Republic of Macedonia Multiple Indicator Cluster Survey 2011

Publication date: 2011

Republic of Macedonia Multiple Indicator Cluster Survey 2011 Montoring the situation of children and women I Republic of Macedonia Multiple indicatoR clusteR suRvey 2011 II MultIple IndIcator cluster survey 2011 The Macedonia Multiple Indicator Cluster Survey (MICS) was carried out in 2011 in cooperation between the Ministry of Health, Ministry of Education and Science, and Ministry of Labour and Social Policy of the Gov- ernment of Republic of Macedonia. Data collection was conducted by private research company IPSOS Strategic Puls. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF), with additional financial support from the United Nations Population Fund (UNFPA). MICS is an international household survey programme developed by UNICEF. The 2011 Macedonia MICS was conducted as part of the fourth global round of MICS surveys (MICS4). MICS provides up-to-date information on the situation of children and women and measures key indicators that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. Addi- tional information on the global MICS project may be obtained from www.childinfo.org. Republic of Macedonia Multiple indicatoR clusteR suRvey 2011 CIP – Каталогизација во публикација Национална и универзитетска библиотека „Св. Климент Охридски“, Скопје 316.346.2-053.2(497.7)»2011»(047.31) 316.346.2-055.2(497.7)»2011»(047.31) MULTIPLE indicator cluster survey : 2011. - Скопје : Министерство за здравство : Министерство за образование и наука : Министерство за труд и социјална политика, 2012. - 244 стр. : табели, граф. прикази ; 29 см ISBN 978-608-4518-41-9 (мин.здрав.) ISBN 978-608-226-361-8 (мин.образ.) ISBN 978-608-4595-21-2 (мин.труд.) а)Жени – Социјална положба – Македонија - 2011 – Истражувања б)Деца – Социјална положба – Македонија – 2011 - Истражувања COBISS.MK-ID 92995594 III summary table of findings Multiple indicatoR clusteR suRveys (Mics) and MillenniuM developMent Goals (MdG) indicatoRs, Macedonia, 2011 topic Mics4 indicator number MdG indicator number indicator value Macedonia Roma set-tlements CHILD MORTALITY Child Mortality 1.2 4.2 Infant mortality rate N/A 131 per thousand 1.1 4.1 Under five mortality rate N/A 142 per thousand NUTRITION Nutritional status 2.1a 2.1b 1.8 Underweight prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 1.3 0.2 7.6 2.0 percent percent 2.2a 2.2b Stunting prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 4.9 2.0 16.5 3.0 percent percent 2.3a 2.3b Wasting prevalence Moderate and Severe (- 2 SD) Severe (- 3 SD) 1.8 0.2 4.5 1.7 percent percent Breastfeeding and infant feeding 2.4 Children ever breastfed 93.9 95.5 percent 2.5 Early initiation of breastfeeding 21.0 38.6 percent 2.6 Exclusive breastfeeding under 6 months 23.0 (32.1) percent 2.7 Continued breastfeeding at 1 year 33.8 (52.8) percent 2.8 Continued breastfeeding at 2 years 12.8 (54.7) percent 2.9 Predominant breastfeeding under 6 months 44.1 (67.6) percent 2.10 Duration of breastfeeding 12.1 17.5 months 2.11 Bottle feeding 79.3 68.0 percent 2.12 Introduction of solid, semi-solid or soft foods 40.5 (*) percent 2.13 Minimum meal frequency 65.2 62.5 percent 2.14 Age-appropriate breastfeeding 22.4 42.9 percent 2.15 Milk feeding frequency for non-breastfed children 92.0 76.1 percent Low birth weight 2.18 Low-birth weight infants 5.5 11.2 percent 2.19 Infants weighed at birth 96.3 94.0 percent CHILD HEALTH Vaccinations 3.1 Tuberculosis immunization coverage 97.6 98.2 percent 3.2 Polio immunization coverage 96.7 91.0 percent 3.3 Immunization coverage for diphtheria, pertussis and tetanus (DPT) 95.2 90.9 percent 3.4 4.3 Measles immunization coverage 96.0 96.3 percent 3.5 Hepatitis B immunization coverage 95.5 91.7 percent Solid fuel use 3.11 Solid fuels 33.6 33.0 percent 1 Rate refers to 2005 2 Ibid Iv MultIple IndIcator cluster survey 2011 topic Mics4 indicator number MdG indicator number indicator value Macedonia Roma set-tlements WATER AND SANITATION Water and sanitation 4.1 7.8 Use of improved drinking water sources 99.6 99,1 percent 4.2 Water treatment 1.5 15,1 percent 4.3 7.9 Use of improved sanitation 92.9 91,1 percent 4.4 Safe disposal of child’s faeces 17.3 25,0 percent REPRODUCTIVE HEALTH Contraception and unmet need 5.1 5.4 Adolescent birth rate 13 (94)3 per 1,000 5.2 Early childbearing 1.6 27.3 percent 5.3 5.3 Contraceptive prevalence rate 40.4 37.0 Percent 5.4 5.6 Unmet need 17.2 22.2 percent Maternal and newborn health 5.5a 5.5b 5.5 Antenatal care coverage At least once by skilled personnel At least four times by any provider 98.6 93.9 94.0 85.9 percent percent 5.6 Content of antenatal care 94.1 82.7 percent 5.7 5.2 Skilled attendant at delivery 98.3 99.5 percent 5.8 Institutional deliveries 98.4 99.1 percent 5.9 Caesarean section 24.9 13.1 percent CHILD DEVELOPMENT Child devel- opment 6.1 Support for learning 91.5 61.8 percent 6.2 Father’s support for learning 71.1 56.8 percent 6.3 Learning materials: children’s books 52.4 27.1 percent 6.4 Learning materials: playthings 70.7 62.1 percent 6.5 Inadequate care 5.0 7.4 percent 6.6 Early child development index 92.7 72.2 percent 6.7 Attendance to early childhood education 21.8 3.9 percent EDUCATION Literacy and education 7.1 2.3 Literacy rate among young women age 15-24 years 97.4 76.6 percent 7.2 School readiness 40.0 36.1 percent 7.3 Net intake rate in primary education 91.2 84.3 percent 7.4 2.1 Primary school net attendance ratio (adjusted) 98.3 85.6 percent 7.5 Secondary school net attendance ratio (adjust- ed) 82.7 38.2 percent 7.6 2.2 Children reaching last grade of primary 98.6 89.2 percent 7.7 Primary completion rate 97.4 67.1 percent 7.8 Transition rate to secondary school 98.0 98.0 percent 7.9 Gender parity index (primary school) 1.00 1.00 ratio 7.10 Gender parity index (secondary school) .96 .80 ratio 3 Figure based on 125-259 person-years of exposure v topic Mics4 indicator number MdG indicator number indicator value Macedonia Roma set-tlements CHILD PROTECTION Birth registra- tion 8.1 Birth registration 99.7 98.4 percent Child labour 8.2 Child labour 16.6 10.3 percent 8.3 School attendance among child labourers 83.6 74.0 percent 8.4 Child labour among students 16.2 10.3 percent Child disci- pline 8.5 Violent discipline 69.3 82.0 percent Early marriage and polygyny 8.6 Marriage before age 15 among women age 15-49 years 1.4 11.9 percent 8.7 Marriage before age 18 among women age 20-49 years 10.7 47.0 percent 8.8 Young women age 15-19 years currently married or in union 4.3 22.4 percent 8.10.b Spousal age difference women age 20-24 years 8.4 5.1 percent Domestic violence 8.14 Attitudes towards domestic violence women age 15-49 years 14.5 25.4 percent Orphaned children 9.17 Children’s living arrangements 0.7 2.2 percent 9.18 Prevalence of children with one or both parents dead 1.9 3.3 percent SUBJECTIVE WELL-BEING Subjective well-being SW.1 Life satisfaction among women age 15-24 years 68.5 60.2 percent SW.2 Happiness among women age 15-24 years 91.2 81.4 percent SW.3 Perception of a better life among women age 15-24 years 54.6 39.0 percent TOBACCO AND ALCOHOL USE Tobacco use TA.1 Tobacco use among women age 15-49 years 30.0 42.1 percent TA.2 Smoking before age 15 among women age 15-49 years 5.2 22.7 percent Alcohol use TA.3 Alcohol use among women age 15-49 years 2.6 4.8 percent TA.4 Use of alcohol before age 15 among women age 15-49 years 28.5 11.2 percent ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases vI MultIple IndIcator cluster survey 2011 suMMaRy table of findinGs . iii list of tables .vii list of fiGuRes . Xiv list of abbReviations . Xv acKnoWledGeMents . Xvi eXecutive suMMaRy . Xvii i intRoduction . 2 Background . 2 Survey Objectives . 3 ii saMple and suRvey MethodoloGy . 4 Sample Design . 4 Questionnaires . 5 Training and Fieldwork . 6 Data Processing . 6 The Report Structure . 6 How to Read the Tables . 6 iii saMple coveRaGe and the chaRacteRistics of households and Respondents . 7 Sample Coverage . 7 Characteristics of Households . 8 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 . 10 Children Living Arrangements . 12 iv child MoRtality . 18 v nutRition . 19 Nutritional Status . 19 Breastfeeding and Infant and Young Child Feeding . 24 Low Birth Weight . 35 vi child health . 37 Vaccinations. 37 Prevalence of Diarrhoea . 42 Knowledge About the Signs of Pneumonia . 43 Solid Fuel Use . 45 Child Disability . 49 vii WateR and sanitation . 50 Use of Improved Water Sources . 50 Use of Improved Sanitation . 57 viii RepRoductive health . 64 Fertility and Early Childbearing . 64 Contraception . 66 Unmet Need . 72 Antenatal Care . 77 Assistance at Delivery . 82 Place of Delivery . 85 Abortions . 87 iX child developMent . 90 Early Childhood Education and Learning . 90 Early Childhood Development . 99 X liteRacy and education .102 Literacy Among Young Women . 102 School Readiness . 104 Primary and Secondary School Participation . 105 Xi child pRotection .114 Birth Registration . 114 Child Labour . 116 Child Discipline . 121 Early Marriage . 124 Attitudes toward Domestic Violence . 129 Xii tobacco and alcohol use . 132 Tobacco Use . 132 Alcohol Use . 137 Xiii subjective Well-beinG . 139 appendices . 146 Appendix A1. Sample Design - Macedonia . 147 Appendix A2. Sample Design – Roma Settlements. 151 Appendix B. List of Personnel Involved in the Survey . 154 Appendix C. Estimates of Sampling Errors. 157 Appendix D. Data Quality Tables . 172 Appendix E. MICS4 Indicators: Numerators and Denominators . 188 Appendix F. Questionnaires . 193 Appendix G. ISCED Tables . 238 Appendix H. Nutritional status of children based on NCHS/CDC/WHO International Reference Population . 241 Table of ConTenTs vII list of tables saMple coveRaGe and the chaRacteRistics of houshold Respondents 7 Table HH.1: Results of household, women’s and under-5 interviews, Macedonia, 2011 13 Table HH.1R: Results of household, women’s and under-5 inter- views, Roma settlements, 2011 8 Table HH.2: Household age distribution by sex, Macedo- nia, 2011 13 Table HH.2R: Household age distribution by sex, Roma settle- ments, 2011 9 Table HH.3: Household composition, Macedonia, 2011 14 Table HH.3R: Household composition, Roma settlements, 2011 10 Table HH.4: Women’s background characteristics, Mace- donia, 2011 15 Table HH.4R: Women’s background characteristics, Roma settlements, 2011 11 Table HH.5: Under-5’s background characteristics, Mace- donia, 2011 16 Table HH.5R: Under-5’s background characteristics, Roma settlements, 2011 12 Table HH.6: Children’s living arrangements and orphan- hood, Macedonia, 2011 17 Table HH.6R: Children’s living arrangements and orphanhood Roma settlements, 2011 child MoRtality 18 Table CM.1R: Children ever born, children surviving and propor- tion dead, Roma settlements, 2011 nutRition 20 Table NU.1: Nutritional status of children, Macedonia, 2011 22 Table NU.1R: Nutritional status of children, Roma settlements, 2011 25 Table NU.2: Initial breastfeeding, Macedonia, 2011 31 Table NU.2R: Initial breastfeeding, Roma settlements, 2011 26 Table NU.3: Breastfeeding, Macedonia 2011 31 Table NU.3R: Breastfeeding, Roma settlements 2011 27 Table NU.4: Duration of breastfeeding, Macedonia, 2011 32 Table NU.4R: Duration of breastfeeding, Roma settlements, 2011 28 Table NU.5: Age-appropriate breastfeeding, Macedonia, 2011 32 Table NU.5R: Age-appropriate breastfeeding, Roma settle- ments, 2011 29 Table NU.7: Minimum meal frequency, Macedonia, 2011 33 Table NU.7R: Minimum meal frequency, Roma settlements, 2011 vII Macedonia Roma settlements vIII MultIple IndIcator cluster survey 2011 30 Table NU.8: Bottle feeding, Macedonia, 2011 34 Table NU.8R: Bottle feeding, Roma settlements, 2011 35 Table NU.11: Low birth weight infants, Macedonia, 2011 36 Table NU.11R: Low birth weight infants, Roma settlements, 2011 child health 38 Table CH.1: Vaccinations in first year of life, Macedonia, 2011 40 Table CH.1R: Vaccinations in first year of life, Roma settle- ments, 2011 39 Table CH.2: Vaccinations by background characteristics, Macedonia, 2011 41 Table CH.2R: Vaccinations by background characteristics, Roma settlements, 2011 42 Table CH.4: Oral rehydration solutions and recommended homemade fluids, Macedonia, 2011 42 Table CH.4R: Oral rehydration solutions and recommended homemade fluids, Roma settlements, 2011 43 Table CH.8: Knowledge of the two danger signs of pneu- monia, Macedonia, 2011 44 Table CH.8R: Knowledge of the two danger signs of pneumo- nia, Roma settlements, 2011 45 Table CH.9: Solid fuel use, Macedonia, 2011 47 Table CH.9R: Solid fuel use, Roma settlements, 2011 46 Table CH.10: Solid fuel use by place of cooking, Macedo- nia, 2011 48 Table CH.10R: Solid fuel use by place of cooking, Roma settle- ments, 2011 WatteR and sanitation 51 Table WS.1: Use of improved water sources, Macedonia, 2011 55 Table WS.1R: Use of improved water sources, Roma settle- ments, 2011 52 Table WS.2: Household water treatment, Macedonia, 2011 56 Table WS.2R: Household water treatment, Roma settlements, 2011 53 Table WS.3: Time to source of drinking water, Macedonia 2011 56 Table WS.3R: Time to source of drinking water, Roma settle- ments 2011 54 Table WS.4: Person collecting water, Macedonia, 2011 57 Table WS.5: Types of sanitation facilities, Macedonia, 2011 61 Table WS.5R: Types of sanitation facilities, Roma settlements, 2011 58 Table WS.6: Use and sharing of sanitation facilities, Macedonia, 2011 62 Table WS.6R: Use and sharing of sanitation facilities, Roma settlements, 2011 59 Table WS.7: Disposal of child’s faeces, Macedonia, 2011 62 Table WS.7R: Disposal of child’s faeces, Roma settlements, 2011 60 Table WS.8: Drinking water and sanitation ladders, Mace- donia, 2011 63 Table WS.8R: Drinking water and sanitation ladders, Roma settlements, 2011 IX RepRoductive health 64 Table RH.1: Adolescent birth rate and total fertility rate, Macedonia, 2011 65 Table RH.2R: Early childbearing, Roma settlements, 2011 65 RH.3R: Trends in early childbeating 66 RH.3A: Knowledge of specific contraceptive methods, Macedonia, 2011 70 RH.3AR: Knowledge of specific contraceptive methods, Roma settlements, 2011 67 RH.3B: Knowledge of contraceptive methods by background characteristics, Macedonia, 2011 70 RH.3BR: Knowledge of contraceptive methods by back- ground characteristics, Roma settlements, 2011 68 Table RH.4: Use of contraception, Macedonia, 2011 71 Table RH.4R: Use of contraception, Roma settlements, 2011 73 Table RH.5: Unmet need for contraception, Macedonia, 2011 75 Table RH.5R: Unmet need for contraception, Roma settle- ments, 2011 77 Table RH.6: Antenatal care coverage, Macedonia, 2011 80 Table RH.6R: Antenatal care coverage, Roma settlements, 2011 78 Table RH.7: Number of antenatal care visits, Macedonia, 2011 81 Table RH.7R: Number of antenatal care visits, Roma settle- ments, 2011 79 Table RH.8: Content of antenatal care, Macedonia, 2011 81 Table RH.8R: Content of antenatal care, Roma settlements, 2011 83 Table RH.9: Assistance during delivery, Macedonia, 2011 84 Table RH.9R: Assistance during delivery, Roma settlements, 2011 85 Table RH.10: Place of delivery, Macedonia, 2011 86 Table RH.10R: Place of delivery, Roma settlements, 2011 87 Table RH.18: Lifetime experience with wasted pregnan- cies, Macedonia, 2011 89 Table RH.18R: Lifetime experience with wasted pregnancies, Roma settlements, 2011 88 Table RH.19: Induced abortion rates by area, Macedonia, 2011 89 Table RH.19R: Induced abortion rates by area, Roma settle- ments, 2011 88 Table RH.20: Induced abortion rates, Macedonia, 2011 child developMent 90 Table CD.1: Early childhood education, Macedonia, 2011 95 Table CD.1R: Early childhood education, Roma settlements, 2011 91 Table CD.2: Support for learning, Macedonia, 2011 96 Table CD.2R: Support for learning, Roma settlements, 2011 IX X MultIple IndIcator cluster survey 2011 93 Table CD.3: Learning materials, Macedonia, 2011 97 Table CD.3R: Learning materials, Roma settlements, 2011 94 Table CD.4: Inadequate care, Macedonia, 2011 98 Table CD.4R: Inadequate care, Roma settlements, 2011 100 Table CD.5: Early child development index, Macedonia, 2011 101 Table CD.5R: Early child development index, Roma settle- ments, 2011 liteRacy and education 102 Table ED.1: Literacy among young women, Macedonia, 2011 103 Table ED.1R: Literacy among young women, Roma settle- ments, 2011 104 Table ED.2: School readiness, Macedonia, 2011 105 Table ED.3: Primary school entry, Macedonia, 2011 106 Table ED.4: Primary school attendance, Macedonia, 2011 111 Table ED.4R: Primary school attendance, Roma settlements, 2011 107 Table ED.5: Secondary school attendance, Macedonia, 2011 112 Table ED.5R: Secondary school attendance, Roma settlements, 2011 108 Table ED.6: Children reaching last grade of primary school, Macedonia, 2011 109 Table ED.7: Primary school completion and transition to secondary school, Macedonia, 2011 110 Table ED.8: Education gender parity, Macedonia, 2011 113 Table ED.8R: Education gender parity, Roma settlements, 2011 child pRotection 114 Table CP.1: Birth registration, Macedonia, 2011 115 Table CP.1R: Birth registration, Roma settlements, 2011 117 Table CP.2: Child labour, Macedonia, 2011 119 Table CP.2R: Child labour, Roma settlements, 2011 118 Table CP.3: Child labour and school attendance, Macedonia, 2011 120 Table CP.3R: Child labour and school attendance, Roma settle- ments, 2011 121 Table CP.4: Child discipline, Macedonia, 2011 123 Table CP.4R: Child discipline, Roma settlements, 2011 125 Table CP.5: Early marriage, Macedonia, 2011 127 Table CP.5R: Early marriage, Roma settlements, 2011 126 Table CP.6: Trends in early marriage, Macedonia, 2011 128 Table CP.6R: Trends in early marriage, Roma settlements, 2011 126 Table CP.7: Spousal age difference, Macedonia, 2011 XI 130 Table CP.11: Attitudes toward domestic violence, Macedo- nia, 2011 131 Table CP.11R: Attitudes toward domestic violence, Roma settle- ments, 2011 tobacco and alcohol use 133 Table TA.1: Current and ever use of tobacco, Macedonia, 2011 135 Table TA.1R: Current and ever use of tobacco, Roma settle- ments, 2011 134 Table TA.2: Age at first use of cigarettes and frequency of use, Macedonia, 2011 136 Table TA.2R: Age at first use of cigarettes and frequency of use, Roma settlements, 2011 137 Table TA.3: Use of alcohol, Macedonia, 2011 138 Table TA.3R: Use of alcohol, Roma settlements, 2011 subjective Well-beinG 140 Table SW.1: Domains of life satisfaction, Macedonia, 2011 143 Table SW.1R: Domains of life satisfaction, Roma settlements, 2011 141 Table SW.2: Life satisfaction and happiness, Macedonia, 2011 144 Table SW.2R: Life satisfaction and happiness, Roma settle- ments, 2011 142 Table SW.3: Perception of a better life, Macedonia, 2011 145 Table SW.3R: Perception of a better life, Roma settlements, 2011 appendiX c: estiMates of eRRoRs 158 Table SE.1: Indicators selected for sampling error calcu- lations, Macedonia, 2011 170 Table SE.1R: Indicators selected for sampling error calcula- tions, Roma settlements, 2011 159 Table SE.2: Sampling errors: Total sample, Macedonia, 2011 171 Table SE.2R: Sampling errors: Total sample, Roma settlements, 2011 160 Table SE.3: Sampling errors: Urban areas, Macedonia, 2011 161 Table SE.4: Sampling errors: Rural areas, Macedonia, 2011 162 Table SE.5: Sampling errors: Vardar Region, Macedonia, 2011 163 Table SE.6: Sampling errors: East Region, Macedonia, 2011 164 Table SE.7: Sampling errors: Southwest Region, Macedo- nia, 2011 XI XII MultIple IndIcator cluster survey 2011 165 Table SE.8: Sampling errors: Southeast Region, Macedo- nia, 2011 166 Table SE.9: Sampling errors: Pelagonia Region, Macedo- nia, 2011 167 Table SE.10: Sampling errors: Polog Region, Macedonia, 2011 168 Table SE.11: Sampling errors: Northeast Region, Macedo- nia, 2011 169 Table SE.12: Sampling errors: Skopje Region, Macedonia, 2011 appendiX d: data quality tables 172 Table DQ.1: Age distribution of household population, Macedonia, 2011 180 Table DQ.1R: Age distribution of household population, Roma settlements, 2011 173 Table DQ.2: Age distribution of eligible and interviewed women, Macedonia, 2011 181 Table DQ.2R: Age distribution of eligible and interviewed women, Roma settlements, 2011 173 Table DQ.3: Age distribution of under-5s in household and under-5 questionnaires, Macedonia, 2011 181 Table DQ.3R: Age distribution of under-5s in household and under-5 questionnaires, Roma settlements, 2011 174 Table DQ.4: Women’s completion rates by socio-economic characteristics of households, Macedonia, 2011 182 Table DQ.4R: Women’s completion rates by socio-economic characteristics of households, Roma settlements, 2011 174 Table DQ.5: Completion rates for under-5 questionnaires by socio-economic characteristics of house- holds, Macedonia, 2011 182 Table DQ.5R: Completion rates for under-5 questionnaires by socio-economic characteristics of households, Roma settlements, 2011 175 Table DQ.6: Completeness of reporting, Macedonia, 2011 183 Table DQ.6R: Completeness of reporting, Roma settlements, 2011 176 Table DQ.7: Completeness of information for anthropo- metric indicators, Macedonia, 2011 184 Table DQ.7R: Completeness of information for anthropometric indicators, Roma settlements, 2011 177 Table DQ.8: Heaping in anthropometric measurements, Macedonia, 2011 185 Table DQ.8R: Heaping in anthropometric measurements, Roma settlements, 2011 177 Table DQ.11: Observation of under-5s birth certificates, Macedonia, 2011 185 Table DQ.11R: Observation of under-5s birth certificates, Roma settlements, 2011 XIII 178 Table DQ.12: Observation of vaccination cards, Macedonia, 2011 185 Table DQ.12R: Observation of vaccination cards, Roma settle- ments, 2011 178 Table DQ.13: Presence of mother in the household and the person interviewed for the under-5 question- naire, Macedonia, 2011 186 Table DQ.13R: Presence of mother in the household and the person interviewed for the under-5 questionnaire, Roma settlements, 2011 179 Table DQ.14: Selection of children age 2-14 years for the child discipline module, Macedonia, 2011 186 Table DQ.14R: Selection of children age 2-14 years for the child discipline module, Roma settlements, 2011 179 Table DQ.15: School attendance by single age, Macedonia, 2011 187 Table DQ.15R: School attendance by single age, Roma settle- ments, 2011 appendiX G: isced tables 238 Table ED.4 (a): Primary school attendance, Macedonia, 2011 240 Table ED.4R (a): Primary school attendance, Roma settlements, 2011 239 Table ED.5 (a): Lower secondary school attendance, Mace- donia, 2011 240 Table ED.5R (a): Lower secondary school attendance, Roma settlements, 2011 appendiX h: nutRitional status of childRen based on nchs/cdc/Who inteRnational RefeRence population 241 Table NU.1 (a): Nutritional status of children based on NCHS/CDC/WHO International Reference Population, Macedonia, 2011 242 Table NU.1R (a): Nutritional status of children based on NCHS/ CDC/WHO International Reference Population, Roma settlements, 2011 XIII XIv MultIple IndIcator cluster survey 2011 Macedonia Roma settlements list of figures 9 Figure HH.1: Age and sex distribution of household popu- lation, Macedonia, 2011 14 Figure HH.1R: Age and sex distribution of household population, Roma settlements, 2011 21 Figure NU.1: Percentage of children under age 5 who are underweight, stunted and wasted, Macedo- nia, 2011 23 Figure NU.1R: Percentage of children under age 5 who are underweight, stunted and wasted, Roma settle- ments, 2011 24 Figure NU.2: Percentage of mothers who started breast- feeding within one hour and within one day of birth, Macedonia, 2011 26 Figure NU.3: Infant feeding patterns by age, Macedonia, 2011 38 Figure CH.1: Percentage of children aged 18-29 months who received the recommended vaccinations by 12 months, Macedonia, 2011 41 Figure CH.1R: Percentage of children aged 18-29 months who received the recommended vaccinations by 12 months, Roma settlements, 2011 173 Figure DQ.1: Number of household population by single ages, Macedonia, 2011 181 Figure DQ.1R: Number of household population by single ages, Roma settlements, 2011 Xv list of abbreviations anc Antenatal Care bcG Bacillis-Cereus-Geuerin (Tuberculosis) cspro Census and Survey Processing System dpt Diphteria Pertussis Tetanus ecdi Early Child Development Index epi Expanded Programme on Immunization eu European Union GfR General Fertility rate Gpi Gender Parity Index hiv Human Immunodeficiency Virus ict Information/Communication Technology iMR Infant Mortality rate iud Intrauterine Device jMp Joint Monitoring Programme laM Lactational Amenorrhea Method MdG Millennium Development Goals Mics Multiple Indicator Cluster Survey Moh Ministry of Health naR Net Attendance Rate oRs Oral Rehydration Salts oRt Oral Rehydration Treatment ppm Parts Per Million ppp Preparatory Preschool Programme psu Primary Sampling Unit Rhf Recommended Home Fluid spss Statistical Package for Social Sciences tfR Total Fertility rate u5MR Under-Five Mortality Rate undp United Nations Development Programme undaf United Nations Development Assistance Framework unfpa United Nations Population Fund unicef United Nations Children’s Fund Wffc World Fit For Children Who World Health Organization XvI MultIple IndIcator cluster survey 2011 acknowledgements This survey would have not been possible without the participation of the citizens of the Republic of Macedonia. They contributed their hospitality, time, patience, and personal information, which is the essence of this report. Under the leadership of IPSOS Strategic Puls, the data collection teams carried out their work in a highly professional manner contributing to the quality and value of this report. UNICEF personnel in the Macedonia Country office, the CEE/CIS Regional office and the Global MICS team con- tributed in all stages of the survey and the development of the report through their knowledge, experience, enthusiasm and flexibility. A number of local and international experts provided critical support and inputs in the data collection process and during the preparation of the report. Members of the MICS4 Steering Committee provided valuable advice and comments during the preparation of the survey, the development of the questionnaires, and the drafting of the report. XvII eXecutive suMMaRy Introduction The Multiple Indicator Cluster Survey (MICS) is an international household survey programme developed by the United Nations Children’s Fund (UNICEF). The Republic of Macedonia MICS 2011 was conducted as part of the fourth global round of MICS surveys (MICS4). MICS provides up-to-date information on the situation of children and women and measures key indicators that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. The survey was conducted in cooperation between UNICEF and the Institute of Public Health of the Republic of Macedonia with the data collection being carried out by private research company IPSOS Strategic Puls. Financial and technical support was provided by UNICEF, with additional financial support from the United Nations Population Fund (UNFPA). In addition to conducting the MICS4 on a national scale, a separate sample of Roma settlements in Macedonia was also conducted. Results from both samples are presented jointly in this report. The following are major findings highlighted from each chapter of the report. Child Nutritional Status In Macedonia, 5 percent of children in the national sample and 17 percent of children from Roma settlements are stunted. The percentage of stunted children in Roma settlements decreases with the improvement of the material situation in the household. Stunting is nine times more frequent in children living in households from the poorest quintile. Roma boys (21 percent) are more likely to have stunted growth than Roma girls (12 percent). At the national level, 12 percent of children under the age of five are overweight. Breastfeeding In both samples, over 90 percent of children born within the last two years were breastfed. The percentage of children less than six months old who were exclusively breastfed is very low at 23 percent at the national level and 32 percent in Roma settlements. Child Health In both samples, over 90 percent of children were immunized. Children in Roma settlements, however, are less likely to receive the full round of vaccinations compared to children in the national level. Water and Sanitation More than 90 percent of the population in the country use both improved water sources and sanitation. 99.6 percent of the population has access to an improved drinking water source (if one uses a broad definition of access where improved drinking water sources include piped water, a public tap/standpipe, a tubewell/ borehole, a protected well or spring). The situation is similar in Roma settlements where 99 percent of the population uses an improved source of drinking water. 93 percent in the national sample and 91 percent in the Roma population use improved sanitation. However, approximately one third of the poorest households in Roma settlements do not have access to improved water sources and/or sanitation as compared to the rest of the population where over 90 percent have access to these two commodities. Reproductive Health In both samples, over 90 percent of women aged 15-49 years have heard of at least one modern contraceptive method. At the same time, only 13 percent of women in the national sample and 7 percent in the Roma sample use modern contraceptive methods, and 60 percent in the national sample and 63 percent in the Roma sample do not use any contraception. Traditional methods are used by 28 percent of women in the national sample and 30 percent in the Roma sample. One in every four babies born in Macedonia is delivered by cesarean section (C-section). C-section deliveries are more frequent as the wealth status of XvIII MultIple IndIcator cluster survey 2011 a woman increases. Pregnant women in the richest quintile will likely deliver by C-section four times more compared to pregnant women in the poorest quintile. Child Development Less than a quarter of pre-school aged children (36- 59 months) in the national sample attend some form of early childhood education while children in Roma settlements are five times less likely to attend. There is a strong correlation between the mother’s education level and the likelihood of her child’s early childhood education attendance. 47 percent of children whose mothers have completed higher education are attending some form of organized early childhood education programme. Meanwhile, only 1 percent of children whose mothers have completed primary or less education are included in such programmes. Literacy and Education Literacy among young women in the national sample is higher than in the Roma settlements. Considerable disparities exist within the women in Roma settlements, particularly in terms of wealth quintile. Only one in two Roma women aged 15-24 years and living in the poorest households are able to read. Over half of Roma youth at secondary school age do not attend secondary school. This situation contributes to the higher level of unemployment, social exclusion and poverty among the Roma population. Child Discipline There are a low percentage of respondents, from both samples, who believe that a child needs to be physically punished. In contrast, the percentage of parents or other adult household members who use violence as a way to discipline children is high. Among children aged 2-14 years, seven in ten children in the national sample and eight in ten in the Roma settlements have been violently punished either psychologically or physically by their parents or primary caretakers or another adult household member within a month preceding the survey. Domestic violence 15 percent of women aged 15-49 years believe that a husband is justified in beating the wife/partner in specific circumstances. The percentage is higher in the Roma population with 25 percent of women justifying the use of domestic violence by husbands. The contrast is even higher between ethnic Macedonians and Albanians within the national sample. Women in Albanian households justify a partner’s violent behavior in specific circumstances five times more than in Macedonian households (30 percent in Albanian households compared to 6 percent in Macedonian households). Acceptance of domestic violence is closely associated with a woman’s education level. Violence is seen as being acceptable ten times more by women with a primary or less education compared with those with a higher education. Tobacco and Alcohol use The prevalence of smoking, particularly during pregnancy, is a significant public health issue in the country. Smoking among women aged 15-49 years increases with the rise in household wealth. Among Roma women, however, smoking decreases with household wealth. The use of alcohol among women aged 15-49 also tends to increase with household wealth, with five times more women using alcohol in the richest quintile compared to the poorest quintile. Almost one in every four pregnant women from the national sample is a smoker. The percentage is slightly lower in the Roma community, where every fifth women smokes during pregnancy. 1 2 MultIple IndIcator cluster survey 2011 i intRoduction background This report is based on the Macedonia Multiple Indicator Cluster Survey, conducted in 2011 by the Institute of Public Health of the Republic of Macedonia and UNICEF. The survey provides valuable information on the situation of children and women in Macedonia, and was based in large part, on the needs to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see table below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and 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 (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of period- ic 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.” 3 In Macedonia, commitment to these international agreements and priorities has been demonstrated through the development of national policies, strategies, and plans, and in conducting activities for their implementation. The most important are the following: National Plan for Action for Children 2006-2015; National Strategy on Integrated Education (2010); National Strategy on deinstitutionalization (2008); National Programme for Social Protection (2010); Social Inclusion Strategy (2011). The MICS4 Steering Committee was established to provide advice during the preparation of the report, implementation of the surveys, and the dissemination of the results of the report. Members from the following institutions were included in the Steering Committee: „ Institute of Public Health – Chair; „ Ministry of Health; „ Ministry of Education; „ Ministry of Labor and Social Policy; „ Institute for Social Activities; „ State Statistics Office; „ UNDP; „ UNFPA; „ WHO; „ UNICEF; „ IPSOS Strategic Puls. This final report presents the results of the indicators and topics covered in the survey. survey objectives The 2011 Macedonia Multiple Indicator Cluster Survey primary objectives are: „ To provide up-to-date information for assessing the situation of children and women in Macedonia; „ 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 Macedonia and to strengthen technical expertise in the design, implementation, and analysis of such systems; „ To generate data on the situation of children and women, including the identification of vulnerable groups and of disparities, to inform policies and interventions. 4 MultIple IndIcator cluster survey 2011 ii saMple and suRvey MethodoloGy The Macedonia MICS 2011 was conducted using two separate samples. One sample was designed to cover the general population (referred in the report as the national sample) and the other sample was developed specifically for the Roma population living in Roma settlements (referred in the report as the Roma sample). In Macedonia, the Roma population is among the most deprived and excluded groups in the country. To collect more accurate data on issues affecting this population a separate sample covering the Roma population in Roma settlements was included in the survey. sample design of the national sample The sample for the Macedonia MICS was designed to provide estimates for a large number of indicators on the situation of children and women at the national level, for both urban and rural areas and for eight regions: Vardar, East, Southwest, Southeast, Pelagonia, Polog, Northeast, and Skopje. The urban and rural 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 were selected systematically with probability proportional to size. After a household listing was carried out within the selected enumeration areas, the households were divided into two groups: households with children under age 5 and households without children under age 5. A separate systematic sample for each group of households was drawn in each sample enumeration area. A total of 300 enumeration areas were selected- 175 urban and 125 rural. In 17 of the selected enumeration areas distributed in three regions in the western part of the country, more than 20 percent of the selected households were empty during the data collection. As these households were occupied at the time of the listing, it is assumed that residents were engaged in seasonal work abroad. The empty households were replaced by selecting additional households from the same enumeration areas. The change of the selected households was reflected in the calculation of the sample weights after the data collection. The sample was stratified by region, urban and rural areas, and is not self-weighting. For reporting national level results, sample weights are used. sample Design of the Roma sample The sample for the Roma settlements Macedonia MICS was designed to provide estimates for a large number of indicators on the situation of Roma children and women at the national level. Roma settlements are situated in urban areas; therefore no urban-rural distinction is reflected in the sample. Similarly, being concentrated in major urban areas (with over 50 percent of Roma population living in Skopje) Roma settlements are not evenly distributed across the regions. Enumeration areas where Roma population was at least 15 percent of the total pop- ulation were identified as Roma enumeration areas (Roma settlements). There are a total of 204 such enumeration areas in the country, of which 70 were selected proportional to size and included in the sample. The sample is not self-weighting. For report- ing national level results, sample weights are used. As the national sample was designed using a random model, it also includes respondents of Roma ethnic- ity to the extent they are represented in the popula- tion. They are included in the category Other in the report. A more detailed description of the sample designs can be found in Appendix A1 and A2. 5 empty during the data collection. As these households were occupied at the time of the listing, it is assumed that residents were engaged in seasonal work abroad. The empty households were replaced by selecting additional households from the same enumeration areas. The change of the selected households was reflected in the calculation of the sample weights after the data collection. The sample was stratified by region, urban and rural areas, and is not self-weighting. For reporting national level results, sample weights are used. sample Design of the Roma sample The sample for the Roma settlements Macedonia MICS was designed to provide estimates for a large number of indicators on the situation of Roma children and women at the national level. Roma settlements are situated in urban areas; therefore no urban-rural distinction is reflected in the sample. Similarly, being concentrated in major urban areas (with over 50 percent of Roma population living in Skopje) Roma settlements are not evenly distributed across the regions. Enumeration areas where Roma population was at least 15 percent of the total pop- ulation were identified as Roma enumeration areas (Roma settlements). There are a total of 204 such enumeration areas in the country, of which 70 were selected proportional to size and included in the sample. The sample is not self-weighting. For report- ing national level results, sample weights are used. As the national sample was designed using a random model, it also includes respondents of Roma ethnic- ity to the extent they are represented in the popula- tion. They are included in the category Other in the report. A more detailed description of the sample designs can be found in Appendix A1 and A2. questionnaires Five questionnaires were used in the survey: 1) A Household Questionnaire, used to collect information on all de jure household members (usual residents), the household, and the dwelling; 2) A Women’s Questionnaire administered in each household to all women aged 15-49 years; 3) An Under 5 Questionnaire administered to mothers or caretakers for all children under 5 living in the household; 4) A Questionnaire for Child Disability administered to mothers or caretakers for all children aged 2-9 years; 5) A Questionnaire for Vaccinations at a health facility. The Household Questionnaire included the following modules: „ Household Listing Form „ Education „ Water and Sanitation „ Household Characteristics „ Child Labour „ Child Discipline The Questionnaire for Individual Women was administered to all women aged 15-49 years living in each household, and included the following modules: „ Women’s Background „ Child Mortality4 (full module for Roma sample only) „ Desire for Last Birth „ Maternal and Newborn Health „ Illness Symptoms „ Contraception „ Unmet Need „ Attitudes Towards Domestic Violence „ Marriage/Union „ Tobacco and Alcohol Use „ Life Satisfaction The Questionnaire for Children Under Five was administered to mothers or primary caretakers of 4 The module on child mortality also incorporates questions on abortion. These questions were answered by respondents in both samples. children under 5 years of age5 living in the households. The questionnaire was administered to mothers of under 5 children; in cases where the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: „ Age „ Birth Registration „ Early Childhood Development „ Breastfeeding „ Care of Illness „ Immunization „ Anthropometry The Questionnaire Form For Child Disability contained the Ten Question Module for identifying children with an increased risk of disability. The Questionnaire Form for Vaccinations at Health Facility was used to check the consistency in recording the immunizations between the documents kept in the health facilities and the immunization cards in the households. The questionnaires were based on the MICS4 model questionnaire6. From the MICS4 model English version, the questionnaires were customized, translated into Macedonian and Albanian, back translated into English, and pre-tested in Skopje in March 2011. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the Macedonia MICS questionnaires is provided in Appendix F. In addition to the administration of the questionnaires, fieldwork teams measured the weights and heights of children under 5 years of age. Details and findings of these measurements are provided in the respective sections of the report. 5 The terms “children under 5,” “children age 0-4 years,” and “children aged 0-59 months” are used interchangeably in this report. 6 The model MICS4 questionnaires can be found at www.childinfo.org 6 MultIple IndIcator cluster survey 2011 training and fieldwork Fieldwork training was conducted for 12 days in March/April 2011. 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 two days practicing interviews in urban and rural areas near Struga city. 12 teams collected the data. Each team comprised of four interviewers, one editor, one measurer and a supervisor. Fieldwork began in April 2011 and concluded in July 2011. data processing Data were entered using the CSPro software. The data were entered on 12 microcomputers and carried out by 20 data entry operators and 10 data entry supervisors. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS4 programme and adapted to the Macedonia questionnaire were used throughout. Data processing began almost simultaneously with data collection in May 2011 and was completed in August 2011. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, Version 18, and the model syntax and tabulation plans developed by UNICEF were used for this purpose. the Report structure This report presents findings from the MICS4 surveys carried out on two samples. Although they can be interpreted as two independent surveys, the findings are jointly presented in one report to ease data comparison between both samples. Each sub-chapter comprises of a common introduction and a description of the findings from the national sample and the Roma sample. In order to visually differentiate findings from the two samples, survey results from the Roma sample are shaded in a different colour. how to Read the tables Some of the data collected by the questionnaires are not shown in the tables but are discussed in the text because the number of cases in the disaggregated categories was not sufficient for making conclusions. The number of cases in the education category None within the national sample was too small to be reported separately. Thus the category None was merged with the category Primary and presented (except in HH tables) as Primary or Less. The education category Higher within the Roma sample was too small to be reported separately. As such, the category Higher was merged with the category Secondary and presented (except in HH tables) as Secondary+. Note: (R) — Letter R after a Table/Figure code indicates that it refers only to the Roma settlements sample. (*) — An asterisk in the tables indicates that the percentage or proportion has been suppressed because it is based on fewer than 25 unweighted cases. (Number) — Figure in parenthesis indicate that the percentage or proportion is based on just 25 to 49 unweight- ed cases and should be treated with caution. 7 iii saMple coveRaGe and the chaRacteRistics of households and Respondents sample coverage Of the 4703 households selected for the sample, 4397 were found to be occupied. Of these, 4018 were successfully interviewed for a household response rate of 91 percent. In the interviewed households, 4024 women (aged 15-49 years) were identified as eligible. Of these, 3831 were successfully interviewed, yielding a response rate of 95 percent within interviewed households. There were 1398 children under age 5 listed in the household questionnaire. Questionnaires were completed for 1376 of these children yielding a response rate of 98 percent within interviewed households. Overall, response rates of 87 percent and 90 percent are calculated for the interviews with women and children under age 5 (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 inter- views, and household, women’s and under-5’s response rates, Macedonia, 2011   Area Region To ta l    Urban Rural Vardar East South-west South- east Pelago- nia Polog North- east Skopje Households Sampled 2678 2025 358 444 507 369 551 742 408 1324 4703 Occupied 2517 1880 348 407 464 362 550 666 372 1228 4397 Interviewed 2206 1812 338 370 428 354 550 625 341 1012 4018 Household response rate 87.6 96.4 97.1 90.9 92.2 97.8 100.0 93.8 91.7 82.4 91.4 Women Eligible 1949 2075 263 261 450 314 500 802 362 1072 4024 Interviewed 1838 1993 257 254 417 299 490 779 353 982 3831 Women’s response rate 94.3 96.0 97.7 97.3 92.7 95.2 98.0 97.1 97.5 91.6 95.2 Women’s overall response rate 82.7 92.6 94.9 88.5 85.5 93.1 98.0 91.2 89.4 75.5 87.0 Children under 5 Eligible 758 640 139 132 137 118 199 220 95 358 1398 Mothers/caretakers interviewed 750 626 139 131 131 118 199 216 93 349 1376 Under-5’s response rate 98.9 97.8 100.0 99.2 95.6 100.0 100.0 98.2 97.9 97.5 98.4 Under-5’s overall response rate 86.7 94.3 97.1 90.2 88.2 97.8 100.0 92.1 89.7 80.3 89.9 8 MultIple IndIcator cluster survey 2011 There are differences in response rates by region and area, with significant differences in household response rates between Pelagonia region (100 percent) and Skopje (82 percent), and between rural (96 percent) and urban (88 percent) areas. In the responses from women and children under 5, similar differences are registered between region and area. The results for Skopje region should be interpreted with some caution since the household response rate was only 82 percent. Three regions were affected by empty households that were replaced during the data collection process. 32 households were replaced in the Southwest region, 47 households in the Polog region, and 22 in Northeast region. 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 4018 households successfully interviewed in the survey, 14764 household members were listed; of these, 7445 were males, and 7319 were females. table hh.2: household age distribution 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, Macedonia, 2011 Males Females Total Number Percent Number Percent Number Percent age 0-4 432 5.8 427 5.8 859 5.8 5-9 444 6.0 401 5.5 846 5.7 10-14 449 6.0 407 5.6 856 5.8 15-19 592 7.9 493 6.7 1085 7.3 20-24 534 7.2 524 7.2 1058 7.2 25-29 580 7.8 554 7.6 1134 7.7 30-34 578 7.8 522 7.1 1100 7.5 35-39 524 7.0 503 6.9 1026 7.0 40-44 496 6.7 495 6.8 991 6.7 45-49 529 7.1 468 6.4 996 6.7 50-54 510 6.8 524 7.2 1034 7.0 55-59 500 6.7 536 7.3 1036 7.0 60-64 417 5.6 447 6.1 864 5.9 65-69 312 4.2 313 4.3 625 4.2 70-74 230 3.1 282 3.9 512 3.5 75-79 194 2.6 263 3.6 457 3.1 80-84 76 1.0 94 1.3 170 1.1 85+ 44 .6 62 .8 106 .7 Missing/DK 3 .0 4 .1 8 .1 Dependency age groups 0-14 1326 17.8 1235 16.9 2561 17.3 15-64 5259 70.6 5066 69.2 10326 69.9 65+ 857 11.5 1013 13.8 1869 12.7 Missing/DK 3 .0 4 .1 8 .1 Child and adult populations Children age 0-17 years 1680 22.6 1524 20.8 3204 21.7 Adults age 18+ years 5762 77.4 5791 79.1 11552 78.2 Missing/DK 3 .0 4 .1 8 .1 Total 7445 100.0 7319 100.0 14764 100.0 9 The age and sex distribution of the MICS4 survey household population is in accordance with the demographic estimates of the national population in 20107. For broad age groups, i.e. 0-14 years of age with 17 percent females and 18 percent males; 15-64 years of age with 69 percent females and 71 percent males; and 65+ years of age with 14 percent females and 12 percent males. The pyramid in Figure HH.1 shows the negative trend in the population growth with the proportion of population aged 0-17 (23 percent males and 21 percent females) is almost four times lower than the proportion of adults over 18 years and only twice as big as the group of 65+ years. figure hh.1: age and sex distribution of household population, Macedonia, 2011 Tables HH.3-HH.5 provide basic information on the households, female respondents aged 15-49, and children under 5, by presenting the unweighted and weighted numbers. Information on the basic characteristics of households, women, and children under-5 interviewed in the survey is essential for the interpretation of findings presented later in the report and can also provide an indication of the representativeness of the survey. The remaining tables in this report are presented only with weighted numbers. See Appendix A1 for more details about the weighting. Table HH.3 provides basic background information on the households. Within the households, the sex of the household head, region, area, number of household members, education of household head and ethnicity8 of the household head are shown in the table. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. 7 http://makstat.stat.gov.mk/pxweb2007bazi/temp/01Nas_reg_06_10_ PolVoz_mk2012426311420_1p1_1336891.gif 8 This was determined by asking respondents what ethnic group the head of household belonged to. The number of respondents with no education is too small to be reported as a separate category. Therefore the categories None and Primary education are presented separately only in Tables HH.3, HH.4 and HH.5, while in the remaining tables they are merged and marked as Primary or Less. table hh.3: household composition percent and frequency distribution of households by selected characteristics, Macedonia, 2011 Weighted percent Number of households Weighted Unweighted sex of household head Male 83.9 3372 3489 Female 16.1 646 529 Region Vardar 8.8 352 338 East 10.1 405 370 Southwest 8.4 339 428 Southeast 9.1 364 354 Pelagonia 13.9 560 550 Polog 10.7 429 625 Northeast 9.4 376 341 Skopje 29.7 1194 1012 number of household members 1 9.7 388 279 2 21.6 869 663 3 17.3 695 661 4 23.6 947 939 5 12.4 496 623 6 8.7 348 478 7 3.7 150 200 8 1.5 61 90 9 .9 36 41 10+ .7 28 44 education of household head None 2.4 94 103 Primary 36.7 1474 1606 Secondary 41.6 1670 1609 High 19.4 778 698 Missing/DK .0 1 2 ethnicity of household head Macedonian 72.7 2921 2606 Albanian 19.5 784 1071 Other 7.7 310 340 Missing/DK .1 3 1 Total 100.0 4018 4018 Households with at least One child age 0-4 years 16.9 4018 4018 One child age 2-9 years 24.3 4018 4018 One child age 0-17 years 44.4 4018 4018 One woman age 15-49 years 63.0 4018 4018 Mean household size 3.7 4018 4018 10 MultIple IndIcator cluster survey 2011 In Table HH.3, the weighted and unweighted numbers of households in total are equal (4018) since sample weights were normalized (see Appendix A). The table also shows the proportions of households with at least one child under 18, at least one child under 5, and at least one eligible woman aged 15-49. The table also shows the weighted average household size estimated by the survey. In 84 percent of the households, the household head was male, with the remaining 16 percent of households headed by a female. There are differences in frequency distribution of households by region with the highest frequency in Skopje (30 percent) and the lowest in the Southwest region (8 percent); this is similar to the population distribution by regions at the end of 2010. The mean household size is 3.7. 24 percent of households have four members, 17 percent have three, 22 percent have two and 12 percent consist of five members. Households with one member and with six members have similar frequencies- 10 percent and 9 percent respectively. 7 percent of households have seven or more members. Most of the household heads have a secondary (42 percent) or primary school (37 percent) education, compared to 19 percent with a higher education. Most of the household heads are Macedonians (73 percent), followed by Albanians (20 percent), and the remaining comprised of other ethnicities. 17 percent of households have at least one child aged 0-4 years, 44 percent with at least one child aged 0-17 years and 63 percent with one woman aged 15-49 years. 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 respondents 15- 49 years of age and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal since sample weights have been normalized (standardized). The tables present the numbers 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, Macedo- nia, 2011 Weighted percent Number of women Weighted Unweighted Region Vardar 6.3 243 257 East 6.7 258 254 Southwest 9.2 353 417 Southeast 8.3 317 299 Pelagonia 13.4 512 490 Polog 15.6 597 779 Northeast 10.0 385 353 Skopje 30.4 1166 982 area Urban 54.6 2092 1838 Rural 45.4 1739 1993 age 15-19 13.8 530 529 20-24 14.1 541 555 25-29 15.0 574 657 30-34 14.8 567 600 35-39 14.2 545 533 40-44 14.5 555 499 45-49 13.5 519 458 Marital/Union status Currently married/in union 66.2 2537 2675 Widowed 1.0 39 38 Divorced 1.4 54 43 Separated .6 25 21 Never married/in union 30.7 1175 1053 Missing .0 0 1 Motherhood status Ever gave birth 63.2 2423 2577 Never gave birth 36.8 1408 1254 births in last two years Yes 9.4 362 503 No 90.6 3469 3328 education None 1.2 46 55 Primary 29.4 11271 1312 Secondary 43.9 1682 1623 High 25.5 976 841 Wealth index quintile Poorest 18.1 695 784 Second 18.9 725 850 Middle 20.4 782 781 Fourth 20.6 791 713 Richest 21.9 839 703 ethnicity of household head Macedonian 60.8 2330 2042 Albanian 31.3 1199 1453 Other 7.9 302 336 Total 100.0 3831 3831 11 Table HH.4 provides background characteristics of female respondents 15-49 years of age. The table includes information on the distribution of women according to region, area, age, marital status, motherhood status, births in last two years, education9, wealth index quintiles10, and ethnicity of the household head. Distribution of women according to region varies from 6 percent in the Vardar region to 30 percent in the Skopje region, and from 55 percent in urban areas compared to 45 percent in rural areas. There are differences between the weighted and unweighted numbers in particular categories due to over-sampling or under-sampling such as the regional distribution in Southeast and Polog, some age groups, marital status, primary or less education, poorest and richest wealth index quintiles, and the ethnicity of the household head (Macedonian and Albanian). Some background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, region and area, age, mother’s/caretaker’s education, and wealth. 9 Unless otherwise stated, “education” refers to the educational level attend- ed by the respondent throughout this report when it is used as a background variable. 10 Principal components analysis was performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth to assign weights (factor scores) to each of the household assets. Each household was then assigned a wealth score based on these weights and the assets owned by that household. The survey household population was then ranked according to the wealth score of the household they are living in, and was finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). The assets used in these calculations were as follows: type of water and sanitation, number of rooms used for sleeping, main material of dwelling floor, roof and exterior walls; type of fuel used for cooking; presence in the household of electricity, radio, television, plasma/ LCD TV, landline telephone, refrigerator, washing machine, cooker, water boiler, air-conditioning, dish-washer, microwave-oven, dryer, sitting set/ sofa, sleeping bed, dining table; possesion by household members of watch, mobile phone, bicycle, motorcycle/scooter, cart pulled by animals, car/truck, motor boat, computer or laptop, caravan and ownership of bank account by the household members. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Filmer, D. and Pritchett, L., 2001. “Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India”. Demography 38(1): 115-132.Gwatkin, D.R., Rutstein, S., Johnson, K. ,Pande, R. and Wagstaff. A., 2000.Socio-Economic Differences in Health, Nutrition, and Population. HNP/Poverty Thematic Group, Washington, DC: World Bank. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro. table hh.5: under-5’s background characteristics percent and frequency distribution of children under five years of age by selected characteristics, Macedo- nia, 2011 Weighted percent Number of under-5 children Weighted Unweight-ed sex Male 50.3 692 704 Female 49.7 684 672 Region Vardar 7.3 100 139 East 8.0 110 131 Southwest 8.8 121 131 Southeast 6.0 83 118 Pelagonia 11.3 156 199 Polog 18.6 256 216 Northeast 9.9 136 93 Skopje 30.1 415 349 area Urban 50.9 701 750 Rural 49.1 675 626 age 0-5 months 8.3 114 112 6-11 months 10.5 144 145 12-23 months 20.5 283 265 24-35 months 19.9 274 296 36-47 months 20.0 276 273 48-59 months 20.7 285 285 Mother’s education* None 1.5 20 20 Primary 38.1 525 447 Secondary 37.9 522 601 High 22.5 309 308 Wealth index quintile Poorest 23.0 316 248 Second 19.8 272 280 Middle 18.5 255 293 Fourth 18.9 261 267 Richest 19.8 272 288 ethnicity of household head Macedonian 51.4 708 846 Albanian 37.8 521 389 Other 10.7 148 141 Total 100.0 1376 1376 * Mother’s education refers to educational attainment of mothers and caretakers of children under 5. 12 MultIple IndIcator cluster survey 2011 Distribution of children under 5 according to region is similar with the distribution of women, varying from 7 percent in the Vardar region to 30 percent in the Skopje region. Distribution by area is similar in urban areas (51 percent) and rural areas (49 percent) and equally distributed by sex with 50 percent males and 50 percent females. Age groups older than 12 months are equally distributed with around 20 percent. There are children living arrangements Table HH.6 presents information on the living arrangements and orphanhood status of children under age 18. differences between the weighted and unweighted numbers in particular categories due to extensive over-sampling or under- sampling, such as regional distribution in Northeast and Skopje, primary or less and secondary education, poorest and fourth wealth index quintiles and ethnicity of the household head (Macedonian and Albanian). table hh.6: children’s living arrangements and orphanhood Percent and frequency distribution of children under five years of age by selected characteristics, Macedonia, 2011 Liv in g w ith b ot h pa re nt s Living with neither parent Living with mother only Living with father only Im po ss ib le to de te rm in e Total No t l ivi ng w ith a bi ol og ica l pa re nt 1 On e or b ot h pa re nt s d ea d 2 Nu m be r o f ch ild re n ag e 0- 17 ye ar s Only father alive Only mother alive Both alive Both dead Father alive Father dead Mother alive Mother dead sex Male 93.6 .1 .0 .6 .1 3.0 .9 1.0 .3 .4 100.0 .8 1.4 1680 Female 93.8 .1 .1 .4 .0 2.4 1.8 .7 .4 .3 100.0 .6 2.4 1524 Region Vardar 92.1 .5 .0 1.5 .0 3.8 .6 .2 .6 .7 100.0 2.0 1.7 193 East 91.5 .6 .0 .9 .5 3.8 .5 1.6 .4 .1 100.0 2.0 2.1 225 Southwest 95.5 .0 .0 .1 .0 1.7 .9 .9 .0 .8 100.0 .1 .9 312 Southeast 93.8 .0 .0 .8 .0 2.5 2.4 .5 .0 .0 100.0 .8 2.4 262 Pelagonia 94.6 .0 .0 .0 .0 2.1 .8 1.1 .6 .8 100.0 .0 1.4 392 Polog 93.5 .0 .0 .7 .1 3.5 1.8 .0 .1 .3 100.0 .8 2.0 513 Northeast 92.9 .0 .0 .4 .0 1.0 3.6 1.3 .1 .6 100.0 .4 3.8 352 Skopje 93.9 .0 .2 .5 .0 3.0 .6 1.2 .6 .0 100.0 .7 1.4 955 area Urban 92.0 .0 .0 .7 .1 3.5 1.6 1.4 .4 .3 100.0 .8 2.1 1604 Rural 95.4 .2 .1 .3 .0 1.9 1.0 .4 .3 .4 100.0 .6 1.6 1599 age 0-4 95.8 .0 .0 .2 .0 2.3 1.0 .5 .0 .1 100.0 .2 1.0 859 5-9 92.0 .1 .0 .2 .0 4.3 1.8 .5 .6 .3 100.0 .4 2.5 846 10-14 95.1 .0 .0 .4 .0 1.7 1.0 1.4 .4 .0 100.0 .4 1.4 856 15-17 91.1 .2 .3 1.5 .2 2.3 1.5 1.2 .6 1.1 100.0 2.2 2.8 643 Wealth index quintile Poorest 93.5 .3 .0 .6 .2 2.7 .8 .7 .4 .7 100.0 1.1 1.8 690 Second 93.3 .0 .3 .5 .1 2.1 3.0 .4 .1 .3 100.0 .8 3.4 651 Middle 91.5 .0 .0 1.2 .0 4.1 1.4 1.1 .6 .0 100.0 1.2 2.1 614 Fourth 94.1 .0 .0 .4 .0 1.9 1.0 1.4 .7 .5 100.0 .4 1.7 588 Richest 95.8 .0 .0 .1 .0 2.7 .4 .9 .0 .2 100.0 .1 .4 660 ethnicity of household head Macedonian 93.4 .1 .1 .6 .0 3.1 1.0 .9 .4 .3 100.0 .8 1.7 1758 Albanian 94.9 .0 .0 .3 .0 2.2 1.6 .5 .2 .3 100.0 .3 1.8 1161 Other 90.1 .0 .0 1.1 .4 2.2 2.1 2.6 .8 .7 100.0 1.5 3.4 285 Total 93.7 .1 .1 .5 .1 2.7 1.3 .9 .4 .3 100.0 .7 1.9 3204 1 MICS indicator 9.17 2 MICS indicator 9.18 Of the 3204 children covered in the survey, 94 percent live with both parents, 4 percent live with their mother only, and 1 percent with their father only. Less than 1 percent of children do not live with their biological parents and 2 percent have lost one or both parents. 13 sample coverage – Roma settlements Of the 1079 households selected for the sample, 997 were found to be occupied. Of these, 953 were successfully interviewed for a household response rate of 96 percent. In the interviewed households, 1134 women (aged 15-49 years) were identified. Of these, 1091 were successfully interviewed, yielding a response rate of 96 percent within interviewed households. There were 483 children under age 5 listed in the household questionnaire. Questionnaires were completed for 476 of these children, which correspond to a response rate of 99 percent within interviewed households. Overall, response rates of 92 and 94 percentages are calculated for the interviews with women and children under age 5 (Table HH.1R). table hh.1R: Results of house- hold, women’s, men’s and under-5 interviews number of households, women, men, and children under 5 by results of the household, women’s, men’s and under-5’s interviews, and household, women’s, men’s and under-5’s response rates, Roma settle- ments, 2011   Total Households Sampled 1079 Occupied 997 Interviewed 953 Household response rate 95.6 Women Eligible 1134 Interviewed 1091 Women’s response rate 96.2 Women’s overall response rate 92.0 Children under 5 Eligible 483 Mothers/caretakers interviewed 476 Under-5’s response rate 98.6 Under-5’s overall response rate 94.2 characteristics of households – Roma settlements The weighted age and sex distribution of the survey population is provided in Table HH.2R. The distribution is also used to produce the population pyramid in Figure HH.1R. In the 953 households successfully interviewed, 4229 household members were listed; of these, 2093 were males, and 2136 were females. table hh.2R: household age distribution 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 pop- ulations (age 18 or more), by sex, Roma settlements, 2011 Males Females Total Num- ber Per- cent Num- ber Per- cent Num- ber Per- cent age 0-4 246 11.8 253 11.8 499 11.8 5-9 212 10.1 221 10.4 433 10.2 10-14 172 8.2 176 8.2 348 8.2 15-19 186 8.9 178 8.3 365 8.6 20-24 178 8.5 189 8.8 367 8.7 25-29 185 8.8 162 7.6 347 8.2 30-34 164 7.8 171 8.0 335 7.9 35-39 134 6.4 117 5.5 251 5.9 40-44 113 5.4 153 7.2 266 6.3 45-49 134 6.4 127 6.0 261 6.2 50-54 132 6.3 140 6.5 271 6.4 55-59 92 4.4 100 4.7 193 4.6 60-64 68 3.2 58 2.7 125 3.0 65-69 27 1.3 49 2.3 77 1.8 70-74 27 1.3 28 1.3 55 1.3 75-79 19 .9 8 .4 27 .6 80-84 0 .0 4 .2 4 .1 85+ 4 .2 3 .1 6 .1 Dependency age groups 0-14 630 30.1 650 30.4 1280 30.3 15-64 1385 66.2 1395 65.3 2780 65.7 65+ 78 3.7 92 4.3 170 4.0 Child and adult populations Children age 0-17 years 751 35.9 772 36.1 1523 36.0 Adults age 18+ years 1342 64.1 1364 63.9 2706 64.0 Total 2093 100.0 2136 100.0 4229 100.0 13 14 MultIple IndIcator cluster survey 2011 Data from Table HH.2R suggests a positive population growth among the Roma population. The proportion of children aged 0-4 year is the highest, consisting of almost 12 percent of the Roma population. Meanwhile, the proportion of the other age groups is decreasing by age. Children aged 0-17 years constitute 36 percent of Roma population in contrast to the group of 65 years and above, which constitute only 4 percent. figure hh.1R: age and sex distri- bution of household population, Roma settlements, 2011 Tables HH.3R - HH.5R provide basic information on the households, female respondents aged 15-49, and children under age 5, by presenting the unweighted and the weighted numbers. Information on the basic characteristics of households, women and children under 5 interviewed in the survey is essential for the interpretation of findings presented later in the report and can also provide an indication of the representativeness of the survey. The remaining tables in this report are presented only with weighted numbers. (See Appendix A2 for more details about the weighting). Table HH.3R provides basic background information on the households in Roma settlements. Within households, the sex of the household head, number of household members and education of household head are shown in the table. These background characteristics are used in subsequent tables in this report. The figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. The number of respondents with a higher education is too small to be reported as a separate category. Therefore the categories Secondary and High education are presented separately only in Tables HH.3, HH.4 and HH.5, while in the remaining tables they are merged and marked as Secondary+. table hh.3R: household composi- tion percent and frequency distribution of households by selected characteristics, Roma settlements, 2011 Weighted percent Number of households Weighted Unweight-ed sex of household head Male 85.3 813 815 Female 14.7 140 138 number of household members 1 6.3 60 54 2 13.0 124 109 3 13.9 132 124 4 21.6 206 218 5 17.3 165 157 6 13.0 124 140 7 8.2 78 76 8 3.1 29 35 9 1.8 17 16 10+ 2.0 19 24 education of household head None 14.9 142 132 Primary 66.8 636 631 Secondary 16.9 161 179 High 1.5 14 11 Total 100.0 953 953 Households with at least One child age 0-4 years 38.0 953 953 One child age 2-9 years 46.7 953 953 One child age 0-17 years 69.7 953 953 One woman age 15-49 years 80.3 953 953 The weighted and unweighted numbers of households in total are equal (953) since sample weights were normalized (see Appendix A). The table also shows the proportions of households with at least one child under 18 years of age, at least one child under 5 years of age, and at least one eligible woman aged 15-49 years. The table also shows the weighted average household size estimated by the survey. In 85 percent of the households, the household head was male, with the remaining 15 percent of households headed by a female. A majority of household heads 15 (67 percent) have a primary education. The mean household size of 4.4 members reflects the structure of the households by the number of members, with four to five member households having the highest frequencies in the sample. Characteristics of female Respondents 15-49 Years of age and Children Under-5 – Roma settlements Tables HH.4R and HH.5R provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal since sample weights have been normalized (standardized). The tables present the numbers of observations in each background category that are used in the subsequent tabulations of this report. table hh.4R: Women’s background characteristics percent and frequency distribution of women age 15-49 years by selected background characteristics, Roma settlements, 2011 Weighted percent Number of women Weighted Unweighted age 15-19 15.8 173 175 20-24 17.4 190 199 25-29 15.2 166 166 30-34 15.7 172 161 35-39 10.3 112 113 40-44 13.7 149 148 45-49 11.9 129 129 Marital/Union status Currently married/in union 73.3 799 801 Widowed 2.0 22 21 Divorced 4.3 47 41 Separated 2.1 22 21 Never married/in union 18.3 200 207 Motherhood status Ever gave birth 76.7 837 824 Never gave birth 23.3 254 267 births in last two years Yes 16.7 182 174 No 83.3 909 917 education None 16.8 183 186 Primary 66.3 724 708 Secondary 14.1 153 165 High 2.8 31 32 Wealth index quintile Poorest 18.4 201 170 Second 18.5 202 201 Middle 19.4 212 206 Fourth 21.3 232 259 Richest 22.4 245 255 Total 100.0 1091 1091 16 MultIple IndIcator cluster survey 2011 Table HH.4R provides background characteristics of female respondents 15-49 years of age. The table includes information on the distribution of women according to age, marital status, motherhood status, births in last two years, education11, and wealth index quintiles. The majority of the women belong to the groups categorized as currently married/in union, with primary education, and with no birth in the last two years. Some background characteristics of children under age 5 are presented in Table HH.5R. These include the distribution of children by several attributes: sex, age, mother’s/caretaker’s education, and wealth. table hh.5R: under-5’s back- ground characteristics percent and frequency distribution of children under five years of age by selected characteristics, Roma settlements, 2011 Weighted percent Number of under-5 children Weighted Unweight-ed Sex Male 49.8 237 250 Female 50.2 239 226 age 0-5 months 7.5 36 37 6-11 months 9.1 43 44 12-23 months 20.7 99 102 24-35 months 21.0 100 105 36-47 months 19.4 92 83 48-59 months 22.1 105 105 Mother’s education* None 21.3 102 102 Primary 68.6 327 318 Secondary 10.1 48 56 High 2.3 11 9 Wealth index quintile Poorest 25.7 122 108 Second 22.7 108 107 Middle 19.5 93 90 Fourth 16.7 79 92 Richest 15.4 73 79 Total 100.0 476 476 * Mother’s education refers to educational attainment of mothers and caretakers of children under 5. 11 Unless otherwise stated, “education” refers to the educational level attend- ed by the respondent throughout this report when it is used as a background variable. Approximately 17 percent of children in the Roma population are less than one year old, with the remaining four age groups each comprising 19 to 22 percent. A majority of the children (69 percent) have mothers with a primary education, while the number of children whose mothers have no education is twice the number of those whose mothers have a secondary and higher education. In contrast to the distribution of women, the percentage of children under age 5 is highest in the poorest households (27 percent) and lowest in the richest (15 percent). 17 children living arrangements – Roma settlements Table HH.6R presents information on the living arrangements and orphanhood status of children under age 18 in Roma settlements. table hh.6R: children’s living arrangements and orphanhood Percent and frequency distribution of children under five years of age by selected characteristics, Roma settlements, 2011 Liv in g w ith b ot h pa re nt s Living with neither parent Living with mother only Living with father only Im po ss ib le to de te rm in e Total No t l ivi ng w ith a bi ol og ica l pa re nt 1 On e or b ot h pa re nt s d ea d 2 Nu m be r o f ch ild re n ag e 0- 17 ye ar s Only father alive Only mother alive Both alive Both dead Father alive Father dead Mother alive Mother dead sex Male 91.2 .0 .0 .8 .1 3.1 2.2 1.6 .2 .8 100.0 .9 2.5 751 Female 84.4 .1 .2 3.2 .1 5.0 3.6 1.8 .3 1.4 100.0 3.5 4.1 772 age 0-4 89.7 .0 .0 .2 .0 6.1 2.8 .7 .0 .5 100.0 .2 2.8 499 5-9 90.6 .0 .0 .7 .0 3.8 1.5 2.9 .0 .4 100.0 .7 1.5 433 10-14 87.0 .1 .1 2.9 .1 2.8 4.9 1.3 .2 .5 100.0 3.3 5.5 348 15-17 80.0 .0 .4 6.6 .4 2.2 2.5 2.2 1.3 4.5 100.0 7.4 4.5 244 Wealth index quintile Poorest 82.4 .0 .1 3.3 .2 2.8 5.8 2.7 .0 2.6 100.0 3.6 6.1 392 Second 87.6 .1 .3 2.7 .0 5.8 2.5 .4 .2 .4 100.0 3.1 3.1 315 Middle 90.0 .0 .0 .9 .2 2.6 1.5 2.4 1.1 1.2 100.0 1.1 2.8 292 Fourth 89.4 .0 .0 1.2 .0 3.9 2.6 2.3 .0 .7 100.0 1.2 2.6 280 Richest 92.1 .0 .0 1.2 .0 5.7 .8 .2 .0 .0 100.0 1.2 .8 245 Total 87.8 .0 .1 2.0 .1 4.1 2.9 1.7 .3 1.1 100.0 2.2 3.3 1523 1 MICS indicator 9.17 2 MICS indicator 9.18 Of the 1523 children in Roma settlements covered in the survey, 88 percent live with both parents. 7 percent live only with their mother, and 2 percent only with their father. 2 percent of children do not live with their biological parents and 3 percent have lost one or both parents. 18 MultIple IndIcator cluster survey 2011 iv child MoRtality One of the overarching goals of the Millennium Development Goals (MDGs) is the reduction of infant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mortality by two- thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Measuring childhood mortality may seem easy, but attempts using direct questions, such as “Has anyone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust estimates that are comparable with the ones obtained from other sources. Indirect methods minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing technique. The child mortality module was administered only in the sample from the Roma settlements. The infant and under-five mortality at the national level is too low to be measured through MICS questionnaire. The infant mortality rate is the probability of dying before the first birthday. The under-five mortality rate is the probability of dying before the fifth birthday. In MICS surveys, infant and under five mortality rates are calculated based on an indirect estimation technique known as the Brass method12. The data used in the estimation are: the mean number of children ever born for five year age groups of women from age 15 to 49, and the proportion of these children who are dead, also for five-year age groups of women (Table CM.1R). The technique converts the proportion of dead children among women in each age group into probabilities of dying by taking into account the approximate length of exposure of children to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in Roma settlements in Macedonia, the East model life table was selected as most appropriate. table cM.1R: children ever born, children surviving and proportion dead Mean and total numbers of children ever born, children surviving and proportion dead by age of women, Roma settlements, 2011 Children ever born Children surviving Proportion dead Number of womenMean Total Mean Total age 15-19 .080 14 .080 14 .000 173 20-24 .608 115 .595 113 .022 190 25-29 1.106 183 1.094 181 .011 166 30-34 1.206 207 1.180 203 .022 172 35-39 1.501 168 1.412 158 .059 112 40-44 1.456 217 1.369 204 .060 149 45-49 1.676 217 1.573 204 .061 129 Total 1.029 1122 .987 1077 .040 1091 The infant mortality rate in Roma settlements is estimated at 13 per thousand live births, while the probability of dying under age 5 (U5MR) is around 14 per thousand13. These estimates have been calculated by averaging mortality estimates obtained from women aged 25-29 and 30-34 and refer to mid-2005. 12 United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations publication, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Pop Division. United Nations, 1990b. Step-by-step Guide to the Estimation of Child Mortality. New York, UN. 13 Table not shown due to the small number of cases for disaggregated categories. 18 MultIple IndIcator cluster survey 2011 19 v nutRition nutritional status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they can reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, they are likely to have recurring sicknesses and faltering growth. Three- quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. 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 standards14. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. 14 http://www.who.int/childgrowth/standards/second_set/technical_re- port_2.pdf 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 stunted. Those whose height- for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In the MICS, weights and heights of all children under 5 years of age were measured using anthropometric equipment recommended by UNICEF. Findings in this section are based on the results of these measurements. Table NU.1 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 the percentage of children who are overweight, which takes into account those children whose weight for height is above 2 standard deviations from the median of the reference population, and mean z-scores for all three anthropometric indicators. 20 MultIple IndIcator cluster survey 2011 table nu.1: nutritional status of children percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Macedonia, 2011 Weight for age Nu m be r o f ch ild re n un de r ag e 5 Height for age Nu m be r o f ch ild re n un de r ag e 5 Weight for height Nu m be r o f ch ild re n un de r ag e 5Underweight M ea n Z- Sc or e (S D) Stunted M ea n Z- Sc or e (S D) Wasted Overweight M ea n Z- Sc or e (S D) percent below percent below percent below percent above - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD sex Male 1.5 .2 .5 669 5.6 2.4 .1 667 2.2 .3 13.4 .6 653 Female 1.1 .2 .4 663 4.3 1.7 .0 652 1.4 .1 11.4 .6 646 Region Vardar 1.3 .0 .3 99 5.1 2.3 .1 98 3.8 .8 6.5 .3 98 East 3.3 .0 .1 110 6.3 2.7 -.3 110 2.8 .6 7.3 .4 109 Southwest 2.8 .7 .6 117 13.3 8.4 -.2 111 3.8 1.5 22.5 .8 103 Southeast .4 .0 .6 81 1.3 .0 .3 81 1.0 .0 12.8 .7 79 Pelagonia 1.8 1.3 .4 152 4.1 1.4 .0 152 2.3 .0 13.1 .6 152 Polog .5 .0 .2 251 5.0 1.7 .0 250 3.4 .0 6.0 .3 244 Northeast 1.5 .0 .9 135 5.0 3.1 .0 135 .4 .0 28.5 1.2 130 Skopje .6 .0 .5 388 3.1 .5 .1 382 .0 .0 10.9 .7 382 area Urban .8 .3 .6 671 4.1 1.5 .1 666 1.2 .2 15.8 .7 657 Rural 1.8 .1 .3 661 5.8 2.6 .0 653 2.4 .2 9.0 .4 642 age 0-5 months 5.1 1.3 -.1 110 7.3 2.3 -.2 108 1.7 .0 3.2 .2 107 6-11 months .4 .0 .3 141 2.5 1.5 .5 137 8.5 .0 3.5 .1 136 12-23 months .7 .5 .6 273 5.8 1.8 .0 270 1.9 .6 12.8 .7 265 24-35 months .3 .0 .6 268 3.6 1.0 .1 261 .3 .0 17.9 .8 261 36-47 months .6 .0 .5 268 5.3 3.0 -.1 270 .1 .0 15.6 .8 264 48-59 months 2.5 .0 .4 273 5.3 2.4 -.1 272 1.6 .6 11.8 .5 266 Mother’s education Primary or less 2.0 .3 .2 528 6.2 1.9 -.2 522 2.8 .3 8.5 .4 516 Secondary 1.0 .3 .5 507 5.1 2.0 .0 501 1.6 .2 15.1 .7 493 High .4 .0 .8 297 2.5 2.2 .4 295 .5 .2 14.9 .8 290 Wealth index quintile Poorest 1.9 .2 .0 308 7.2 1.9 -.3 303 3.5 .0 4.3 .3 301 Second 1.3 .0 .3 268 5.8 1.8 -.1 266 1.2 .0 9.6 .5 264 Middle 2.1 .3 .6 242 4.7 2.1 .1 241 2.3 .7 22.2 .8 235 Fourth 1.1 .5 .7 250 4.6 3.3 .2 251 1.3 .3 14.2 .7 242 Richest .0 .0 .7 264 2.0 1.2 .3 258 .6 .3 14.2 .7 256 ethnicity of household head Macedo- nian .9 .3 .6 683 3.6 1.3 .1 678 1.3 .2 14.6 .7 672 Albanian .7 .1 .4 508 5.4 2.3 .0 500 2.0 .0 10.7 .5 487 Other 5.0 .0 .0 141 9.6 4.4 -.4 141 3.7 1.1 7.9 .3 139 Total 1.3 .2 .4 1332 4.9 2.0 .0 1318 1.8 .2 12.4 .6 1299 1 MICS indicator 2.1a and MDG indicator 1.8 2 MICS indicator 2.1b 3 MICS indicator 2.2a, 4 MICS indicator 2.2b 5 MICS indicator 2.3a, 6 MICS indicator 2.3b 21 Children whose full birth date (month and year) were not obtained, and children whose measurements are outside a plausible range are excluded from Table NU.1. 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.6 and DQ.7. Overall, 94 percent of children had both valid weight and height measurements (Table DQ.7). All children have their date of birth recorded, meaning that no child was excluded from the calculations for that reason (Table DQ.6). Table DQ.7 shows that due to implausible measurements and missing weight and/or height, 3 percent of children have been excluded from calculations of the weight- for-age indicator, while the figures are 4 percent for the height-for-age indicator, and 6 percent for the weight- for-height indicator. In Macedonia, one percent of children under age five are underweight and 0.2 percent are classified as severely underweight (Table NU.1). Some 5 percent of children are stunted or too short for their age and 2 percent are wasted or too thin for their height. For both comparison with the MICS3 and for global reporting purposes, Table NU.1 (a), based on NCHS/ CDC/WHO ‘s International Reference Population, was created (see Appendix H). figure nu.1: percentage of children under age 5 who are underweight, stunted and wasted, Macedonia, 2011 22 MultIple IndIcator cluster survey 2011 nutritional status – Roma settlements Almost 8 percent of Roma children under age five in Macedonia are underweight and 2 percent are classified as severely underweight (Table NU.1R). Some 17 percent of children are stunted or too short for their age and 5 percent are wasted or too thin for their height. table nu.1R: nutritional status of children percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Roma settlements, 2011 Weight for age Num- ber of children under age 5 Height for age Num- ber of children under age 5 Weight for height Num- ber of children under age 5 Underweight Mean Z-Score (SD) Stunted Mean Z-Score (SD) Wasted Overweight Mean Z-Score (SD) percent below percent below percent below percent above - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD sex Male 8.1 1.8 -.4 235 21.1 2.9 -.8 224 4.3 1.4 5.9 .1 224 Female 7.0 2.3 -.5 235 12.0 3.0 -.8 234 4.7 1.9 4.3 -.1 233 age 0-5 months (11.8) (7.5) (-.4) 36 (15.9) (9.9) (-.7) 34 (8.0) (6.4) (14.8) (.2_) 33 6-11 months (7.4) (1.5) (-.4) 43 (2.6) (.0) (-.2) 43 (8.8) (5.0) (4.4) (-.2) 43 12-23 months 7.5 1.5 -.4 98 16.1 4.2 -.9 95 3.6 .6 4.4 .0 96 24-35 months 3.0 .0 .0 96 14.9 1.6 -.5 92 .9 .0 3.6 .4 91 36-47 months 8.0 5.2 -.6 92 22.2 5.3 -1.0 89 5.2 2.1 6.9 -.2 89 48-59 months 9.9 .0 -.8 105 19.1 .0 -1.0 104 4.9 .9 2.7 -.3 104 Mother’s education None 5.9 .0 -.6 101 25.9 2.8 -1.1 100 2.0 .0 4.0 .0 100 Primary 8.7 2.8 -.5 321 14.9 3.5 -.8 311 4.4 1.8 3.7 -.1 310 Secondary+ 3.3 1.4 .1 48 6.8 .0 -.1 47 10.6 4.6 16.4 .3 47 Wealth index quintile Poorest 13.1 5.6 -.9 122 28.7 8.1 -1.3 122 6.9 1.5 4.7 -.2 122 Second 5.9 1.1 -.6 107 16.0 2.2 -.8 102 2.9 1.7 2.6 -.1 103 Middle 11.1 .9 -.5 91 15.0 1.7 -.7 87 3.1 1.2 4.8 -.2 86 Fourth 1.9 .0 -.1 79 11.2 .0 -.7 77 .8 .0 5.6 .2 75 Richest 2.2 1.0 .1 71 3.5 .0 -.1 70 8.2 4.2 9.3 .2 70 Total 7.6 2.0 -.5 470 16.5 3.0 -.8 458 4.5 1.7 5.1 .0 457 1 MICS indicator 2.1a and MDG indicator 1.8 2 MICS indicator 2.1b 3 MICS indicator 2.2a, 4 MICS indicator 2.2b 5 MICS indicator 2.3a, 6 MICS indicator 2.3b ( ) – figures based on 25–49 unweighted cases The percentage of stunted children is ten times higher in the poorest wealth quintile compared to the richest one. Similarly, there are nearly six times more underweighted children in the poorest quintile than in the richest. In regard to gender, boys appear to be more likely stunted than girls. For comparison with the MICS3 and for global reporting purposes, Table NU.1R (a), based on NCHS/CDC/WHO International Reference Population, was created (see Appendix H). 23 figure nu.1R: percentage of children under age 5 who are underweight, stunted and wasted, Roma settlements, 2011 * Figures for the age groups of 0-5 and 6-11 months are based on 25-49 unweighted cases 24 MultIple IndIcator cluster survey 2011 breastfeeding and infant and young child feeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula. This can contribute to growth faltering and micronutrient malnutrition, and it is also unsafe if clean water is not readily available. WHO/UNICEF have the following feeding recommendations: „ Exclusive breastfeeding for first six months „ Continued breastfeeding for two years or more „ Safe and age-appropriate complementary foods beginning at 6 months „ Frequency of complementary feeding: 2 times per day for 6-8 month olds; 3 times per day for 9-11 month olds It is also recommended that breastfeeding be initiated within one hour of birth. The indicators related to recommended child feeding practices are as follows: „ Early initiation of breastfeeding (within 1 hour of birth) „ Exclusive breastfeeding rate (< 6 months) „ Predominant breastfeeding (< 6 months) „ Continued breastfeeding rate (at 1 year and at 2 years) „ Duration of breastfeeding „ Age-appropriate breastfeeding (0-23 months) „ Introduction of solid, semi-solid and soft foods (6-8 months) „ Minimum meal frequency (6-23 months) „ Milk feeding frequency for non-breastfeeding chil- dren (6-23 months) „ Bottle feeding (0-23 months) Table NU.2 shows the proportion of children born in the two years preceding the survey who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed. Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 21 percent of babies are breastfed for the first time within one hour of birth, while 64 percent of newborns in Macedonia start breastfeeding within one day of birth. 94 percent of babies were ever breastfed while 34 percent received a prelacteal feed, which was more likely in urban areas and in the Skopje region, in households in the richest quintile, and households whose head is of Macedonian ethnicity. Mothers with a higher education were more likely to breastfeed their babies. figure nu.2: percentage of mothers who started breastfeeding within one hour and within one day of birth, Macedonia, 2011 In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids during the previous day or night prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life, as well as continued breastfeeding of children at 12-15 and 20-23 months of age. 25 table nu.2: initial breastfeeding percentage of last-born children in the 2 years preceding the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Macedonia, 2011 Percentage who were ever breastfed1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last-born children in the two years preceding the survey Within one hour of birth2 Within one day of birth Region Vardar (100.0) (24.6) (80.9) (31.7) 16 East (97.5) (32.0) (77.6) (21.9) 25 Southwest 97.8 18.1 58.9 16.3 39 Southeast (93.0) (21.6) (72.8) (25.6) 16 Pelagonia 91.3 29.0 51.6 37.5 42 Polog 93.7 15.4 71.2 14.1 69 Northeast (82.7) (46.6) (66.2) (22.3) 37 Skopje 95.6 11.3 59.1 56.3 118 area Urban 96.0 20.9 59.2 46.1 178 Rural 91.8 21.0 68.8 21.2 183 Months since last birth 0-11 months (89.9) (11.6) (56.4) (11.3) 35 12-23 months (88.0) (31.2) (61.6) (28.5) 37 assistance at delivery Skilled attendant 94.3 20.8 64.3 33.5 355 Traditional birth attendant (*) (*) (*) (*) 1 Other/Missing (*) (*) (*) (*) 5 Place of delivery Public sector health facility 94.6 20.9 65.7 30.8 332 Private sector health facility (*) (*) (*) (*) 23 Home (*) (*) (*) (*) 1 Other/Missing (*) (*) (*) (*) 5 Mother’s education Primary or less 90.7 18.2 66.7 21.6 146 Secondary 95.2 22.9 68.0 33.0 128 High 97.1 22.6 54.0 53.9 88 Wealth index quintile Poorest 89.5 17.4 67.9 15.9 84 Second 92.2 18.6 65.7 26.2 70 Middle 98.1 18.5 68.1 32.9 64 Fourth 94.8 21.8 59.5 41.3 75 Richest 96.0 29.0 58.9 54.3 68 ethnicity of household head Macedonian 95.8 20.9 62.8 45.2 171 Albanian 90.8 17.4 63.6 22.3 146 Other 96.1 32.7 70.5 24.9 45 Total 93.9 21.0 64.1 33.5 362 1 MICS indicator 2.4 2 MICS indicator 2.5 ( ) - Figures based on 25 - 49 unweighted cases (*) - Figures based on less than 25 unweighted cases 26 MultIple IndIcator cluster survey 2011 table nu.3: breastfeeding percentage of living children according to breastfeeding status at selected age groups, Macedonia, 2011   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 sex Male 31.1 47.2 53 (28.4) 49 (14.4) 39 Female 16.1 41.5 62 (38.6) 55 (11.4) 43 area Urban 21.1 45.6 58 (35.0) 53 (13.6) 40 Rural 25.0 42.5 56 (32.4) 51 (12.1) 42 Mother’s education Primary or less (26.4) (46.7) 49 (30.6) 47 (19.7) 32 Secondary (24.6) (36.0) 31 (49.3) 29 (6.7) 39 High (16.9) (47.6) 35 (23.3) 29 (*) 11 ethnicity of household head Macedonian 19.6 41.0 53 36.1 48 5.4 44 Albanian (23.0) (46.8) 46 (23.8) 41 (14.7) 31 Other (*) (*) 15 (*) 15 (*) 8 Total 23.0 44.1 114 33.8 104 12.8 82 1 MICS indicator 2.6 2 MICS indicator 2.9 3 MICS indicator 2.7 4 MICS indicator 2.8 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases Approximately 23 percent of children aged less than 6 months are exclusively breastfed, a level considerably lower than recommended. At the age of 12-15 months, 34 percent of children are still being breastfed and at 20-23 months, 13 percent are still breastfed. Four out of ten children in Macedonia are predominantly breastfed (44 percent) within the first six months. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, 60 percent of children are receiving liquids or foods other than exclusively breast milk. By the end of the sixth month, none of the children are breastfed. Only about 8 percent of children are receiving breast milk after two years. figure nu.3: infant feeding patterns by age, Macedonia, 2011 * Data for the age groups 1-0, 2-3, 4-5, 6-7, 8-9, 12-13, 18-19, 20-21 and 22-23 is based on 25-49 unweighted cases Table NU.4 shows the median duration of breastfeeding by selected background characteristics. Among children aged 0-35 months the median duration is 12.1 months for any breastfeeding, 1.3 months for exclusive breastfeeding, and 2.8 months for predominant breastfeeding. There are differences by region, area and wealth index. 27 table nu.4: duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Macedonia, 2011 Median duration (in months) of Number of children age 0-35 monthsAny breastfeeding1 Exclusive breast-feeding Predominant breastfeeding sex Male 8.1 1.2 2.2 399 Female 11.4 .5 .6 417 Region Vardar 4.0 1.2 2.8 50 East 10.4 2.2 2.2 60 Southwest 13.0 2.8 4.7 74 Southeast 16.5 2.5 2.5 49 Pelagonia 9.3 .5 2.1 98 Polog 7.6 .6 .7 154 Northeast 11.0 . . 78 Skopje 12.4 .6 .6 253 area Urban 10.2 .7 2.1 417 Rural 9.5 .6 .7 398 Mother’s education Primary or less 8.4 .6 .7 323 Secondary 6.8 1.5 2.0 300 High 11.4 .5 .7 192 Wealth index quintile Poorest 9.7 .5 .5 190 Second 5.9 .7 1.8 153 Middle 7.9 1.5 3.1 153 Fourth 10.2 .4 .5 158 Richest 10.5 1.7 2.7 161 ethnicity of household head Macedonian 9.8 .6 1.6 406 Albanian 8.4 .6 .6 314 Other 15.8 1.7 2.2 95 Median 10.0 .6 1.3 815 Mean for all children (0-35 months) 12.1 1.3 2.8 815 1 MICS indicator 2.10 The adequacy of infant feeding in children under 24 months is provided in Table NU.5. Different criteria of feeding are used depending on the age of the child. For infants 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. Of infants aged 0-5 months, 23 percent are exclusively breastfed, while 22 percent of the infants aged 6-23 months are receiving breast milk and solid, semi-solid or soft food. As a result of these feeding patterns, only 22 percent of children aged 0-23 months are being appropriately fed. There are no differences in the breastfeeding pattern by wealth index of households, and by the mother’s educational level. 28 MultIple IndIcator cluster survey 2011 table nu.5: age-appropriate breastfeeding percentage of children age 0-23 months who were appropriately breastfed during the previous day, Macedonia, 2011 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 sex Male 31.1 53 24.2 218 25.6 271 Female 16.1 62 20.2 208 19.3 270 area Urban 21.1 58 26.8 210 25.6 268 Rural 25.0 56 17.9 217 19.3 273 Mother’s education Primary or less (26.4) 49 20.7 167 22.0 216 Secondary (24.6) 31 23.4 166 23.6 197 High (16.9) 35 23.2 94 21.5 129 Wealth index quintile Poorest 30.2 28 21.2 94 23.3 122 Second 14.1 21 20.9 86 19.5 108 Middle 31.9 23 24.1 76 25.9 99 Fourth 6.7 20 20.6 91 18.1 111 Richest 28.1 22 25.2 79 25.8 101 ethnicity of household head Macedonian 19.6 53 28.2 204 26.4 257 Albanian (23.0) 46 8.2 170 11.3 216 Other (*) 15 44.7 53 42.5 68 Total 23.0 114 22.3 427 22.4 541 1 MICS indicator 2.6 2 MICS indicator 2.14 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases Appropriate complementary feeding of children from 6 months to 2 years of age is particularly important for growth and development and the prevention of under-nutrition. Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary foods that help meet nutritional requirements when breast milk is no longer sufficient. This requires that for breastfed children, two or more meals of solid, semi-solid or soft foods are needed if they are six to eight months old, and three or more meals if they are 9-23 months of age. For children aged 6-23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. In Macedonia, 41 percent of children aged 6-8 months received solid, semi-solid or soft food the day before the interview. Table NU.7 presents the proportion of children aged 6-23 months who received semi-solid or soft foods the minimum number of times or more during the day or night preceding the interview by breastfeeding status (see the note in Table NU.7 for a definition of minimum number of times for different age groups). Overall, two-thirds of all children aged 6-23 months (65 percent) were receiving solid, semi- solid and soft foods the minimum number of times. A higher proportion of males (71 percent) were achieving the minimum meal frequency as compared to females (59 percent). 29 table nu.7: Minimum meal frequency percentage of children age 6-23 months who received solid, semi-solid, or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the previous day, according to breast- feeding status, Macedonia, 2011 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid and soft foods the minimum number of times Number of children age 6-23 months Percent receiving at least 2 milk feeds1 Percent receiving solid, semi- solid and soft foods or milk feeds 4 times or more Number of children age 6-23 months Percent with minimum meal frequency2 Number of children age 6-23 months sex Male 37.5 75 93.1 88.2 143 70.8 218 Female 23.7 85 90.8 83.8 123 59.2 208 age 6-8 months (28.2) 41 98.1 73.5 22 44.2 63 9-11 months (14.0) 41 96.3 96.1 40 54.0 81 12-17 months (42.6) 58 92.3 87.6 97 70.7 155 18-23 months (*) 20 88.9 83.8 108 75.8 128 area Urban 38.2 80 91.3 88.6 129 69.3 210 Rural 22.1 80 92.7 83.8 137 61.2 217 Mother’s education Primary or less 32.2 58 96.2 81.9 109 64.7 167 Secondary 32.1 60 87.8 88.1 106 67.8 166 High (24.7) 42 91.8 91.2 52 61.4 94 Wealth index quintile Poorest 38.8 32 98.3 85.0 62 69.1 94 Second 25.6 32 86.0 74.4 54 56.3 86 Middle 29.8 27 94.9 82.7 49 64.1 76 Fourth 30.0 36 87.9 93.5 55 68.5 91 Richest 26.6 33 92.6 96.4 46 67.4 79 ethnicity of household head Macedonian 40.2 76 89.6 91.3 128 72.2 204 Albanian 10.7 53 93.6 79.1 117 57.9 170 Other (38.5) 31 (*) (*) 22 61.2 53 Total 30.2 160 92.0 86.2 267 65.2 427 1 MICS indicator 2.15 2 MICS indicator 2.13 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases Among currently breastfeeding children age 6-8 months, minimum meal frequency is defined as children who also received solid, semi-solid or soft foods 2 times or more. Among currently breastfeeding children age 9-23 months, receipt of solid, semi-solid or soft foods at least 3 times constitutes minimum meal frequency. For non-breastfeeding children age 6-23 months, minimum meal frequency is defined as children receiving solid, semi-solid or soft foods, and milk feeds, at least 4 times during the previous day. Among currently breastfeeding children aged 6-23 months, nearly one-third (30 percent) were receiving solid, semi-solid and soft foods the minimum number of times. This proportion was higher among males (38 percent) as compared to females (24 percent); in urban areas than in rural areas; and among Macedonians. Among non-breastfeeding children, 86 percent of the children were receiving solid, semi-solid and soft foods or milk feeds four times or more. The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and/or lack of hygiene in preparation. Table NU.8 shows that bottle-feeding is still highly prevalent in Macedonia. 79 percent of children aged 0-23 months are fed using a bottle with a nipple. 30 MultIple IndIcator cluster survey 2011 table nu.8: bottle feeding percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Mace- donia, 2011 Percentage of children age 0-23 months fed with a bottle with a nipple1 Number of children age 0-23 months sex Male 82.2 271 Female 76.5 270 age 0-5 months 64.6 114 6-11 months 77.5 144 12-23 months 86.2 283 Region Vardar (87.0) 27 East (84.5) 37 Southwest 72.8 59 Southeast (*) 24 Pelagonia 81.7 62 Polog 75.1 103 Northeast 86.9 54 Skopje 78.6 175 area Urban 82.2 268 Rural 76.5 273 Mother’s education Primary or less 74.1 216 Secondary 85.1 197 High 79.2 129 Wealth index quintile Poorest 73.1 122 Second 81.2 108 Middle 78.4 99 Fourth 79.1 111 Richest 86.0 101 ethnicity of household head Macedonian 84.9 257 Albanian 74.9 216 Other 72.6 68 Total 79.3 541 1 MICS indicator 2.11 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases 31 breastfeeding and infant and young child feeding – Roma settlements Table NU.2R shows the proportion of children from Roma settlements born in the two years preceding the survey who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed. Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 39 percent of babies are breastfed for the first time within one hour of birth, while 75 percent of newborns from Roma settlements in Macedonia start breastfeeding within one day of birth. 96 percent of babies were ever breastfed while 18 percent received a prelacteal feed. table nu.2R: initial breastfeeding percentage of last-born children in the 2 years preced- ing the survey who were ever breastfed, percentage who were breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Roma settlements, 2011 Percent- age who were ever breast- fed1 Percentage who were first breastfed: Percent- age who received a prelac- teal feed Num- ber of last-born children in the two years preced- ing the survey Within one hour of birth2 Within one day of birth Months since last birth 0-11 months 94.1 43.8 78.2 18.6 82 12-23 months 96.6 35.5 73.6 17.8 97 assistance at delivery Skilled atten- dant 95.5 38.6 75.5 18.1 182 Other/Miss- ing (*) (*) (*) (*) 1 Place of delivery Public sector health facility 95.5 37.9 75.2 18.3 180 Other/Miss- ing (*) (*) (*) (*) 2 Mother’s education None (97.3) (36.6) (68.4) (13.9) 41 Primary 97.0 38.7 80.1 19.4 120 Secondary+ (84.2) (41.6) (61.7) (20.9) 22 Total 95.5 38.6 75.3 18.3 182 1 MICS indicator 2.4 2 MICS indicator 2.5 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases 31 In Table NU.3R15, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed refers to infants who received only breast milk (and vitamins, mineral supplements, or medicine). The table shows exclusive breastfeeding of infants during the first six months of life, as well as continued breastfeeding of children at 12- 15 and 20-23 months of age. Due to the small number of children in the specific age groups, the table presents the results for the total sample, without disaggregation by background characteristics. table nu.3R: breastfeeding percentage of living children according to breastfeeding status at selected age groups, Roma settlements, 2011   Children age 0-5 months Children age 12-15 months Children age 20-23 months Pe rce nt ex clu siv ely br ea stf ed 1 Pe rce nt pr ed om ina nt ly br ea stf ed 2 Nu m be r o f ch ild re n Pe rce nt br ea stf ed (C on tin ue d br ea stf ee din g a t 1 y ea r)3 Nu m be r o f ch ild re n Pe rce nt br ea stf ed (C on tin ue d br ea stf ee din g a t 2 y ea rs) 4 Nu m be r o f ch ild re n To ta l (32.1) (67.6) 36 (52.8) 43 (54.7) 28 1 MICS indicator 2.6 2 MICS indicator 2.9 3 MICS indicator 2.7 4 MICS indicator 2.8 ( ) – figures based on 25–49 unweighted cases Table NU.4R shows the median duration of breastfeeding by selected background characteristics. Among Roma children aged 0-35 months, the median duration is 18 months for any breastfeeding, 2 months for exclusive breastfeeding, and 5 months for predominant breastfeeding. Median duration of any breastfeeding among boys is 22 months compared to 14 among girls, while figures are comparable between boys and girls with respect to exclusive or predominant breastfeeding. 15 Background characteristics are not shown due to the small number of cases for disaggregated categories. 32 MultIple IndIcator cluster survey 2011 table nu.4R: duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Roma settlements, 2011 Median duration (in months) of Nu m be r o f c hi ld re n ag e 0- 35 m on th s An y br ea st fe ed in g1 Ex clu siv e br ea st fe ed in g Pr ed om in an t br ea st fe ed in g sex Male 22.3 .6 2.7 137 Female 13.6 2.1 5.5 141 Mother’s education None 15.9 2.6 3.6 64 Primary 24.7 1.3 3.8 183 Secondary+ (12.8) (1.2) (3.2) 32 Wealth index quintile Poorest 20.4 1.0 3.0 68 Second 19.6 1.7 4.6 70 Middle 15.4 2.1 3.0 50 Fourth 16.0 2.6 4.8 46 Richest (14.3) (1.1) (4.9) 44 Median 17.9 1.6 3.8 278 Mean for all children (0-35 months) 17.5 1.8 4.8 278 1 MICS indicator 2.10 ( ) – figures based on 25–49 unweighted cases The adequacy of infant feeding in children under 24 months is provided in Table NU.5R. Different criteria of feeding are used depending on the age of the child. For infants 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. Of Roma infants aged 0-5 months, 32 percent are exclusively breastfed, while 46 percent of the infants aged 6-23 months are receiving breast milk and solid, semi-solid or soft food. As a result of these feeding patterns, only 43 percent of children aged 0-23 months are being appropriately fed. table nu.5R: age-appropriate breastfeeding percentage of children age 0-23 months who were ap- propriately breastfed during the previous day, Roma settlements, 2011 Children age 0-5 months Children age 6-23 months Children age 0-23 months Pe rc en t e xc lu siv el y br ea st fe d1 Nu m be r o f c hi ld re n Pe rc en t c ur re nt ly br ea st fe ed in g an d re ce ivi ng so lid , s em i- so lid o r s of t f oo ds Nu m be r o f c hi ld re n Pe rc en t a pp ro pr ia te ly br ea st fe d2 Nu m be r o f c hi ld re n sex Male (*) 21 52.0 74 46.8 95 Female (*) 15 38.7 68 38.4 83 Mother’s education None (*) 4 (45.2) 35 (46.1) 39 Primary (31.0) 27 50.5 92 46.1 119 Secondary+ (*) 5 (*) 15 (17.2) 20 Total (32.1) 36 45.6 142 42.9 178 1 MICS indicator 2.6 2 MICS indicator 2.14 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases Appropriate complementary feeding of children from 6 months to 2 years of age is particularly important for growth and development and the prevention of under-nutrition. Continued breastfeeding beyond six months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary foods that help meet nutritional requirements when breast milk is no longer sufficient. This requires that for breastfed children, two or more meals of solid, semi-solid or soft foods are needed if they are six to eight months old, and three or more meals if they are 9-23 months of age. For children aged 6-23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. Table NU.7R presents the proportion of Roma children aged 6-23 months who received semi-solid or soft foods the minimum number of times or more during the day or night preceding the interview by breastfeeding status (see the note in Table NU.7R for a definition of minimum number of times for different age groups). Overall, two-thirds of all Roma children aged 6-23 months (63 percent) were receiving solid, semi-solid and soft foods the minimum number of times. 33 table nu.7R: Minimum meal frequency percentage of children age 6-23 months who received solid, semi-solid, or soft foods (and milk feeds for non-breastfeeding children) the minimum number of times or more during the previous day, according to breast- feeding status, Roma settlements, 2011 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid and soft foods the minimum number of times Number of children age 6-23 months Percent receiving at least 2 milk feeds1 Percent receiving solid, semi-solid and soft foods or milk feeds 4 times or more Number of children age 6-23 months Percent with minimum meal frequency2 Number of children age 6-23 months sex Male (53.2) 44 (83.9) (92.4) 30 68.9 74 Female (37.8) 38 (68.6) (77.6) 31 55.6 68 age 6-8 months (*) 9 (*) (*) 5 (*) 14 9-11 months (*) 22 (*) (*) 8 (46.3) 29 12-17 months (53.7) 31 84.9 90.3 29 71.1 60 18-23 months (*) 20 (*) (*) 19 (61.6) 39 Mother’s education None (*) 18 (*) (*) 17 (59.7) 35 Primary 45.7 59 77.3 (91.5) 33 62.3 92 Secondary+ (*) 5 (*) (*) 10 (*) 15 Wealth index quintile Poorest 58.1 22 (*) (*) 10 65.0 32 Second 35.9 25 (*) (*) 16 61.0 41 Middle 32.5 15 (*) (*) 14 52.2 29 Fourth 50.7 8 (*) (*) 11 69.4 19 Richest 61.1 11 (*) (*) 9 69.9 20 Total 46.1 82 76.1 84.9 60 62.5 142 1 MICS indicator 2.15 2 MICS indicator 2.13 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases Among currently breastfeeding children age 6-8 months, minimum meal frequency is defined as children who also received solid, semi-solid or soft foods 2 times or more. Among currently breastfeeding children age 9-23 months, receipt of solid, semi-solid or soft foods at least 3 times constitutes minimum meal frequency. For non-breastfeeding children age 6-23 months, minimum meal frequency is defined as children receiving solid, semi-solid or soft foods, and milk feeds, at least 4 times during the previous day. Among currently breastfeeding Roma children aged 6-23 months, nearly half of them (46 percent) were receiving solid, semi-solid and soft foods the minimum number of times; this proportion was higher among males. Among non-breastfeeding children, nearly 85 percent of the children were receiving solid, semi-solid and soft foods or milk feeds four times or more. The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and/or lack of hygiene in preparation. Table NU.8R shows that bottle-feeding is still highly prevalent in Roma population in Macedonia. 68 percent of Roma children aged 0-23 months are fed using a bottle with a nipple. There was no gender difference in this proportion. 34 MultIple IndIcator cluster survey 2011 table nu.8R: bottle feeding percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Roma settlements, 2011 Percentage of children age 0-23 months fed with a bottle with a nipple1 Number of children age 0-23 months sex Male 68.1 95 Female 67.9 83 age 0-5 months (48.2) 36 6-11 months (74.9) 43 12-23 months 72.2 99 Mother’s education None (75.2) 39 Primary 63.4 119 Secondary+ (*) 20 Wealth index quintile Poorest 60% 66.6 124 Richest 40% 71.3 54 Total 68.0 178 1 MICS indicator 2.11 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases 34 MultIple IndIcator cluster survey 2011 35 low birth Weight Weight at birth is a good indicator not only of a mother’s health and nutritional status but also the newborn’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have an impaired immune function and an increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. Low birth weight stems primarily from the mother’s poor health and nutrition. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. Teenagers, who give birth when their own bodies have yet to finish growing, run the risk of bearing underweight babies. The percentage of births weighing below 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 birth16. Overall, 96 percent of births in Macedonia were weighed at birth and approximately 6 percent of infants are estimated to weigh less than 2500 grams at birth (Table NU.11). 16 For a detailed description of the methodology, see Boerma, J. T., Wein- stein, 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. table nu.11: low birth weight infants percentage of last-born children in the 2 years preced- ing the survey that are estimated to have weighed below 2500 grams at birth and percentage of live births weighed at birth, Macedonia, 2011 Percent of live births: Number of last-born children in the two years preceding the survey Below 2500 grams1 Weighed at birth2 Region Vardar (4.3) (97.3) 16 East (6.2) (97.5) 25 Southwest 4.0 98.6 39 Southeast (10.6) (100.0) 16 Pelagonia 8.2 98.7 42 Polog 6.2 91.3 69 Northeast (3.6) (95.2) 37 Skopje 4.6 97.3 118 area Urban 5.0 98.4 178 Rural 6.0 94.4 183 Mother’s education Primary or less 6.0 93.6 146 Secondary 5.9 98.1 128 High 4.2 98.3 88 Wealth index quintile Poorest 7.1 91.7 84 Second 5.2 93.6 70 Middle 5.0 99.7 64 Fourth 3.8 98.7 75 Richest 6.2 99.2 68 ethnicity of household head Macedonian 5.7 99.0 171 Albanian 5.5 92.1 146 Other 5.1 100.0 45 Total 5.5 96.3 362 1 MICS indicator 2.18 2 MICS indicator 2.19 ( ) – figures based on 25–49 unweighted cases 36 MultIple IndIcator cluster survey 2011 low birth Weight– Roma settlements 36 MultIple IndIcator cluster survey 2011 Among the Roma population, 94 percent of births were weighed at birth and approximately 11 percent of infants are estimated to weigh less than 2500 grams at birth (Table NU.11R) table nu.11R: low birth weight infants percentage of last-born children in the 2 years preced- ing the survey that are estimated to have weighed be- low 2500 grams at birth and percentage of live births weighed at birth, roma settlements, 2011 Percent of live births: Number of last-born children in the two years preceding the survey Below 2500 grams1 Weighed at birth2 Mother’s education None (12.9) (97.9) 41 Primary 10.8 92.2 120 Secondary+ (*) (*) 22 Wealth index quintile Poorest 60% 10.8 93.7 129 Richest 40% 12.0 94.9 54 Total 11.2 94.0 182 1 MICS indicator 2.18 2 MICS indicator 2.19 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases 37 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. Immunizations have saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children overlooked by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure full immunization of children under one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to protect against tuberculosis, three doses of a DPT vaccine to protect against diphtheria, pertussis, and tetanus, three doses of a polio vaccine, and a measles vaccination by the age of 12 months. The vaccination schedule (calendar for immunization) followed by the Macedonia National Immunization Programme provides all of the above mentioned vaccinations as well as three doses of vaccine against Hepatitis B and Haemophilus influenza type B (HiB), and one dose of rubella and mumps. All vaccinations should be received during the first year of life. Taking into consideration this vaccination schedule, the estimates for full immunization coverage from the Macedonia MICS are based on children aged 18-29 months. calendar for immunization age Disease Vaccination Revaccina- tion Up to 24 hours of birth, 1 and 6 months Hepatitis B (3 doses) Vaccination Up to 12 months tuberculosis (without testing) I dose Vaccination 2, 3 and 5 months Haemophilus influenza type B (Hib)(3 doses) Vaccination 2, 3 and 5 months diphtheria, pertussis, and tetanus (3 doses) Vaccination 2, 3 and 5 months polio (3 doses three type oral vaccine) Vaccination 12 months Measles, rubella, mumps (1 dose) Vaccination Information on vaccination coverage was collected for all children under five years of age. All mothers/ caretakers were asked to provide vaccination cards. If the vaccination card for a child was available, interviewers copied the vaccination information from the cards onto the MICS questionnaire. If no vaccination card was available, the interviewer asked the mother to recall whether or not the child had received each of the vaccinations, and how many doses were received for Polio, DPT and Hepatitis B. The interviewer also checked the medical records that were kept at the health facilities where the children were immunized. The final vaccination coverage estimates are based on the information obtained from the vaccination card, the mother’s report of vaccinations received by the child, and from the medical records at the health centres. 38 MultIple IndIcator cluster survey 2011 table ch.1: vaccinations in first year of life percentage of children age 18-29 months immunized against childhood diseases at any time before the survey and by the first birthday (by 18 months of age against measles), Macedonia, 2011 Vaccinated at any time before the survey according to: Va cc in at ed b y 1 2 m on th s o f a ge (1 8 m on th s o f a ge a ga in st m ea sle s) Va cc in at io n ca rd o r h ea lth fa cil ity re co rd s M ot he r’s re po rt Ei th er bCG1 95.9 1.8 97.6 97.0 Polio 1 96.2 1.8 97.9 97.9 2 96.2 1.8 97.9 97.2 32 94.9 1.8 96.7 92.5 DPT 1 96.2 1.8 97.9 97.9 2 96.2 1.8 97.9 97.9 33 94.3 .9 95.2 91.9 Measles4 94.3 1.8 96.0 91.6 Hepb At birth 96.1 1.8 97.8 97.4 1 92.1 4.8 96.9 96.5 2 90.7 4.8 95.5 90.6 HIb 1 97.0 .9 97.9 97.9 2 96.3 .9 97.2 96.8 3 94.4 .9 95.3 93.5 all vaccinations 84.7 6.6 91.3 79.2 no vaccinations .0 2.1 2.1 2.1 number of children age 18-29 months 270 270 270 270 1 MICS indicator 3.1; 2 MICS indicator 3.2; 3 MICS indicator 3.3 4 MICS indicator 3.4; MDG indicator 4.3 Table CH.1 presents the percentage of children aged 18 to 29 months who have received each of the specific vaccinations according to a vaccination card and/or mother’s recall. The denominator for the table is comprised of children aged 18-29 months so that only children who are old enough to be fully vaccinated are counted. In the first three columns of the table, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In the last column, only those children who were vaccinated by their first birthday, as recommended, are included. For children without vaccination cards, the proportion of vaccinations given by the first birthday is assumed to be the same as for children with vaccination cards. Figure CH.1 presents the percentage of children who received the recommended vaccinations by the age of 12 months (and by 18 months for measles). Approximately 97 percent of children received a BCG vaccination by the age of 12 months - the first and second dose of DPT are given to 98 percent of children but the third dose of DPT is given to only 92 percent. Similarly, 98 percent of children received polio 1 by aged 12 months, but the coverage with polio vaccine declines to 92 percent by the third dose. Coverage for the measles vaccine by 18 months is lower than for the other vaccines. The primary reason is that although 96 percent of children received the vaccine, only 92 percent received it by the age of 18 months. There is also a slight decline in the Hepatitis B vaccination from 97 percent for the first and second dose, to 91 percent for the third dose, reflecting a small dropout rate of less than 6 percent. HiB was administered by the age of 12 months to approximately 98 percent of children aged 18-29 for the first dose, 97 percent for the second dose and 94 percent for the third dose. The percentage of children who had all the recommended vaccinations by their first birthday is low at only 79 percent. figure ch.1: percentage of children aged 18-29 months who received the recommended vaccinations by 12 months, Macedonia, 2012 39 Table CH.2 presents vaccination coverage estimates among children aged 18-29 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and report by the mother/caretaker. The interviewer reviewed the vaccination cards for 89 percent of children. table ch.2: vaccinations by background characteristics percentage of children age 18-29 months currently vaccinated against childhood diseases according to vaccination cards or health facility records, Macedonia, 2011   Percentage of children who received:   Pe rc en ta ge w ith va cc in at io n ca rd se en Nu m be r o f c hi ld re n ag e 18 -2 9 m on th s BCG Polio DPT M ea sle s HepB HIB No ne Al l   1 2 3 1 2 3 At birth 1 2 1 2 3 sex Male 96.5 97.1 97.1 97.1 97.1 97.1 95.3 95.9 96.8 95.0 94.6 97.0 95.5 94.3 2.9 90.2 87.9 132 Female 98.8 98.8 98.8 96.3 98.8 98.8 95.1 96.1 98.8 98.8 96.3 98.8 98.8 96.2 1.2 92.4 90.8 138 area Urban 98.1 98.7 98.7 96.5 98.7 98.7 93.5 95.5 98.4 96.7 94.1 98.7 98.7 95.5 1.3 88.5 89.7 132 Rural 97.2 97.2 97.2 96.8 97.2 97.2 96.8 96.6 97.2 97.2 96.8 97.2 95.7 95.0 2.8 94.0 89.0 138 Mother’s education Primary or less 94.8 94.8 94.8 94.8 94.8 94.8 94.8 94.8 94.5 94.5 94.5 94.8 92.9 92.3 5.2 91.9 87.2 107 Secondary 100.0 100.0 100.0 99.2 100.0 100.0 99.2 96.4 100.0 100.0 100.0 100.0 100.0 99.2 .0 95.6 94.3 107 High 98.5 100.0 100.0 95.3 100.0 100.0 88.1 97.7 100.0 95.7 88.6 100.0 100.0 93.2 .0 81.9 84.2 55 Wealth index quintile Poorest 92.7 92.7 92.7 92.7 92.7 92.7 92.7 92.7 92.2 92.2 92.2 92.7 89.5 86.9 7.3 86.3 92.7 63 Second 100.0 100.0 100.0 98.9 100.0 100.0 98.9 94.2 100.0 100.0 100.0 100.0 100.0 98.9 .0 94.2 100.0 59 Middle 98.0 98.0 98.0 96.2 98.0 98.0 96.2 96.2 98.0 98.0 98.0 98.0 98.0 98.0 2.0 96.2 98.0 49 Fourth (100.0) (100.0) (100.0) (98.9) (100.0) (100.0) (94.0) (98.1) (100.0) (95.1) (91.0) (100.0) (100.0) (96.8) (.0) (89.1) (90.1) 48 Richest 98.4 100.0 100.0 97.1 100.0 100.0 94.0 100.0 100.0 100.0 96.1 100.0 100.0 97.1 .0 91.4 100.0 51 ethnicity of household head Macedonian 98.1 98.7 98.7 96.4 98.7 98.7 96.4 97.1 98.7 98.7 96.1 98.7 98.7 96.0 1.3 93.8 91.9 131 Albanian 97.7 97.7 97.7 97.2 97.7 97.7 93.7 95.0 97.4 95.3 94.8 97.7 95.8 94.9 2.3 87.9 87.1 111 Other (95.4) (95.4) (95.4) (95.4) (95.4) (95.4) (95.4) (95.4) (95.4) (95.4) (95.4) (95.4) (95.4) (93.2) (4.6) (93.2) (86.9) 28 Total 97.6 97.9 97.9 96.7 97.9 97.9 95.2 96.0 97.8 96.9 95.5 97.9 97.2 95.3 2.1 91.3 89.4 270 ( ) – figures based on 25–49 unweighted cases 40 MultIple IndIcator cluster survey 2011 vaccinations – Roma settlements The percentage of children aged 18 to 29 months in Roma settlements who have received each of the specific vaccinations by source of information (vaccination card and mother’s recall) is shown in Table CH.1R. The denominator for the table is comprised of children aged 18-29 months so that only children who are old enough to be fully vaccinated are counted. In the first three columns of the table, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In the last column, only those children who were vaccinated before their first birthday, as recommended, are included. For children without vaccination cards, the proportion of vaccinations given by the first birthday is assumed to be the same as for children with vaccination cards. table ch.1R: vaccinations in first year of life percentage of children age 18-29 months immunized against childhood diseases at any time before the survey and by the first birthday (by 18 months of age against measles), Roma settlements, 2011 Vaccinated at any time before the survey according to: Vaccinated by 12 months of age (18 months of age against measles) Vaccination card or health facility records Mother’s report Eithe r bCG1 98.2 .0 98.2 96.6 Polio 1 98.2 .0 98.2 95.2 2 94.4 .0 94.4 85.9 32 91.0 .0 91.0 80.2 DPT 1 98.2 .0 98.2 95.2 2 95.4 .0 95.4 85.9 33 90.9 .0 90.9 77.9 Measles4 96.3 .0 96.3 88.9 Hepb At birth 97.7 1.2 98.9 98.9 1 94.4 2.7 97.0 95.8 2 90.4 1.3 91.7 85.3 HIb 1 98.2 .0 98.2 96.0 2 95.4 .0 95.4 91.3 3 94.3 .0 94.3 90.3 all vaccinations 83.6 5.6 89.2 63.1 no vaccinations .0 1.1 1.1 1.1 number of children age 18-29 months 86 86 86 86 1 MICS indicator 3.1; 2 MICS indicator 3.2; 3 MICS indicator 3.3 4 MICS indicator 3.4; MDG indicator 4.3 Figure CH.1R presents the percentage of children who received recommended vaccinations by the age of 12 months (and by 18 months for measles). Approximately 97 percent of the children in Roma settlements received a BCG vaccination by the age of 12 months – the first dose of DPT was given to 95 percent but the second and third dose of DPT declined to 86 percent and 78 percent respectively. Similarly, 95 percent of Roma children received Polio 1 by age 12 months and this declines to 80 percent by the third dose. 96 percent of Roma children received the measles vaccine, however, only 89 percent had received it by the age of 18 months. There is also a big decline in the Hepatitis B vaccination from 99 percent for the first dose given at birth to 96 percent for the second dose, and 85 percent for the third dose, reflecting a big dropout rate of 14 percent. HiB was administered by the age of 12 months to approximately 96 percent of Roma children aged 18-29 months (first dose), 91 percent for the second dose and 90 percent for the third dose. The percentage of Roma children who had all the recommended vaccinations by their first birthday is low at only 63 percent. 41 figure ch.1R: percentage of chil- dren aged 18-29 months who received the recommended vacci- nations by 12 months, Roma settle- ments, 2012 table ch.2R: vaccinations by background characteristics percentage of children age 18-29 months currently vaccinated against childhood diseases according to vaccina- tion cards or health facility records, Roma settlements, 2011   Percentage of children who received: Al l Pe rc en ta ge w ith va cc in at io n ca rd or fa cil ity re co rd se en Nu m be r o f ch ild re n ag e 18 -2 9 m on th s BC G Polio DPT M ea sle s HepB HIB No ne  1 2 3 1 2 3 At birth 1 2 1 2 3 sex Male (98.0) (98.0) (96.7) (96.7) (98.0) (96.7) (94.2) (97.0) (98.0) (98.0) (94.2) (98.0) (96.7) (96.7) (2.0) (93.3) (98.0) 45 Female (98.4) (98.4) (91.8) (84.8) (98.4) (94.0) (87.3) (95.5) (100.0) (96.1) (89.1) (98.4) (93.9) (91.6) (.0) (84.8) (100.0) 42 Total 98.2 98.2 94.4 91.0 98.2 95.4 90.9 96.3 98.9 97.0 91.7 98.2 95.4 94.3 1.1 89.2 98.9 86 ( ) – figures based on 25–49 unweighted cases Table CH.2R presents vaccination coverage estimates among children aged 18-29 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from the vaccination cards, mothers’/caretakers’ reports and health records. The interviewer reviewed the vaccination cards or facility records for 99 percent of Roma children (100 percent for females). Only 1 percent of Roma children were not vaccinated with any vaccine. At birth, 99 percent received the hepatitis B vaccine; 98 percent were vaccinated with BCG, and received a first dose of polio, DPT and HiB; and 96 percent received a measles vaccine. What is noticeable from Table CH.2R is the higher drop-off rate for girls although the figures are based on 25-49 unweighted cases. 42 MultIple IndIcator cluster survey 2011 prevalence of diarrhoea Diarrhoea is the second leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) - can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. The goals of A World Fit for Children is to reduce by one half death due to diarrhoea among children under five by 2010 compared to 2000, and to reduce the incident of diarrhoea by 25 percent. The Millennium Development Goal is to reduce by two thirds the mortality rate among children under five by 2015 compared to 1990. In the MICS, prevalence of diarrhoea was estimated by asking mothers/caretakers whether their child under age five had an episode of diarrhoea in the two weeks prior to the survey. Overall, 6 percent of under five children had diarrhoea in the two weeks preceding the survey (Table CH.4). Diarrhoea prevalence in children from rural (7 percent) and urban areas (6 percent) are almost equal, indicating good water and sanitation conditions in rural areas. table ch.4: prevalence of diarrhoeal diseases percentage of children age 0-59 months with diarrhoea in the last two weeks, Macedonia, 2011 Had diarrhea in last two weeks Number of children age 0-59 months sex Male 7.0 692 Female 5.8 684 area Urban 5.9 701 Rural 6.9 675 age 0-11 months 7.8 258 12-23 months 9.6 283 24-35 months 7.8 274 36-47 months 3.1 276 48-59 months 3.9 285 Mother’s education Primary or less 8.1 545 Secondary 4.8 522 High 6.2 309 Wealth index quintile Poorest 8.7 316 Second 7.6 272 Middle 5.0 255 Fourth 6.3 261 Richest 4.1 272 ethnicity of household head Macedonian 5.1 708 Albanian 8.4 521 Other 5.8 148 Total 6.4 1376 prevalence of diarrhoea – Roma settlements Overall, 13 percent of children under five years in Roma settlements had diarrhoea in the two weeks preceding the survey (Table CH.4R17). 17 Background characteristics are not shown due to the small number of cases for disaggregated categories. table ch.4R: prevalence of diarrhoeal diseases percentage of children age 0-59 months with diarrhoea in the last two weeks, Roma settlements, 2011 Had diarrhoea in last two weeks Number of children age 0-59 months sex Male 13.4 237 Female 12.7 239 Total 13.1 476 43 Knowledge about the signs of pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in children under 5 years of age with suspected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one-third the deaths due to acute respiratory infections. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.8. The mothers’ knowledge of the danger signs is an important determinant of care-seeking behaviour. Overall, only 6 percent of women know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility is developed fever. 16 percent of mothers identified fast breathing and 21 percent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. Mothers’ knowledge of the danger signs of pneumonia varies by region, education, wealth index and ethnicity. table ch.8: Knowledge of the two danger signs of pneumonia percentage of mothers and caretakers of children age 0-59 months by symptoms that would cause to take the child immediately to a health facility, and percentage of mothers who recognize fast and difficult breathing as signs for seeking care immediately, Macedonia, 2011 Percentage of mothers/caretakers of children age 0-59 months who think that a child should be taken immediately to a health facility if the child: M ot he rs / c ar et ak er s w ho re co gn ize th e tw o da ng er si gn s o f pn eu m on ia Nu m be r o f m ot he rs / ca re ta ke rs o f ch ild re n ag e 0- 59 m on th s Is no t a bl e to d rin k o r br ea st fe ed Be co m es sic ke r De ve lo ps a fe ve r Ha s f as t br ea th in g Ha s d iffi cu lty br ea th in g Ha s b lo od in st oo l Is dr in kin g po or ly Region Vardar 1.6 6.3 95.5 19.2 22.2 10.9 2.2 2.0 54 East 1.5 9.6 89.1 2.7 3.2 .7 8.2 .7 61 Southwest 33.0 36.3 92.5 22.5 24.2 15.1 25.0 11.3 72 Southeast 6.5 19.2 98.7 11.8 13.2 5.2 .9 2.9 48 Pelagonia 13.9 30.9 96.3 8.9 10.7 1.7 2.0 .6 83 Polog 16.4 32.8 88.4 23.0 26.0 12.2 17.5 9.7 140 Northeast 36.9 30.1 93.3 30.6 41.1 8.3 11.2 7.4 77 Skopje 5.4 11.5 88.1 12.3 18.7 2.9 4.7 6.3 234 area Urban 9.0 15.8 91.1 13.3 20.7 5.1 7.4 5.5 401 Rural 18.5 28.0 91.3 19.7 20.5 8.4 11.1 6.4 368 Mother’s education Primary or less 16.0 27.8 88.9 22.5 23.2 6.4 10.5 7.1 285 Secondary 9.0 17.9 94.1 13.9 19.3 4.9 8.9 4.8 292 High 17.0 18.1 90.4 11.0 18.6 9.9 7.6 5.8 192 Wealth index quintile Poorest 21.3 27.6 88.9 21.9 24.0 10.8 9.7 9.9 165 Second 13.2 23.5 90.9 23.6 18.0 7.1 11.2 7.6 150 Middle 14.8 25.6 90.4 15.6 22.2 4.7 10.8 5.6 136 Fourth 11.8 21.5 92.2 16.2 21.0 3.2 7.8 5.6 155 Richest 6.6 10.7 93.6 4.8 17.8 7.2 6.7 1.0 163 ethnicity of household head Macedonian 7.3 13.7 93.2 10.2 16.5 4.3 6.5 3.0 408 Albanian 24.0 34.7 88.3 25.8 27.3 9.6 13.3 10.1 285 Other 7.8 15.5 91.9 14.1 17.2 8.7 7.7 6.1 75 Total 13.6 21.6 91.2 16.4 20.6 6.7 9.2 5.9 768 44 MultIple IndIcator cluster survey 2011 Knowledge about signs of pneumonia – Roma settlements 19 percent of mothers identified difficult breathing as symptoms for taking children immediately to a health care provider. 20 percent of Roma mothers go to a health care provider when the child becomes sicker, while 19 percent of mothers go when the child is unable to drink or breastfeed. Knowledge of the danger signs of pneumonia is higher among mothers in the richest households compared to all other wealth quintiles. table ch.8R: Knowledge of the two danger signs of pneumonia percentage of mothers and caretakers of children age 0-59 months by symptoms that would cause to take the child immediately to a health facility, and percentage of mothers who recognize fast and difficult breathing as signs for seeking care immediately, Roma settlements, 2011 Percentage of mothers/caretakers of children age 0-59 months who think that a child should be taken immediately to a health facility if the child: M ot he rs / c ar et ak er s w ho re co gn ize th e tw o da ng er sig ns o f p ne um on ia Nu m be r o f m ot he rs / ca re ta ke rs o f c hi ld re n ag e 0- 59 m on th s Is no t a bl e to d rin k or b re as tfe ed Be co m es si ck er De ve lo ps a fe ve r Ha s f as t b re at hi ng Ha s d iffi cu lty br ea th in g Ha s b lo od in st oo l Is dr in kin g po or ly Mother’s education None 30.5 31.5 93.7 18.6 23.1 3.2 1.8 4.1 73 Primary 16.2 15.4 92.8 10.1 17.9 2.9 3.6 2.0 259 Secondary+ (12.4) (26.4) (89.6) (9.3) (16.9) (6.2) (13.9) (9.3) 43 Wealth index quintile Poorest 20.3 28.4 95.8 9.5 17.3 2.2 1.8 .0 89 Second 31.5 14.4 95.4 9.0 17.9 .8 3.6 3.7 77 Middle 11.7 17.4 91.3 10.5 16.2 8.9 1.1 1.1 77 Fourth 13.9 14.2 92.8 13.7 19.4 2.9 8.7 2.1 68 Richest 13.4 23.1 86.1 17.2 24.5 1.7 8.5 10.8 64 Total 18.5 19.8 92.6 11.6 18.8 3.3 4.4 3.2 375 ( ) – figures based on 25–49 unweighted cases 44 MultIple IndIcator cluster survey 2011 Issues related to knowledge of danger signs of pneumonia are presented in Table CH.8R. The mothers’ knowledge of the danger signs is an important determinant of care-seeking behaviour. Overall, only 3.2 percent of Roma women know of the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility is developed fever (93 percent). 12 percent of Roma mothers identified fast breathing and 45 solid fuel use More than 3 billion people around the world rely on solid fuels for their basic energy needs, including cooking and heating. Solid fuels include biomass fuels, such as wood, charcoal, crops or other agricultural waste, dung, shrubs and straw, and coal. Cooking and heating with solid fuels leads to high levels of indoor smoke which contains a complex mix of health- damaging pollutants. The main problem with the use of solid fuels is their incomplete combustion, which produces toxic elements such as carbon monoxide, polyaromatic hydrocarbons, and sulphur dioxide, among others. Use of solid fuels increases the risks of incurring acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, asthma, cataracts, and possibly tuberculosis, and may contribute to low birth weight of babies born to pregnant women exposed to smoke. The primary indicator for monitoring use of solid fuels is the proportion of the population using solid fuels as the primary source of domestic energy for cooking, as shown in Table CH.9. table ch.9: solid fuel use percent distribution of household members according to type of cooking fuel used by the household, and percentage of household members living in households using solid fuels for cooking, Macedonia, 2011 Percentage of household members in households using: El ec tri cit y Pe tro le um Bi og as Solid fuels Ot he r f ue l M iss in g No fo od co ok ed in th e ho us eh ol d To ta l So lid fu el s f or co ok in g1 Nu m be r o f ho us eh ol d m em be rs Ch ar co al W oo d St ra w, sh ru bs , gr as s Region Vardar 61.0 16.5 .0 .0 22.2 .2 .0 .0 .0 100.0 22.5 1064 East 30.2 16.1 .0 .0 53.0 .6 .0 .0 .1 100.0 53.6 1235 Southwest 38.6 5.3 .0 .0 56.1 .1 .0 .0 .0 100.0 56.1 1337 Southeast 61.1 8.9 .0 .0 29.9 .0 .0 .0 .1 100.0 29.9 1293 Pelagonia 55.3 10.2 .2 .0 33.9 .0 .4 .0 .0 100.0 33.9 1957 Polog 37.8 7.2 .0 .3 54.5 .0 .0 .2 .0 100.0 54.8 2059 Northeast 61.5 3.1 .0 .1 35.2 .0 .0 .0 .0 100.0 35.3 1466 Skopje 76.8 9.1 .0 .0 13.9 .1 .0 .0 .1 100.0 14.0 4353 area Urban 75.6 11.4 .0 .0 12.8 .1 .1 .0 .0 100.0 12.9 8202 Rural 34.0 6.4 .1 .1 59.2 .1 .0 .1 .1 100.0 59.4 6562 education of household head Primary or less 39.5 5.4 .1 .1 54.6 .2 .0 .1 .0 100.0 55.0 6047 Secondary 66.9 11.8 .0 .0 21.1 .0 .1 .0 .1 100.0 21.1 6143 High 75.4 11.8 .0 .0 12.8 .0 .0 .0 .0 100.0 12.8 2569 Wealth index quintiles Poorest 14.8 2.0 .0 .0 82.9 .1 .2 .0 .0 100.0 83.0 2955 Second 42.3 6.2 .0 .2 50.7 .4 .0 .0 .2 100.0 51.3 2950 Middle 63.9 9.6 .0 .1 26.1 .0 .0 .3 .0 100.0 26.2 2953 Fourth 76.9 16.2 .1 .0 6.8 .0 .0 .0 .0 100.0 6.8 2950 Richest 87.6 11.8 .0 .0 .6 .0 .0 .0 .0 100.0 .6 2955 ethnicity of household head Macedonian 65.0 12.1 .0 .0 22.7 .0 .1 .0 .1 100.0 22.7 9537 Albanian 39.1 2.7 .0 .2 57.7 .1 .0 .1 .0 100.0 58.0 4040 Other 54.5 7.6 .0 .0 37.3 .6 .0 .0 .0 100.0 37.9 1182 Total 57.1 9.2 .0 .0 33.4 .1 .1 .0 .0 100.0 33.6 14764 1 MICS indicator 3.11 46 MultIple IndIcator cluster survey 2011 Overall, more than a third (34 percent) of all households in Macedonia use solid fuels for cooking. Use of solid fuels is low in urban areas (13 percent), but very high in rural areas, where more than half of the households (59 percent) use solid fuels. Differentials in regard to household wealth and the educational level of the household head are also considerable. The findings show that use of solid fuels is very uncommon among households in the Skopje region and among the richest households. The table also shows that the overall percentage is high due to the common use of wood for cooking purposes. Solid fuel use by place of cooking is depicted in Table CH.10. The presence and extent of indoor pollution are dependent on cooking practices, places used for cooking, as well as types of fuel used. In most households solid fuel is used for cooking in a separate room such as a kitchen (77 percent). In 13 percent of households, it is used elsewhere in the house- 7 percent in a separate building and 3 percent outdoors. This distribution is similar through the country even though there are differences by region, area of living and wealth index of households, as well as the education and ethnicity of household head. table ch.10: solid fuel use by place of cooking percent distribution of household members in households using solid fuels by place of cooking, Macedonia, 2011 Place of cooking: In a se pa ra te ro om u se d as kit ch en El se w he re in th e ho us e In a se pa ra te bu ild in g Ou td oo rs At a no th er pl ac e M iss in g To ta l Nu m be r o f ho us eh ol d m em be rs in ho us eh ol ds us in g so lid fu el s f or co ok in g Region Vardar 48.4 9.3 26.1 14.5 .0 1.7 100.0 239 East 60.5 31.7 4.7 3.1 .0 .0 100.0 662 Southwest 93.9 2.9 .9 2.2 .0 .1 100.0 750 Southeast 77.3 5.4 13.1 3.6 .6 .0 100.0 386 Pelagonia 83.5 6.1 7.3 3.1 .0 .0 100.0 664 Polog 71.6 16.8 7.8 2.9 .0 .8 100.0 1128 Northeast 88.8 10.3 .0 .9 .0 .0 100.0 518 Skopje 79.5 11.0 5.9 3.4 .0 .2 100.0 610 area Urban 85.2 10.9 2.7 1.1 .0 .0 100.0 1058 Rural 75.0 13.1 7.5 3.9 .1 .4 100.0 3900 education of household head Primary or less 73.6 15.3 6.8 3.8 .1 .4 100.0 3325 Secondary 82.5 8.0 6.6 2.7 .0 .1 100.0 1298 High 91.9 4.2 3.0 1.0 .0 .0 100.0 330 Wealth index quintiles Poorest 67.4 18.5 8.1 5.5 .1 .5 100.0 2454 Second 84.8 7.3 6.0 1.7 .0 .2 100.0 1512 Middle 90.6 6.7 2.0 .7 .0 .0 100.0 773 Fourth 86.4 4.5 9.1 .0 .0 .0 100.0 201 Richest (*) (*) (*) (*) (*) (*) 100.0 17 ethnicity of household head Macedonian 73.4 14.9 8.6 3.0 .0 .2 100.0 2167 Albanian 81.1 11.5 4.9 2.0 .0 .5 100.0 2342 Other 75.1 7.3 4.9 12.3 .5 .0 100.0 448 Total 77.2 12.6 6.5 3.3 .0 .3 100.0 4957 (*) – figures based on less than 25 unweighted cases 47 solid fuel use – Roma settlements table ch.9R: solid fuel use percent distribution of household members according to type of cooking fuel used by the household, and percent- age of household members living in households using solid fuels for cooking, Roma settlements, 2011 Percentage of household members in households using: Nu m be r o f h ou se ho ld m em be rs El ec tri cit y Pe tro le um Bi og as Solid fuels Ot he r f ue l M iss in g No fo od co ok ed in th e ho us eh ol d To ta l So lid fu el s f or co ok in g1 Ch ar co al W oo d St ra w, sh ru bs , gr as s education of household head None 63.1 .0 .0 .0 34.6 2.1 .0 .0 .2 100.0 36.7 593 Primary 61.9 1.8 .0 .0 36.3 .0 .0 .0 .0 100.0 36.3 2887 Secondary+ 79.4 3.4 .0 .0 17.2 .0 .0 .0 .0 100.0 17.2 749 Wealth index quintiles Poorest 41.8 .1 .0 .0 56.6 1.5 .0 .0 .1 100.0 58.0 845 Second 58.4 1.0 .0 .0 40.6 .0 .0 .0 .0 100.0 40.6 842 Middle 63.1 1.7 .0 .0 35.2 .0 .0 .0 .0 100.0 35.2 848 Fourth 74.4 1.1 .0 .0 24.5 .0 .0 .0 .0 100.0 24.5 845 Richest 88.2 5.1 .0 .0 6.7 .0 .0 .0 .0 100.0 6.7 848 Total 65.2 1.8 .0 .0 32.7 .3 .0 .0 .0 100.0 33.0 4229 1 MICS indicator 3.11 Overall, a third (33 percent) of all households in Roma settlements in Macedonia use solid fuels for cooking. Use of solid fuels is very low in the richest households (7 percent) and high in the poorest households, where more than half of the households (58 percent) use solid fuels. Differentials with respect to the educational level of the household head are also considerable with more educated household heads using less solid fuels. The table also shows that the overall percentage is high (33 percent) due to the common use of wood for cooking purposes Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pollution, while an open stove or fire with no chimney or hood means there is no protection from the harmful effects of solid fuels. Solid fuel use by place of cooking is depicted in Table CH.10R. In most Roma households, solid fuel is used for cooking in a separate room, such as a kitchen (75 percent). In 11 percent of households solid fuel is used elsewhere in the house, 9 percent outdoors, and 4 percent in a separate building. This distribution is similar throughout the country despite differences by wealth index of households and the education of the household head. 47 48 MultIple IndIcator cluster survey 2011 table ch.10R: solid fuel use by place of cooking percent distribution of household members in households using solid fuels by place of cooking, Roma settle- ments, 2011 Place of cooking: Nu m be r o f h ou se ho ld m em be rs in ho us eh ol ds u sin g so lid fu el s f or co ok in g In a se pa ra te ro om u se d as kit ch en El se w he re in th e ho us e In a se pa ra te bu ild in g Ou td oo rs At a no th er p la ce M iss in g To ta l education of household head None 72.7 9.0 8.3 8.3 1.7 .0 100.0 218 Primary 74.0 11.9 3.8 9.7 .0 .5 100.0 1048 Secondary+ 87.4 6.2 .0 .4 6.0 .0 100.0 129 Wealth index quintiles Poorest 58.7 13.7 9.1 16.1 2.3 .0 100.0 491 Second 83.3 4.1 2.6 10.1 .0 .0 100.0 342 Middle 88.8 8.9 .0 2.3 .0 .0 100.0 299 Fourth 83.1 11.9 2.2 .0 .0 2.7 100.0 207 Richest 65.8 34.2 .0 .0 .0 .0 100.0 57 Total 75.1 10.9 4.2 8.6 .8 .4 100.0 1395 48 MultIple IndIcator cluster survey 2011 49 child disability One of the World Fit for Children goals is to protect children against abuse, exploitation, and violence, including the elimination of discrimination against children with disabilities. In Macedonia there is a national preventive programme for mother and child health care and a programme for check-ups (including medical assessments) for school children. Disability assessment was conducted in two stages. In the first stage, a standard MICS module was used, asking mothers/caretakers of all children age 2 through 9 years, to assess a number of disabilities/impairments, such as sight impairment, deafness, and difficulties with speech. This approach rests in the concept of functional disability developed by WHO and aims to identify the implications of any impairment or disability for the development of the child (e.g. health, nutrition, education). The results from this stage were used for selecting children to be included in the second stage. All children that were assessed as positive (having at least one impairment) in the first stage, as well as an additional 10 percent of children whose mothers/care takers reported no impairment, were included and randomly selected in the survey. The second stage assessment took place in October- November 2011. Eleven teams were trained in September 2011 to conduct the medical assessment. Each team was composed of four members: pediatrician, ophthalmologist, audiologist and psychologist. Data collection was organized in kindergartens. Kindergartens provided a relaxed and friendly atmosphere where the child could be examined and observed with less stress and better reactions from both the children and parents. Health facilities could provoke negative reactions in children, while day care centers could increase refusal rate from parents who may be more reluctant to bring the child to that type of institution (In Macedonia, day care centers are for children with disabilities). All parents were contacted prior to the commencement of screening and informed of the procedure, date, etc. Overall, the response rate was 80 percent (85 percent for children with disabilities and 74 percent of those with no disability). Screening was scheduled to take place during the weekends. It was easier to convince parents to bring the child during the weekends as they were not working and generally had more time to participate in the process. Additionally, kindergartens were available during the weekends, which is not always the case for workdays. The following data collection tools were used for the screening: 1. Medical Assessment Form – used for collecting data on the child’s health status and on presence of physical impairment; 2. Psychological Development Test – for assessing the mental status/disability; 3. Sleeping assessment – for collecting data on sleeping problems; 4. M-Chat – used for checking the presence of autism; 5. ADHD Rating Scale – used for checking the presence of the Attention Deficit Hyperactivity Disorder. Medical Assessment Form and Psychological Development Test were used for all children; other instruments were administered only to the children for which there were an indication that the presence of the specific condition is possible. At the time of this report’s publication, the analysis of the data collected in the second stage assessment was still in process. As such, the results will be presented in a separate report on child disabilities. 50 MultIple IndIcator cluster survey 2011 vii WateR and sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases and/or can be tainted with chemical, physical and radiological contaminants with harmful effects on human health. In addition to its association with disease, access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility for carrying water, often for long distances. The MDG goal (7, C) is to reduce by half, between 1990 and 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The list of indicators used in MICS is as follows: Water „ Use of improved drinking water sources „ Use of adequate water treatment method „ Time to source of drinking water „ Person collecting drinking water Sanitation „ Use of improved sanitation „ Sanitary disposal of child’s faeces For more details on water and sanitation and to access some reference documents, please visit the UNICEF’s website at www.chilinfo.org/wes.html. Use of Improved Water sources The distribution of the population by main source of drinking water is shown in Table WS.1 and Figure WS.1. The population using improved sources of drinking water are those using any of the following types of supply: piped water (into dwelling, compound, yard or plot, to neighbour, public tap/standpipe), tubewell/borehole, protected well, protected spring and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for hand washing and cooking. 51 table Ws.1: use of improved water sources percent distribution of household population according to main source of drinking water and percentage of house- hold population using improved drinking water sources, Macedonia, 2011 Main source of drinking water To ta l Pe rc en ta ge u sin g im pr ov ed so ur ce s o f d rin kin g w at er 1 Nu m be r o f h ou se ho ld m em be rs Improved sources Unimproved sources Piped water Tu be -w el l/ bo re -h ol e Pr ot ec te d w el l Pr ot ec te d sp rin g Bo ttl ed w at er Un pr ot ec te d w el l Un pr ot ec te d sp rin g In to d w el lin g In to ya rd /p lo t To n ei gh bo r Pu bl ic ta p/ st an d- pi pe Region Vardar 76.1 .9 .0 2.4 .8 8.3 5.1 6.4 .0 .0 100.0 100.0 1064 East 89.6 .5 .1 .0 .2 1.7 4.9 2.6 .3 .0 100.0 99.7 1235 Southwest 94.1 .1 .1 .4 .0 2.3 1.2 1.4 .0 .2 100.0 99.8 1337 Southeast 86.0 3.6 .0 .0 4.6 .4 .0 3.0 1.4 1.0 100.0 97.6 1293 Pelagonia 85.8 .4 .0 .0 2.2 1.1 3.9 6.6 .0 .0 100.0 100.0 1957 Polog 94.0 .0 .0 .1 1.6 1.0 1.5 1.5 .0 .3 100.0 99.7 2059 Northeast 70.1 .0 .0 4.1 3.0 14.6 4.5 2.6 .0 1.0 100.0 99.0 1466 Skopje 87.7 1.5 .3 .2 .0 1.0 2.7 6.4 .1 .1 100.0 99.8 4353 area Urban 91.3 .1 .0 .3 .1 .5 .9 6.6 .0 .0 100.0 100.0 8202 Rural 80.1 1.9 .2 1.1 2.7 6.1 5.3 1.4 .4 .6 100.0 99.0 6562 education of household head Primary or less 84.1 1.6 .3 .8 2.2 3.9 4.9 1.3 .3 .6 100.0 99.1 6047 Secondary 88.3 .6 .0 .6 .9 2.9 1.9 4.7 .1 .1 100.0 99.9 6143 High 87.0 .1 .0 .6 .1 1.3 .4 10.4 .0 .1 100.0 99.9 2569 Wealth index quintile Poorest 72.0 3.9 .5 2.5 3.0 7.7 8.7 .3 .7 .7 100.0 98.6 2955 Second 87.3 .7 .1 .2 2.4 4.8 2.7 .9 .2 .7 100.0 99.2 2950 Middle 93.4 .0 .0 .3 .9 1.0 1.9 2.3 .0 .0 100.0 100.0 2953 Fourth 93.4 .0 .0 .1 .1 1.0 .7 4.7 .0 .0 100.0 100.0 2950 Richest 85.6 .0 .0 .2 .0 .5 .3 13.4 .0 .0 100.0 100.0 2955 ethnicity of household head Macedonian 86.9 .8 .0 .8 1.5 2.0 2.3 5.3 .2 .2 100.0 99.6 9537 Albanian 86.5 1.1 .4 .4 .8 5.3 3.8 1.1 .1 .6 100.0 99.3 4040 Other 81.1 1.2 .1 .6 1.8 3.6 4.2 7.2 .2 .0 100.0 99.8 1182 Total 86.3 .9 .1 .7 1.3 3.0 2.9 4.3 .2 .3 100.0 99.6 14764 1 MICS indicator 4.1; MDG indicator 7.8 Overall, 99.6 percent of the population is using an improved source of drinking water – 100 percent in urban areas and 99 percent in rural areas. 52 MultIple IndIcator cluster survey 2011 Table WS.1 shows that the source of drinking water for the population varies strongly by region. In both the Southwest and Polog regions, 94 percent of the population uses drinking water that is piped into their dwelling. In contrast, only 76 percent of those residing in Vardar and 70 percent of those in Northeast have piped water into the dwelling. In Vardar and Northeast, the second most important source of drinking water is a protected well, while in Pelagonia and Skopje it is bottled water. Use of household water treatment is presented in Table WS.2. Households were asked of ways they may be treating water at home to make it safer to drink. Boiling water, adding bleach or chlorine, using a water filter, and using solar disinfection are considered as appropriate means for the proper treament of drinking water. 2 percent of household members living in households with unimproved water sources use appropriate water treatment methods (the respective column is not presented in the table due to the small number of unweighted cases by background characteristics). table Ws.2: household water treatment percentage of household population by drinking water treatment method used in the household, and for house- hold members living in households where an unimproved drinking water source is used, the percentage who are using an appropriate treatment method, Macedonia, 2011 Water treatment method used in the household Nu m be r o f ho us eh ol d m em be rs No ne Bo il Ad d bl ea ch / ch lo rin e St ra in th ro ug h a clo th Us e w at er fil te r So la r d is- in fe ct io n Le t i t s ta nd an d se ttl e Ot he r Region Vardar 98.0 .5 .2 .2 1.2 .0 .1 .0 1064 East 95.6 2.5 .0 .0 1.3 .0 .1 .6 1235 Southwest 92.2 5.3 .3 .0 1.7 .0 .3 .0 1337 Southeast 95.1 3.9 .0 .8 .5 .0 .2 .2 1293 Pelagonia 93.0 5.6 .0 .5 1.2 .0 .2 .5 1957 Polog 92.2 4.2 .0 2.6 2.0 .0 .2 .1 2059 Northeast 97.5 2.5 .0 .1 .3 .0 .0 .0 1466 Skopje 94.8 1.6 .0 .3 2.8 .0 .4 .8 4353 area Urban 94.8 2.3 .0 .0 2.4 .0 .0 .4 8202 Rural 94.2 4.1 .1 1.4 .8 .0 .4 .3 6562 education of household head Primary or less 95.9 2.9 .0 1.1 .5 .0 .3 .3 6047 Secondary 93.8 3.5 .1 .4 2.2 .0 .1 .4 6143 High 93.0 2.8 .0 .1 3.4 .0 .4 .7 2569 Wealth index quintile Poorest 95.4 3.6 .2 1.5 .2 .0 .5 .4 2955 Second 94.2 4.5 .0 1.1 .6 .0 .1 .0 2950 Middle 95.8 3.0 .0 .5 .7 .0 .2 .2 2953 Fourth 95.0 2.7 .0 .1 2.2 .0 .2 .3 2950 Richest 92.2 1.8 .0 .0 4.7 .0 .0 1.0 2955 ethnicity of household head Macedonian 94.5 3.0 .0 .2 2.2 .0 .1 .4 9537 Albanian 95.0 2.8 .0 1.5 .7 .0 .5 .4 4040 Other 93.1 5.3 .3 .7 1.2 .0 .3 .4 1182 Total 94.5 3.1 .0 .6 1.7 .0 .2 .4 14764 53 Table WS.3 presents the amount of time it takes to obtain water, and Table WS.4 shows who usually collected the water. These results refer to one round trip from home to drinking water source. Information on the number of trips made in one day was not collected. Table WS.3 shows that for 97 percent of the population live in households with drinking water source on the premises. For 1.6 percent of household population, it takes less than 30 minutes to get to the water source and bring water, while 0.5 percent of population spend 30 minutes or more for this purpose. One striking finding is the high percentage of households spending 30 minutes or more to go to the source of drinking water in Vardar region (3 percent). table Ws.3: time to source of drinking water percent distribution of household population according to time to go to source of drinking water, get water and return, for users of improved and unimproved drinking water sources, Macedonia, 2011 Time to source of drinking water To ta l Users of improved drinking water sources Users of unimproved drinking water sources Nu m be r o f h ou se ho ld m em be rs W at er o n pr em ise s Le ss th an 3 0 m in ut es 30 m in ut es o r m or e M iss in g/ DK W at er o n pr em ise s Le ss th an 3 0 m in ut es 30 m in ut es o r m or e Region Vardar 89.9 7.3 2.6 .3 .0 .0 .0 100.0 1064 East 98.4 .5 .3 .4 .0 .3 .0 100.0 1235 Southwest 98.0 1.5 .0 .3 .0 .2 .0 100.0 1337 Southeast 97.0 .4 .0 .1 .0 2.4 .0 100.0 1293 Pelagonia 95.8 2.0 1.4 .8 .0 .0 .0 100.0 1957 Polog 99.4 .0 .3 .1 .3 .0 .0 100.0 2059 Northeast 93.8 4.2 .2 .8 .0 .0 1.0 100.0 1466 Skopje 99.1 .5 .0 .2 .1 .1 .0 100.0 4353 area Urban 98.5 .9 .4 .3 .0 .0 .0 100.0 8202 Rural 95.5 2.5 .6 .4 .1 .7 .2 100.0 6562 education of household head Primary or less 96.0 2.0 .7 .4 .1 .5 .2 100.0 6047 Secondary 97.7 1.3 .5 .4 .0 .1 .0 100.0 6143 High 98.6 1.2 .0 .1 .0 .1 .0 100.0 2569 Wealth index quintile Poorest 93.3 3.3 1.2 .9 .3 .6 .5 100.0 2955 Second 96.5 1.7 .5 .5 .0 .8 .0 100.0 2950 Middle 97.9 1.5 .3 .2 .0 .0 .0 100.0 2953 Fourth 98.8 .8 .3 .1 .0 .0 .0 100.0 2950 Richest 99.3 .6 .1 .1 .0 .0 .0 100.0 2955 ethnicity of household head Macedonian 97.1 1.5 .6 .4 .0 .4 .0 100.0 9537 Albanian 98.0 .8 .3 .3 .2 .1 .3 100.0 4040 Other 94.5 4.8 .4 .0 .0 .2 .0 100.0 1182 Total 97.2 1.6 .5 .3 .1 .3 .1 100.0 14764 54 MultIple IndIcator cluster survey 2011 Table WS.4 shows that for the majority of households (56 percent) an adult male is usually the person collecting the water when the source of drinking water is not on the premises. Adult females collect water in 41 percent of households, while male children under 15 years of age collect water in the rest of the households (2 percent). table Ws.4: person collecting water percentage of households without drinking water on premises, and percent distribution of households without drinking water on premises according to the person usually collecting drinking water used in the household, Macedonia, 2011 Pe rc en ta ge o f h ou se ho ld s w ith ou t d rin kin g w at er o n pr em ise s Nu m be r o f h ou se ho ld s Person usually collecting drinking water Nu m be r o f h ou se ho ld s w ith ou t d rin kin g w at er on p re m ise s Ad ul t w om an Ad ul t m an Fe m al e ch ild u nd er ag e 15 M al e ch ild u nd er ag e 15 M iss in g/ DK To ta l area   Urban 1.6 2437 29.7 66.0 .0 4.3 .0 100.0 40 Rural 5.3 1581 47.1 51.1 .0 .9 .9 100.0 84 education of household head Primary or less 4.6 1568 47.3 49.5 .0 2.8 .3 100.0 73 Secondary 2.3 1670 32.5 65.2 .0 1.0 1.3 100.0 39 High 1.6 778 35.5 64.5 .0 .0 .0 100.0 12 ethnicity of household head Macedonian 3.2 2921 44.6 53.5 .0 1.9 .0 100.0 94 Albanian 1.7 784 36.7 51.9 .0 5.5 5.8 100.0 13 Other 5.5 310 27.6 72.4 .0 .0 .0 100.0 17 Total 3.1 4018 41.4 55.9 .0 2.0 .6 100.0 124 55 use of improved Water sources – Roma settlements The distribution of the population in Roma settlements by main source of drinking water is presented in Table WS.1R. table Ws.1R: use of improved water sources percent distribution of household population according to main source of drinking water and percentage of household population using improved drinking water sources, Macedonia, 2011 Main source of drinking water To ta l Pe rc en ta ge u sin g im pr ov ed so ur ce s o f d rin kin g w at er 1 Nu m be r o f h ou se ho ld m em be rs Improved sources Unimproved sources Piped water Tu be -w el l/ bo re -h ol e Pr ot ec te d w el l Bo ttl ed w at er Su rfa ce w at er (ri ve r, st re am , d am , la ke , p on d, ca na l, irr ig at io n ch an ne l Un pr ot ec te d sp rin g In to d w el lin g In to ya rd /p lo t To n ei gh bo r Pu bl ic ta p/ st an d- pi pe education of household head None 81.3 6.7 8.2 3.2 .0 .0 .0 .0 .6 100.0 99.4 593 Primary 92.4 3.0 .8 .4 1.2 .5 .5 .2 .9 100.0 98.9 2887 Secondary+ 96.8 .7 .0 .1 .0 .0 2.4 .0 .0 100.0 100.0 749 Wealth index quintile Poorest 69.2 13.1 8.4 2.6 2.8 .0 .3 .7 2.9 100.0 96.4 845 Second 91.9 2.0 .0 1.1 1.1 1.6 1.5 .0 .8 100.0 99.2 842 Middle 99.4 .3 .0 .0 .0 .3 .0 .0 .0 100.0 100.0 848 Fourth 98.9 .3 .0 .0 .0 .0 .8 .0 .0 100.0 100.0 845 Richest 98.6 .0 .0 .0 .0 .0 1.4 .0 .0 100.0 100.0 848 Total 91.6 3.1 1.7 .7 .8 .4 .8 .1 .7 100.0 99.1 4229 1 MICS indicator 4.1; MDG indicator 7.8 Overall, 99 percent of the population in Roma settlements uses an improved source of drinking water. What is noticeable from the data in Table WS.1R is that almost one in five household members (18 percent) in the poorest category does not have drinking water piped into their dwelling or yard/plot. Table WS.2R presents the use of household water treatment. 96 percent of all household members use water in the household without any treatment, while 3 percent treat water by boiling it. 55 56 MultIple IndIcator cluster survey 2011 table Ws.2R: household water treatment percentage of household population by drinking water treatment method used in the household, and for house- hold members living in households where an unimproved drinking water source is used, the percentage who are using an appropriate treatment method, Macedonia, 2011 Water treatment method used in the household Nu m be r o f ho us eh ol d m em be rs No ne Bo il Ad d bl ea ch / ch lo rin e St ra in th ro ug h a clo th Us e w at er fil te r So la r d is- in fe ct io n Le t i t st an d an d se ttl e Ot he r education of household head None 97.9 2.1 .0 .0 .0 .0 .0 .0 593 Primary 95.3 3.4 .0 .7 .1 .0 .0 .1 2887 Secondary+ 95.0 3.3 .4 .4 .8 .0 .0 .0 749 Wealth index quintile Poorest 94.3 5.1 .0 .6 .0 .0 .0 .0 845 Second 94.3 2.7 .0 1.4 .0 .0 .0 .0 842 Middle 97.3 2.2 .0 .3 .2 .0 .0 .0 848 Fourth 97.2 2.3 .0 .0 .1 .0 .0 .3 845 Richest 95.0 3.6 .3 .3 .7 .0 .0 .0 848 Total 95.6 3.2 .1 .5 .2 .0 .0 .1 4229 1 MICS indicator 4.2 The amount of time it takes to obtain water is presented in Table WS.3R and the person who usually collected the water is shown in Table WS.4R. These results refer to one round trip from home to drinking water source. Information on the number of trips made in one day was not collected. Table WS.3R shows that for 99 percent of Roma household members, the improved drinking water source is on the premises. For 0.3 percent, it takes less than 30 minutes to get to the improved water source and bring water. Only 0.7 percent of household members have unimproved drinking water source on premises while 0.2 percent spend less than 30 minutes to bring water from an unimproved source. table Ws.3R: time to source of drinking water percent distribution of household population according to time to go to source of drinking water, get water and return, for users of improved and unimproved drinking water sources, Macedonia, 2011 Time to source of drinking water To ta l Nu m be r o f h ou se ho ld m em be rs Users of improved drinking water sources Users of unimproved drinking water sources W at er on pr em ise s Le ss th an 3 0 m in ut es W at er on pr em ise s Le ss th an 3 0 m in ut es education of household head None 98.9 .4 .0 .6 100.0 593 Primary 98.5 .4 1.0 .1 100.0 2887 Secondary+ 100.0 .0 .0 .0 100.0 749 Wealth index quintile Poorest 95.9 .5 2.7 .8 100.0 845 Second 98.1 1.1 .8 .0 100.0 842 Middle 100.0 .0 .0 .0 100.0 848 Fourth 100.0 .0 .0 .0 100.0 845 Richest 100.0 .0 .0 .0 100.0 848 Total 98.8 .3 .7 .2 100.0 4229 Only 1 percent of the population in Roma settlements are without drinking water on premises. An adult woman is usually the person collecting the water when the source of drinking water is not on the premises. 56 MultIple IndIcator cluster survey 2011 57 use of improved sanitation Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases including diarrhoeal diseases and polio. Improved sanitation can reduce diarrheal disease by more than a third, and can significantly lessen the adverse health impacts of other disorders responsible for death and disease among millions of children in developing countries. An improved sanitation facility is defined as one that hygienically separates human excreta from human contact. Improved sanitation facilities for excreta disposal include flush or pour flush to a piped sewer system, septic tank, or pit latrine; ventilated improved pit latrine, pit latrine with slab, and use of a composting toilet. The data on the use of improved sanitation facilities in Macedonia are provided in Tables WS.5 and WS.5R. However, sharing of sanitation facilities, even if those are improved, is assumed to compromise their safety. Therefore, “improved sanitation” is used both in the context of this report and as an MDG indicator to refer to improved sanitation facilities, which are not shared. Data on improved sanitation are presented in Tables WS.6, WS.6R, WS.8 and WS.8R in this report. In Macedonia, 94 percent of the population lives in households using improved sanitation facilities (Table WS.5) - 99.8 percent in urban areas and 88 percent in rural areas. Residents of Polog and East regions are less likely than others to use improved facilities. The most common facilities in urban areas and in the richest quintile are flush toilets with connection to a sewage system. Households with more educated household heads are more likely to use improved water sanitation facilities. table Ws.5: types of sanitation facilities percent distribution of household population according to type of toilet facility used by the household, Macedonia, 2011 Type of toilet facility used by household Op en d ef ec at io n (n o fa cil ity , b us h, fi el d) To ta l Nu m be r o f h ou se ho ld m em be rs Improved sanitation facility Unimproved sanitation facility Flush/pour flush to: Ve nt ila te d im pr ov ed p it la tri ne Pi t l at rin e w ith sl ab Co m po s- tin g to ile t Flu sh / p ou r flu sh to so m ew he re el se Pi t l at rin e w ith ou t s la b/ op en p it Ha ng in g to ile t/ ha ng in g la tri ne Ot he r M iss in g Pi pe d se w er sy st em Se pt ic ta nk Pi t l at rin e Un kn ow n pl ac e/ no t su re /D K w he re Region Vardar 83.4 1.2 .0 .0 2.0 8.5 .0 .0 4.2 .0 .6 .0 .0 100.0 1064 East 83.0 .4 .4 .9 .5 3.0 4.7 .0 3.7 .0 .4 .0 3.0 100.0 1235 Southwest 66.5 30.4 .8 .1 .1 1.1 .6 .1 .2 .0 .0 .0 .0 100.0 1337 Southeast 52.4 21.7 .0 .0 .1 19.7 .0 .0 5.7 .0 .0 .0 .4 100.0 1293 Pelagonia 81.7 4.4 1.8 .2 1.1 6.2 .0 3.3 1.0 .0 .0 .0 .3 100.0 1957 Polog 36.9 44.8 .3 .7 .0 .0 .0 16.6 .0 .0 .0 .7 .0 100.0 2059 Northeast 74.3 6.7 1.8 1.7 .9 11.0 .0 1.1 2.4 .0 .0 .0 .0 100.0 1466 Skopje 79.8 14.3 .5 .3 1.2 1.5 .0 1.1 .3 .1 .1 .0 .8 100.0 4353 area Urban 98.1 1.1 .0 .0 .2 .4 .0 .0 .1 .0 .1 .0 .0 100.0 8202 Rural 35.8 35.7 1.6 1.1 1.5 10.9 1.0 7.2 3.5 .1 .1 .2 1.3 100.0 6562 education of household head Primary or less 49.8 25.4 1.2 1.0 1.5 8.8 1.0 6.7 3.0 .0 .2 .2 1.1 100.0 6047 Secondary 82.6 11.2 .5 .1 .4 3.1 .1 .7 .9 .1 .0 .0 .3 100.0 6143 High 90.1 7.9 .1 .1 .0 .8 .1 .9 .0 .0 .0 .0 .0 100.0 2569 Wealth index quintile Poorest 20.7 29.4 1.9 1.8 3.2 18.1 2.1 11.7 7.7 .1 .5 .0 2.9 100.0 2955 Second 60.3 27.7 1.4 .5 .6 5.5 .0 3.4 .3 .0 .0 .3 .0 100.0 2950 Middle 81.5 15.6 .3 .1 .1 1.5 .1 .8 .0 .0 .0 .0 .0 100.0 2953 Fourth 91.5 8.2 .0 .0 .0 .0 .0 .1 .0 .0 .0 .2 .0 100.0 2950 Richest 98.3 1.6 .0 .0 .0 .1 .0 .1 .0 .0 .0 .0 .0 100.0 2955 ethnicity of household head Macedonian 79.2 9.4 .3 .1 .9 6.6 .6 .3 2.1 .0 .0 .0 .5 100.0 9537 Albanian 48.1 34.8 1.7 1.4 .1 1.4 .0 10.9 .1 .0 .2 .3 .9 100.0 4040 Other 76.2 11.4 .4 .0 1.7 5.2 1.0 .5 2.7 .0 .6 .0 .3 100.0 1182 Total 70.4 16.5 .7 .5 .8 5.0 .4 3.2 1.6 .0 .1 .1 .6 100.0 14764 58 MultIple IndIcator cluster survey 2011 The MDGs and the WHO / UNICEF Joint Monitoring Programme ( JMP) for Water Supply and Sanitation classify households as using an unimproved sanitation facility if they are using otherwise acceptable sanitation facilities but sharing a facility between two or more households or using a public toilet facility. As shown in Table WS.6, 94 percent of the household population are using an improved sanitation facility with 1 percent of them sharing the facility with other household. 5 percent of the household members use unimproved sanitation, and 0.1 percent of them share it with other households. table Ws.6: use and sharing of sanitation facilities percent distribution of household population by use of private and public sanitation facilities and use of shared facilities, by users of improved and unimproved sanitation facilities, Macedonia, 2011 Users of improved sanitation facilities Users of unimproved sanitation facilities Op en d ef ec at io n (n o fa cil ity , bu sh , fi el d) To ta l Nu m be r o f h ou se ho ld m em be rs No t s ha re d 1 Pu bl ic fa cil ity Shared by No t s ha re d Shared by M iss in g/ DK 5 ho us eh ol ds o r le ss M or e th an 5 ho us eh ol ds 5 ho us eh ol ds o r le ss M or e th an 5 ho us eh ol ds Region Vardar 93.1 .0 2.0 .0 3.2 1.4 .0 .3 .0 100.0 1064 East 88.5 .0 4.4 .0 3.8 .3 .0 .0 3.0 100.0 1235 Southwest 98.0 1.0 .0 .7 .3 .0 .0 .0 .0 100.0 1337 Southeast 92.7 .0 1.1 .0 5.7 .0 .0 .0 .4 100.0 1293 Pelagonia 94.1 .7 .6 .0 4.4 .0 .0 .0 .3 100.0 1957 Polog 81.4 .2 1.0 .1 17.3 .0 .0 .0 .0 100.0 2059 Northeast 94.1 .4 .9 1.0 3.5 .0 .0 .0 .0 100.0 1466 Skopje 97.1 .0 .5 .0 1.6 .0 .0 .0 .8 100.0 4353 area Urban 98.9 .1 .7 .1 .1 .1 .0 .0 .0 100.0 8202 Rural 85.4 .4 1.5 .3 10.9 .2 .0 .0 1.3 100.0 6562 education of household head Primary or less 85.9 .5 1.8 .4 9.9 .2 .0 .0 1.1 100.0 6047 Secondary 97.3 .0 .7 .0 1.7 .1 .0 .0 .3 100.0 6143 High 98.8 .2 .1 .0 .9 .0 .0 .0 .0 100.0 2569 Wealth index quintile Poorest 72.4 .5 3.6 .6 19.5 .5 .0 .1 2.9 100.0 2955 Second 94.1 .5 1.0 .3 3.9 .1 .0 .0 .0 100.0 2950 Middle 98.6 .2 .4 .0 .8 .0 .0 .0 .0 100.0 2953 Fourth 99.5 .0 .3 .0 .3 .0 .0 .0 .0 100.0 2950 Richest 99.9 .0 .0 .0 .1 .0 .0 .0 .0 100.0 2955 ethnicity of household head Macedonian 96.0 .1 .9 .1 2.3 .1 .0 .0 .5 100.0 9537 Albanian 86.1 .5 .6 .4 11.6 .0 .0 .0 .9 100.0 4040 Other 90.9 .6 4.2 .2 2.9 .7 .0 .2 .3 100.0 1182 Total 92.9 .2 1.1 .2 4.9 .1 .0 .0 .6 100.0 14764 1 MICS indicator 4.3; MDG indicator 7.9 59 Safe disposal of a child’s faeces is disposing of the stool, by the child using a toilet or by rinsing the stool into a toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table WS.7. The most common place to dispose a child’s faeces is in the garbage as solid waste (80 percent of households), while 10 percent of children use toilet/latrine, and 7 percent put/rinse the faeces into toilet or latrine. 17 percent of children had their last stools disposed of safely. There are differences by regions in the percentage of children using toilet/ latrine; for example, the percentage is three times more in Skopje (15 percent) than in Polog (5 percent). table Ws.7: disposal of child’s faeces percent distribution of children age 0-2 years according to place of disposal of child’s faeces, and the percentage of children age 0-2 years whose stools were disposed of safely the last time the child passed stools, Macedonia, 2011 Place of disposal of child’s faeces Pe rc en ta ge o f ch ild re n w ho se la st st oo ls w er e di sp os ed o f sa fe ly1 Nu m be r o f ch ild re n ag e 0- 2 ye ar s Ch ild u se d to ile t/l at rin e Pu t/r in se d in to to ile t o r l at rin e Pu t/r in se d in to dr ai n or d itc h Th ro w n in to ga rb ag e Bu rie d Le ft in th e op en Ot he r DK M iss in g To ta l Type of sanitation facility in dwelling Improved 10.3 7.6 1.1 79.8 .2 .2 .3 .1 .6 100.0 17.9 730 Unimproved (4.1) (2.9) (5.9) (85.7) (.0) (1.4) (.0) (.0) (.0) 100.0 (6.9) 80 Open defacation (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 6 Region Vardar 10.7 8.1 .0 81.1 .0 .0 .0 .0 .0 100.0 18.9 50 East 5.4 20.5 1.0 67.3 .0 5.7 .0 .0 .0 100.0 26.0 60 Southwest 8.6 23.8 .0 62.5 .0 .0 .0 .7 4.4 100.0 32.4 74 Southeast 7.6 12.0 .9 75.0 2.6 .0 1.9 .0 .0 100.0 19.6 49 Pelagonia 10.3 3.2 1.1 85.4 .0 .0 .0 .0 .0 100.0 13.5 98 Polog 5.0 6.5 2.1 85.9 .0 .0 .0 .0 .5 100.0 11.5 154 Northeast 10.1 .0 2.0 87.9 .0 .0 .0 .0 .0 100.0 10.1 78 Skopje 15.2 1.9 2.2 80.1 .0 .0 .5 .0 .0 100.0 17.2 253 area Urban 11.1 8.0 .8 79.9 .0 .0 .2 .0 .0 100.0 19.1 417 Rural 9.2 6.1 2.3 79.7 .3 .9 .3 .1 1.0 100.0 15.3 398 Mother’s education Primary or less 12.1 6.2 2.6 77.2 .0 1.1 .4 .2 .3 100.0 18.3 323 Secondary 9.3 8.4 .8 81.2 .4 .0 .0 .0 .0 100.0 17.6 300 High 8.4 6.5 1.0 82.0 .0 .0 .5 .0 1.6 100.0 14.9 192 Wealth index quintile Poorest 10.6 8.0 4.2 74.6 .0 1.8 .7 .0 .1 100.0 18.6 190 Second 15.4 5.2 .2 77.5 .8 .0 .0 .3 .5 100.0 20.6 153 Middle 8.4 13.3 1.3 76.4 .0 .0 .6 .0 .0 100.0 21.7 153 Fourth 6.8 3.2 .9 87.2 .0 .0 .0 .0 1.9 100.0 10.0 158 Richest 9.6 5.8 .6 84.0 .0 .0 .0 .0 .0 100.0 15.4 161 ethnicity of household head Macedonian 8.8 10.1 1.2 79.4 .3 .0 .2 .0 .0 100.0 18.9 406 Albanian 12.2 2.6 2.1 81.7 .0 .0 .0 .2 1.3 100.0 14.7 314 Other 9.2 9.4 1.4 75.1 .0 3.6 1.4 .0 .0 100.0 18.5 95 Total 10.2 7.1 1.5 79.8 .2 .4 .3 .1 .5 100.0 17.3 815 1 MICS indicator 4.4 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases 60 MultIple IndIcator cluster survey 2011 In its 2008 report18, the WHO/UNICEF Joint Monitoring Programme (JMP) developed a new way of presenting the access figures- by disaggregating and refining the data on drinking-water and sanitation and reflecting them in “ladder” format. This ladder allows a disaggregated analysis of trends in a three rung ladder for drinking water and a four-rung ladder for sanitation. For sanitation, this gives an understanding of the proportion of population with no sanitation facilities at all, of those reliant on technologies defined by JMP as “unimproved,” of those sharing sanitation facilities of otherwise acceptable technology, and those using “improved” sanitation facilities. Table WS.8 presents the percentages of household members by drinking water and sanitation ladders. The table also shows the percentage of household members using improved sources of drinking water and sanitary means of excreta disposal. Overall, as presented in Table WS.8, more 18 WHO/UNICEF JMP (2008), MDG assessment report - http://www.wssinfo.org/fileadmin/user_upload/resources/1251794333-JMP_08_en.pdf than 90 percent of the population in the country use both improved water sources and sanitation. Of all households, 99.6 percent use improved drinking water, 93 percent use improved sanitation, while 93 percent use improved drinking water sources and improved sanitation. However, more detailed analysis reveals disparities between the poorest quintile and the rest of the population in the national sample. Approximately, almost 30 percent of the poorest households do not have access to improved water sources and/or sanitation, unlike the rest of population where over 90 percent have access to these two commodities. Urban households and households from richest quintile are more likely to use improved drinking water sources and improved sanitation. There are differences by regions, education and ethnicity similar to those presented in the tables above. table Ws.8: drinking water and sanitation ladders percentage of household population by drinking water and sanitation ladders, Macedonia, 2011 Percentage of household population using: Nu m be r o f ho us eh ol d m em be rs Improved drinking water1 Un im pr ov ed dr in kin g w at er To ta l Im pr ov ed sa ni ta tio n2 Unimproved sanitation To ta l Im pr ov ed d rin kin g w at er so ur ce s an d im pr ov ed sa ni ta tio n Pi pe d in to dw el lin g, pl ot o r y ar d Ot he r im pr ov ed Sh ar ed im pr ov ed fa cil iti es Un im pr ov ed fa cil iti es Op en de fe ca tio n Region Vardar 83.4 16.6 .0 100.0 93.1 2.0 4.9 .0 100.0 93.1 1064 East 92.8 6.9 .3 100.0 88.5 4.4 4.1 3.0 100.0 88.5 1235 Southwest 95.5 4.2 .2 100.0 98.0 1.7 .3 .0 100.0 97.7 1337 Southeast 92.6 5.0 2.4 100.0 92.7 1.1 5.7 .4 100.0 90.3 1293 Pelagonia 92.7 7.3 .0 100.0 94.1 1.2 4.4 .3 100.0 94.1 1957 Polog 95.6 4.2 .3 100.0 81.4 1.3 17.3 .0 100.0 81.2 2059 Northeast 72.3 26.7 1.0 100.0 94.1 2.3 3.5 .0 100.0 94.1 1466 Skopje 95.5 4.3 .2 100.0 97.1 .5 1.6 .8 100.0 96.9 4353 area Urban 98.1 1.9 .0 100.0 98.9 .9 .2 .0 100.0 98.9 8202 Rural 83.3 15.7 1.0 100.0 85.4 2.2 11.2 1.3 100.0 84.7 6562 education of household head Primary or less 87.0 12.1 .9 100.0 85.9 2.8 10.2 1.1 100.0 85.4 6047 Secondary 93.4 6.4 .1 100.0 97.3 .7 1.7 .3 100.0 97.1 6143 High 97.5 2.4 .1 100.0 98.8 .3 .9 .0 100.0 98.7 2569 Wealth index quintile Poorest 76.0 22.6 1.4 100.0 72.4 4.7 20.0 2.9 100.0 71.7 2955 Second 88.7 10.5 .8 100.0 94.1 1.9 4.0 .0 100.0 93.3 2950 Middle 95.7 4.3 .0 100.0 98.6 .6 .8 .0 100.0 98.6 2953 Fourth 98.1 1.9 .0 100.0 99.5 .3 .3 .0 100.0 99.5 2950 Richest 98.9 1.1 .0 100.0 99.9 .0 .1 .0 100.0 99.9 2955 ethnicity of household head Macedonian 93.1 6.6 .4 100.0 96.0 1.0 2.4 .5 100.0 95.7 9537 Albanian 88.6 10.8 .7 100.0 86.1 1.5 11.6 .9 100.0 85.8 4040 Other 88.9 10.9 .2 100.0 90.9 5.1 3.8 .3 100.0 90.8 1182 Total 91.5 8.1 .4 100.0 92.9 1.5 5.0 .6 100.0 92.6 14764 1 MICS indicator 4.1; MDG indicator 7.8 2 MICS indicator 4.3; MDG indicator 7.9 61 use of improved sanitation – Roma settlements open pit (14 percent). In contrast, the most common facilities in the richest quintile are flush toilets with connection to a sewage system (97 percent) or septic tank (3 percent). Households with more educated household heads are more likely to use improved water sanitation facilities. table Ws.5R: types of sanitation facilities percent distribution of household population according to type of toilet facility used by the household, Roma settlements, 2011 Type of toilet facility used by household Op en d ef ec at io n (n o fa cil ity , b us h, fie ld ) To ta l Nu m be r o f h ou se ho ld m em be rs Improved sanitation facility Unimproved sanitation facility Flush/pour flush to: Ve nt ila te d im pr ov ed pi t l at rin e Pi t l at rin e w ith sl ab Flu sh / p ou r fl us h to so m ew he re e lse Pi t l at rin e w ith ou t sla b/ o pe n pi t Ot he r Pi pe d se w er sy st em Se pt ic ta nk Pi t l at rin e Un kn ow n pl ac e/ no t s ur e/ DK w he re education of household head None 59.0 6.1 .0 .6 5.7 14.2 2.2 9.0 2.5 .7 100.0 593 Primary 78.9 3.4 .5 .3 3.9 8.0 .7 2.6 1.6 .1 100.0 2887 Secondary+ 93.3 3.4 .0 .0 1.1 1.4 .0 .0 .8 .0 100.0 749 Wealth index quintile Poorest 32.6 3.2 1.0 .8 12.0 27.2 1.8 13.5 7.2 .7 100.0 845 Second 75.8 5.7 .6 .6 5.6 8.0 1.9 1.7 .2 .0 100.0 842 Middle 90.9 4.5 .0 .0 .7 2.8 .3 .0 .8 .0 100.0 848 Fourth 96.4 3.0 .0 .0 .0 .6 .0 .0 .0 .0 100.0 845 Richest 97.4 2.6 .0 .0 .0 .0 .0 .0 .0 .0 100.0 848 Total 78.7 3.8 .3 .3 3.7 7.7 .8 3.0 1.6 .1 100.0 4229 As shown in Table WS.6R, 94 percent of the Roma household population is using an improved sanitation facility. Use of a facility not shared is more common among household members using an unimproved facility. 3 percent of household members use an improved toilet facility that is shared with other households. Poorest households are more likely than richest households to use a shared improved toilet facility (8 percent and 0 percent respectively). The highest use of an unshared improved sanitation is among households in which the head has secondary education (98 percent, as compared to those with no education at 82 percent). 0.1 percent of all interviewed Roma household members do not have a sanitation facility and use open defecation (bush, field etc.). 61 In Macedonia, 94 percent of Roma population is living in households using improved sanitation facilities. Table WS.5R indicates that use of improved sanitation facilities is strongly correlated with the wealth index. In the poorest quintile, only 33 percent of the Roma population uses flush to piped sewer system, pit latrines with slabs (27 percent), or pit latrines without slab / 62 MultIple IndIcator cluster survey 2011 table Ws.6R: use and sharing of sanitation facilities percent distribution of household population by use of private and public sanitation facilities and use of shared facilities, by users of improved and unimproved sanitation facilities, Roma settlements, 2011 Users of improved sanitation facilities Users of unimproved sanitation facilities Op en d ef ec at io n (n o fa cil ity , b us h, fie ld ) To ta l Nu m be r o f ho us eh ol d m em be rs No t s ha re d 1 Pu bl ic fa cil ity Shared by No t s ha re d Shared by M iss in g/ DK 5 ho us eh ol ds or le ss DK /M iss in g 5 ho us eh ol ds or le ss M or e th an 5 ho us eh ol ds education of household head None 82.1 .0 3.5 .0 11.0 2.8 .0 .0 .7 100.0 593 Primary 91.3 .3 3.0 .5 4.0 1.0 .0 .0 .1 100.0 2887 Secondary+ 97.7 .4 1.1 .0 .7 .2 .0 .0 .0 100.0 749 Wealth index quintile Poorest 69.2 .0 7.6 .0 17.5 5.1 .0 .0 .7 100.0 845 Second 93.2 .0 3.1 .0 3.3 .4 .0 .0 .0 100.0 842 Middle 95.5 .0 1.8 1.6 1.1 .0 .0 .0 .0 100.0 848 Fourth 98.9 .0 1.1 .0 .0 .0 .0 .0 .0 100.0 845 Richest 98.7 1.3 .0 .0 .0 .0 .0 .0 .0 100.0 848 Total 91.1 .3 2.7 .3 4.4 1.1 .0 .0 .1 100.0 4229 1 MICS indicator 4.3; MDG indicator 7.9 Safe disposal of a child’s faeces is disposing of the stool, by the child using a toilet, or by rinsing the stool into a toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table WS.7R. The most common place to dispose a child’s faeces is in the garbage as solid waste (74 percent of households), and put/rinsed into a toilet or latrine (17 percent of households). 8 percent of children use a toilet/latrine. 25 percent of children had their last stools disposed of safely. table Ws.7R: disposal of child’s faeces percent distribution of children age 0-2 years according to place of disposal of child’s faeces, and the percentage of children age 0-2 years whose stools were disposed of safely the last time the child passed stools, Roma settle- ments, 2011 Place of disposal of child’s faeces Pe rc en ta ge of ch ild re n w ho se la st st oo ls w er e di sp os ed o f sa fe ly1 Nu m be r o f ch ild re n ag e 0- 2 ye ar s Ch ild u se d to ile t/ la tri ne Pu t/r in se d in to to ile t or la tri ne Pu t/r in se d in to d ra in o r di tc h Th ro w n in to ga rb ag e M iss in g To ta l Type of sanitation facility in dwelling Improved 8,1 18,1 ,8 72,1 ,8 100.0 26,2 262 Unimproved (*) (*) (*) (*) (*) (*) (*) 16 Mother’s education None 6,4 10,3 2,3 79,8 1,3 100.0 16,7 64 Primary 9,0 19,3 ,4 70,5 ,7 100.0 28,3 183 Secondary+ (4,2) (17,8) (,0) (77,9) (,0) 100.0 (22,1) 32 Wealth index quintile Poorest 3.1 18.2 .0 77.8 .9 100.0 21.3 68 Second 13.0 13.3 2.0 71.7 .0 100.0 26.2 70 Middle 7.5 17.3 .5 73.2 1.5 100.0 24.8 50 Fourth 10.4 22.4 1.1 64.3 1.7 100.0 32.8 46 Richest (5.1) (15.5) (.0) (79.4) (.0) 100.0 (20.6) 44 Total 7,9 17,1 ,8 73,5 ,8 100.0 25,0 278 1 MICS indicator 4.4 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases 62 MultIple IndIcator cluster survey 2011 63 Table WS.8R presents the percentages of household population by drinking water and sanitation ladders. The table also shows the percentage of household members using improved sources of drinking water and sanitary means of excreta disposal. Overall, as presented in Table WS.8R, more than 90 percent of the Roma population in the country use both improved water sources and sanitation. Of all household members, 99 percent use improved drinking water, 91 percent use improved sanitation, while 91 percent use improved drinking water sources and improved sanitation. However, more detailed analysis reveals disparities between the poorest quintile and the rest of the population in the Roma sample. Almost one third of population in the poorest households do not have access to improved water sources and/or sanitation, unlike the rest of population where over 90 percent have access to these two commodities. table Ws.8R: drinking water and sanitation ladders percentage of household population by drinking water and sanitation ladders, Roma settlements, 2011 Percentage of household population using: Nu m be r o f h ou se ho ld m em be rs Improved drinking water1 Un im pr ov ed d rin kin g w at er To ta l Im pr ov ed sa ni ta tio n2 Unimproved sanitation To ta l Im pr ov ed d rin kin g w at er so ur ce s a nd im pr ov ed sa ni ta tio n Pi pe d in to dw el lin g, p lo t o r ya rd Ot he r i m pr ov ed Sh ar ed im pr ov ed fa cil iti es Un im pr ov ed fa cil iti es Op en d ef ec at io n education of household head None 88,0 11,4 ,6 100,0 82,1 3,5 13,8 ,7 100,0 81,6 593 Primary 96,0 2,9 1,1 100,0 91,3 3,7 5,0 ,1 100,0 90,9 2887 Secondary+ 99,9 ,1 ,0 100,0 97,7 1,5 ,8 ,0 100,0 97,7 749 Wealth index quintile Poorest 82.7 13.8 3.6 100,0 69.2 7.6 22.5 .7 100,0 67.5 845 Second 95.4 3.8 .8 100,0 93.2 3.1 3.7 .0 100,0 93.2 842 Middle 99.7 .3 .0 100,0 95.5 3.4 1.1 .0 100,0 95.5 848 Fourth 100.0 .0 .0 100,0 98.9 1.1 .0 .0 100,0 98.9 845 Richest 100.0 .0 .0 100,0 98.7 1.3 .0 .0 100,0 98.7 848 Total 95,6 3,6 ,9 100,0 91,1 3,3 5,5 ,1 100,0 90,8 4229 1 MICS indicator 4.1; MDG indicator 7.8 2 MICS indicator 4.3; MDG indicator 7.9 63 64 MultIple IndIcator cluster survey 2011 viii RepRoductive health fertility and early childbearing In MICS4, adolescent birth rates and total fertility rates are calculated by using information on the date of last birth of each woman and are based on the one-year period (1-12 months) preceding the survey. Rates are underestimated by a very small margin due to the absence of information on multiple births (twins, triplets, etc.) and on women having multiple deliveries during the one-year period preceding the survey. Table RH.1 shows adolescent birth rates and the total fertility rate. The adolescent birth rate (age-specific fertility rate for women aged 15-19) is defined as the number of births to women aged 15-19 years during the one-year period preceding the survey, divided by the average number of women aged 15-19 (number of women-years lived between ages 15 through 19, inclusive) during the same period, expressed per 1000 women. 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 49. The TFR denotes the average number of children to which a woman will have given birth by the end of her reproductive years if current fertility rates prevailed. In Macedonia, total fertility rate is 2.1, while adolescent birth rate is 13 per 1000 women aged 15-19 years. table Rh.1: adolescent birth rate and total fertility rate adolescent birth rates and total fertility rates, Mace- donia, 2011 Adolescent birth rate1 (Age-specific fertility rate for women age 15-19) Total fertility rate area Urban (4) 2.0 Rural 21 2.3 ethnicity of household head Macedonian (5) 2.0 Albanian 13 2.3 Other (*) 2.1 Total 13 2.1 1 MICS indicator 5.1; MDG indicator 5.4 ( ) – figures based on 125–259 person-year of exposure (*) – figures based on less than 125 person-year of exposure 64 MultIple IndIcator cluster survey 2011 65 fertility and early childbearing – Roma settlements table Rh.2R: early childbearing percentage of women age 15-19 years who have had a live birth, are pregnant with the first child, and have begun childbearing, and those who have had a live birth before age 15, and percentage of women age 20-24 who have had a live birth before age 18, Roma settlements, 2011 Percentage of women age 15-19 who: Number of wom- en age 15-19 Percentage of women age 20-24 who have had a live birth before age 181 Number of wom- en age 20-24 Have had a live birth Are pregnant with first child Have begun childbearing Have had a live birth before age 15 education None (*) (*) (*) (*) 11 45.8 28 Primary 16.4 7.4 23.8 .0 89 31.2 125 Secondary+ 3.6 .5 4.2 .0 72 (.0) 37 Wealth index Poorest 60% 18.7 6.5 25.3 .8 108 38.4 106 Richest 40% 4.8 1.3 6.1 .0 65 13.2 84 Total 13.5 4.6 18.0 .5 173 27.3 190 1 MICS indicator 5.2 ( ) – figures based on 25–49 unweighted cases (*) – figures based on less than 25 unweighted cases RH.3R presents the trends for early childbearing (tables RH2 and RH3 are not presented for the national sample because data on the first born child was not collected in the national survey). As shown in Table RH.2R, 18 percent have begun childbearing: 14 percent of Roma women aged 15-19 have already had a birth, while 5 percent are pregnant with their first child. 0.5 percent have had a live birth before age 15. Out of all Roma women aged 20-24, 27 percent had a live birth before the age of 18, with similar distribution as described for early childbearing before the age 15. Table RH.3R presents the trends in early childbearing. 3 percent of all Roma women aged 15-49 have had a live birth before age 15, with some differences acr

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