Saint Lucia - Multiple Indicator Cluster Survey - 2012

Publication date: 2012

The Saint Lucia Multiple Indicator Cluster Survey (MICS) was carried out in 2012 by the Ministry of Social Transformation, Local Government and Community Empowerment and the Central Statistics Office (CSO) in collaboration with the Ministry of Health, Wellness, Human Services and Gender Relations and the Ministry of Education, Human Resource Development and Labour. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF), Government of Saint Lucia, UN Women and United Nations Population Fund (UNFPA). MICS is an international household survey programme developed by UNICEF. The Saint Lucia 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. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: Ministry of Social Transformation, Local Government and Community Empowerment and Central Statistics Office, ‘Saint Lucia Multiple Indicator Cluster Survey 2012: Final Report’, Castries, Saint Lucia, 2014. 1 SAINT LUCIA MULTIPLE INDICATOR CLUSTER SURVEY 2012 United Nations Children’s Fund (UNICEF) Government of Saint Lucia Ministry of Social Transformation, Local Government and Community Empowerment Central Statistics Office Final Report - April 2014 1 2 SUMMARY TABLE OF FINDINGS Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) indicators, Saint Lucia, 2012 ( ) figures based on 24 -49 unweighted cases. 2 3 3 4 ( ) Figures based on 24 -49 unweighted cases. ** The category of women 15-24 also included girls between 15-18 years 4 5 CONTENTS SUMMARY TABLE OF FINDINGS 2 LIST OF TABLES 7 LIST OF FIGURES 10 ACRONYMS AND ABBREVIATIONS 11 ACKNOWLEDGEMENTS 12 EXECUTIVE SUMMARY 13 1. INTRODUCTION 17 Background 17 Survey objectives 19 2. SAMPLE AND SURVEY METHODOLOGY 20 Sample design 20 Questionnaires 20 Training and fieldwork 21 Data processing 22 3. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 23 Sample coverage 23 Characteristics of households 24 Characteristics of female and male respondents 15–49 years of age and children under 5 26 4. NUTRITION 31 Nutritional status 31 Breastfeeding and infant and young child feeding 34 Salt iodization 40 Low birth weight 41 5. CHILD HEALTH 42 Neonatal tetanus protection 42 Oral rehydration treatment 44 Care seeking and antibiotic treatment of pneumonia 44 Solid fuel use 45 6. WATER AND SANITATION 47 Use of improved water sources 48 Use of improved sanitation facilities 52 Handwashing 56 7. REPRODUCTIVE HEALTH 59 Contraception 59 Unmet need for contraception 61 Antenatal care 63 Assistance at delivery 66 Place of delivery 66 Post-natal health checks 67 5 6 8. CHILD DEVELOPMENT 73 Early childhood education and learning 73 Inadequate Care 77 Early childhood development 78 9. LITERACY AND EDUCATION 80 Literacy among young people 80 School readiness 80 Primary and secondary school participation 82 10. CHILD PROTECTION 86 Birth registration 86 Child labour 87 Child discipline 90 Early marriage/union/polygyny 93 Attitudes toward domestic violence 98 11. HIV AND AIDS, SEXUAL BEHAVIOUR AND ORPHANS 101 Knowledge about HIV transmission and misconceptions about HIV and AIDS 101 Knowledge of mother-to-child HIV transmission 104 Sexual behaviour related to HIV transmission 104 Accepting attitudes toward people living with HIV and AIDS 105 Knowledge of a place for HIV testing, counselling and testing during antenatal care 107 Knowledge of a place for HIV testing and counselling among sexually active women 108 HIV counselling and testing during antenatal care 109 Orphans 114 12. ACCESS TO MASS MEDIA AND USE OF INFORMATION AND COMMUNICATIONS TECHNOLOGY 115 Access to mass media 115 Use of information and communications technology 117 13. ALCOHOL USE 118 APPENDIX A. SAMPLE DESIGN 122 APPENDIX B. LIST OF PERSONNEL INVOLVED IN THE SURVEY 128 APPENDIX C. ESTIMATES OF SAMPLING ERRORS 134 APPENDIX D. DATA QUALITY TABLES 140 APPENDIX E. MICS4 INDICATORS: NUMERATORS AND DENOMINATORS 150 APPENDIX F. QUESTIONNAIRES 162 6 7 LIST OF TABLES Table HH.1: Results of household, women’s and under-5 interviews 23 Table HH.2: Household age distribution by sex 24 Table HH.3: Household composition 26 Table HH.4: Women’s background characteristics 28 Table HH.5: Under-5’s background characteristics 30 Table NU.1: Nutritional status of children 33 Table NU.2: Initial breastfeeding 35 Table NU.3: Duration of breastfeeding 37 Table NU.4: Age-appropriate breastfeeding 38 Table NU.5: Minimum meal frequency 39 Table NU.6: Bottle feeding 39 Table NU.7: Iodized salt consumption 40 Table NU.8: Low birth weight infants 41 Table CH.1: Neonatal tetanus protection 43 Table CH.2: Solid fuel use 45 Table CH.3: Solid fuel use by place of cooking 46 Table WS.1 Use of improved water sources 49 Table WS.2: Household water treatment 50 Table WS.3: Time to source of drinking water 51 Table WS.4: Person collecting water 52 Table WS.5: Types of sanitation facilities 53 Table WS.6: Use and sharing of sanitation facilities 54 Table WS.7: Disposal of child’s faeces 55 Table WS.8: Drinking water and sanitation ladders 56 Table WS.9: Water and soap at place for handwashing 57 Table WS.10: Availability of soap 57 Table RH.1: Use of contraception 60 Table RH.2: Met and unmet need for contraception 62 Table RH.3: Antenatal care provider 64 Table RH.4: Number of antenatal care visits 65 Table RH.5: Content of antenatal care 65 Table RH.6: Assistance during delivery 66 Table RH.7: Place of delivery 67 Table RH.8: Post-partum stay in health facility 68 Table RH.9: Post-natal health checks for newborns 69 Table RH.10: Post-natal care (PNC) visits for newborns within one week of birth 70 Table RH.11: Post-natal health checks for mothers 70 Table RH.12: Post-natal care (PNC) visits for mothers within one week of birth 71 Table RH.13: Post-natal health checks for mothers and newborns 71 7 8 Table CD.1: Early childhood education 74 Table CD.2: Support for learning 75 Table CD.3: Learning materials 76 Table CD.4: Inadequate care 77 Table CD.5: Early child development index 79 Table ED.1: Literacy among young women 81 Table ED.2: School readiness 81 Table ED.3: Primary school entry 82 Table ED.4: Primary school attendance 83 Table ED.5: Secondary school attendance84 Table ED.6: Primary school completion and transition to secondary school 85 Table ED.7: Education gender parity 85 Table CP.1: Birth registration 87 Table CP.2: Child labour 89 Table CP.3: Child labour and school attendance 90 Table CP.4A: Child discipline – practice 91 Table CP.4B: Child discipline – beliefs 92 Table CP.5: Early marriage and polygyny 95 Table CP.6A: Trends in early marriage 96 Table CP. 6B: Trends in early marriage (excludes women in visiting relationships) 97 Table CP.7: Spousal age difference 98 Table CP.8: Attitudes toward domestic violence 99 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV and AIDS, and comprehensive Knowledge about HIV transmission 103 Table HA.2: Knowledge about HIV transmission, misconceptions about HIV and AIDS, and comprehensive. Knowledge about HIV transmission among young women 104 Table HA.3: Knowledge of mother-to-child HIV transmission 105 Table HA.4: Accepting attitudes toward people living with HIV and AIDS 106 Table HA.5: Knowledge of a place for HIV testing 107 Table HA.6: Knowledge of a place for HIV testing among sexually active young women108 Table HA.7: HIV counselling and testing during antenatal care 109 Table HA.8: Sexual behaviour that increases the risk of HIV infection 110 Table HA.9: Sex with multiple partners 111 Table HA.10: Sex with multiple partners among young women 112 Table HA.11: Sex with non-regular partners 113 Table HA.12: Children’s living arrangements and orphanhood 114 Table HA.13: School attendance of orphans and non-orphans 114 8 9 Table MT.1: Exposure to mass media 116 Table MT.2: Use of computers and Internet 117 Table TA.3: Use of alcohol 119 Table SD.1. Enumerated and estimated households and population in 2010 Census, Saint Lucia 122 Table SD.2. Summary of sampling frame for MICS (provisional figures) 123 Table SD.3. Some alternative methods of allocating the sample to urban and rural areas 124 Table SE.1: Indicators selected for sampling error calculations 135 Table SE.2: Sampling errors: total sample 136 Table SE.3: Sampling errors: urban areas 137 Table SE.4: Sampling errors: rural areas 138 Table DQ.1: Age distribution of household population 140 Table DQ.2: Age distribution of eligible and interviewed women 141 Table DQ.3: Age distribution of under-5s in household and under-5 questionnaires 141 Table DQ.4: Women’s completion rates by socio-economic characteristics of households 142 Table DQ.5: Completion rates for under-5 questionnaires by socio-economic characteristics of households 142 Table DQ.6: Completeness of reporting 143 Table DQ.7: Completeness of information for anthropometric indicators 144 Table DQ.8: Heaping in anthropometric measurements 145 Table DQ.9: Observation of places for handwashing 145 Table DQ.10: Observation of women’s health cards 145 Table DQ.11: Observation of under-5s birth certificates 146 Table DQ.12: Presence of mother in the household and the person interviewed for the under-5 questionnaire 146 Table DQ.13: Selection of children aged 2–14 years for the child discipline module 146 Table DQ.14: School attendance by single age 147 9 10 LIST OF FIGURES Figure HH.1: Age and sex distribution of household population, MICS Saint Lucia, 2012 25 Figure HH.2: Population pyramid, Saint Lucia Population and Housing Census, 2010 25 Figure NU.1: Percentage of newborns who started breastfeeding within one hour and within one day of birth 36 Figure WS.1: Percentage distribution of household members by source of drinking water 48 Figure CP.1: Percentage of children 2–14 years according to method of discipline and sex 93 Figure HA.1: Percentage of women who have comprehensive knowledge of HIV and AIDS transmission, by education 102 Figure HA.2: Sexual behaviour that increases risk of HIV infection 111 Figure Map 1: Map showing Saint Lucia MICS4 Urban and Rural clusters 126 10 11 ACRONYMS AND ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome CSO Central Statistics Office DQ Data Quality Tables ECDI Early Childhood Development Index ED Enumeration District GPI Gender Parity Index HIV Human Immunodeficiency Virus IUD Intrauterine Device JMP WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MICS4 Fourth global round of Multiple Indicator Cluster Surveys programme MoE Ministry of Education, Human Resource Development and Labour MoH Ministry of Health, Wellness, Human Services and Gender Relations MoST Ministry of Social Transformation, Local Government and Community Empowerment ORS Oral Rehydration Salts ORT Oral Rehydration Treatment PNC Post-Natal Care PNHC Post-Natal Health Checks PPM Parts Per Million PPS Probability Proportional To Size PSUS Primary Sampling Units RHF Recommended Home Fluid SD Standard Deviation SPSS Statistical Package For Social Sciences STI Sexually Transmitted Infection UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund UN Women United Nations Entity for Gender Equality and the Empowerment of Women WHO World Health Organization 11 12 ACKNOWLEDGEMENTS It is with great pride and appreciation that the government of Saint Lucia through the Ministry of Social Transformation, Local Government and Community Empowerment and the Central Statistics Office wishes to acknowledge the United Nations Development Fund for Children (UNICEF) for their valuable role in commissioning the Multiple Indicator Cluster Survey. We are indeed grateful for the contributions of the Ministry of Health, Wellness, Human Services and Gender Relations, the Ministry of Education, Human Resource Development and Labour and other collaborating ministries. We wish to acknowledge the contribution of the Permanent Secretaries Mr. Donavan Williams, Ms. Joanna Reynald-Arthurton and Ms. Juliana Alfred, the National MICS Coordinator Mr. Augustus Cadette, the MICS Focal Point, Mr. Eulampius Frederick and other support staff from the Ministry of Social Transformation, Local Government and Community Empowerment. Our sincere gratitude goes to Mr. Edwin St. Catherine, Director of The Central Statistics Office and Ms. Jeanne Majella Louis, Assistant Director/ MICS Technical Cordinator for their invaluable leadership and technical guidance. We thank the Steering and Technical Committees and the MICS report writers for their valuable work and guidance. A special note of thanks goes to the data processing team, mapping staff, field staff and allother support staff of the Central Statistics Office, as outlined in Appendix B, for their hard work. We would like to express thanks to the respondents within the households who participated in the survey and their willingness to give their time to provide valuable information. 13 Special thanks goes to UNICEF Global MICS Team (Headquarters, New York) and the Latin America and Caribbean Regional Office (LACRO) team for their technical and financial support. We also acknowledge the financial support provided by UNICEF, United Nations Population Fund (UNFPA) and UNWOMEN towards the collection of data on the situation of women and children in Saint Lucia. EXECUTIVE SUMMARY The Saint Lucia Multiple Indicator Cluster Survey (MICS) is a nationally representative household survey developed under the guidance of the United Nations Children’s Fund (UNICEF) to provide internationally comparable and up-to-date information on the country’s children and women. The survey measure key indicators used to monitor progress towards the Millennium Development Goals (MDGs) and will assist in policy decisions and government interventions. Additional information on the global MICS project can be obtained from www. childinfo.org. The Saint Lucia MICS was conducted in 2012 as part of the fourth global round of MICS (MICS4), with the implementing agencies within the Government of Saint Lucia being the Ministry of Social Transformation, Local Government and Community Empowerment (MoST) and the Central Statistics Office (CSO) in collaboration with the Ministry of Health, Wellness, Human Services and Gender Relations (MoH), Ministry of Education, Human Resource Development and Labour (MoE) and other government departments as well as non- government agencies. The Saint Lucia MICS was conducted using a sample of 2,000 households from both rural and urban areas in all the country’s districts. Information was collected from 1,718 households about 1,253 women aged 15–49 years and 291 children under the age of 5 living in the households. A set of three questionnaires – a household questionnaire, a questionnaire for women aged 15–49years and a questionnaire for children under 5 – was used to conduct face-to-face interviews, and each yielded response rates of over 90 percent. The head of the household, whether male or female, provided information on the composition of its members by age and sex, access to improved water and sanitation, education levels, child labour, methods used to discipline children and other living conditions. Women aged 15–49 were interviewed and provided information on issues such as reproductive health, literacy and education, attitude towards domestic violence, knowledge and practices related to HIV and AIDS, access to mass media, the use of information and communication technology and the use of alcohol. Information was obtained from the mothers or caregivers about children under 5 on issues such as nutrition, child health, child development, birth registration, breastfeeding, care of illness and anthropometry. The Saint Lucia MICS data reflected similar patterns in age and sex distribution when compared with data from the country’s 2010 Population and Housing Census. Generally the ratio of approximately one male to one female (1:1) was observed for most of the age groups in both the MICS and the Census. The MICS data showed that the population of children below the age of 17 was about 27 percent compared to approximately 30 percent for the corresponding age group in the Census. 14 Nutrition Children in Saint Lucia are more likely to be overweight (7 percent) than underweight or stunted. The MICS data showed that approximately 3 percent of children below the age of 5 are underweight or stunted. Almost all children (96 percent) were breastfed at some time. However, despite recommendations from UNICEF and the World Health Organization (WHO), only one out of two infants (50 percent) were breastfed within one hour of birth while one in every four infants under 2 years (23 percent) were appropriately breastfed. About nine out of ten children aged 0–23 months (86 percent) were bottle fed with a nipple. All children in Saint Lucia under the age of 5 were weighed at birth, and the MICS data revealed that 28 percent had a low birth weight (i.e., less than the recommended weight of 2,500 grams). The level of iodine contained in salt consumed in the households was found to be appropriate in 46 percent of the households. The use of iodized salt was slightly lower in the poorest households (42 percent) compared to the richest households (48 percent) Child Health Reported cases of diarrhoea (approximately 7 percent) and suspected pneumonia among children under age 5 in the two weeks preceding the survey were minimal. About 3 percent of children under 5 years were suspected to have pneumonia during the two weeks preceding the survey. Water and Sanitation Overall the majority of household members in Saint Lucia (99 percent) are using improved sources of drinking water, with the two main sources being water piped into dwelling (57 percent) and bottled water (26 percent). The members of the poorest 40 percent of households are less likely to use water piped into their dwelling (47 percent) as the main improved source of drinking water compared with the highest 60 percent of households (63 percent). Almost all household members (90 percent) use improved sanitation facilities that are not shared. The safe disposal of children’s faeces, particularly as it relates to faeces in disposable nappies, must be addressed since the data revealed that the last stools of only one in every four children aged 2 years and younger (27 percent) were disposed of safely. Reproductive Health Approximately 56 percent of women who are currently married or in a union reported using some method of contraception, with the two most popular methods being the pill (22 percent) and male condoms (14 percent). One of the least popular methods was periodic abstinence. The unmet need for contraception is 17 percent. Ninety-seven percent of women received antenatal care at least once during their pregnancy from skilled personnel. The antenatal care was more than twice as likely to be provided by a doctor (67 percent) than by a nurse (30 percent). Almost all births during the two years preceding the survey were delivered at a health facility. Nurses and midwives were much more likely than medical doctors to assist during delivery (63 percent nurses/ midwives compared with 35 percent medical doctors). Approximately 19 percent of deliveries were done by Caesarean section. The majority of women stayed 1–2 days at the health facility 15 following birth. However, it is of concern that about one out of every three women (37 percent) spent 3 or more days. About 88 percent of newborns and mothers received post-natal health checks. Child development Approximately 85 percent of children aged 36–59 months are attending pre-school in Saint Lucia. The MICS data showed that nearly all children aged 36–59 months (99 percent) are developmentally on track in the physical and learning domains; however, attention must be directed to the social-emotional domain (87 percent) and the literacy-numeracy domain (70 percent). Overall, 91 percent of children aged 36–59 months are developmentally on track, as measured by the Early Childhood Development Index. While approximately 93 percent of children aged 36–59 months are engaged in four or more activities with adult household members, just about half of them (50 percent) are engaged in one or more activities with their father. This may be primarily due to the situation that half of the children aged 36–59 months (48 percent) do not live with their biological father. About 5 percent of children under age 5 were left in inadequate care. Literacy and education The vast majority of children of primary school age (over 99 percent) are attending school, with 98 percent of children of school entry age entering grade K. Approximately 92 percent of children are attending secondary school, with attendance higher among children from the wealthier households. In secondary schools, attendance generally decreases slightly as the children grow older. The primary school completion rate was about 98 percent while the transition rate to secondary school was 96 percent. In Saint Lucia the net attendance ratio of girls to boys, also known as the gender parity index, is 0.99 for primary schools and 1.01 for secondary schools indicating parity in attendance. Child protection The goal to ensure that every child is registered with civil authorities and acquires a name and a nationality has not been met. While nine out of ten children under the age of 5 (92 percent) have been registered, approximately 8 percent have not. About 98 percent of children in the wealthiest 60 percent of households are registered compared with 86 percent from the poorest 40 percent of households. Eight percent of children ages 5–14 years are engaged in child labour, and they are three times more likely to be from the poorest 40 percent of households (12 percent) compared to the richest 60 percent of households (4 percent). The prevalence of child labour is higher among children in the age group of 5–11 years than those within the age group of 12–14 years. Overall two out of every three children aged 2–14 years (68 percent) experienced at least one form of psychological or physical punishment through their parents or other adult household members during the month preceding the survey, with male children more likely to be subjected to psychological aggression and/or any form of physical punishment compared to females. About 3 percent of women aged 15–49 in Saint Lucia were married or entered a marital union before the age of 15 with approximately 14 percent of those within the age group of 15–19 years being married or in a union at the time of the survey. These 16 figures include women who were in visiting relations, which are common among the youngest women. One in every five women (21 percent) aged 20–24 years was married or in a union with a man who was older by 10 or more years at the time of the survey. Approximately 7 percent of women aged 15–49 believe that a husband is justified in beating his wife/partner in a number of specified circumstances. This justification is particularly high among young women aged 15–19 compared with women who are older. HIV and AIDS Almost all women in Saint Lucia have heard of HIV and AIDS (99 percent). Overall two out of every three women aged 15–49 years (65 percent) had comprehensive knowledge of HIV with both education and wealth having a positive correlation with this. While the majority of women (95 percent) knew that HIV can be transmitted from mother to child, only half knew of the three methods of mother-to-child transmission. Although the majority of women aged 15–49 years (99 percent) agreed with at least one accepting attitude towards persons living with HIV and AIDS, the results show that stigma and discrimination still exist as only one in ten women (14 percent) agreed with all four accepting attitudes. The majority of women (95 percent) knew of a place to get tested for HIV. Although 72 percent had been tested previously, only 28 percent had been tested in the last 12 months. While 97 percent of women aged 15–49 years reported having received antenatal care from a health care professional for the last pregnancy, only two of every three women (63 percent) reported having received HIV counselling during the antenatal period. Mass media On a weekly basis, about two out of every five women aged 15–49 (39 percent) are exposed to all three types of media (newspaper/magazine, radio and television). Generally women were twice as likely to watch television (93 percent) on a weekly basis than to read a newspaper or magazine (48 percent). Television and radio were the two most popular media among women aged 15–49 years. Almost all women aged 15–24 years (93 percent) had used the Internet in the last 12 months. Alcohol use Approximately 14 percent of women aged 15–49 years had never consumed any alcohol but half of them (51 percent) had at least one drink of alcohol on one or more days during the previous month. 17 1INTRODUCTIONBackgroundSaint Lucia is a 616 sq. km volcanic island located in the Lesser Antilles in the Eastern Caribbean. It is an independent nation with English as the official language and an estimated population of 165,595 (see Appendix A). This report is based on the Saint Lucia Multiple Indicator Cluster Survey (MICS), conducted in 2012 by the Ministry of Social Transformation, Local Government and Community Empowerment and the Central Statistics Office (CSO) and funded by the United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA) and UN Women. The survey provides valuable information on the situation of children and women in the country and was undertaken, in large part, due to the need to monitor progress towards goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of A World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build on promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see box). The survey provides valuable information on the situation of children and women in the country 18 19 This final report presents the results of the indicators and topics covered in the survey. Survey objectives The 2012 Saint Lucia MICS has as its primary objectives: u To provide up-to-date information for assessing the situation of children and women in Saint Lucia; u To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed goals as a basis for future action; u To contribute to the improvement of data and monitoring systems in Saint Lucia and to strengthen technical expertise in the design, implementation and analysis of such systems. u To generate data on the situation of children and women, including the identification of vulnerable groups and of disparities, to inform policies and interventions. 20 Sample design The sample for the Saint Lucia Multiple Indicator Cluster Survey (MICS) was designed to provide estimates for a large number of indicators on the situation of children and women at the national level and for urban and rural areas. The urban and rural census enumeration districts (EDs) were identified as the main sampling strata. The sample was selected in two stages. First, the EDs were selected systematically with probability proportional to size and 40 EDs were selected from the urban stratum and 60 from the rural stratum, making a total of 100 EDs. Second, household visitation records from the 2010 Population and Household Census were used for the selection of households within each of the selected EDs. A systematic sample of 20 households was drawn from each sample ED, making a total of 2,000 selected households. All of the selected EDs were visited during the fieldwork period. The sample was stratified by urban and rural areas and is not self-weighting. For reporting national level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three sets of questionnaires were used in the survey: (1) a household questionnaire, which was used to collect information on all de jure household members (usual residents), the household and the dwelling; (2) a women’s questionnaire administered to all women aged 15–49 years in each household; and (3) an under-5 questionnaire administered to mothers or caretakers for all children under 5 living in the household. The household questionnaire, which was administered to the head of the household whether male or female, included the following modules: u Household listing form u Education 2SAMPLE AND SURVEY METHODOLOGY 21 u Water and sanitation u Household characteristics u Child labour u Child discipline u Handwashing u Salt iodization The questionnaire for individual women was administered to all women aged 15–49 years living in the households and included the following modules: u Women’s background u Access to mass media and use of information and communications technology u Child mortality without birth history (abridged module used to calculate births in the last 2 years) u Desire for last birth u Maternal and newborn health u Post-natal health checks u Contraception u Unmet need for contraception u Attitudes toward domestic violence u Marriage/union u Sexual behaviour u HIV and AIDS u Alcohol use The questionnaire for children under 51 was administered to mothers or caretakers of such children living in the households. In cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: u Age u Birth registration u Early childhood development u Breastfeeding u Care of illness u Anthropometry The questionnaires are based on the MICS4 model questionnaire.2 Four questionnaires – the household questionnaire, questionnaire for individual women and questionnaire for children under 5 as well as a questionnaire for individual men – were pre-tested in six EDs during November 2012. Three urban and three rural EDs were selected. The three urban EDs were located in Faux A Chaud/ Tapion (Castries), Gros Islet Town and La Pointe Dennery Village. The three rural EDs were located in Ciceron (Castries), Belle Vue, Vieux-Fort and La Pointe (Micoud). Based on the results of the pre-test, modifications were made to the wording of the questionnaires and a decision was taken not to administer the questionnaire for individual men in the main survey. This was due to the difficulty in finding men aged 15– 49 at home to be interviewed and the low response rate. A copy of Saint Lucia’s MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the places used for handwashing and 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. Training and fieldwork Training for the fieldwork was conducted for 10 days during the month of March 1 The terms ‘children under 5’, ‘children age 0–4 years’ and ‘children aged 0–59 months’ are used interchangeably in this report. 2 The model MICS4 questionnaires can be found at www.childinfo.org/mics4_questionnaire.html 22 MICS4 programme and adapted to the Saint Lucia questionnaire were used throughout. Data processing began simultaneously with data collection in April 2012 and was completed in June 2012. 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. 2012. Training included lectures on interviewing techniques and the contents of the questionnaires as well as mock interviews between trainees for them to gain experience in asking questions. Towards the end of the training period, trainees spent two days in practice interviews in six enumeration areas: three urban (Vieux Fort Town, Entrepot and Anse la Raye Village) and three rural (Augier, Monchy and Coolie Town). There were also two data processing training workshops. The first was conducted for two days to familiarize all MICS project staff who would be involved in the administration of the MICS with the procedures for data processing. It was also attended by some members of the technical committee (this training ran simultaneously with the two days of practice interviewing during the fieldwork training). The second data processing workshop was conducted for five days and was attended by the data entry operators. The MICS survey data were collected by four teams. Each team was comprised of four interviewers, one driver, one editor, one measurer and a supervisor. Fieldwork began in March 2012 and ended in May 2012. Data processing Data were entered on four desktop computers using the Census and Survey Processing System (CSPro) software by four data entry operators, one questionnaire administrator, one secondary editor and a data entry supervisor. In order to ensure quality control, all questionnaires were double entered (entered and verified) and internal consistency checks were performed. Procedures and standard programmes developed under the global 23 Sample coverage The 2,000 households selected were found to contain 2,009 households. All the households were visited and 1,800 were found to be occupied. Of these, 1,718 households were successfully interviewed, yielding a household response rate of 95 percent. In the interviewed households, 1,341 eligible women (aged 15–49 years) were identified. Of these, 1,253 women were successfully interviewed, yielding a response rate of 93 percent within interviewed households. There were 300 eligible children under age 5 listed in the household questionnaire, and questionnaires were completed for 291 of these children (a response rate of 97 percent). Overall response rates of 89 and 93 percent were calculated for the women’s and under-5’s interviews respectively (Table HH.1). The response rates were similar for both the urban and rural areas, yielding rates of over 90 percent for the household, women and children under 5. 3SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Area Total Urban Rural Households sampled 803 1,206 2,009 Households occupied 711 1,089 1,800 Households interviewed 678 1,040 1,718 Household response rate 95.4 95.5 95.4 Women eligible 497 844 1,341 464 789 1,253 Women's response rate 93.4 93.5 93.4 Women's overall response rate 89.0 89.3 89.2 Children under 5 eligible 112 188 300 Children under 5 mother/caretaker interviewed 111 180 291 Under-5's response rate 99.1 95.7 97.0 Under-5's overall response rate 94.5 91.4 92.6 Women interviewed Table HH.1: Results of household, women's and under-5 interviews Number of households, women, and children under 5 by results of the household, women's, and under-5's interviews, and household, women's and under-5's response rates, Saint Lucia, 2012 24 the population pyramid in Figure HH.1. In the 1,718 households successfully interviewed in the survey, 4,961 household members were listed. Of these, 2,424 were males and 2,537 were females. Characteristics of households The weighted age and sex distribution of the survey population is provided in Table HH.2. The distribution was used to produce Males Females Total Number Number Number Age 0–4 149 6.1 155 6.1 304 6.1 5–9 171 7.0 154 6.1 325 6.5 10–14 221 9.1 196 7.7 418 8.4 15–19 247 10.2 230 9.1 477 9.6 20–24 206 8.5 210 8.3 416 8.4 25–29 183 7.5 194 7.6 376 7.6 30–34 187 7.7 181 7.2 369 7.4 35–39 154 6.3 166 6.5 319 6.4 40–44 157 6.5 196 7.7 353 7.1 45–49 188 7.7 188 7.4 376 7.6 50–54 150 6.2 150 5.9 300 6.0 55–59 106 4.4 116 4.6 222 4.5 60–64 101 4.2 104 4.1 205 4.1 65–69 73 3.0 80 3.1 153 3.1 70–74 45 1.8 65 2.6 110 2.2 75–79 34 1.4 65 2.5 98 2.0 80–84 28 1.1 32 1.3 59 1.2 85+ 21 0.9 53 2.1 74 1.5 Missing/DK 5 0.2 1 0.0 6 0.1 Dependency age groups 0–14 541 22.3 506 19.9 1,047 21.1 15–64 1,677 69.2 1,736 68.4 3,413 68.8 65+ 201 8.3 294 11.6 495 10.0 Missing/DK 5 0.2 1 0.0 6 0.1 Children and adult populations Children 0–17 years 698 28.8 641 25.3 1,339 27.0 Adults aged 18+ years 1,721 71.0 1,894 74.7 3,616 72.9 Missing/DK 5 0.2 1 0.0 6 0.1 Total 2,424 100 2,537 100 4,961 100 % % % Table HH.2: Household age distribution by sex Percentage and frequency distribution of the household population by five-year age groups, by dependency age groups, by child (aged 0–17 years) and adult populations (aged 18 or more) and by sex, Saint Lucia, 2012 25 percent respectively. There were no major differences in terms of the sex distribution of households from the MICS data when compared to that of the 2010 Census except for females 85 years and over, who had a margin of less than 1 percent. The population of children below the age of 17 also reflected small differences to that of the 2010 Census. Whereas the MICS data showed 27 percent, the corresponding rate from the Census was about 30 percent. The trend in the age and sex distribution from the MICS mirrored that of the 2010 Population and Housing Census in most of the categories with no major differences among various groupings (Figure HH.1 and HH.2). There were only minor differences among the broad age groups 0–14, 15–64 and 65+. The rates obtained from the MICS showed 21 percent of the household population were 0–14 years, 69 percent were between 15–64 years and the remaining 10 percent were over 65 years. The corresponding groups from the 2010 Census recorded rates of 24 percent, 67 percent and 9 26 Appendix A for more details about the weighting. Table HH.3 provides basic background information on the households. Within households, the sex of the household head, area, number of household members, education of household head and ethnicity3 of the household head are shown in the table. These background characteristics were used Tables HH.3 – HH.5 provide basic information on the households, female respondents aged 15–49 and children under 5 by presenting the weighted as well as the unweighted 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 were presented only with weighted numbers. See 3 This was determined by asking the respondent to state the ethnic group to which the head of the household belonged. Note that the category ‘mixed descent’ refers to any ethnic mix: black and white, black and Asian and other. Weighted percentage Weighted Unweighted Sex of household head Male 58.6 1006 984 Female 41.4 712 734 Area Urban 19.8 340 678 Rural 80.2 1,378 1,040 Number of household members 1 26.8 460 476 2 24.3 418 409 3 17.6 303 301 4 14.3 246 248 5 7.4 127 124 6 5.0 86 80 7 2.2 37 40 8 1.3 22 21 9 0.6 10 9 10+ 0.6 10 10 Education of household head None 4.0 69 56 Primary 51.8 889 911 Secondary + 42.4 729 720 Missing/DK 1.8 31 31 Ethnicity of household head African descent 84.8 1,457 1,460 Mixed descent 11.9 204 193 East Indian 2.3 39 37 Other ethnicity 0.7 12 18 Missing/DK 0.3 6 10 Total 100.0 1,718 1,718 Households with at least: one child aged 0– years 15.4 1,718 1,718 one child aged 0– 17 years 42.5 1,718 1,718 one woman aged 15–49 years 57.0 1,718 1,718 Mean household size 2.9 1,718 1,718 Background characteristics Table HH.3: Household composition Percentage distribution of households by selected characteristics, Saint Lucia, 2012 27 Among the household heads, 85 percent were of African descent and about 15 percent were of mixed or other descent. Table HH.3 also shows that the proportion of households with at least one woman aged 15–49 years (57 percent) was about four times that of households with at least one child below the age of 5 years (15 percent). Households with at least one child between the ages of 0–17 years accounted for about 43 percent. 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 and of children under age 5. In the two tables, the total numbers of weighted and unweighted observations are equal since sample weights have been normalized (standardized) (see Appendix A). In addition to providing useful information on the background characteristics of women and children, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. 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. Table HH.3 shows that the MICS found the proportion of households headed by females to be 41 percent (the same as the results of the 2010 Census). The differences between the number of urban households (20 percent) and rural households (80 percent) are primarily due to the methodology employed in the selection of the sample. A comparison of the 2010 Census and the MICS shows marginal differences in the household compositions between the two sources. The decreasing trend in the total fertility rate over the past two decades and the small average household size of three persons observed in the data from the 2010 Census were also observed in the MICS (2.9 persons). The proportion of households with fewer than five members as indicated by the MICS was 83 percent, with single person households accounting for about 27 percent. The corresponding percentages for the 2010 Census were 82 percent and 27 percent. Table HH.3 shows that about one in two households (56 percent) are headed by persons with no/primary school as the highest level of education and two out of every five households are headed by persons with secondary or greater education (42 percent). 27 28 Background characteristics Weighted percentage Number of women Weighted Unweighted Area Urban 18.2 228 464 Rural 81.8 1,025 789 Age 15–19 17.0 213 213 20–24 15.2 191 189 25–29 14.2 178 178 30–34 13.1 164 160 35–39 12.6 158 158 40–44 13.9 174 183 45–49 14.0 175 172 Marital/union status Currently in visiting relationship 18.3 228 242 Currently married/in union 39.1 489 482 Widowed 0.1 2 2 Divorced 0.8 10 10 Separated 7.2 91 82 Formerly in a visiting relationship 7.8 97 103 Never married/in union 26.7 334 331 Motherhood status Ever gave birth 58.8 736 748 Never gave birth 41.2 517 505 Births in last two years Had a birth in last two years 8.0 101 98 Had no birth in last two years 92.0 1,152 1,155 Women’s education None 0.5 6 5 Primary 21.7 272 279 Secondary + 77.8 975 969 Wealth index quintiles Poorest 16.6 207 210 Second 19.8 248 258 Middle 20.1 252 271 Fourth 22.1 277 270 Richest 21.4 269 244 Ethnicity of household head African descent 84.5 1058 1066 Mixed descent 13.0 162 152 East Indian 2.0 25 24 Other ethnicity 0.4 5 7 Missing/DK 0.2 2 4 Total 100 1,253 1,253 Table HH.4: Women's background characteristics Percentage and frequency distribution of women aged 15–49 years by selected characteristics, Saint Lucia, 2012 29 The age distribution of the women showed that the proportion aged 15–24 years was 32 percent while those aged 45–49 years stood at 14 percent. A look at the marital/union status of the women 15–49 years showed that 39 percent were currently married or in a cohabiting union whereas approximately 18 percent were in a visiting relationship. In the two years preceding the MICS, nine out of ten of the women (92 percent) had not given birth to any children while a large percentage (41 percent) had never had a child. Overall, three out of every four women between 15–49 years (78 percent) had attained secondary or higher levels of education. A wealth index using a quintile distribution of households was computed to determine the wealth status of households.4 Table HH.4 shows that about 17 percent of the women fell within the poorest quintile and a further 20 percent were in the second poorest quintile while 21 percent were within the wealthiest quintile. Some background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, area, age, mother’s or caretaker’s education, wealth and ethnicity. There was no notable difference between the sexes. Similar to the distribution of the sample, there were more children in the rural areas compared to the urban areas. The age categories of the children ranged from 0–59 months with the majority (over 65 percent) falling within the ages 2–5 years. 4 Principal components analysis was performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics related to the household’s wealth to assign weights (factor scores) to each of the household assets. Next, each household was 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 then into five equal parts (quintiles) from lowest (poorest) to highest (richest).The wealth score was finally divided into two parts, the poorest 40 percent and the richest 60 percent to ensure sufficient number of cases. The assets used in these calculations were: main source of water, type of toilet facility, number of rooms in the household for sleeping, main material of dwelling floor, main material of roof, main material of exterior walls, electricity, radio, television, non-mobile phone/fixed line telephone, refrigerator, table, bed, sofa, stove, washing machine, Internet service, air conditioning unit, cable/ satellite television, mobile/cellular telephone, car/ truck, boat for livelihood, computer, stereo/CD player, boat for pleasure/yacht, portable audio device (iPod/ MP3), owns household, owns land, number of acres of agricultural land, owns livestock, herds or other animals or poultry, owns cattle, milk cows or bulls, owns horses, donkeys or mules, goats, sheep, chickens, pigs, has a bank account. The wealth index is intended to produce a ranking of households by wealth, from poorest to richest and 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 L. Pritchett, ‘Estimating Wealth Effects Without Expenditure Data – or Tears: An application to educational enrolments in states of India’, Demography, vol. 38, no. 1, pp. 115–132; Gwatkin, D.R., S. Rutstein, K. Johnson, R. Pande, and A. Wagstaff, ‘Socio-Economic Differences in Health, Nutrition, and Population’, HNP/Poverty Thematic Group, World Bank, Washington, DC, 2000; and Rutstein, S.O. and K. Johnson, ‘The DHS Wealth Index’, DHS Comparative Reports No. 6, ORC Macro, Calverton, Maryland, 2004. 30 In terms of the educational status of the mothers/caretakers of children under 5, three out of four (over 76 percent) had achieved secondary or higher level of formal schooling and a further one out of five (23 percent) had at least attained education at the primary level. An analysis of the wealth index of those households where children under 5 years were found showed that two out of three (over 65 percent) were in the bottom three quintiles. The issue of ethnicity remains the same throughout the tables, with persons of African descent being the most frequent ethnicity in Saint Lucia. Background characteristics Weighted percentage Number of children Weighted Unweighted Sex Male 49.5 144 144 Female 50.5 147 147 Area Urban 18.5 54 111 Rural 81.5 237 180 Age in months 0–5 9.0 26 25 6–11 10.3 30 28 12–23 15.7 46 47 24–35 22.6 66 69 36–47 22.0 64 62 48–59 20.4 59 60 Mother's education None 2.0 5 3 Primary 23.8 69 70 Secondary + 74.5 217 218 Wealth index quintiles Poorest 21.6 63 68 Second 25.2 73 73 Middle 19.6 57 61 Fourth 17.7 51 46 Richest 16.0 46 43 Ethnicity of household head African descent 86.7 252 251 Mixed descent 12.3 36 36 East Indian 0.7 2 2 Other ethnicity 0.4 1 2 Total 100 291 291 Table HH.5: Under-5's background characteristics Percentage and frequency distribution of children under 5 years by selected characteristics, Saint Lucia, 2012 31 Nutritional status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness and are well cared for, they reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and those who survive have recurring sicknesses and faltering growth. Three quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. 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 5. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the World Health Organization (WHO) growth standards.5 Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median of the reference population are considered moderately or severely underweight, while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. 4NUTRITION 5 World Health Organization, ‘WHO Child Growth Standards’, WHO, Geneva, 2007, available at www.who.int/childgrowth/ standards/second_set/technical_report_2.pdf 32 Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. In the Saint Lucia MICS, weights and heights of children under 5 years of age were measured using anthropometric equipment recommended by UNICEF (www.childinfo.org). Findings in this section are based on the results of these measurements. 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 more than two standard deviations above the median of the reference population, and mean z-scores for all three anthropometric indicators. Children in Saint Lucia are more likely to be overweight (7 percent) than underweight or stunted. The MICS data showed that approximately 3 percent of children below the age of 5 are underweight or stunted. 32 33 34 (i.e., low weight for height) while 7 percent were overweight (i.e., excess weight for height). Children in Saint Lucia are thus more likely to be overweight than underweight or stunted. Table NU.1 shows that boys fare worse than girls on the anthropometric indicators. However, these differences appear relatively small except in the case of overweight, where boys are much more likely to be overweight than girls (9 percent compared with 4 percent). Differences by sex should be investigated in further analysis of the data. Breastfeeding and infant and young child feeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients and is economical and safe. However, many mothers stop breastfeeding too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and is unsafe if clean water is not readily available. WHO/UNICEF have the following feeding recommendations: u Exclusive breastfeeding for the first six months u Continued breastfeeding for two years or more u Safe and age-appropriate complementary foods beginning at 6 months u Frequency of complementary feeding: two times per day for 6–8-month-olds; three times per day for 9–11-month-olds It is also recommended that breastfeeding be initiated within one hour of birth. The indicators related to recommended child feeding practices are as follows: Children whose full birth date (month and year) was not obtained and children whose measurements were outside a plausible range were excluded from Table NU.1. Children were excluded from one or more of the anthropometric indicators if their weights or heights were not measured, whichever applicable. For example, if a child had been weighed but his/her height had not been measured, the child was included in underweight calculations but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality tables (Table DQ.7) in Appendix D. Table DQ.7 shows that almost all children under 5 years (96 percent) had valid weight and date of birth. The same proportion (96 percent) also had valid height and date of birth, while more than nine out of ten (94 percent) had valid weight and height. The table also shows that due to implausible measurements and missing weight and/ or height, approximately 4 percent of the children were excluded from calculations of the weight-for-age indicator. The same percentage were excluded for the height- for-age indicator, while slightly more of the children (6 percent) were excluded for the weight-for-height indicator. Table DQ.8 also shows that approximately 40 percent of measures for height are heaped on 0 or 5. This may affect the validity of results for small samples such as this survey. Table NU.1 shows that whilst no children were severely underweight, about 3 percent of children under 5 years were moderately underweight (i.e., weighed less than the required weight for their age), with an equal percentage (3 percent) being moderately stunted (i.e., too short for their age). Three percent were also moderately wasted 35 Although breastfeeding is a very important step in the management of lactation and establishment of a physical and emotional relationship between baby and mother, only one out of two babies (50 percent) were breastfed for the first time within one hour of birth. There was no difference in this early initiation of breastfeeding when the urban areas were compared to the rural areas. Seven out of every ten newborns (72 percent) began breastfeeding within one day of birth and approximately one in four newborns (28) percent) received a prelacteal feed. However, almost all babies (96 percent) were breastfed at some point between 0–23 months. Approximately 4 percent of children less than 6 months were exclusively breastfed. However, this figure is based on 25 unweighted cases and should be interpreted with caution (Table NU4). u Early initiation of breastfeeding (within 1 hour of birth) u Exclusive breastfeeding rate (< 6 months) u Predominant breastfeeding (< 6 months) u Continued breastfeeding rate (at 1 year and at 2 years) u Duration of breastfeeding u Age-appropriate breastfeeding (0–23 months) u Introduction of solid, semi-solid and soft foods (6–8 months) u Minimum meal frequency (6–23 months) u Milk feeding frequency for non- breastfeeding children (6–23 months) u 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. 36 Figure NU.1 shows that when the urban and rural areas were compared, there were no differences in the percentage of newborns who started breastfeeding within one hour of birth. Approximately 3.5 percent of children aged less than 6 months were exclusively breastfed and 21.3 percent were predominantly breastfeeding (data not shown). However, these two indicators must be taken with extreme caution due to the small sample size below 50 unweighted cases. Table NU.3 shows the median duration of any breast feeding, exclusive breastfeeding and predominant breastfeeding among children aged 0–35 months in Saint Lucia. The median duration of any breastfeeding was 12.6 months whereas it was less than one month for exclusive breastfeeding and less than two months for predominant breastfeeding. The median for any breastfeeding was higher among male children (12.8 months) compared with female children (7.3 months). ( ) Figures based on 25–49 unweighted cases. 37 receiving breastmilk and solid, semi-solid or soft food. On this basis, only one quarter of the children aged 0–23 months were being appropriately fed. Age-appropriate feeding among all infants aged 0–5 months decreased drastically to 4 percent for those who were exclusively breastfed. The adequacy of infant feeding in children under 24 months is provided in Table NU.4. 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 37 38 semi-solid or soft foods if they are 6–8 months old and three or more meals if they are 9–23 months. For children 6–23 months and older who are not breastfed, four or more meals of solid, semi-solid or soft foods or milk feeds are needed. Table NU.4 shows that about 30 percent of the children who were aged 6–23 months were breastfeeding and receiving solid, semi-solid or soft foods. Appropriate complementary feeding of children from 6 months to 2 years of age is particularly important for growth and development and the prevention of undernutrition. Continued breastfeeding beyond 6 months should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary foods that help meet nutritional requirements when breastmilk is no longer sufficient. Breastfed children need two or more meals of solid, 39 children who were currently breastfeeding, only 4 percent were receiving solid, semi- solid and soft foods the minimum number of times (Table NU.5). Among non-breastfeeding children, a very high percentage (88 percent) received at least two milk feeds, with a slightly lower percentage (84 percent) being fed solid, semi-solid and soft foods or milk feeds four times or more daily. However, among The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Overall, a total of 86 percent of children 0–23 months were fed with a bottle with a nipple (Table NU.6). 40 pregnant women. It is most commonly and visibly associated with goitre. Iodine deficiency disorders (IDD) take their greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). Salt iodization Iodine deficiency is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children and, in its most extreme form, causes cretinism. It also increases the risks of stillbirth and miscarriage in In about 89 percent of households, salt used for cooking was tested for iodine content by using salt test kits that check for the presence of potassium iodide and potassium iodate content. Table NU.7 shows that no salt was available in about 6 percent of households, while in 46 percent of the households salt was found to contain 15 parts per million (ppm) or more of iodine. Use of adequately iodized salt was slightly lower in the poorest households (42 percent) compared to the richest households (48 percent). Less than half of urban households (43 percent) were found to be using adequately iodized salt, and this was almost as low in the rural areas (46 percent) 41 pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. The percentage of newborns weighing below 2,500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.6 Table NU.8 shows that, overall, 100 percent of last-born children were weighed at birth and approximately 28 percent of infants are estimated to have weighed less than 2,500 grams. Low birth weight Weight at birth is a good indicator not only of a mother’s health and nutritional status but also the newborn’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased vulnerability to disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have the most impact: the mother’s poor nutritional status before conception, short stature (due mostly to undernutrition and infections during her childhood) and poor nutrition during the pregnancy. Inadequate weight gain during 6 For a detailed description of the methodology, see Boerma, J. T., K. I. Weinstein, S. O. Rutstein, and A. E. Sommerfelt, ‘Data on Birth Weight in Developing Countries: Can surveys help?’, Bulletin of the World Health Organization, vol. 74, no. 2, pp. 209–16. 42 Neonatal tetanus protection One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy being to eliminate maternal tetanus. In addition, another goal is to reduce the incidence of neonatal tetanus to less than 1 case per 1,000 live births in every district. A World Fit for Children goal was to eliminate maternal and neonatal tetanus by 2005. The strategy for preventing maternal and neonatal tetanus is to ensure all pregnant women receive at least two doses of tetanus toxoid vaccine. If a woman has not received at least two doses during a particular pregnancy, she (and her newborn) are not considered to be protected against tetanus. A woman is also considered to be protected against maternal and neonatal if she has received: u at least two doses of tetanus toxoid vaccine, with the last one received within the previous 3 years; u at least three doses, with the last one within the previous five years; u at least four doses, the last one within the previous 10 years; or u five or more doses any time during her life. To assess the status of tetanus vaccination coverage in Saint Lucia, women who had given birth during the two years before the survey were asked if they had received tetanus toxoid injections during the pregnancy for their most recent birth and, if so, how many. Women who had not received two or more tetanus toxoid vaccinations during this pregnancy were then asked about such vaccinations they might have received prior to this pregnancy. Interviewers also asked women to present their vaccination card, on which dates of tetanus toxoid are recorded, and referred to information from the cards when available. Table CH.1 shows the protection status from tetanus of women who had a live birth within the two years prior to the survey by urban/rural area of residence. 5CHILD HEALTH 43 Adult DT is administered in pregnancy only if the woman missed the required number of doses during the child to adolescent period. (Source: Immunization Policy, WHO/EPI/ GEN 95.03 Rev. 1) Data from the MICS Survey indicate low immunization with tetanus vaccine during pregnancy; this is as a result of St. Lucia’s high immunization coverage (95% and over) during childhood. Further, PAHO Immunization Newsletter Volume xxxv number 2, April 2013 revealed that St. Lucia was among the countries with no cases of Neonatal Tetanus in 2011-2012. The results of the survey indicate that protection of women against neonatal tetanus is relatively low in Saint Lucia. Overall, about two out of ten women (17 percent) aged 15–49 years with a live birth in the previous two years were protected against neonatal tetanus. Only 4 percent of women had received at least two doses of tetanus toxoid vaccine during the last pregnancy, while about one in ten (13 percent) had received two doses within the three previous years. No women had received three, four, five or more doses within the recommended time period. According to The World Health Organization (WHO) the requirement to be fully covered for tetanus is five (5) doses during childhood plus one (1) booster dose during the adolescent period (11-12 years). 44 Overall, only 7 percent of children under age 5 had diarrhoea in the two weeks preceding the survey (data not shown). No conclusive analysis could be done about how these children were treated because there were less than 25 unweighted cases in the data normally used to present results in MICS surveys. Care seeking and antibiotic treatment of pneumonia Pneumonia is the leading cause of death in children under age 5, and the use of antibiotics in under-5-year-olds 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. In the Saint Lucia MICS, the prevalence of suspected pneumonia was estimated by asking mothers or caretakers whether their child under age 5 had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were due to a problem in the chest or both a problem in the chest and a blocked nose. The indicators are: u Prevalence of suspected pneumonia u Care seeking for suspected pneumonia u Antibiotic treatment for suspected pneumonia u Knowledge of the signs of pneumonia Overall, 3 percent of children aged 0–59 months were reported to have had symptoms of pneumonia during the two weeks preceding the survey (data not shown). No conclusive analysis could be done about how the children with suspected pneumonia were treated because there were too few cases. Oral rehydration treatment Diarrhoea is the second leading cause of death among children under 5 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. One of the goals for A World Fit for Children was to reduce death due to diarrhoea among children under 5 by one half by 2010 compared to 2000, and one of the indicators of MDG4 is to reduce the mortality rate among children under 5 by two thirds by 2015 compared to 1990. In addition, the World Fit for Children called for a reduction in the incidence of diarrhoea by 25 percent. The indicators are: u Prevalence of diarrhoea u Oral rehydration therapy (ORT) u Home management of diarrhoea u ORT with continued feeding In the Saint Lucia MICS, mothers or caretakers were asked whether their child under age 5 years had experienced an episode of diarrhoea in the two weeks prior to the survey. In cases where mothers reported that the child had diarrhoea, a series of questions were asked about the treatment of the illness, including what the child had to drink and eat during the episode and whether this was more or less than the child usually drank and ate. 45 hydrocarbons and sulphur dioxide (SO2), among others. Use of solid fuels increases the risks of incurring acute respiratory illness, pneumonia, chronic obstructive lung disease and cancer – and possibly tuberculosis, asthma or cataracts – 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, shown in Table CH.2. 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, 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 46 extent of indoor pollution are dependent on cooking practices and places used for cooking as well as types of fuel used. According to the Saint Lucia MICS, 13 percent of household members who cook using solid fuels utilize a separate room as a kitchen while 10 percent use a separate building. Overall, three out of four members in households (75 percent) use solid fuels for cooking outdoors. This is higher in urban areas (83 percent) compared to rural areas (73 percent). The use of solid fuel is uncommon in Saint Lucia; only 3 percent of households use this while close to 97 percent use liquefied petroleum gas for cooking. Solid fuel use was more prevalent among the poorest households (6 percent) while almost no one in the richest households used solid fuels. Solid fuel use by place of cooking is depicted in Table CH.3. The presence and 47 Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid and schistosomiasis. Drinking water can also be tainted with chemicals, physical and radiological contaminants with harmful effects on human health. In addition, access to drinking water may be particularly important for women and children, who usually bear the primary responsibility for collecting water. In many countries they have to carry it for long distances, especially in rural areas. Target C of MDG 7 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 the Saint Lucia MICS is as follows: Water u Use of improved drinking water sources u Use of adequate water treatment method u Time to source of drinking water u Person collecting drinking water Sanitation u Use of improved sanitation facilities u Sanitary disposal of child’s faeces Handwashing u Availability and conditions of place for handwashing u Availability of soap For more details on water and sanitation and to access some reference documents, please visit the UNICEF childinfo website.7 6WATER AND SANITATION 7 www.childinfo.org/wes.html 48 following types of supply: piped water (into dwelling, compound, yard or plot, to neighbour, public tap/ standpipe), protected well, protected spring and rainwater collection. Bottled water was considered as an improved water source only if the household is using this for handwashing and cooking. Use of improved water sources The distribution of the population of Saint Lucia 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 The majority of household members in Saint Lucia (99 percent) are using improved sources of drinking water 48 49 Table WS 1 shows that almost all persons in Saint Lucia (99 percent) have access to improved drinking water sources. The three main improved sources of drinking water used are water piped into dwelling (57 percent), bottled water (26 percent) and drinking water piped into compound, yard or plot (8 percent). The use of bottled water as the main source of drinking water among household members increased with level of education of the head of household. Moreover, as the wealth of the household increased so did the use of bottled water, ranging from 14 percent among the members of the poorest households to 34 percent among members of the richest households. The use of water piped into dwelling as the main source of drinking water is also higher in the richest households (63 percent) than in the poorest households (47 percent). More household members in the urban areas have water piped into their dwellings (62 percent), collect less rain water (2 percent) and use less bottled water (22 percent) compared to household members in the rural areas who have less access to water piped into dwelling (55 percent), collect more rain water (4 percent) and use more bottled water (27 percent). 50 piped to consumers. Of the household members who treated their drinking water, the main method was boiling (28 percent), followed by the use of water filters (15 percent) and then the addition of chlorine or bleach (3 percent). As household wealth increases so does the use of water filters with the poorest households recording usage of about 5 percent compared to 22 percent among the richest households. Household members with secondary or greater education are twice as likely to use water filters (21 percent) than those with primary education (11 percent). About 40 percent of household members using unimproved water supplies treated the water with an appropriate water treatment method (data not shown as they are based on less than 49 unweighted cases). Use of household water treatment is presented in Table WS.2. Households were asked about ways they might 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 proper treatment of drinking water. The table shows water treatment by all households and the percentage of household members living in households using unimproved water sources but using appropriate water treatment methods. Overall, about half of household members (57 percent) do not treat their drinking water since public water is treated before it is 51 spend 30 minutes or more to get to the water source and bring water, while approximately 2 percent take less than 30 minutes for this purpose. A comparison by household wealth shows that about nine out of every ten household members from the poorest households (92 percent) have water on their premises compared to 99 percent of the richest households. The amount of time it takes to obtain water from its source is presented in Table WS.3 and the person who usually collects the water in Table WS.4. Note that these results refer to one roundtrip from home to drinking water source. Information on the number of trips made in one day was not collected. Table WS.3 shows that almost all persons in Saint Lucia (96 percent) have their drinking water source on the premises. About 1 percent of households 52 women from the household collect water in only 21 percent of cases, while male children under age 15 are the ones collecting water for the rest of the households (2 percent). Table WS.4 shows that 4 percent of households are without drinking water on premises. An adult male from the household is usually the person collecting water in these circumstances (74 percent). Adult Use of improved sanitation facilities Inadequate disposal of human excreta and poor personal hygiene are associated with a range of diseases including diarrhoeal diseases and polio. An improved sanitation facility is defined as one that hygienically separates human excreta from human contact. Improved sanitation can reduce diarrheal 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. 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. Almost all persons in Saint Lucia (98 percent) live in households using improved sanitation facilities (Table WS.5). The three most commonly used types are flush to septic tank systems (72 percent), pit latrine with slabs (18 percent) and flush to piped sewer system (5 percent). Of the household members who use improved sanitation facilities, the two most popular in the urban areas are flush to septic tank (74 percent) and flush to piped sewer system (11 percent) in contrast to the two most popular in the rural areas, which are flush to septic tank (71 percent) and pit latrine with slab (20 percent). 53 Table WS.5 indicates that the use of improved sanitation facilities is strongly associated with wealth. Over 90 percent of members of the three wealthiest quintiles use toilet facilities that flush to septic tank. In contrast, members of the poorest quintile are the least likely to use that type of toilet facilities (42 percent); in fact, the pit latrine with slab (42 percent) is the most common toilet facility used among the poorest households. It should be noted that there is limited access to a public sewer system in Saint Lucia. Overall, 2 percent of the population had no facility and used the bush or field. The percentage in the urban areas was higher at 5 percent compared to the rural areas at 1 percent. The use of buckets, pit latrine without slabs or open pits and other forms of unimproved sanitation facilities was about 1 percent or less. 54 As shown in Table WS.6, nine out of ten households in Saint Lucia (90 percent) do not share toilet facilities. Out of the total population who use public facilities, more persons (4 percent) are from the urban areas as compared to the rural areas (less than 1 percent). Close to 7 percent of households use an improved sanitation facility that is shared by up to five households. 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. 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 the faeces of children aged 0–2 years is presented in Table WS.7. The last stools of about one in every four children (27 percent) were disposed of safely. The most common method of disposal was in the garbage as solid waste (71 percent), followed by the children using the toilet or latrine (19 percent). Further, 8 percent put or rinsed the stool into the toilet or latrine. Less than 1 percent left the stool in the open or used other places. In its 2008 report,8 the 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 allows a disaggregated analysis of trends in a three-rung ladder for drinking water and a four-rung ladder for sanitation. For the latter, it gives an understanding of the proportion of population with no sanitation 8 World Health Organization and United Nations Children’s Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP), Progress on Drinking Water and Sanitation: Special focus on sanitation, UNICEF, New York and WHO, Geneva, 2008, available at: www.wssinfo.org/fileadmin/user_upload/ resources/1251794333-JMP_08_en.pdf 55 higher percentage (98 percent) compared to the poorest households (76 percent). Nine out of ten household members (90 percent) had improved sanitation, which also increased with household wealth. In terms of unimproved sanitation, 8 percent of households use shared improved facilities, of which 17 percent were from the poorest households compared to 2 percent from the richest households. A relatively small percentage of households (2 percent) engage in open defecation with the highest percentage coming from the urban areas (5 percent) and the poorest wealth quintile (4 percent). facilities at all, those reliant on technologies defined by JMP as ‘unimproved’, those sharing sanitation facilities of otherwise acceptable technology and those using ‘improved’ sanitation facilities. Table WS.8 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. The vast majority of household members (89 percent) use both improved drinking water sources and improved sanitation. Use of improved drinking water sources and improved sanitation increases with wealth, with the richest households having a 56 A place for hand washing was observed in nine out of ten households (90 percent). Water and soap were available in nine out of ten of these households (92 percent). Water was available but soap was not in 4 percent of households and water was not available but soap was in 3 percent of households. Water and soap were both not available in 1 percent of households. The number of households where neither soap nor water was available was highest among the poorest (3 percent). The lack of permission to observe the place of washing was highest among the richest households (7 percent). As seen in Table WS.10, about nine out of ten households (95 percent) had soap anywhere in the dwelling. In places where handwashing was observed, soap was also observed in 85 percent of households, soap was shown to interviewers in 4 percent while no soap was observed in 1 percent. Soap was shown to interviewers in 7 percent of households where handwashing was not observed, there was no soap in 1 percent of such households and in 3 percent of households soap was not seen. Handwashing Handwashing with water and soap is the most cost-effective health intervention to reduce the incidence of both diarrhoea and pneumonia in children under 5. It is most effective when done using water and soap after visiting a toilet or cleaning a child, before eating or handling food and before feeding a child. Monitoring correct handwashing behaviour at these critical times is challenging. A reliable alternative to observation or self-reported behaviour is assessing the likelihood that correct handwashing behaviour takes place by observing whether a household has a specific place where people most often wash their hands and whether water and soap are present at a specific place for handwashing. 57 5858 59 Contraception Appropriate family planning is important to the health of women and children. It is crucial that all couples have access to information and services to enable them to prevent pregnancies that are too early or too late, extend the period between births and limit the number of children. Approximately half of the women aged 15–49 who are currently married or in union (including visiting unions) in Saint Lucia reported currently using some method of contraception (Table RH.1). The use of any method of contraception was somewhat more prevalent among women in the rural areas (56 percent) compared to women in the urban areas (52 percent). A comparison by age group revealed that the women aged 30–34 years were most likely to use contraception (69 percent) compared to those aged 45–49 years (about 35 percent). There was little disparity in terms of the use of contraception by wealth index. Women’s education level is also associated with contraceptive prevalence, with the percentage of women using any method of contraception varying from 46 percent among women with no/primary education to 59 percent among women with secondary or higher education. The most popular contraception method is the pill, which is used by one out of every five women using contraception (22 percent) . The second most popular is male condoms, which are used by 14 percent of the partners of women currently married or in a union. Women also reported the use of the intrauterine device (IUD) (3 percent), injectables (5 percent) and female sterilization (7 percent). The least popular methods are periodic abstinence (1 percent), withdrawal (1 percent), lactational amenorrhea (less than 1 percent) and male sterilization (no cases). In addition to differences in prevalence, the method mix varied by education. More than twice as many women currently married or in union with secondary or greater education use the pill (26 percent) than 7REPRODUCTIVE HEALTH 60 using any method of contraceptive. Women from the older age groups are more likely to not be using any method compared to those from the younger age groups. About three out of every ten women aged 30–34 years (31 percent) do not use any method of contraception, with more than twice that percentage being reported for women aged 45–49 years (65 percent). those with no or primary education (11 percent). Conversely, those with secondary or more education level are three times less likely to use female sterilization (5 percent) than those with no or primary education (13 percent). It must be noted that about 45 percent of women aged 15–49 years in union are not 61 u are postpartum amenorrheic and say that the birth was mistimed: they would have wanted to wait Unmet need for limiting is defined as the percentage of women who are not using a method of contraception AND u are not pregnant and not postpartum amenorrheic and are fecund and say they do not want any more children OR u are pregnant and say they do not want to have a child OR u are postpartum amenorrheic and say that they did not want the birth Total unmet need for contraception is the sum of unmet need for spacing and unmet need for limiting. Table RH.2 shows the levels of met need for contraception, unmet need and demand for contraception satisfied. Unmet need for contraception Unmet need for contraception refers to fecund women who are not using any method of contraception but who wish to postpone the next birth (spacing) or to stop childbearing altogether (limiting). Unmet need is identified in the MICS by using a set of questions eliciting current behaviours and preferences pertaining to contraceptive use, fecundity and fertility preferences. Unmet need for spacing is defined as the percentage of women who are not using a method of contraception AND u are not pregnant and not postpartum amenorrheic9 and are fecund10 and say they want to wait two or more years for their next birth OR u are not pregnant and not postpartum amenorrheic and are fecund and unsure whether they want another child OR u are pregnant and say that the pregnancy was mistimed: they would have wanted to wait OR 9 A women is postpartum amenorrheic if she had a birth in last two years, is not currently pregnant and her has not had a menstrual period since the birth of the last child. 10 A women is considered infecund if she is neither pregnant nor postpartum amenorrheic, and (1a) has not had menstruation for at least six months, or (1b) never menstruated, or (1c) her last menstruation occurred before her last birth, or (1d) in menopause/has had hysterectomy, OR (2) she declares that she has had hysterectomy, or that she has never menstruated or that she is menopausal, or that she has been trying to get pregnant for two or more years without result in response to questions on why she thinks she is not physically able to get pregnant at the time of survey, OR (3) she declares she cannot get pregnant when asked about desire for future birth, OR (4) she has not had a birth in the preceding five years, is currently not using contraception and is currently married and was continuously married during the five years preceding the survey. 62 97 percent of women received antenatal care at least once during their pregnancy from skilled personnel. The antenatal care was more than twice as likely to be provided by a doctor (67 percent) than by a nurse (30 percent). 63 or greater education (11 percent) in comparison to women with no/primary education (3 percent). The unmet need for contraception for limiting was also higher in the urban areas (12 percent) than the rural areas (8 percent) and among women with no/primary education (14 percent) compared with women with secondary or greater education (7 percent). The table also highlights that total demand for contraception has been satisfied for three out of four women (77 percent), though the demand satisfied in the rural areas (78 percent) is higher than that in the urban areas (71 percent). Antenatal care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. Better understanding of foetal growth and development and its relationship to the mother’s health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about the risks of labour and delivery, it may help ensure that pregnant women do, in practice, deliver with the assistance of a skilled health-care provider. The antenatal period also provides an opportunity to supply information on birth spacing, which is recognized as an important factor in improving infant survival. Tetanus immunization during pregnancy can be life saving for both the mother and infant. The prevention and treatment of malaria Met need for limiting includes women who are using (or whose partner is using) a contraceptive method and who want no more children, have been sterilized (or their partner has) or declare themselves to be infecund. Met need for spacing includes women who are using (or whose partner is using) a contraceptive method and who want to have another child or are undecided whether to have another child. The total of met need for spacing and limiting add up to the total met need for contraception. Using information on contraception and unmet need, the percentage of demand for contraception satisfied is also estimated from the MICS data. This is defined as the proportion of women currently married or in a marital union who are currently using contraception out of the total demand for contraception. The total demand for contraception includes women who currently have an unmet need (for spacing or limiting) plus those who are currently using contraception. Table RH.2 shows that the total met need for contraception (56 percent) is more than three times the total unmet need (17 percent). Unmet need is higher among women who live in the urban areas (22 percent) compared to women who live in the rural areas (16 percent). This means that 22 percent of women aged 15–49 in the urban areas in Saint Lucia who are married or in a union are not using contraceptives but want to stop having children (limit) or postpone the next pregnancy for at least two years (space). There is no difference in unmet need by educational levels. The survey shows, however, that there are age differentials for unmet need for contraception. One in five women from the 20–24 age group (23 percent) have unmet need for contraception compared to one out of ten for those in the 30–34 age group (11 percent). Women from the poorest households (19 percent) have somewhat higher levels of unmet need than women from the richest households (16 percent). The unmet need for contraception for spacing was much higher among women with secondary 64 u Blood testing to detect syphilis and severe anaemia u Weight/height measurement (optional) Coverage of antenatal care in Saint Lucia by a doctor or nurse/ midwife is relatively high. The type of personnel providing antenatal care to women aged 15–49 years who gave birth in the two years preceding the survey is presented in Table RH.3. Almost all women (97 percent) received antenatal care at least once from a skilled personnel. The table shows that a relatively small percentage (1 percent) of women did not receive antenatal care and another 2 percent received this care from a community health worker. Two out of three women (67 percent) received antenatal care provided by a medical doctor while about one out of three (30 percent) received care from a nurse/midwife. UNICEF and WHO recommend a minimum of four antenatal care visits during pregnancy. Table RH.4 shows the number of antenatal care visits during the last pregnancy for the two years preceding the survey, regardless of provider by selected among pregnant women, management of anaemia during pregnancy and treatment of sexually transmitted infections (STIs) can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women’s nutritional status and prevent infections (e.g., STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content on antenatal care visits, which include: u Blood pressure measurement u Urine testing for bateriuria and proteinuria 65 The types of services pregnant women received during antenatal care are shown in Table RH.5. background characteristics. Nine out of ten mothers (90 percent) received antenatal care at least four times, while 1 percent of mothers had no antenatal care visits. Among those women who had a live birth during the two years preceding the survey, almost all (96 percent) reported that all three tests took place during antenatal care visits: blood pressure measured (99 percent), urine specimen taken (99 percent) and blood sample taken (96 percent). Ongoing efforts need to be intensified to ensure full coverage of the contents of antenatal care. 66 infection that can cause morbidity and mortality to either mother or baby. Table RH.7 presents the percentage distribution of women aged 15–49 who had a live birth in the two years preceding the survey by place of delivery and the percentage of births delivered in a health facility, according to background characteristics. Place of delivery Increasing the proportion of births that take place in health facilities is an important factor in reducing the health risks to both mother and baby. Proper medical attention and hygienic conditions during delivery can reduce the risks of complications and progress toward the Millennium Development target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. The MICS included a number of questions to assess the proportion of births attended by a skilled attendant (such as a doctor, nurse, midwife or auxiliary midwife). Almost all births in Saint Lucia occurring in the two years preceding the MICS survey (99 percent) were delivered by skilled personnel (Table RH.6). Two out of three births (63 percent) were delivered with assistance by a nurse/midwife while doctors assisted with the delivery of one out of three (35 percent). Caesarian (C-)sections accounted for about one out of five births (19 percent). Assistance at delivery Three quarters of all maternal deaths occur during delivery and in the immediate post-partum period. The most critical interventions for safe motherhood are to ensure a competent health worker with midwifery skills is present at every birth and transport is available to a referral facility for obstetric care in case of emergency. A World Fit For Children goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and the proportion of institutional deliveries. The skilled attendant at delivery indicator is also used to track 67 In Saint Lucia there are three public sector hospitals and one private sector hospital where births are managed. All births are delivered in a health facility. Of these, almost all of the deliveries (97 percent) occur in public sector facility while only 3 percent occur in private sector facility. Post-natal health checks The time of birth and immediately after is a critical window of opportunity to deliver life-saving interventions for both the mother and newborn. Across the world, approximately 3 million newborns annually die in the first month of life11 and the majority of these deaths occur within a day or two of birth,12 which is also the time when the majority of maternal deaths occur.13 Despite the importance of the first few days following birth, large-scale, nationally representative household survey programmes have not systematically included questions on the post-natal period and care for the mother and newborn. The Countdown to 2015 initiative, which monitors progress on maternal, newborn and child health interventions, highlighted this data gap in 2008 and called not only for post-natal care (PNC) programmes to be strengthened but also for better data availability and quality.14 Following the establishment and discussions of an Inter-Agency Group on PNC, and drawing on lessons learned from earlier attempts of collecting PNC data, a new questionnaire module for MICS was 11 Liu, Li, Hope L. Johnson, Simon Cousens, et al., ‘Global, Regional, and National Causes of Child Mortality in 2000–2010: An updated systematic analysis’, The Lancet, vol. 379, no. 9832, 9 June 2012, pp. 2151–61. 12 Lawn, Joy E., Simon Cousens and Jelka Zupan, ‘4 Million Neonatal Deaths: When? Where? Why?’, The Lancet, vol. 365, no. 9462, 3 March 2005, pp. 891–900. 13 World Health Organization, United Nations Children’s Fund, United Nations Population Fund and the World Bank, Trends in Maternal Mortality: 1990–2010, WHO, Geneva, 2012. 14 United Nations Children’s Fund, ‘Countdown to 2015: Tracking progress in maternal, newborn and child survival – The 2008 report’, UNICEF, New York, 2008. 68 Almost all women (99 percent) who gave birth in a health facility in the two years preceding the survey stayed 12 hours or more after delivery. Over half of women (59 percent) stayed for 1–2 days while about one out of three women (37 percent) spent three or more days there. One percent of mothers spent less than 6 hours in the health facility after delivery while 3 percent spent 12–23 hours. Safe motherhood programmes have recently increased their emphasis on the importance of post-natal care, recommending that all women and newborns receive a health check within two days of delivery. To assess the extent of PNC utilization, women were asked whether they and their newborn had received a health check after the delivery, the timing of the first check and the type of health provider for their last birth in the two years preceding the survey. developed and validated. Named the post-natal health checks (PNHC) module, its objective is to collect information on newborns’ and mothers’ contact with a provider, not content of care. The rationale for this is that as PNC programmes scale up, it is important to measure the coverage of that scale up and ensure that the platform for providing essential services is in place. Content is considered more difficult to measure, particularly because the respondent is asked to recall services delivered up to two years preceding the interview. Table RH.8 presents the percentage distribution of women aged 15–49 who gave birth in a health facility in the two years preceding the survey by duration of stay in the facility following the delivery, according to background characteristics. 69 Table RH.9 shows the percentage of babies born in the last two years who received health checks and PNC visits from any health provider after birth. Note that health checks following birth while in facility or at home refer to checks provided by any health provider regardless of timing (column 1), whereas PNC visits refer to a separate visit to check on the health of the newborn and provide preventive care services. The PNHC indicator includes any health check after birth received while in the health facility and at home (column 1), regardless of timing, as well as PNC visits within two days of delivery (columns 2, 3, and 4). Almost all newborns in Saint Lucia (98 percent) received a health check following birth while in a facility or at home. PNC visits are more likely to be conducted 3–6 days following birth (30 percent) than after the first week following birth (25 percent). The survey showed that about 15 percent of newborns did not receive any PNHC. All efforts must be made to ensure all newborns receive this. 69 70 Almost all of the first PNC visits for newborns occur in a public facility (95 percent) compared to the private facility (5 percent). All of the first PNC visits for newborns in Saint Lucia were provided by either a doctor or a nurse/midwife. Table RH.10 shows the percentage of newborns who received the first PNC visit within one week of birth is shown by location and type of provider of service. As defined above, a visit does not include a check in the facility or at home following birth. Tables RH.11 and RH.12 present information collected on PNHC and visits of the mother and are identical to Tables RH.9 and RH.10 that presented the data collected for newborns. Here too, health checks following birth while in facility or at home refer to checks provided by any health provider regardless of timing (column 1), whereas PNC visits refer to a separate visit to check on the health of the mother and provide preventive care services. The PNHC indicator includes any health check after birth received while in the health facility and at home (column 1), regardless of timing, as well as PNC visits within two days of delivery (columns 2, 3, and 4). About 88 percent of mothers receive a health check following birth while in a facility or at home. PNC visits after the first week of delivery were higher 71 shows that the public sector provided 91 percent of PNC visits and all visits were attended by doctors/nurses/midwives. Table RH.13 presents the distribution of women with a live birth in the two years (33 percent) compared to PNC visits during 3–6 days following delivery (19 percent). Nine out of ten mothers (90 percent) received a PNHC. As defined above, a visit does not include a check in the facility or at home following birth. Table RH12 preceding the survey by receipt of health checks or PNC visits within two days of birth for the mother and the newborn, thus combining the indicators presented in previous tables. Table RH.13 shows that, of the women aged 15–49 who gave birth during the two years preceding the MICS, about nine out of ten of both the mothers and their newborns (88 percent) received either a health check following birth or a timely PNC visit. Health checks following birth or PNC visit within two days of birth for newborns only was higher (10 percent) compared to less than 1 percent for similar checks for mothers only. 72 91 percent of ch i ld renaged 36–59 months are as measured by the Early Childhood Development Index developmentally on track, 72 73 Early childhood education and learning Readiness of children for primary school can be improved through attendance at early childhood education programmes or through pre-school attendance. The former includes programmes for children that have organized educational and learning components – as opposed to baby-sitting and day-care, which do not typically have such components. Pre-school programmes in Saint Lucia are for children aged 3–5 years (36–59 months). They are largely privately owned and operated. There were 94 registered preschools in 2012.15 Quality early childhood programmes are necessary to close existing gaps in access and equity. Over the last five years, Saint Lucia has been experiencing a dwindling school population, which has resulted in excess spaces at a number of primary schools on the island – an average of 37 percent surplus capacity.16 It is therefore recommended that the Ministry of Education explore the possibility of introducing pre-kindergarten programmes in some primary schools where extra space is available. Table CD.1 contains information on children aged 36–59 months enrolled in early childhood education programmes. These data provide a reliable baseline to support government plans for universal early childhood education. They indicate that more than four out of five children aged 36–59 months (85 percent) are attending an organized early childhood education programme. More children are attending such a programme at 48–59 months (90 percent) compared to those attending at 36–47 months (81 percent). This may be because the 48–59 age cohort is the year preceding attendance to formal education (kindergarten). Children from the poorest households are much less likely (79 percent) to attend an early childhood education programme compared with children from wealthier households (93 percent). 8CHILD DEVELOPMENT 15 Saint Lucia Education Statistical Digest, 2012, Past Trends, Present Position and Projections up to 2015/2016, Data Management, Corporate Planning Unit, Ministry of Education, Human Resource Development and Labour 16 Ibid. 74 children in the following activities: reading books or looking at picture books; telling stories; singing songs; taking children outside the home, compound or yard; playing with children; and spending time with children naming, counting or drawing things. Overall, about nine out of ten children (93 percent) aged 36–59 months were engaged by an adult household member in four or more activities that promote learning and school readiness during the three days preceding the survey (Table CD.2). The average number of activities that adults engaged in with children was more than five (mean: 5.5 activities). The table also indicates that fathers are engaged in one or more activities with about half (50 percent) of children aged 36–59 months. It is well recognized that a period of rapid brain development occurs in the first 3–4 years of life, and the quality of home care is the major determinant of the child’s development during this period. In this context, the engagement of adults in activities with children, the presence of books for the child and the conditions of care are important indicators of quality of home care. Children should be physically healthy, mentally alert, emotionally secure, socially competent and ready to learn. Table CD 2 provides information on adult- child engagement in activities at home. This includes the involvement of adults with 75 The data show that adult household members engage in more learning activities with girls than boys. Some 96 percent of female children aged 36–59 months were engaged in four or more activities with an adult household member compared to 89 The average number of learning activities in which fathers engaged their children in the three days preceding the survey was only two. It must be noted that nearly half of the children aged 36–59 months do not live with their biological fathers. percent for boys. Fathers’ engagement in one or more activities was the same for boys and girls. Adult engagement in activities with children was slightly higher with those aged 36–47 months (95 percent) compared to those aged 48–59 months (90 percent). Exposure to books in the early years can provide the child with a love of reading and learning and is important for later school performance. The mothers/caretakers of all children under 5 were asked about the number of children’s books or picture books they have for the child, homemade 76 with 10 or more books is lower (49 percent). Gender differentials are observed as more females (75 percent) are exposed to three or more books compared to males (60 percent). There is also disparity in the ownership of books according to the wealth of households. For three or more books, the wealthiest 60 percent of households have a higher percentage (81 percent) compared to the poorest households (53 percent). A similar pattern toys or toys that came from a shop that are available at home and household objects or outside objects that the child plays with. Responses reveal that two out of three children aged 0–59 months (68 percent) in Saint Lucia live in households where at least three children’s books are present (Table CD.3). The proportion of children is observed for those with 10 or more children’s books. Mothers with secondary or greater education are much more likely to have books for children compared with mothers with none/primary education. Table CD.3 also shows that over half of the children aged 0–59 months (59 percent) had two or more types of playthings to play with in their homes. The types of playthings asked about in the MICS included homemade toys (such as dolls, cars or other toys made at home), toys that came from a store, household objects (such as pots and bowls) and objects and materials found outside the home 77 to find out whether children aged 0–59 months had been left alone during the week preceding the interview and whether children were left in the care of other children under 10 years of age. Table CD.4 shows that about 5 percent of children aged 0–59 months were left with inadequate care during the week preceding the survey. Children whose mother had attained none/primary education (11 percent) were more likely to have been left with inadequate care in the past week compared to children whose mother had secondary or greater education (2 percent). Similarly, children aged 0–23 months were more than twice as likely to have been left with inadequate care (8 percent) than (such as sticks, rocks, animal shells or leaves). Almost all children (95 percent) play with toys that come from a store; however, one out of five children (19 percent) play with homemade toys. More male children (62 percent) have two or more types of playthings compared to female children (56 percent). Children whose mother has secondary or greater education (60 percent) are somewhat more likely to have two or more types of playthings compared to children whose mother has either no education or only primary education (56 percent). Inadequate care Leaving children alone or in the presence of other young children is known to increase the risk of accidents. In the MICS, two questions were asked 78 Each of the 10 items is used in one of the four domains to determine whether children aged 36–59 months are developmentally on track in that domain. The domains are: u Literacy-numeracy: Children are identified as being developmentally on track based on their ability to do two of the following: identify/ name at least 10 letters of the alphabet; read at least four simple, popular words; and know the name and recognize the symbols of all numbers from 1 to 10. u Physical: If the child can pick up a small object such as a stick or a rock from the ground with two fingers and/or the mother/ caretaker does not indicate that the child is sometimes too sick to play, then the child is regarded as being developmentally on track in the physical domain. u Social-emotional: Children are considered to be developmentally on track if two of the following are true: the child gets along well with other children; the child does not kick, bite or hit other children; and the child does not get distracted easily u Learning: If the child follows simple directions on how to do something correctly and/or when given something to do is able to do it independently, then the child is considered to be developmentally on track in this domain. children aged 24–59 months (3 percent). As regards the wealth status of the household, Table CD4 suggests that the wealthier the household, the less likely the child will be left with inadequate care. The poorest households have the highest percentage of children left with inadequate care (7 percent) compared with the wealthiest households (3 percent). Early Childhood Development Early child development is defined as an orderly, predictable process along a continuous path as a child learns to handle more complicated levels of moving, thinking, speaking, feeling and relating to others. Physical growth, literacy and numeracy skills, socio-emotional development and readiness to learn are vital domains of a child’s early development, which is a basis for overall human development. A 10-item module that has been developed for the MICS programme was used to calculate the Early Child Development Index (ECDI). This indicator is based on some benchmarks that children would be expected to have if they are developing as the majority of children in that age group. The primary purpose of calculating the ECDI in Saint Lucia is to inform public policy regarding the developmental status of children. 79 on track in the socio-emotional domains (87 percent) and literacy-numeracy domain (70 percent). The literacy-numeracy indicator is usually higher when children have more exposure to learning opportunities such as attending early childhood education programmes. MICS results show that boys slightly outperform girls in the literacy-numeracy domain with minimal differences in other domains. This is in contrast to statistics of national examinations (Minimum Standards), which indicate that later on in life (from the age of seven) girls outperform boys in literacy and numeracy. There is a need to further investigate the reasons why this occurs. ECDI is calculated as the percentage of children who are developmentally on track in at least three of these four domains. The results for Saint Lucia are presented in Table CD 5. Nine out of ten children aged 36–59 months (91 percent) in Saint Lucia are developmentally on track. The results show that the ECDI score for both boys and girls is about the same. As expected, ECDI is much higher in the older age group of 48–59 months (96 percent) compared to children aged 36–47 months old (87 percent) since more skills are acquired with increasing age. The analysis of the four domains of child development shows that, overall, almost all children aged 36–59 months (99 percent) are on track in the physical development domain and the learning domain. However, it is observed that they are less 80 Literacy among young women One of the World Fit for Children goals is to increase adult literacy, especially among women. Adult literacy is also an MDG indicator relating to both women and men. Only a women’s questionnaire was administered (to women aged 15–49 years) in the Saint Lucia MICS, and the literacy level was obtained only among women aged 15–24 years. It was assessed on the ability of the respondent to read a short simple statement or based on school attendance. Table ED.1 shows the literacy level among these women. Overall, almost all women aged 15–24 years (99 percent) in Saint Lucia are literate, and literacy status does not vary significantly among the various levels of disaggregation. School readiness Attendance at pre-school education in an organized learning or child education programme is important for the readiness of children for school. Table ED.2 shows the proportion of children in the first grade (grade K) of infant/primary school who attended pre-school the previous year. Overall, 92 percent of children who were attending the first grade at the time of the survey had attended pre-school the previous year. Disaggregations by sex and area are not presented in the table due to the low numbers of cases on which estimates are based (i.e., less than 25 unweighted cases). 9LITERACY AND EDUCATION 80 81 82 The indicators of school progression include: u Children reaching last grade of primary u Primary completion rate u Transition rate to secondary school Children in Saint Lucia enter infant/primary school at age 5 and enter secondary school at age 12. There are seven grades in primary school – infant grades K, 1, 2 and primary grades 3 to 6 – and five grades in secondary school – forms 1 to 5. The school year typically runs from September of one year to July of the following year. Of the children who are of primary school entry age, 98 percent are attending primary school (Table ED.3). Even though the official age of school entry is 5, there are a number of children aged 5 who are attending grades higher than grade K, indicating that these children entered school earlier than expected. Consequently, these children are included in the numerator of MICS indicator 7.3. Table ED.4 provides the percentage of children of primary school aged 5–11 years who are attending Primary and secondary school participation Universal access to basic education and the achievement of primary education by the world’s children are among the most important goals of the MDGs and A World Fit for Children. Education is a vital prerequisite for combating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment and influencing population growth. The indicators for primary and secondary school attendance include: u Net intake rate in primary education u Primary school net attendance ratio (adjusted) u Secondary school net attendance ratio (adjusted) u Female-to-male education ratio (or gender parity index – GPI) in primary and secondary school 83 The secondary school net attendance ratio is presented in Table ED.5. Approximately nine out of ten children of secondary school age (92 percent) were attending secondary primary or secondary school.17 The net attendance ratio for children of primary school age was over 99 percent. As this percentage was so high, there were little differences by background characteristics. school or higher. Additionally, about 4 percent of secondary school aged children were attending primary school. Attendance generally decreased as age increased. At the beginning of the school year during the survey period almost all 13-year-olds (99 percent) were attending a secondary school or higher- level school compared to the 16-years-olds, who recorded a net attendance ratio of 86 percent. The attendance of the poorest 40 percent of households was lower (89 percent) than that of the richest 60 percent of households (94 percent). Children whose mothers had attained secondary or greater education were more likely (93 percent) to attend school than those whose mothers had attained primary education (89 percent). 17 Ratios presented in this table are ‘adjusted’ since they include not only primary school attendance but also secondary school attendance in the numerator. 84 attending the first grade (form 1) of secondary school. This indicates that about 4 percent of these children either repeated grade 6 or were no longer part of the education system in Saint Lucia. They had either dropped out or received transfers to overseas schools. The ratio of girls to boys attending primary and secondary education is provided in Table ED.7. These ratios are better known as the gender parity index (GPI). Notice that the ratios included are net attendance rather than gross attendance. The table shows that the GPI for is 0.99 for primary school and 1.01 for secondary school, indicating parity (GPI between 0.97 and 1.03) between boys and girls. The households in the poorest 40 percent have more girls than boys attending secondary school (GPI 1.04) compared with the wealthiest 60 percent of households where the GPI is 1.00. The primary school completion rate and transition rate to secondary education are presented in Table ED.6. The primary completion rate is the ratio of the total number of students, regardless of age, entering the last grade (grade 6) of primary school for the first time to the number of children of the primary graduation age (age 11) at the beginning of the current (or most recent) school year. The survey revealed that the primary school completion rate is 98 percent. This is consistent with data from Saint Lucia’s Education Digest 2012, which indicate an average drop-out rate of 0.09 percent over the past five years. Out of the children attending grade 6 of the previous academic year (2010–2011), almost all (96 percent) were found to be 85 86 Birth registration The Convention on the Rights of the Child states that every child has the right to a name and a nationality and the right to protection from being deprived of her or his identity. Birth registration is a fundamental means of securing these rights for children. The World Fit for Children states the goal of developing systems to ensure the registration of every child at or shortly after birth and to fulfil his or her right to acquire a name and a nationality in accordance with national laws and relevant international instruments. The MICS indicator related to birth registration is the percentage of children under 5 years of age whose birth is registered. Approximately nine out of ten children under 5 years (92 percent) in Saint Lucia have been registered with civil authorities (Table CP.1). The table shows that there are no large variations in birth registration by most of the background characteristics. However, comparing birth registration by wealth status reveals that the poorest 40 percent households attained 86 percent birth registration compared with 98 percent among the richest households. Table CP.1 also shows that there is a gradual increase in the proportion of children registered as their ages increases While approximately eight out of ten children aged 0–11 months (78 percent) were registered, almost all children aged 48–59 months (99 percent) were registered. This pattern may be because a birth certificate is a requirement for school registration. 10 CHILD PROTECTION 87 Table CP.1 also shows that while 91 percent of children are registered, one in every five children under age 5 (25 percent) do not have a birth certificate, indicating other forms of registration are common in Saint Lucia. These children are more likely to be from the urban (26 percent) than the rural areas (21 percent) and from the poorest (23 percent) compared with the richest households (19 percent). It is of grave concern that there are some children in Saint Lucia who are not registered. Given the importance of birth registration to the fulfilment of the rights of the child, the parents, civic registration authorities, Ministry of Health and other relevant stakeholders need to work together to ensure full registration of all children in the country. Child labour Article 32 of the Convention on the Rights of the Child states: “States Parties recognize the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child’s education, or to be harmful to the child’s health or physical, mental, spiritual, moral or social development.” The World Fit for Children mentions nine strategies to combat child labour and the MDGs call for the protection of children against exploitation. In the MICS questionnaire, a number of questions 88 richest households (4 percent). Other differentials are small. Children aged 5–11 years account for a much higher involvement in child labour (12 percent) compared to those aged 12–14 years (less than 1 percent). Children aged 5–11 who are involved in child labour are more likely to be male (14 percent), whose mother has no/primary level education (14 percent), from the poorest households (18 percent) and where the head of the household is of other ethnicity (20 percent). Children aged 12–14 years who were involved in economic activities for less than 14 hours during the week preceding the survey are more likely to be females (19 percent), who live in the rural areas (17 percent), whose mother has no/primary level education (24 percent) and from the poorest households (27 percent). About half of children aged 5–11 years (46 percent) perform household chores for less than 28 hours, while two in three children aged 12–14 years (67 percent) perform household chores for less than 28 hours. This indicates that there is a large disparity in performance of household chores between the two age groups. addressed the issue of child labour, that is, children 5–14 years of age involved in labour activities. A child is considered to be involved in child labour activities at the moment of the survey if during the week preceding the survey he/she performed the following activities: u At least one hour of economic work or 28 hours of domestic work per week if the child is aged 5–11 years. u At least 14 hours of economic work or 28 hours of domestic work per week if the child is aged 12–14 years. Table CP.2 presents the results of the Saint Lucia MICS concerning child labour by the type of work. It shows that about one out of every twelve children in the country aged 5–14 years (8 percent) are engaged in child labour. As the wealth increased, child labour decreased. Children aged 5–14 years who live in the poorest households are about three times more likely to be involved in child labour (12 percent) than those from the 88 89 90 the other hand, 8 percent of the children 5–14 years attending school are involved in child labour activities. Table CP.3 shows that all children aged 5–14 years who are child labourers (100 percent) are also attending school. On Children attending school who are involved in child labour are most likely to be male (9 percent), within the 5–11years age group (12 percent) and from the poorest households (12 percent). Child discipline As stated in A World Fit for Children, “children must be protected against any acts of violence …” and the Millennium Declaration calls for the protection of children against abuse, exploitation and violence. In the Saint Lucia MICS survey, respondents to the household questionnaire were asked a series of questions on the ways adults in the household had tended to discipline children during the past month preceding the survey. Note that for the child discipline module, one child aged 2–14 per household was selected randomly during fieldwork. The two indicators used to describe aspects of child discipline are: (1) the number of children aged 2–14 years who experience either psychological aggression as punishment or physical punishment; 91 through their parents or other adult household members during the month preceding the survey, with 6 percent of these children being subjected to severe physical punishment. However, only one in every five respondents to the household questionnaires (21 percent) believed that children should be physically punished (see Table CP.4B). This implies an interesting contradiction between beliefs on physical discipline and the actual practice. Three out of every five children aged 2–14 years (60 percent) were subjected to psychological aggression compared to one out of five children (18 percent) who experienced only non-violent discipline. and (2) the number of respondents who believe that in order for children to be raised properly, they need to be physically punished. Psychological aggression is defined as shouting, yelling and screaming at the child and/or addressing her or him with offensive names. Physical (or corporal) punishment is defined as actions intended to cause the child physical pain or discomfort but not injuries. This includes: shaking the child and slapping or hitting him or her on the hand, arm, leg or bottom; hitting the child on the face, head or ears; or hitting the child hard or repeatedly. Two out of three children aged 2–14 years (68 percent) in Saint Lucia had experienced at least one form of psychological or physical punishment 92 aged 10–14. On the other hand, children aged 10–14 years experienced the highest levels of psychological aggression (67 percent) compared to those aged 2–4 years and 5–9 years (55 percent each). These findings suggest that different methods of discipline are used with children of different ages, i.e., punishment is more physical at younger ages while psychological punishment is used more at older ages. As the wealth index increases, children aged 2–14 years are less likely to experience physical punishment. Moreover, psychological aggression is used more often to discipline children aged 2–14 years in the poorest households and in urban areas. It must be noted that the children aged 2–4 years are experiencing the least non-violent method of discipline (14 percent). A large percentage of both male (71 percent) and female (64 percent) children aged 2–14 years are experiencing some violent discipline method. This is slightly more prevalent in the urban areas (77 percent) than the rural areas (65 percent). Children from the poorest households are more likely to be disciplined using a violent method (75 percent) compared to those from the richest households (62 percent). Male children are more likely to be subjected to physical discipline (50 percent) compared to female children (38 percent). Approximately half of the children aged 2–4 years (51 percent) were subjected to physical punishment and this was also the experience for 37 percent of those 93 an adequate legislative framework with an accompanying enforcement mechanism to address cases of child marriage; and the existence of customary or religious laws and practices that condone the practice. In many parts of the world parents encourage the marriage of their daughters while they are still children in hopes that the marriage will benefit them both financially and socially while also relieving financial burdens on the family. In fact, child marriage is a violation of human rights, compromising the development of girls and often resulting in early pregnancy and social isolation, with little education and poor vocational training reinforcing the gendered nature of poverty. The right to ‘free and full’ consent to a marriage is set out in the Universal Declaration of Human Rights – with the Figure CP.1 shows that severe physical punishment was reported as the form of discipline that was least likely to be used (6 percent) compared to the other methods. Psychological aggression was the most popular method of disciplining children aged 2–14 years followed by any kind of physical punishment. The survey shows that whereas non-violent discipline is more prevalent among female children, physical punishment is more prevalent among male children. Early marriage/union/polygyny Marriage before the age of 18 is a reality for many young girls. According to UNICEF’s worldwide estimates, around 70 million women aged 20–24 were married/in union before the age of 18. Factors that influence child marriage rates include: the state of the country’s civil registration system, which provides proof of age for children; the existence of 94 While marriage before age 15 is illegal in Saint Lucia (and is a violation of human rights), 3 percent of women aged 15–49 years were married or in a union before this age. The survey shows a strong relationship between early marriage/union and women from the poorest households, with 6 percent of women aged 15–49 years from the poorest households married or in a union before age 15 years compared to 2 percent from the richest households. Women aged 15–49 years whose highest level of education was no/primary were about three times more likely (7 percent) to be married or in a union before the age of 15 than those with secondary or greater education (2 percent). About one in six women aged 20–49 years (17 percent) were married or in a union before the age of 18. The proportion was slightly higher among women with no/primary education (23 percent) than those with secondary or greater education (15 percent). Women from the poorest households were more likely to be married or in a union before the age of 18 (25 percent) compared to those from the wealthiest households (13 percent). Slightly more than one in ten young women aged 15–19 years (14 percent) were currently married or in a union at the time of the survey. This proportion was higher among women in the poorest households (22 percent) compared to women in the richest households (8 percent). The percentage of women in a polygynous union (a man married to more than one wife at a time) is also provided in Table CP.5. Approximately 6 percent of women aged 15–49 are in a polygynous marriage or union. These relationships are highest among women 40–44 years (12 percent) and non-existent among the youngest women (15–19). Overall, 4 percent of the women aged 20–49 years were married or in a union before the age of 15 years. Those from the poorest households were the most vulnerable. recognition that consent cannot be ‘free and full’ when one of the parties involved is not sufficiently mature to make an informed decision about a life partner. Closely related to the issue of child marriage is the age at which girls become sexually active. Women who are married before the age of 18 tend to have more children than those who marry later in life. Pregnancy- related deaths are known to be a leading cause of mortality for both married and unmarried girls between the ages of 15 and 19, particularly among the youngest of this cohort. There is evidence to suggest that girls who marry at young ages are more likely to marry older men, which puts them at increased risk of HIV infection. The demand for a young wife to reproduce and the power imbalance resulting from the age differential lead to very low condom use among such couples. The indicators for early marriage (entered a marital union) in Saint Lucia were to estimate the percentage of women aged 15–49 years who were married or in a marital union before the age of 15 years, the percentage of women aged 20–49 married or in a union before 15 and 18 years of age, the percentage of women aged 15–19 years currently married or in a union and the percentage of women aged 15–49 years in a polygynous marriage or union. The percentage of women married or in a union at various ages is provided in Table CP.5. In all tables in this chapter except CP.6B, a visiting relationship is considered as a union. This relationship usually entails a prolonged relationship where the man does not live with the woman but returns to her household from time to time, has sexual relations with her and may provide support to her household. 95 96 women in visiting relationships are excluded. A smaller proportion, 2 percent of the women aged 15–49 who resided in the urban areas, were first married or in a union before the age of 15 compared to 3 percent of those who resided in the rural areas. The percentage of women aged 20–49 who were first married or in a union before the age of 18 was the same in both the urban and rural areas (10 percent). The percentage of women aged 20–49 who were first married or in a union by age 18 decreased to 10 percent with the exclusion of women in visiting relationships. The women within the 35–39 year cohort were the least likely to be married or in a union before age 18 (7 percent). A comparison of the total percentage in Tables CP.6A and Table CP.6B shows that with the inclusion of visiting relationships in Table CP.6A, the percentage of women aged 20–24 years who are married or in a marital union before age 18 is three times higher (24 percent) than the percentage for that same Tables CP.6A and CP6.B present the proportion of women who were first married or entered into a marital union before age 15 and 18 by area and age groups for all types of unions and for all unions except visiting relationships, respectively. Examining the percentages married before age 15 and 18 by different age groups reveals the trends in early marriage. Table CP.6A shows that 4 percent of the women aged 15–49 who resided in the urban areas were first married or in a union before the age of 15 compared to 3 percent of those who resided in the rural areas. The percentage of women aged 20–49 who were first married or in a union before the age of 18 was 18 percent in the urban areas compared to 17 percent in the rural areas. By cohort, there is no clear trend over time. Table CP.6B shows the same data when 97 women or those in a marital union who are 10 or more years younger than their current spouse. Table CP.7 shows that about one in five women aged 20–24 years (21 percent) are currently married or in a union to a man who is older by 10 years or more. Approximately one in ten women aged 20– 24 (13 percent) who are currently married or in a union have a husband or spouse who is younger than them. Most women aged 20–24 years (two out of five or 41 percent) have a husband or spouse who is 0–4 years older than them. age group (8 percent) when visiting relationships are excluded. This indicates that visiting relations are a key union structure for this age group. Even so, there are no clear trends across age cohorts. However, when the tables are analysed together, results appear to indicate that formal unions and cohabiting are less prevalent by cohort over time, i.e., younger women engage in formal unions and cohabiting less than older cohorts. However, visiting relations before the age of 18 appear to be more prevalent among these younger women compared to older cohorts. Another component is the spousal age difference, and the indicator is the percentage of married 98 autonomy, e.g. goes out without telling her husband, argues with him or refuses to have sex with him. Justification of domestic violence is more prevalent among women in the urban areas (10 percent) compared to the rural areas (6 percent). Justification of violence among women from the poorest households is more than twice as likely (10 percent) than among women of the wealthiest households (4 percent). Justification is also higher among younger women aged 15–19 (15 percent) compared with older women aged 45–49 (3 percent). Interestingly, belief that the husband/partner is justified in beating his wife/partner is slightly higher among women who had never been married/in union (9 percent) and women who are currently married/in union (6 percent) compared to those formerly married/in union (4 percent). Table CP.8 also includes several country-specific reasons why wife beating would be justifiable and a composite indicator of these. About 4 percent of women say that beating a wife is justified if she is unfaithful. The composite indicator shows that using all the reasons in the table, about 8 percent of women say that wife beating is justified in a number of circumstances. Attitudes toward domestic violence A number of questions were asked of women aged 15–49 years to assess whether they think that a husband/partner is justified to hit or beat his wife/partner in a variety of scenarios. These questions were asked to have an indication of cultural beliefs that tend to be associated with the prevalence of violence against women. The responses to these questions can be found in Table CP.8. Approximately 7 percent of women aged 15–49 years in Saint Lucia believe that a husband/partner is justified to hit or beat his wife/partner for at least one of the following reasons: if she (1) goes out without telling him; (2) neglects the children; (3) refuses to have sex with him; (4) argues with him; and (5) burns the food. Women who justify a husband’s violence do so in most cases in instances when the woman neglects the children (5 percent). Women are equally likely (1 percent in each case) to believe a husband to be justified in hitting or beating his wife/partner if she demonstrates her 99 100100 101 Knowledge about HIV transmission and misconceptions about HIV and AIDS One of the most important prerequisites for reducing the rate of HIV infection is accurate knowledge about how HIV is transmitted and strategies for preventing transmission. Correct information is the first step towards raising awareness and giving young people the tools to protect themselves from infection. Misconceptions about HIV are common and can confuse young people and hinder prevention efforts. Different areas (such as rural and urban areas) are likely to have variations in misconceptions although some appear to be universal (e.g., that mosquito bites or sharing food can transmit HIV). The United Nations General Assembly Special Session on HIV/AIDS (UNGASS) called on governments to improve the knowledge and skills of young people to protect themselves from HIV. The indicators to measure this goal, as well as the MDG goal of reducing HIV infections by half, include improving the level of knowledge of HIV and its prevention and changing behaviours to prevent further spread of the disease. HIV modules were administered to women 15–49 years of age. The percentage of young women who have comprehensive and correct knowledge of HIV prevention and transmission is both an MDG and UNGASS indicator. MICS interviewers in Saint Lucia asked women aged 15–49 years whether they had heard of AIDS and knew the three main ways of preventing HIV transmission – having only one faithful uninfected partner, using a condom every time and abstaining from sex. The results are presented in Table HA.1 and Figure HA.1. Almost all of the women aged 15–49 interviewed (99 percent) had heard of AIDS. Nine out of ten (90 percent) knew about having one faithful uninfected sex partner and about the same percentage (89 percent) knew about using a condom every time as the main ways of preventing HIV transmission. The women from the poorest households appeared to be 11HIV AND AIDS, SEXUAL BEHAVIOUR AND ORPHANS 102 rejected the view that the virus can be transmitted by sharing a meal with an infected person. Comprehensive knowledge of HIV is defined as being able to identify two ways of preventing HIV transmission, know that a healthy-looking person can have HIV and reject two common misconceptions about HIV transmission. Of the women aged 15–49 years interviewed, two out of three (65 percent) had comprehensive knowledge of HIV. Higher educational level positively influenced comprehensive knowledge, which ranged from only 45 percent among women with no/primary school education to 71 percent among women with secondary school education, as shown in Table HA1 and Figure HA.1. Wealth also influenced comprehensive knowledge positively. Women from the poorest households were less likely to have comprehensive knowledge about HIV transmission (57 percent) compared to those from the wealthiest households (71 percent). the least knowledgeable about condom use (85 percent), while those from the wealthiest households appeared to be the most knowledgeable (92 percent). Four out of five women (83 percent) knew of both main ways of preventing HIV transmission. Table HA.1 also presents the percentage of women who could correctly identify misconceptions concerning HIV. The indicators are based on the three most common and relevant misconceptions in Saint Lucia about how HIV can be transmitted: by supernatural means, mosquito bites and sharing food with an infected person. Eight out of ten women (84 percent) were aware that HIV cannot be transmitted by mosquito bites, about nine out of ten (88 percent) knew that transmission by supernatural means is not possible and nine out of ten (92 percent) 103 were able to identify both ways of preventing transmission. Eight out of ten women (82 percent) were aware that HIV cannot be transmitted by mosquito bites, about nine out of ten (88 percent) knew that it cannot be transmitted by supernatural means and nine out of ten (93 percent) rejected the misconception that the virus can be transmitted by sharing food with an infected person. Overall, about two out of three women aged 15–24 (62 percent) had comprehensive knowledge of HIV transmission. Comprehensive knowledge of HIV transmission was lower among women in the urban areas (62 percent) compared to women in the rural areas (66 percent). It was higher among women who had been married/in union (67 percent) compared to women who were never married/in union (59 percent). Women aged 15–24 years from the wealthiest households had a higher comprehensive knowledge of HIV transmission (66 percent) compared to women from the poorest households (56 percent). Table HA.1 shows that the older of the women interviewed (aged 40–49) years appeared to be least likely to have comprehensive knowledge about HIV transmission: 57 percent of them had comprehensive knowledge compared to 76 percent for those aged 25–29. Comprehensive knowledge about HIV transmission was slightly lower among women from the urban areas (62 percent) than those from the rural areas (66 percent). Whereas the majority of the women aged 40–49 years reported that they had heard of AIDS, it is of concern that women from this age group recorded the lowest rate for variables such as knowledge about HIV prevention through the use of condoms and that a healthy-looking person can have the AIDS virus. The results for women aged 15–24 are presented separately in Table HA.2. The table shows that whereas almost all (99 percent) of the women aged 15–24 have heard of AIDS, about nine out of ten (88 percent) knew that HIV transmission can be reduced through having a single faithful uninfected partner and a similar percentage (87 percent) knew that HIV transmission can be reduced through consistent condom use. Four out of five women (80 percent) 104 during pregnancy. Women with a secondary or greater education (90 percent) were more knowledgeable of this fact than those with primary education (81 percent). Two out of three women (68 percent) knew that transmission may occur during delivery, with the greatest knowledge among women aged 40–49 years (72 percent) and the least among the 15–19 years age group (66 percent). Sixty-seven percent of the women reported knowledge of HIV transmission through breastfeeding. Overall, only half (50 percent) of all women knew all three ways of mother-to-child transmission, while 5 percent did not know of any specific way. This suggests the need for a campaign to increase the knowledge of women on all three ways of mother-to-child transmission. Knowledge of Mother-To-Child HIV Transmission Knowledge of mother-to-child transmission of HIV is also an important first step for women to seek HIV testing when they are pregnant to avoid infection in the baby. Women should know that HIV can be transmitted during pregnancy, during delivery and through breastfeeding. The level of knowledge among women in Saint Lucia aged 15–49 years concerning mother-to-child transmission is presented in Table HA.3. Overall, almost all women (95 percent) know that HIV can be transmitted from mother to child, with slight variations by age groups, wealth, education or marital status. About nine out of ten women (88 percent) were aware that HIV can be transmitted 105 Accepting attitudes toward people living with HIV and AIDS The indicators on attitudes toward people living with HIV measure stigma and discrimination in the community. Stigma and discrimination are low if respondents report an accepting attitude on the following four issues: (1) would care for family member sick with AIDS; (2) would buy fresh vegetables from a vendor who is HIV positive; (3) thinks that a female teacher who is HIV positive should be allowed to teach in school; and (4) would not want to keep secret the HIV status of a family member. 106 education (90 percent) than women with none/ primary education (85 percent). The second most common accepting attitude is the belief that a female teacher with the AIDS virus but who is not sick should be allowed to continue teaching in school (84 percent) followed by willingness to buy fresh vegetables from a shopkeeper or vendor who has the AIDS virus. Only 31 percent of the women 15–49 years would not want to keep secret that a family member was infected with the AIDS virus. Differentials are shown in Table HA.4. Advocacy is required to ensure that more women express accepting attitudes on all four indicators. Table HA.4 presents the attitudes of women in Saint Lucia towards people living with HIV and AIDS. Although almost all women (99 percent) agreed with at least one accepting attitude towards individuals with HIV, only one in ten women (14 percent) expressed accepting attitudes on all four indicators. This reveals serious stigma and discriminative attitudes among women aged 15–49 years toward persons living with HIV and AIDS. The most common accepting attitude was willingness to care for a family member with the AIDS virus in their own home (89 percent). This attitude is higher among women with secondary or greater 107 Although almost all the women aged 15–49 (95 percent) knew where to be tested, about three out of four women (72 percent) had actually been tested. This is of concern, considering that HIV tests are done free of charge in the public health system. Of those tested, only one out of five (28 percent) had been tested within the 12 months preceding the survey, while even fewer had been tested and told the result during this time period (26 percent). Women with no/ primary education were less likely to have been tested and told the results compared to those with secondary or higher education. Knowledge of a place for HIV testing and counselling during antenatal care Another important indicator is the knowledge of where to be tested for HIV and use of such services. In order to protect themselves and to reduce the spread of infection to others, it is important for individuals to know their HIV status. Knowledge of own status is also a critical factor in the decision to seek treatment. Questions related to knowledge among women of a facility for HIV testing and whether they have ever been tested are presented in Table HA.5. 108 the survey provides a measure of the effectiveness of interventions that promote HIV counselling and testing among young people. This is important to know because young people may feel that there are barriers to accessing services related to sensitive issues such as sexual health. More than half of women aged 15–24 years (57 percent) reported having had sex in the 12 months preceding the survey. Generally, although 95 percent of sexually active young women know of a place to get tested, only 67 percent had ever been tested and an even lower proportion (37 percent) had received an HIV test during the 12 months preceding the survey. This raises the need for further research to investigate the reasons for low testing among groups that are aware of sites where HIV testing is being done. Overall, there is a slight difference among the women who were tested in the last 12 months and those who were tested and received results. This trend is more obvious among women aged 15–19 years where 34 percent of them got tested but only 26 percent received results. Surprisingly, this is not the case among the age group 20–24 years, where 38 percent were tested in the last 12 months and 37 percent received results. More effort needs to be made to ensure that all those who have been tested are told their results. Women aged 15–24 years had the lowest testing rates (45 percent) compared to all other age groups. Within this age group, women aged 20–24 years have more than three times (72 percent) the testing rates of women aged 15–19 years (21 percent), probably due to the fact that some of the latter are not sexually active as yet. Women who are ever married or in union are twice as likely (84 percent) to have been tested as women who are never married/ in union (40 percent). Knowledge of a place for HIV testing and counselling among sexually active women Table HA.6 presents the results on knowledge among sexually active young women (aged 15–24) of a place for HIV testing and counselling. The proportion of young women who were tested and told the result within the 12 months preceding 109 Overall, the results indicate that almost all pregnant women (97 percent) are being tested and receiving their results though fewer (63 percent) are offered additional counselling. The Ministry of Health’s policy on the prevention of mother-to-child transmission (PMTCT) mandates that all women in labour on the maternity ward at any of the hospitals in Saint Lucia be offered an HIV test. Women who deliver at home and are transported to the hospital afterwards are also offered an HIV test It is recommended that all pregnant women are supported to ensure they attend the recommended number of antenatal visits and laboratories and voluntary counselling and testing (VCT) providers are assisted to give equal attention to testing of individuals and providing counselling. HIV counselling and testing during antenatal care Among women who had given birth within the two years preceding the survey, the percentage who had received counselling and HIV testing during antenatal care (ANC) is presented in Table HA.7. Almost all women aged 15–49 years (97 percent) received ANC from a health-care professional during their last pregnancy. Although a significant proportion reported having received ANC from a health-care professional, only about two of every three women (63 percent) reported having received HIV counselling during the antenatal period. This is of concern since HIV and STIs are included as one of the topics for discussion/education at antenatal clinics in the public health centres, and HIV counselling must be given before each test. 110 years of age to assess their risk of HIV infection. Risk factors for HIV include sex at an early age, sex with older men, sex with a non-marital non- cohabitating partner and failure to use a condom. The frequency of sexual behaviours that increase the risk of HIV infection among women is presented in Table HA.8 and Figure HA.2. About two out of every three women in Saint Lucia aged 15–24 years (61 percent) who have never been married have never had sex. Six percent had sex before the age of 15 years and 16 percent had sex with a man 10 years or more in the last 12 months. Sexual behaviour related to HIV transmission Promoting safer sexual behaviour is critical for reducing HIV prevalence. The use of condoms during sex, especially with non- regular partners, is especially important for reducing the spread of HIV. In most countries, over half of new HIV infections are among young people aged 15–24 years, thus a change in behaviour among this age group will be especially important to reduce new infections. A set of questions was administered to all women aged 15–49 111 112 About three out of every four women aged 15–49 years (73 percent) had sex in the 12 months preceding the survey. About 5 percent had sex with more than one partner in this period. This percentage tended to decrease with age, ranging from 8 percent among women 15–24 years to 2 percent among those aged 40–49 years. Around half of women aged 15–49 years (48 percent) who had more than one sexual partner in the last 12 months reported that a condom was used the last time they had sex. Sexual behaviour and condom use during sex were assessed for all women and separately for women aged 15–24 years who had sex with multiple partners in the previous year (Tables HA.9 and HA.10). About four out of every five women aged 15–49 years (87 percent) have ever had sex. Though differentials are not strong, women who had been married were more likely to have ever had sex compared with those who had not (see Table HA9). 113 in the last 12 months and, among this last group, percentage who used a condom the last time they had sex with such a partner. Of the women aged 15–24 years who had sex in the 12 months prior to the MICS, about half (53 percent) had had sex with a non-marital, non-cohabitating partner during the year. Of these women, about three in every four (70 percent) reported that a condom was used at the last sexual encounter with such a partner. Table HA.10 shows that about two out of every three women aged 15–24 years (63 percent) had had sex (ever had sex). More than half (57 percent) had sex in the 12 months prior to the survey, and about 8 percent had sex with more than one partner. Differentials are not strong. Of women aged 15–24 who had sex in the last 12 months with multiple partners, about 42 percent used a condom (data not shown). Tables HA.11 presents the percentage of women aged 15–24 years who ever had sex, percentage who had sex in the last 12 months, percentage who had sex with a non-marital, non-cohabiting partner 114 parents. Two out of every three children aged 0–17 years (40 percent) live with both parents. More children from the rural areas (41 percent) live with both parents than children from the urban areas (33 percent). About one out of every ten children (9 percent) have both parents alive but live with neither parent. Table HH.12 also shows that more children from the wealthiest families live with both parents (41 percent) compared to those from the poorest families (38 percent). The data reveal that older children are less likely than younger children to live with both parents. Two out of every three children (41 percent) whose father is still alive live with their mother only, compared to just 4 percent who live with their father only although their mother is alive. This indicates that there are more single mothers than single fathers raising children in Saint Lucia . Usually MICS calculates the ratio of school attendance of orphans and non-orphans. In the case of Saint Lucia, this was not done due to the low numbers of orphans. However, the percentage of non-orphans who are attending school is 99 percent (data not shown). Orphans As the HIV epidemic progresses, more and more children are becoming orphaned because of AIDS. Children who are orphaned may be at increased risk of neglect or exploitation if suitable guardians are not available to assist them. Monitoring the variations in different outcomes for orphans and comparing them to their peers provides a measure of how well communities and governments are responding to their needs. Although the majority of cases of orphanhood in Saint Lucia are probably not due to HIV and AIDS, it remains important to monitor the living arrangements of orphaned children. Table HA.12 presents information on the living arrangements and orphanhood status of children under age 18 in Saint Lucia. Some children may not be living with one or both of their parents primarily because of various social living arrangements and family structure such as the extended family rather than as a result of death of their 115 The 2012 Saint Lucia MICS collected information on exposure to mass media and the use of computers and Internet. Information was collected on exposure to newspapers/magazines, radio and television among women aged 15–49 years as well as on computer and Internet use among younger women aged 15–24 years. Access to mass media The proportion of women who read a newspaper/ magazine, listen to the radio and watch television at least once a week is shown in Table MT.1. Approximately two out of every five women (39 percent) are exposed to all three types of media in Saint Lucia on a weekly basis. Women were least exposed to reading a newspaper/magazine while they were most exposed to watching television. At the national level, about half of all women aged 15– 49 years (48 percent) read a newspaper/ magazine at least once a week. Further, four out of five women (83 percent) listen to the radio at least once a week while nine out of ten (93 percent) watch television at least once a week. Generally women aged 15–49 were twice as likely to watch television than to read a newspaper or magazine. Table MT.1 also shows that women in the 30–34 age group (46 percent) were the most exposed to all three types of mass media while women aged 15–19 years (35 percent) were the least exposed. Exposure to all three types of media varied by education and socio-economic status. Women with secondary or greater education were twice as likely (45 percent) to be exposed to all three types of media compared to women with none/ primary education (19 percent). The data indicate that exposure to all three types of media increased as the household wealth increased. Women in the richest households (44 percent) were more likely to be exposed to all three media types than women in the poorest households (30 percent). There was no difference by area of residence (rural and urban) regarding exposure to all three media. 12 ACCESS TO MASS MEDIA AND USE OF INFORMATION AND COMMUNICATIONS TECHNOLOGY 116 primary education (27 percent). As the wealth index increases, the percentage of women who read a newspaper/magazine also increases. Women from the richest households (55 percent) are more likely to read a newspaper/magazine on a weekly basis than those from the poorest households (36 percent). Table MT.1 also shows that 1 percent of women aged 15–49 years do not have regular exposure to any of the three media during the period of a week. The women in the 25–29 age group are those most likely to have no media exposure on a weekly basis (4 percent). Women aged 40–44 years (88 percent) were the most exposed to radio, while those aged 20–24 years are the least exposed (78 percent). Exposure to radio was about the same for both the urban and rural areas (82 percent). Further work to see if these figures are statistically significant should be done. Of the women who read a newspaper/ magazine, more than half (56 percent) are women aged 30–34 years compared to 42 percent of those 15–19 years. Women with secondary or greater education are twice as likely (54 percent) to read a newspaper/magazine as those with none/ 117 12 months was more widespread among women aged 15–19 years. The Internet in Saint Lucia can also be accessed through cellular mobile phones and other media. Almost all women aged 15–19 years (95 percent) had used a computer during the last 12 months compared to about nine out of ten (91 percent) for the 20–24 age group. Internet use between these age groups followed a similar pattern. Computer and Internet use was also related to the wealth of the household. Nearly all women in the richest quintiles (98 percent) had used the Internet during the last year compared to about 86 percent of women from the poorest households. Internet use during the last 12 months was observed to be higher among young women in the rural areas (94 percent) compared to those in the urban areas (89 percent). Use of information and communications technology The questions on access to mass media and Internet use were directed only to women aged 15–24 years. Table MT.2 shows that almost every woman in this age group (98 percent) had used a computer before and nine out of ten (91 percent) had used one during the last year. Eight out of ten women (82 percent) had used a computer at least once a week during the last month. Almost all women aged 15–24 (96 percent) have ever used the Internet, while nine out of ten (93 percent) had used the Internet during the last year. The proportion of young women who had used the Internet more frequently, at least once a week during the last month, was lower (86 percent). Both computer and Internet use during the last 118 Harmful alcohol use is regarded as one of the world’s leading health risks. It is associated with and believed to be the causal factor in more than 60 major types of diseases and injuries and is also linked with the course of disease. According to the 2011 WHO Global Report on Alcohol and Health, approximately 5 percent of the global burden of disease and injury is attributable to alcohol.18 In the long term, excessive drinking can lead to cardiovascular problems, neurological impairments, liver disease and social problems. Alcohol abuse is also associated with injuries and violence, including intimate partner violence and child maltreatment.19 The impact of alcohol consumption on disease and injury is associated with two separate but related dimensions of drinking by individuals: the volume of alcohol consumed and the pattern of drinking. Patterns of alcohol use are also noted to have a profound impact on health risks especially when associated with heavy episodic drinking. The Saint Lucia MICS collected information on alcohol use among women aged 15–49 years. This information will help to understand the current use of alcohol among women, the intensity of use and the percentage who ever used alcohol. In this survey one drink of alcohol was considered to be equal to one can or bottle of beer or shandy, one glass of wine or alcoholic punch, or one shot of cognac, vodka, whiskey or rum. The results suggests that about one in every eight women aged 15–49 years (13 percent) had at least one drink of alcohol before the age of 15. Half of all the women aged 15–49 years (51 percent) had drunk alcohol on one or more days during the last one month while 14 percent had never had a drink of alcohol (see Table TA.1). 13ALCOHOL USE 18 World Health Organization, ‘Global Report on Alcohol and Health’, WHO, Geneva, 2011, available at who.int/substance_ abuse/publications/global_alcohol_report/msbgsruprofiles.pdf 19 US Centers for Disease Control and Prevention, ‘Fact Sheet: Alcohol abuse and health’, www.cdc.gov/alcohol/fact-sheets/ alcohol-use.htm 119 or greater education (15 percent) than among women with none/primary education (5 percent). The findings suggest that drinking alcohol on one or more days during the month preceding the survey increased with wealth. Consumption of alcohol was slightly more prevalent among women from the richest households (53 percent) than those from the poorest households (48 percent). Among the women who drank during the month preceding the survey, the prevalence of alcohol use was slightly higher among women in the urban areas (55 percent) than those in the rural areas (51 percent). Consumption of alcohol seemed to be higher among women with secondary or greater education (54 percent) compared with those with none/primary education (43 percent). Drinking of alcohol is highest among women aged 25– 29 years (62 percent) and lowest among women aged 15–19 years (43 percent). Drinking of alcohol before age 15 is more prevalent among women with secondary 120 A P P E N D IX A 121 A P P E N D IX A 122 The major features of the sample design are described in this appendix. Sample design features include target sample size, sample allocation, sampling frame and listing, choice of domains, sampling stages, stratification and the calculation of sample weights. The primary objective of the sample design for the Saint Lucia Multiple Indicator Cluster Survey (MICS) was to produce statistically reliable estimates of most indicators both at the national level and for urban and rural areas Sampling strata There are 10 geographic districts in Saint Lucia, as shown in Table SD.1. Five of these districts contain less than 3,000 households: Canaries (786 households), Anse la Raye (2,162 households), Soufriere (2,875 households), Choiseul (2,069 households) and Laborie (2,180 households). Due to the small size of so many districts it is not realistic to provide estimates at the district level. There is no obvious grouping of districts into a smaller sub-set of three or four regions, which would have made sampling more manageable. Thus urban and rural population were selected as the sampling strata for the purpose of the MICS. The urban population was defined as the administrative centres of the 10 districts. With the assistance of the Geographic Information Systems Manager in the Central Statistics Office (CSO), it was possible to identify which enumeration districts (EDs) are included in these administrative centres. The urban households (11,957) represent 21 percent of the total number of households (57,369) in Saint Lucia. The rest of the EDs were considered to be in the rural stratum. A P P E N D IX A 123 Sampling frame and selection of clusters The 2010 Population and Household Census is used as the sample frame for the Saint Lucia MICS and census EDs are defined as the primary sampling units (PSUs)/ clusters. These were selected from each of the sampling strata by using systematic pps (probability proportional to size) sampling procedures based on the estimated sizes of the enumeration districts (clusters) from the 2010 Census. Sample size and sample allocation There were no obvious sources of data that could provide indicative values of some of the key MICS indicators. The CSO has not conducted any previous surveys of this nature, although the Core Wealth Indicator Questionnaire Survey (CWIQ) conducted in 2004 provided estimates showed almost 100 percent coverage for prenatal care and for professional attendance at delivery. In the absence of any guidance on expected levels of indicators, the next approach used was to examine potential levels of indicators for various groups of people and determine what sample size would be required to estimate each one with a certain level of precision. Adequate urban and rural estimates could be achieved for women aged 15–49 by taking samples of between 200 and 1,000 households (for indicators in the range from 0.7 to 0.3 respectively). Similar estimates for girls aged 15–24 would require samples of between 500 and 3,000; for the under-5 population the sample sizes would range from 700 to 4,000 households; and for estimating a single year age group, such as children aged 12–23 months, samples of between 4,000 and 19,000 households would be required. Since many of the indicators in Saint Lucia would take fairly high values (often exceeding 0.7), it was decided that a sample of 2,000 households should be adequate. The average number of households selected per cluster was determined as 20 households based on a number of considerations including the design effect, the budget available and the time that would be needed per team to complete one cluster. Dividing the total number of households (2,000) by the number of sample households per cluster, it was calculated that 100 sample clusters would be selected. A P P E N D IX A 124 Table SD.3 below shows some alternative methods of allocating the clusters to the sampling strata considered. A proportional allocation would have required selecting 21 urban and 79 rural EDs. This procedure would be best for getting a precise national estimate, but it would not have been good enough for estimating the urban component since the sample is too small. At the other extreme, equal allocation would have required 50 EDs being selected for both the urban and rural samples. While this approach would be the most satisfactory design for estimating the urban and rural components, it would not be so efficient for estimating at the national level since rural areas would be inadequately represented in the overall sample. For the Saint Lucia MICS it was therefore decided to select 40 EDs in urban areas and 60 EDs in rural areas, resulting in an urban sample of 800 households and a rural sample of 1,200 households. This is roughly equivalent to cube root allocation. Sampling frame and selection of clusters The 2010 Population and Household Census was used as the sample frame for the selection of clusters. Census ED/clusters were defined as primary sampling units (PSUs) and selected from each of the sampling strata by using systematic pps sampling procedures, based on the estimated sizes of the enumeration areas from the 2010 Census. To select the sample of clusters, EDs/clusters within each stratum were listed in order by district and by ED/cluster number within each district. In cases where larger EDs/clusters had been subdivided previously, these parts were listed next to each other (even if they did not have adjacent ED numbers). EDs/clusters with less than 20 households were combined with the ED/cluster immediately preceding them in the list, and if the small ED/cluster was the first ED/cluster shown in a district it was combined with the next ED/cluster on the list. The first stage of sampling was completed by selecting the required number of EDs/clusters from each stratum (urban and rural). Listing activities The visitation records from the 2010 Population and Housing Census were used for the listing for most of the households. A new listing of households was conducted in six enumeration districts prior to the selection of households for the MICS Survey. For this exercise five enumerators were used, who visited these enumeration district (clusters), and listed the occupied households. The enumeration districts (clusters) were relisted either because of the number of households which were not contacted on the visitation record from the 2010 Population and Household Census or because subdivisions must to be done to enumeration districts (clusters) that contain two hundred or more households . A P P E N D IX A 125 Selection of households The households within the selected EDs/ clusters were then sequentially numbered from 1 to n (the total number of households in each enumeration area) at the CSO, where the selection of 20 households in each enumeration area was carried out using random systematic selection procedures. Calculation of sample weights The Saint Lucia MICS sample is not self- weighting. Essentially, by allocating equal numbers of households to each of the clusters, different sampling fractions were used in each cluster since the size of the clusters varied. For this reason, sample weights were calculated and these were used in the subsequent analyses of the survey data. The major component of the weight is the reciprocal of the sampling fraction employed in selecting the number of sample households in that particular sampling stratum (h) and PSU (i): The term fhi, the sampling fraction for the i-th sample PSU in the h-th stratum, is the product of probabilities of selection at every stage in each sampling stratum: Where pshi is the probability of selection of the sampling unit at stage s for the i-th sample PSU in the h-th sampling stratum. Since the estimated number of households in each enumeration area (PSU) in the sampling frame used for the first stage selection and the updated number of households in the enumeration district (cluster) from the listing were different, individual sampling fractions for households in each sample enumeration area (cluster) were calculated. The sampling fractions for households in each enumeration district (cluster) therefore included the first stage probability of selection of the enumeration district (cluster) in that particular sampling stratum and the second stage probability of selection of a household in the sample enumeration district (cluster). A second component in the calculation of sample weights takes into account the level of non-response for the household and individual interviews. The adjustment for household non- response is equal to the inverse value of: RRh = Number of interviewed households in stratum h/ Number of occupied households listed in stratum h After the completion of fieldwork, response rates were calculated for each sampling stratum. These were used to adjust the sample weights calculated for each cluster. Response rates in the Saint Lucia MICS are shown in Table HH.1 in this report. Similarly, the adjustment for non-response at the individual level (women and under-5 children) for each stratum is equal to the inverse value of: RRh = Completed women’s (or under-5’s) questionnaires in stratum h / Eligible women (or under-5s) in stratum h The non-response adjustment factors for the women’s and under-5’s questionnaires are applied to the adjusted household weights. Numbers of eligible women and under-5 children were obtained from the roster of household members from the household questionnaire where interviews were completed. The design weights for the households were calculated by multiplying the above factors for each enumeration area. These weights were then standardized (or normalized), one purpose of which is to make the weighted A P P E N D IX A 126 sum of the interviewed sample units equal the total sample size at the national level. Normalization is performed by dividing the aforementioned design weights by the average design weight at the national level. This involves multiplying the sample weights by a constant factor equal to the unweighted number of households at the national level divided by the weighted total number of households (using the full sample weights adjusted for non-response). A similar standardization procedure was followed in obtaining standardized weights for the women’s and under-5’s questionnaires. Adjusted (normalized) weights varied between 0.477712 and 1.603220 in the 100 sample enumeration areas (clusters). Sample weights were appended to all data sets and analyses were performed by weighting each household, woman or under-5 with these. Recommendations for future MICS surveys This is the first MICS survey in Saint Lucia. The current sample design provides a sound basis for future sampling for similar two-stage cluster design surveys. While the MICS4 sample was adequately powered to detect differences across the sampling domains of urban and rural for the vast majority of indicators (see Appendix C: Sampling Errors), some indicators related to children could not be adequately disaggregated. Future sample designs should take into consideration the low fertility in Saint Lucia and implement a design that oversamples households with children in an effort to boost the number of children included. A P P E N D IX B 127 A P P E N D IX B 127 A P P E N D IX B 128 List of Personnel Involved in the Survey The Saint Lucia MICS 4 was implemented by the Ministry of Social Transformation, Local Government and Community Empowerment (MoST) and the Central Statistics Office (CSO) in collaboration with the Ministry of Health, Wellness, Human Services and Gender Relations (MoH) and the Ministry of Education, Human Resource Development and Labour (MoE) with the support and financial and technical assistance of the United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA) and UN Women. 1. Saint Lucia MICS4 Steering Committee members 2. Saint Lucia MICS4 Technical Committee members A P P E N D IX B 129 3. Saint Lucia MICS4 implementing personnel 4. Sampling exercise 5. Listing/mapping exercise A P P E N D IX B 130 6. Data processing team 7. Teams of field staff for pre-test 8. Teams of field staff for main survey A P P E N D IX B 131 9. Training facilitators 10. Report writers A P P E N D IX B 132 11. Other contributing stakeholders 12. UNICEF Regional and Head Office Staff Ms Khin-Sandi Lwin UNICEF Representative, UNICEF Office for the Eastern Caribbean Area Ms Violet Speek-Warnery Deputy Representative, UNICEF Office for the Eastern Caribbean Area Mr Alexandru Nartea MICS 4 Regional Coordinator, UNICEF Office for the Eastern Caribbean Area Mr Frederic Unterreiner Chief of Monitoring and Evaluation, UNICEF Office for the Eastern Caribbean Area Mr Oladimeji Olowu Planning Monitoring and Evaluation Specialist (Saint Lucia MICS focal point) UNICEF Office for the Eastern Caribbean Area Mr Shane Khan Household Survey Specialist, Global MICS Consultant, UNICEF Office for the Eastern Caribbean Area 13. Consultants Mr Peter Wingfield-Digby MICS Sampling Consultant (supplied by UNICEF to assist in sample size determination and in sample selection) Mr Martin Wulfe MICS Data Processing Expert (supplied by UNICEF to assist in sample size determination and in sample selection) Ms Euphemia Edmund MICS Report Consultant (hired by UNICEF to support and coordinate the drafting, review and preparation of the final MICS Report) A P P E N D IX C 133 A P P E N D IX C 133 A P P E N D IX C 134 Estimates of Sampling Errors The sample of respondents selected in the Saint Lucia MICS is only one of the samples that could have been selected from the same population using the same design and size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between the estimates from all possible samples. The extent of variability is not known exactly but can be estimated statistically from the survey data. The following sampling error measures are presented in this appendix for each of the selected indicators: u Standard error (se): Sampling errors are usually measured in terms of standard errors for particular indicators (means, proportions, etc). Standard error is the square root of the variance of the estimate. The Taylor linearization method is used for the estimation of standard errors. u Coefficient of variation (se/r) is the ratio of the standard error to the value of the indicator and is a measure of the relative sampling error. u Design effect (deff) is the ratio of the actual variance of an indicator, under the sampling method used in the survey, to the variance calculated under the assumption of simple random sampling. The square root of the design effect (deft) is used to show the efficiency of the sample design in relation to the precision. A deft value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a deft value above 1.0 indicates an increase in the standard error due to the use of a more complex sample design. u Confidence limits are calculated to show the interval within which the true value for the population can be reasonably assumed to fall, with a specified level of confidence. For any given statistic calculated from the survey, the value of that statistic will fall within a range of plus or minus two times the standard error (r + 2.se or r – 2.se) of the statistic in 95 percent of all possible samples of identical size and design. For the calculation of sampling errors from MICS data, SPSS Version 18 Complex Samples module has been used. The results are shown in the tables that follow. In addition to the sampling error measures described above, the tables also include weighted and unweighted counts of denominators for each indicator. Sampling errors are calculated for indicators of primary interest, for the national level and for urban and rural areas. One of the selected indicators is based on households, 7 are based on household members, 19 are based on women and 8 are based on children under 5. All indicators presented here are in the form of proportions. Table SE.1 shows the list of indicators for which sampling errors are calculated, including the base population (denominator) for each indicator. Tables SE.2 to SE.4 show the calculated sampling errors for selected domains. A P P E N D IX C 135 Table SE.1: Indicators selected for sampling error calculations List of indicators selected for sampling error calculations and base populations (denominators) for each indicator, Saint Lucia, 2012 A P P E N D IX C 136 Table SE.2: Sampling errors: total sample Standard errors, coefficients of variation, design effects (deff), square root of design effects (deft) and confidence intervals for selected indicators, Saint Lucia, 2012 A P P E N D IX C 137 A P P E N D IX C 138 A P P E N D IX D 139 A P P E N D IX D 139 A P P E N D IX D 140 Data Quality Tables A P P E N D IX D 141 A P P E N D IX D 142 A P P E N D IX D 143 A P P E N D IX D 144 A P P E N D IX D 145 A P P E N D IX D 146 A P P E N D IX D 147 A P P E N D IX E 148148 A P P E N D IX E 149 A P P E N D IX E 149 A P P E N D IX E 150 Saint Lucia MICS4 Indicators: Numerators and Denominators 1 Some indicators are constructed by using questions in several modules. In such cases, only the module(s) that contains most of the necessary information is indicated. 2 MDG indicators as of February 2010. 3 Infants receiving breast milk and not receiving any other fluids or foods, with the exception of oral rehydration solution, vitamins, mineral supplements and medicines. A P P E N D IX E 151 4 Infants who receive breast milk and certain fluids (water and water-based drinks, fruit juice, ritual fluids, oral rehydration solution, drops, vitamins, minerals and medicines) but do not receive anything else (in particular, non-human milk and food-based fluids). 5 Breastfeeding children: Solid, semi-solid, or soft foods, two times for infants age 6–8 months, three times for children 9–23 months; Non-breastfeeding children: Solid, semi-solid, or soft foods, or milk feeds, four times for children age 6–23 months. 6 Infants aged 0–5 who are exclusively breastfed and children aged 6–23 months who are breastfed and ate solid, semi-solid or soft foods. 7 See MICS4 manual for a detailed description. A P P E N D IX E 152 8 See MICS4 manual for a detailed description. A P P E N D IX E 153 A P P E N D IX E 154 A P P E N D IX E 155 A P P E N D IX E 156 9 Using condoms and limiting sex to one faithful, uninfected partner. A P P E N D IX E 157 10 Transmission during pregnancy, during delivery and through breastfeeding. 11 Women (1) who think that a female teacher with the AIDS virus should be allowed to teach in school, (2) who would buy fresh vegetables from a shopkeeper or vendor who has the AIDS virus, (3) who would not want to keep it as a secret if a family member became infected with the AIDS virus, and (4) who would be willing to care for a family member who became sick with the AIDS virus. A P P E N D IX E 158 A P P E N D IX E 159 A P P E N D IX F 160160 A P P E N D IX F 161 A P P E N D IX F 161 A P P E N D IX F 162 HOUSEHOLD QUESTIONNAIRE Saint Lucia HOUSEHOLD  INFORMATION  PANEL   HH   HH1. Cluster number: ___ ___ ___ HH2. Household number: ___ ___ HH3. Interviewer name and number: HH4. Supervisor name and number: Name _________________________ ___ ___ Name__________________________ ___ ___ HH5. Day / Month / Year of interview: ___ ___ / ___ ___ / ___ ___ ___ ___ HH6. AREA: Urban . 1 Rural . 2 WE ARE FROM THE CENTRAL STATISTICAL OFFICE. WE ARE WORKING ON A PROJECT IN COLLABORATION WITH UNICEF CONCERNED WITH FAMILY HEALTH AND EDUCATION. I WOULD LIKE TO TALK TO YOU ABOUT THESE SUBJECTS. THE INTERVIEW WILL TAKE ABOUT 15 MINUTES. ALL THE INFORMATION WE OBTAIN WILL REMAIN STRICTLY CONFIDENTIAL AND YOUR ANSWERS WILL NEVER BE SHARED WITH ANYONE OTHER THAN OUR PROJECT TEAM. MAY I START NOW? ¨ Yes, permission is given ð Go to HH18 to record the time and then begin the interview. ¨ No, permission is not given ð Complete HH9. Discuss this result with your supervisor. After all questionnaires for the household have been completed, fill in the following information: HH8. Name of head of household: __________________________________________ HH9. Result of household interview: Completed . 01 No household member or no competent respondent at home at time of visit . 02 Entire household absent for extended period of time . 03 Refused . 04 Dwelling vacant / Address not a dwelling . 05 Dwelling destroyed . 06 Dwelling not found . 07 Other (specify) ________________________ 96 HH10. Respondent to household questionnaire: Name: ____________________________________ Line Number: ___ ___ HH11. Total number of household members: ___ ___ HH12. Number of women age 15-49 years: ___ ___ HH13. Number of woman’s questionnaires completed: ___ ___ HH14. Number of children under age 5: ___ ___ HH15. Number of under-5 questionnaires completed: ___ ___ HH16. Field edited by (Name and number): Name _________________________ ___ ___ HH17. Data entry clerk (Name and number): Name ___________________________ ___ ___ A P P E N D IX F 163   H H 18 . R ec or d   th e   ti m e. H ou r . . . . . _ _ __ M in ut es . . . _ _ __   H O U SE H O LD  L IS TI N G  F O R M   H L   FI R S T, P LE A S E T E LL M E T H E N A M E O F E A C H P E R S O N W H O U S U A LL Y L IV E S H E R E , S TA R TI N G W IT H T H E H EA D O F TH E H O U S E H O LD .     Li st  t he  h ea d   of  t he  h ou se ho ld  in  li ne  0 1.  L is t   al l  h ou se ho ld  m em be rs  ( H L2 ),  t he ir  r el at io ns hi p   to  t he  h ou se ho ld  h ea d   (H L3 ),  a nd  t he ir  s ex   (H L4 ) T he n   as k:  A R E T H E R E A N Y O TH E R S W H O L IV E H E R E , E V E N IF T H E Y A R E N O T A T H O M E N O W ?     If  y es ,  c om pl et e   lis ti ng  fo r   qu es ti on s   H L2 -­‐H L4 .  T he n,  a sk  q ue st io ns  s ta rt in g   w it h   H L5  fo r   ea ch  p er so n   at  a  t im e.       U se  a n   ad di ti on al  q ue st io nn ai re  if  a ll   ro w s   in  t he  h ou se ho ld  li st in g   fo rm  h av e   be en  u se d. Fo r w om en ag e 15 –4 9 Fo r c hi ld re n ag e 5– 14 Fo r ch ild re n un de r a ge 5   Fo r   ch ild re n   ag e   0 –1 7  y ea rs   H L1 . Li ne N o H L2 . N am e H L3 . W H A T IS TH E R E LA TI O N -S H IP O F (n am e) TO T H E H E A D O F H O U S E - H O LD ? H L4 . IS (n am e) M A LE O R FE M A LE ? 1 M al e 2 Fe m al e H L5 . W H A T IS (n am e) ’S D A TE O F B IR TH ? H L6 . H O W O LD IS (n am e) ? Re co rd in co m pl et ed ye ar s. If ag e is 9 5 or ab ov e, re co rd ‘9 5’ H L7 . C ir cl e lin e no . if w om an is ag e 15 –4 9 H L8 . W H O IS T H E M O TH E R O R P R IM A R Y C A R E TA K E R O F TH IS C H IL D ? Re co rd lin e no . o f m ot he r/ ca re ta ke r H L9 . W H O IS TH E M O TH E R O R P R IM A R Y C A R E TA K E R O F TH IS C H IL D ? Re co rd lin e no . o f m ot he r/ ca re ta ke r H L1 1. IS (n am e) ’S N A TU R A L M O TH E R A LI V E ? 1 Y es 2 N oø H L1 3 8 D K ø H L1 3 H L1 2. D O E S (n am e) ’S N A TU R A L M O TH E R LI V E IN TH IS H O U S E - H O LD ? Re co rd lin e no . o f m ot he r o r 00 fo r “N o” H L1 3. IS (n am e) ’ S N A TU R A L FA TH E R A LI V E ? 1 Y es 2 N oø N ex t L in e 8 D K ø N ex t L in e H L1 4. D O E S (n am e) ’S N A TU R A L FA TH E R LI V E IN T H IS H O U S E - H O LD ?   Re co rd lin e no . o f fa th er o r 00 fo r “N o” 98 D K 99 98 D K Li ne N am e R el at io n * M F M on th Y ea r A ge 15 –4 9 M ot he r M ot he r Y N D K M ot he r Y N D K Fa th er 01 0 1 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 01 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 02 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 02 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 03 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 03 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 04 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 04 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 05 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 05 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 06 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 06 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 07 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 07 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ A P P E N D IX F 164 H L1 . Li ne N o H L2 . N am e H L3 . W H A T IS TH E R E LA TI O N -S H IP O F (n am e) TO T H E H E A D O F H O U S E - H O LD ? H L4 . IS (n am e) M A LE O R FE M A LE ? 1 M al e 2 Fe m al e H L5 . W H A T IS (n am e) ’S D A TE O F B IR TH ? H L6 . H O W O LD IS (n am e) ? Re co rd in co m pl et ed ye ar s. If ag e is 9 5 or ab ov e, re co rd ‘9 5’ H L7 . C ir cl e lin e no . if w om an is ag e 15 –4 9 H L8 . W H O IS T H E M O TH E R O R P R IM A R Y C A R E TA K E R O F TH IS C H IL D ? Re co rd lin e no . o f m ot he r/ ca re ta ke r H L9 . W H O IS TH E M O TH E R O R P R IM A R Y C A R E TA K E R O F TH IS C H IL D ? Re co rd lin e no . o f m ot he r/ ca re ta ke r H L1 1. IS (n am e) ’S N A TU R A L M O TH E R A LI V E ? 1 Y es 2 N oø H L1 3 8 D K ø H L1 3 H L1 2. D O E S (n am e) ’S N A TU R A L M O TH E R LI V E IN TH IS H O U S E - H O LD ? Re co rd lin e no . o f m ot he r o r 00 fo r “N o” H L1 3. IS (n am e) ’ S N A TU R A L FA TH E R A LI V E ? 1 Y es 2 N oø N ex t L in e 8 D K ø N ex t L in e H L1 4. D O E S (n am e) ’S N A TU R A L FA TH E R LI V E IN TH IS H O U S E - H O LD ?   Re co rd lin e no . o f fa th er o r 00 fo r “N o” 98 D K 99 98 D K Li ne N am e R el at io n * M F M on th Y ea r A ge 15 –4 9 M ot he r M ot he r Y N D K M ot he r Y N D K Fa th er 08 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 08 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 09 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 09 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 10 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 10 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 11 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 11 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 12 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 12 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 13 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 13 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 14 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 14 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ 15 __ _ __ _ 1 2 __ _ _ __ _ _ __ __ __ _ _ __ 15 __ _ _ __ __ _ _ __ 1 2 8 __ _ _ __ 1 2 8 __ _ _ __ Ti ck h er e if ad di tio na l q ue st io nn ai re u se d ¨ A P P E N D IX F 165 Probe  for  additional  household  members.   Probe  especially  for  any  infants  or  small  children  not  listed,  and  others  who  may  not  be   members  of  the  family  (such  as  servants,  friends)  but  who  usually  live  in  the  household.   Insert  names  of  additional  members  in  the  household  list  and  complete  form   accordingly. Now  for  each  woman  age  15–49  years,  write  her  name  and  line  number  and  other   identifying  information  in  the  information  panel  of  a  separate  Individual  Women’s   Questionnaire. For  each  child  under  age  5,  write  his/her  name  and  line  number  AND  the  line  number   of  his/her  mother  or  caretaker  in  the  information  panel  of  a  separate  Under-­‐5   Questionnaire. You  should  now  have  a  separate  questionnaire  for  each  eligible  woman  and  each  child   under  five  in  the  household. * Codes for HL3: Relationship to head of household: 01 Head 02 Wife / Husband/ Common Law Partner 03 Son / Daughter 04 Son-In-Law / Daughter-In- Law 05 Grandchild 06 Parent 07 Parent-In-Law 08 Brother / Sister 09 Brother-In-Law / Sister-In-Law 10 Uncle / Aunt 11 Niece / Nephew 12 Other relative 13 Adopted / Foster / Stepchild 14 Not related 98 Don't know A P P E N D IX F 166 ED U CA TI O N   ED   Ta bl e1 : G ra de c on ve rs io n ta bl e fo r P rim ar y an d Se co nd ar y ed uc at io n in S ai nt L uc ia o U se th is ta bl e to a ss is t y ou w ith th e co nv er si on o f g ra de s i n th e qu es tio ns E D 4B , E D 6 an d ED 8. T he c on ve rs io n sh ou ld b e do ne fr om th e ol d ed uc at io n gr ad e sy st em (t ill 1 99 6/ 19 97 sc ho ol y ea r) o r c ur re nt e du ca tio n gr ad e sy st em (f ro m 1 99 7/ 19 98 sc ho ol o nw ar ds ) t o th e M IC S gr ad e (c od es ). Th e M IC S gr ad e eq ui va le nt sh ou ld b e re co rd ed in th e sp ac e pr ov id ed . O ld G ra de S ys te m (ti ll 19 96 /1 99 7) C ur re nt G ra de S ys te m (fr om 1 99 7/ 19 98 ) M IC S G ra de Le ve l G ra de Le ve l G ra de Le ve l G ra de In fa nt S ta ge 1 In fa nt G ra de K In fa nt /P rim ar y 01 S ta ge 2 G ra de 1 02 S ta ge 3 G ra de 2 03 P rim ar y S ta nd ar d 1 P rim ar y G ra de 3 04 S ta nd ar d 2 G ra de 4 05 S ta nd ar d 3 G ra de 5 06 S ta nd ar

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