table HC.14A: Safety nets (Government social protection schemes) . 265 Table HC.14B: Safety nets (Purchasing goods from government utility stores) . 267 Table HC.15: Possession of Bank Account . 269 Table HC.16: Type of house . 271 Table HC.17: Marital status of household members . 273 65S T A T I S T I C A L T A B L E S HOUSEHOLD HH S T A T I S T I C A L T A

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