Palestinian Multiple Indicator Cluster Survey 2014

Publication date: 2015

Final Report December 2015 Monitoring the situation of children and women Palestinian Central Bureau of Statistics United Nations Children’s Fund United Nations Population Fund Palestinian Multiple Indicator Cluster Survey 2014 Palestinian Central Bureau of Statistics Palestinian Multiple Indicator Cluster Survey 2014 Final Report December 2015   The Palestinian Multiple Indicator Cluster Survey (MICS) was carried out in 2014 by Palestinian Central Bureau of Statistics in collaboration with Ministry of Health, as part of the global MICS programme. Technical support was provided by the United Nations Children’s Fund (UNICEF). The survey was financially supported by the government of the State of Palestine, UNICEF and UNFPA. The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to support countries in the collection of internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. The Palestinian Multiple Indicator Cluster Survey has as its primary objectives: To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action. To contribute to the improvement of data and monitoring systems in Palestine and to strengthen technical expertise in the design, implementation, and analysis of such systems. Suggested Citation: Palestinian Central Bureau of Statistics, 2015. Palestinian Multiple Indicator Cluster Survey 2014, Final Report, Ramallah, Palestine ii Palestinian Multiple Indicator Cluster Survey 2014   Table of Contents List of Tables . v List of Figures . viii List of Abbreviations . ix Acknowledgements . x Summary Table of Survey Implementation and the Survey Population, The Palestinian Multiple Indicator Cluster Survey, 2014 . xi Summary Table of Findings . xiii Executive Summary . xxiii I. Introduction Background . 2 Survey Objectives . 3 II. Sample and Survey Methodology . 6 Sample Design . 6 Questionnaires . 6 Training and Fieldwork . 7 Data Processing . 7 III. Sample Coverage and the Characteristics of Households and Respondents . 10 Sample Coverage . 10 Characteristics of Households . 11 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 . 14 Housing characteristics, asset ownership, and wealth quintiles . 19 IV. Child Mortality . 24 V. Nutrition Low Birth Weight . 32 Nutritional Status . 34 Breastfeeding and Infant and Young Child Feeding . 38 Salt Iodization . 50 VI. Child Health . 54 Vaccinations . 54 Care of Illness . 60 VII. Water and Sanitation . 80 Use of Improved Water Sources . 80 Use of Improved Sanitation . 88 VIII. Reproductive Health . 96 Fertility . 96 Contraception . 101 Unmet Need . 105 Antenatal Care . 108 Assistance at Delivery . 114 Place of Delivery . 117 Post-natal Health Checks . 119 iii   IX. Early Child Development . 136 Early Childhood Care and Education . 136 Quality of Care . 138 Developmental Status of Children . 145 X. Literacy and Education . 150 Literacy among Young Women . 150 School Readiness . 152 Basic and Secondary School Participation . 154 XI. Child Protection . 172 Birth Registration . 172 Child Discipline . 174 Early Marriage and Polygyny . 178 Children’s Living Arrangements . 185 XII. HIV/AIDS . 190 Knowledge about HIV Transmission and Misconceptions about HIV . 190 Accepting Attitudes toward People Living with HIV . 196 Knowledge of a Place for HIV Testing . 199 Appendices: Appendix A. Sample Design . 202 Appendix B. List of Personnel Involved in the Survey . 208 Appendix C. Estimates of Sampling Errors . 210 Appendix D. Data Quality Tables . 218 Appendix E. Palestinian MICS5 Indicators: Numerators and Denominators . 238 Appendix F. Questionnaires . 248 Appendix G. ISCED Tables . 315 iv Palestinian Multiple Indicator Cluster Survey 2014   List of Tables Table HH.1: Results of household, women's, men's and under-5 interviews . 10 Table HH.2: Age distribution of household population by sex . 11 Table HH.3: Household composition . 13 Table HH.4: Women's background characteristics . 14 Table HH.5: Under-5's background characteristics . 18 Table HH.6: Housing characteristics . 19 Table HH.7: Household and personal assets . 20 Table HH.8: Wealth quintiles . 22 Table CM.1: Early childhood mortality rates . 24 Table CM.2: Early childhood mortality rates by socioeconomic characteristics . 26 Table CM.3: Early childhood mortality rates by demographic characteristics . 27 Table NU.1: Low birth weight infants . 33 Table NU.2: Nutritional status of children . 36 Table NU.3: Initial breastfeeding . 40 Table NU.4: Breastfeeding . 42 Table NU.5: Duration of breastfeeding . 44 Table NU.6: Age-appropriate breastfeeding . 45 Table NU.7: Introduction of solid, semi-solid, or soft foods . 46 Table NU.8: Infant and young child feeding (IYCF) practices . 47 Table NU.9: Bottle feeding . 49 Table NU.10: Iodized salt consumption . 51 Table CH.1: Vaccinations in the first years of life . 55 Table CH.2: Vaccinations by background characteristics . 58 Table CH.4: Reported disease episodes . 61 Table CH.5: Care-seeking during diarrhoea . 63 Table CH.6: Feeding practices during diarrhoea . 65 Table CH.7: Oral rehydration solutions, recommended homemade fluids, . 67 Table CH.8: Oral rehydration therapy with continued feeding and other treatments . 69 Table CH.9: Source of ORS . 72 Table CH.10: Care-seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI) . 73 Table CH.12: Solid fuel use . 76 Table CH.13: Solid fuel use by place of cooking . 77 Table WS.1: Use of improved water sources . 81 Table WS.2: Household water treatment . 84 Table WS.3: Time to source of drinking water . 86 Table WS.4: Person collecting water . 87 Table WS.5: Types of sanitation facilities . 89 Table WS.6: Use and sharing of sanitation facilities . 90 Table WS.7: Drinking water and sanitation ladders . 92 Table RH.1: Fertility rates . 96 Table RH.2: Adolescent birth rate and total fertility rate . 98 Table RH.3: Early childbearing . 99 Table RH.4: Trends in early childbearing . 100 Table RH.5: Use of contraception . 102 Table RH.6: Unmet need for contraception . 106 Table RH.7: Antenatal care coverage . 110 Table RH.8: Number of antenatal care visits and timing of first visit . 111 Table RH.9: Content of antenatal care . 113 v   Table RH.10: Assistance during delivery and caesarian section . 115 Table RH.11: Place of delivery . 118 Table RH.12: Post-partum stay in health facility . 121 Table RH.13: Post-natal health checks for newborns . 123 Table RH.14: Post-natal care visits for newborns within one week of birth . 126 Table RH.15: Post-natal health checks for mothers . 128 Table RH.16: Post-natal care visits for mothers within one week of birth . 131 Table RH.17: Post-natal health checks for mothers and newborns . 133 Table CD.1: Early childhood education . 137 Table CD.2: Support for learning . 139 Table CD.3: Learning materials . 142 Table CD.4: Inadequate care . 144 Table CD.5: Early child development index . 146 Table ED.1: Literacy (young women) . 151 Table ED.2: School readiness . 153 Table ED.3: Basic school entry . 155 Table ED.4: Basic school attendance and out of school children . 157 Table ED.5: Secondary school attendance and out of school children . 160 Table ED.6: Children reaching last grade of basic school . 163 Table ED.7: Basic school completion and transition to secondary school . 166 Table ED.8: Education gender parity . 167 Table ED.9: Out of school gender parity . 168 Table CP.1: Birth registration . 173 Table CP.5: Child discipline . 175 Table CP.6: Attitudes toward physical punishment . 177 Table CP.7: Early marriage and polygyny (women) . 179 Table CP.8: Trends in early marriage (women) . 182 Table CP.9: Children's living arrangements and orphanhood . 184 Table CP.14: Children's living arrangements and orphanhood . 186 Table CP.15: Children with parents living abroad . 188 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (women) . 191 Table HA.2: Knowledge of mother-to-child HIV transmission (women) . 195 Table HA.3: Accepting attitudes toward people living with HIV (women) . 197 Table HA.4: Knowledge of a place for HIV testing (women) . 200 Appendices: Table SE.1: Indicators selected for sampling error calculations . 204 Table SE.2: Sampling errors: Total sample . 212 Table SE.3: Sampling errors: West Bank . 213 Table SE.4: Sampling errors: Gaza Strip . 214 Table SE.5: Sampling errors: Urban . 215 Table SE.6: Sampling errors: Rural . 216 Table SE.7: Sampling errors: Camp . 217 DQ.1: Age distribution of household population . 218 DQ.2: Age distribution of eligible and interviewed women . 219 DQ.4: Age distribution of children in household and under-5 questionnaires . 219 DQ.5: Birth date reporting: Household population . 220 DQ.6: Birth date and age reporting: Women . 221 DQ.8: Birth date and age reporting: Under-5s . 222 DQ.9: Birth date reporting: Children, adolescents and young people . 223 DQ.10: Birth date reporting: First and last births . 224 DQ.11: Completeness of reporting . 225 vi Palestinian Multiple Indicator Cluster Survey 2014   DQ.12: Completeness of information for anthropometric indicators: Underweight . 226 DQ.13: Completeness of information for anthropometric indicators: Stunting . 226 DQ.14: Completeness of information for anthropometric indicators: Wasting . 227 DQ.15: Heaping in anthropometric measurements . 227 DQ:16: Observation of birth certificates . 228 DQ.17: Observation of vaccination cards . 229 DQ.20: Respondent to the under-5 questionnaire . 230 DQ.21: Selection of children age 1-17 years for the child labour and child discipline modules . 231 DQ.22: School attendance by single age . 232 DQ.23: Sex ratio at birth among children ever born and living . 233 DQ.24: Births in years preceding the survey . 234 DQ.25: Reporting of age at death in days . 235 DQ.26: Reporting of age at death in months . 236 ED.4 (ISCED): Primary school attendance and out of school children . 316 ED.5 (ISCED) Secondary school attendance and out of school children . 318 ED.6 (ISCED) Children reaching last grade of primary school . 320 ED.7 (ISCED) Primary school completion and transition to secondary school . 321 ED.8(ISCED): Education gender parity . 322 ED.10(ISCED) Summary of education indicators . 323 vii   List of Figures Figure HH.1: Age and sex distribution of household population . 12 Figure CM.1: Early child mortality rates . 25 Figure CM.2: Under-5 mortality rates by area and region . 28 Figure CM.3: Trend in under-5 mortality rates . 29 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe) . 38 Figure NU.2: Initiation of breastfeeding . 41 Figure NU.3: Infant feeding patterns by age . 43 Figure NU.4: Consumption of iodized salt . 52 Figure CH.1: Vaccinations by age 12 months (measles by 24 months) . 57 Figure CH.2: Children under-5 with diarrhoea who received ORS . 68 Figure CH.3: Children under-5 with diarrhoea receiving oral rehydration therapy (ORT) and continued feeding . 71 Figure WS.1: Percent distribution of household members by source of drinking water . 83 Figure WS.3: Use of improved drinking water sources and improved sanitation facilities by household members . 93 Figure RH.1: Age-specific fertility rates by region . 97 Figure RH.2: Differentials in contraceptive use . 104 Figure RH.3: Person assisting at delivery . 117 Figure RH.4: Continuum of reproductive and maternal health interventions . 119 Figure ED.1: Education indicators by sex . 169 Figure CP.1: Children under-5 whose births are registered . 174 Figure CP.2: Child disciplining methods, children age 1-14 years . 176 Figure CP.3: Early marriage among women . 183 Figure HA.1: Women and men with comprehensive knowledge of HIV transmission . 194 Figure HA.2: Accepting attitudes toward people living with HIV/AIDS . 199 viii Palestinian Multiple Indicator Cluster Survey 2014   List of Abbreviations AIDS Acquired Immune Deficiency Syndrome BCG Bacillus Calmette-Guérin (Tuberculosis) CSPro Census and Survey Processing System DPT Diphteria Pertussis Tetanus vaccine EPI Expanded Programme on Immunization GPI Gender Parity Index Hep.B Hepatitis B Hib Haemophilus influenzae type b HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders IGME Inter-agency Group for Child Mortality Estimation IPV Inactivated Polio Vaccine ITN Insecticide Treated Net IUD Intrauterine Device LAM Lactational Amenorrhea Method MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS5 Fifth global round of Multiple Indicator Clusters Surveys programme MMR Measles Mumps and Rubella MoH Ministry of Health NAR Net Attendance Rate ORT Oral rehydration treatment PAPFAM Pan Arab Family Health Survey ppm Parts Per Million SPSS Statistical Package for Social Sciences UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund UNRWA The United Nations Relief and Works Agency for Palestine Refugees in the Near East WFFC World Fit for Children WHO World Health Organization ix   Acknowledgements The Palestinian Central Bureau of Statistics for Palestinian extends its gratitude to the Palestinian families living in Palestine for their cooperation and responsiveness with field workers during survey data collection. The Palestinian Central Bureau of Statistics also extends it thanks and appreciation to technical staff; the manager, supervisors, editors, field supervisors, fieldworkers, and the steering committee for their dedication and loyalty in performing their duties which led to the availability of high quality data. The Palestinian Bureau of Statistics also would like to extend its appreciation to the United Nations Children’s Fund (UNICEF) and the United Nations Fund for Population (UNFPA) on the technical and financial support which contributed greatly to the success of implementation of the survey. The Palestinian Central Bureau of statistics hopes to have contributed in providing reliable data on the situation of the Palestinians to planners and policy makers, in addition to providing data for researchers and academicians for further in-depth analysis on the reality of the Palestinian’s situation in Palestine. Ola Awad President, Palestinian Central Bureau of Statistics x Palestinian Multiple Indicator Cluster Survey 2014 P  a  g  e  |  xi   Summary Table of Survey Implementation and the Survey Population, Palestinian Multiple Indicator Cluster Survey, 2014 Survey implementation Sample frame -­‐ Updated Population Housing and Establishment Census 2007 Household Listing 2013 Questionnaires Household Women (age 15-49) Children under five Interviewer training February 2014 Fieldwork March-April 2014 Survey sample Households -­‐ Sampled -­‐ Occupied -­‐ Interviewed -­‐ Response rate (Per cent) 11, 125 10, 568 10, 182 96.3 Children under five -­‐ Eligible -­‐ Mothers/caretakers interviewed -­‐ Response rate (Per cent) 7, 919 7, 816 98.7 Women -­‐ Eligible for interviews -­‐ Interviewed -­‐ Response rate (Per cent) 13, 964 13, 367 95.7       Survey population Average household size 5.5 Percentage of population living in -­‐ West Bank -­‐ Gaza Strip -­‐ Urban -­‐ Rural -­‐ Camps   59.1   40.9     74.5   16.7   8.8   Percentage of population under: -­‐ Age 5 -­‐ Age 18   14.3   46.3   Percentage of women age 15-49 years with at least one live birth in the last 2 years 22.0               xi P  a  g  e  |  xii   HOUSEHOLD OR PERSONAL ASSETS HOUSING CHARACTERISTICS Palestine West Bank Gaza Strip Palestine West Bank Gaza Strip Percentage of households that own Percentage of households with -­‐ Radio -­‐ A television 38.6 80.1 44.6 75.2 28.6 88.2 -­‐ Electricity 99.9 99.9 99.9 -­‐ LCD /LED /3D TV 26.9 34.8 13.5 -­‐ Finished floor 99.9 99.9 99.8 -­‐ Non-mobile phone 36.2 40.1 29.7 -­‐ Finished roofing 99.8 99.9 99.8 -­‐ A refrigerator 95.5 97.0 93.0 -­‐ Finished walls 99.0 98.5 99.8 -­‐ Central heating 2.6 3.8 0.5 -­‐ Clothes Dryer 5.4 7.2 2.4 Mean number of persons per room used for sleeping 2.5 2.4 2.7 -­‐ Freezer 6.9 9.5 2.6 -­‐ Dishwasher 2.3 3.6 0.2 -­‐ Air Conditioner 16.9 22.5 7.5 -­‐ Play Station / X-Box 4.2 5.9 1.5 -­‐ Satellite Dish 94.7 95.3 93.6 -­‐ Solar Heater 59.0 65.4 48.2 -­‐ Vacuum Cleaner 37.0 49.9 15.4 -­‐ Washing Machine 95.1 96.2 93.2 -­‐ Agricultural land 17.6 22.1 10.0 -­‐ Farm animals/livestock 10.6 10.6 10.8 Percentage of households where at least a member has or owns a -­‐ I pad / Tablet 14.3 20.5 3.9 -­‐ A Smart Mobile telephone 48.2 58.6 30.8 -­‐ A Laptop 37.4 43.4 27.3 -­‐ Animal - Drawn cart 1.5 0.4 3.2 -­‐ A car or Truck 26.8 36.8 10.1 -­‐ Bank account 44.2 52.1 30.9 xii Palestinian Multiple Indicator Cluster Survey 2014 P  a  g  e  |  xiii   Summary Table of Findings1 Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Palestinian Multiple Indicator Cluster Survey, 2014 CHILD MORTALITY Early childhood mortality MICS Indicator Indicator Description Value A Palestine West Bank Gaza Strip 1.1 Neonatal mortality rate Probability of dying within the first month of life 11 11 12 1.2 MDG 4.2 Infant mortality rate Probability of dying between birth and the first birthday 18 17 20 1.3 Post-neonatal mortality rate Difference between infant and neonatal mortality rates 7 6 8 1.4 Child mortality rate Probability of dying between the first and the fifth birthdays 4 3 4 1.5 MDG 4.1 Under-five mortality rate Probability of dying between birth and the fifth birthday 22 20 24 A Indicator values are per 1,000 live births and refer to the five-year period before the survey NUTRITION Nutritional status MICS Indicator Indicator Description Palestine West Bank Gaza Strip 2.1a 2.1b MDG 1.8 Underweight Prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard 1.4 0.2 1.5 0.3 1.3 0.2 2.2a 2.2b Stunting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height for age of the WHO standard 7.4 1.8 7.7 2.4 7.1 1.1 2.3a 2.3b Wasting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard 1.2 0.3 1.7 0.6 0.7 0.1 2.4 Overweight prevalence Percentage of children under age 5 who are above two standard deviations of the median weight for height of the WHO standard 8.2 9.8 6.5 1  See  Appendix  E  for  a  detailed  description  of  MICS  indicators   xiii P  a  g  e  |  xiv   Breastfeeding and infant feeding MICS Indicator Indicator Description Palestine West Bank Gaza Strip 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 96.6 95.8 97.6 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last newborn to the breast within one hour of birth 40.8 40.7 41.0 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 38.6 40.6 36.4 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 50.0 52.9 46.7 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 52.9 48.4 58.7 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 11.5 13.8 8.4 2.11 Median duration of breastfeeding The age in months when 50 percent of children age 0-35 months did not receive breast milk during the previous day 13.9 13.3 14.2 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fed during the previous day 43.4 42.0 45.1 2.13 Introduction of solid, semi-solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day 89.6 87.7 91.6 2.14 Milk feeding frequency for non-breastfed children Percentage of non-breastfed children age 6-23 months who received at least 2 milk feedings during the previous day 69.6 79.1 57.6 2.15 Minimum meal frequency Percentage of children age 6-23 months who received solid, semi-solid and soft foods (plus milk feeds for non-breastfed children) the minimum number of times or more during the previous day 75.4 75.4 75.4 2.16 Minimum dietary diversity Percentage of children age 6–23 months who received foods from 4 or more food groups during the previous day 62.6 68.9 55.1 2.17a 2.17b Minimum acceptable diet (a) Percentage of breastfed children age 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day (b) Percentage of non-breastfed children age 6–23 months who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day 40.2 43.8 44.5 51.6 35.7 33.9 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 42.4 47.5 36.3 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of potassium iodide or potassium iodate 73.2 69.3 79.7 Low-birthweight 2.20 Low-birthweight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 8.3 8.4 8.3 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 99.7 99.6 99.8 xiv Palestinian Multiple Indicator Cluster Survey 2014 P  a  g  e  |  xv   CHILD HEALTH Vaccinations MICS Indicator Indicator Description Palestine West Bank Gaza Strip 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 98.8 98.2 99.3 3.2 Polio immunization coverage Percentage of children age 12-23 months who received the third dose of OPV vaccine (OPV3) by their first birthday 97.9 97.6 98.2 3.3 3.5 3.6 Diphtheria, pertussis and tetanus (DPT), hepatitis B (HepB) and haemophilus influenza type B (Hib) immunization coverage (Pentavalent) Percentage of children age 12-23 months who received the third dose of Penta vaccine (diphtheria, pertussis, tetanus, hepatitis B and haemophilus influenza B) by their first birthday 96.9 96.6 97.2 3.4 MDG 4.3 Measles immunization coverage Percentage of children age 24-35 months who received measles vaccine by their second birthday 97.0 96.9 97.1 3.8 Full immunization coverage Percentage of children age 24-35 months who received all vaccinations recommended in the national immunization schedule by their first birthday (measles by second birthday) 89.9 89.8 90.0 Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 11.3 11.4 11.1 3.10 Care-seeking for diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 52.9 52.4 53.4 3.S1 Diarrhoea treatment with oral rehydration salts (ORS) Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS 31.5 35.8 26.5 3.12 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet, pre-packaged ORS fluid, or increased fluids) and continued feeding during the episode of diarrhoea 38.2 41.4 34.4 Acute Respiratory Infection (ARI) symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 10.7 11.0 10.4 3.13 Care-seeking for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 76.5 78.6 74.0 3.14 Antibiotic treatment for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics 70.3 72.7 67.4 xv P  a  g  e  |  xvi   Solid fuel use 3.15 Use of solid fuels for cooking Percentage of household members in households that use solid fuels as the primary source of domestic energy to cook 1.8 0.5 3.7 WATER AND SANITATION MICS Indicator Indicator Description Palestine West Bank Gaza Strip 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 61.5 96.8 10.4 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 1.3 11.0 0.8 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 98.6 98.8 98.4 REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Palestine West Bank Gaza Strip - Total fertility rate Total fertility rateA for women age 15-49 years 4.1 3.7 4.5 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rateA for women age 15-19 years 48 35 66 5.2 Early childbearing Percentage of women age 20-24 years who had at least one live birth before age 18 22.0 19.6 25.1 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women age 15-49 years currently married who are using (or whose partner is using) a (modern or traditional) contraceptive method 57.2 59.8 53.4 5.4 MDG 5.6 Unmet need Percentage of women age 15-49 years who are currently married who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 10.9 11.0 10.7 A The age-specific fertility rate is defined as the number of live births to women in a specific age group during a specified period, divided by the average number of women in that age group during the same period, expressed per 1,000 women. The age-specific fertility rate for women age 15-19 years is also termed as the adolescent birth rate. The total fertility rate (TFR) is calculated by summing the age-specific fertility rates calculated for each of the 5-year age groups of women, from age 15 through to age 49. The TFR denotes the average number of children to which a woman will have given birth by the end of her reproductive years (by age 50) if current fertility rates prevailed. xvi Palestinian Multiple Indicator Cluster Survey 2014 P  a  g  e  |  xvii   Maternal and newborn health MICS Indicator Indicator Description Palestine West Bank Gaza Strip 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women age 15-49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 99.5 95.3 99.4 99.3 95.5 95.7 5.6 Content of antenatal care Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 95.8 93.9 98.1 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women age 15-49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 99.6 99.6 99.5 5.8 Institutional deliveries Percentage of women age 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 99.3 99.3 99.4 5.9 Caesarean section Percentage of women age 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 20.3 22.7 17.4 Post-natal health checks MICS Indicator Indicator Description Palestine West Bank Gaza Strip 5.10 Post-partum stay in health facility Percentage of women age 15-49 years who stayed in the health facility for 12 hours or more after the delivery of their most recent live birth in the last 2 years 58.5 81.3 31.0 5.11 Post-natal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery 93.9 96.9 90.2 5.12 Post-natal health check for the mother Percentage of women age 15-49 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 90.7 89.7 91.8 xvii P  a  g  e  |  xviii   CHILD DEVELOPMENT MICS Indicator Indicator Description Palestine West Bank Gaza Strip 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 26.4 27.2 25.5 6.2 Support for learning Percentage of children age 36-59 months with whom an adult has engaged in four or more activities to promote learning and school readiness in the last 3 days 77.5 82.7 71.5 6.3 Father’s support for learning Percentage of children age 36-59 months whose biological father has engaged in four or more activities to promote learning and school readiness in the last 3 days 12.0 14.1 9.7 6.4 Mother’s support for learning Percentage of children age 36-59 months whose biological mother has engaged in four or more activities to promote learning and school readiness in the last 3 days 54.4 59.2 48.9 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 19.9 20.2 19.5 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 69.1 71.9 65.9 6.7 Inadequate care Percentage of children under age 5 left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week 14.3 13.1 15.6 6.8 Early child development index Percentage of children age 36-59 months who are developmentally on track in at least three of the following four domains: literacy- numeracy, physical, social-emotional, and learning 72.0 76.0 67.5 xviii Palestinian Multiple Indicator Cluster Survey 2014 P  a  g  e  |  xix   LITERACY AND EDUCATION Survey Indicator Indicator Description Palestine West Bank Gaza Strip MICS 7.1 MDG 2.3 Literacy rate among young woman Percentage of young woman age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education 97.2 97.6 96.5 7.2 School readiness Percentage of children in first grade of basic school who attended pre-school during the previous school year 94.1 91.9 97.2 7.3 Net intake rate in basic education Percentage of children of school-entry age who enter the first grade of basic school 96.9 97.3 96.5 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school 98.8 98.9 98.7 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 89.8 89.5 90.2 7.6 MDG 2.2 Children reaching last grade of primary Percentage of children entering the first grade of primary school who eventually reach last grade 99.8 99.7 99.9 7.7 Primary completion rate Number of children attending the last grade of primary school (excluding repeaters) divided by number of children of primary school completion age (age appropriate to final grade of primary school) 99.6 98.6 101.0 7.8 Transition rate to secondary school Number of children attending the last grade of primary school during the previous school year who are in the first grade of secondary school during the current school year divided by number of children attending the last grade of primary school during the previous school year 98.3 99.9 96.3 7.9 MDG 3.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 1.00 1.00 1.00 7.10 MDG 3.1 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 1.06 1.12 1.08 7.S1 Basic school net attendance ratio (adjusted) Percentage of children of basic school age currently attending basic or secondary school 96.8 96.7 97.0 7.S2 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 71.7 70.7 73.2 7.S3 Children reaching last grade of basic Percentage of children entering the first grade of basic school who eventually reach last grade 92.1 92.1 92.0 7.S4 Basic completion rate Number of children attending the last grade of basic school (excluding repeaters) divided by number of children of basic school completion age (age appropriate to final grade of basic school) 88.7 90.7 85.4 7.S5 Transition rate to secondary school Number of children attending the last grade of basic school during the previous school year who are in the first grade of secondary school during the current school year divided by number of children attending the last grade of basic school during the previous school year 93.5 92.7 94.7 7.S6 Gender parity index (basic school) Basic school net attendance ratio (adjusted) for girls divided by basic school net attendance ratio (adjusted) for boys 1.03 1.04 1.02 P  a  g  e  |  xx   7.S7 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 1.27 1.32 1.20 xix P  a  g  e  |  xxi   CHILD PROTECTION Birth registration MICS Indicator Indicator Description Palestine West Bank Gaza Strip 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 99.3 99.1 99.6 Child discipline 8.3 Violent discipline Percentage of children age 1-14 years who experienced psychological aggression or physical punishment during the last one month 92.2 90.4 94.5 Early marriage and polygyny MICS Indicator Indicator Description Palestine West Bank Gaza Strip 8.4 Marriage before age 15 Percentage of women age 15-49 years who were first married before age 15 2.1 1.8 2.6 8.5 Marriage before age 18 Percentage of women age 20-49 years who were first married before age 18 24.2 21.4 28.6 8.6 Young Woman age 15-19 years currently married Percentage of young women age 15-19 years who are married 9.3 6.8 12.8 8.7 Polygyny Percentage of women age 15-49 years who are in a polygynous marriage 4.3 3.2 5.8 8.8a 8.8b Spousal age difference Percentage of women who are married and whose spouse is 10 or more years older, (a) among women age 15-19 years (b) among women age 20-24 years 13.2 11.9 15.1 14.5 11.8 8.9 Children’s living arrangements 8.13 Children’s living arrangements Percentage of children age 0-17 years living with neither biological parent 0.6 0.3 0.9 8.14 Prevalence of children with one or both parents dead Percentage of children age 0-17 years with one or both biological parents dead 2.3 2.0 2.6 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 0.3 0.3 0.3 xx Palestinian Multiple Indicator Cluster Survey 2014 P  a  g  e  |  xxii   HIV/AIDS HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Palestine West Bank Gaza Strip - Have heard of AIDS Percentage of woman age 15-49 years who have heard of AIDS 95.0 96.4 92.9 Knowledge about HIV prevention among woman (15-49) Percentage of woman age 15-49 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission 7.7 9.9 4.5 9.1 MDG 6.3 Knowledge about HIV prevention among young woman Percentage of woman age 15-24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission 6.2 8.2 4.6 9.2 Knowledge of mother-to-child transmission of HIV Percentage of woman age 15-49 years who correctly identify all three means of mother-to- child transmission of HIV 43.5 42.6 44.9 9.3 Accepting attitudes towards people living with HIV Percentage of woman age 15-49 years expressing accepting attitudes on all four questions toward people living with HIV 5.0 5.1 4.8 HIV testing MICS Indicator Indicator Description Palestine West Bank Gaza Strip 9.4 People who know where to be tested for HIV Percentage of Women age 15-49 years who state knowledge of a place to be tested for HIV 19.7 19.1 20.6 xxi P  a  g  e  |  xxiii   Executive Summary The Palestinian Multiple Indicator Cluster Survey (PMICS) was carried out in 2014 by Palestinian Central Bureau of Statistics in collaboration with Ministry of Health, as part of the global MICS programme. Technical and financial support was provided by the Palestinian Government, the United Nations Children’s Fund (UNICEF) and United Nations Population Fund (UNFPA). The findings pertain to March–April 2014, when the fieldwork was conducted. Findings from the survey are presented in this report. The Palestinian Multiple Indicator Cluster Survey, 2014 was conducted for a representative sample of Palestine. The survey was designed as a multi- stage cluster sample covering the entire country including two geographic regions; The West Bank which includes 11 governorates: (Jenin, Tubas, Tulkarm, Qalqiliya, Salfit, Nablus, Ramallah and Al Bireh, Jerusalem, Jericho and Al Aghwar, Bethlehem, Hebron) and Gaza Strip which includes 5 governorates (Gaza, Khan Yunis, Rafah, Deir El Balah and North Gaza) and was stratified according to urban, rural and camp areas. Of the 11,125 households selected in the sample, results showed that the number of occupied households were 10,568 of which 10,182 households were successfully interviewed during the survey, giving a response rate of 96 percent. There were 13,964 women in the 15-49 age group of which a total of 13,367 eligible women were successfully interviewed, achieving a response rate of 96 percent. In addition, the number of children was 7,919 child in the Household Questionnaire of which a total of 7,816 child were interviewed giving a response rate of 99 percent. The total households interviewed included 56,367 individual members who were listed. Of these, 28,542 were males and 27,825 were females with a sex ratio of 103 males per hundred females. It is noted that the Palestinian population is a young one. The percentage of individuals in the age group 0-17 years was 46 percent, whereas the percentage of individuals in the age group 18 and above was 54 percent. According to economic and social dependency categories, 39 percent individuals were in the age group 0-14 years, 58 percent in the age group 15-64 years which is the age category of economically active individuals; and 3 percent in the age group 65 years and over. The average household size in Palestine in 2014 was about 5.5 persons. About 91 percent of households are headed by men and about 9 percent of households are headed by women. Early Childhood Mortality The infant mortality rate in Palestine is 18 per 1,000 live births, with 17 per 1,000 live births in the West Bank compared to 20 per 1,000 live births in the Gaza Strip. The Under-Five Mortality rate in Palestine is 22 per 1,000 live births with 20 per 1,000 live births in the West Bank compared to 24 per 1,000 live births in the Gaza Strip. Mortality estimates is for the periods of five years preceding the survey; where differences appear in the mortality rates between male and female infants and children under 5. Among males, the infant mortality rate was 19 per 1000 live birth, with neonatal mortality rate of 11 per 1000 live birth, and the post neonatal mortality of 8 per 1000 live birth. These rates are higher among males than females as corresponding rates for infant mortality rate among girls is (17 per 1000 live birth, neonatal mortality is 11 per 1000 live birth; while the post neonatal mortality rate is 6 per 1000 live birth). Differences were also noted in the infant mortality rates according to area, where infant mortality rate in urban locations was around 19 per 1000 live births, 18 per 1,000 live births in rural areas and 12 per 1,000 live births in Camps. xxii Palestinian Multiple Indicator Cluster Survey 2014 P  a  g  e  |  xxiv   Malnutrition indicators Among the child survival indicators are the malnutrition indicators, which are expressed in anthropometric measurements (height, weight, age). Weights and height measurements were conducted for children under-five years of age in Palestinian households. Data results revealed that one percent of the children under-5 in Palestine are moderately underweight and a negligible proportion (0.2) are severely underweight, seven percent of children under-5 are moderately stunted i.e. too short for their age, and two percent are severely stunted. Results also show that one percent of children are also moderately wasted (short for their height). They also show that eight percent of children are suffering from overweight. Breastfeeding For monitoring the nutritional status, it is important to follow up the pattern of breast feeding and complementary feeding for children from birth to three years. WHO and the UNICEF recommend continued breastfeeding for two years or more. Although breastfeeding is an important factor in dealing with feeding and building a physical and emotional connection between mother and infant. Results show that only 41 percent of infants are breastfed for the first time within the first hour of birth; while results show that around 97 percent of children under five had been ever- breastfed. Results also show that no differences according to the region. Differences are noted according to the area where the highest percentage was among children in the rural areas reaching 45 percent compared to 40 percent of urban children and 43 percent of children in Camps. Moreover, it was noted that there are large differences in the results for early initiation of breast feeding at the governorate level, the lowest seem in 25 percent in Hebron governorate, followed by 33 percent in Gaza governorate. The highest percentage was in Jericho and Al Aghwar governorate with 66 percent followed by Rafah with 63 percent. It is also found that only 39 percent of children aged less than six months are exclusively breastfed (breast milk only, or with vitamins or medicine) which is considerably lower than the international standards Immunization Immunization coverage is an important health concern that helps to protect children from deadly diseases. Countries follow globally accepted programmes of vaccination where the child receives vaccinations within a specified period of time. These vaccinations include Bacillis-Cereus-Geuerin (BCG), a birth dose of Hepatitis B (Hep B) Inactivated Polio Vaccine(IPV), Pentavalent i.e. Diptheria, Pertussis and Tetanus (DPT); Hep B; Hemophilus Influenza type b (Hib), Polio, and measles. In the survey, vaccination cards were mainly used for recording vaccines received by the child, and if the child did not have a card, the mother was asked to recall whether or not the child had received each of the vaccinations and, they were also asked how many times. Percentage of measles vaccine and full immunization were been calculated to children aged 24-35 months who received measles by their second birthday. Overall, 94 percent of children age 12-23 months and 89 percent of those age 24-35 months have ever received a vaccination card, and that cards were actually seen by the interviewer in 93 percent and 84 percent of cases respectively for these two age groups. Approximately 99 percent of children age 12-23 months received a BCG vaccination by the age of 12 months and the first and second doses of Pentavalent vaccine (DPT-HepB-Hib) vaccine were given to 98 percent, the coverage was maintained at 97 percent for the third xxiii P  a  g  e  |  xxv   dose. Similarly, 99 percent of children received Polio 1 by age 12 months and this was maintained at 98 percent by the third dose. The coverage for measles vaccine for children 24-35 months by any time before the survey was 99 while 97 percent of children 24-35 months received the measles vaccine by the age of 12 months. As a result, the children who had received all the recommended vaccinations by their first birthday and measles by their second birthday, i.e. who were fully immunised was 90 percent Diarrhoeal disease, pneumonia and acute respiratory tract infections Diarrhoeal disease, pneumonia and acute respiratory tract infections are important risk factors that increase the risk of death of infants and children under-five. Mothers (or caretakers) were asked to report; whether their child had diarrhoea in the two weeks prior to the survey; the treatment methods used (by oral rehydration therapy, increased foods and liquids). Questions were also asked about symptoms of pneumonia. About 11 percent of children under-five years of age had diarrhoea in the two weeks preceding the survey. This percentage ranged from five percent in Qalqiliya governorate to 18 percent in Tubas governorate. The highest period-prevalence is seen among children age 12-23 months (18 percent) which grossly corresponds to the weaning period. The results showed differences between children who had diarrhea in the two weeks preceding the survey based on mother’s education; where only three percent of children who had diarrhea their mothers had basic education compared to 11 percent for mothers with higher education. Information on symptoms of ARI was collected during the Palestinian MICS to capture risk to pneumonia which was noted by a child who had rapid breathing or difficulty breathing which was accompanied by a cough. Results show that 11 percent of children aged 0-59 months were reported to have had symptoms of acute respiratory infections a during the two weeks preceding the survey. Seventy seven percent of children age 0-59 months with symptoms of ARI were taken to a qualified provider. (79 percent, males; 74 percent, females), the percentage was better in the West Bank; 79 percent compared to 74 percent in Gaza Strip, while it was 73 percent for rural children compared to 77 percent in camps and urban areas. Seventy percent of under-5 children with symptoms of ARI received antibiotics during the two weeks prior to the survey. The percentage was considerably higher in urban (72 percent) than in camps and rural areas, and ranges from 50 percent in Bethlehem governorate to 91 percent in Rafah. Water and Sanitation Use of unimproved sources of drinking water and sanitation, are considered to be major factors leading to disease and infection. Overall, 62 percent of the population living in Palestine has access to improved drinking water sources. This coverage does not indicate that the sources are necessarily safe. The situation is considerably worse in Gaza Strip region compared with the West Bank where only 10 percent of the population in Gaza Strip has access to improved drinking water sources compared to 97 percent in the West Bank. It should be noted that this percentage is low because 68 percent of Gaza Strip residents use tankered water which is not considered an improved source of water. Results also show that residents of the rural regions have better access to improved sources of drinking water compared to urban areas and Camps, 87 percent in rural areas compared to about 58 percent in urban regions and 42 percent in Camps. xxiv Palestinian Multiple Indicator Cluster Survey 2014 P  a  g  e  |  xxvi   Results show that about 89 percent of households that use unimproved drinking water source do not use any method for water treatment whereas eight percent of households use a water filter and one percent adds chlorine. The majority of the Palestinian households are using improved sanitation facilities (99 percent). Fifty six percent of the households are connected to piped sewer system; of which 38 percent are in the Gaza Strip and 82 percent in the West Bank. The lowest proportion of households connected to piped sewer system is in rural areas (only 10 percent) compared to 89 percent in Camps and 62 percent in urban areas. Ten percent of households use pit latrines which are considered as improved sanitation facility. Reproductive health: Governments seek to promote knowledge and provide reproductive health services for women, because such services have an effect on reducing maternal mortality rates and help avoid unsafe pregnancies which increase the likelihood of death among teenage mothers age 15-19. The survey addressed a number of reproductive health indicators. The Total Fertility Rate (TFR) for the three years preceding the Palestinian MICS 2014 is 4.1 births per woman. Results reveal that fertility rates differ according to region where it was 3.7 births per woman in the West Bank compared to 4.5 births per woman in Gaza Strip. Current use of contraception was reported by 57 percent of currently married women. The most popular method is the IUD which is used by 26 percent of married women in Palestine. The next most popular method is withdrawal, which accounts for nine percent of use among married couples. Contraceptive prevalence ranges from 60 percent in the West Bank to 53 percent in Gaza Strip. About 57 percent of married women in urban and 60 percent in rural areas and 58 in camps use a method of contraception. Adolescents are far less likely to use contraception than older women. Only about 16 percent of women age 15-19 married currently use a method of contraception compared to 38 percent of 20-24 year olds, while the use of contraception among older women ranges from 52 percent to 73 percent. The total of met need for spacing and limiting adds up to the total met need for contraception. Results show that met need for limiting is 36 percent and for spacing is 21 percent. The total demand for contraception includes women who currently have an unmet need (for spacing or limiting), plus those who are currently using contraception. Results show that unmet need for limiting is 5 percent and for spacing is 6 percent. About 96 percent of women who gave birth to their last child in the past two years from the survey on Palestinian households in 2014 received antenatal care from skilled personnel (doctor, nurse, midwife or auxiliary midwife), at least four times by visiting antenatal care centers. Among women who received antenatal care at least four times, about 96 percent were in the West Bank and 95 percent in Gaza Strip, this reflects women’s degree of awareness of the importance of consistency of care during the progress of pregnancy. About 99 percent of births in the two years preceding the survey were delivered in a health facility and by skilled personnel (Doctor, Nurse or Midwife). Twenty percent of births were delivered through Caesarean section. Overall, 59 percent of women who gave birth in a health facility stay 12 hours or more in the facility after delivery; 81 percent in the West Bank to 31 percent in Gaza Strip. A much higher proportion (78 percent) of women delivering in NGO's facilities stay 12 hours or more than those delivering in private facilities (65 percent). A similar disparity exists between rural xxv P  a  g  e  |  xxvii   (74 percent) and urban women (57 percent). As expected, nearly all women (99 percent) giving birth through C-section stay 12 hours or more in the facility after giving birth. Overall, 94 percent of newborns receive a health check following birth while in a facility or at home. With regards to PNC visits, these predominantly occur late, either after the first week or 3-6 days after the delivery (50 percent and 20 percent, respectively). As a result, a total of 94 percent of all newborns receive a post-natal health check. This percentage varies from 97 percent in the West Bank to 90 percent in Gaza Strip. Overall, 91 percent of mothers receive a health check following birth while in a facility or at home. With regards to PNC visits, the majority take place after the first week or 3-6 days after the delivery (32 percent and 11 percent, respectively). As a result, a total of 91 percent of all mothers receive a post-natal health check. This percentage varies from 90 percent in the West Bank to 92 percent in Gaza Strip. Education: Overall, 94 percent of children who are currently attending the first grade of primary school were attending pre-school the previous year. The proportion among females is slightly higher (96 percent) than males (93 percent). Also slight differential between West Bank and Gaza Strip is noticed (92 percent and 97 percent) respectively. Governorate differentials are also significant; first graders in Bethlehem governorate have attended pre-school by 82 percent compared to 100 percent in Deir El Balah and Khan Yunis governorates. Of children who are of basic school entry age (age 6), overall 97 percent are attending the first grade of basic school, with no differentials by any of the background characteristics. Only 72 percent of the children are attending secondary school, 63 percent for males compared to 80 percent for females. Gender parity for basic school is 1.03, and the gender parity for secondary school is 1.27, which is in favour for females. Inadequate care: Around 12 percent of children age 0-59 months were left in the care of other children, while 4 percent were left alone during the week preceding the interview. Combining the two care indicators, it is calculated that a total of 14 percent of children were left with inadequate care during the past week, either by being left alone or in the care of another child. No differences were observed by the sex of the child or between urban and rural and camps areas. Children age 48-59 months were left with inadequate care (17 percent) more than those who were age 36-47 months (9 percent). Early Childhood Development Around 72 percent of children age 36-59 months are developmentally on track. Early Child Development Index (ECDI) is higher among girls (77 percent) than boys (68 percent). ECDI is much higher in older age group (79 percent among 48-59 months old compared to 66 percent among 36-47 months old). Higher ECDI is seen in children attending to an early childhood education programme at 87 percent compared to 67 percent among those who are not attending. Children living in poorest households have lower ECDI (63 percent) compared to children living in richest households (81 percent of children developmentally on track). The analysis of four domains of child development shows that 96 percent of children are on track in the physical domain, but much less on track in literacy-numeracy (22 percent), learning (92 percent) and social-emotional (71 percent) domains. In each individual xxvi Palestinian Multiple Indicator Cluster Survey 2014 P  a  g  e  |  xxviii   domain the higher score is associated with children living in richest households, with children attending an early childhood education programme, older children, and among girls. Knowledge of AIDS: In Palestine, 95 percent of the women age 15-49 years have heard of AIDS. However, the percentage of those who know of both main ways of preventing HIV transmission – having only one faithful uninfected partner and using a condom every time – is only 34 percent. About 77 percent of women know of having one faithful uninfected sex partner and 38 percent of women know of using a condom every time as main ways of preventing HIV transmission. Overall, only eight percent of women age 15-49 years were found to have comprehensive knowledge. As expected, the percentage of women with comprehensive knowledge increases with their education level, the percentage is higher among women who have higher education (12 percent) compared with women with no education (1 percent). And the percentage of women with comprehensive knowledge is higher among women in the West Bank (10 percent) compared with women in Gaza Strip (5 percent), also a clear variation was noticed among governorates, with the lowest percentage in Deir El-Balah governorate (2 percent) while the highest was seen in Jericho and Al-Aghwar governorate (21 percent). xxvii I. Introduction 1 I. Introduction Background This report is based on the Palestinian Multiple Indicator Cluster Survey (PMICS), conducted in 2014 by the Palestinians Central Bureau of Statistics. The survey provides statistically sound and internationally comparable data essential for developing evidence-based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating from the World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action of the World Fit for Children (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to collect internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor 2 Palestinian Multiple Indicator Cluster Survey 2014 2 progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. The Palestinian MICS results will be critically important for final MDG reporting in 2015, and are expected to form part of the baseline data for the post-2015 era. The Palestinian MICS is expected to contribute to the evidence base of several other important initiatives, including Committing to Child Survival: A Promise Renewed, a global movement to end child deaths from preventable causes, and the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women's and Children's Health. This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The 2014 Palestinian MICS has as its primary objectives: • To provide up-to-date information for assessing the situation of children and women in Palestine • To generate data for the critical assessment of the progress made in various areas, and to put additional efforts in those areas that require more attention; • To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action; • To collect disaggregated data for the identification of disparities, to allow for evidence based policy-making aimed at social inclusion of the most vulnerable; • To contribute to the generation of baseline data for the post-2015 agenda; • To validate data from other sources and the results of focused interventions. 3 II. Sample and Survey Methodology 3 II. Sample and Survey Methodology Sample Design The sample for the Palestinian Multiple Indicator Cluster Survey was designed to provide estimates for a large number of indicators on the situation of children and women in the State of Palestine. The urban, rural and camps areas within each region were identified as the main sampling strata and the sample was selected in two stages. Within each stratum, a specified number of census enumeration areas (EAs) were selected systematically with probability proportional to size; a total of 445 sample EAs were selected at the first stage. After a household listing was carried out within the selected enumeration areas, a random systematic sample of 25 households was selected for each sample EA; this resulted in a total sample size of 11,125 households. The sample was stratified by region, urban, rural and refugee camps areas, and it is not self-weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect basic demographic information on all de jure household members (usual residents), the household, and the dwelling; 2) a questionnaire for individual women administered in each household to all women age 15-49 years; and 3) an under-5 questionnaire, administered to mothers (or caretakers) for all children under 5 years of age1 living in the household. The questionnaires included the following modules: The Household Questionnaire included the following modules: o List of Household Members o Education o Child Discipline o Household Characteristics o Water and Sanitation o Salt Iodization The Questionnaire for Individual Women was administered to all women age 15-49 years living in the households, and included the following modules: o Woman’s Background o Fertility/Birth History o Desire for Last Birth o Maternal and Newborn Health o Post-natal Health Checks o Contraception o Unmet Need o Marriage o HIV/AIDS The Questionnaire for Children Under Five was administered to mothers (or caretakers) of children under 5 years of age living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the 1  The  terms  “children  under  5”,  “children  age  0-­‐4  years”,  and  “children  age  0-­‐59  months”  are  used   interchangeably  in  this  report.   6 Palestinian Multiple Indicator Cluster Survey 2014 4 household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Age o Birth Registration o Early Childhood Development o Breastfeeding and Dietary Intake o Immunization o Care of Illness o Anthropometry The questionnaires are based on the MICS5 model questionnaire2. From the MICS5 model English version, the questionnaires were customised and translated into Arabic and were pre-tested in December, 2013 in 4 clusters, out of each cluster 25 households were selected for interview, 25 households in Al-Bireh city and 25 households in Ramallah city (Urban), 25 households in Abu-Qash village (rural) and 25 in Al-Jalazoun refugee camp (refugee camps). The clusters were covered Ramallah governorate in the central of the West Bank. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Palestinian MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the place for handwashing, and measured the weights and heights of children age under 5 years. Details and findings of these observations and measurements are provided in the respective sections of the report. Training and Fieldwork Training for the fieldwork was conducted for 16 days in February /2014. Training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Towards the end of the training period, trainees spent 2 days in practice interviewing in Jenin, Tulkarm, Nablus, Ramallah, Jerusalem, Bethlehem and Hebron governorates in the West Bank, and Gaza, Deir El-Balah, Khan Yunis governorates in Gaza Strip. The data were collected by 28 teams; each was comprised of 4-5 interviewers, one editor, one measurer and a supervisor. Fieldwork began in March/2014 and concluded in April/2014. Data Processing Data were entered using the CSPro software, Version 5.0. All the questionnaires were entered by using desktop computers, this process was done by 46 data entry operators and 2 data entry supervisors. For quality assurance purposes, all questionnaires were double- entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS programme and adapted to the Palestinian Multiple Indicator Cluster Survey questionnaire were used throughout. Data processing began simultaneously with data collection in February /2014 and was completed in July /2014. Data were analysed using the Statistical Package for Social Sciences (SPSS) software, Version 19. Model syntax and tabulation plans developed by UNICEF were customized and used for this purpose. 2  The  model  MICS5  questionnaires  can  be  found  at  http://mics.unicef.org/tools     7 III. Sample Coverage and the Characteristics of Households and Respondents 5 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 11,125 households selected for the sample, 10,568 were found to be occupied. Of these, 10,182 were successfully interviewed for a household response rate of 96.3 percent. In the interviewed households, 13,964 women (age 15-49 years) were identified. Of these, 13,367 were successfully interviewed, yielding a response rate of 95.7 percent within the interviewed households. There were 7,919 children under age five listed in the household questionnaires. Questionnaires were completed for 7,816 of these children, which corresponds to a response rate of 98.7 percent within interviewed households. Overall response rates of 92.2 and 95.1 are calculated for the individual interviews of women and under-5s, respectively (Table HH.1). Table HH.1: Results of household, women's and under-5 interviews Number of households, women, and children under 5 by results of the household, women's and under-5's interviews, and household, women's and under-5's response rates, Palestine, 2014 Total Region Area West Bank Gaza Strip Urban Rural Camps Households Sampled 11125 7375 3750 8025 1975 1125 Occupied 10568 6986 3582 7615 1878 1075 Interviewed 10182 6687 3495 7290 1833 1059 Household response rate 96.3 95.7 97.6 95.7 97.6 98.5 Women Eligible 13964 8825 5139 9959 2483 1522 Interviewed 13367 8429 4938 9538 2375 1454 Women's response rate 95.7 95.5 96.1 95.8 95.7 95.5 Women's overall response rate 92.2 91.4 93.8 91.7 93.4 94.1 Children under 5 Eligible 7919 4508 3411 5765 1279 875 Mother/Caretaker Interviewed 7816 4453 3363 5698 1256 862 Response rate 98.7 98.8 98.6 98.8 98.2 98.5 Overall response rate 95.1 94.6 96.2 94.6 95.8 97.0 10 Palestinian Multiple Indicator Cluster Survey 2014 6 Characteristics of Households The weighted age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 10,182 households successfully interviewed in the survey, 56,367 household members were listed. Of these, 28,542 were males, and 27,825 were females. Table HH.2: Age distribution of household population by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Palestine, 2014 Total Males Females Number Percent Number Percent Number Percent Total 56367 100.0 28542 100.0 27825 100.0 Region West Bank 33333 59.1 16884 59.2 16449 59.1 Gaza Strip 23034 40.9 11658 40.8 11376 40.9 Area Urban 41987 74.5 21209 74.3 20778 74.7 Rural 9439 16.7 4803 16.8 4636 16.7 Camp 4941 8.8 2530 8.9 2411 8.7 Age 0-4 8047 14.3 4174 14.6 3873 13.9 5-9 7391 13.1 3689 12.9 3702 13.3 10-14 6711 11.9 3424 12.0 3288 11.8 15-19 6608 11.7 3370 11.8 3237 11.6 20-24 6150 10.9 3183 11.2 2967 10.7 25-29 4243 7.5 2157 7.6 2086 7.5 30-34 3404 6.0 1691 5.9 1713 6.2 35-39 3083 5.5 1493 5.2 1589 5.7 40-44 2628 4.7 1315 4.6 1313 4.7 45-49 2274 4.0 1215 4.3 1060 3.8 50-54 1848 3.3 932 3.3 916 3.3 55-59 1285 2.3 655 2.3 630 2.3 60-64 905 1.6 473 1.7 432 1.6 65-69 696 1.2 312 1.1 384 1.4 70-74 438 0.8 193 0.7 244 0.9 75-79 321 0.6 142 0.5 179 0.6 80-84 199 0.4 80 0.3 119 0.4 85+ 132 0.2 42 0.1 90 0.3 Missing/DK 5 0.0 2 0.0 3 0.0 Dependency age groups 0-14 22149 39.3 11287 39.5 10863 39.0 15-64 32427 57.5 16484 57.8 15943 57.3 65+ 1785 3.2 769 2.7 1016 3.7 Missing/DK 5 0.0 2 0.0 3 0.0 Child and adult populations Children age 0-17 years 26105 46.3 13282 46.5 12823 46.1 Adults age 18+ years 30257 53.7 15258 53.5 14999 53.9 Missing/DK 5 0.0 2 0.0 3 0.0 11 7 The age structure shows that the Palestinian population is young. The percentage of individuals in the age group 0-17 years is about 46 percent, whereas the percentage of individuals in the age group 18 and above is 54 percent – distributed almost equally among males and females. Given the population distribution in the categories of economic and social dependency, it is noted that the age group 0-14 years account for 39 percent of the population and the group 65 years and over account for 3 percent. The economically active individuals in the age group 15-64 years account for about 58 percent of the population. In the age group 15-64 years, similarities in the age distribution between males and females i.e. around 58 percent for each sex are noted. On the contrary, a clear difference was observed in the age group 65 years and over with females constituting four percent compared to around three percent for males, while in the age group 0-14 years this percentage was 40 percent for the males compared to 39 percent of the females. Figure HH.1: Age and sex distr ibut ion of household populat ion, The Palest inian Mult iple Indicator Cluster Survey, 2014 Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15-49, male respondents 15-49, and children under-5. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in the report and provide background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers.1 Table HH.3 provides basic background information on the households, including the sex of the household head, region, area, number of household members, and education of household head. These background characteristics are used in subsequent tables in this 1  See  Appendix  A:  Sample  Design,  for  more  details  on  sample  weights.   10   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+   Per  cent   Age   Males   Females   Note:  5  household  members  with  missing  age  are  excluded   12 Palestinian Multiple Indicator Cluster Survey 2014 8 report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. Table HH.3: Household composition Percent distribution of households by selected characteristics Palestine, 2014 Selected background characteristics Weighted percent Number of households Weighted Unweighted Total 100.0 10182 10182 Region West Bank 62.7 6385 6687 Gaza Strip 37.3 3797 3495 Sex of household head Male 90.8 9246 9220 Female 9.2 936 962 Governorate Jenin 7.3 743 762 Tubas 1.3 128 191 Tulkarm 4.1 421 430 Nablus 8.8 892 858 Qalqiliya 2.2 224 252 Salfit 1.6 164 191 Ramallah & Al-Bireh 7.6 770 782 Jericho and Al Aghwar 1.1 113 162 Jerusalem 9.7 988 1001 Bethlehem 4.9 497 532 Hebron 14.2 1446 1526 North Gaza 6.9 701 672 Gaza 13.1 1337 1161 Deir El-Balah 5.7 579 533 Khan Yunis 7.1 724 710 Rafah 4.5 455 419 Area Urban 74.7 7602 7290 Rural 17.1 1740 1833 camp 8.2 840 1059 Number of household members 1 3.3 335 350 2 9.2 935 929 3 10.6 1079 1083 4 13.5 1377 1377 5 14.5 1472 1476 6 15.4 1570 1568 7 12.7 1293 1290 8 9.3 951 951 9 5.6 574 570 10+ 5.9 596 588 Education of household head None 5.1 516 529 Basic 42.5 4327 4341 Secondary 25.8 2623 2619 Higher 26.7 2714 2691 Missing/DK 0.0 2 2 Mean household size 5.5 10182 10182 The weighted and unweighted total number of households are equal, since sample weights were normalized.1 The table also shows the weighted mean household size estimated by the survey. 13 9 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 Tables HH.4 and HH.5 provide information on the background characteristics of female and male respondents 15-49 years of age and of children under age 5. In all three tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized)1. In addition to providing useful information on the background characteristics of women and children under age five, the tables are also intended to show the number of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Palestine, 2014 Weighted percent Number of women Weighted Unweighted Total 100.0 13367 13367 Region West Bank 60.1 8032 8429 Gaza Strip 39.9 5335 4938 Governorate Jenin 6.9 921 947 Tubas 1.3 169 261 Tulkarm 3.9 518 551 Nablus 8.0 1072 1001 Qalqiliya 2.0 271 317 Salfit 1.6 211 252 Ramallah & Al-Bireh 6.9 927 941 Jericho and Al Aghwar 1.3 170 237 Jerusalem 9.0 1197 1118 Bethlehem 4.9 657 712 Hebron 14.4 1919 2092 North Gaza 7.1 945 928 Gaza 14.5 1942 1676 Deir El-Balah 6.3 842 776 Khan Yunis 7.6 1012 1002 Rafah 4.4 594 556 Area Urban 74.3 9938 9538 Rural 17.0 2272 2375 Camps 8.7 1157 1454 Age 15-19 22.8 3047 3061 20-24 21.0 2813 2812 25-29 14.9 1997 1980 30-34 12.3 1650 1629 35-39 11.6 1556 1558 40-44 9.5 1276 1282 45-49 7.7 1028 1045 14 Palestinian Multiple Indicator Cluster Survey 2014 10 Table HH.4 Continued: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Palestine, 2014 Weighted percent Number of women Weighted Unweighted Marital status Currently married 59.6 7960 7900 Widowed 1.0 128 128 Divorced 1.4 181 178 Separated 0.0 5 6 Never married 38.1 5093 5155 Motherhood and recent births Never gave birth 43.7 5846 5888 Ever gave birth 56.3 7521 7479 Gave birth in last two years 22.0 2941 2891 No birth in last two years 34.3 4581 4589 Education None 0.6 85 87 Basic 35.7 4770 4776 Secondary 29.4 3931 3896 Higher 34.3 4580 4607 Missing/DK 0.0 1 1 Wealth index quintile Poorest 19.3 2580 2403 Second 19.8 2647 2512 Middle 19.8 2646 2817 Fourth 20.3 2719 2835 Richest 20.8 2775 2800 15 11 Table HH.4 provides background characteristics of female respondents, age 15-49 years. The table includes information on the distribution of women according to region, area, age, marital status, motherhood status, births in last two years, education2, wealth index quintiles3, 4. Women aged 15-49 years are distributed among the following age groups: about 59 percent in the age group 15-29 years, about 24 percent in the age group 30-39 years and 17 percent in the age group 40-49 years. Sixty percent of women 15-49 years were currently married, and around 38 percent never married. To assess their education, women were asked about highest level of school they attained. Less than one percent of all women did not attend any form of education. The majority of women have attained either secondary or higher education (65 percent). Sixty two percent of women were ever-married. Among the total women aged 15-49 years, 56 percent had ever given birth of which 22 percent had given birth in the past two years preceding the survey. Background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, region and area, age in months, respondent type, mother’s (or caretaker’s) education, and wealth. The percentage of male children under-five years is slightly higher than female (52 percent vs 48 percent respectively). About 19 percent of children were under one year of age, 20 2  Throughout this report, unless otherwise stated, “education” refers to highest educational level ever attended by the respondent when it is used as a background variable. 3 The wealth index is a composite indicator of wealth. To construct the wealth index, principal components analysis is 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 generate weights (factor scores) for each of the items used. First, initial factor scores are calculated for the total sample. Then, separate factor scores are calculated for households in urban and rural areas. Finally, the urban and rural factor scores are regressed on the initial factor scores to obtain the combined, final factor scores for the total sample. This is carried out to minimize the urban bias in the wealth index values. Each household in the total sample is then assigned a wealth score based on the assets owned by that household and on the final factor scores obtained as described above. The survey household population is then ranked according to the wealth score of the household they are living in, and is finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). In Palestinian MICS, the following assets were used in these calculations: Electricity, radio, tube television, LCD /LED /3D TV, non-mobile telephone, refrigerator, central heating, clothes dryer, freezer, dish washer, air conditioner, play station/ xbox, satellite dish, solar heater, vacuum cleaner, clothes washer, iPad /Tablet, Smart mobile telephone, laptop, animal-drawn cart, and car or truck. 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. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro and Rutstein, S.O., 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. Calverton, Maryland: Macro International Inc. 4 When describing survey results by wealth quintiles, appropriate terminology is used when referring to individual household members, such as for instance “women in the richest household population”, which is used interchangeably with “women in the wealthiest survey population” and similar. 16 Palestinian Multiple Indicator Cluster Survey 2014 12 percent were 12-23 months, 20 percent were 24-35 months, about 21 percent were 36-47 months and 20 percent were 48-59 months. Less than one percent of children’s mothers or care takers were uneducated, 30 percent had basic education, while the majority of them had secondary or higher education (70 percent). The percentage of poorest children were the highest quintile according to the wealth index (25 percent) while richest children were about 16 percent. It is noticed that the number of weighted and unweighted number of cases are generally similar within the education categories. 17 13 Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Palestine, 2014 Weighted percent Number of under-5 children Weighted Unweighted Total 100.0 7816 7816 Region West Bank 53.7 4201 4453 Gaza Strip 46.3 3615 3363 Sex Male 51.9 4058 4070 Female 48.1 3758 3746 Governorate Jenin 6.0 468 489 Tubas 0.8 65 99 Tulkarm 2.8 217 228 Nablus 6.7 523 509 Qalqiliya 2.0 157 175 Salfit 1.3 104 120 Ramallah & Al-Bireh 6.0 466 461 Jericho and Al Aghwar 1.2 94 139 Jerusalem 8.1 634 642 Bethlehem 4.3 340 368 Hebron 14.5 1132 1223 North Gaza 8.9 695 678 Gaza 16.5 1292 1122 Deir El-Balah 6.2 488 459 Khan Yunis 8.5 667 662 Rafah 6.1 473 442 Area Urban 76.0 5944 5698 Rural 15.2 1186 1256 Camps 8.8 686 862 Age 0-5 months 8.5 668 665 6-11 months 10.3 803 788 12-23 months 19.6 1530 1538 24-35 months 19.7 1540 1545 36-47 months 21.5 1677 1678 48-59 months 20.4 1597 1602 Respondent to the under-5 questionnaire Mother 99.4 7758 7758 Other primary caretaker 0.6 44 43 Mother’s education* None 0.5 37 37 Basic 30.0 2346 2340 Secondary 33.8 2641 2620 Higher 35.7 2792 2819 Wealth index quintile Poorest 24.8 1937 1804 Second 20.5 1601 1523 Middle 19.9 1555 1673 Fourth 19.1 1491 1550 Richest 15.8 1233 1266 * In this table and throughout the report, mother's education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. 18 Palestinian Multiple Indicator Cluster Survey 2014 14 Housing characteristics, asset ownership, and wealth quintiles Tables HH.6, HH.7 and HH.8 provide further details on household level characteristics. HH.6 presents characteristics of housing, disaggregated by area and region, distributed by whether the dwelling has electricity, the main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. Table HH.6 shows similarities of the housing characteristics between West Bank and Gaza strip and between the area categories. Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and regions, Palestine, 2014 Total Region Area West Bank Gaza Strip Urban Rural Camps Electricity Yes 99.9 99.9 99.9 99.8 100.0 99.8 No 0.1 0.1 0.1 0.1 0.0 0.2 Missing/DK 0.0 0.1 0.0 0.1 0.0 0.0 Flooring Natural floor 0.1 0.0 0.2 0.1 0.1 0.1 Finished floor 99.9 99.9 99.8 99.9 99.9 99.9 Other 0.0 0.1 0.0 0.1 0.0 0.0 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.0 Roof Natural roofing 0.0 0.0 0.0 0.0 0.0 0.0 Finished roofing 99.8 99.9 99.8 99.9 99.6 100.0 Other 0.1 0.1 0.2 0.1 0.3 0.0 Missing/DK 0.0 0.1 0.0 0.1 0.0 0.0 Exterior walls Natural walls 0.0 0.0 0.0 0.0 0.1 0.1 Rudimentary walls 0.8 1.2 0.0 0.7 1.5 0.2 Finished walls 99.0 98.5 99.8 99.2 97.9 99.7 Other 0.1 0.1 0.2 0.1 0.4 0.0 Missing/DK 0.1 0.1 0.0 0.1 0.2 0.0 Rooms used for sleeping 1 19.9 19.0 21.5 19.9 19.5 21.1 2 39.6 42.1 35.4 39.1 41.6 40.1 3 or more 40.4 38.7 43.1 40.9 38.9 38.7 Missing/DK 0.1 0.1 0.0 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 10182 6385 3797 7602 1740 840 Mean number of persons per room used for sleeping 2.54 2.44 2.70 2.52 2.51 2.74 19 15 In Table HH.7 households are distributed according to ownership of assets by households and by individual household members. This also includes ownership of dwelling. Table HH.7: Household and personal assets Percentage of households by ownership of selected household and personal assets, and percent distribution by ownership of dwelling, according to area of residence and regions, Palestine, 2014 Total Area Region West Bank Gaza Strip Urban Rural Camps Percentage of households that own a Radio 38.6 44.6 28.6 39.4 40.1 28.2 Television 80.1 75.2 88.2 79.1 81.8 85.2 LCD /LED /3D TV 26.9 34.8 13.5 27.9 25.8 19.5 Non-mobile phone 36.2 40.1 29.7 36.7 36.3 31.6 Refrigerator 95.5 97.0 93.0 95.5 96.2 93.8 Central heating 2.6 3.8 0.5 2.8 1.9 2.2 Clothes Dryer 5.4 7.2 2.4 5.8 3.1 6.4 Freezer 6.9 9.5 2.6 7.0 8.3 3.6 Dishwasher 2.3 3.6 0.2 2.7 1.4 1.1 Air Condition 16.9 22.5 7.5 17.3 17.1 13.1 Play Station / X-box 4.2 5.9 1.5 4.5 4.1 2.3 Satellite Dish 94.7 95.3 93.6 95.0 94.3 92.9 Solar Heater 59.0 65.4 48.2 58.7 66.6 45.8 Vacuum Cleaner 37.0 49.9 15.4 39.1 37.2 17.7 Washing Machine 95.1 96.2 93.2 95.3 95.0 93.2 Percentage of households that own Agricultural land 17.6 22.1 10.0 15.4 33.7 4.2 Farm animals/Livestock 10.6 10.6 10.8 9.4 18.9 4.7 Percentage of households where at least one member owns or has a Ipad / Tablet 14.3 20.5 3.9 14.5 16.4 7.9 A Smart Mobile telephone 48.2 58.6 30.8 47.9 53.6 40.2 A Laptop 37.4 43.4 27.3 37.4 40.1 30.9 Animal - drawn cart 1.5 0.4 3.2 1.6 1.5 0.4 A car or Truck 26.8 36.8 10.1 27.5 31.2 11.8 Bank account 44.2 52.1 30.9 44.6 47.0 34.8 Ownership of dwelling Owned by a household member 82.5 84.1 79.6 80.4 90.4 84.3 Not owned 17.5 15.8 20.4 19.5 9.6 15.7 Rented 9.1 10.3 7.0 10.3 4.4 7.4 Other 8.4 5.5 13.4 9.2 5.2 8.3 Missing/DK 0.1 0.1 0.0 0.1 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 10182 6385 3797 7602 1740 840 Table HH.7a presents the ownership of assets by households and by individual household members within each governorate. This also includes ownership of dwelling. 20 Palestinian Multiple Indicator Cluster Survey 2014 16 Ta bl e H H .7 : H ou se ho ld a nd p er so na l a ss et s P er ce nt ag e of h ou se ho ld s by o w ne rs hi p of s el ec te d ho us eh ol d an d pe rs on al a ss et s, a nd p er ce nt d is tri bu tio n by o w ne rs hi p of d w el lin g, a cc or di ng to g ov er no ra te s, P al es tin e, 20 14 G ov er no ra te Je ni n Tu ba s Tu lk ar m N ab lu s Q al qi liy a S al fit R am al la h & A l-B ire h Je ric ho & A l A gh w ar Je ru sa le m B et hl eh em H eb ro n N or th G az a G az a D ei r E l- B al ah K ha n Y un is R af ah Pe rc en ta ge o f h ou se ho ld s th at o w n a R ad io 39 .6 31 .3 31 .8 52 .8 33 .6 49 .1 46 .8 51 .4 42 .3 41 .9 48 .8 27 .2 33 .4 30 .4 24 .2 20 .9 Te le vi si on 86 .0 77 .2 82 .4 76 .2 82 .4 83 .1 62 .4 79 .8 54 .6 76 .7 84 .8 89 .9 85 .6 91 .2 88 .8 88 .3 LC D /L E D /3 D T V 23 .8 29 .1 30 .3 33 .0 28 .5 32 .4 52 .4 26 .5 56 .0 33 .9 21 .7 9. 6 17 .1 10 .8 12 .0 14 .8 N on -m ob ile p ho ne 36 .0 44 .1 47 .4 45 .5 45 .1 45 .2 59 .7 26 .5 36 .4 36 .2 29 .4 19 .5 33 .1 30 .4 28 .2 36 .3 R ef rig er at or 96 .5 97 .6 96 .2 98 .0 96 .5 97 .7 99 .5 95 .8 98 .3 94 .6 95 .3 89 .8 94 .5 93 .2 94 .6 90 .9 C en tra l h ea tin g 0. 8 0. 7 1. 6 3. 5 1. 1 1. 8 7. 3 2. 0 6. 5 6. 1 2. 7 0. 7 0. 6 0. 0 0. 1 1. 2 C lo th es D ry er 1. 7 3. 9 4. 1 3. 6 2. 5 2. 4 10 .8 7. 4 21 .8 7. 9 2. 7 1. 0 1. 7 2. 7 3. 5 3. 9 Fr ee ze r 4. 1 9. 5 11 .6 10 .6 9. 9 18 .4 15 .8 6. 6 15 .2 9. 1 2. 7 1. 5 2. 4 1. 8 3. 1 5. 4 D is hw as he r 1. 2 0. 6 3. 0 2. 0 0. 3 3. 6 6. 7 1. 8 5. 8 7. 4 2. 5 0. 0 0. 3 0. 4 0. 1 0. 0 A ir C on di tio n 21 .1 26 .0 67 .5 13 .3 36 .4 21 .3 17 .8 75 .2 28 .0 15 .7 10 .5 4. 3 10 .7 6. 3 5. 5 7. 3 P la y S ta tio n/ X -b ox 3. 5 4. 6 6. 1 6. 2 3. 6 4. 6 9. 7 10 .2 9. 5 4. 4 3. 1 0. 8 2. 0 1. 5 1. 4 1. 0 S at el lit e D is h 95 .5 93 .4 89 .6 96 .5 95 .7 94 .4 97 .5 93 .0 97 .2 95 .1 94 .1 93 .6 92 .7 94 .1 92 .6 97 .3 S ol ar H ea te r 65 .9 55 .7 68 .1 70 .3 64 .8 84 .4 81 .8 40 .2 55 .1 68 .5 59 .5 48 .8 46 .2 52 .8 47 .7 47 .9 V ac uu m C le an er 45 .3 44 .3 45 .4 52 .4 37 .0 43 .9 53 .6 27 .0 62 .3 33 .1 52 .4 5. 6 18 .8 14 .1 18 .0 17 .8 W as hi ng M ac hi ne 95 .5 95 .5 94 .0 96 .9 95 .5 94 .5 97 .4 98 .8 98 .2 93 .7 95 .8 90 .5 93 .6 94 .0 93 .0 95 .1 Pe rc en ta ge o f h ou se ho ld s th at o w n A gr ic ul tu ra l l an d 29 .9 20 .4 22 .6 20 .6 32 .3 52 .2 28 .2 3. 4 7. 4 22 .6 22 .1 12 .3 7. 3 13 .3 12 .3 6. 6 Fa rm an im al s/ Li ve st oc k 14 .8 13 .5 9. 3 9. 9 11 .3 14 .2 8. 7 15 .8 3. 8 15 .7 11 .9 9. 2 6. 8 15 .6 16 .1 10 .3 Pe rc en ta ge o f h ou se ho ld s w he re a t l ea st o ne m em be r o w ns o r h as a Ip ad / Ta bl et 14 .2 16 .9 18 .5 21 .6 23 .3 19 .9 29 .3 15 .4 34 .3 14 .2 11 .9 3. 1 4. 4 4. 1 4. 2 3. 0 A S m ar t M ob ile te le ph on e 58 .2 57 .1 58 .1 65 .5 56 .9 61 .2 68 .3 59 .3 68 .7 60 .0 42 .3 25 .6 34 .3 31 .5 26 .0 35 .2 A L ap to p 47 .1 45 .7 57 .9 54 .4 38 .0 46 .4 47 .2 35 .7 45 .7 38 .6 29 .3 21 .6 33 .3 24 .5 23 .5 28 .0 A ni m al - dr aw n ca rt 0. 6 1. 3 0. 9 0. 4 2. 3 0. 6 0. 4 0. 4 0. 2 0. 0 0. 1 4. 2 2. 4 4. 0 3. 6 2. 6 A c ar o r T ru ck 30 .1 30 .2 32 .2 32 .8 24 .7 28 .3 46 .1 29 .5 52 .2 35 .4 32 .9 7. 6 12 .2 8. 0 10 .2 10 .1 B an k ac co un t 54 .4 65 .2 39 .6 55 .0 55 .5 56 .5 64 .3 49 .7 59 .9 41 .9 42 .3 24 .3 29 .1 41 .4 32 .7 29 .7 O w ne rs hi p of d w el lin g O w ne d by a h ou se ho ld m em be r 94 .0 78 .4 85 .4 81 .7 89 .8 86 .2 78 .4 93 .8 77 .8 91 .7 83 .6 75 .1 73 .9 81 .9 86 .2 89 .9 N ot o w ne d 6. 0 20 .9 14 .6 18 .3 10 .2 13 .8 21 .5 6. 2 21 .8 8. 3 16 .3 24 .9 26 .1 18 .1 13 .8 10 .1 R en te d 1. 9 10 .2 10 .5 12 .2 9. 3 6. 2 18 .6 4. 1 21 .0 3. 2 5. 2 7. 1 8. 3 7. 5 3. 3 8. 4 O th er 4. 2 10 .7 4. 1 6. 1 0. 9 7. 6 2. 9 2. 1 0. 9 5. 1 11 .1 17 .8 17 .8 10 .6 10 .5 1. 7 M is si ng /D K 0. 0 0. 7 0. 0 0. 0 0. 0 0. 0 0. 1 0. 0 0. 3 0. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f h ou se ho ld s 74 3 12 8 42 1 89 2 22 4 16 4 77 0 11 3 98 8 49 7 14 46 70 1 13 37 57 9 72 4 45 5 21 17 Table HH.8 shows how the household populations in areas and regions are distributed according to household wealth quintiles. The data show that households in the Gaza Strip are poorer than in the West Bank, and with regard to the area of residence the camps are poorer than urban and rural areas. Table HH.8: Wealth quintiles Percent distribution of the household population by wealth index quintiles, according to area of residence, regions and governorates, Palestine,2014 Wealth index quintiles Total Number of household members Poorest Second Middle Fourth Richest Total 20.0 20.0 20.0 20.0 20.0 100.0 56366 Region West Bank 0.6 7.5 27.3 31.6 33.1 100.0 33333 Gaza Strip 48.0 38.2 9.5 3.3 1.1 100.0 23034 Area Urban 21.3 21.8 18.6 17.5 20.8 100.0 41987 Rural 3.3 10.9 27.0 35.7 23.2 100.0 9439 Camp 41.1 21.8 18.7 11.4 7.0 100.0 4941 Governorate Jenin 0.2 10.0 32.5 35.3 22.1 100.0 3773 Tubas 0.0 8.1 38.2 28.6 25.1 100.0 671 Tulkarm 0.6 5.6 28.7 31.4 33.8 100.0 2081 Nablus 0.4 5.1 28.7 32.9 32.9 100.0 4486 Qalqiliya 0.0 7.3 31.6 36.3 24.9 100.0 1174 Salfit 0.8 6.2 23.3 36.2 33.4 100.0 876 Ramallah & Al-Bireh 0.1 3.3 14.6 32.1 49.9 100.0 3744 Jericho and Al Aghwar 2.5 13.1 27.2 30.8 26.4 100.0 664 Jerusalem 0.2 2.5 18.5 27.0 51.8 100.0 5115 Bethlehem 2.3 4.1 30.0 34.6 28.9 100.0 2640 Hebron 0.9 13.8 33.1 29.9 22.3 100.0 8110 North Gaza 53.8 36.0 7.3 2.4 0.5 100.0 4307 Gaza 48.8 38.1 8.7 3.4 0.9 100.0 8341 Deir El-Balah 51.0 37.9 9.7 1.3 0.2 100.0 3419 Khan Yunis 39.4 42.3 11.2 5.0 2.1 100.0 4297 Rafah 46.5 35.6 11.9 3.9 2.1 100.0 2670 22 Palestinian Multiple Indicator Cluster Survey 2014 IV. Child Mortality 19 IV. Child Mortality One of the overarching goals of the Millennium Development Goals (MDGs) is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction of under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Mortality rates presented in this chapter are calculated from information collected in the birth histories of the Women’s Questionnaires. All interviewed women were asked whether they had ever given birth, and if yes, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In addition, they were asked to provide a detailed birth history of live births of children in chronological order starting with the firstborn. Women were asked whether births were single or multiple, the sex of the children, the date of birth (month and year), and survival status. Further, for children still alive, they were asked the current age of the child and, if not alive, the age at death. Childhood mortality rates are expressed by conventional age categories and are defined as follows: • Neonatal mortality (NN): probability of dying within the first month of life • Post-neonatal mortality (PNN): difference between infant and neonatal mortality rates • Infant mortality (1q0): probability of dying between birth and the first birthday • Child mortality (4q1): probability of dying between the first and the fifth birthdays • Under-five mortality (5q0): the probability of dying between birth and the fifth birthday Rates are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age one, and post-neonatal mortality, which is the difference between infant and neonatal mortality rates. Table CM.1: Early childhood mortality rates Neonatal, post-neonatal, Infant, child and under-five mortality rates for five year periods preceding the survey, Palestine, 2014 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Years preceding the survey 0-4 11.2 7.1 18.2 3.6 21.7 5-9 11.8 8.6 20.3 3.8 24.1 10-14 12.9 8.4 21.3 2.2 23.4 15-19 13.2 9.6 22.8 5.9 28.6 20-24 20.3 11.5 31.9 10.0 41.5 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Table CM.1 and Figure CM.1 present neonatal, post-neonatal, infant, child, and under-five mortality rates for the three most recent five-year periods before the survey. Neonatal mortality in the most recent 5-year period is estimated at 11 per 1,000 live births, while the 24 Palestinian Multiple Indicator Cluster Survey 2014 20 post-neonatal mortality rate is estimated at 7 per 1,000 live births. The table and figure also show a declining trend at the national level, during the last 15 years, with under-five mortality at 23 per 1,000 during the 10-14 year period preceding the survey, and 22 per 1,000 live births during the most recent 5-year period. A similar pattern is observed in all other early childhood mortality indicators. The tables show that some improvement has taken place during the last 15 years. Infant mortality rate in the five years preceding the survey was at 18 per 1,000 live births with 17 per 1000 live births in the West Bank compared to 20 per 1000 live births in the Gaza Strip. Estimates of under-five mortality were 22 per 1,000 live births for the same period, with 20 per 1000 live birth in the West Bank and 24 per 1000 live birth in the Gaza Strip. The estimates roughly refer to the most recent 5 year period, roughly referring to the years 2010-2014. F i g u r e C M . 1 : E a r l y c h i l d h o o d m o r t a l i t y r a t e s , P a l e s t i n e , 2 0 1 4 Tables CM.2 and CM.3 provide estimates of child mortality by socioeconomic and demographic characteristics. Differences were noted when comparing the mortality estimates of male and females, with infant mortality rate of 19 per 1000 live births (neonatal rate 12 per 1000 live births, post-neonatal 8 per 1000 live births) for males; and 17 per 1000 live births (neonatal 11 per 1000 live births, post-neonatal 7 per 1000 live births) among females. Difference in the infant mortality rate were also noted according to area where these were 19 per 1000 live births in urban areas , about 18 per 1000 live births in the rural areas and 12 per 1000 live births in the camps . Similarly, differences were noted in the under 5 mortality rates of children among males and females which are 23 per 1000 live births compared to 21 per 1000 live births respectively. 11   7   18   4   22   12   9   20   4   24   13   8   21   2   23   Neonatal   mortality  rate   Post-­‐neonatal   mortality  rate   Infant   mortality  rate   Child   mortality  rate   Under-­‐five   mortality  rate   Years  preceding  the   survey   Note:  Indicator  values  are  per  1,000  live  births   0-­‐4   5-­‐9   10-­‐14   25 21 Table CM.2: Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, Infant, child and under-five mortality rates for the five year period preceding the survey, by socioeconomic characteristics, Palestine, 2014 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total 11.2 7.1 18.2 3.6 21.7 Region West Bank 10.9 6.2 17.1 3.0 20.0 Gaza Strip 11.5 8.1 19.6 4.2 23.7 Area Urban 12.0 7.0 19.1 3.2 22.2 Rural 8.0 9.7 17.7 3.4 21.0 Camps 9.4 2.7 12.1 6.9 18.9 Mother's education None (*) (*) (*) (*) (*) Basic 11.8 19.9 31.7 9.1 40.5 Secondary 14.7 7.3 22.0 2.0 24.0 Higher 10.4 6.3 16.7 3.5 20.1 Wealth index quintile Poorest 7.2 10.3 17.5 3.6 21.1 Second 17.9 5.3 23.2 4.9 28.0 Middle 15.9 6.2 22.2 4.4 26.5 Fourth 8.3 6.9 15.2 2.3 17.5 Richest 6.0 5.6 11.6 2.2 13.8 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates (*) Figures that are based on less than 250 unweighted exposed persons 26 Palestinian Multiple Indicator Cluster Survey 2014 22 Table CM.3: Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, Infant, child and under-five mortality rates for the five year period preceding the survey, by demographic characteristics, Palestine, 2014 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total 11.2 7.1 18.2 3.6 21.7 Sex of child Male 11.5 7.7 19.2 3.4 22.5 Female 10.8 6.4 17.2 3.8 20.9 Mother's age at birth Less than 20 5.9 6.0 11.9 7.9 19.7 20-34 11.2 7.4 18.6 2.7 21.2 35-49 15.3 5.7 21.0 5.4 26.3 Birth order 1 10.4 4.5 14.9 5.2 20.0 2-3 10.9 8.0 19.0 4.0 22.9 4-6 10.3 8.0 18.3 2.1 20.3 7+ 16.8 6.4 23.2 3.5 26.6 Previous birth intervalb < 2 years 12.3 7.0 19.4 4.1 23.4 2 years 8.8 7.7 16.5 2.4 18.8 3 years 12.3 6.8 19.1 3.6 22.6 4+ years 9.8 6.4 16.2 3.6 19.7 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates b Excludes first order births 27 23 F i g u r e C M . 2 : U n d e r - 5 m o r t a l i t y r a t e s b y a r e a a n d r e g i o n , P a l e s t i n e , 2 0 1 4 Figure CM.3 compares the findings of Palestinian MICS on under-5 mortality rates with those from other data sources. Palestinian MICS 2014 findings are obtained from Table CM.1. The MICS estimates indicate a decline in mortality during the last 20 years. The most recent U5MR estimate from MICS is about 22 percent which is lower than the estimate from IGME for the same year (2012), while the trend indicated by the survey results are in broad agreement with those estimated in 2006 and 2007 in the previous MICS survey (PFS/MICS4). Further qualification of this apparent decline and differences as well as its determinants should be taken up in a more detailed and separate analysis. 22   20   24   22   21   19   0   5   10   15   20   25   30   PalesGne   West  Bank   Gaza  Strip   Urban   Rural   Camps   Under-­‐5  Mortality  Rates  per  1,000  Births   28 Palestinian Multiple Indicator Cluster Survey 2014 24 Figure CM.3: Trend in under -5 morta l i ty ra tes , Pa lest ine , 2014 PAPFAM: Pan Arab Family Health Survey UNRWA: The United Nations Relief and Works Agency for Palestine Refugees in the Near East IGME: Inter-agency Group for Child Mortality Estimation 0   10   20   30   40   50   60   70   1982   1986   1990   1994   1998   2002   2006   2010   2014   Per  1,000  live  births   Year    PFS/MICS4  2010   PAPFAM  2006   MICS  2014   IGME   29 V. Nutrition 25 V. Nutrition 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 (defined as less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early days, months and years. Those who survive may 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 with low birth weight also risk 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: the 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. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.1 1  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   32 Palestinian Multiple Indicator Cluster Survey 2014 26 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Palestine, 2014 Percent distribution of births by mother's assessment of size at birth Total Percentage of live births: Number of last live-born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams1 Weighed at birth2 Total 3.8 9.9 68.2 18.0 0.2 100.0 8.3 99.7 2941 Region West Bank 3.5 10.3 69.1 16.8 0.4 100.0 8.4 99.6 1610 Gaza Strip 4.1 9.3 67.0 19.4 0.1 100.0 8.3 99.8 1331 Area Urban 4.1 9.5 68.4 17.8 0.2 100.0 8.4 99.7 2265 Rural 1.9 12.6 65.8 19.0 0.6 100.0 8.1 99.5 437 Camp 4.2 8.5 70.1 17.2 0.0 100.0 8.1 100.0 240 Governorate Jenin 4.1 13.1 69.1 13.6 0.0 100.0 9.5 100.0 186 Tubas (5.3) (5.4) (78.0) (11.3) (.0) (100.0) (8.0) (100.0) 25 Tulkarm 6.6 11.4 64.2 17.8 0.0 100.0 10.4 100.0 71 Nablus 1.6 13.2 73.5 11.7 0.0 100.0 8.0 99.4 189 Qalqiliya (10.8) (1.5) (76.0) (11.8) (0.0) (100.0) (10.4) (100.0) 48 Salfit (.0) (2.6) (79.6) (15.3) (2.6) (100.0) (5.0) (100.0) 34 Ramallah & Al-Bireh 6.3 11.4 61.1 20.2 0.9 100.0 10.6 99.5 190 Jericho and Al Aghwar (4.9) (5.8) (76.8) (12.5) (.0) (100.0) (7.9) (100.0) 44 Jerusalem 4.1 11.2 70.3 13.5 0.9 100.0 9.3 98.7 257 Bethlehem 1.9 10.4 70.7 16.2 0.7 100.0 7.6 99.3 137 Hebron 1.6 8.9 67.3 22.2 0.0 100.0 6.5 100.0 427 North Gaza 8.3 11.3 61.6 18.8 0.0 100.0 11.4 100.0 258 Gaza 2.7 8.5 68.6 20.3 0.0 100.0 7.1 99.7 471 Deir El-Balah 1.9 9.9 65.5 22.7 0.0 100.0 6.9 100.0 173 Khan Yunis 6.5 10.0 68.8 14.3 0.4 100.0 10.1 99.6 255 Rafah 0.6 7.3 69.7 22.3 0.0 100.0 5.4 100.0 178 Mother's age at birth Less than 20 years 4.0 10.4 69.1 16.3 0.2 100.0 8.6 99.6 1620 20-34 years 3.5 9.2 67.5 19.5 0.2 100.0 7.9 99.8 1270 35-49 years 1.8 9.4 56.4 32.4 0.0 100.0 6.4 100.0 50 Birth order 1 4.4 13.2 72.8 9.3 0.3 100.0 9.9 99.3 641 2-3 3.8 8.8 70.0 17.2 0.3 100.0 8.1 99.6 1142 4-5 2.1 9.2 67.3 21.2 0.1 100.0 7.0 100.0 683 6+ 5.3 8.9 58.8 26.8 0.2 100.0 8.7 100.0 474 Mother’s education None (*) (*) (*) (*) (*) (*) (*) (*) 9 Basic 3.6 9.5 67.7 19.2 .1 100.0 8.0 99.9 783 Secondary 4.7 11.0 65.9 18.4 .1 100.0 9.1 99.7 967 Higher 3.1 8.6 71.7 16.2 .4 100.0 7.7 99.6 1132 Wealth index quintile Poorest 4.9 10.2 67.3 17.7 0.0 100.0 9.0 100.0 728 Second 2.8 9.1 68.3 19.5 0.2 100.0 7.4 99.6 563 Middle 4.2 10.5 68.0 17.1 0.2 100.0 8.8 99.8 578 Fourth 3.6 10.2 69.1 16.8 0.3 100.0 8.4 99.7 606 Richest 2.9 9.0 68.2 19.2 0.7 100.0 7.7 99.3 466 1 MICS indicator 2.20 - Low-birthweight infants 2 MICS indicator 2.21 - Infants weighed at birth ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on less than 25 unweighted cases 33 27 Overall, nearly all children were weighed at birth of which approximately 8 percent of infants estimated to weigh less than 2500 grams at birth (Table NU.1). There are some variations by governorates. The highest prevalence of low birth weight infants was in North Gaza and Khan Yunis governorates at 11 percent and 10 percent respectively. As shown in table NU.1, no significant disparities were observed at the regional level or by area of residence but the prevalence of low birth weight was highest among first-borns and mothers aged less than 20 years Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Under-nutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development Goal target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. 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 WHO growth standards2. Each of the three nutritional status indicators – weight-for-age, height-for-age, and weight-for-height - 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. Weight-for-height can be used to assess wasting and overweight status. 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 of wasting may exhibit 2  http://www.who.int/childgrowth/standards/technical_report   34 Palestinian Multiple Indicator Cluster Survey 2014 28 significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. In MICS, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommended3 by UNICEF. Findings in this section are based on the results of these measurements. Table NU.2 shows percentages of children classified into each of the above described categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes mean z-scores for all three anthropometric indicators. 3  See  MICS  Supply  Procurement  Instructions  here:  http://www.childinfo.org/mics5_planning.html   35 29 Ta bl e N U .2 : N ut rit io na l s ta tu s of c hi ld re n P er ce nt ag e of c hi ld re n un de r a ge 5 b y nu tri tio na l s ta tu s ac co rd in g to th re e an th ro po m et ric in di ce s: w ei gh t f or a ge , h ei gh t f or a ge , a nd w ei gh t f or h ei gh t, P al es tin e, 2 01 4 W ei gh t f or a ge N um be r o f ch ild re n un de r a ge 5 H ei gh t f or a ge N um be r o f ch ild re n un de r a ge 5 W ei gh t f or h ei gh t N um be r o f ch ild re n un de r a ge 5 U nd er w ei gh t M ea n Z- S co re (S D ) St un te d M ea n Z- S co re (S D ) W as te d O ve rw ei gh t M ea n Z- S co re (S D ) P er ce nt b el ow P er ce nt b el ow P er ce nt b el ow P er ce nt a bo ve - 2 S D 1 - 3 S D 2 - 2 S D 3 - 3 S D 4 - 2 S D 5 - 3 S D 6 + 2 S D 7 To ta l 1. 4 0. 2 0. 2 72 22 7. 4 1. 8 -0 .4 69 50 1. 2 0. 3 8. 2 0. 6 69 06 R eg io n W es t B an k 1. 5 0. 3 0. 3 37 29 7. 7 2. 4 -0 .3 35 30 1. 7 0. 6 9. 8 0. 6 34 89 G az a S tri p 1. 3 0. 2 0. 1 34 92 7. 1 1. 1 -0 .5 34 20 0. 7 0. 1 6. 5 0. 6 34 18 Se x M al e 1. 6 0. 3 0. 2 37 23 8. 1 1. 9 -0 .4 35 81 1. 2 0. 3 9. 1 0. 6 35 65 Fe m al e 1. 1 0. 1 0. 2 34 99 6. 6 1. 7 -0 .4 33 69 1. 2 0. 3 7. 1 0. 6 33 42 A re a U rb an 1. 3 0. 2 0. 2 54 98 7. 5 1. 9 -0 .4 53 08 1. 1 0. 3 7. 9 0. 6 52 78 R ur al 1. 6 0. 3 0. 3 10 71 7. 6 1. 6 -0 .3 10 17 1. 1 0. 6 10 .9 0. 6 10 05 C am p 1. 4 0. 2 0. 1 65 3 6. 4 1. 3 -0 .5 62 5 1. 8 0. 2 6. 1 0. 5 62 4 A ge 0- 5 m on th s 2. 5 0. 6 0. 2 62 9 9. 0 3. 2 -0 .2 60 9 2. 6 1. 2 13 .6 0. 7 60 8 6- 11 m on th s 1. 4 0. 5 0. 4 75 8 5. 0 0. 9 0. 1 74 3 1. 9 0. 7 7. 7 0. 5 74 4 12 -1 7 m on th s 1. 1 0. 3 0. 4 74 6 7. 8 2. 7 -0 .3 72 3 1. 7 0. 3 8. 5 0. 7 72 4 18 -2 3 m on th s 1. 2 0. 0 0. 3 71 2 8. 2 2. 2 -0 .4 66 8 0. 5 0. 2 10 .0 0. 7 66 6 24 -3 5 m on th s 1. 0 0. 1 0. 2 14 15 9. 4 2. 1 -0 .6 13 10 1. 1 0. 3 9. 1 0. 7 13 01 36 -4 7 m on th s 1. 4 0. 3 0. 1 15 22 7. 0 1. 4 -0 .5 14 72 0. 7 0. 1 6. 6 0. 6 14 59 48 -5 9 m on th s 1. 5 0. 1 0. 1 14 39 6. 0 0. 9 -0 .4 14 26 0. 8 0. 1 5. 8 0. 5 14 03 M ot he r’s e du ca tio n N on e (2 .9 ) (0 .0 ) (0 .1 ) 31 (2 1. 5) (6 .0 ) (- 0. 1) 30 (3 .1 ) (0 .0 ) (8 .5 ) (0 .6 ) 29 B as ic 2. 1 0. 5 0. 1 21 71 9. 3 1. 8 -0 .5 21 00 1. 2 0. 3 7. 9 0. 6 20 82 S ec on da ry 1. 0 0. 1 0. 2 24 53 7. 1 1. 7 -0 .4 23 64 1. 0 0. 3 8. 4 0. 6 23 56 H ig he r 1. 1 0. 1 0. 3 25 66 5. 9 1. 6 -0 .3 24 56 1. 3 0. 3 8. 2 0. 6 24 39 W ea lth in de x qu in til e P oo re st 1. 6 0. 3 0. 1 18 87 7. 6 1. 2 -0 .6 18 43 .2 0. 9 0. 1 6. 4 0. 6 18 40 S ec on d 1. 2 0. 3 0. 1 15 50 8. 2 1. 5 -0 .5 15 16 .2 0. 7 0. 0 6. 2 0. 6 15 11 M id dl e 1. 2 0. 3 0. 3 13 67 6. 8 1. 4 -0 .2 13 12 .4 1. 3 0. 6 11 .3 0. 6 13 04 Fo ur th 1. 2 0. 1 0. 3 13 33 7. 0 2. 3 -0 .2 12 63 .3 1. 7 0. 5 8. 0 0. 6 12 51 R ic he st 1. 6 0. 2 0. 3 10 85 7. 0 2. 9 -0 .2 10 14 .6 1. 8 0. 5 10 .3 0. 6 10 01 1 M IC S in di ca to r 2 .1 a an d M D G in di ca to r 1 .8 - U nd er w ei gh t p re va le nc e (m od er at e an d se ve re ) 5 M IC S in di ca to r 2 .3 a - W as tin g pr ev al en ce (m od er at e an d se ve re ) 2 M IC S in di ca to r 2 .1 b - U nd er w ei gh t p re va le nc e (s ev er e) 6 M IC S in di ca to r 2 .3 b - W as tin g pr ev al en ce (s ev er e) 3 M IC S in di ca to r 2 .2 a - S tu nt in g pr ev al en ce (m od er at e an d se ve re ) 7 M IC S in di ca to r 2 .4 - O ve rw ei gh t p re va le nc e 4 M IC S in di ca to r 2 .2 b - S tu nt in g pr ev al en ce (s ev er e) ( ) Fi gu re s th at a re b as ed o n 25 -4 9 un w ei gh te d ca se s 36 Palestinian Multiple Indicator Cluster Survey 2014 30 Children whose measurements are outside a plausible range are excluded from table NU.2. Children are excluded from one or more of the anthropometric indicators when their weights and heights have not been measured, whichever applicable. For example, if a child has been weighed but his/her height has not been measured, the child is 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.12, DQ.13, and DQ.14 in Appendix D. The tables show that due to implausible measurements, and/or missing weight and/or height, 7.8 percent of children have been excluded from calculations of the weight-for-age indicator, 11.2 percent from the height-for-age indicator, and 11.8 percent for the weight-for-height indicator. About one of 100 children under age five living in Palestine is moderately underweight (1.4 percent) and 0.2 percent are classified as severely underweight (Table NU.2). Seven percent of children are moderately stunted (or too short for their age) and two percent are severely stunted. Only one percent of children are moderately wasted (or too thin for their height) and 0.3 percent are severely wasted. Results also show that 8 in 100 Palestinian children in Palestine suffer from overweight (9 percent for males and 7 percent females, 10 percent in the West Bank and 7 percent in Gaza Strip). Results in Table NU.2 show differentials in the nutrition indicators according to some background characteristics. The data show differences among children suffering from malnutrition according to geographic areas and regions. Eight percent of children in urban and rural areas are stunted, while the lowest prevalence was noted in camps (6 percent). Children in the West Bank showed higher prevalence rates (8 percent) compared to Gaza Strip (7 percent). Children whose mothers have higher education are less likely to be stunted compared to children of mothers with basic education with 9 percent for children of mothers with basic education, compared to 7 percent for children of mothers with secondary education and 6 percent for children of mothers with higher education. It also seems that boys are more likely to underweight, and stunted than girls. The age pattern shows higher percentage in all three malnutrition indicators for children in the age group 12-30 months compared to children who are younger or older (Figure NU.1). This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food, and environment. 37 31 Figure NU.1: Underweight , s tunted, wasted and overweight ch i ldren under age 5 (moderate and severe) , Pa lest ine , 2014 Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival; it can also promote optimal growth and development, especially in the critical window from birth to 2 years of age. 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 don’t start to breastfeed early enough, do not breastfeed exclusively for the recommended 6 months or stop breastfeeding too soon. There are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and can be unsafe if hygienic conditions, including safe drinking water are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of appropriate, adequate and safe solid, semi-solid and soft foods from the age of 6 months onwards leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life.4 UNICEF and WHO recommend that infants be breastfed within one hour of birth, breastfed exclusively for the first six months of life and continue to be breastfed up to 2 years of age and beyond.5 Starting at 6 months, breastfeeding should be combined with safe, age- appropriate feeding of solid, semi-solid and soft foods.6 A summary of key guiding principles7, 8 for feeding 6-23 month olds is provided in the table below along with proximate measures for these guidelines collected in this survey. 4  Bhuta  Z.  et  al.  (2013).  Evidence-­‐based  interventions  for  improvement  of  maternal  and  child  nutrition:  what   can  be  done  and  at  what  cost?  The  Lancet  June  6,  2013.   5  WHO  (2003).  Implementing  the  Global  Strategy  for  Infant  and  Young  Child  Feeding.  Meeting  Report  Geneva,   3-­‐5  February  2003.   6  WHO  (2003).  Global  Strategy  for  Infant  and  Young  Child  Feeding.   7  PAHO  (2003).  Guiding  principles  for  complementary  feeding  of  the  breastfed  child.   8  WHO  (2005).  Guiding  principles  for  feeding  non-­‐breastfed  children  6-­‐24  months  of  age   38 Palestinian Multiple Indicator Cluster Survey 2014 32 The guiding principles for which proximate measures and indicators exist are: (i) continued breastfeeding; (ii) appropriate frequency of meals (but not energy density); and (iii) appropriate nutrient content of food. Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds for non-breastfed children) for their age. Diet diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For diet diversity, seven food groups were created for which a child consuming at least four of these is considered to have a better quality diet. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber).9 These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of “minimum acceptable diet”. To have a minimum acceptable diet in the previous day, a child must have received: (i) the appropriate number of meals/snacks/milk feeds; (ii) food items form at least 4 food groups; and (iii) breastmilk or at least 2 milk feeds (for non-breastfed children). Guiding Principle (age 6-23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups10 eaten in the last 24 hours NU.6 Appropriate amount of food No standard indicator exists na Appropriate consistency of food No standard indicator exists na Use of vitamin-mineral supplements or fortified products for infant and mother No standard indicator exists na Practice good hygiene and proper food handling While it was not possible to develop indicators to fully capture programme guidance, one standard indicator does cover part of the principle: Not feeding with a bottle with a nipple NU.9 Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists na 9  WHO  (2008).  Indicators  for  assessing  infant  and  young  child  feeding  practices.  Part  1:  Definitions.   10  Food  groups  used  for  assessment  of  this  indicator  are  1)  Grains,  roots  and  tubers,  2)  legumes  and  nuts,  3)   dairy  products  (milk,  yogurt,  cheese),  4)  flesh  foods  (meat,  fish,  poultry  and  liver/organ  meats),  5)  eggs,  6)   vitamin-­‐A  rich  fruits  and  vegetables,  and  7)  other  fruits  and  vegetables.   39 33 Table NU.3: Initial breastfeeding Percentage of last live-born children in the last two years who were ever breastfed, breastfed within one hour of birth, and within one day of birth, and percentage who received a prelacteal feed, Palestine, 2014 Percentage who were ever breastfed1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last live- born children in the last two years Within one hour of birth2 Within one day of birth Total 96.6 40.8 85.2 38.6 2941 Region West Bank 95.8 40.7 83.9 33.3 1610 Gaza Strip 97.6 41.0 86.9 44.9 1331 Governorate Jenin 93.1 51.0 80.7 32.5 186 Tubas (100.0) (48.6) (86.3) (27.3) 25 Tulkarm 97.2 57.1 82.7 33.6 71 Nablus 94.9 37.6 79.2 41.1 190 Qalqiliya 92.2 33.7 79.8 38.0 48 Salfit (98.0) (35.9) (88.2) (23.7) 35 Ramallah & Al-Bireh 95.8 55.1 91.7 25.1 190 Jericho and Al Aghwar 91.8 66.4 82.4 15.4 44 Jerusalem 96.6 42.7 82.8 43.3 257 Bethlehem 95.6 42.0 85.6 34.5 137 Hebron 97.3 24.7 84.5 30.0 427 North Gaza 95.0 35.3 83.4 45.6 258 Gaza 98.8 33.0 86.1 40.3 471 Deir El-Balah 98.1 48.1 87.9 48.7 173 Khan Yunis 97.3 41.9 86.6 46.4 255 Rafah 98.3 62.9 93.5 50.8 175 Area Urban 96.9 39.8 85.2 39.4 2265 Rural 95.6 44.9 87.0 33.3 437 Camps 96.0 43.0 82.2 40.1 240 Months since last birth 0-11 months 96.5 41.0 84.5 34.7 204 12-23 months 96.0 40.0 85.2 36.1 230 Place of delivery Home (*) (*) (*) (*) 15 Public sector health facility 96.7 41.0 85.4 39.2 1788 Private sector health facility 96.7 42.7 85.8 36.1 749 NGO's sector health facility 97.1 35.4 84.5 37.8 271 UNRWA sector health facility (100.0) (63.6) (89.9) (17.2) 23 Israeli sector health facility 96.3 35.5 81.1 52.7 90 Other/Missing (*) (*) (*) (*) 5 Mother’s education None (*) (*) (*) (*) 9 Basic 96.9 40.1 84.4 36.2 798 Secondary 96.2 39.4 85.1 40.3 996 Higher 96.9 42.6 86.0 38.8 1139 Wealth index quintile Poorest 97.6 40.7 86.6 43.5 728 Second 97.5 40.1 87.4 42.4 563 Middle 96.5 42.3 85.3 32.6 578 Fourth 95.4 40.5 84.8 36.8 606 Richest 95.9 40.6 81.0 36.1 466 1 MICS indicator 2.5 - Children ever breastfed 2 MICS indicator 2.6 - Early initiation of breastfeeding ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on less than 25 unweighted cases 40 Palestinian Multiple Indicator Cluster Survey 2014 34 Table NU.3 is based on mothers’ reports of what their last-born child, born in the last two years, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed.11 Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 41 percent of babies are breastfed for the first time within one hour of birth, while 85 percent of newborns in Palestine start breastfeeding within one day of birth. Moreover, among children born in the last two years preceding the survey, 97 percent were ever-breastfed. Table NU.3 show some differentials for ever-breast children by geographical regions, with the percentage being lower in the West Bank (96 percent) compared to Gaza Strip (98 percent). The proportions of children who fed within one hour differ according to area where the lowest percentage was observed among children in urban areas; 40 percent compared to 45 percent of rural children and 43 percent in Camps. Large variations were also noted at the governorate level with the lowest percentage in Hebron (25 percent) and the highest being 66 percent in Jericho and Al Aghwar. Figure NU.2: Ini t iat ion of breastfeeding, Palest ine, 2014 The set of Infant and Young Child Feeding indicators reported in tables NU.4 through NU.8 are based on the mother’s report of consumption of food and fluids during the day or night prior to being interviewed. Data are subject to a number of limitations, some related to the respondent’s ability to provide a full report on the child’s liquid and food intake due to recall errors as well as lack of knowledge in cases where the child was fed by other individuals. 11  Prelacteal  feed  refers  to  the  provision  any  liquid  or  food,  other  than  breastmilk,  to  a  newborn  during  the   period  when  breastmilk  flow  is  generally  being  established  (estimated  here  as  the  first  3  days  of  life).     84   87   85   87   82   85   41   41   40   45   43   41   0   20   40   60   80   100   Pe r   ce nt   Within  one  day   Within  one  hour   41 35 In Table NU.4, breastfeeding status is presented for both Exclusively breastfed and Predominantly breastfed; referring to infants age less than 6 months who are breastfed, distinguished by the former only allowing vitamins, mineral supplements, and medicine and the latter allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Palestine, 2014 Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent exclusively breastfed1 Percent predominantly breastfed2 Number of children Percent breastfed (Continued breastfeeding at 1 year)3 Number of children Percent breastfed (Continued breastfeeding at 2 years)4 Number of children Total 38.6 50.0 668 52.9 504 11.5 504 Region West Bank 40.6 52.9 356 48.4 284 13.8 290 Gaza Strip 36.4 46.7 312 58.7 219 8.4 214 Sex Male 38.9 50.0 370 56.6 253 14.1 264 Female 38.3 50.0 298 49.2 251 8.6 240 Governorate Jenin (52.5) (71.2) 37 (50.5) 29 15.1 26 Tubas (*) (*) 5 (*) 7 (*) 6 Tulkarm (*) (*) 16 (*) 10 (*) 14 Nablus (39.0) (44.5) 38 (48.1) 39 (*) 24 Qalqiliya 6.9 (*) 14 (*) 4 (*) 12 Salfit 39.9 (*) 11 (*) 4 (*) 9 Ramallah & Al-Bireh 24.8 34.7 50 (38.1) 26 (14.9) 46 Jericho and Al Aghwar 23.4 (*) 9 (*) 7 (*) 7 Jerusalem (38.6) (44.1) 43 40.0 53 (10.3) 38 Bethlehem (55.9) (76.0) 43 (*) 22 (*) 21 Hebron 45.6 59.5 88 55.3 83 9.8 86 North Gaza 37.1 48.7 68 63.5 51 (2.8) 37 Gaza 39.0 52.7 105 59.3 80 6.7 78 Deir El-Balah (40.2) (48.1) 42 (53.4) 30 (10.2) 30 Khan Yunis 40.9 47.7 66 (57.8) 34 (14.3) 40 Rafah (12.4) (18.3) 32 (*) 24 (9.9) 29 Area Urban 38.2 50.0 512 52.4 392 9.4 363 Rural 40.7 52.2 103 55.0 68 17.8 92 camp 39.1 45.2 53 (54.0) 43 (15.1) 49 Mother’s education None 61.9 (*) 5 (*) 1 (*) 1 Basic 43.7 56.7 156 53.2 133 15.6 134 Secondary 38.4 49.7 235 54.9 174 9.4 172 Higher 35.5 46.1 272 51.2 196 10.6 197 Wealth index quintile Poorest 37.2 49.2 169 65.6 114 6.7 121 Second 37.2 46.5 136 60.1 98 8.1 88 Middle 41.9 53.7 113 48.0 106 18.1 103 Fourth 36.8 51.2 147 41.8 111 12.5 106 Richest 41.8 50.0 103 47.2 74 12.5 86 [1] MICS indicator 2.7 - Exclusive breastfeeding under 6 months [2] MICS indicator 2.8 - Predominant breastfeeding under 6 months [3] MICS indicator 2.9 - Continued breastfeeding at 1 year [4] MICS indicator 2.10 - Continued breastfeeding at 2 years ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on less than 25 unweighted cases 42 Palestinian Multiple Indicator Cluster Survey 2014 36 Table NU.4 show that only 39 percent of children aged less than six months are exclusively breastfed, a level considerably lower than recommended, with a noticeable variation between West Bank and Gaza Strip (41% and 36%) respectively. About 53 percent of the children are breastfed at one year, which is higher in Gaza Strip and among male children. Twelve percent of children continued to be breastfed at 2 years of age, which is higher in the West Bank and among male children. It is also observed that the incidence of exclusive breastfeeding decreases with increasing levels of mother’s education; the percentage of children whose mothers have no education and continued to be breastfed at age 2 is 62 percent compared to 36 percent of children whose mothers had higher level of education. F i g u r e N U . 3 : I n f a n t f e e d i n g p a t t e r n s b y a g e , P a l e s t i n e , 2 0 1 4 Exclusively   breas@ed   Breas@ed  and   complementary   foods   Weaned  (not   breas@ed)   0%   10%   20%   30%   40%   50%   60%   70%   80%   90%   100%   0-­‐1   2-­‐3   4-­‐5   6-­‐7   8-­‐9   10-­‐11   12-­‐13   14-­‐15   16-­‐17   18-­‐19   20-­‐21   22-­‐23   Age  in  months   Exclusively  breas@ed   Breas@ed  and  plain  water  only   Breas@ed  and  non-­‐milk  liquids   Breas@ed  and  other  milk  /  formula   Breas@ed  and  complementary  foods   Weaned  (not  breas@ed)   43 37 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3, the median duration is 14 months for any breastfeeding, almost 1 month for exclusive breastfeeding, and around 3 months for predominant breastfeeding. The data indicates that the median for any breastfeeding was the lowest in Salfit governorate (10 months) and generally similar in the other governorates (about 14 months) except for Jericho and Al Aghwar governorate where it was 16 months. The median duration of breastfeeding median is higher among males (15 months) compared to females (13 months). Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Palestine, 2014 Median duration (in months) of Number of children age 0-35 months Any breastfeeding[1] Exclusive breastfeeding Predominant breastfeeding Total 13.9 0.8 2.5 4541 Region West Bank 13.3 1.6 2.8 2452 Gaza Strip 14.2 0.6 0.7 2090 Sex Male 14.5 1.1 2.5 2368 Female 13.2 0.7 2.5 2173 Governorate Jenin 14.7 2.7 3.8 281 Tubas 14.7 2.3 3.5 42 Tulkarm 14.4 0.6 0.6 123 Nablus 12.6 0.5 0.6 290 Qalqiliya 14.4 0.0 0.7 81 Salfit 10.2 2.2 2.4 53 Ramallah & Al-Bireh 11.4 0.6 0.7 291 Jericho and Al Aghwar 16.4 1.2 1.4 62 Jerusalem 12.0 1.4 1.7 369 Bethlehem 14.0 3.0 4.8 211 Hebron 14.9 2.1 3.6 648 North Gaza 14.8 0.6 0.7 420 Gaza 13.9 0.7 2.7 729 Deir El-Balah 14.4 0.5 0.6 271 Khan Yunis 14.1 0.7 0.7 405 Rafah 13.8 0.4 0.4 264 Area Urban 13.7 0.7 2.5 3476 Rural 14.6 2.0 2.7 682 Camps 14.3 0.7 0.7 384 Mother's education None (*) (*) (*) 19 Basic 14.1 1.9 3.2 1244 Secondary 13.8 0.7 2.4 1541 Higher 13.8 0.7 1.7 1738 Wealth index quintile Poorest 14.6 0.6 0.7 1143 Second 14.5 0.7 1.8 902 Middle 13.6 0.7 3.0 894 Fourth 12.1 1.6 2.6 899 Richest 12.4 1.8 2.5 703 [1] MICS indicator 2.11 - Duration of breastfeeding (*) Figures that are based on less than 25 unweighted cases The adequacy of infant feeding in children under the age of 24 months is provided in Table NU.6. Different criteria of feeding are used depending on the age of the child. For infants 44 Palestinian Multiple Indicator Cluster Survey 2014 38 aged 0-5 months, exclusive breastfeeding is considered as age-appropriate feeding, while infants aged 6-23 months are considered to be appropriately fed if they are receiving breast milk and solid, semi-solid or soft food. As a result of these feeding patterns, 45 percent percent of children age 6-23 months are being appropriately breastfed, where male children are more likely to be appropriately fed compared to female children (48% and 42% respectively) and children in the Gaza Strip compared to children in the West Bank (48% and 42%) respectively. Additionally, 43 percent of children aged 0-23 months are being appropriate fed, with some variations by region and sex and area of residence. Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Palestine, 2014 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed1 Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed2 Number of children Total 38.6 668 44.8 2334 43.4 3002 Region West Bank 40.6 356 42.4 1264 42.0 1620 Gaza Strip 36.4 312 47.7 1069 45.1 1381 Sex Male 38.9 370 47.7 1207 45.7 1577 Female 38.3 298 41.7 1127 41.0 1424 Governorate Jenin (52.5) 37 50.9 145 51.2 182 Tubas (*) 5 (*) 21 (44.4) 26 Tulkarm (*) 16 47.2 58 45.6 74 Nablus (39.0) 38 44.8 146 43.6 184 Qalqiliya (*) 14 (37.7) 33 28.7 47 Salfit (*) 11 31.3 27 (33.9) 38 Ramallah & Al-Bireh 24.8 50 39.4 151 35.8 201 Jericho and Al Aghwar (*) 9 51.9 34 45.7 44 Jerusalem (38.6) 43 35.9 193 36.4 237 Bethlehem (55.9) 43 46.2 100 49.1 144 Hebron 45.6 88 41.3 355 42.1 443 North Gaza 37.1 68 46.4 200 44.1 268 Gaza 39.0 105 47.1 389 45.3 494 Deir El-Balah (40.2) 42 47.8 138 46.0 180 Khan Yunis 40.9 66 49.8 196 47.6 262 Rafah (12.4) 32 47.9 146 41.6 178 Area Urban 38.2 512 44.4 1798 43.0 2310 Rural 40.7 103 45.8 347 44.6 450 Camps 39.1 53 47.6 188 45.7 242 Mother’s education None (*) 5 (*) 7 (*) 12 Basic (43.6) 156 47.9 631 47.0 788 Secondary 38.4 235 44.2 806 42.9 1041 Higher 35.5 272 43.4 890 41.6 1161 Wealth index quintile Poorest 37.2 169 45.9 596 44.0 765 Second 37.2 136 50.6 447 47.5 583 Middle 41.9 113 46.1 463 45.3 576 Fourth 36.8 147 40.0 469 39.2 616 Richest 41.8 103 40.6 359 40.8 462 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.12 - Age-appropriate breastfeeding ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on less than 25 unweighted cases 45 39 Overall, 90 percent of infants age 6-8 months received solid, semi-solid, or soft foods at least once during the previous day of the interview (Table NU.7). Among currently breastfeeding infants this percentage is 89 percent while it is 92 percent among infants currently not breastfeeding. Data shows that 92 percent of infants in Gaza received solid, semi-solid, or soft foods at least once during the previous day compared to 88 percent among children in the West Bank. This percentage was higher among males compared to females at 91 percent and 89 percent respectively. Table NU.7: Introduction of solid, semi-solid, or soft foods Percentage of infants age 6-8 months who received solid, semi-solid, or soft foods during the previous day, Palestine, 2014 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi- solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods1 Number of children age 6-8 months Total 89.2 365 91.6 74 89.6 439 Region West Bank 87.9 176 (86.9) 47 87.7 223 Gaza Strip 90.4 189 (100.0) 26 91.6 216 Sex Male 90.6 185 (90.8) 35 90.6 220 Female 87.8 181 (92.3) 39 88.6 219 Area Urban 89.5 285 93.1 59 90.1 344 Rural 89.4 56 (*) 12 88.1 68 camp (*) 24 (*) 3 (87.0) 27 1 MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on less than 25 unweighted cases Overall, 75 percent of the children age 6-23 months were receiving solid, semi-solid and soft foods the minimum number of times. A slightly higher proportion of males (76 percent) were achieving the minimum meal frequency compared to females (75 percent). The proportion of children receiving the minimum diet diversity, or foods from at least 4 food groups, was lower than that for minimum meal frequency, indicating the need to focus on improving diet quality and nutrient intake among this vulnerable group. A higher proportion of older (18-23 month old) children (80 percent) were achieving the minimum diet diversity compared to younger (6-8 month old) children (28 percent). The overall assessment using the indicator of minimum acceptable diet revealed that only 42 percent were benefitting from a diet sufficient in both diversity and frequency. Some differences are noted according to area of residence, a higher proportion of rural children (78 percent) achieving the minimum meal frequency compared to those living in urban areas and camps (75 percent each). 46 Palestinian Multiple Indicator Cluster Survey 2014 40 Ta bl e N U .8 : I nf an t a nd y ou ng c hi ld fe ed in g (IY C F) p ra ct ic es P er ce nt ag e of c hi ld re n ag e 6- 23 m on th s w ho re ce iv ed a pp ro pr ia te li qu id s an d so lid , s em i-s ol id , o r s of t f oo ds th e m in im um n um be r o f t im es o r m or e du rin g th e pr ev io us d ay , b y br ea st fe ed in g st at us , P al es tin e, 2 01 4 C ur re nt ly b re as tfe ed in g C ur re nt ly n ot b re as tfe ed in g A ll P er ce nt o f c hi ld re n w ho re ce iv ed : N um be r of ch ild re n ag e 6- 23 m on th s P er ce nt o f c hi ld re n w ho re ce iv ed : N um be r of ch ild re n ag e 6- 23 m on th s P er ce nt o f c hi ld re n w ho re ce iv ed : N um be r of ch ild re n ag e 6- 23 m on th s M in im um di et ar y di ve rs ity [a ] M in im um m ea l fre qu en cy [b ] M in im um ac ce pt ab le di et [1 ], [c ] M in im um di et ar y di ve rs ity [a ] M in im um m ea l fre qu en cy [b ] M in im um ac ce pt ab le di et [2 ], [c ] A t le as t 2 m ilk fe ed s [3 ] M in im um di et ar y di ve rs ity [4 ], [a ] M in im um m ea l fre qu en cy [5 ], [b ] M in im um ac ce pt ab le di et [c ] To ta l 49 .3 68 .6 40 .2 11 02 74 .5 81 .9 43 .8 69 .6 11 49 62 .6 75 .4 42 .1 23 34 R eg io n W es t B an k 57 .5 65 .3 44 .5 56 8 78 .6 84 .2 51 .6 79 .1 64 2 68 .9 75 .4 48 .3 12 64 G az a S tri p 40 .7 72 .2 35 .7 53 4 69 .4 78 .9 33 .9 57 .6 50 7 55 .1 75 .4 34 .8 10 70 Se x M al e 50 .2 68 .5 41 .4 60 5 75 .9 83 .5 47 .8 72 .6 56 0 63 .1 75 .7 44 .4 12 07 Fe m al e 48 .3 68 .8 38 .9 49 8 73 .2 80 .4 40 .1 66 .7 58 9 62 .0 75 .1 39 .5 11 27 A ge (m on th s) 6- 8 26 .2 70 .5 23 .7 36 5 38 .6 93 .7 20 .4 95 .3 65 28 .1 74 .0 23 .2 43 9 9- 11 47 .5 60 .3 36 .2 26 0 57 .5 91 .9 43 .5 91 .5 93 50 .8 68 .7 38 .1 36 4 12 -1 7 65 .7 71 .0 53 .3 35 8 74 .8 83 .0 47 .3 74 .8 38 3 70 .5 77 .2 50 .2 77 1 18 -2 3 75 .1 74 .2 60 .3 12 0 80 .8 78 .4 44 .2 60 .2 60 8 80 .0 77 .7 46 .8 75 9 G ov er no ra te Je ni n 74 .2 70 .4 52 .1 75 81 .5 80 .9 54 .9 76 .1 59 76 .5 75 .0 53 .3 14 5 Tu ba s (* ) (* ) (* ) 9 (* ) (* ) (* ) (* ) 12 (* ) (* ) (* ) 21 Tu lk ar m (5 3. 5) (6 7. 4) (4 4. 2) 27 (7 6. 0) (8 2. 7) (4 6. 0) (6 9. 9) 30 65 .8 75 .4 45 .1 58 N ab lu s 56 .1 73 .3 46 .9 65 77 .7 82 .6 50 .0 77 .2 70 66 .2 78 .1 48 .5 14 6 Q al qi liy a (* ) (* ) (* ) 13 (* ) (* ) (* ) (* ) 20 84 .4 86 .7 62 .9 33 S al fit (* ) (* ) (* ) 9 (* ) (* ) (* ) (* ) 15 77 .5 65 .1 50 .1 27 R am al la h & A l- B ire h 74 .1 74 .9 62 .1 61 84 .3 89 .6 60 .5 83 .9 87 80 .5 83 .5 61 .1 15 1 Je ric ho a nd A l A gh w ar (* ) (* ) (* ) 19 (* ) (* ) (* ) (* ) 12 60 .7 67 .8 47 .4 34 Je ru sa le m 60 .9 62 .3 44 .0 76 82 .8 94 .3 65 .5 89 .2 11 0 74 .4 81 .2 56 .7 19 3 B et hl eh em 40 .5 77 .0 34 .7 50 (7 5. 6) (8 6. 0) (4 0. 7) (7 6. 8) 45 57 .8 81 .3 37 .6 10 0 H eb ro n 47 .4 53 .2 36 .0 16 4 71 .5 78 .9 39 .4 72 .8 18 3 60 .7 66 .7 37 .8 35 5 N or th G az a 41 .4 78 .1 40 .4 10 4 71 .2 89 .3 38 .7 56 .3 84 55 .3 83 .1 39 .6 20 0 G az a 28 .0 61 .1 19 .4 18 6 54 .0 62 .8 26 .1 55 .4 19 2 42 .5 62 .0 22 .8 38 9 D ei r E l-B al ah 53 .1 81 .5 51 .5 69 88 .5 91 .7 38 .6 56 .6 67 71 .0 86 .6 45 .2 13 8 K ha n Y un is 47 .4 72 .5 41 .8 10 4 81 .1 85 .2 38 .8 63 .6 90 62 .9 78 .4 40 .4 19 6 R af ah 51 .1 82 .8 47 .1 71 75 .6 89 .7 38 .5 58 .2 73 62 .7 86 .3 42 .8 14 6 47 41 Ta bl e N U .8 C on tin ue d: In fa nt a nd y ou ng c hi ld fe ed in g (IY C F) p ra ct ic es P er ce nt ag e of c hi ld re n ag e 6- 23 m on th s w ho re ce iv ed a pp ro pr ia te li qu id s an d so lid , s em i-s ol id , o r s of t f oo ds th e m in im um n um be r o f t im es o r m or e du rin g th e pr ev io us d ay , b y br ea st fe ed in g st at us , P al es tin e, 2 01 4 C ur re nt ly b re as tfe ed in g C ur re nt ly n ot b re as tfe ed in g A ll P er ce nt o f c hi ld re n w ho re ce iv ed : N um be r of ch ild re n ag e 6- 23 m on th s P er ce nt o f c hi ld re n w ho re ce iv ed : N um be r of ch ild re n ag e 6- 23 m on th s P er ce nt o f c hi ld re n w ho re ce iv ed : N um be r o f ch ild re n ag e 6- 23 m on th s M in im um di et ar y di ve rs ity [a ] M in im um m ea l fre qu en cy [b ] M in im um ac ce pt ab le di et [1 ], [c ] M in im um di et ar y di ve rs ity [a ] M in im um m ea l fre qu en cy [b ] M in im um ac ce pt ab le di et [2 ] [ c] A t l ea st 2 m ilk fe ed s [3 ] M in im u m di et ar y di ve rs it y [4 ], [a ] M in im um m ea l fre qu en cy [5 ], [b ] M in im um ac ce pt ab le di et [c ] A re a U rb an 46 .7 69 .0 39 .2 84 2 71 .4 80 .5 41 .1 67 .7 89 9 59 .9 75 .0 40 .2 17 99 R ur al 60 .8 68 .5 46 .3 16 6 85 .9 87 .4 56 .0 79 .6 16 3 73 .1 77 .9 51 .1 34 7 ca m p 53 .0 65 .4 39 .3 95 86 .1 85 .9 49 .1 70 .2 86 68 .8 75 .2 44 .0 18 8 M ot he r’s e du ca tio n N on e (* ) (* ) (* ) 2 (* ) (* ) (* ) (* ) 4 (* ) (* ) (* ) 7 B as ic 41 .6 62 .9 31 .7 31 6 62 .4 77 .2 29 .7 64 .1 29 3 51 .4 69 .7 30 .8 63 1 S ec on da ry 46 .2 68 .5 37 .3 37 8 70 .6 80 .9 36 .6 65 .1 39 5 59 .5 74 .8 37 .0 80 6 H ig he r 58 .5 73 .6 49 .7 40 7 85 .5 86 .0 59 .0 77 .0 45 7 73 .1 80 .2 54 .6 89 0 W ea lth in de x qu in til e P oo re st 37 .0 66 .3 31 .7 29 2 65 .6 76 .7 30 .5 53 .9 28 8 51 .6 71 .4 31 .1 59 6 S ec on d 44 .9 72 .7 37 .4 23 3 70 .4 81 .2 36 .1 62 .7 20 2 57 .2 76 .7 36 .8 44 7 M id dl e 51 .1 64 .6 38 .9 22 8 81 .1 77 .0 42 .1 68 .7 21 5 65 .2 70 .6 40 .5 46 3 Fo ur th 56 .9 72 .4 47 .4 19 4 79 .0 84 .4 53 .3 79 .8 25 2 69 .8 79 .2 50 .7 46 9 R ic he st 67 .2 68 .3 53 .6 15 5 79 .2 92 .7 61 .5 88 .1 19 1 74 .5 81 .7 58 .0 35 9 1 M IC S in di ca to r 2 .1 7a - M in im um a cc ep ta bl e di et (b re as tfe d) 2 M IC S in di ca to r 2 .1 7b - M in im um a cc ep ta bl e di et (n on -b re as tfe d) 3 M IC S in di ca to r 2 .1 4 - M ilk fe ed in g fre qu en cy fo r n on -b re as tfe d ch ild re n 4 M IC S in di ca to r 2 .1 6 - M in im um d ie ta ry d iv er si ty 5 M IC S in di ca to r 2 .1 5 - M in im um m ea l f re qu en cy a M in im um d ie ta ry d iv er si ty is d ef in ed a s re ce iv in g fo od s fro m a t l ea st 4 o f 7 fo od g ro up s: 1 ) G ra in s, ro ot s an d tu be rs , 2 ) l eg um es a nd n ut s, 3 ) d ai ry p ro du ct s (m ilk , y og ur t, ch ee se ), 4) fl es h fo od s (m ea t, fis h, p ou ltr y an d liv er /o rg an m ea ts ), 5) e gg s, 6 ) v ita m in -A ri ch fr ui ts a nd v eg et ab le s, a nd 7 ) o th er fr ui ts a nd v eg et ab le s. b M in im um m ea l f re qu en cy a m on g cu rr en tly b re as tfe ed in g ch ild re n is d ef in ed a s ch ild re n w ho a ls o re ce iv ed s ol id , s em i-s ol id , o r s of t f oo ds 2 ti m es o r m or e da ily fo r c hi ld re n ag e 6- 8 m on th s an d 3 tim es o r m or e da ily fo r c hi ld re n ag e 9- 23 m on th s. F or n on -b re as tfe ed in g ch ild re n ag e 6- 23 m on th s it is d ef in ed a s re ce iv in g so lid , s em i-s ol id o r s of t f oo ds , o r m ilk fe ed s, a t l ea st 4 ti m es . c Th e m in im um a cc ep ta bl e di et fo r b re as tfe d ch ild re n ag e 6- 23 m on th s is d ef in ed a s re ce iv in g th e m in im um d ie ta ry d iv er si ty a nd th e m in im um m ea l f re qu en cy , w hi le it fo r n on -b re as tfe d ch ild re n fu rth er re qu ire s at le as t 2 m ilk fe ed in gs a nd th at th e m in im um d ie ta ry d iv er si ty is a ch ie ve d w ith ou t c ou nt in g m ilk fe ed s. ( ) F ig ur es th at a re b as ed o n 25 -4 9 un w ei gh te d ca se s (* ) F ig ur es th at a re b as ed o n le ss th an 2 5 un w ei gh te d ca se s 48 Palestinian Multiple Indicator Cluster Survey 2014 42 The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.8 shows that bottle- feeding is still prevalent in among Palestinian children. Forty two percent of children aged 0- 23 months are fed using a bottle with a nipple. There is a higher proportion of bottle use was noted among children in the West Bank (48 percent) compared to 36 percent in Gaza Strip. Children in rural areas are more likely to bottle fed, than children in urban and Camps areas (49 percent and 41 percent respectively).The higher levels of bottle usage is found to be correlated with wealth, where this was 55 percent among children of the richest households compared to 32 percent among children of the poorest households. Table NU.9: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Palestine, 2014 Percentage of children age 0-23 months fed with a bottle with a nipple [1] Number of children age 0-23 months: Total 42.4 3002 Region West Bank 47.5 1620 Gaza Strip 36.3 1382 Sex Male 41.6 1577 Female 43.2 1424 Age 0-5 months 42.1 668 6-11 months 43.7 803 12-23 months 41.8 1530 Governorate Jenin 49.6 182 Tubas (22.9) 26 Tulkarm 35.9 74 Nablus 52.9 184 Qalqiliya (53.7) 47 Salfit (51.5) 38 Ramallah & Al-Bireh 53.3 201 Jericho and Al Aghwar 48.3 44 Jerusalem 54.2 237 Bethlehem 46.8 144 Hebron 40.9 443 North Gaza 32.6 268 Gaza 29.2 494 Deir El-Balah 40.1 180 Khan Yunis 43.3 262 Rafah 47.7 178 Area Urban 41.2 2311 Rural 49.1 450 camp 41.2 241 Mother's education None (*) 12 Basic 36.0 788 Secondary 41.9 1041 Higher 47.1 1161 Wealth index quintile Poorest 31.7 765 Second 37.7 583 Middle 45.0 576 Fourth 48.5 616 Richest 54.5 462 1 MICS indicator 2.18 - Bottle feeding ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on less than 25 unweighted cases 49 43 Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). In almost all households (98 percent), salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of either the potassium iodide or potassium iodate. Potassium iodide is an inorganic compound with the chemical formula KI. This kind of salt is the most commercially significant iodide compound, it’s the mostly salt use in Palestine, bust since Palestine have its own salt from different sources so some are potassium iodate Table NU.10 shows that in about one percent of households, there was no salt available. These households are included in the denominator of the indicator. In 73 percent of households, salt was found to contain 15 parts per million (ppm) or more of iodine. Use of iodized salt was lowest in West Bank (69 percent) and highest in Gaza Strip (80 percent). Approximately 80 percent of households in camps were found to be using adequately iodized salt as compared to only 72 percent of urban households and 75 percent of households in rural areas. A noticeable variation between governorates is also noted, as only 46 percent of households in Hebron governorate were found to be using adequately iodized salt, while this percent exceeded 90 percent in Tubas, Deir El Balah and Rafah governorates. 50 Palestinian Multiple Indicator Cluster Survey 2014 44 Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Palestine, 2014 Percent of households in which salt was tested Number of households Percent of households with salt test result Total Number of households in which salt was tested or with no salt Percent of households with no salt Not iodized 0 PPM >0 and <15 PPM 15+ PPM [1] Total 97.5 10182 1.4 10.3 15.0 73.2 100.0 10074 Region West Bank 97.4 6386 1.3 13.2 16.3 69.3 100.0 6296 Gaza Strip 97.8 3796 1.7 5.6 13.0 79.7 100.0 3779 Governorate Jenin 98.9 744 0.0 0.9 25.2 73.9 100.0 736 Tubas 99.4 128 0.2 1.2 5.3 93.3 100.0 127 Tulkarm 96.6 421 1.6 3.6 24.8 70.1 100.0 413 Nablus 96.9 892 0.9 3.2 8.2 87.7 100.0 872 Qalqiliya 97.3 224 1.2 2.7 19.6 76.5 100.0 220 Salfit 99.4 164 0.0 6.3 9.5 84.2 100.0 163 Ramallah & Al-Bireh 94.7 770 2.7 3.3 13.2 80.9 100.0 749 Jericho and Al Aghwar 99.4 112 0.0 10.6 20.3 69.1 100.0 111 Jerusalem 98.1 988 0.9 20.9 12.5 65.7 100.0 978 Bethlehem 97.8 497 0.6 15.0 12.6 71.8 100.0 488 Hebron 97.3 1446 2.1 31.2 20.4 46.3 100.0 1437 North Gaza 98.4 701 1.5 9.1 13.8 75.6 100.0 701 Gaza 97.0 1336 2.6 7.6 17.4 72.4 100.0 1331 Deir El- Balah 98.1 581 1.3 2.6 5.6 90.5 100.0 578 Khan Yunis 98.4 723 1.2 3.7 16.1 78.9 100.0 721 Rafah 97.9 454 0.9 1.4 2.8 94.8 100.0 449 Area Urban 97.6 7600 1.5 11.6 15.0 72.0 100.0 7530 Rural 96.9 1741 1.2 7.1 16.3 75.4 100.0 1707 camp 98.1 841 1.4 5.9 12.8 79.9 100.0 837 Wealth index quintile Poorest 96.9 1896 2.6 7.4 13.5 76.5 100.0 1887 Second 97.6 1926 2.0 7.4 14.9 75.8 100.0 1916 Middle 97.2 2136 1.4 12.5 17.3 68.9 100.0 2104 Fourth 98.2 2162 0.9 11.2 15.2 72.8 100.0 2142 Richest 97.7 2063 0.5 12.9 14.1 72.6 100.0 2026 1 MICS indicator 2.19 - Iodized salt consumption 51 45 F i g u r e N U . 4 : C o n s u m p t i o n o f i o d i z e d s a l t , P a l e s t i n e , 2 0 1 4 86   93   87   92   93   90   91   86   88   87   88   69   80   72   75   80   77   76   69   73   73   73   0   20   40   60   80   100   West   Bank   Gaza   Strip   Urban   Rural   Camp   Poorest   Second   Middle   Fourth   Richest   PalesHne   Pe r   ce nt   Any  iodine   15+  PPM  of  iodine   52 Palestinian Multiple Indicator Cluster Survey 2014 VI. Child Health 46 VI. Child Health Vaccinations The Millennium Development Goal (MDG) 4 is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. In addition, the Global Vaccine Action Plan (GVAP) was endorsed by the 194 Member States of the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. Immunization has saved the lives of millions of children in the four decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still millions of children not reached by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. The WHO Recommended Routine Immunizations for Children1 recommends all children to be vaccinated against tuberculosis, diphtheria, pertussis, tetanus, polio, measles, hepatitis B, haemophilus influenzae type b, pneumonia/meningitis, rotavirus, and rubella. All doses in the primary series are recommended to be completed before the child’s first birthday, although depending on the epidemiology of disease in a country, the first doses of measles and rubella containing vaccines may be recommended at 12 months or later. The recommended number and timing of most other doses also vary slightly with local epidemiology and may include booster doses later in childhood. The vaccination schedule followed by the Palestinian National Immunization Programme provides the following vaccinations: a birth dose of Hepatitis B vaccine, BCG, two doses of Inactivated Polio Vaccine (IPV), three doses of Pentavalent 2 vaccine (Penta), three doses of Oral Polio Vaccine (OPV), administered by 12 months of age, three doses of Pneumococcal conjugate vaccine (PCV), the first dose of measles vaccine (administered as Measles Mumps and Rubella MMR1), by age of 12 months. Based on this vaccination schedule the estimates for full immunization coverage from the Palestinian MICS are based on children age 24-35 months to ensure that children receiving measles vaccination are included. 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 and MMR, how many doses were received. The final vaccination coverage estimates are based on information obtained from the vaccination card and the mother’s report of vaccinations received by the child. 1  http://www.who.int/immunization/diseases/en.  Table  2  includes  recommendations  for  all  children  and  additional   antigens  recommended  only  for  children  residing  in  certain  regions  of  the  world  or  living  in  certain  high-­‐risk  population   groups.   2 According  to  the  Palestinian  national  immunization  schedule,  DPT,  Hepatitis,  Haemophilus  influenza  vaccines  are  part  of   the  Pentavalent  vaccine,  which  is  administered  in  three  doses,  at  age  two  months,  four  months  and  six  months,  as  follows:     Penta1  includes:  DPT1,  Hep1,  and  Haemophilus  influenza1,  Penta2  includes:  DPT2,  Hep2,  and  Haemophilus  influenza2,   Penta3  includes:  DPT3,  Hep3,  and  Haemophilus  influenza3 54 Palestinian Multiple Indicator Cluster Survey 2014 47 Ta bl e C H .1 : V ac ci na tio ns in th e fir st y ea rs o f l ife P er ce nt ag e of c hi ld re n ag e 12 -2 3 m on th s an d 24 -3 5 m on th s va cc in at ed a ga in st v ac ci ne p re ve nt ab le c hi ld ho od d is ea se s at a ny ti m e be fo re th e su rv ey a nd b y th ei r fir st b irt hd ay , P al es tin e, 2 01 4 C hi ld re n ag e 12 -2 3 m on th s: C hi ld re n ag e 24 -3 5 m on th s: Va cc in at ed a t a ny ti m e be fo re th e su rv ey a cc or di ng to : V ac ci na te d by 1 2 m on th s of ag ea Va cc in at ed a t a ny ti m e be fo re th e su rv ey ac co rd in g to : V ac ci na te d by 1 2 m on th s of a ge (m ea sl es b y 24 m on th s) a V ac ci na tio n ca rd M ot he r's re po rt E ith er V ac ci na tio n ca rd M ot he r's re po rt E ith er A nt ig en H ep B A t b irt h 91 .7 7. 9 99 .6 99 .1 83 .2 16 .0 99 .2 98 .9 B C G 1 92 .0 7. 6 99 .6 98 .8 83 .3 16 .0 99 .3 99 .1 Pe nt a 1 91 .4 8. 4 99 .8 98 .4 83 .1 16 .5 99 .6 98 .6 2 91 .0 8. 5 99 .5 97 .9 82 .7 16 .6 99 .3 98 .4 31 89 .4 9. 8 99 .3 96 .9 82 .4 16 .7 99 .0 97 .3 IP V 1 91 .1 8. 6 99 .8 99 .4 83 .6 16 .0 99 .6 99 .3 22 90 .6 9. 0 99 .6 98 .9 83 .1 16 .0 99 .1 98 .8 Po lio 1 91 .6 8. 4 10 0. 0 99 .2 83 .0 16 .4 99 .4 99 .0 2 91 .1 8. 6 99 .7 99 .0 82 .5 16 .5 99 .0 98 .6 32 89 .3 9. 6 99 .0 97 .9 81 .9 16 .7 98 .6 97 .4 M ea sl es (M C V 1) 7 na 81 .6 17 .5 99 .1 97 .0 Fu lly v ac ci na te d8 , b na na na na 82 .0 12 .8 94 .9 89 .9 N o va cc in at io ns 0. 0 0. 0 0. 0 0. 1 0. 0 0. 3 0. 3 0. 3 N um be r o f c hi ld re n 14 44 14 44 14 44 14 44 14 66 14 66 14 66 14 66 [1 ] M IC S in di ca to r 3 .1 - Tu be rc ul os is im m un iz at io n co ve ra ge [2 ] M IC S in di ca to r 3 .2 - P ol io im m un iz at io n co ve ra ge [a ] M IC S in di ca to rs 3 .1 , 3 .2 , 3 .3 , 3 .5 , 3 .6 , a nd re fe r t o re su lts o f t hi s co lu m n in th e le ft pa ne l; M IC S in di ca to rs 3 .4 a nd 3 .8 re fe r t o th is c ol um n in th e rig ht p an el [b ] I nc lu de s: B C G , H ep .B 0, IP V 1, IP V 2, p en ta 1, p en ta 2, p en ta 3, P ol io 1, P ol io 2, P ol io 3 by th e fir st b irt hd ay a nd m ea sl es b y th e se co nd b irt hd ay , a s pe r t he va cc in at io n sc he du le in P al es tin e 55 48 The percentage of children age 12-23 months and 24-35 months who have received each of the specific vaccinations by source of information vaccination card and mother’s recall is shown in Table CH.1 and Figure CH.1. The denominators for the table are comprised of children age 12- 23 months and 24-35 months so that only children who are old enough to be fully vaccinated are counted. In the first three columns in each panel 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 in each panel, 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. As indicated in Table DQ.17 in Appendix D, it is seen that 94 percent of children age 12-23 months and 89 percent of those age 24-35 months have ever received a vaccination card, and that cards were actually seen by the interviewer in 93 percent and 84 percent of cases respectively for these two age groups. Taking into consideration that 2 percent of children age 12-23 months and 5 percent of those age 24-35 months previously had a vaccination card but did not have one at the time of the survey. Approximately 99 percent of children age 12-23 months received a BCG vaccination by the age of 12 months and the first dose of Penta (DPT-HepB-Hib) vaccine was given to 98 percent. Coverage levels were sustained with 98 percent of children receiving the second dose of DPT- HepB-Hib, and 97 percent the third dose. Similarly, 99 percent of children received Polio 1 by age 12 months and this coverage is maintained at 98 percent by the third dose. The coverage for measles vaccine for children 24-35 months by any time before the survey was 99 while 97 percent of children 24-35 months received the measles vaccine by the recommended age of 12 months. As a result, the percentage of children who had all the recommended vaccinations by their second birthday was 90 percent. 56 Palestinian Multiple Indicator Cluster Survey 2014 49 Figure CH.1: Vaccinat ions by age 12 months (measles by 24 months) , Palest ine, 2014 Table CH.2 presents vaccination coverage estimates among children 12-23 and 24-35 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and mothers’/caretakers’ reports. Vaccination cards have been seen by the interviewer for 93 percent of children age 12-23 months. No variation in vaccination coverage were noted among males and females, by area, mother’s education or wealth quintiles. 57 50 Ta bl e C H .2 : V ac ci na tio ns b y ba ck gr ou nd c ha ra ct er is tic s P er ce nt ag e of c hi ld re n ag e 12 -2 3 m on th s an d ag e 24 -3 5 m on th s cu rr en tly v ac ci na te d ag ai ns t v ac ci ne p re ve nt ab le c hi ld ho od d is ea se s, P al es tin e, 2 01 4 Pe rc en ta ge o f c hi ld re n ag e 12 -2 3 m on th s w ho re ce iv ed : Pe rc en ta ge o f c hi ld re n ag e 24 -3 5 m on th s w ho re ce iv ed : Hep.B0 (At birth) B C G IP V P en ta P ol io None P er ce nt ag e w ith va cc i na tio n ca rd se en N um be r o f ch ild re n ag e 12 -2 3 m on th s First dose of Measles Fu lla N on e P er ce nt ag e w ith va cc in at io n ca rd se en N um be r of ch ild re n ag e 24 - 35 m on th s 1 2 1 2 3 1 2 3 To ta l 99 .6 99 .6 99 .8 99 .6 99 .8 99 .5 99 .3 10 0. 0 99 .7 99 .0 0. 0 92 .9 14 44 99 .1 94 .9 0. 3 84 .3 14 66 R eg io n W es t B an k 99 .8 99 .4 99 .7 99 .4 99 .8 99 .1 98 .8 10 0. 0 99 .5 98 .6 0. 0 89 .8 74 6 98 .9 94 .2 0. 4 81 .5 75 7 G az a S tri p 99 .5 99 .8 99 .8 99 .8 99 .9 99 .9 99 .9 10 0. 0 10 0. 0 99 .4 0. 0 96 .3 69 8 99 .4 95 .6 0. 3 87 .4 70 9 G ov er no ra te Je ni n 10 0. 0 10 0. 0 10 0. 0 99 .0 98 .9 98 .9 10 0. 0 10 0. 0 10 0. 0 98 .9 0. 0 98 .0 91 98 .9 98 .9 1. 1 98 .9 98 Tu ba s (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 15 (* ) (* ) (* ) (* ) 16 Tu lk ar m (9 7. 7) (1 00 .0 ) (1 00 .0 ) (1 00 .0 ) (1 00 .0 ) (9 7. 9) (9 7. 2) (1 00 .0 ) (1 00 .0 ) (1 00 .0 ) (0 .0 ) (9 4. 3) 37 (9 8. 3) (8 7. 0) (1 .7 ) (9 6. 8) 49 N ab lu s 10 0. 0 99 .0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 99 .0 99 .0 0. 0 96 .3 97 10 0. 0 99 .1 0. 0 83 .7 10 6 Q al qi liy a (1 00 . 0) (1 00 .0 ) (1 00 .0 ) (1 00 .0 ) (1 00 .0 ) (1 00 .0 ) (1 00 .0 ) (1 00 .0 ) (1 00 .0 ) (1 00 .0 ) (0 .0 ) (9 6. 5) 25 (1 00 .0 ) (9 7. 8) (0 .0 ) (9 4. 0) 34 S al fit (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 17 (* ) (* ) (* ) (* ) 15 R am al la h & A l-B ire h 10 0. 0 10 0. 0 10 0. 0 99 .1 99 .1 96 .2 96 .2 10 0. 0 10 0. 0 99 .1 0. 0 83 .2 10 0 98 .8 92 .9 0. 0 73 .5 90 Je ric ho & A l A gh w ar (1 00 . 0) (1 00 .0 ) (1 00 .0 ) (1 00 . 0) (1 00 . 0) (1 00 . 0) (1 00 . 0) (1 00 . 0) (1 00 . 0) (1 00 . 0) 0. 0 (1 00 . 0) 22 (1 00 .0 ) (9 7. 5) 0. 0 (9 1. 8) 19 Je ru sa le m ** (1 00 . 0) (9 1. 7) (9 5. 5) (9 5. 5) (1 00 . 0) (1 00 . 0) (1 00 . 0) (1 00 . 0) (9 5. 5) (9 5. 5) (0 .0 ) (8 6. 8) 42 10 0. 0 81 .0 0. 0 77 .3 58 B et hl eh em 10 0. 0 10 0. 0 10 0. 0 98 .6 10 0. 0 10 0. 0 96 .2 10 0. 0 10 0. 0 95 .1 0. 0 98 .5 63 98 .5 93 .2 1. 5 89 .5 67 H eb ro n 99 .6 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 99 .6 10 0. 0 10 0. 0 99 .3 0. 0 83 .1 23 6 98 .4 96 .0 0. 0 70 .1 20 5 N or th G az a 99 .3 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 98 .3 0. 0 93 .0 13 5 99 .3 94 .7 0. 0 78 .9 15 2 G az a 99 .5 99 .5 10 0. 0 10 0. 0 99 .6 99 .6 99 .6 10 0. 0 10 0. 0 99 .6 0. 0 98 .7 24 9 10 0. 0 94 .8 0. 0 90 .2 23 6 D ei r E l-B al ah 10 0. 0 10 0. 0 98 .9 98 .9 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 0. 0 94 .6 97 10 0. 0 94 .3 0. 0 90 .6 91 K ha n Y un is 98 .9 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 99 .4 0. 0 98 .2 11 9 98 .3 98 .3 0. 8 89 .4 14 3 R af ah 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 0. 0 94 .0 98 98 .9 95 .7 1. 1 87 .8 87 [a ] In cl ud es : B C G , H ep .B 0, IP V 1, IP V 2, p en ta 1, p en ta 2, p en ta 3, P ol io 1, P ol io 2, P ol io 3 by th e fir st b irt hd ay a nd m ea sl es b y th e se co nd b irt hd ay , a s pe r t he v ac ci na tio n sc he du le in P al es tin e ( ) F ig ur es th at a re b as ed o n 25 -4 9 un w ei gh te d ca se s (* ) F ig ur es th at a re b as ed o n le ss th an 2 5 un w ei gh te d ca se s ** : D oe s no t i nc lu de th os e pa rts o f J er us al em w hi ch w er e an ne xe d by Is ra el in 1 96 7, d ue to th e fa ct th at th e P al es tin ia n va cc in at io n sc he du le is d iff er en t f ro m th e Is ra el i v ac ci na tio n sc he du le . P al es tin ia n ch ild re n liv in g in E as t J er us al em re ce iv e th ei r v ac ci na tio ns fr om th e Is ra el i H ea lth c en te rs . 58 Palestinian Multiple Indicator Cluster Survey 2014 51 Ta bl e C H .2 C on tin ue d: V ac ci na tio ns b y ba ck gr ou nd c ha ra ct er is tic s P er ce nt ag e of c hi ld re n ag e 12 -2 3 m on th s cu rr en tly v ac ci na te d ag ai ns t v ac ci ne p re ve nt ab le c hi ld ho od d is ea se s, P al es tin e, 2 01 4 Pe rc en ta ge o f c hi ld re n ag e 12 -2 3 m on th s w ho re ce iv ed : Pe rc en ta ge o f c hi ld re n ag e 24 -3 5 m on th s w ho re ce iv ed : Hep.B0 (At birth) B C G IP V P en ta P ol io None P er ce nt ag e w ith va cc i na tio n ca rd se en N um be r o f ch ild re n ag e 12 -2 3 m on th s First dose of Measles Fu lla N on e P er ce nt ag e w ith va cc in at i on c ar d se en N um be r of ch ild re n ag e 24 - 35 m on th s 1 2 1 2 3 1 2 3 Se x M al e 99 .9 99 .6 99 .6 99 .5 99 .8 99 .4 99 .6 10 0. 0 99 .6 99 .1 0. 0 93 .3 75 5 98 .9 94 .0 0. 3 85 .3 75 4 Fe m al e 99 .3 99 .6 10 0. 0 99 .7 99 .9 99 .6 99 .0 10 0. 0 99 .8 98 .9 0. 0 92 .5 68 9 99 .3 95 .8 0. 4 83 .2 71 2 A re a U rb an 99 .6 99 .6 99 .7 99 .6 99 .8 99 .6 99 .5 10 0. 0 99 .8 99 .2 0. 0 92 .7 99 .6 98 .9 94 .6 0. 5 83 .7 10 96 R ur al 10 0. 0 99 .6 10 0. 0 99 .6 10 0. 0 99 .2 98 .2 10 0. 0 99 .1 98 .2 0. 0 92 .9 10 0. 0 99 .7 96 .1 0. 0 85 .1 23 3 C am p 99 .2 10 0. 0 10 0. 0 99 .3 99 .3 98 .7 99 .3 10 0. 0 10 0. 0 98 .7 0. 0 95 .0 99 .2 10 0. 0 95 .1 0. 0 88 .0 13 8 M ot he r's ed uc at io n N on e (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 5 (* ) (* ) (* ) (* ) 7 B as ic 99 .5 99 .3 10 0. 0 99 .8 99 .5 99 .5 99 .2 10 0. 0 10 0. 0 98 .7 0. 0 95 .2 39 6 98 .9 92 .8 0. 7 82 .2 42 6 S ec on da ry 99 .8 99 .6 99 .6 99 .4 10 0. 0 99 .7 99 .5 10 0. 0 99 .6 98 .7 0. 0 94 .0 49 4 99 .6 95 .8 0. 2 89 .5 47 4 H ig he r 99 .6 99 .8 99 .8 99 .7 99 .8 99 .2 99 .2 10 0. 0 99 .6 99 .5 0. 0 90 .3 55 0 98 .9 95 .6 0. 2 81 .6 55 9 W ea lth in de x qu in til e P oo re st 99 .7 99 .7 10 0. 0 10 0. 0 99 .7 99 .7 99 .7 10 0. 0 10 0. 0 99 .2 0. 0 96 .3 39 8 99 .3 97 .6 0. 3 85 .9 37 8 S ec on d 98 .9 10 0. 0 10 0. 0 99 .3 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 99 .6 0. 0 95 .1 28 1 99 .7 98 .3 0. 3 88 .9 31 9 M id dl e 99 .7 96 .2 99 .1 98 .8 99 .4 99 .1 98 .9 99 .5 97 .2 96 .4 0. 3 91 .5 30 0 98 .5 93 .0 0. 3 84 .7 31 8 Fo ur th 99 .4 93 .4 97 .6 97 .6 99 .4 98 .1 96 .9 98 .5 92 .5 91 .6 0. 3 90 .4 33 0 97 .7 88 .7 1. 0 82 .1 28 3 R ic he st 10 0. 0 85 .0 98 .2 96 .9 99 .6 98 .1 96 .6 98 .7 85 .0 82 .8 0. 0 85 .7 22 1 98 .4 82 .7 1. 3 74 .7 24 1 [a ] In cl ud es : B C G , H ep .B 0, IP V 1, IP V 2, p en ta 1, p en ta 2, p en ta 3, P ol io 1, P ol io 2, P ol io 3 by th e fir st b irt hd ay a nd m ea sl es b y th e se co nd b irt hd ay , a s pe r t he v ac ci na tio n sc he du le in P al es tin e ( ) F ig ur es th at a re b as ed o n 25 -4 9 un w ei gh te d ca se s (* ) F ig ur es th at a re b as ed o n le ss th an 2 5 un w ei gh te d ca se s 59 52 Care of Illness A key strategy for accelerating progress toward MDG 4 is to tackle the diseases that are the leading killers of children under 5. Diarrhoea and pneumonia are two such diseases. The Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) aims to end preventable pneumonia and diarrhoea death by reducing mortality from pneumonia to 3 deaths per 1000 live births and mortality from diarrhoea to 1 death per 1000 live births by 2025. Table CH.4 presents the percentage of children under 5 years of age who were reported to have had an episode of diarrhoea, symptoms of acute respiratory infection (ARI), or fever during the 2 weeks preceding the survey. These results are not measures of true prevalence, and should not be used as such, but rather the period-prevalence of those illnesses over a two-week time window. The definition of a case of diarrhoea, in this survey, was the mother’s (or caretaker’s) report that the child had such symptoms over the specified period; no other evidence were sought beside the opinion of the mother. A child was considered to have had an episode of ARI if the mother or caretaker reported that the child had, over the specified period, an illness with a cough with rapid or difficult breathing, and whose symptoms were perceived to be due to a problem in the chest or both a problem in the chest and a blocked nose. While this approach is reasonable in the context of a MICS survey, these basically simple case definitions must be kept in mind when interpreting the results, as well as the potential for reporting and recall biases. Further, diarrhoea, fever and ARI are not only seasonal but are also characterized by the often rapid spread of localized outbreaks from one area to another at different points in time. The timing of the survey and the location of the teams might thus considerably affect the results, which must consequently be interpreted with caution. For these reasons, although the period-prevalence over a two-week time window is reported, these data should not be used to assess the epidemiological characteristics of these diseases but rather to obtain denominators for the indicators related to use of health services and treatment. 60 Palestinian Multiple Indicator Cluster Survey 2014 52 Care of Illness A key strategy for accelerating progress toward MDG 4 is to tackle the diseases that are the leading killers of children under 5. Diarrhoea and pneumonia are two such diseases. The Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) aims to end preventable pneumonia and diarrhoea death by reducing mortality from pneumonia to 3 deaths per 1000 live births and mortality from diarrhoea to 1 death per 1000 live births by 2025. Table CH.4 presents the percentage of children under 5 years of age who were reported to have had an episode of diarrhoea, symptoms of acute respiratory infection (ARI), or fever during the 2 weeks preceding the survey. These results are not measures of true prevalence, and should not be used as such, but rather the period-prevalence of those illnesses over a two-week time window. The definition of a case of diarrhoea, in this survey, was the mother’s (or caretaker’s) report that the child had such symptoms over the specified period; no other evidence were sought beside the opinion of the mother. A child was considered to have had an episode of ARI if the mother or caretaker reported that the child had, over the specified period, an illness with a cough with rapid or difficult breathing, and whose symptoms were perceived to be due to a problem in the chest or both a problem in the chest and a blocked nose. While this approach is reasonable in the context of a MICS survey, these basically simple case definitions must be kept in mind when interpreting the results, as well as the potential for reporting and recall biases. Further, diarrhoea, fever and ARI are not only seasonal but are also characterized by the often rapid spread of localized outbreaks from one area to another at different points in time. The timing of the survey and the location of the teams might thus considerably affect the results, which must consequently be interpreted with caution. For these reasons, although the period-prevalence over a two-week time window is reported, these data should not be used to assess the epidemiological characteristics of these diseases but rather to obtain denominators for the indicators related to use of health services and treatment. 53 Table CH.4: Reported disease episodes Percentage of children age 0-59 months for whom the mother/caretaker reported an episode of diarrhoea, fever, and/or symptoms of acute respiratory infection (ARI) in the last two weeks, Palestine, 2014 Percentage of children who in the last two weeks had: Number of children age 0-59 months An episode of diarrhoea Symptoms of ARI Total 11.3 10.7 7816 Region West Bank 11.4 11.0 4202 Gaza Strip 11.1 10.4 3614 Sex Male 12.2 11.7 4058 Female 10.3 9.6 3758 Governorate Jenin 11.4 9.6 469 Tubas 17.6 14.7 65 Tulkarm 9.5 15.9 217 Nablus 14.7 10.7 523 Qalqiliya 5.1 6.9 157 Salfit 5.8 3.4 104 Ramallah & Al-Bireh 11.5 9.2 466 Jericho and Al Aghwar 13.9 11.9 93 Jerusalem 12.1 9.1 635 Bethlehem 16.9 22.2 340 Hebron 8.8 10.1 1132 North Gaza 12.7 6.7 695 Gaza 10.5 9.9 1290 Deir El-Balah 10.1 12.2 489 Khan Yunis 10.8 11.3 667 Rafah 12.1 13.7 472 Area Urban 10.9 10.4 5942 Rural 11.9 12.1 1186 camp 13.1 11.3 688 Age 0-11 15.4 11.2 1471 12-23 17.8 11.7 1530 24-35 10.8 11.3 1540 36-47 7.0 9.0 1678 48-59 6.0 10.4 1597 Mother’s education None (10.2) (12.4) 37 Basic 11.0 12.0 2346 Secondary 11.4 10.4 2641 Higher 11.4 9.9 2792 Wealth index quintile Poorest 12.6 11.5 1937 Second 9.6 9.1 1601 Middle 11.8 12.2 1555 Fourth 11.7 11.9 1491 Richest 10.1 8.2 1233 ( ) Figures that are based on 25-49 unweighted cases Overall, 11 percent of under five children were reported to have had diarrhoea in the two weeks preceding the survey, and 11 percent of under five children were reported with symptoms of ARI (Table CH.4). The results showed differences between children who had diarrhea in the two weeks preceding the survey based on mother’s education; where only 3 percent of children who had diarrhea their mothers had basic education compared to 11 percent for mothers with higher education. 61 54 Diarrhoea Diarrhoea is a leading cause of death among children under five worldwide. Most diarrhoea- related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) – can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. In the MICS, mothers or caretakers were asked 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 been given to drink and eat during the episode and whether this was more or less than what was usually given to the child. The overall period-prevalence of diarrhoea in children under 5 years of age is 11 percent (Table CH.4) and ranges from 5 percent in Qalqiliya governorate to 18 percent in Tubas governorate. The highest period-prevalence is seen among children age 12-23 months (18 percent) which grossly corresponds to the weaning period. 62 Palestinian Multiple Indicator Cluster Survey 2014 54 Diarrhoea Diarrhoea is a leading cause of death among children under five worldwide. Most diarrhoea- related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) – can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. In the MICS, mothers or caretakers were asked 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 been given to drink and eat during the episode and whether this was more or less than what was usually given to the child. The overall period-prevalence of diarrhoea in children under 5 years of age is 11 percent (Table CH.4) and ranges from 5 percent in Qalqiliya governorate to 18 percent in Tubas governorate. The highest period-prevalence is seen among children age 12-23 months (18 percent) which grossly corresponds to the weaning period. 55 Table CH.5: Care-seeking during diarrhoea Percentage of children age 0-59 months with diarrhoea in the last two weeks for whom advice or treatment was sought, by source of advice or treatment, Palestine, 2014 Percentage of children with diarrhoea for whom: Number of children age 0-59 months with diarrhoea in the last two weeks Advice or treatment was sought from: No advice or treatment sought Health facilities or providers Other source A health facility or provider [1] [a] Public Private NGOS UN Israeli Total 21.5 23.2 1.5 9.7 3.1 3.7 52.9 40.9 880 Region West Bank 15.4 30.3 1.1 3.8 5.8 4.6 52.4 42.3 478 Gaza Strip 28.6 14.9 1.9 16.7 0.0 2.7 53.4 39.3 402 Sex Male 22.5 22.0 1.6 10.8 3.0 4.6 53.3 40.4 494 Female 20.1 24.8 1.3 8.2 3.3 2.5 52.4 41.6 386 Governorate Jenin 24.8 48.0 0.0 0.0 0.0 3.6 65.1 29.2 54 Tubas 29.9 36.3 0.0 5.1 0.0 2.6 54.8 45.2 11 Tulkarm 18.3 31.2 0.0 3.8 0.0 0.0 49.1 43.1 21 Nablus 11.9 30.0 1.2 6.4 0.0 11.1 44.8 44.8 77 Qalqiliya 37.0 34.8 0.0 0.0 0.0 0.0 46.9 41.3 8 Salfit 0.0 58.7 0.0 0.0 0.0 0.0 58.7 41.3 6 Ramallah & Al-Bireh 19.0 36.6 0.0 2.4 0.0 3.4 55.9 40.7 54 Jericho and Al Aghwar 29.2 31.9 0.0 15.7 0.0 0.0 76.8 23.2 13 Jerusalem 4.1 7.6 2.6 3.0 35.9 2.1 51.6 46.8 77 Bethlehem 11.1 33.1 1.6 6.0 0.0 1.6 48.6 47.9 58 Hebron 17.5 30.1 1.7 2.5 0.0 6.8 49.8 43.6 100 North Gaza 36.0 4.7 1.3 16.3 0.0 0.0 54.8 41.6 88 Gaza 31.6 16.6 2.5 12.0 0.0 2.6 53.5 38.1 136 Deir El- Balah 29.3 27.5 0.0 25.4 0.0 0.0 60.6 31.1 49 Khan Yunis 21.1 11.9 2.7 13.7 0.0 4.7 45.2 48.7 72 Rafah 19.1 19.5 2.1 24.8 0.0 6.7 55.4 34.0 57 Area Urban 23.5 21.0 2.0 7.6 3.8 3.2 52.2 41.8 649 Rural 18.7 37.6 0.0 5.1 0.0 6.1 55.8 36.3 141 camp 11.0 16.8 0.0 31.9 3.4 3.8 53.5 41.6 90 Age in months 0-11 23.1 22.5 3.2 8.3 1.1 3.2 54.1 41.2 227 23-Dec 23.2 24.4 0.8 11.1 4.7 4.8 56.1 37.3 273 24-35 18.9 22.2 0.5 9.9 1.9 2.8 47.5 46.5 166 36-47 20.6 22.9 0.8 8.1 4.7 3.2 50.9 41.8 118 48-59 18.2 24.1 1.8 10.5 3.7 4.3 52.4 39.8 96 Mother’s education None 0.0 46.0 0.0 26.0 0.0 0.0 72.0 28.0 4 Basic 25.2 17.3 2.4 12.9 4.0 3.6 55.8 38.1 258 Secondary 20.9 21.8 1.0 8.5 3.7 3.5 49.9 42.9 301 Higher 19.2 29.1 1.2 8.0 1.9 4.1 53.2 41.5 317 Wealth index quintile Poorest 29.5 11.2 2.2 18.3 0.0 2.9 50.9 40.3 244 Second 26.4 15.6 0.6 13.8 0.0 4.1 51.2 44.4 154 Middle 25.5 24.7 1.2 6.0 1.5 5.5 55.1 38.1 183 Fourth 14.5 37.2 1.1 3.3 5.1 2.0 54.9 39.6 174 Richest 3.3 34.6 2.0 2.1 12.8 4.5 52.7 44.0 125 [1] MICS indicator 3.10 - Care-seeking for diarrhoea [a] Includes all public and private health facilities and providers, but excludes private pharmacy (*) Figures that are based on less than 25 unweighted cases 63 56 Table CH.5 presents the percentage of children under 5 years of age who were reported to have had an episode of diarrhoea during the 2 weeks preceding the survey. Of these children, 52 percent were taken to an appropriate provider (40 percent, males; 42 percent, females), the percentage was better in the West Bank 42 percent compared to 39 percent in Gaza Strip, while it was 54 percent for Camps children compared to 56 percent in rural and 52 percent in urban areas. 64 Palestinian Multiple Indicator Cluster Survey 2014 56 Table CH.5 presents the percentage of children under 5 years of age who were reported to have had an episode of diarrhoea during the 2 weeks preceding the survey. Of these children, 52 percent were taken to an appropriate provider (40 percent, males; 42 percent, females), the percentage was better in the West Bank 42 percent compared to 39 percent in Gaza Strip, while it was 54 percent for Camps children compared to 56 percent in rural and 52 percent in urban areas. 57 Ta bl e C H .6 : F ee di ng p ra ct ic es d ur in g di ar rh oe a P er ce nt d is tri bu tio n of c hi ld re n ag e 0- 59 m on th s w ith d ia rr ho ea in th e la st tw o w ee ks b y am ou nt o f l iq ui ds a nd fo od g iv en d ur in g ep is od e of d ia rr ho ea , P al es tin e, 2 01 4 D rin ki ng p ra ct ic es d ur in g di ar rh oe a: Ea tin g pr ac tic es d ur in g di ar rh oe a: N um be r o f ch ild re n ag ed 0 -5 9 m on th s w ith di ar rh oe a C hi ld w as g iv en to d rin k: C hi ld w as g iv en to e at : M uc h le ss S om ew ha t l es s A bo ut th e sa m e M or e N ot hi ng M is si ng /D K To ta l M uc h le ss S om e w ha t le ss A bo ut th e sa m e M or e N ot hi ng M is si ng / D K To ta l To ta l 7. 5 11 .9 38 .5 39 .4 2. 4 0. 3 10 0. 0 16 .2 31 .5 30 .8 9. 6 11 .6 0. 3 10 0. 0 88 0 R eg io n W es t B an k 8. 2 10 .0 39 .4 39 .7 2. 1 0. 6 10 0. 0 16 .1 29 .9 32 .9 10 .4 10 .0 0. 6 10 0. 0 47 8 G az a S tri p 6. 6 14 .2 37 .4 39 .0 2. 8 0. 0 10 0. 0 16 .2 33 .4 28 .3 8. 7 13 .5 0. 0 10 0. 0 40 2 Se x M al e 7. 8 11 .5 40 .1 38 .2 2. 1 0. 2 10 0. 0 14 .9 30 .7 33 .2 7. 8 13 .0 0. 4 10 0. 0 49 4 Fe m al e 7. 0 12 .4 36 .5 40 .8 2. 7 0. 5 10 0. 0 17 .8 32 .5 27 .8 11 .9 9. 7 0. 3 10 0. 0 38 6 G ov er no ra te Je ni n 3. 2 14 .0 32 .6 43 .2 5. 1 1. 9 10 0. 0 24 .9 27 .7 24 .3 3. 5 19 .5 0. 0 10 0. 0 54 Tu ba s (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 11 Tu lk ar m (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 21 N ab lu s 11 .7 5. 3 53 .5 29 .5 0. 0 0. 0 10 0. 0 14 .2 32 .8 37 .9 5. 4 9. 8 0. 0 10 0. 0 77 Q al qi liy a (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 8 S al fit (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 6 R am al la h & A l- B ire h 17 .8 10 .0 39 .5 32 .7 0. 0 0. 0 10 0. 0 25 .9 11 .1 35 .0 13 .0 15 .0 0. 0 10 0. 0 54 Je ric ho a nd A l A gh w ar (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 13 Je ru sa le m 12 .7 10 .8 38 .3 36 .9 0. 0 1. 3 10 0. 0 16 .0 39 .3 32 .5 7. 7 3. 4 1. 3 10 0. 0 77 B et hl eh em 1. 6 3. 1 54 .2 41 .1 0. 0 0. 0 10 0. 0 4. 8 26 .5 49 .7 19 .0 0. 0 0. 0 10 0. 0 58 H eb ro n 4. 5 10 .9 32 .2 46 .7 4. 8 1. 0 10 0. 0 15 .0 30 .6 26 .2 15 .3 11 .9 1. 0 10 0. 0 10 0 N or th G az a 4. 8 17 .4 35 .5 39 .9 2. 4 0. 0 10 0. 0 21 .9 28 .7 24 .8 8. 0 16 .6 0. 0 10 0. 0 88 G az a 8. 8 14 .7 35 .2 39 .9 1. 5 0. 0 10 0. 0 13 .5 39 .9 20 .5 12 .4 13 .7 0. 0 10 0. 0 13 6 D ei r E l-B al ah (4 .6 ) (1 1. 0) (3 6. 9) (4 5. 0) (2 .6 ) (0 .0 ) (1 00 .0 ) (2 1. 6) (2 0. 9) (3 6. 8) (3 .8 ) (1 6. 8) (0 .0 ) (1 00 .0 ) 49 K ha n Y un is 5. 7 10 .4 54 .3 29 .6 0. 0 0. 0 10 0. 0 14 .2 27 .9 39 .2 8. 7 10 .0 0. 0 10 0. 0 72 R af ah 7. 0 15 .6 25 .3 42 .1 10 .1 0. 0 10 0. 0 11 .6 42 .6 31 .3 4. 8 9. 7 0. 0 10 0. 0 57 ( ) F ig ur es th at a re b as ed o n 25 -4 9 un w ei gh te d ca se s (* ) F ig ur es th at a re b as ed o n le ss th an 2 5 un w ei gh te d ca se s 65 58 Ta bl e C H .6 C on tin ue d: F ee di ng p ra ct ic es d ur in g di ar rh ea P er ce nt d is tri bu tio n of c hi ld re n ag e 0- 59 m on th s w ith d ia rr ho ea in th e la st tw o w ee ks b y am ou nt o f l iq ui ds a nd fo od g iv en d ur in g ep is od e of d ia rr ho ea , P al es tin e, 2 01 4 D rin ki ng p ra ct ic es d ur in g di ar rh oe a: Ea tin g pr ac tic es d ur in g di ar rh oe a: N um be r o f ch ild re n ag ed 0 -5 9 m on th s w ith di ar rh oe a C hi ld w as g iv en to d rin k: C hi ld w as g iv en to e at : M uc h le ss S om ew ha t l es s A bo ut th e sa m e M or e N ot hi ng M is si ng /D K To ta l M uc h le ss S om e w ha t le ss A bo ut th e sa m e M or e N ot hi n g M is si n g/ D K To ta l A re a U rb an 6. 3 12 .3 37 .6 40 .8 2. 6 0. 3 10 0. 0 15 .9 31 .7 30 .9 10 .0 11 .2 0. 3 10 0. 0 64 9 R ur al 11 .2 11 .2 40 .5 35 .7 0. 8 0. 7 10 0. 0 17 .2 31 .2 33 .0 7. 1 10 .8 0. 6 10 0. 0 14 1 ca m p 9. 8 10 .0 41 .9 35 .0 3. 3 0. 0 10 0. 0 16 .3 30 .5 27 .2 10 .8 15 .1 0. 0 10 0. 0 90 A ge in m on th s 0- 11 6. 1 18 .3 41 .8 27 .1 6. 7 0. 0 10 0. 0 7. 3 25 .7 29 .2 10 .2 27 .6 0. 0 10 0. 0 22 7 12 -2 3 6. 4 10 .2 36 .2 46 .1 0. 8 0. 4 10 0. 0 20 .9 31 .2 28 .7 9. 5 9. 0 0. 7 10 0. 0 27 3 24 -3 5 9. 4 10 .0 41 .7 38 .9 0. 0 0. 0 10 0. 0 17 .9 37 .2 35 .3 5. 3 4. 4 0. 0 10 0. 0 16 6 36 -4 7 11 .7 7. 9 34 .4 42 .7 2. 3 0. 8 10 0. 0 22 .7 34 .6 27 .4 11 .8 3. 4 0. 0 10 0. 0 11 8 48 -5 9 5. 2 9. 9 36 .8 45 .9 1. 1 1. 0 10 0. 0 12 .6 32 .2 37 .2 13 .4 3. 5 1. 0 10 0. 0 96 M ot he r’s ed uc at io n N on e (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) (* ) 4 B as ic 7. 5 15 .6 38 .8 35 .0 2. 3 0. 8 10 0. 0 18 .1 31 .4 31 .7 6. 5 11 .8 0. 4 10 0. 0 25 8 S ec on da ry 7. 5 12 .0 37 .6 40 .1 2. 6 0. 3 10 0. 0 16 .9 35 .9 26 .3 8. 2 12 .4 0. 3 10 0. 0 30 1 H ig he r 7. 2 8. 9 39 .1 42 .4 2. 4 0. 0 10 0. 0 13 .8 27 .8 34 .2 13 .2 10 .7 0. 3 10 0. 0 31 7 W ea lth in de x qu in til e P oo re st 8. 9 15 .6 38 .9 32 .8 3. 9 0. 0 10 0. 0 16 .0 35 .7 26 .7 7. 4 14 .2 0. 0 10 0. 0 24 4 S ec on d 3. 3 12 .1 32 .6 50 .1 1. 9 0. 0 10 0. 0 14 .4 29 .3 30 .3 12 .6 13 .5 0. 0 10 0. 0 15 4 M id dl e 4. 9 11 .2 36 .6 42 .5 3. 8 1. 1 10 0. 0 14 .5 32 .1 31 .9 10 .3 10 .6 0. 6 10 0. 0 18 3 Fo ur th 12 .2 9. 1 42 .1 35 .5 0. 5 0. 6 10 0. 0 18 .3 28 .7 33 .3 7. 1 11 .6 1. 1 10 0. 0 17 4 R ic he st 7. 0 9. 5 43 .0 39 .6 0. 9 0. 0 10 0. 0 18 .1 29 .2 34 .7 12 .8 5. 3 0. 0 10 0. 0 12 5 ( ) F ig ur es th at a re b as ed o n 25 -4 9 un w ei gh te d ca se s (* ) F ig ur es th at a re b as ed o n le ss th an 2 5 un w ei gh te d ca se s 66 Palestinian Multiple Indicator Cluster Survey 2014 59 Table CH.6 provides statistics on drinking and feeding practices during diarrhoea. About 39 percent of under-five children with diarrhoea given more than usual while 60 percent drank the same or less. About 63 percent were given somewhat less, same or more (continued feeding), but 28 percent were given much less or almost nothing. Table CH.7: Oral rehydration solutions Percentage of children age 0-59 months with diarrhoea in the last two weeks and treatment with oral rehydration salts (ORS), Palestine, 2014 Percentage of children with diarrhoea who received: Number of children aged 0-59 months with diarrhoea Oral rehydration salts (ORS) Fluid from packet Pre-packaged fluid Any ORS [1] Total 21.8 12.1 31.5 880 Region West Bank 25.8 12.8 35.8 478 Gaza Strip 17.0 11.4 26.5 402 Sex Male 22.8 11.2 31.4 494 Female 20.5 13.4 31.7 386 Governorate Jenin 18.4 7.3 25.7 54 Tubas (*) (*) (*) 11 Tulkarm (*) (*) (*) 21 Nablus 29.6 8.8 38.5 77 Qalqiliya (*) (*) (*) 8 Salfit (*) (*) (*) 6 Ramallah & Al-Bireh 21.2 19.3 34.1 54 Jericho and Al Aghwar (*) (*) (*) 13 Jerusalem 26.2 8.0 31.7 77 Bethlehem 24.1 11.6 35.7 58 Hebron 26.6 17.9 38.3 100 North Gaza 19.6 12.2 31.8 88 Gaza 19.0 16.4 33.5 136 Deir El-Balah (20.3) (4.1) (20.3) 49 Khan Yunis 7.7 7.0 13.3 72 Rafah 17.2 9.7 23.5 57 Area Urban 20.6 12.2 30.3 649 Rural 24.6 11.1 34.0 141 camp 25.7 13.3 36.5 90 Age in months 0-11 19.9 10.6 27.8 227 12-23 28.5 14.3 39.2 273 24-35 19.9 13.6 30.8 166 36-47 16.6 10.9 27.5 118 48-59 17.0 8.7 24.9 96 Wealth index quintile Poorest 15.1 9.9 23.4 244 Second 20.9 15.4 33.1 154 Middle 28.8 10.2 35.8 183 Fourth 24.5 15.9 37.3 174 Richest 21.8 9.9 31.1 125 [1] MICS indicator 3.S1 - Diarrhoea treatment with oral rehydration salts (ORS) ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on less than 25 unweighted cases 67 60 Table CH.7 shows the percentage of children receiving ORS during the episode of diarrhoea. Since children may have been given more than one type of liquid, the percentages do not necessarily add to 100. About one-third of children with diarrhoea in the last two weeks received fluids from ORS packets (22 percent) or pre-packaged ORS fluids (12 percent). Children with diarrhoea who received any ORS was higher in the West Bank (36 percent) compared to 27 percent in Gaza Strip. Also the results showed differences between children living in Camps, urban and rural areas, where it was 37 percent of children living in Camps compared to 30 percent in urban and 34 percent in rural areas. Meanwhile children with diarrhoea in Khan Yunis governorate were less likely to receive any ORS (13 percent) than the other governorates, and children with diarrhoea in Nablus governorate were the most likely to receive ORS (39 percent). Figure CH.2: Chi ldren under-5 with diarrhoea who received ORS, Palest ine, 2014 68 Palestinian Multiple Indicator Cluster Survey 2014 61 Table CH.8: Oral rehydration therapy with continued feeding and other treatments Percentage of children age 0-59 months with diarrhoea in the last two weeks who were given oral rehydration therapy with continued feeding and percentage who were given other treatments, Palestine, 2014 Children with diarrhoea who were given: Not given any treatm ent or drug Number of children age 0- 59 months with diarrhoe a in the last two weeks O R S or increased fluids O R T w ith continued feeding [1] Other treatment: P ill or syrup: A ntibiotic P ill or syrup: A ntim otility P ill or syrup: U nknow n Injection: A ntibiotic Injection: U nknow n Intravenous H om e rem edy, herbal m edicine O ther Total 55.7 38.2 19.0 14.1 2.1 2.1 0.7 0.8 28.7 8.1 19.2 880 Region West Bank 58.4 41.4 12.9 8.6 2.2 2.3 0.2 0.7 34.8 8.7 18.5 478 Gaza Strip 52.5 34.5 26.3 20.6 2.0 1.8 1.3 0.9 21.3 7.4 20.0 402 Sex Male 55.2 37.8 21.1 13.5 2.4 1.5 1.0 0.9 28.6 7.8 21.0 494 Female 56.3 38.8 16.3 14.8 1.8 2.7 0.3 0.7 28.7 8.6 16.9 386 Governorate Jenin 52.1 27.5 23.8 7.0 1.7 1.8 1.8 4.3 23.4 7.0 22.0 54 Tubas (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 11 Tulkarm (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 21 Nablus 52.8 34.8 9.1 5.7 0.0 1.3 0.0 0.0 35.0 18. 0 20.8 77 Qalqiliya (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 8 Salfit (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 6 Ramallah & Al-Bireh 53.9 28.2 7.3 12.1 8.6 0.0 0.0 0.0 33.2 5.1 16.3 54 Jericho and Al Aghwar (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 13 Jerusalem 52.2 40.5 4.7 10.2 1.3 1.3 0.0 0.0 35.5 12. 4 24.4 77 Bethlehem 65.0 60.3 13.2 14.0 2.7 0.0 0.0 0.0 30.2 6.1 17.2 58 Hebron 64.0 46.1 13.3 5.0 1.3 4.8 0.0 1.0 47.7 7.5 15.0 100 North Gaza 57.8 33.8 15.8 26.5 3.8 2.0 0.0 1.0 21.6 8.9 24.9 88 Gaza 56.2 36.8 22.5 15.0 0.0 2.0 1.6 0.0 22.1 4.1 18.1 136 Deir El-Balah (58.7 ) (38.0) (41.6) (17.3) (4.1) (0.0) (1.7) (2.0) (28.0) (27 .4) (10.7) 49 Khan Yunis 36.4 22.4 22.0 18.5 1.2 2.7 3.0 2.7 15.8 4.4 30.8 72 Rafah 49.7 41.8 43.4 30.1 3.3 1.4 0.0 0.0 20.1 0.0 11.6 57 [1] MICS indicator 3.12 - Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding 69 62 Table CH.8 Continued: Oral rehydration therapy with continued feeding and other treatments Percentage of children age 0-59 months with diarrhoea in the last two weeks who were given oral rehydration therapy with continued feeding and percentage who were given other treatments, Palestine, 2014 Children with diarrhoea who were given: N ot given any treatm ent or drug Number of children age 0-59 months with diarrhoea in the last two weeks O R S or increased fluids O R T w ith continued feeding [1] Other treatment: P ill or syrup: A ntibiotic P ill or syrup: A ntim otility P ill or syrup: U nknow n Injection: A ntibiotic Injection: U nknow n Intravenous H om e rem edy, herbal m edicine O ther Area Urban 55.8 38.2 20.0 14.9 2.6 1.8 0.9 0.7 29.9 7.5 19.5 649 Rural 56.7 39.2 14.8 9.7 0.0 3.3 0.0 0.6 32.9 10.6 16.8 141 camp 52.8 37.1 18.9 15.2 2.0 2.0 0.0 1.7 12.9 8.5 20.5 90 Age in months 0-11 45.0 28.9 18.9 12.5 3.3 1.3 0.4 0.7 21.3 5.0 26.6 227 12-23 62.7 40.2 17.2 16.1 1.9 1.1 0.4 1.4 31.1 7.3 15.8 273 24-35 55.8 40.9 16.2 10.8 1.0 2.7 0.7 0.0 28.4 14.5 21.3 166 36-47 55.2 39.3 23.4 19.5 0.9 1.9 0.7 0.8 32.9 8.2 14.1 118 48-59 61.2 48.5 23.8 11.2 3.3 5.5 2.1 0.9 34.0 6.8 14.0 96 Wealth index quintile Poorest 45.7 28.6 25.6 23.3 2.4 0.9 0.5 0.8 23.0 6.2 23.6 244 Second 64.6 46.2 25.1 14.5 2.0 2.7 2.6 1.2 21.6 6.3 14.2 154 Middle 60.4 45.3 17.8 11.0 1.3 3.3 0.0 1.3 26.4 8.7 17.2 183 Fourth 54.7 33.9 12.9 7.8 3.8 1.1 0.6 0.5 39.5 9.8 19.3 174 Richest 58.5 42.7 9.1 8.8 0.6 3.1 0.0 0.0 36.4 10.9 19.8 125 [1] MICS indicator 3.12 - Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding 70 Palestinian Multiple Indicator Cluster Survey 2014 62 Table CH.8 Continued: Oral rehydration therapy with continued feeding and other treatments Percentage of children age 0-59 months with diarrhoea in the last two weeks who were given oral rehydration therapy with continued feeding and percentage who were given other treatments, Palestine, 2014 Children with diarrhoea who were given: N ot given any treatm ent or drug Number of children age 0-59 months with diarrhoea in the last two weeks O R S or increased fluids O R T w ith continued feeding [1] Other treatment: P ill or syrup: A ntibiotic P ill or syrup: A ntim otility P ill or syrup: U nknow n Injection: A ntibiotic Injection: U nknow n Intravenous H om e rem edy, herbal m edicine O ther Area Urban 55.8 38.2 20.0 14.9 2.6 1.8 0.9 0.7 29.9 7.5 19.5 649 Rural 56.7 39.2 14.8 9.7 0.0 3.3 0.0 0.6 32.9 10.6 16.8 141 camp 52.8 37.1 18.9 15.2 2.0 2.0 0.0 1.7 12.9 8.5 20.5 90 Age in months 0-11 45.0 28.9 18.9 12.5 3.3 1.3 0.4 0.7 21.3 5.0 26.6 227 12-23 62.7 40.2 17.2 16.1 1.9 1.1 0.4 1.4 31.1 7.3 15.8 273 24-35 55.8 40.9 16.2 10.8 1.0 2.7 0.7 0.0 28.4 14.5 21.3 166 36-47 55.2 39.3 23.4 19.5 0.9 1.9 0.7 0.8 32.9 8.2 14.1 118 48-59 61.2 48.5 23.8 11.2 3.3 5.5 2.1 0.9 34.0 6.8 14.0 96 Wealth index quintile Poorest 45.7 28.6 25.6 23.3 2.4 0.9 0.5 0.8 23.0 6.2 23.6 244 Second 64.6 46.2 25.1 14.5 2.0 2.7 2.6 1.2 21.6 6.3 14.2 154 Middle 60.4 45.3 17.8 11.0 1.3 3.3 0.0 1.3 26.4 8.7 17.2 183 Fourth 54.7 33.9 12.9 7.8 3.8 1.1 0.6 0.5 39.5 9.8 19.3 174 Richest 58.5 42.7 9.1 8.8 0.6 3.1 0.0 0.0 36.4 10.9 19.8 125 [1] MICS indicator 3.12 - Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding 63 Table CH.8 provides the proportion of children age 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and the percentage of children with diarrhoea who were given other treatments. Overall, 56 percent of children with diarrhoea given ORS or increased fluids, 38 percent given ORT (ORS or recommended homemade fluids or increased fluids). Combining the information in Table CH.6 with that of Table CH.7 on oral rehydration therapy, it is observed that 38 percent of children given ORT and, at the same time, feeding was continued, as is the recommendation. There are notable differences in the home management of diarrhoea by background characteristics. The figures for ORT and continued feeding range from 22 percent in Khan Yunis to 60 percent in Bethlehem governorate. Table CH.8 also shows the percentage of children having had diarrhoea in the two weeks preceding the survey who were given various forms of treatment, leaving 42 percent of them without any treatment or drug. Generally, it is noted that children in Gaza Strip are more advantaged from treatments as compared to children in the West Bank with 38 percent not given any treatment compared to 45 percent in the West Bank. Figure CH.3: Chi ldren under-5 with diarrhoea who were given oral rehydrat ion therapy (ORT) and continued feeding, Palest ine, 2014 71 64 Table CH.9: Source of ORS Percentage of children age 0-59 months with diarrhoea in the last two weeks who were given ORS, by the source of ORS, Palestine, 2014 P ercentage of children w ho w ere given O R S as treatm ent for diarrhoea: Number of children age 0-59 months with diarrhoea in the last two weeks Percentage of children for whom the source of ORS was: Number of children age 0-59 months who were given ORS as treatment for diarrhoea in the last two weeks Health facilities or providers A health facility or provider [b] P ublic P rivate N G O S U N R W A Israeli O ther D K / M issing Total 31.5 880 26.7 51.1 0.8 17.4 1.6 1.

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