Sierra Leone - Demographic and Health Survey - 2009

Publication date: 2009

Sierra Leone 2008Demographic and Health Survey SIERRA LEONE DEMOGRAPHIC AND HEALTH SURVEY 2008 Statistics Sierra Leone Ministry of Health and Sanitation Freetown, Sierra Leone ICF Macro Calverton, Maryland USA July 2009 World Bank This report presents the findings of the 2008 Sierra Leone Demographic and Health Survey (SLDHS) carried out by Statistics Sierra Leone (SSL) in collaboration with the Ministry of Health and Sanitation (MOHS). The Government of Sierra Leone provided financial assistance in terms of funding and in-kind contributions of government staff time, office space, and logistical support. Additional funding for the survey was provided by the U.S. Agency for International Development (USAID), the United Nations Population Fund (UNFPA), the United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF), the Department for International Development (DFID), and The World Bank. Logistical support was also received from the United Nations High Commission for Refugees (UNHCR), the World Health Organization (WHO), and the World Food Programme (WFP). ICF Macro, an ICF International Company, provided technical assistance and medical supplies and equipment for the survey through the MEASURE DHS programme, which is funded by USAID and designed to assist developing countries to collect data on fertility, family planning, and maternal and child health. The UNFPA Country Support Team provided backstopping support. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of the donor organizations. Additional information about the survey may be obtained from Statistics Sierra Leone, A.J. Momoh Street, Tower Hill, PMB 595, Freetown, Sierra Leone; Telephone +232-22-223287/ +232-76-609989; Fax +232-22- 223897; Email: statistics@statistics.sl / info@statistics.sl Information about the DHS programme may be obtained from MEASURE DHS, ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 1-301-572-0200; Fax: 1-301-572-0999; Email: reports@macrointernational.com; Internet: www.measuredhs.com. Suggested citation: Statistics Sierra Leone (SSL) and ICF Macro. 2009. Sierra Leone Demographic and Health Survey 2008. Calverton, Maryland, USA: Statistics Sierra Leone (SSL) and ICF Macro. Contents | iii CONTENTS TABLES AND FIGURES . ix ACKNOWLEDGEMENTS . xvii FOREWORD . xix PREFACE . xxi SUMMARY OF FINDINGS . xxiii CONTRIBUTORS TO THE SIERRA LEONE DEMOGRAPHIC AND HEALTH SURVEY . xxix MILLENNIUM DEVELOPMENT GOAL INDICATORS . xxxi MAP OF SIERRA LEONE .xxxii CHAPTER 1 INTRODUCTION 1.1 Geography . 1 1.2 History. 1 1.3 Economy . 2 1.4 Population . 3 1.5 Population and Family Planning Policies and Programmes . 3 1.6 Health Policies and Programmes . 4 1.7 Objectives and Organization of the 2008 SLDHS . 6 1.8 Sample Design . 6 1.9 Questionnaires . 7 1.10 Anaemia and HIV Testing . 8 1.10.1 Haemoglobin Testing . 8 1.10.2 HIV Testing . 8 1.11 Training of Field Staff . 9 1.12 Main Fieldwork (Data Collection) . 10 1.13 Data Processing . 10 1.14 Response Rates . 10 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Introduction . 13 2.2 Household Population by Age, Sex and Residence . 13 2.2.1 Household Composition . 14 2.2.2 Children’s Living Arrangement and Orphanhood . 15 2.3 School Attendance by Survivorship of Parents and by Orphanhood Status . 17 2.4 Education of the Household Population . 18 2.5 School Attendance Ratios . 21 2.6 Grade Repetition and Drop-out Rate . 22 2.7 Household Drinking Water . 23 2.8 Sanitation Facilities . 25 2.9 Other Household Characteristics . 26 2.10 Household Durable Goods . 28 2.11 Wealth Quintiles . 28 2.12 Birth Registration . 29 2.13 Child Labour . 29 iv | Contents CHAPTER 3 CHARACTERISTICS OF RESPONDENTS 3.1 Background Characteristics of Survey Respondents . 33 3.2 Educational Attainment . 34 3.3 Literacy. 36 3.4 Access to Mass Media . 38 3.5 Employment . 39 3.6 Occupation . 42 3.7 Earnings, Employers, and Continuity of Employment . 44 3.8 Health Insurance . 45 3.9 Knowledge and Attitudes Concerning Tuberculosis . 45 3.10 Smoking . 47 CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4.1 Current Fertility . 51 4.2 Fertility Differentials . 53 4.3 Fertility Trends . 55 4.4 Children Ever Born and Children Surviving . 56 4.5 Birth Intervals . 57 4.6 Age at First Birth . 58 4.7 Adolescent Fertility and Motherhood . 59 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods . 63 5.2 Ever Use of Contraception . 65 5.3 Current Use of Contraceptive Methods . 67 5.4 Differentials in Contraceptive Use by Background Characteristics . 69 5.5 Number of Children at First Use of Contraception . 70 5.6 Knowledge of the Fertile Period . 72 5.7 Source of Contraception . 72 5.8 Informed Choice . 73 5.9 Future Use of Contraception . 74 5.10 Reasons for Not Intending to Use Contraception . 75 5.11 Preferred Method for Future Use . 76 5.12 Exposure to Family Planning Messages . 76 5.13 Contact of Non-users with Family Planning Providers . 78 5.14 Husband/Partner’s Knowledge of Women’s Contraceptive Use . 79 5.15 Men’s Attitudes Towards Contraception . 80 CHAPTER 6 PROXIMATE DETERMINANTS OF FERTILITY 6.1 Current Marital Status . 83 6.2 Polygyny . 84 6.3 Age at First Marriage . 86 6.4 Age at First Sexual Intercourse . 88 6.5 Recent Sexual Activity . 90 6.6 Postpartum Amenorrhoea, Abstinence, and Insusceptibility . 93 6.7 Menopause . 94 Contents | v CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children . 95 7.2 Desire to Limit Childbearing by Background Characteristics . 97 7.3 Need for Family Planning Services . 98 7.4 Ideal Family Size . 100 7.5 Mean Ideal Number of Children by Background Characteristics . 101 7.6 Fertility Planning Status . 102 7.7 Wanted Fertility Rates . 102 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Definition, Methodology, and Data Quality . 105 8.2 Levels and Trends . 106 8.3 Differentials in Infant and Child Mortality . 107 8.3.1 Socioeconomic Differentials in Infant and Child Mortality . 107 8.3.2 Demographic Differentials in Infant and Child Mortality . 109 8.4 Perinatal Mortality . 110 8.5 High-Risk Fertility Behaviour . 112 CHAPTER 9 MATERNAL HEALTH 9.1 Antenatal Care . 115 9.2 Number and Timing of Antenatal Care Visits . 117 9.3 Components of Antenatal Care . 117 9.4 Tetanus Toxoid Injections . 119 9.5 Place of Delivery . 120 9.6 Assistance during Delivery . 121 9.7 Postnatal Care . 123 9.8 Problems in Accessing Health Care . 126 CHAPTER 10 CHILD HEALTH 10.1 Child’s Size at Birth . 129 10.2 Vaccination Coverage . 130 10.3 Trends in Vaccination Coverage . 133 10.4 Acute Respiratory Infection . 134 10.5 Fever . 135 10.6 Diarrhoeal Disease . 137 10.7 Knowledge of ORS Packets . 141 10.8 Stool Disposal . 141 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS 11.1 Nutritional Status of Children . 143 11.1.1 Measurement of Nutritional Status among Young Children . 143 11.1.2 Results of Data Collection . 144 11.1.3 Levels of Malnutrition . 147 11.2 Initiation of Breastfeeding . 148 11.3 Breastfeeding Status by Age . 150 11.4 Duration and Frequency of Breastfeeding . 152 vi | Contents 11.5 Types of Complementary Foods . 154 11.6 Infant and Young Child Feeding (IYCF) Practices . 156 11.7 Anaemia in Children . 158 11.8 Iodization of Household Salt . 160 11.9 Micronutrient Intake among Children . 161 11.10 Nutritional Status of Women . 164 11.11 Foods Consumed by Mothers . 165 11.12 Micronutrient Intake among Mothers . 167 11.13 Anaemia in Adults . 169 CHAPTER 12 MALARIA 12.1 Mosquito Nets . 171 12.1.1 Ownership of Mosquito Nets . 171 12.1.2 Use of Mosquito Nets by Children . 173 12.1.3 Use of Mosquito Nets by Women . 174 12.2 Intermittent Preventive Treatment of Malaria in Pregnancy . 176 12.2.1 Malaria Prophylaxis during Pregnancy . 176 12.2.2 Prevalence and Management of Childhood Malaria . 178 CHAPTER 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 13.1 HIV/AIDS Knowledge, Transmission, and Prevention Methods . 183 13.1.1 Awareness of HIV/AIDS . 183 13.1.2 Knowledge of HIV/AIDS Transmission and Prevention Methods . 185 13.1.3 Rejection of Misconceptions about HIV/AIDS . 187 13.2 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 189 13.3 Stigma Associated with AIDS and Attitudes Related to HIV/AIDS . 190 13.4 Attitudes towards Negotiating Safer Sex . 193 13.5 Attitudes towards Condom Education for Youth . 194 13.6 Higher-risk Sex . 196 13.6.1 Multiple Partners and Condom Use . 196 13.6.2 Transactional Sex . 200 13.7 Coverage of HIV Counselling and Testing . 200 13.7.1 HIV Testing during Antenatal Care . 203 13.8 Male Circumcision . 204 13.9 Self-reporting of Sexually Transmitted Infections . 204 13.10 Prevalence of Medical Injections . 206 13.11 HIV/AIDS-Related Knowledge and Sexual Behaviour among Youth . 208 13.11.1 HIV/AIDS-Related Knowledge among Young Adults . 208 13.11.2 Knowledge of Condom Sources among Young Adults . 209 13.11.3 Trends in Age at First Sex . 209 13.11.4 Condom Use at First Sex . 211 13.11.5 Abstinence and Premarital Sex . 212 13.11.6 Higher-risk Sex and Condom Use among Young Adults . 213 13.11.7 Cross-generational Sexual Partners . 215 13.11.8 Drunkenness during Sexual Intercourse among Young Adults . 216 13.11.9 Voluntary HIV Counselling and Testing among Young Adults . 217 Contents | vii CHAPTER 14 HIV PREVALENCE AND ASSOCIATED FACTORS 14.1 Coverage of HIV Testing . 220 14.1.1 Coverage by Sex, Residence, and Region . 220 14.1.2 Coverage by Socio-demographic Characteristics . 221 14.2 HIV Prevalence . 223 14.2.1 HIV Prevalence by Age . 223 14.2.2 HIV Prevalence by Socio-economic Characteristics . 223 14.2.3 HIV Prevalence by Demographic Characteristics . 224 14.2.4 HIV Prevalence by Sexual Behaviour Indicators . 226 14.3 HIV Prevalence by Other Characteristics Related to HIV Risk . 228 14.4 HIV Prevalence among Youth . 229 14.5 HIV Prevalence among Couples . 232 14.6 Measuring the HIV Burden in Sierra Leone . 232 CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15.1 Employment and Form of Earnings. 235 15.2 Use of Earnings . 236 15.3 Woman’s Participation in Decision-making . 239 15.4 Attitudes toward Wife Beating . 243 15.5 Attitudes toward Refusing Sex with Husband . 246 15.6 Women’s Empowerment Indicators . 250 15.7 Current Use of Contraception by Women’s Status . 252 15.8 Reproductive Health Care by Women’s Status . 253 CHAPTER 16 FEMALE CIRCUMCISION 16.1 Knowledge and Prevalence of Female Circumcision. 255 16.2 Flesh Removal and Infibulation . 256 16.3 Age at Circumcision . 256 16.4 Person Performing Circumcision . 258 16.5 Circumcision of Daughters . 258 16.6 Perceived Benefits of Undergoing Female Circumcision . 261 16.7 Attitudes toward Female Circumcision . 264 CHAPTER 17 ADULT AND MATERNAL MORTALITY 17.1 Introduction . 267 17.2 Data Collection. 267 17.3 Data Quality . 268 17.4 Direct Estimates of Adult Mortality . 270 17.5 Direct Estimates of Maternal Mortality . 271 REFERENCES . 273 APPENDIX A SAMPLE DESIGN . 275 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 283 viii | Contents APPENDIX C DATA QUALITY TABLES . 293 APPENDIX D PERSONS INVOLVED IN THE 2008 SIERRA LEONE DEMOGRAPHIC AND HEALTH SURVEY . 305 APPENDIX E QUESTIONNAIRES . 311 Tables and Figures | ix TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . 10 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 13 Table 2.2 Household composition . 15 Table 2.3 Children’s living arrangements and orphanhood . 16 Table 2.4 School attendance by survivorship of parents and by orphanhood status . 17 Table 2.5.1 Educational attainment of the female household population . 19 Table 2.5.2 Educational attainment of the male household population . 20 Table 2.6 School attendance ratios . 22 Table 2.7 Grade repetition and dropout rates . 23 Table 2.8 Household drinking water . 25 Table 2.9 Household sanitation facilities . 26 Table 2.10 Household characteristics . 27 Table 2.11 Household durable goods . 28 Table 2.12 Wealth quintiles . 29 Table 2.13 Birth registration of children under age five . 29 Table 2.14 Child labour . 30 Figure 2.1 Population Pyramid . 14 Figure 2.2 Age-specific Attendance Rates for the de facto Population Age 5-24 . 21 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents . 34 Table 3.2.1 Educational attainment: Women . 35 Table 3.2.2 Educational attainment: Men . 36 Table 3.3.1 Literacy: Women . 37 Table 3.3.2 Literacy: Men . 37 Table 3.4.1 Exposure to mass media: Women . 38 Table 3.4.2 Exposure to mass media: Men . 39 Table 3.5.1 Employment status: Women . 40 Table 3.5.2 Employment status: Men . 42 Table 3.6.1 Occupation: Women . 43 Table 3.6.2 Occupation: Men . 44 Table 3.7 Type of employment: Women . 45 Table 3.8.1 Knowledge and attitudes concerning tuberculosis: Women . 46 Table 3.8.2 Knowledge and attitudes concerning tuberculosis: Men . 47 Table 3.9.1 Use of tobacco: Women . 48 Table 3.9.2 Use of tobacco: Men . 49 Figure 3.1 Women’s Employment Status in the Past 12 Months . 41 x | Contents CHAPTER 4 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS Table 4.1 Current fertility . 52 Table 4.2 Fertility by background characteristics . 54 Table 4.3 Trends in age-specific fertility rates . 55 Table 4.4 Children ever born and living . 56 Table 4.5 Birth intervals . 57 Table 4.6 Age at first birth . 58 Table 4.7 Median age at first birth . 59 Table 4.8 Teenage pregnancy and motherhood . 60 Figure 4.1 Age-specific Fertility Rates by Urban-Rural Residence . 53 Figure 4.2 Total Fertility Rate by Background Characteristics . 54 Figure 4.3 Percentage of Adolescent Women Who Have Begun Childbearing by Background Characteristics . 60 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 64 Table 5.2 Knowledge of contraceptive methods by background characteristics . 65 Table 5.3.1 Ever use of contraception: Women . 66 Table 5.3.2 Ever use of contraception: Men . 67 Table 5.4 Current use of contraception by age . 68 Table 5.5 Current use of contraception by background characteristics . 70 Table 5.6 Number of children at first use of contraception . 71 Table 5.7 Knowledge of fertile period . 72 Table 5.8 Source of modern contraception methods . 73 Table 5.9 Informed choice . 74 Table 5.10 Future use of contraception . 75 Table 5.11 Reason for not intending to use contraception in the future . 75 Table 5.12 Preferred method of contraception for future use . 76 Table 5.13 Exposure to family planning messages . 77 Table 5.14 Contact of non-users with family planning providers . 79 Table 5.15 Husband/partner’s knowledge of women’s use of contraception . 80 Table 5.16 Male attitudes towards contraceptive use . 81 Figure 5.1 Current Use of Contraception among Currently Married Women Age 15-49 . 69 Figure 5.2 Contraceptive Use among Currently Married Women by Residence, Level of Education, and Wealth Quintile . 71 Figure 5.3 Exposure to Specific Family Planning Messages . 78 CHAPTER 6 PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status . 84 Table 6.2.1 Number of women’s co-wives . 85 Table 6.2.2 Number of men’s wives . 85 Table 6.3 Age at first marriage . 86 Table 6.4.1 Median age at first marriage: Women . 87 Table 6.4.2 Median age at first marriage: Men . 88 Table 6.5 Age at first sexual intercourse . 89 Table 6.6.1 Median age at first intercourse: Women . 89 Tables and Figures | xi Table 6.6.2 Median age at first intercourse: Men . 90 Table 6.7.1 Recent sexual activity: Women . 91 Table 6.7.2 Recent sexual activity: Men . 92 Table 6.8 Postpartum amenorrhoea, abstinence and insusceptibility . 93 Table 6.9 Median duration of amenorrhoea, postpartum abstinence and postpartum insusceptibility . 94 Table 6.10 Menopause . 94 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 96 Table 7.2.1 Desire to limit childbearing: Women . 97 Table 7.2.2 Desire to limit childbearing: Men . 97 Table 7.3 Unmet need and demand for family planning among currently married women . 99 Table 7.4 Ideal number of children . 100 Table 7.5 Mean ideal number of children. 101 Table 7.6 Fertility planning status . 102 Table 7.7 Wanted fertility rates . 103 Figure 7.1 Fertility Preferences among Married Women . 96 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 106 Table 8.2 Early childhood mortality rates by background characteristics . 108 Table 8.3 Early childhood mortality rates by demographic characteristics . 110 Table 8.4 Perinatal mortality . 111 Table 8.5 High-risk fertility behaviour . 113 Figure 8.1 Trends in Infant and Under-five Mortality in the 15 Years Preceding the Survey . 107 Figure 8.2 Under-five Mortality by Mother’s Background Characteristics . 109 CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care . 116 Table 9.2 Number of antenatal care visits and timing of first visit . 117 Table 9.3 Components of antenatal care . 118 Table 9.4 Tetanus toxoid injections . 120 Table 9.5 Place of delivery . 121 Table 9.6 Assistance during delivery . 122 Table 9.7 Timing of first postnatal check-up . 124 Table 9.8 Type of provider of first postnatal check-up . 125 Table 9.9 Problems in accessing health care . 126 Figure 9.1 Assistance of Skilled Provider during Childbirth . 123 xii | Contents CHAPTER 10 CHILD HEALTH Table 10.1 Child’s weight and size at birth . 130 Table 10.2 Vaccinations by source of information . 131 Table 10.3 Vaccinations by background characteristics . 133 Table 10.4 Vaccinations in first year of life. 134 Table 10.5 Prevalence and treatment of symptoms of ARI . 135 Table 10.6 Prevalence and treatment of fever . 136 Table 10.7 Prevalence of diarrhoea . 137 Table 10.8 Diarrhoea treatment . 139 Table 10.9 Feeding practices during diarrhoea . 140 Table 10.10 Knowledge of ORS packets . 141 Table 10.11 Disposal of children’s stools . 142 Figure 10.1 Vaccination Coverage among Children Age 12-23 Months . 132 Figure 10.2 Vaccination Coverage during the First Year of Life among Children Age 12-23 Months . 132 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS Table 11.1 Nutritional status of children . 145 Table 11.2 Initial breastfeeding . 149 Table 11.3 Breastfeeding status by age . 151 Table 11.4 Median duration and frequency of breastfeeding . 153 Table 11.5 Foods and liquids consumed by children in the day and night preceding the interview . 155 Table 11.6 Infant and young child feeding (IYCF) practices . 157 Table 11.7 Prevalence of anaemia in children . 160 Table 11.8 Presence of iodized salt in household . 161 Table 11.9 Micronutrient intake among children . 163 Table 11.10 Nutritional status of women . 164 Table 11.11 Foods consumed by mothers in the day and night preceding the interview . 166 Table 11.12 Micronutrient intake among mothers . 168 Table 11.13.1 Prevalence of anaemia in women . 169 Table 11.13.2 Prevalence of anaemia in men . 170 Figure 11.1 Nutritional Status of Children by Age . 147 Figure 11.2 Types of Prelacteal Liquids Received by Last-born Children in the Five Years Preceding the Survey . 150 Figure 11.3 Infant Feeding Practices . 152 Figure 11.4 Infant and Young Child Feeding (IYCF) Practices . 158 CHAPTER 12 MALARIA Table 12.1 Ownership of mosquito nets . 172 Table 12.2 Use of mosquito nets by children . 173 Table 12.3.1 Use of mosquito nets by women . 175 Table 12.3.2 Use of mosquito nets by pregnant women . 176 Table 12.4 Prophylactic use of anti-malarial drugs and use of Intermittent Preventive Treatment (IPT) by women during pregnancy . 177 Table 12.5 Prevalence and prompt treatment of fever . 179 Table 12.6 Type and timing of anti-malarial drugs . 180 Table 12.7 Availability at home of anti-malarial drugs received by children with fever . 181 Tables and Figures | xiii CHAPTER 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR Table 13.1 Knowledge of AIDS. 184 Table 13.2 Knowledge of HIV prevention methods . 186 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 187 Table 13.3.2 Comprehensive knowledge about AIDS: Men . 188 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 190 Table 13.5.1 Accepting attitudes towards those living with HIV/AIDS: Women . 192 Table 13.5.2 Accepting attitudes towards those living with HIV/AIDS: Men . 193 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 194 Table 13.7 Adult support of education about condom use to prevent AIDS . 195 Table 13.8.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Women . 197 Table 13.8.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men . 199 Table 13.9 Payment for sexual intercourse: Men . 200 Table 13.10.1 Coverage of prior HIV testing: Women . 201 Table 13.10.2 Coverage of prior HIV testing: Men . 202 Table 13.11 Pregnant women counselled and tested for HIV. 203 Table 13.12 Male circumcision . 204 Table 13.13 Self-reported prevalence of sexually transmitted infections (STIs) and STIs symptoms . 205 Table 13.14 Prevalence of medical injections . 207 Table 13.15 Comprehensive knowledge about AIDS and knowledge of a source for condoms among youth . 209 Table 13.16 Age at first sexual intercourse among youth . 210 Table 13.17 Condom use at first sexual intercourse among youth . 211 Table 13.18 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 212 Table 13.19.1 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Women . 213 Table 13.19.2 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: Men . 214 Table 13.20 Age-mixing in sexual relationships among women age 15-19 . 216 Table 13.21 Drunkenness during sexual intercourse among youth . 217 Table 13.22 Recent HIV tests among youth . 218 Figure 13.1 Women and Men Age 15-49 Who Sought Advice or Treatment for STIs . 206 Figure 13.2 Facility Where Last Medical Injection Was Received . 208 Figure 13.3 Abstinence, Being Faithful, and Condom Use (ABC) among Young Women and Men . 215 xiv | Contents CHAPTER 14 HIV PREVALENCE AND ASSOCIATED FACTORS Table 14.1 Coverage of HIV testing by residence and region . 221 Table 14.2 Coverage of HIV testing by selected background characteristics . 222 Table 14.3 HIV prevalence by age . 223 Table 14.4 HIV prevalence by socio-economic characteristics . 224 Table 14.5 HIV prevalence by demographic characteristics . 225 Table 14.6 HIV prevalence by sexual behaviour . 227 Table 14.7 HIV prevalence by selected characteristics . 228 Table 14.8 Prior HIV testing by current HIV status . 229 Table 14.9 HIV prevalence among young people by background characteristics . 230 Table 14.10 HIV prevalence among young people by sexual behaviour . 231 Table 14.11 HIV prevalence among couples . 233 CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 15.1 Employment and cash earnings of currently married women. 236 Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s earnings: Women . 237 Table 15.2.2 Control over men’s cash earnings . 238 Table 15.3 Women’s control over her own earnings and over those of her husband . 239 Table 15.4.1 Women’s participation in decision-making . 240 Table 15.4.2 Women’s participation in decision-making according to men . 240 Table 15.5.1 Women’s participation in decision-making . 241 Table 15.5.2 Men’s attitudes towards wives’ participation in decision-making . 243 Table 15.6.1 Attitude toward wife beating: Women . 245 Table 15.6.2 Attitude toward wife beating: Men . 246 Table 15.7.1 Attitudes towards a wife refusing to have sexual intercourse with husband: Women . 247 Table 15.7.2 Attitudes towards a wife refusing to have sexual intercourse with husband: Men . 248 Table 15.7.3 Men’s attitudes towards a husband’s rights when his wife refuses to have sexual intercourse . 250 Table 15.8 Indicators of women’s empowerment . 252 Table 15.9 Current use of contraception by women’s empowerment . 253 Table 15.10 Reproductive health care by women’s empowerment . 254 Figure 15.1 Number of Household Decisions in Which Currently Married Women Participate . 242 CHAPTER 16 FEMALE CIRCUMCISION Table 16.1 Knowledge and prevalence of female circumcision . 256 Table 16.2 Age at circumcision . 257 Table 16.3 Person performing circumcision . 258 Table 16.4 Practice of female circumcision among respondent’s daughters . 259 Table 16.5 Type of female circumcision among daughters . 260 Table 16.6 Daughter’s age at circumcision . 261 Table 16.7 Perceived benefits of undergoing female circumcision . 262 Table 16.8 Beliefs about female circumcision . 264 Table 16.9 Attitudes toward female circumcision . 265 Tables and Figures | xv CHAPTER 17 ADULT AND MATERNAL MORTALITY Table 17.1 Data on siblings . 268 Table 17.2 Indicators on data quality . 269 Table 17.3 Estimates of age-specific female and male adult mortality . 270 Table 17.4 Maternal mortality . 272 Figure 17.1 Female Mortality Rates for the Period 2001-2008 and Model Life Table Rates, by Age Group . 271 Figure 17.2 Male Mortality Rates for the Period 2001-2008 and Model Life Table Rates, by Age Group . 271 APPENDIX A SAMPLE DESIGN Table A.1 Distribution of Enumeration Areas (EAs) by domain and local council, and by urban-rural specification . 276 Table A.2 Distribution of the household population by domain and local council, and by urban-rural specification . 276 Table A.3 Distribution of households by domain and local council, and by urban-rural specification . 277 Table A.4 Sample allocation of Enumeration Areas (EAs) and households by domain and local council, and by urban-rural specification . 278 Table A.5 Expected number of completed interviews for women and men by domain and local council, and by urban-rural specification . 279 Table A.6 Sample implementation: Women . 281 Table A.7 Sample implementation: Men . 282 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Sierra Leone 2008 . 285 Table B.2 Sampling errors: Total sample, SLDHS 2008 . 286 Table B.3 Sampling errors: Urban sample, SLDHS 2008 . 287 Table B.4 Sampling errors: Rural sample, SLDHS 2008 . 288 Table B.5 Sampling errors: Eastern sample, SLDHS 2008 . 289 Table B.6 Sampling errors: Northern sample, SLDHS 2008. 290 Table B.7 Sampling errors: Southern sample, SLDHS 2008 . 291 Table B.8 Sampling errors: Western sample, SLDHS 2008 . 292 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 293 Table C.2.1 Age distribution of eligible and interviewed women . 294 Table C.2.2 Age distribution of eligible and interviewed men . 294 Table C.3 Completeness of reporting . 295 Table C.4 Births by calendar year . 296 Table C.5 Reporting of age at death in days . 296 Table C.6 Reporting of age at death in months . 297 Table C.7 Nutritional status of children by NCHS/CDC/WHO International Reference Population . 298 Table C.8 Coverage of HIV testing by social and demographic characteristics: Women . 300 Table C.9 Coverage of HIV testing by social and demographic characteristics: Men . 301 Table C.10 Coverage of HIV testing by sexual behaviour characteristics: Women . 302 Table C.11 Coverage of HIV testing by sexual behaviour characteristics: Men . 303 Acknowledgements | xvii ACKNOWLEDGEMENTS The 2008 Sierra Leone Demographic and Health Survey (SLDHS) represents the continued efforts in Sierra Leone to obtain reliable and accurate data on fertility behaviour, contraceptive practice, and other reproductive health issues. The survey results are critical and timely as additional information is provided relating to child survival and knowledge regarding HIV/AIDS. Such wealth of information will no doubt be tremendously useful in charting future directions for the population and health programmes including monitoring, evaluation, and research. The 2008 SLDHS overwhelmingly received active support from a large number of institutions and individuals who were instrumental in the implementation and its overall success. The support and active involvement of the officials of the Ministry of Health and Sanitation are greatly acknowledged. As a result of the adequate funding provided by the Sierra Leone Government, UNFPA, UNDP, DFID, UNICEF, USAID and The World Bank, logistical support by WHO, WFP, and UNHCR, and technical support by ICF Macro, a huge success was recorded and achieved. I wish to acknowledge with much gratitude the tremendous support received from the Senior Management and staff of Statistics Sierra Leone, and in particular the Demographic and Social Statistics Division, Geographic Information System Division and the Data Processing Division. The unflinching support and leadership role provided by the resident SLDHS Consultant, during the implementation period of the survey, is worth mentioning. All the field staffs who were engaged in data collection, and all the data processing staff, and coordinators, worked tirelessly and their efforts are hereby acknowledged. Sincere thanks are extended to the 2008 SLDHS Technical and Steering Committees, whose technical and policy guidance, respectively, made possible the successful implementation of the entire process. Finally, my appreciation goes to all the households, men and women who were selected and who responded very well during the survey. Without their participation and support, this project would have been a failure. Their cooperation is therefore greatly appreciated. Samura Kamara (Ph.D.) Minister of Finance and Economic Development Ministerial Building Freetown Foreword | xix FOREWORD It is generally acknowledged that meaningful development for any Nation can be achieved only when the Statistical information needed for the formulation of polices is readily available and properly documented. Statistics Sierra Leone (SSL), being the agency charged with the responsibility of demographic data collection and analysis has been relentless in the efforts to obtain reliable and up-to- date data for the country. The Demographic and Health Survey (DHS) is an internationally acknowledged survey designed to obtain information on health issues that affect the management and development of the population. Although the objectives of the 2008 Sierra Leone Demographic and Health Survey (SLDHS) focus on the specific issues and trends that are peculiar to the Sierra Leone situation, the survey was designed in conformity with international standards. The 2008 SLDHS, which is the first DHS conducted in Sierra Leone, is specifically aimed at obtaining and providing information on general fertility and fertility preferences, use and knowledge of family planning methods, maternal and childhood health, maternal and childhood mortality, breast feeding practices, nutrition, HIV/AIDS and other health issues. Although the 2008 SLDHS estimates the national total fertility rate (TFR), at 5.1 children which is still relatively high compared to the desired targets, the reported increase in the knowledge of other health issues among the population offers a ray of hope. The 2008 SLDHS was funded by the Sierra Leone government, UNFPA, UNDP, UNICEF, DFID, The World Bank, USAID, while UNHCR, WFP, and WHO provided logistical support, and ICF Macro and the UNFPA Country Support Team provided technical backstopping. The Ministry of Health and Sanitation and other stakeholders also assisted in various ways to ensure the overall success of the project. The efforts of all these organizations are deeply appreciated by the Ministry of Health and Sanitation of Sierra Leone. It is hoped that users at all levels will find the report useful. Honorable Mr. Sheiku Tejan Koroma Ministry of Health and Sanitation of Sierra Leone Freetown Preface | xxi PREFACE One of the mandates of Statistics Sierra Leone (SSL) is to collect, collate, process, analyse, publish and disseminate population census and survey data at all levels. Statistics Sierra Leone has the additional mandate of being the focal point for policy formulation and coordination of population activities in the country. By this mandate, Statistics Sierra Leone occupies the leadership position in the population sector and the major provider of information on the Sierra Leone population. The successful conduct of the 2008 Sierra Leone Demographic and Health Survey (SLDHS) and the production of this report, within a reasonably short time frame, undoubtedly underscores Statistics Sierra Leone’s leadership role. The compilation of the report has been borne out of the need to meet the yearnings of policy makers, programme implementers, and researchers, who require timely data for their day-to-day operations. The report contains detailed information on the demographic, health, and social indicators that will enable us measure progress in the Sierra Leone Society. I commend the following for funding the survey: 1. Government of Sierra Leone 2. UNFPA 3. UNDP 4. UNICEF 5. USAID 6. DFID 7. The World Bank The following provided logistical support to the survey: UNHCR,WFP, and WHO. It is my sincere hope that the end users will thoroughly acquaint themselves with this report and take advantage of the findings for their developmental aspirations. Professor Lawrence Kamara Statistician General Statistics Sierra Leone Freetown Summary of Findings | xxiii SUMMARY OF FINDINGS The 2008 Sierra Leone Demographic and Health Survey (SLDHS) is the first DHS survey to be held in Sierra Leone. Teams visited 353 sample points across Sierra Leone and collected data from a nationally representative sample of 7,374 women age 15-49 and 3,280 men age 15- 59. The primary purpose of the 2008 SLDHS is to provide policy-makers and planners with de- tailed information on fertility, family planning, childhood mortality, maternal and child health, female circumcision, maternal mortality, nutri- tion, knowledge of HIV/AIDS and other sexu- ally transmitted infections, and HIV prevalence rates. FERTILITY Survey results indicate that there has been little or no decline in the total fertility rate over the past two decades, from 5.7 children per woman in 1980-85 to 5.1 children per woman for the three years preceding the 2008 SLDHS (approximately 2004-07). Fertility is lower in urban areas than in rural areas (3.8 and 5.8 chil- dren per woman, respectively). Regional varia- tions in fertility are marked, ranging from 3.4 births per woman in the Western Region (where the capital, Freetown, is located) to almost six births per woman in the Northern and Eastern regions. Women with no education give birth to almost twice as many children as women who have been to secondary school (5.8 births, com- pared with 3.1 births). Fertility is also closely associated with household wealth, ranging from 3.2 births among women in the highest wealth quintile to 6.3 births among women in the lowest wealth quintile, a difference of more than three births. Research has demonstrated that children born too close to a previous birth are at increased risk of dying. In Sierra Leone, only 18 percent of births occur within 24 months of a previous birth. The interval between births is relatively long; the median interval is 36 months. Childbearing begins early in Sierra Leone. The median age at first birth is 19.3 years for women age 25-49. Thirty-four percent of girls age 15-19 have begun childbearing: more than one-quarter have already had a child and 6 per- cent are pregnant with their first child. Marriage and sexual behaviour patterns are important determinants of fertility levels. Almost three-fourths of women age 15-49 are currently married—65 percent are formally married and 10 percent are living together with a man. The proportion of men age 15-49 who are married (55 percent) is lower than the proportion of women who are married, probably because men tend to marry later than women. Thirty-seven percent of married women in Sierra Leone are in polygynous unions. The median age at first marriage is 17.0 years for women age 25-49, compared with 24.5 years for men the same age. Women who are currently in their early 20s have a slightly higher median age at first marriage than older women, indicating that younger women may be marrying at later ages than women did in the past. Women and men generally do not wait until marriage to initiate sexual activity. The median age at first intercourse is 16.1 years among women and 18.7 years among men age 25-49. Urban women, those living in the Western Re- gion, better educated women and those in the highest wealth quintile tend to wait longer to initiate sexual activity. Among men, the median age at first sexual intercourse is similar across all sub-groups. There is a considerable desire among Sierra Leonean women to control the number and tim- ing of their births. Thirty percent of married women do not want any more children or are sterilized, and another 25 percent would like to wait at least two years before their next child. On average, Sierra Leonean women would like to have five children (5.0); this number is slightly less than the current fertility rate of 5.1 children per woman, and one child more than the four children suggested in the National Popula- tion Policy. Sixteen percent of recent births were mistimed (wanted later) and 10 percent were not wanted at all. These results indicate that there is a need for additional family planning services, especially those concerned with spacing births. xxiv | Summary of Findings FAMILY PLANNING The vast majority of Sierra Leonean women and men know of at least one method of contra- ception. Contraceptive pills and injectables are known to about 60 percent of currently married women and 49 percent of married men. Male condoms are known to 58 percent of married women and 80 percent of men. A higher propor- tion of respondents reported knowing a modern method of family planning than a traditional method. About one in five (21 percent) currently married women has used a contraceptive method at some time—19 percent have used a modern method and 6 percent have used a traditional method. However, only about one in twelve cur- rently married women (8 percent) is currently using a contraceptive method. Modern methods account for almost all contraceptive use, with 7 percent of married women reporting use of a modern method, compared with only 1 percent using a traditional method. Injectables and the pill are the most widely used methods (3 and 2 percent of married women, respectively), fol- lowed by LAM and male condoms (less than 1 percent each). Current use of contraception is slightly high- er among all women (10 percent) than among currently married women (8 percent). This is because contraceptive use is much higher among sexually active unmarried women (34 percent), who are included in the all women category. Married women in urban areas are more likely to use contraception (16 percent) than those in rural areas (5 percent). Use increases with educational attainment, from 6 percent among married women with no education to 22 percent among those who have attended secon- dary school. Use of contraception also rises as wealth status increases, from 4 percent among married women in the lowest wealth quintile to 20 percent among those in the highest wealth quintile. Half of women using modern contraceptive methods obtain their methods from the public sector, primarily from government health centres (18 percent), government family planning clinics (15 percent), and government hospitals (14 per- cent). More than one-third (39 percent) of women use the private medical sector to obtain their contraceptive methods; 26 percent of users get their methods from pharmacies. Eight per- cent of women using a modern method obtain their method from a private hospital or clinic, and 6 percent get their method from other sources, mostly from friends or relatives. Twenty-eight percent of currently married women who are not using contraception say they intend to use family planning in the future, 48 percent do not intend to use a family planning method, and 23 percent are unsure. The most common reasons for not intending to use a con- traceptive method are opposition to the use of family planning by respondents or their hus- band/partner (each mentioned by 14 percent), desire for more children, lack of knowledge of methods, and fear of side effects (11 percent each). There continues to be considerable scope for increased use of family planning in Sierra Leone. Overall, 36 percent of married women in Sierra Leone have an unmet need for family planning, most of which is due to a desire for spacing births (21 percent) rather than a need for limiting births (15 percent). CHILD HEALTH Examination of levels of infant and child mortality is essential for assessing population and health policies and programmes. Infant and child mortality rates are also used as indices re- flecting levels of poverty and deprivation in a population. The 2008 survey data show that over the past 15 years, infant and under-five mortality have decreased by 26 percent. Still, one in seven Sierra Leonean children dies before reaching age five. For the most recent five-year period before the survey (approximately calendar years 2003 to 2008), the infant mortality rate was 89 deaths per 1,000 live births and the under-five mortality rate was 140 deaths per 1,000 live births. The neonatal mortality rate was 36 deaths per 1,000 live births and the post-neonatal mortality rate was 53 deaths per 1,000 live births. The child mortality rate was 56 deaths per 1,000 children surviving to age one year. Mortality rates at all ages of childhood show a strong relationship with the length of the pre- ceding birth interval. Under-five mortality is three times higher among children born less than two years after a preceding sibling (252 deaths Summary of Findings | xxv per 1,000 births) than among children born four or more years after a previous child (deaths 81 per 1,000 births). Only 40 percent of Sierra Leonean children age 12-23 months are fully immunized, i.e., re- ceived BCG and measles vaccinations, and three doses each of DPT and polio vaccines. Looking at coverage for specific vaccines, 82 percent of children received the BCG vaccination, 77 per- cent received the first dose of DPT vaccine, and 76 percent received the first dose of polio vac- cine (Polio 1). Coverage declines for subsequent vaccinations, with only 60 percent of children receiving the recommended three doses of DPT vaccine, and 50 percent receiving all three doses of polio vaccine. Only 60 percent of children received the measles vaccination. Sixteen per- cent of children have received no vaccinations at all. Seven percent of children under five years were reported to have had a cough with short, rapid breathing—not just a blocked or runny nose—in the two weeks preceding the survey. Almost five in ten children (46 percent) with these symptoms were taken to a health facility or provider for treatment. Children who were less likely to be taken for treatment were those age 24-35 months, children living in the Eastern Re- gion, children whose mothers have little or no education, and children in the poorest house- holds (lowest wealth quintile). Fever is a symptom of malaria and other acute infections in children. Twenty-five percent of children under age five were reported to have had a fever in the two weeks before the survey. About four in ten children with fever were taken to a health facility or provider for treatment, and three in ten children with fever were given anti- malarial drugs. Almost half of children who were ill with diarrhoea in the two weeks preceding the survey were taken to a health facility or provider (47 percent). Mothers reported that almost nine in ten (86 percent) children with diarrhoea were treated with some form of oral rehydration ther- apy (ORT) or increased fluids, and over two- thirds were given a solution prepared from a packet of oral rehydration salts (68 percent). MATERNAL HEALTH Almost nine in ten mothers (87 percent) in Sierra Leone receive antenatal care from a health professional (doctor, nurse, midwife, or MCH aid). Only 5 percent of mothers receive antenatal care from a traditional midwife or a community health worker; 7 percent of mothers do not re- ceive any antenatal care. In Sierra Leone, over half of mothers have four or more antenatal care (ANC) visits, about 20 percent have one to three ANC visits, and only 7 percent have no antenatal care at all. The survey shows that not all women in Sierra Leone receive antenatal care services early in preg- nancy. Only 30 percent of mothers obtain ante- natal care in the first three months of pregnancy, 41 percent make their first visit in the fourth or fifth month, and 17 percent in have their first visit in the sixth or seventh month. Only 1 per- cent of women have their first ANC visit in their eighth month of pregnancy or later. Neonatal tetanus is a leading cause of neona- tal death in developing countries where a high proportion of deliveries occur at home or in places where hygienic conditions may be poor. Tetanus toxoid (TT) vaccinations are given to pregnant women to prevent neonatal tetanus. The survey results show that, for the most recent live birth in the five years preceding the survey, most women (75 percent) in Sierra Leone re- ceived two or more tetanus injections during pregnancy and 79 percent of births are protected against neonatal tetanus. One-third (34 percent) of women age 15-49 with a live birth in the two years preceding the survey received some type of anti-malarial medicine during their last pregnancy. However, in the vast majority of cases, the practice was not in accordance with national policy, i.e., only 20 percent of women reported taking SP/Fansidar— the recommended drug for intermittent preven- tive treatment of malaria during pregnancy in Sierra Leone—at least once during their preg- nancy. Increasing the proportion of babies delivered in health facilities is an important factor in re- ducing health risks to both mother and child. SLDHS data show that the majority of births in Sierra Leone (72 percent) are delivered at home; only 25 percent are delivered in health facilities, mostly public sector facilities. Less than half (42 xxvi | Summary of Findings percent) of births in Sierra Leone are delivered with the help of a health professional (i.e., doc- tor, nurse/midwife, or MCH aid), while 45 per- cent are delivered by a traditional birth atten- dant. About one in eleven births are attended by relatives (9 percent) and 1 percent of all births occur without any type of assistance. Postnatal care coverage is low in Sierra Leone: only 38 percent of mothers receive post- natal care within 4 hours of delivery, 20 percent receive care within two days after delivery, and 5 percent receive care 3-41 days after delivery. About one-third of mothers (33 percent) do not get any postnatal care. The maternal mortality ratio estimated from SLDHS data for the seven-year period preceding the survey is 857 maternal deaths per 100,000 births. BREASTFEEDING AND NUTRITION Poor nutritional status is one of the most im- portant health and welfare problems facing Si- erra Leone today and particularly afflicts women and children. The data show that 36 percent of children under five are stunted (too short for their age) and 10 percent of children under five are wasted (too thin for their height). Overall, 21 percent of children are underweight, which may reflect stunting, wasting, or both. For women, at the national level 11 percent of women are con- sidered to be thin (body mass index <18.5); however, only 4 percent of women are consid- ered severely thin. At the other end of a spec- trum, 20 percent of women age 15-49 are con- sidered to be overweight (body mass index 25.0- 25.9) and 9 percent are considered obese (body mass index ≥30.0). Poor breastfeeding and infant feeding prac- tices can have adverse consequences for the health and nutritional status of children. Fortu- nately, breastfeeding in Sierra Leone is almost universal and generally of fairly long duration; 86 percent of newborns are breastfed within the first day after delivery. However, only 11 per- cent of infants under six months of age are ex- clusively breastfed, which is the recommended practice for children under six months. The me- dian duration of any breastfeeding is 19.7 months in Sierra Leone, although the median duration of exclusive breastfeeding is extremely short—less than one month. Infant and young child feeding (IYCF) prac- tices include timely introduction of solid and semi-solid foods beginning at age six months, and thereafter increasing the amount and variety of foods and the frequency of feeding as the child gets older, while still maintaining frequent breastfeeding. Guidelines have been established with respect to IYCF practices for children age 6-23 months. Overall, only 23 percent of chil- dren are fed in accordance with IYCF practices. Ensuring that children age 6-59 months re- ceive enough vitamin A may be the single most effective child survival intervention. The survey results show that 26 percent of children age 6-59 months received a vitamin A supplement in the six months preceding the survey. Moreover, 75 percent of children age 6-35 months living with their mother consumed foods rich in vitamin A in the 24 hours preceding the survey, and 59 percent consumed foods rich in iron. With re- gard to iron supplements, only 20 percent of children age 6-59 months received an iron sup- plement in the seven days preceding the survey. Determining anaemia levels among women and their children under five was one component of the SLDHS. As a result of the testing carried out during the survey it was found that 76 per- cent of children age 6-59 months have anaemia; 28 percent have mild anaemia, 44 percent have moderate anaemia, and about 4 percent have se- vere anaemia. Prevalence of anaemia in children decreases with increasing level of the mother’s education and increasing household wealth status (wealth index). Urban children are some- what less likely to be anaemic than rural chil- dren. Children in the Northern Region (79 per- cent) were the most likely to be anaemic. Forty-five percent of women in Sierra Leone have some level of anaemia; the majority are mildly anaemic (34 percent), 11 percent are moderately anaemic, and about 1 percent were found to be severely anaemic. The prevalence of any anaemia in women varies by regions, with the lowest level in the Eastern and Southern re- gions (43 percent each) and the highest level in the Western Region (50 percent). HIV/AIDS The HIV/AIDS pandemic is one of the most serious health concerns in the world today be- cause of its high case-fatality rate and the lack of a cure. Awareness of AIDS is relatively high Summary of Findings | xxvii among Sierra Leonean adults age 15-49, with 69 percent of women and 83 percent of men saying that they have heard about AIDS. Nevertheless, only 14 percent of women and 25 percent of men are classified as having ‘comprehensive knowl- edge’ about AIDS, i.e., knowing that consistent use of condoms during sexual intercourse and having just one faithful, HIV-negative partner can reduce the chances of getting HIV/AIDS, knowing that a healthy-looking person can have HIV (the virus that causes AIDS), and knowing that HIV cannot be transmitted by sharing food/utensils with someone who has HIV/AIDS, or by mosquito bites. Such a low level of knowledge about HIV/AIDS implies that a concerted effort is needed to address misconceptions about the transmission of HIV in Sierra Leone. Compre- hensive knowledge is substantially lower among respondents with no education and those who live in the poorest households. Programmes could be targeted to populations in rural areas, and especially women in the Northern and Southern regions and men in the Eastern Region, where comprehensive knowledge is lowest. A composite indicator on stigma towards people who are HIV positive shows that only 5 percent of women and 15 percent of men age 15-49 ex- pressed accepting attitudes towards persons liv- ing with HIV/AIDS. Regarding condom use, only 7 percent of women who had more than one partner in the 12 months before the survey said they used a con- dom during the most recent sexual intercourse, far lower than the 15 percent reported by men. Among women who reported having higher-risk sexual intercourse in the past 12 months, only 7 percent used a condom at the last higher-risk sexual intercourse. For men, the comparable fig- ure is three times higher—22 percent. Overall, only about one-quarter of women age 15-49 years and one-third of men age 15-49 know where to get an HIV test. Even fewer have ever been tested; only 13 percent of women and 8 percent of men have ever had an HIV test, and only 4 percent of women and 3 percent of men have been tested and received their test results in the 12 months before the survey. Several recent studies have shown that male circumcision may have a protective effect against transmission of HIV. The results of the 2008 SLDHS indicate that male circumcision is widespread in Sierra Leone, with almost all men age 15-49 being circumcised (96 percent). This is seen for all age groups, residential areas, and levels of education. One of the most important elements in the 2008 SLDHS was the inclusion of HIV testing for adults who were interviewed. Overall, HIV tests were conducted for 88 percent of the 3,954 eligible women age 15-49 and 85 percent of the 3,541 eligible men age 15-59 interviewed in every second household selected for the SLDHS. The test results indicate that overall, 1.5 per- cent of Sierra Leonean adults age 15-49 are HIV positive. HIV prevalence is slightly higher among women (1.7 percent) than men (1.2 per- cent). There are few differentials in HIV preva- lence by socio-economic, demographic, and sex- ual behaviour characteristics. FEMALE CIRCUMCISION The 2008 SLDHS collected data on the prac- tice of female circumcision (or female genital cutting) in Sierra Leone. Awareness of the prac- tice is universally high. Almost all (99 percent) of Sierra Leonean women and 96 percent of men age 15-49 have heard of the practice. The preva- lence of female circumcision is high (91 per- cent). Most women (82 percent) reported that the cutting involves the removal of flesh. The most radical procedure, infibulation—when vagina is sewn closed during the circumcision—is re- ported by only 3 percent of women. The survey results indicate that almost all of the women were circumcised by traditional practitioners (95 percent); only a small proportion of circumci- sions were performed by a trained health profes- sional (0.3 percent). Among Sierra Leonean adults age 15-49 who have heard of female circumcision, more men than women oppose the practice (41 and 26 percent, respectively), which is similar to pat- terns in other West African countries. Contributors to the Sierra Leone Demographic and Health Survey | xxix CONTRIBUTORS TO THE SIERRA LEONE DEMOGRAPHIC AND HEALTH SURVEY Professor Joseph A.L. Kamara Statistician General, Statistics Sierra Leone Mohamed K. Koroma Deputy Statistician General, Statistics Sierra Leone Moses L.J. Williams Director of Demographic and Social Statistics Andrew Bob Johnny Director of Geographic Information System Paul Sengeh Monitoring and Evaluation Specialist - UNICEF Dr. Edward Magbity Monitoring and Evaluation Specialist - MOHS Dr. Francis Smart Programme Manager, RH and Family Planning Programme - MOHS Dr. Duramani Conteh Ag. Director, Hospitals and Laboratory Services - MOHS Alhaji Vandy Sovula National Professional Project Personnel, Data and Development - UNFPA Mr. Samuel O. Weekes Institute for Population Studies - USL Mrs. Elizabeth Sam Institute for Population Studies - USL Samuel Ogunlade SLDHS Consultant - UNFPA Other Contributors to the SLDHS Ade Renner Health Economist - World Health Organization James L. Kamara Monitoring and Evaluation Office - National AIDS Secretariat Gbogboto B. Musa Senior Statistician - Statistics Sierra Leone Sahr E. Yambasu Senior Statistician - Statistics Sierra Leone Sonnia Magba Bu-Buakei Jabbi Senior Statistician - Statistics Sierra Leone Ibrahim G. Kargbo Statistician - Statistics Sierra Leone Francis Tommy Statistician - Statistics Sierra Leone Peter Bangura Statistician - Statistics Sierra Leone Andrew Kamara Statistician - Statistics Sierra Leone Wogba Kamara Statistician - Statistics Sierra Leone Alusine Kamara Statistician - Statistics Sierra Leone Bridget Moseray (Mrs) Statistician - Statistics Sierra Leone Yeabu Tholley (Mrs) Statistician - Statistics Sierra Leone Mohamed Kamara Statistician - Statistics Sierra Leone Yalice Bangura (Mrs) Statistician - Statistics Sierra Leone Harriet Farmer (Mrs) Asst. Statistician - Statistics Sierra Leone Alimatu Musa (Ms) Asst. Statistician - Statistics Sierra Leone Millennium Development Goal Indicators | xxxi Millennium Development Goal Indicators Goal Indicator Value (percent) Male Female Total 1. Eradicate extreme poverty and hunger 4. Prevalence of underweight children under five years1 23.6 18.8 21.1 2. Achieve universal primary education 6. Net attendance ratio in primary education2 60.6 62.9 61.7 7. Percentage of pupils starting grade 1 who reach grade 53 96.2 95.4 95.8 7b. Primary completion rate4 14.5 11.3 12.9 8. Literacy rate for those age 15-24 years 69.6 43.5 na 3. Promote gender equality and empower women 9. Ratio of girls to boys in primary, secondary, and tertiary education5 na na 84.9 10. Ratio of literate women to men age 15-24 years na na 62.5 11. Share of women in wage employment in the non- agricultural sector6 na na 28.3 4. Reduce child mortality 13. Under-five mortality rate7 na na 140.0 14. Infant mortality rate7 na na 56.0 15. Percentage of children age one year immunized against measles8 58.8 60.7 59.7 5. Improve maternal health 16. Maternal mortality ratio9 na na 857.0 17. Percentage of births attended by skilled health personnel10 na na 42.4 6. Combat HIV/AIDS, malaria and other diseases 19. Percentage of current users of contraception using condoms11 49.3 7.5 na 19A. Condom use at last higher-risk sex12 22.4 9.6 na 19B. Percentage of population age 15-24 years with comprehensive correct knowledge of HIV/AIDS13 27.6 17.3 na 19C. Contraceptive prevalence rate14 na 8.2 na 20. Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years15 0.7 0.6 0.6 22. Percentage of population in malaria-risk areas using effective malaria prevention and treatment measures16 na na 38.2 22A. Percentage of children under five sleeping under ITN 25.5 26.0 25.8 22B. Percentage of children under five with fever appropriately treated with antimalarial drugs 30.1 30.1 30.1 Urban Rural Total 7. Ensure environmental sustainability 29. Percentage of population using solid fuels17 98.9 99.7 99.4 30. Percentage of population with sustainable access to an improved water source, urban and rural18 81.7 35.2 50.5 31. Percentage of population with access to improved sanitation, urban and rural19 26.1 6.6 13.0 32. Percentage of households with access to secure tenure na na na na = Not applicable 1 Based on children who slept in the household the night before the interview (de facto). 2 Based on de facto population. Numerator is children age 6-11 currently attending school; denominator is children age 6-11 years. 3 Based on de facto population. This indicator is calculated using rates of promotion, dropout, and repetition for a given school year. The rates are used to project an estimate for the percentage of students attending grade 1 who are expected to reach grade 5, with or without repetition. 4 Based on de facto population. Numerator is children who completed grade 6 or higher; denominator is children age 11-13 years. 5 Based on de facto population age 6-24 years 6 Numerator is all women working in the non-agricultural sector who received payment in cash, or in cash and in kind; denominator is all women and all men with non-agricultural occupation. 7 Mortality rates refer to a 5-year period before the survey. 8 In Sierra Leone, the measles vaccinations are given at the age of 9 months. The values presented in the table are for children age 12-23 months who have been vaccinated at any time against measles. 9 Per 100,000 live births; calculated as maternal mortality rate divided by the general fertility rate (for the period 2001-2008) 10 Skilled health personnel includes: doctor, nurse, midwife, and MCH aid. 11 The number of women age 15-49 in marital or consensual unions who report they are using a condom to avoid pregnancy (regardless of whether they are also using additional methods) is divided by the total number of women age 15-49 in union who are practicing, or whose sexual partners are practicing, contraception. The indicator is not equivalent to condom use prevalence as a main method of contraception). 12 Based on de facto population age 15-24. Higher-risk sex is sexual intercourse with a non-marital, non-cohabiting partner. 13 Respondents with “comprehensive correct knowledge” of AIDS are those who say that using a condom every time for sexual intercourse and having just one uninfected and faithful partner can reduce the chances of getting the AIDS virus, and furthermore say that a healthy-looking person can have the AIDS virus, and who reject the common misconception that HIV can be spread by mosquito bites and by sharing food with someone with AIDS. 14 Based on women age 15-49 in marital or consensual unions 15 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent. Note that these indicators do not take into account children who live outside of households, e.g., in institutions or on the street, because the SLDHS includes only households in its sample. 16 Based on de facto population with at least one insecticide-treated bednet (ITN) 17 Solid fuel includes: coal, charcoal, wood, straw, crops, animal dung and other. 18 Improved drinking water source includes: water from pipe/tap, from protected well, protected spring and rainwater. 19 Improved sanitary means of excreta disposal includes: flush toilet, improved pit latrine, and latrine with a slab. xxxii | Summary of Findings ATLANTIC OCEAN GUINEA LIBERIA NORTHERN SOUTHERN EASTERNWESTERN Bo Koinadugu Kono Bombali Tonkolili Kenema Moyamba Port Loko Pujehun Kailahun Bonthe Kambia Bonthe Western Area SIERRA LEONE 0 50 10025 Kilometres ± Freetown Introduction | 1 INTRODUCTION 1 1.1 GEOGRAPHY Sierra Leone is located on the west coast of Africa and covers an area of about 72,000 square kilometres (28,000 square miles). It extends from latitude 7 degrees north to 10 degrees north, and from longitude 10 degrees west to 14 degrees west. The Republic of Guinea borders it on the north and northeast, and the Republic of Liberia borders it on the east and southeast. On the west and southwest, the Atlantic Ocean extends approximately 340 kilometres (211 miles). Administratively, Sierra Leone is divided into 4 provinces. Each province is subdivided into districts, and each district is divided into chiefdoms. Overall, there are 14 districts and 149 chiefdoms. Among the 14 districts, there are 5 city councils and 14 district councils, including Freetown, the capital, for a total of 19 local councils (SSL, 2006). Sierra Leone has four main physical regions: the Freetown Peninsula raised beaches and hills, the Coastal Plains, the Interior Lowlands, and the Interior Plateau. The Freetown peninsula consists of three roughly parallel ranges of highlands that are narrow but extend about 30km south of Freetown. The hills and mountains in these highlands rise impressively from 200 to 1000m above the low-lying narrow coastal area. The Interior Lowlands region makes up about half of the country. Most of the area, which is largely swamp, is less than 150m above sea level. The Interior Plateau region makes up the eastern half of the country. It is the most extensive physical region and includes the greatest variety of land forms. It is 300 to 450m above sea level. The Interior Plateau is dissected by the main rivers flowing westward towards the sea. Rising above the general level of this region are a number of hills and mountains, including the Kambui, Nimini, and Gori hills and the Sula, Kangari, Loma, Tingi, and Wara Wara mountains. Climate in Sierra Leone is determined mainly by the seasonal movements of two air masses: the north-easterly Continental Tropical Winds (commonly called North-East Trade Winds) and the south-westerly Maritime Tropical Winds (commonly called South-West Monsoon). The country experiences two main seasons: the dry season, which is between November and May, and the wet/raining season, which lasts from April/May to November. The present distribution of vegetation in Sierra Leone has been influenced not only by factors of climate and soil, but also by man. At present the following vegetation communities can be distinguished: forest, savanna, grassland, and swamp. The country has eight main river systems. The Great Scarcies, Little Scarcies, Rokel, Jong, Sewa, Wanjei, Moa, and Mano. The rivers typically flow from north east to south west, eventually reaching the Atlantic Ocean. 1.2 HISTORY Sierra Leone’s earliest known contact with Europe was in the fifteenth century during the Portuguese voyages of exploration. One such voyage to discover a sea route to India resulted in the Portuguese reaching the Sierra Leone Peninsula. Because the high coastal ranges resembled lions to the explorers, the area was called Sierra Lyoa, meaning Lion Mountains. Contact stimulated trade, with manufactured goods coming from Europe, in return for fruit, carvings, and gold from Sierra Leone. However, in the sixteenth century, there was the added dimension of the introduction of the slave trade. In 1562 the earliest known shipment of slaves was 2 | Introduction taken from the country to the Americas. There was a further strengthening of the European link in 1789 with the founding of settlements for freed slaves. The first group of 411 freed slaves was settled on land bought from King Tom of the Sierra Leone Peninsula. The settlement was under the administration of the Sierra Leone Company, which was founded in 1791 with the aim of re-establishing legitimate trade with the inhabitants. With the abolition of the slave trade and pressure from individuals and organizations in Britain, the British Government took direct responsibility for the new settlement. In 1808 the British Government declared the new settlement to be a Crown Colony. This move was intended to facilitate the enforcement of the Slave Trade Abolition Act. British rule covered only the colony, which was then the Freetown Peninsula and Bonthe Island. The largest part of the country, referred to as the hinterland, was in the hands of traditional rulers. However, in 1896, the rest of the country was declared a protectorate, followed two years later by the Hut Tax War. Today, Sierra Leone is a republic within the British Commonwealth of Nations, having gained independence from Britain on 27 April, 1961. It gained the status of republic in April 1971 and adopted a one-party system of government in 1978. In 1991, however, the country reverted to a multiparty state, with two main political parties: the Sierra Leone Peoples Party (SLPP) and the All Peoples Congress (APC). The country then went through a 10-year civil conflict that began in 1991 and ended in 2002. English is the official language of the country, which has about 15 ethnic groups. The major tribes include the Mende, Temne, Limba, and Creole. The main religions are Christianity and Islam. 1.3 ECONOMY According to the results of the 2004 Sierra Leone Population and Housing Census (SSL, 2006), the population of Sierra Leone is estimated at about 4.9 million in an estimated 819,854 households. For the period 1985-2004, the population growth rate was estimated at 1.8 percent. About 64 percent of the population resides in rural areas. Sierra Leone was ranked last among the 177 countries surveyed globally in the 2007/2008 United Nations Human Development Index, with a per capita GDP of about US$806, a life expectancy of 41.8 years, and an adult literacy rate of 34.8 percent. The UNDP 2007/2008 Human Development Report estimates that in 2005 about 52 percent of the population lived on less than US$1 a day (UNDP, 2007). In 2007, Sierra Leone’s real GDP grew by 6.4 percent, or about 0.9 percentage points below the 2006 growth rate of 7.3 percent. Of the total 2007 GDP, the contribution of agriculture declined to 46 percent; industry and services (less FISIM1) remained unchanged at 10 percent and 37 percent, respectively; while the Net-Tax contribution went up by 1 percent to 7 percent. The economy has been unable to create jobs at a rate to match the rising labour force demand. The most recent household income and expenditure survey (2003-04) showed that about 70 percent of the population lives below the poverty line according to the National Poverty Line of Le2 2,111 per day (SSL, 2004). Overall, poverty is highest in rural areas, with 79 percent of the rural population living below the poverty line. The most acute form of poverty, insufficient food, is concentrated mainly in rural areas. About 68 percent of the population cannot afford enough food to eat. Three out of four people (75 percent) in rural areas outside Freetown do not attain the minimum daily calorie intake (2700 calories). The poor in Sierra Leone can meet only about 71 percent of their 1 FISIM is Financial Intermediation Services Indirectly Measured. The SNA 93 recommends that it should be treated as Intermediate Consumption and therefore deducted from the output of sectors that incur them; or appears in the account but deducted from the total. 2 National currency is Sierra Leonean leone (Le): 1 Le = 0.000324 U.S. dollars (as per March 2009) Introduction | 3 basic needs. The rebel war resulted in a substantial reduction in the standard of living and, for many people, reduced access to food. A poor and undernourished population is more susceptible to various diseases. Thus, rising maternal and child mortality rates, increasing rates of illiteracy, and rising unemployment levels characterize the living conditions in many parts of Sierra Leone. The HIV/AIDS pandemic has also had a major impact on all sectors of the economy through loss of production and labour force. Against this background, the government of Sierra Leone in 2005 launched the Economic Recovery Strategy, aimed at restoring economic growth, generating employment opportunities, and reducing poverty levels (Poverty Reduction Strategy Paper, March 2005). 1.4 POPULATION The population of Sierra Leone increased from 2,180,355 in 1963 to 4,976,871 in 2004 (Central Statistics Office, 1963; SSL, 2006). The results of the previous censuses indicate that the annual population growth rate was 1.8 percent per annum during the 1985-2004 period, down from 2.3 percent reported during the 1974-1985 period, and 2.0 percent during the 1963-1974 inter-censual period. 1.5 POPULATION AND FAMILY PLANNING POLICIES AND PROGRAMMES In 1993, the Government of Sierra Leone launched the National Population Policy for Development, Progress and Welfare (Ministry of Development, 1993). The population policy is being revised, and a first draft will be completed later in 2009. The 1993 National Population Policy for Development, Progress and Welfare sought to be humane and responsible, respecting individual freedoms and rights as well as religious beliefs and cultural values. It also recognizes that all couples and individuals have the basic right to make decisions freely and responsibly on the number and the spacing of their children and to receive the information, education, and the means to do so. Only those means or methods deemed morally acceptable, scientifically sound, culturally appropriate, and economically feasible were made available in the implementation of the policy. The population policy reinforces and enriches national development, especially human resource development, improves the quality of life of the people, and enhances human welfare and dignity. Special emphasis was placed on regulating population quantity, enhancing population quality, and improving the health and welfare of women and children. The interplay between population and development was a constant consideration in the preparation of the 1993 policy. In more specific terms, the goals of the national population policy include the following: • To make development planning and policy more comprehensive and effective, by the incorporation of the demographic dimension. • To achieve a rate of growth of the population that is sustainable by the economy. • To contribute towards meeting the basic needs of the people and enhancing the quality and utilization of the nation’s human resources. • To promote the health and welfare of the people especially those in the high risk groups of mothers and children. • To moderate initially the expected rise in population, and later to progressively reduce population growth rates through the promotion of voluntary family planning and small family norms, so as to facilitate the attainment of national economic and social targets. • To guide rural-urban migration, so as to minimize socio-economic problems and to optimize benefits to migrants and non-migrants alike in rural as well as urban areas. 4 | Introduction In order to achieve the above mentioned goals, the 1993 population policy set the following objectives: • To improve the demographic knowledge base (i.e., data collection, processing, analysis, projections, and research on population and development interaction) on a regular basis. • To actively promote and facilitate utilization of the knowledge base in social and economic planning, policies and projects, etc. • To promote, clarify, and sharpen awareness and understanding amongst leaders and the public at large of population and development problems and issues. • To provide men and women with information and education on the value of reasonable family size and child spacing to improve the welfare of the family and its members, the community, and the nation • To pay special attention to selected groups such as young persons, women of reproductive age, and members of organized groups, in providing information and education relating to family life, fertility regulation, etc. • To improve the quality and availability of maternal and child health care services so as to reduce infant, child, and maternal morbidity and mortality. • To make family planning services easily accessible and affordable to couples and individuals, and to actively promote the acceptance of contraceptive practice. • To design and implement programmes on integrated rural and urban development, to moderate and orient rural-urban migration. • To review existing legislation as it pertains to key areas of population policy, and to provide for the improved quality of life, so as to enhance the welfare of men, women, and children. 1.6 HEALTH POLICIES AND PROGRAMMES The Ministry of Health and Sanitation launched the National Health Policy in October 2002 (Ministry of Health and Sanitation, 2002). This document sets out the policy of the Government of Sierra Leone motivating and guiding the health sector. The previous health policy was written in 1993, nearly 17 years ago. Since then there have been a number of changes that have led to the need for updating health sector policy. Most important, the civil war suffered by the country caused major disruptions of the health system, including damage to the physical infrastructure, loss of skilled professionals and, through the wider economic effects, reduction in the resources available to the health sector. It has also resulted in changes in population patterns, and specific health problems ranging from mental trauma to physical disability. In addition to these war-related effects, there are wider changes that many countries in sub-Saharan Africa are facing that have implications for health policy. These include changing patterns of disease distribution such as the spread of HIV/AIDS, the escalating of TB and malaria, as well as the more general problems associated with the epidemiological and demographic transition. They also include a general recognition of the need to re- examine the way in which the health care sector is structured, particularly regarding increased decentralization, more partnership between the public and private sectors, and greater transparency in decision-making, including involvement of communities and other key stakeholders in the decision- making and accountability processes. Introduction | 5 The 2002 National Health Policy is set against this varied background and has been developed to provide clear direction for the health sector in the medium term (Ministry of Health and Sanitation, 2002). It includes policies related to both the reconstruction of the health sector and the reform and development of the sector. It also fully recognizes the existence of specific policies in defined technical areas. The goals, objectives and national health priorities are as follows: • The overall goal of the health sector is to maintain and improve the health of all Sierra Leonean residents within the country. • The Government of Sierra Leone is committed to pursuing such a goal in an equitable manner. It will work towards ensuring that all citizens have access to basic good quality health care. It has special responsibility to ensure the health of those citizens who are particularly vulnerable as a result of poverty, conflict, gender, or specific health problems. • The Government of Sierra Leone also has responsibility for ensuring the provision of adequate public health services (including sanitation), for food safety, and for effective action against specific communicable diseases. • The health of a country is not the result of health services alone, but can be affected both positively and negatively by the activities of a number of other sectors. The Ministry of Health and Sanitation has a responsibility to provide leadership and health-related advocacy to such sectors to ensure their activities are health promoting. • Sierra Leone faces a number of major health problems. However, resource constraints, particularly regarding the availability of finance and health care professionals, means that priorities have to be set for the key health problems that will be the focus of the health sector. This does not imply that other health problems will be ignored, but rather that they will not receive targeted national investment. It is also recognized that there are differences between districts in the prevalence and incidence of specific health problems (such as Lassa fever). As such, there will be opportunities during the planning processes for local setting of priorities within the national framework. National health priorities have been set on the basis of a number of criteria. These are: the severity of the disease in terms of its contribution to the overall burden of disease in the country, the distribution of the health problem within the country as a national problem, the feasibility and cost-effectiveness of interventions concerning the health problem, public expectations concerning the problem, and compliance with international regulations. On the basis of the above criteria, the current national priority health problems are: • Malaria • Sexually transmitted infections including HIV/AIDS • Tuberculosis • Unsatisfactory reproductive health including maternal and neo-natal mortality • Acute respiratory infections • Childhood immunizable diseases • Nutrition-related disease 6 | Introduction • Water, food, and sanitation-borne diseases • Disability • Mental illness Technical policies exist for a number of these health priorities; they set specific objectives, targets, strategies and, where appropriate, treatment protocols. In August 2002, these were policies on environmental health, immunization, drugs, health education, malaria, and HIV/AIDS (draft), and a national strategy for the development of prosthetics and orthotics services (Ministry of Health and Sanitation, 2002). Further technical policies will be developed in each of the remaining priority areas, and the existing ones will be updated as necessary. 1.7 OBJECTIVES AND ORGANIZATION OF THE 2008 SLDHS The 2008 Sierra Leone Demographic and Health Survey (SLDHS) is a nationally representative sample survey designed to provide information on population and health issues in Sierra Leone. This is the first Demographic and Health Survey conducted in Sierra Leone and was carried out by Statistics Sierra Leone (SSL) in collaboration with the Ministry of Health and Sanitation. The 2008 SLDHS was funded by the Sierra Leone government, UNFPA, UNDP, UNICEF, DFID, USAID, and The World Bank. WHO, WFP and UNHCR provided logistical support. ICF Macro, an ICF International Company, provided technical support for the survey through the MEASURE DHS project. MEASURE DHS is sponsored by the United States Agency for International Development (USAID) to assist countries worldwide in obtaining information on key population and health indicators. The purpose of the SLDHS is to collect national- and regional-level data on fertility and contraceptive use, marriage and sexual activity, fertility preferences, breastfeeding practices, nutritional status of women and young children, childhood and adult mortality, maternal and child health, female genital cutting, awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections, adult health, and other issues. The survey obtained detailed information on these topics from women of reproductive age and, for certain topics, from men as well. The 2008 SLDHS was carried out from late April 2008 to late June 2008, using a nationally representative sample of 7,758 households. The survey results are intended to assist policymakers and planners in assessing the current health and population programmes and in designing new strategies for improving reproductive health and health services in Sierra Leone. 1.8 SAMPLE DESIGN The SLDHS sample was designed to provide most of the indicators for the country as a whole, for urban and rural areas separately, and for each of four regions that were formed by grouping the 14 districts. The regional groups are as follows: Eastern: Kailahun, Kenema, Kono districts Northern: Bombali, Kambia, Koinadugu, Port Loko, Tonkolili districts Southern: Bo, Bonthe, Moyamba, Pujehun districts Western: Western Area Urban and Western Area Rural districts A representative probability sample of households was selected for the 2008 SLDHS sample. The sample was selected in two stages. In the first stage, 353 clusters were selected from a list of enumeration areas in the master sample frame that was designed for the 2004 Sierra Leone Population Introduction | 7 and Housing Census (SSL, 2006). In the second stage, a complete listing of households was carried out in each selected cluster. Twenty-two households were then systematically selected from each cluster for participation in the survey. This design resulted in a final sample of 7,758 households. All women age 15-49 who were either permanent residents of the households or visitors present in the household on the night before the survey were eligible to be interviewed. In addition, all men age 15-59 in half of the households selected for the survey were eligible to be interviewed if they were either permanent residents or visitors present in the household on the night before the survey. Height and weight measurements of female respondents and children under the age of five years were done only in the households selected for the male survey. Eligible adults and children age 6-59 months in the households selected for the male survey were tested for anaemia, and women and men were asked to provide blood samples for HIV testing. The blood samples were dried and transported to the National Reference Laboratory of the Ministry of Health and Sanitation at Lakka, where they were tested for the human immunodeficiency virus (HIV). 1.9 QUESTIONNAIRES Three types of questionnaires were administered for the 2008 SLDHS: the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. The contents of these questionnaires were based on the model questionnaires developed by the MEASURE DHS programme for use in countries with low levels of contraceptive use. The SSL, in collaboration with other stakeholders and ICF Macro staff, held a series of meetings to adapt the model questionnaires to the situation in Sierra Leone regarding relevant issues in population, family planning, HIV/AIDS, and other health issues in Sierra Leone. Given that there are many local languages in Sierra Leone—most of which have no accepted written script, and are not taught in the schools—and given that English is widely spoken, it was decided not to attempt to translate the questionnaires into vernaculars. However, many of the questions were ‘broken down’ to generate a list of key words and translated into the main languages using Roman script. A list with the key words was provided to each interviewer with suggestions for using it during data collection to standardize the translation; this aspect was emphasized during the main training. The household and individual questionnaires were pretested in February 2008. The Household Questionnaire was used to list all the usual members and visitors in the selected households. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of household. The main purpose of the Household Questionnaire was to identify women and men who were eligible for the individual interview. The Household Questionnaire also collected information on the characteristics of the household dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor and roof, ownership of various durable goods, and ownership and use of mosquito nets. The Household Questionnaire was also used to record height and weight measurements of women age 15- 49 and children under the age of 5 years, and women’s and men’s voluntary consent to give blood samples for testing. The HIV and anaemia testing procedures are described in detail in the next section. The Women’s Questionnaire was used to collect information from all women age 15-49 years and covered the following topics: • Background characteristics (education, residential history, media exposure, etc.) • Reproductive history and child mortality • Knowledge and use of family planning methods • Fertility preferences • Antenatal and delivery care 8 | Introduction • Breastfeeding and infant feeding practices • Vaccinations and childhood illnesses • Marriage and sexual activity • Woman’s work and husband’s background characteristics • Infant and child feeding practices • Awareness and behaviour about AIDS and other sexually transmitted infections (STIs) • Other health issues • Female genital cutting • Adult mortality including maternal mortality The Men’s Questionnaire was administered to all men age 15-59 living in every second household in the 2008 SLDHS sample. The Men’s Questionnaire collected much the same information found in the Women’s Questionnaire, but was shorter because it did not contain questions on reproductive history or maternal and child health and nutrition. 1.10 ANAEMIA AND HIV TESTING 1.10.1 Haemoglobin Testing Haemoglobin testing is the primary method of anaemia diagnosis. Reliable measures are obtained using the HemoCue system (Hb 201+). In half of the households selected for the 2008 SLDHS, men age 15-59, women age 15-49, and children age 6-59 months were tested for anaemia. A consent statement was read to all eligible respondents or to the parent or responsible adult for children and young women age 15-17. This statement explained the purpose of the test, informed them that the results would be made available as soon as the test was completed, and requested permission for the test to be carried out. Before taking any blood, the finger was wiped with an alcohol swab and allowed to air dry. Then, the palm side of the end of a finger was punctured with a sterile, single-use, self-retracting lancet. A drop3 of blood was collected in a HemoCue microcuvette, which also serves as a measuring device, and placed in a HemoCue photometer where the results are displayed. An informative brochure was given to each household explaining what anaemia is, the symptoms, and measures people can take to prevent anaemia. Each person whose haemoglobin level was lower than the recommended cut-off point was given a written referral recommending immediate follow-up with a health professional. 1.10.2 HIV Testing All eligible women age 15-49 and men age 15-59 (in every second household) who were interviewed were asked to voluntarily provide three drops of blood for HIV testing. The protocol for the blood specimen collection and analysis was based on the anonymous linked protocol developed by the DHS programme and approved by ICF Macro’s Institutional Review Board. The protocol for the SLDHS was also reviewed and approved by the Sierra Leone National Ethics Committee on Bio- Medical Research. The protocol allows for the merging of the HIV results with the socio-demographic data collected in the individual questionnaires, provided that information which could potentially identify an individual is destroyed before the linking is effected. This requires that identification codes 3 From consenting adults, the blood was first collected for the HIV test, followed by the anaemia test. Introduction | 9 be deleted from the data file and that the back page of the Household Questionnaire, which contains the bar code labels and names of respondents, be destroyed prior to merging the HIV results with the individual data file. For the purposes of blood sample collection, to obtain informed consent for collecting blood for HIV testing, interviewers explained the procedures, the confidentiality of the data, the fact that test results could not be linked or made available to the subject, and informed respondents how they could establish their HIV status through voluntary counselling and testing (VCT) services. Interviewers then collected a dried blood spot sample on a filter paper card from a finger prick using a single-use, spring-loaded, sterile lancet. Each blood sample was given a bar code label, with a duplicate label attached to the Household Questionnaire on the line showing consent for that respondent. A third copy of the same bar code label was affixed to a Blood Sample Transmittal Form to track the blood sample from the field to the laboratory. The filter papers were dried overnight in a plastic drying box, after which they were packed in individual ziploc bags with desiccants and a humidity indicator card, then placed in a larger airtight bag for each sample point. Blood samples were periodically collected in the field along with the completed questionnaires and transported to SSL headquarters in Freetown to be logged in. After this, they were taken to the National Reference Laboratory of the Ministry of Health and Sanitation at Lakka Hospital for HIV testing. At the laboratory, the bar code labels on the dried blood spot samples were scanned into the computer using a programme specially developed by ICF Macro that pre-assigns to each sample a sequential number for ease in tracking. The blood spots were kept refrigerated or frozen depending on how long it would be until they could be tested. After the samples were allowed to attain room temperature, a circle—i.e., a completely filled and well-saturated spot without blood clot—at least 6.3 mm in diameter was taken from each filter paper using a hole punch. Each blot was placed into its pre-assigned well in the elution plate that contained 200 µl of phosphate buffered saline (PBS, pH 7.3- 7.4) and left in the refrigerator overnight at 2-8°C. These eluates were then diluted and tested with Vironostika HIV Uniform II Plus O (BioMerieux). All positive samples and 10 percent of negative samples were then tested with Murex HIV 1.2.O test kit (Abbott). Finally, any discordant samples were tested on Western Blot 2.2 (Abbott) to resolve the discrepancies. Prior to the survey, the National Reference Laboratory (NRL) had experience using its ELISA machine for testing for HIV. ICF Macro supplied the NRL staff with the necessary equipment and reagents. ICF Macro consultants visited and worked with the NRL staff and trained seven laboratory technicians in how to run the various tests and use the software. The HIV test results were merged with the individual questionnaire records after the questionnaires were destroyed and the cluster numbers scrambled. 1.11 TRAINING OF FIELD STAFF Two hundred qualified candidates were recruited for training by Statistics Sierra Leone to serve as supervisors, field editors, interviewers, bio-marker technicians, and quality control personnel. Efforts were made to recruit high-calibre personnel nationwide to ensure appropriate linguistic and cultural diversity. The main survey training was conducted by Statistics Sierra Leone during a four- week period from 17 March to 15 April, 2008. The training was conducted by senior staff from Statistics Sierra Leone, who participated in the pretest, with support from UNFPA, UNICEF, the Ministry of Health and Sanitation, and ICF Macro. Training consisted of lectures, demonstrations, practice interviews in small groups, and examinations. The last week of training provided instruction on how to take anthropometric measurements and the procedures for anaemia and HIV testing—how to administer informed consent, how to take blood spot samples, how to dry the filter papers, and how to pack them up the next morning. During the final week of training, participants had two days of field practice. The final day of training consisted of a session with the team supervisors and field editors to train them on how to supervise the fieldwork and how to edit completed questionnaires. 10 | Introduction 1.12 MAIN FIELDWORK (DATA COLLECTION) Fieldwork for the 2008 SLDHS took place over a two-month period from the end of April to the end of June 2008. Twenty-four teams carried out the data collection. Each team consisted of a team supervisor, one field editor, one bio-marker technician, two female interviewers, and one male interviewer. Senior DHS technical staff visited teams regularly to review the work and monitor data quality. Eight SSL staff and members of the Technical Committee coordinated fieldwork activities and visited the teams at regular intervals to monitor the work. The SSL Director in charge of the project, ICF Macro staff, and the DHS resident consultant monitored fieldwork in addition to SSL top management and the UN interagency team. 1.13 DATA PROCESSING The processing of the SLDHS results began shortly after fieldwork commenced. Completed questionnaires were returned regularly from the field to SSL headquarters in Freetown, where they were entered and edited by data processing personnel recruited and trained for this task. The data processing personnel included two supervisors, five office editors, 15 data entry editors, 23 data entry operators, and four secondary editors. Data were entered using the CSPro computer package. All data were entered twice for 100 percent verification. The concurrent processing of data was a distinct advantage for assessing data quality because SSL was able to advise field teams of errors detected during data entry. The data entry and editing phase of the survey was completed in October 2008. 1.14 RESPONSE RATES Table 1.1 shows response rates for the 2008 SLDHS. A total of 7,758 households were selected in the sample, of which 7,461 were found occupied at the time of the fieldwork. The shortfall is largely due to households that were away for an extended period of time and structures that were found to be vacant or destroyed. Of the existing households, 7,284 were successfully interviewed, yielding a household response rate of 98 percent. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Sierra Leone 2008 Result Residence Total Urban Rural Household interviews Households selected 3,184 4,574 7,758 Households occupied 3,068 4,393 7,461 Households interviewed 2,956 4,328 7,284 Household response rate1 96.3 98.5 97.6 Interviews with women age 15-49 Number of eligible women 3,385 4,460 7,845 Number of eligible women interviewed 3,160 4,214 7,374 Eligible women response rate2 93.4 94.5 94.0 Interviews with men age 15-59 Number of eligible men 1,559 1,982 3,541 Number of eligible men interviewed 1,403 1,877 3,280 Eligible men response rate2 90.0 94.7 92.6 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents In the households interviewed in the survey, a total of 7,845 eligible women were identified, of whom 7,374 were successfully interviewed, yielding a response rate of 94 percent. With regard to the male survey results, 3,541 eligible men were identified, of whom 3,280 were successfully interviewed, yielding a response rate of 93 percent. The response rates are lower in the urban than rural sample, especially for men. Introduction | 11 The principal reason for non-response among eligible men and women was the failure to find individuals at home despite repeated visits to the household, followed by refusal to be interviewed. The slightly lower response rate for men reflects the more frequent and longer absences of men from the households. Household Population and Housing Characteristics | 13 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 2.1 INTRODUCTION This chapter presents a description of the demographic and socio-economic characteristics of the population in households1 sampled and interviewed in the 2008 Sierra Leone Demographic and Health Survey (SLDHS). All usual residents and visitors were listed in the Household Questionnaire. The Household Questionnaire collected information on characteristics of the household population, such as age, sex, education, and survivorship of biological parents. This chapter also describes the characteristics of the household dwelling, including source of drinking water, availability of electricity, sanitation facilities, building materials, and possession of household durable goods. The information presented in this chapter is intended to facilitate the interpretation of key demographic, socio-economic, and health indicators presented later in this report. It is also intended to assist in the measurement of the representativeness of the survey sample. 2.2 HOUSEHOLD POPULATION BY AGE, SEX AND RESIDENCE Age and sex are the most important demographic variables upon which the needs and services of a population are based. Age and sex structure have a major impact on the population’s fertility, mortality, and nuptiality (marriage) patterns. Table 2.1 shows the percent distribution of the de facto household population by five-year age groups according to age, sex, and residence. The household population totals 41,608 persons, of which 49 percent are males and 51 percent are females. Just over two-thirds of the population live in rural areas. The population of Sierra Leone is youthful, with about 49 percent under 15 years of age, an indication of a population with high fertility. Approximately 36 percent of the population is age 15-49. Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Sierra Leone 2008 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 13.3 12.6 13.0 17.7 16.7 17.2 16.2 15.4 15.8 5-9 14.7 14.8 14.8 19.5 16.6 18.0 17.9 16.0 17.0 10-14 18.2 17.9 18.0 16.2 14.5 15.3 16.9 15.6 16.2 15-19 10.5 8.5 9.5 6.0 4.9 5.4 7.5 6.1 6.7 20-24 7.8 7.9 7.9 4.0 5.1 4.5 5.2 6.0 5.6 25-29 6.4 8.1 7.2 4.9 8.4 6.7 5.4 8.3 6.9 30-34 4.7 5.4 5.1 4.0 5.0 4.5 4.2 5.1 4.7 35-39 5.0 5.8 5.4 5.9 5.6 5.7 5.6 5.6 5.6 40-44 4.2 3.1 3.6 3.6 3.3 3.5 3.8 3.3 3.5 45-49 3.6 2.1 2.8 3.9 2.8 3.3 3.8 2.6 3.2 50-54 2.1 4.9 3.5 2.2 6.5 4.4 2.2 5.9 4.1 55-59 1.8 2.5 2.1 2.2 2.7 2.5 2.0 2.6 2.3 60-64 3.4 2.6 3.0 3.7 2.9 3.3 3.6 2.8 3.2 65-69 1.7 1.4 1.6 2.4 1.9 2.2 2.2 1.8 2.0 70-74 1.1 1.0 1.1 1.7 1.3 1.5 1.5 1.2 1.4 75-79 0.8 0.6 0.7 1.2 0.7 0.9 1.0 0.7 0.8 80 + 0.5 0.7 0.6 0.9 0.9 0.9 0.7 0.9 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 6,657 6,985 13,642 13,545 14,421 27,966 20,202 21,406 41,608 1 In this survey, a household is defined as a person or a group of persons, related or unrelated, who live together and share a common source of food and livelihood, and recognize one person as head. 14 | Household Population and Housing Characteristics Figure 2.1 shows the age and sex structure of the population. The population pyramid has a wide base, indicating that a large proportion of the population is made up of children under age 15. Figure 2.1 Population Pyramid Sierra Leone, 2008 80 + 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 <5 Age 0246810 0 2 4 6 8 10 Percent Male Female 2.2.1 Household Composition Table 2.2 shows the composition of households in the survey. Overall, 22 percent of households are headed by females. Female-headed households are more common in urban than in rural areas (26 and 21 percent, respectively). The average household size in Sierra Leone is 5.9 persons. The household size is slightly larger in rural areas than in urban areas (6.0 persons, compared with 5.7 persons). Urban households are more likely than rural households to have just one or two members (13 percent, compared with 8 percent). Overall, one in six households (16 percent) have nine or more members. Almost four in ten households (39 percent) include children whose mother and father are not present (foster children), and 43 percent of households include foster children and/or orphans. Urban households are much more likely than rural households to have foster children (45 and 36 percent, respectively). Consequently, urban households are more likely than rural households to have foster children and/or orphans (49 and 41 percent, respectively). There are more households with single orphans than with double orphans (17 and 4 percent, respectively). Household Population and Housing Characteristics | 15 Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18 years of age, according to residence, Sierra Leone 2008 Characteristic Residence Total Urban Rural Household headship Male 74.3 79.3 77.6 Female 25.7 20.7 22.4 Total 100.0 100.0 100.0 Number of usual members 0 0.0 0.0 0.0 1 6.6 2.8 4.1 2 6.0 4.9 5.3 3 11.7 9.7 10.4 4 14.4 14.7 14.6 5 15.0 17.1 16.4 6 14.6 15.8 15.4 7 9.5 11.3 10.7 8 6.5 7.0 6.9 9+ 15.8 16.5 16.2 Total 100.0 100.0 100.0 Mean size of households 5.7 6.0 5.9 Percentage of households with orphans and foster children under 18 years of age Foster children1 45.0 35.6 38.8 Double orphans 5.0 3.5 4.0 Single orphans 18.3 15.9 16.8 Foster and/or orphan children 48.6 40.6 43.3 Number of households 2,469 4,815 7,284 Note: Table is based on de jure household members, i.e., usual residents. 1 Children under 18 years of age living in households with neither their mother nor their father present. 2.2.2 Children’s Living Arrangement and Orphanhood Detailed information on living arrangements and orphanhood for children under 18 years of age is presented in Table 2.3. Of the 22,280 children under age 18 reported in the 2008 SLDHS, about half live with both parents, 10 percent live with their mother only and their father is living, 9 percent live with their father only and their mother is living, and 26 percent live with neither of their natural parents although both parents are living. The table also provides information on type of orphanhood, that is, the proportion of children who have lost one or both parents. Eleven percent of children under 18 years of age have lost one parent, while 2 percent have lost both parents. 16 | H ou se ho ld P op ul at io n an d H ou sin g C ha ra ct er ist ic s T ab le 2 .3 C hi ld re n’ s liv in g ar ra ng em en ts a nd o rp ha nh oo d P er ce nt d ist rib ut io n of d e ju re c hi ld re n un de r 18 y ea rs o f ag e by li vi ng a rr an ge m en ts a nd s ur vi va l s ta tu s of p ar en ts , th e pe rc en ta ge o f ch ild re n no t liv in g w ith a b io lo gi ca l p ar en t, an d th e pe rc en ta ge o f c hi ld re n w ith o ne o r b ot h pa re nt s de ad , a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, S ie rr a Le on e 20 08 B ac kg ro un d ch ar ac te ris tic Li vi ng w ith b ot h pa re nt s Li vi ng w ith m ot he r bu t n ot w ith fa th er Li vi ng w ith fa th er bu t n ot w ith m ot he r N ot li vi ng w ith e ith er p ar en t To ta l Pe rc en ta ge no t l iv in g w ith a bi ol og ic al pa re nt Pe rc en ta ge w ith o ne or b ot h pa re nt s de ad N um be r o f ch ild re n Fa th er al iv e Fa th er de ad M ot he r al iv e M ot he r de ad Bo th a liv e O nl y fa th er al iv e O nl y m ot he r al iv e Bo th d ea d In fo rm at io n m iss in g on fa th er o r m ot he r A ge 0- 4 62 .3 14 .1 2. 6 5. 2 0. 4 11 .3 0. 8 1. 0 0. 7 1. 7 10 0. 0 15 .4 5. 5 6, 70 9 < 2 68 .2 18 .7 3. 0 3. 0 0. 1 4. 1 0. 4 0. 6 0. 4 1. 5 10 0. 0 7. 1 4. 6 2, 69 1 2- 4 58 .4 11 .0 2. 3 6. 6 0. 7 16 .1 1. 1 1. 2 0. 9 1. 8 10 0. 0 21 .0 6. 2 4, 01 7 5- 9 51 .7 7. 7 3. 2 9. 2 1. 1 19 .6 1. 3 2. 7 1. 8 1. 7 10 0. 0 27 .1 10 .1 7, 14 3 10 -1 4 41 .4 7. 2 5. 0 11 .0 1. 9 21 .8 1. 5 4. 7 2. 9 2. 5 10 0. 0 33 .6 16 .1 6, 83 7 15 -1 7 36 .9 7. 8 6. 6 8. 8 2. 4 19 .9 1. 7 8. 1 3. 4 4. 5 10 0. 0 37 .5 22 .1 1, 59 1 S ex M al e 51 .8 9. 1 3. 6 9. 3 1. 5 16 .7 1. 1 3. 1 1. 8 2. 0 10 0. 0 24 .7 11 .2 11 ,3 42 Fe m al e 49 .6 9. 9 3. 9 7. 6 0. 9 18 .9 1. 4 3. 3 2. 0 2. 4 10 0. 0 28 .0 11 .6 10 ,9 38 R es id en ce U rb an 40 .4 13 .0 3. 5 8. 0 0. 9 22 .4 1. 5 4. 5 2. 7 3. 0 10 0. 0 34 .1 13 .2 7, 06 4 Ru ra l 55 .5 7. 8 3. 9 8. 7 1. 4 15 .7 1. 1 2. 6 1. 6 1. 8 10 0. 0 22 .7 10 .6 15 ,2 16 R e g io n Ea st er n 58 .0 9. 4 4. 0 6. 7 0. 9 13 .5 1. 0 2. 8 1. 8 1. 8 10 0. 0 21 .0 10 .6 3, 98 6 N or th er n 51 .0 8. 3 4. 3 9. 7 1. 4 16 .9 1. 1 3. 1 2. 0 2. 1 10 0. 0 25 .4 12 .1 10 ,4 21 So ut he rn 53 .1 9. 2 2. 4 8. 1 1. 2 19 .5 1. 1 2. 5 1. 4 1. 5 10 0. 0 26 .0 8. 6 4, 23 2 W es te rn 39 .1 13 .2 3. 8 7. 5 1. 1 23 .1 1. 9 4. 5 2. 3 3. 4 10 0. 0 35 .3 13 .7 3, 64 0 W ea lth q ui nt ile Lo w es t 56 .8 7. 0 4. 7 7. 4 1. 6 15 .0 1. 2 2. 4 1. 3 2. 6 10 0. 0 22 .5 11 .2 4, 34 5 Se co nd 53 .9 8. 7 3. 8 9. 7 1. 4 15 .3 1. 2 2. 5 1. 8 1. 7 10 0. 0 22 .5 10 .8 4, 63 2 M id dl e 55 .4 7. 6 3. 9 8. 4 1. 1 15 .8 1. 0 2. 9 2. 3 1. 6 10 0. 0 23 .6 11 .1 4, 65 7 Fo ur th 47 .2 11 .5 3. 8 8. 8 1. 1 19 .4 1. 1 3. 4 2. 0 1. 6 10 0. 0 27 .6 11 .5 4, 54 8 H ig he st 39 .0 12 .8 2. 6 8. 1 1. 0 24 .2 1. 7 5. 0 2. 1 3. 4 10 0. 0 36 .4 12 .6 4, 09 7 To ta l < 15 51 .8 9. 6 3. 6 8. 5 1. 1 17 .6 1. 2 2. 8 1. 8 2. 0 10 0. 0 25 .5 10 .6 20 ,6 89 To ta l < 18 50 .7 9. 5 3. 8 8. 5 1. 2 17 .8 1. 2 3. 2 1. 9 2. 2 10 0. 0 26 .3 11 .4 22 ,2 80 N ot e: T ab le is b as ed o n de ju re m em be rs , i .e ., us ua l r es id en ts . 16 | Household Population and Housing Characteristics Household Population and Housing Characteristics | 17 2.3 SCHOOL ATTENDANCE BY SURVIVORSHIP OF PARENTS AND BY ORPHANHOOD STATUS Children who are orphaned or live in a house with chronically ill adults may be at a greater risk of dropping out of school because of lack of money to pay school fees or the need to stay at home to care for the sick relative. The SLDHS included information to monitor such situations. Table 2.4 presents data on school attendance of children age 10-14 by parental survival according to background characteristics. The first panel of the table shows the proportion of children attending school whose parents are both dead and the proportion whose parents are both living and the child is residing with at least one parent. The last panel of the table compares school attendance of orphans and non-orphans. The overall ratio of school attendance of children whose parents are dead to those whose parents are living and the child resides with at least one parent is 0.62. This indicates that six in ten children whose parents are dead have access to school, compared with all children whose parents are living and the child resides with at least one parent. The gap in school attendance between children whose parents are living and children whose parents are dead is wider for girls, children in rural areas, and among children in the lower wealth quintiles. There are large differentials in the ratio by region. In the Eastern and Southern regions the ratio is less than 0.4, while in the Northern and Western regions it is 0.7. Table 2.4 also shows that 61 percent of orphans are attending school, compared with 74 percent of non-orphans. This brings the school attendance ratio of orphans to non-orphans to 0.83, which means that orphans are less likely to attend school compared with non-orphans. The disparity in school attendance between orphans and non-orphans is greater among girls, children in rural areas, and children in households in the lower wealth quintiles. The ratio also varies by region. In the Eastern and Southern regions the ratio is less than 0.8, while in the Northern and Western regions it is 0.84 and 0.87, respectively. Table 2.4 School attendance by survivorship of parents and by orphanhood status For de jure children 10-14 years of age, the percentage attending school by parental survival and by orphanhood status and the ratios of the percentages attending, by parental survival and orphanhood status according to background characteristics, Sierra Leone 2008 Background characteristic Percentage attending school by survivorship of parents Ratio1 Percentage attending school by orphanhood status Ratio2 Both parents dead Number Both parents living and child resides with at least one parent Number Orphan Non-orphan Percentage Number Percentage Number Sex Male 53.1 92 77.7 2,121 0.68 66.4 544 75.8 2,912 0.88 Female 42.4 109 74.3 1,951 0.57 56.2 556 71.9 2,824 0.78 Residence Urban 62.9 101 92.0 1,283 0.68 76.7 435 88.3 2,060 0.87 Rural 31.4 100 68.8 2,789 0.46 51.2 665 65.8 3,676 0.78 Region Eastern (28.2) 23 77.8 671 0.36 60.2 160 76.4 867 0.79 Northern 50.3 101 71.3 2,064 0.70 58.4 560 69.6 2,786 0.84 Southern (24.9) 33 72.2 696 0.35 48.6 149 67.6 1,007 0.72 Western 66.8 44 93.7 641 0.71 77.0 232 88.8 1,077 0.87 Wealth quintile Lowest * 22 50.8 716 0.39 39.5 186 49.7 939 0.79 Second (18.2) 40 70.8 874 0.26 50.9 221 67.0 1,146 0.76 Middle (51.9) 43 74.6 863 0.70 63.3 222 71.0 1,139 0.89 Fourth (57.4) 56 88.1 879 0.65 65.8 251 82.8 1,237 0.79 Highest (72.2) 40 94.1 740 0.77 82.8 221 91.6 1,275 0.90 Total 47.3 201 76.1 4,072 0.62 61.2 1,101 73.8 5,736 0.83 Note: Table is based only on children who usually live in the household. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25 to 49 unweighted cases. 1 Ratio of the percentage with both parents dead to the percentage with both parents living and child resides with at least one parent 2 Ratio of the percentage for orphans to the percentage for non-orphans 18 | Household Population and Housing Characteristics 2.4 EDUCATION OF THE HOUSEHOLD POPULATION Education is a key determinant of the lifestyle and status an individual enjoys in a society. Studies have consistently shown that educational attainment has a strong effect on health behaviours and attitudes. In general, the higher the level of education a woman has attained, the more knowledgeable she is about the use of health facilities, family planning methods, and the health of her children. Results from the 2008 SLDHS can be used to look at educational attainment and current school attendance among household members. Sierra Leone’s education system has been unstable for more than 10 years because of the civil crisis; however, a major restructuring of the infrastructure and educational programme is being undertaken by the government. The government of Sierra Leone has adopted a policy of free primary education in all government schools for all children. The government is undertaking massive renovation of infrastructure damaged during the war, and it is revising and expanding programmes in the educational system. For purposes of this analysis, age six is used as the age for entry into the primary level. Because of the war, however, many children who should have started school when they reached school-going age never got to start school. Officially, primary school consists of six years of education; junior secondary school and senior secondary school each consist of three years of education. Tables 2.5.1 and 2.5.2 show the percent distribution of the female and male household population age six years and over by the highest level of schooling attended or completed, and the median grade completed, according to background characteristics. Overall, 58 percent of women and 46 percent of men have no education. Only one in four women (25 percent) and 28 percent of men have some primary education. Men are almost twice as likely as women to have attended secondary school (22 and 12 percent, respectively). Age is negatively associated with education attainment; younger people are more likely to have received education than older people. While 41 percent of girls and 43 percent of boys age 6-9 have no education, for women age 25 or older the proportion is 70 percent or higher, and for men age 25 or older the proportion is 54 percent or higher. Tables 2.5.1 and 2.5.2 show that younger people are more likely to be educated than older people. Whereas about 57 percent of girls age 6-14 years have some primary education, the corresponding proportions for women age 15-19 and 20-24 are 21 and 12 percent, respectively. The proportion is even lower for older women. The same pattern is observed for men. Household Population and Housing Characteristics | 19 Table 2.5.1 Educational attainment of the female household population Percent distribution of the de facto female household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Sierra Leone 2008 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 40.6 57.5 0.3 0.2 0.0 0.0 1.4 100.0 2,883 0.0 10-14 26.0 57.4 5.3 10.5 0.0 0.1 0.7 100.0 3,333 2.3 15-19 33.8 21.1 8.7 34.9 0.4 0.3 0.9 100.0 1,299 4.4 20-24 57.3 12.0 2.6 20.1 3.4 3.3 1.4 100.0 1,287 0.0 25-29 73.1 8.8 2.2 9.3 1.7 3.4 1.5 100.0 1,781 0.0 30-34 70.2 7.4 3.4 11.7 2.6 3.6 1.1 100.0 1,098 0.0 35-39 74.8 6.2 3.6 10.1 1.7 2.2 1.4 100.0 1,207 0.0 40-44 74.7 5.5 2.8 10.2 2.4 3.0 1.3 100.0 699 0.0 45-49 80.1 4.7 3.0 8.4 0.9 1.6 1.3 100.0 554 0.0 50-54 85.3 1.9 1.9 5.6 1.0 1.4 2.9 100.0 1,271 0.0 55-59 88.2 2.1 0.9 3.0 0.9 1.7 3.2 100.0 564 0.0 60-64 90.1 1.8 1.8 1.9 1.1 1.2 2.2 100.0 603 0.0 65+ 93.1 0.9 0.7 1.0 0.2 0.7 3.4 100.0 964 0.0 Residence Urban 37.0 28.6 5.0 21.4 2.8 3.9 1.3 100.0 5,946 1.9 Rural 68.8 23.5 2.0 3.8 0.1 0.1 1.6 100.0 11,612 0.0 Region Eastern 61.5 27.0 2.9 6.6 0.2 0.5 1.3 100.0 3,082 0.0 Northern 64.6 24.9 2.4 5.7 0.2 0.3 1.8 100.0 7,747 0.0 Southern 64.4 23.4 2.9 7.0 0.4 0.7 1.2 100.0 3,489 0.0 Western 32.2 26.3 5.0 25.3 4.5 5.5 1.3 100.0 3,239 3.3 Wealth quintile Lowest 77.5 17.0 1.2 2.1 0.0 0.0 2.2 100.0 3,390 0.0 Second 68.0 25.4 1.8 3.2 0.0 0.1 1.6 100.0 3,528 0.0 Middle 65.7 26.1 2.5 4.6 0.1 0.1 1.0 100.0 3,426 0.0 Fourth 53.0 29.2 4.2 11.0 0.5 0.8 1.3 100.0 3,562 0.0 Highest 28.0 28.2 5.4 26.8 4.3 5.8 1.4 100.0 3,652 3.7 Total 58.0 25.2 3.1 9.7 1.0 1.4 1.5 100.0 17,558 0.0 Note: Total includes 16 women with information missing on age 1 Completed grade 6 at the primary level 2 Completed grade 3 at the senior secondary school level More than two-thirds (69 percent) of women in the rural areas have no education and only about one-quarter (24 percent) have some primary education. The situation is worse for secondary education; only about 4 percent of women in rural areas have some secondary education. This pattern is seen across all regions except in the Western Region, where 25 percent of women have some secondary education, and 10 percent have completed secondary education. 20 | Household Population and Housing Characteristics Table 2.5.2 Educational attainment of the male household population Percent distribution of the de facto male household populations age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Sierra Leone 2008 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 43.4 54.5 0.1 0.2 0.0 0.0 1.9 100.0 3,061 0.0 10-14 21.8 59.1 6.3 11.8 0.0 0.0 1.0 100.0 3,412 2.7 15-19 23.1 23.0 6.7 45.1 0.7 0.5 0.8 100.0 1,507 5.3 20-24 33.1 9.4 3.4 42.4 7.1 4.1 0.7 100.0 1,058 6.5 25-29 53.7 8.4 2.7 20.7 6.5 6.5 1.5 100.0 1,082 0.0 30-34 55.7 9.7 4.0 15.6 4.5 8.7 1.8 100.0 852 0.0 35-39 58.9 8.4 3.9 18.0 3.8 6.3 0.7 100.0 1,141 0.0 40-44 55.2 6.2 2.4 19.4 7.5 8.3 0.9 100.0 768 0.0 45-49 63.7 8.2 2.3 15.2 4.0 5.5 1.1 100.0 767 0.0 50-54 60.9 5.0 2.6 17.0 5.8 7.5 1.2 100.0 440 0.0 55-59 63.8 6.9 2.8 12.9 6.0 5.6 2.0 100.0 414 0.0 60-64 78.4 1.8 2.4 8.6 2.4 4.5 2.0 100.0 734 0.0 65+ 85.4 3.1 0.9 4.9 1.4 2.6 1.8 100.0 1,108 0.0 Residence Urban 23.8 27.7 5.0 29.3 5.7 7.3 1.2 100.0 5,641 4.6 Rural 57.2 28.4 2.5 8.9 0.8 0.8 1.4 100.0 10,720 0.0 Region Eastern 51.5 28.5 3.6 12.6 1.4 1.5 0.9 100.0 2,866 0.0 Northern 50.1 30.2 3.2 12.2 1.1 1.2 1.9 100.0 7,122 0.0 Southern 54.1 26.9 2.2 12.7 1.5 1.8 0.8 100.0 3,335 0.0 Western 20.6 24.3 4.9 31.4 7.8 10.1 0.9 100.0 3,038 5.8 Wealth quintile Lowest 69.2 22.4 1.8 4.3 0.2 0.1 2.1 100.0 3,191 0.0 Second 57.2 31.0 2.1 7.6 0.5 0.2 1.3 100.0 3,233 0.0 Middle 50.7 31.7 3.1 11.5 1.1 0.8 1.3 100.0 3,203 0.0 Fourth 35.7 32.3 4.8 21.3 2.5 2.5 0.9 100.0 3,258 1.8 Highest 18.2 23.7 4.9 33.5 7.8 10.9 1.0 100.0 3,477 6.2 Total 45.7 28.2 3.4 16.0 2.5 3.0 1.3 100.0 16,361 0.1 Note: Total includes 19 men with information missing on age 1 Completed grade 6 at the primary level 2 Completed grade 3 at the senior secondary school level There are differentials in education attainment by urban-rural residence. In general, urban residents have higher levels of education than rural residents. For instance, the median years of schooling completed for urban women and men are two and five years, respectively, whereas for rural women and men, the corresponding proportions are zero years. As expected, men and women in the Western Region (which includes Freetown, the capital) are better educated than their counterparts in the other regions. As expected, educational attainment is highly correlated with household wealth. The proportion of women with no education increases from 28 percent among those in the highest quintile to 78 percent among those in the lowest wealth quintile, and only 2 percent women in the lowest quintile have at least some secondary education, compared with 27 percent of women in the highest quintile. Similarly, only 4 percent of men in the lowest quintile have at least some secondary education, compared with 34 percent of men in the highest quintile. Figure 2.2 shows the educational attainment of women and men in the 2008 SLDHS. Household Population and Housing Characteristics | 21 Figure 2.2 Age-specific Attendance Rates for the de facto Population Age 5-24 Sierra Leone, 2008 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 Percent Female Male 2.5 SCHOOL ATTENDANCE RATIOS Table 2.6 presents net attendance ratios (NARs) and gross attendance ratios (GARs) for the household population by level of schooling and sex, according to background characteristics The NAR for primary school measures the proportion of children of primary school age who are attending primary school, while the GAR represents the total number of primary school pupils age 5-24 as a percentage of children of primary school age. In Sierra Leone, the levels refer to 6-11 years for primary and 12-17 years for secondary. The GAR is usually higher than the NAR because the GAR includes participation of those who may be older or younger than the official age range for that level. Pupils who are over age for a given level of school may have started school late, may have repeated one or more classes in school, or may have dropped out of school and later returned. The NAR indicates that 62 percent of children of primary school age are attending primary school. The NARs for primary school are higher in urban (76 percent) than in the rural areas (56 percent), and highest in the Western Region (79 percent). The NAR in other regions ranges from 57 percent in the Northern Region to 63 percent in the Eastern Region. The GAR indicates that overall, there are children in primary school who are not of primary school age, with ratios of 92 for males and 93 for females. The Gender Parity Index (GPI) shows the ratio of female to male GARs. The overall GPI at the primary level is about 1.00, which indicates equality in the participation rates for males and females in primary school. At the primary school level, the (GPI) varies slightly across subgroups. At the secondary level, the overall GPI is 0.67. GPI is higher in urban (0.73) than in rural areas (0.55) and ranges from 0.57 in the Northern Region to 0.74 in the Western Region. 22 | Household Population and Housing Characteristics Table 2.6 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Sierra Leone 2008 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index (GPI)3 Male Female Total Gender Parity Index (GPI)3 PRIMARY SCHOOL Residence Urban 75.7 76.4 76.1 1.01 114.9 113.0 113.9 0.98 Rural 54.5 56.5 55.5 1.04 83.4 83.3 83.3 1.00 Region Eastern 61.4 64.5 63.0 1.05 93.6 96.5 95.1 1.03 Northern 56.2 56.9 56.5 1.01 87.6 85.8 86.8 0.98 Southern 58.9 64.0 61.3 1.09 87.5 87.9 87.7 1.00 Western 79.9 78.1 78.7 0.99 117.1 116.1 116.6 0.99 Wealth quintile Lowest 43.9 42.7 43.3 0.97 66.6 62.6 64.7 0.94 Second 54.8 60.3 57.4 1.10 85.0 85.8 85.4 1.01 Middle 58.8 60.3 59.5 1.03 90.4 88.7 89.6 0.98 Fourth 72.2 70.4 71.3 0.97 108.7 107.9 108.3 0.99 Highest 79.4 80.7 80.1 1.02 120.2 119.1 119.6 0.99 Total 60.6 62.9 61.7 1.04 92.4 92.8 92.6 1.00 SECONDARY SCHOOL Residence Urban 48.1 43.4 45.8 0.90 93.0 67.7 80.5 0.73 Rural 19.2 12.7 16.0 0.66 31.7 17.3 24.7 0.55 Region Eastern 23.5 20.6 22.1 0.87 47.5 33.4 40.5 0.70 Northern 27.9 18.8 23.6 0.68 48.2 27.7 38.5 0.57 Southern 18.5 19.7 19.1 1.07 42.5 28.8 35.6 0.68 Western 52.3 45.0 48.5 0.86 91.4 67.9 79.4 0.74 Wealth quintile Lowest 10.7 8.3 9.6 0.78 17.7 11.9 15.0 0.67 Second 15.4 9.7 12.7 0.63 25.8 13.6 20.0 0.53 Middle 22.6 17.2 20.0 0.76 37.4 23.0 30.4 0.61 Fourth 35.8 27.5 31.7 0.77 70.3 41.5 56.0 0.59 Highest 56.7 48.8 52.7 0.86 105.0 76.4 90.6 0.73 Total 30.6 25.1 27.9 0.82 56.0 37.8 47.1 0.67 1 The NAR for primary school is the percentage of the primary-school-age (6-11 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (12-17 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary- school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100.0. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR (GAR) for females to the NAR (GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR (GAR) for females to the NAR (GAR) for males. 2.6 GRADE REPETITION AND DROP-OUT RATE Repetition and drop-out rates describe the flow of pupils through the educational system in Sierra Leone. Repetition rates indicate the percentage of pupils who attended a particular class during the 2006-2007 academic year who attended the same class again during the 2007-2008 academic year. Drop-out rates show the percentage of pupils who attended class during the 2006-2007 academic year but did not attend school the following year. Repetition and drop-out rates approach zero when pupils nearly always progress to the next grade at the end of the school year. Repetition and drop-out rates often vary across grades, indicating points in the school system where pupils are not regularly promoted to the next grade or they decide to drop out of school. Household Population and Housing Characteristics | 23 Table 2.7 shows the repetition and drop-out rates for the de facto household population age 5-24 who attended primary school in the previous school year by school grade, according to background characteristics. The repetition rate declines from 5 percent in grade 1 to 2 percent in grade 5, then rises to 3 percent in grade 6. There are small variations by gender and urban-rural residence; however, larger differentials are observed by region, especially in grade 1. While 9 percent of students in the Eastern Region repeat grade 1, only 2 percent of first graders in the Northern Region repeat the grade. Drop- out rates vary less than repetition rates; in all grades the drop-out rate is around 1 percent. Table 2.7 Grade repetition and dropout rates Repetition and dropout rates for the de facto household population age 5-24 who attended primary school in the previous school year by school grade, according to background characteristics, Sierra Leone 2008 Background characteristic School grade 1 2 3 4 5 6 REPETITION RATE1 Sex Male 4.4 3.1 1.3 2.9 2.1 3.0 Female 5.1 2.9 3.2 2.4 1.6 3.7 Residence Urban 3.7 3.3 2.0 1.6 2.4 3.4 Rural 5.2 2.9 2.5 3.4 1.5 3.2 Region Eastern 9.2 1.7 3.4 3.5 2.5 5.0 Northern 2.2 4.0 1.2 3.4 1.5 1.5 Southern 5.6 2.3 4.6 1.8 2.2 8.5 Western 5.0 2.6 2.3 1.1 2.0 2.9 Wealth quintile Lowest 7.6 2.4 2.1 5.6 2.0 3.6 Second 4.2 3.1 2.7 3.6 1.9 4.1 Middle 3.0 4.7 3.1 2.0 0.7 3.2 Fourth 5.6 1.7 1.5 2.4 2.6 3.5 Highest 4.0 3.1 2.1 1.5 2.0 2.8 Total 4.7 3.0 2.3 2.7 1.9 3.3 DROPOUT RATE2 Sex Male 0.8 0.5 0.8 1.1 1.8 0.8 Female 1.2 0.8 1.3 0.9 1.9 2.0 Residence Urban 0.7 0.3 0.5 0.3 1.7 0.6 Rural 1.1 0.9 1.4 1.5 2.0 2.2 Region Eastern 1.5 1.6 0.6 1.9 0.2 2.7 Northern 1.1 0.5 1.5 1.5 2.0 1.8 Southern 0.2 0.0 0.0 0.0 2.7 0.0 Western 1.1 0.8 1.2 0.3 2.2 0.0 Wealth quintile Lowest 1.3 1.9 0.0 4.2 1.8 0.9 Second 1.1 0.3 2.1 1.1 3.5 7.4 Middle 1.6 0.9 1.4 0.7 0.7 1.5 Fourth 0.3 0.4 0.6 0.8 1.9 0.5 Highest 0.9 0.3 0.9 0.3 1.4 0.4 Total 1.0 0.7 1.1 1.0 1.9 1.3 1 The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. 2 The dropout rate is the percentage of students in a given grade in the previous school year who are not attending school in the current school year. 2.7 HOUSEHOLD DRINKING WATER To assess the socio-economic conditions under which the population lives, respondents were asked to give specific information about their household environment. The 2008 SLDHS collected information about drinking water, including the source, time taken to collect water, persons who 24 | Household Population and Housing Characteristics usually collect the water, and any water treatment prior to drinking. The source of drinking water is an indicator of whether or not the water is suitable for drinking. Sources of water believed to be relatively free of disease are improved sources such as piped water into dwelling/yard/plot; public taps/standpipes, tube wells or bore holes, protected dug wells, protected spring, and rainwater. Non- improved sources, like unprotected dug wells, unprotected springs, and surface water are more likely to have disease-causing agents that have a negative impact on health. Table 2.8 presents information on the drinking water of households in the 2008 SLDHS. More than half (51 percent) of households obtain drinking water from improved sources: 22 percent from protected dug wells and 14 percent from public taps/standpipes. Similar proportions are seen for the population; half of the population obtains drinking water from an improved source: 23 percent from protected dug wells and 13 percent from public taps. There is a substantial difference in access to improved water sources between urban and rural households. More than four-fifths (83 percent) of urban households have access to improved sources of water, compared with 34 percent of rural households. The most common source of water in rural areas is surface water (40 percent), while in urban areas 28 percent of households obtain water from protected dug wells, 27 percent from public stand pipes, and 20 percent have water piped into their dwelling or yard. Only 13 percent of households in Sierra Leone have water on their premises. More than half of households take less than 30 minutes to get water, while 29 percent require 30 minutes or more to obtain drinking water. Urban households are much more likely than rural households to have the water close to home; 30 percent of urban households have the water source on their premises, compared with 4 percent of households in rural areas. Water is most often collected by adult female household members (57 percent), followed by female children under age 15 (14 percent). This pattern is more typical in rural areas (68 percent) than in urban areas (36 percent). Nine in ten households do not treat water prior to drinking. The most popular way to treat water is by adding bleach or chlorine (6 percent). Urban households are more likely than rural households to treat the water; 14 percent of households in urban areas use appropriate treatment of water, compared with 4 percent of households in rural areas. Household Population and Housing Characteristics | 25 Table 2.8 Household drinking water Percent distribution of households and de jure population by source, time to collect, and person who usually collects drinking water; and percentage of households and de jure population by treatment of drinking water, according to residence, Sierra Leone 2008 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 82.9 34.3 50.8 81.3 35.1 50.3 Piped water into dwelling/yard/plot 20.4 1.0 7.6 19.3 1.0 7.1 Public tap/standpipe 26.5 7.1 13.7 24.3 6.9 12.7 Tube well or borehole 6.3 6.4 6.4 5.9 6.3 6.2 Protected dug well 28.0 18.8 21.9 30.1 19.9 23.3 Protected spring 1.6 0.9 1.1 1.6 0.9 1.2 Non-improved source 16.1 65.5 48.7 18.0 64.6 49.2 Unprotected dug well 9.4 15.3 13.3 10.8 15.1 13.7 Unprotected spring 2.6 9.5 7.1 2.8 9.0 6.9 Tanker truck/cart with small tank 0.1 0.4 0.3 0.1 0.4 0.3 Surface water 4.0 40.2 27.9 4.3 40.1 28.3 Bottled water, improved source for cooking/ washing1 0.6 0.1 0.2 0.4 0.1 0.2 Bottled water, non- improved source for cooking/washing1 0.2 0.0 0.1 0.1 0.0 0.0 Missing 0.2 0.2 0.2 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 83.4 34.4 51.0 81.7 35.2 50.5 Time to obtain drinking water (round trip) Water on premises 30.3 4.0 13.0 30.7 4.5 13.1 Less than 30 minutes 32.9 60.5 51.2 33.0 58.5 50.1 30 minutes or longer 33.1 26.8 28.9 32.0 28.2 29.5 Don’t know/missing 3.7 8.7 7.0 4.2 8.7 7.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 35.5 68.0 57.0 35.6 68.2 57.5 Adult male 15+ 14.0 6.0 8.7 10.7 3.9 6.2 Female child under age 15 11.9 14.7 13.7 14.2 16.0 15.4 Male child under age 15 6.2 6.0 6.0 6.6 6.2 6.3 Other 1.5 0.8 1.0 1.4 0.6 0.8 Water on premises 30.3 4.0 13.0 30.7 4.5 13.1 Missing 0.7 0.6 0.6 0.7 0.6 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking2 Boiled 1.6 0.2 0.7 1.5 0.2 0.6 Bleach/chlorine 11.1 2.8 5.6 12.9 2.9 6.2 Strained through cloth 2.2 0.9 1.4 2.1 0.9 1.3 Ceramic, sand or other filter 0.7 0.2 0.4 1.1 0.3 0.6 Solar disinfection 0.0 0.1 0.0 0.0 0.0 0.0 Other 1.3 1.2 1.2 1.2 1.1 1.1 No treatment 83.3 92.9 89.7 81.5 92.7 89.0 Percentage using an appropriate treatment method3 14.4 4.2 7.6 16.1 4.2 8.2 Number 2,469 4,815 7,284 14,104 28,701 42,805 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or non-improved source according to their water source for cooking and washing. 2 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. 2.8 SANITATION FACILITIES Poor sanitation coupled with unsafe water sources increases the risk of water-borne diseases and illnesses due to poor hygiene. Studies have shown that the absence of proper toilet facilities and improper disposal of faecal material increases exposure to the risk of diseases like dysentery, diarrhoea, and typhoid fever. Members of households with improved sanitation facilities are less likely to contract these communicable diseases. Table 2.9 shows that overall, 11 percent of households have improved, not shared toilet facility. Urban households are much more likely than rural households to have this type of facility (21 26 | Household Population and Housing Characteristics and 6 percent, respectively). The most common toilet facility is the open pit (29 percent), which is much more likely to be used in rural areas (35 percent) than in urban areas (15 percent). Overall, one in four households have no toilet facilities, 33 percent in rural areas and 5 percent in urban areas. Table 2.9 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Sierra Leone 2008 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 21.4 5.8 11.1 26.1 6.5 13.0 Flush/pour flush to piped sewer system 0.1 0.0 0.0 0.3 0.0 0.1 Flush/pour flush to septic tank 7.6 0.1 2.6 8.0 0.1 2.7 Flush/pour flush to pit latrine 1.3 0.0 0.5 1.3 0.0 0.5 Ventilated improved pit (VIP) latrine 5.1 2.2 3.2 6.5 2.3 3.7 Pit latrine with slab 7.3 3.5 4.8 10.0 4.1 6.0 Non-improved facility 78.6 94.2 88.9 73.9 93.5 87.0 Any facility shared with other households 52.5 21.8 32.2 47.9 21.8 30.4 Flush/pour flush not to sewer/septic tank/ pit latrine 0.8 0.0 0.3 0.6 0.0 0.2 Pit latrine without slab/open pit 15.3 35.2 28.5 16.1 37.5 30.5 Bucket 0.4 0.1 0.2 0.4 0.1 0.2 Hanging toilet/hanging latrine 2.8 3.0 2.9 2.7 3.0 2.9 No facility/bush/field/stream/river 4.9 33.2 23.6 4.6 30.1 21.7 Other 0.6 0.3 0.4 0.5 0.3 0.4 Missing 1.3 0.6 0.9 1.2 0.7 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,469 4,815 7,284 14,104 28,701 42,805 2.9 OTHER HOUSEHOLD CHARACTERISTICS Table 2.10 provides information on other characteristics of household dwellings, such as access to electricity, construction materials used for the floor, number of rooms used for sleeping, and cooking practices. Only 12 percent of households in Sierra Leone have access to electricity for lighting, with a very large disparity between urban and rural households (33 and 1 percent, respectively) (Table 2.10). The type of flooring material in the dwelling can be viewed as an indicator of the quality of housing, a dimension of wealth, as well as an indicator of health risk. Floor materials like earth, sand, and animal dung pose a health problem because they can act as breeding grounds for pests and may be a source of dust. They are also more difficult to keep clean. Table 2.10 shows that over 61 percent of households have floors made of earth, sand, or animal dung. In general, rural households have poorer quality floors than urban households; 81percent of rural households have earth, sand or dung floors, compared with only 22 percent of the urban households. On the other hand, urban households are more likely to have cement, tile, carpet, or wooden floors (75 percent), compared with rural households (17 percent). The number of rooms used for sleeping gives an indication of the extent of crowding in households. Overcrowding increases the risks of contracting infectious diseases like acute respiratory infections and skin diseases, especially among children. In the survey, a room in which three or more persons sleep is considered to be over crowded. Overall, more than half (52 percent) of the households have three or more rooms for sleeping. Households in rural areas are more likely than urban households to have three or more rooms for sleeping (58 and 39 percent, respectively). Cooking is commonly done outdoors (58 percent) or in a separate building (35 percent). This is observed in both urban and rural areas. Eight in ten households use wood for cooking. While almost all households (97 percent) in rural areas use wood for cooking, 56 percent of urban households use wood and 39 percent use charcoal. Use of solid fuels for cooking is almost universal in Sierra Leone (99 percent). Household Population and Housing Characteristics | 27 The 2008 SLDHS shows that 91 percent of the households that use solid fuel cook without a chimney or hood; 86 percent in urban areas and 94 percent in rural areas. An open fire or stove with hood is used in 6 percent of households. Urban households are more likely than rural households to use an open fire or stove with hood (11 and 3 percent, respectively). Table 2.10 Household characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking; and among those using solid fuels, percent distribution by type of fire/stove, according to residence, Sierra Leone 2008 Housing characteristic Households Population Urban Rural Total Urban Rural Total Electricity Yes 33.1 1.4 12.1 31.0 1.3 11.1 No 66.8 98.5 87.8 68.9 98.6 88.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 19.8 74.7 56.1 20.1 74.2 56.3 Dung 2.1 6.0 4.7 2.0 6.0 4.7 Stone 2.1 2.6 2.4 1.9 2.3 2.2 Wood/planks/palm/bamboo/ parquet or polished wood 0.7 0.2 0.3 0.7 0.2 0.3 Ceramic tiles 7.8 0.3 2.9 9.0 0.3 3.2 Cement 65.4 16.2 32.9 64.7 17.0 32.7 Carpet 1.5 0.0 0.5 1.2 0.0 0.4 Other 0.4 0.0 0.1 0.2 0.0 0.1 Missing 0.2 0.1 0.1 0.2 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 31.3 14.7 20.3 19.9 9.0 12.6 Two 28.4 26.3 27.0 26.9 22.4 23.9 Three or more 39.0 58.0 51.6 51.8 67.4 62.3 Missing 1.3 1.0 1.1 1.4 1.2 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 6.4 4.5 5.2 5.9 4.1 4.7 In a separate building 35.2 35.5 35.4 40.1 36.5 37.7 Outdoors 54.8 58.9 57.5 52.6 58.7 56.7 Other 0.2 0.2 0.2 0.1 0.1 0.1 Missing 3.5 0.9 1.8 1.3 0.6 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 0.1 0.0 0.0 0.0 0.0 0.0 Kerosene 0.4 0.1 0.2 0.2 0.1 0.1 Coal/lignite 1.5 0.0 0.5 1.3 0.0 0.4 Charcoal 38.9 1.2 14.0 35.2 1.2 12.4 Wood 56.0 97.2 83.2 62.4 97.6 86.0 Straw/shrubs/grass 0.1 0.9 0.6 0.1 0.8 0.6 Other fuel 0.1 0.0 0.1 0.0 0.0 0.0 No food cooked in household 2.6 0.3 1.1 0.7 0.1 0.3 Missing 0.2 0.2 0.2 0.2 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 96.5 99.4 98.4 98.9 99.7 99.4 Number of households 2,469 4,815 7,284 14,104 28,701 42,805 Type of fire/stove among households using solid fuel1 Closed stove with chimney 0.7 0.1 0.3 0.6 0.2 0.3 Open fire/stove with chimney 0.8 0.7 0.8 1.0 0.8 0.9 Open fire/stove with hood 11.1 3.0 5.7 9.7 3.1 5.3 Open fire/stove without chimney or hood 86.1 93.8 91.3 87.4 93.7 91.6 Other 0.2 0.9 0.7 0.1 0.9 0.6 Missing 1.2 1.4 1.3 1.1 1.4 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/ population using solid fuel 2,383 4,787 7,171 13,945 28,618 42,563 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung 28 | Household Population and Housing Characteristics 2.10 HOUSEHOLD DURABLE GOODS Information was collected in the 2008 SLDHS on the availability of household durable goods such as household effects, means of transportation, and ownership of agricultural land and farm animals. Table 2.11 shows that 55 percent of households own a radio, 28 percent own a mobile telephone, 10 percent own a television set, and 6 percent own a refrigerator. Urban households are much more likely than rural households to own these goods. For instance, 78 percent of urban households own a radio, compared with 43 percent of rural households. Mobile telephones are available in 64 percent of households in urban areas and 10 percent of rural households. While 28 percent of urban households have a television set, this item is almost non-existent in rural areas (less than 1 percent). Eleven percent of households own a bicycle. Bicycles are the most common means of transportation and are owned almost equally by rural and urban households (11 and 10 percent, respectively). Urban households are three times more likely than rural households to own a motorcycle/scooter (6 and 2 percent, respectively). Sixty percent of households own agricultural land and 50 percent have farm animals. Table 2.11 shows that rural households are almost four times as likely to own agricultural land as urban households (80 and 22 percent, respectively). Similarly, 59 percent of rural households own farm animals, compared with 33 percent of urban households. Table 2.11 Household durable goods Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land and livestock/farm animals by residence, Sierra Leone 2008 Possession Households Population Urban Rural Total Urban Rural Total Household effects Radio 78.2 43.2 55.1 79.6 45.6 56.8 Television 27.9 0.9 10.1 27.5 1.1 9.8 Mobile telephone 63.5 9.9 28.1 67.3 11.1 29.6 Non-mobile telephone 2.3 0.1 0.8 2.2 0.1 0.8 Refrigerator 16.8 0.3 5.9 17.1 0.3 5.8 Means of transport Bicycle 10.1 10.7 10.5 12.4 12.6 12.5 Animal drawn cart 0.4 0.1 0.2 0.3 0.1 0.2 Motorcycle/scooter 6.4 1.6 3.3 7.8 2.1 4.0 Car/truck 4.6 0.4 1.8 5.0 0.5 2.0 Boat with a motor 0.6 1.0 0.9 0.6 1.0 0.9 Ownership of agricultural land 22.2 79.5 60.1 27.0 81.6 63.6 Ownership of farm animals1 32.5 58.6 49.8 39.4 61.8 54.4 Number 2,469 4,815 7,284 14,104 28,701 42,805 1 Cattle, cows, bulls, horses, donkeys, mules, pigs, goats, sheep, rabbits, fowl, rodents for breed or birds for sale 2.11 WEALTH QUINTILES The 2008 SLDHS provided an opportunity to obtain information about the distribution of Sierra Leone’s population by wealth quintiles. Table 2.12 shows the percent distribution of the jure population by wealth quintiles, according to residence and region. It is not surprising that more than half of urban residents (56 percent) live in households that are in the highest wealth quintile, compared with only 2 percent of the rural population; 56 percent of residents in rural households are in the two lowest quintiles. Table 2.12 also shows that three in four residents of the Western Region (which includes Freetown, the capital) are in the highest quintile, while three in four residents of the other regions are in the three lowest quintiles. Household Population and Housing Characteristics | 29 Table 2.12 Wealth quintiles Percent distribution of the jure population by wealth quintiles, according to residence and region, Sierra Leone 2008 Residence/region Wealth quintile Total Number of population Lowest Second Middle Fourth Highest Residence Urban 2.0 4.4 9.2 28.4 56.0 100.0 14,104 Rural 28.8 27.6 25.3 15.9 2.3 100.0 28,701 Region Eastern 24.1 21.9 23.8 20.0 10.2 100.0 7,878 Northern 19.4 25.2 26.3 21.9 7.2 100.0 18,730 Southern 34.9 24.0 17.1 16.3 7.7 100.0 8,531 Western 0.7 0.9 3.9 19.5 75.0 100.0 7,667 Total 20.0 20.0 20.0 20.0 20.0 100.0 42,805 2.12 BIRTH REGISTRATION According to the 2007 Child Rights Act of Sierra Leone, parents are required to give their children a name and to register the child because the child has a right to know who his or her parents are and to have a nationality through registration (SLG, 2007). The birth registration policy in Sierra Leone is being reviewed to ensure that parents and caretakers of children take responsibility for ensuring this child right. Table 2.13 shows the percentage of children under five years of age by registration status. Just over half (51 percent) of children were reported to have been registered; 31 percent have a birth certificate and 20 percent did not. Coverage of birth registration varies little by the child’s age and sex, but varies widely across regions, with the Western Re- gion reporting the highest coverage (61 per- cent) and the Northern Region reporting the lowest coverage (42 percent). In the Eastern and Southern regions, the proportions are 56 and 59 percent, respectively. Births in urban areas are more likely than those in rural areas to be registered (59 and 48 percent, respectively). There is a positive relationship between wealth status and birth registration, with birth registration increasing with wealth quintile. Forty-three percent of births in the lowest wealth quintile are registered, compared with 62 percent of births in the highest quintile. 2.13 CHILD LABOUR Sierra Leone is a signatory to the Convention on the Rights of the Child (SLG, 2007). The SLDHS Household Questionnaire asked a number of questions to obtain information about the prevalence of child labour in Sierra Leone. Child labour is defined as the involvement of children age 5-14 in labour activities. A child is considered to be involved in child labour activities if he or she meets the following criteria: Table 2.13 Birth registration of children under age five Percentage of de jure children under five years of age whose births are registered with the civil authorities, by background characteristics, Sierra Leone 2008 Background characteristic Percentage of children whose births are registered Number of children Had a birth certificate Did not have a birth certificate Total registered Age <2 31.2 21.8 52.9 2,691 2-4 30.0 19.4 49.4 4,017 Sex Male 30.9 21.1 52.0 3,334 Female 30.1 19.6 49.7 3,374 Residence Urban 40.4 18.8 59.1 1,803 Rural 26.9 20.9 47.8 4,906 Region Eastern 34.0 21.7 55.8 1,372 Northern 18.2 23.3 41.6 2,994 Southern 40.8 18.6 59.4 1,343 Western 48.6 11.9 60.5 1,000 Wealth quintile Lowest 25.5 17.5 43.0 1,526 Second 24.8 22.0 46.8 1,410 Middle 26.6 24.1 50.6 1,463 Fourth 34.4 22.0 56.4 1,285 Highest 46.5 15.0 61.5 1,025 Total 30.5 20.4 50.9 6,709 30 | Household Population and Housing Characteristics • Children age 5-11: at least one hour of economic work or 28 hours of domestic work during the week preceding the survey. • Children age 12-14: at least 14 hours of economic work or 28 hours of domestic work during the week preceding the survey. These definitions make it possible to differentiate child labour from child work, which in turn allows organizations working in child protection to identify and advocate the types of work that should be eliminated if the rights of the children are to be preserved. The discussion below provides a minimum estimate of the prevalence of child labour in Sierra Leone because some children may be involved in other labour activities (and thus be performing child labour) for a smaller number of hours than the criteria specified above. Table 2.14 shows that 31 percent of children are involved in child labour. Of these children, less than 1 percent receive payment for their work, 11 percent work without pay, and 26 percent work for a family business. Surprisingly, children age 5-11 are much more likely than children age 12-14 to be involved in child labour (43 and 6 percent, respectively). Small variations in child labour activities Table 2.14 Child labour Percentage of children age 5-14 years who were involved in child labour activities in the past week, by type of work, Sierra Leone 2008 Background characteristic Worked outside household in the past week1 Household chores for 28+ hours/ week Worked for family business in past week1 Total child labour2 Number of children age 5-14 Paid work Unpaid work Age 5-11 years 1.0 15.1 0.4 37.2 42.9 9,617 12-14 years 0.2 0.4 1.0 2.9 6.2 4,447 Sex Male 1.0 10.8 0.4 27.9 32.8 7,149 Female 0.4 10.1 0.8 24.8 29.8 6,914 Residence Urban 0.3 9.0 0.7 15.4 20.7 4,562 Rural 0.9 11.2 0.6 31.7 36.5 9,501 Region Eastern 0.6 12.6 1.8 26.1 34.2 2,353 Northern 0.9 7.8 0.3 28.7 31.1 6,829 Southern 0.9 17.2 0.6 38.3 45.6 2,586 Western 0.4 8.6 0.2 6.2 13.0 2,296 Orphan (mother and/or father deceased) Yes 0.7 8.4 0.6 22.7 26.6 1,833 No 0.7 10.8 0.6 26.9 32.0 12,230 School participation Yes 0.6 10.6 0.6 25.1 30.5 8,853 No 1.0 10.2 0.5 28.5 32.8 5,210 Wealth quintile Lowest 0.7 14.7 0.6 37.2 42.5 2,605 Second 1.3 10.9 0.3 33.0 37.1 2,970 Middle 0.4 10.0 0.8 28.5 33.2 2,945 Fourth 1.0 8.8 0.7 21.9 27.2 2,924 Highest 0.2 8.1 0.6 10.8 16.2 2,619 Total 0.7 10.5 0.6 26.4 31.3 14,063 Note: Equivalent to UNICEF MICS Indicator 71. 1 Defined as any such work for children age 5-11 and 14 hours or more of such work for those age 12-14 2 The numerator for the child labour estimate includes: (a) children age 5-11 who during the past week did at least one hour of economic activity or at least 28 hours of domestic chores and (b) children age 12-14 who during the past week did at least 14 hours of economic activity or at least 28 hours of domestic chores. Household Population and Housing Characteristics | 31 are observed by sex, urban-rural residence, orphanhood status, and whether the child is attending school. However, there are large variations between regions. Whereas only 13 percent of children in the Western Region are involved in child labour, the corresponding proportion in the Southern Region is 46 percent. The level of child labour reported in the 2008 SLDHS (31 percent) is much lower than that reported in the 2005 Multiple Indicator Cluster Survey (MICS) (48 percent) (SSL and UNICEF/Sierra Leone, 2007). Characteristics of Respondents | 33 CHARACTERISTICS OF RESPONDENTS 3 This chapter provides a profile of the respondents interviewed in the 2008 SLDHS: women age 15-49 and men age 15-59. Information is presented on a number of basic characteristics such as age, marital status, place of residence, ethnicity, religion, literacy, and access to mass media. The chapter also explores adults’ employment status, occupation, and earnings. An analysis of these variables provides the socio-economic context within which demographic and reproductive health issues are examined in subsequent chapters. 3.1 BACKGROUND CHARACTERISTICS OF SURVEY RESPONDENTS Information on the basic characteristics of women and men interviewed in the survey is essential for the interpretation of findings presented later in the report. Background characteristics of the 7,374 women and 3,280 men interviewed in the 2008 SLDHS are presented in Table 3.1. Weighted and unweighted numbers are shown. Unweighted numbers indicate the actual number of women and men interviewed, while weighted figures show the parameters of the population. The distribution of respondents according to age shows that 32 percent of women and men are age 15-24. In the 25-29 age group, the proportion of women is notably larger than the proportion of men (22 and 15 percent, respectively). The proportion of women and men age 30-34 is 14 and 13 percent, respectively. In successive age groups thereafter, the proportion of men is larger than the proportion of women. Nearly eight in ten respondents are Muslim. The respondents are almost equally divided among three ethnic groups, Temne, Mende, and other groups. Less than one-fifth (19 percent) of women have never married compared with 37 percent of men. Seventy-five percent of women are currently married or living in an informal marital union, compared with 60 percent of men. This is possibly because men marry later in life than women. While women are as likely as men to be divorced or separated, women are much more likely than men to be widowed (3 percent and less than 1 percent, respectively). Almost two-thirds of respondents (64 percent of women and 62 percent of men) live in rural areas. The distribution of respondents by region shows that four in ten live in the Northern Region (41 percent of women and 38 percent of men), while the Eastern Region has the lowest proportion (18 percent of women and 19 percent of men). Two in three (66 percent) of women have never been to school, compared with 48 percent of men. Men are much more likely than women to complete secondary education (32 percent compared with 19 percent). Similarly, the proportion who go beyond secondary education is higher among men than women (5 and 3 percent, respectively). 34 | Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Sierra Leone 2008 Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 16.2 1,198 1,263 17.9 526 549 20-24 16.1 1,186 1,195 13.7 403 414 25-29 22.3 1,643 1,578 15.2 446 440 30-34 14.1 1,043 1,066 12.7 373 380 35-39 15.3 1,131 1,094 17.8 525 512 40-44 8.8 652 658 11.4 336 337 45-49 7.0 520 520 11.4 335 329 Marital status Never married 19.0 1,399 1,531 36.8 1,085 1,122 Married 65.0 4,794 4,677 54.6 1,607 1,568 Living together 9.9 732 696 5.4 160 171 Divorced/separated 3.5 256 269 2.7 81 87 Widowed 2.6 194 201 0.4 11 13 Residence Urban 36.0 2,655 3,160 38.1 1,123 1,295 Rural 64.0 4,719 4,214 61.9 1,822 1,666 Region Eastern 18.0 1,325 1,759 18.9 557 740 Northern 40.7 3,001 2,165 38.4 1,131 819 Southern 20.9 1,542 1,835 21.0 617 746 Western 20.4 1,506 1,615 21.7 639 656 Education No education 65.9 4,860 4,609 48.4 1,426 1,332 Primary 13.0 960 1,004 14.1 414 442 Secondary 18.6 1,372 1,558 32.4 953 1,017 More than secondary 2.5 182 203 5.1 151 170 Ethnicity Temne 34.8 2,564 2,096 36.0 1,060 868 Mende 31.6 2,331 2,721 30.6 901 1,070 Other 33.6 2,479 2,557 33.4 984 1,023 Religion Christian 22.0 1,625 1,933 21.8 642 739 Muslim 76.8 5,665 5,370 77.7 2,289 2,204 Other 1.1 84 71 0.5 14 18 Wealth quintile Lowest 18.7 1,382 1,323 18.9 558 543 Second 18.6 1,368 1,228 17.7 520 463 Middle 19.4 1,428 1,309 18.0 530 497 Fourth 20.0 1,472 1,560 20.3 597 636 Highest 23.4 1,723 1,954 25.1 739 822 Total 15-49 100.0 7,374 7,374 100.0 2,944 2,961 50-59 na na 0 na 336 319 Total 15-59 na na 0 na 3,280 3,280 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable 3.2 EDUCATIONAL ATTAINMENT Tables 3.2.1 and 3.2.2 present the distribution of female and male respondents by the highest level of education attended according to background characteristics. The results show that the proportion of respondents who have never been to school is higher for women than for men (66 and 48 percent, respectively). For both women and men, younger respondents are more likely than older respondents to have received education. For instance, 5 percent of women age 15-24 have completed primary school, compared with 3 percent women age 45-49. Men show similar proportions. The Characteristics of Respondents | 35 median years of schooling completed by women age 15-19 is five, whereas for older women (age 20-49) it is zero years. The median years completed for men age 15-19 is six, and for older men (age 25-49) it is zero years. Level of education varies by residence. Women and men in rural areas are less likely to be educated than their urban counterparts. For women, 38 percent of those in urban areas have never been to school, compared with 81 percent in rural areas. The gap in educational attainment between urban and rural residents widens with higher education levels. Whereas 6 percent of women in urban areas completed secondary school, the corresponding proportion in rural areas is less than 1 percent. There is wide variation in education across regions: 77 percent of women in the Northern Region have not attended school, compared with 32 percent of women in the Western Region. In the Southern and Eastern regions, the proportions who have no education are 73 and 71 percent, respectively. Further, the Western Region has the highest proportion of women who go beyond secondary school, 9 percent, compared with about 1 percent in other regions. As expected, the level of education increases with household wealth (wealth index). For example, 4 percent of women in the lowest quintile have attained some secondary education, compared with 40 percent of women in the highest quintile. Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Sierra Leone 2008 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 46.1 15.6 4.5 29.0 3.0 1.8 100.0 2.6 2,384 15-19 34.1 20.0 6.3 37.6 1.7 0.2 100.0 4.6 1,198 20-24 58.2 11.1 2.7 20.4 4.2 3.4 100.0 0.0 1,186 25-29 75.3 8.4 1.9 9.5 1.9 3.1 100.0 0.0 1,643 30-34 70.5 7.4 3.9 11.8 2.7 3.7 100.0 0.0 1,043 35-39 76.6 6.1 3.3 10.3 1.8 1.8 100.0 0.0 1,131 40-44 76.3 4.5 2.7 10.9 2.2 3.4 100.0 0.0 652 45-49 81.4 5.0 3.1 7.9 1.2 1.5 100.0 0.0 520 Residence Urban 38.3 10.8 4.8 33.7 6.0 6.3 100.0 5.1 2,655 Rural 81.4 9.0 2.6 6.4 0.3 0.3 100.0 0.0 4,719 Region Eastern 70.8 11.8 3.8 12.2 0.5 0.9 100.0 0.0 1,325 Northern 77.1 8.5 2.2 10.6 0.9 0.6 100.0 0.0 3,001 Southern 72.6 9.6 4.2 11.4 0.9 1.3 100.0 0.0 1,542 Western 32.4 10.0 4.5 36.1 8.2 8.8 100.0 6.3 1,506 Wealth quintile Lowest 87.6 6.9 1.8 3.7 0.0 0.0 100.0 0.0 1,382 Second 82.3 9.6 2.7 5.1 0.1 0.1 100.0 0.0 1,368 Middle 79.1 10.4 2.4 7.7 0.2 0.2 100.0 0.0 1,428 Fourth 61.1 11.5 5.4 19.1 1.5 1.3 100.0 0.0 1,472 Highest 28.7 9.6 4.3 39.9 8.4 9.2 100.0 6.7 1,723 Total 65.9 9.6 3.4 16.3 2.3 2.5 100.0 0.0 7,374 1 Completed 6 grades at the primary level 2 Completed 3 grades at the senior secondary school level Table 3.2.2 shows that the differentials in education for men are similar to those for women. Younger men, men in urban areas, those who live in the Western Region, and men in the highest wealth quintile are more likely than other men to have education. 36 | Characteristics of Respondents Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Sierra Leone 2008 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 25.0 14.5 5.1 44.9 8.6 1.9 100.0 6.2 929 15-19 20.8 18.7 7.8 47.8 4.8 0.0 100.0 5.9 526 20-24 30.4 8.9 1.6 41.3 13.5 4.4 100.0 7.1 403 25-29 56.5 10.4 3.2 14.0 8.6 7.3 100.0 0.0 446 30-34 61.1 8.7 3.5 14.5 3.9 8.3 100.0 0.0 373 35-39 60.6 7.7 4.8 19.6 3.3 4.0 100.0 0.0 525 40-44 51.4 5.7 1.9 17.4 12.2 11.4 100.0 0.0 336 45-49 66.4 7.7 2.5 15.5 4.6 3.3 100.0 0.0 335 Residence Urban 21.3 6.8 4.5 41.6 14.9 11.0 100.0 7.9 1,123 Rural 65.2 12.2 3.5 15.4 2.1 1.5 100.0 0.0 1,822 Region Eastern 57.1 14.7 5.2 18.2 2.5 2.3 100.0 0.0 557 Northern 58.2 10.3 2.9 24.1 2.4 2.1 100.0 0.0 1,131 Southern 55.3 10.6 4.3 22.7 3.9 3.3 100.0 0.0 617 Western 17.0 5.4 4.2 36.4 22.2 14.7 100.0 9.1 639 Wealth quintile Lowest 76.1 12.8 2.8 7.8 0.5 0.0 100.0 0.0 558 Second 68.9 11.6 4.4 13.5 1.4 0.4 100.0 0.0 520 Middle 57.1 15.0 3.0 20.3 3.2 1.4 100.0 0.0 530 Fourth 42.0 7.2 6.3 31.8 6.9 5.8 100.0 5.0 597 Highest 12.2 6.0 3.1 45.4 18.7 14.5 100.0 9.1 739 Total 15-49 48.4 10.2 3.9 25.4 7.0 5.1 100.0 1.2 2,944 50-59 64.8 8.0 3.2 14.6 5.1 4.4 100.0 0.0 336 Total 15-59 50.1 9.9 3.8 24.3 6.8 5.1 100.0 0.0 3,280 1 Completed 6 grades at the primary level 2 Completed 3 grades at the senior secondary school level 3.3 LITERACY The 2008 SLDHS assessed the ability to read and write among women and men who had never been to school or who had attended only the primary level. This was done by asking respondents to read all or part of a short, simple sentence to establish literacy. The sample sentences were written in simple English1. Tables 3.3.1 and 3.3.2 show the percent distribution of women and men, respectively, by level of schooling, level of literacy, and percentage literate, according to background characteristics. The data show that 74 percent of women and 55 percent of men are illiterate. The gender gap in literacy varies by age, ranging from 10 percentage points in age 30-34 to 33 percentage points in age 20-24. The urban-rural differential follows the expected pattern; rural respondents are more likely to be illiterate than their urban counterparts. The proportion of illiterate rural men is almost three times that of urban men (73 and 26 percent, respectively). For women, the proportion is 89 and 47 percent, respectively. The Eastern Region has the highest illiteracy rate among men (68 percent), while the Northern Region has the highest rate among women (84 percent). As expected, illiteracy decreases as wealth increases. For women, the poorest have the highest rate of illiteracy (94 percent), while the richest are the least likely to be illiterate (37 percent). Men show a similar pattern. 1 These sentences include the following: 1) Parents love their children; 2) Farming is hard work; 3) The child is reading a book; 4) Children work hard at school; 5) The rains came late this year. Characteristics of Respondents | 37 Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Sierra Leone 2008 Background characteristic Secondary school or higher No schooling, or primary school only Missing Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Age 15-19 39.6 3.7 11.4 43.9 0.1 0.1 1.2 100.0 54.7 1,198 20-24 28.0 0.1 4.0 67.2 0.2 0.1 0.3 100.0 32.2 1,186 25-29 14.5 0.0 2.5 82.6 0.2 0.0 0.2 100.0 17.0 1,643 30-34 18.2 0.2 3.1 78.3 0.0 0.1 0.2 100.0 21.5 1,043 35-39 14.0 0.2 2.7 82.2 0.5 0.0 0.3 100.0 16.9 1,131 40-44 16.4 0.1 2.0 80.8 0.3 0.0 0.3 100.0 18.6 652 45-49 10.5 0.6 3.6 84.1 0.7 0.0 0.5 100.0 14.7 520 Residence Urban 46.1 1.1 5.6 46.3 0.2 0.1 0.6 100.0 52.8 2,655 Rural 7.0 0.5 3.6 88.2 0.3 0.0 0.3 100.0 11.2 4,719 Region Eastern 13.6 0.9 3.6 81.3 0.0 0.1 0.5 100.0 18.1 1,325 Northern 12.1 0.4 3.9 82.4 0.6 0.0 0.5 100.0 16.5 3,001 Southern 13.6 1.1 5.6 79.4 0.0 0.1 0.2 100.0 20.3 1,542 Western 53.1 0.9 4.5 40.9 0.0 0.1 0.4 100.0 58.6 1,506 Wealth quintile Lowest 3.7 0.2 2.6 92.7 0.3 0.0 0.5 100.0 6.5 1,382 Second 5.4 0.8 4.3 88.8 0.6 0.0 0.2 100.0 10.4 1,368 Middle 8.1 0.5 4.6 86.2 0.3 0.1 0.2 100.0 13.2 1,428 Fourth 22.0 1.3 5.1 71.0 0.1 0.0 0.4 100.0 28.4 1,472 Highest 57.5 0.9 4.8 35.9 0.1 0.1 0.7 100.0 63.2 1,723 Total 21.1 0.8 4.3 73.1 0.2 0.0 0.4 100.0 26.2 7,374 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Sierra Leone 2008 Background characteristic Secondary school or higher No schooling, or primary school only Missing Total Percentage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Age 15-19 52.6 7.7 12.9 25.2 0.8 0.1 0.8 100.0 73.3 526 20-24 59.1 1.4 4.3 34.3 0.1 0.2 0.6 100.0 64.8 403 25-29 29.8 0.9 4.7 62.5 0.4 0.2 1.4 100.0 35.4 446 30-34 26.7 1.1 3.8 67.4 0.5 0.0 0.5 100.0 31.6 373 35-39 26.9 1.4 3.8 67.0 0.4 0.0 0.6 100.0 32.0 525 40-44 41.0 0.6 2.3 55.8 0.2 0.0 0.1 100.0 43.9 336 45-49 23.4 0.2 2.3 73.5 0.0 0.0 0.5 100.0 26.0 335 Residence Urban 67.5 2.0 4.3 25.1 0.1 0.1 0.9 100.0 73.7 1,123 Rural 19.0 2.4 5.9 71.6 0.5 0.1 0.5 100.0 27.3 1,822 Region Eastern 23.0 2.3 6.3 67.6 0.0 0.1 0.7 100.0 31.6 557 Northern 28.6 2.2 6.2 62.4 0.5 0.0 0.1 100.0 37.0 1,131 Southern 29.9 2.9 5.4 59.1 0.9 0.2 1.6 100.0 38.2 617 Western 73.3 1.4 2.7 21.9 0.0 0.0 0.7 100.0 77.5 639 Wealth quintile Lowest 8.3 2.1 5.8 82.7 0.4 0.2 0.5 100.0 16.2 558 Second 15.2 2.1 6.8 75.0 0.3 0.0 0.6 100.0 24.1 520 Middle 24.9 3.2 5.4 65.4 0.6 0.2 0.4 100.0 33.4 530 Fourth 44.5 2.0 5.8 46.4 0.6 0.0 0.6 100.0 52.4 597 Highest 78.6 1.8 3.3 15.0 0.2 0.0 1.0 100.0 83.7 739 Total 15-49 37.5 2.2 5.3 53.9 0.4 0.1 0.7 100.0 45.0 2,944 50-59 24.0 1.9 4.1 68.1 1.0 0.0 0.9 100.0 30.0 336 Total men 15-59 36.1 2.2 5.2 55.3 0.4 0.1 0.7 100.0 43.5 3,280 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 38 | Characteristics of Respondents 3.4 ACCESS TO MASS MEDIA The 2008 SLDHS collected information on the exposure of respondents to common print and electronic media. Respondents were asked how often they read a newspaper, listen to the radio, and watch television. These data are important because they provide an indication of the extent to which Sierra Leoneans are regularly exposed to mass media, which are often used to disseminate messages on family planning and other health issues. Tables 3.4.1 and 3.4.2 show that the most popular media is radio; 46 percent of women and 63 percent of men age 15-49 listen to the radio at least once a week. Eleven percent of women and 17 percent of men age 15-49 watch television weekly. Because of the low literacy rate, readership of newspapers among women is low (7 percent), while 18 percent of men read a newspaper at least once a week. Urban residents are more likely to have access to mass media than rural residents: 8 percent of urban women are exposed to all three media at least once a week, compared with less than 1 percent of rural women; the difference for men is more pronounced, 22 percent of urban men, compared with 1 percent of rural men are exposed to all three media at least once a week. Similarly, the Western Region has the highest proportion of women and men who have access to all three media. There is a positive relationship between level of education and wealth status and exposure to mass media. For instance, 77 percent of women in the lowest wealth quintile have no weekly exposure to any mass media source, compared with 22 percent of women in the highest wealth quintile. The corresponding figures for men are 64 and 9 percent, respectively. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Sierra Leone 2008 Background characteristic At least once a week: Not exposed to any media Number of women Reads the newspaper Watches television Listens to the radio Exposed to all three media Age 15-19 12.3 15.1 48.0 5.1 48.7 1,198 20-24 7.7 14.8 47.5 4.4 48.9 1,186 25-29 3.7 8.1 45.5 1.6 53.1 1,643 30-34 6.8 11.3 46.8 3.7 51.3 1,043 35-39 4.4 7.5 43.7 1.7 55.1 1,131 40-44 7.4 8.0 44.0 2.8 54.2 652 45-49 3.5 6.8 39.6 1.8 58.6 520 Residence Urban 15.7 24.7 64.8 7.9 30.7 2,655 Rural 1.5 2.6 34.8 0.3 64.4 4,719 Region Eastern 2.4 6.0 40.0 1.0 58.4 1,325 Northern 4.2 5.9 42.2 1.9 56.2 3,001 Southern 4.2 6.1 34.9 1.4 63.7 1,542 Western 17.6 28.5 68.3 9.1 27.3 1,506 Education No education 0.0 3.7 34.4 0.0 64.5 4,860 Primary 2.8 11.6 53.2 0.7 44.5 960 Secondary or higher 29.5 31.3 75.9 14.1 18.7 1,554 Wealth quintile Lowest 0.5 0.7 23.1 0.0 76.6 1,382 Second 1.0 2.0 32.5 0.3 67.2 1,368 Middle 2.0 3.1 39.6 0.1 59.0 1,428 Fourth 6.0 8.3 53.4 1.9 44.3 1,472 Highest 20.3 33.4 72.3 11.2 22.1 1,723 Total 6.6 10.6 45.6 3.1 52.3 7,374 Characteristics of Respondents | 39 Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Sierra Leone 2008 Background characteristic At least once a week: Not exposed to any media Number of men Reads the newspaper Watches television Listens to the radio Exposed to all three media Age 15-19 19.2 25.6 62.0 11.5 33.9 526 20-24 27.6 22.5 68.3 14.1 27.7 403 25-29 17.9 18.2 60.8 9.1 36.7 446 30-34 16.9 13.9 62.8 7.5 35.1 373 35-39 12.3 11.4 62.3 4.8 36.5 525 40-44 23.9 15.6 70.3 10.5 27.9 336 45-49 11.7 8.8 55.2 4.8 42.9 335 Residence Urban 37.5 38.5 80.8 21.6 14.9 1,123 Rural 6.5 3.7 52.0 1.0 46.5 1,822 Region Eastern 9.3 4.2 59.6 2.4 39.1 557 Northern 11.2 9.5 55.7 3.2 41.7 1,131 Southern 8.4 9.4 54.8 2.3 44.0 617 Western 48.2 48.7 86.8 31.0 8.2 639 Education No education 0.6 5.2 46.4 0.1 52.0 1,426 Primary 5.3 12.9 67.9 1.4 29.9 414 Secondary or higher 46.0 33.7 82.6 23.0 13.4 1,104 Wealth quintile Lowest 1.6 2.0 35.3 0.5 64.1 558 Second 4.8 3.6 48.2 0.5 51.0 520 Middle 9.0 6.0 59.9 0.8 37.1 530 Fourth 18.3 15.1 74.5 7.0 21.4 597 Highest 47.0 47.1 87.2 28.5 9.0 739 Total 15-49 18.3 17.0 63.0 8.9 34.4 2,944 50-59 12.6 7.8 61.2 2.8 37.7 336 Total 15-59 17.7 16.0 62.8 8.3 34.8 3,280 3.5 EMPLOYMENT Like education, employment can also be a source of empowerment for women, especially if it puts them in control of income. It is difficult however to measure women’s employment because most of the work that women do, especially on family farms, at home, in family businesses, or in the informal sector, is often not perceived by women themselves as employment. Cash payment is not attached to these types of work; therefore, they do not report it as such. To avoid underestimating women’s employment, the DHS questionnaire asked women several probing questions on their employment status to ensure complete coverage of employment in any sector, formal or informal. Women are defined as employed if they are currently working or worked at any time during the 12 months preceding the survey. Additional information was obtained on the type of work, such as whether they worked continuously throughout the year, who they worked for, and the form in which they received their earnings. Men were also asked questions on employment. 40 | Characteristics of Respondents Table 3.5.1 and Figure 3.1 show the percent distribution of women age 15-49 by employment status, according to background characteristics. Overall, 77 percent of women were employed in the 12 months preceding the survey; 72 percent were currently employed while 5 percent, although not currently employed, had worked in the 12 months preceding the survey. Twenty-three percent of women did not work at all in the 12 months before the survey. For men age 15-49, 86 percent were employed in the 12 months preceding the survey (84 percent currently employed and 2 percent not currently employed but worked in the 12 months preceding the survey) (Table 3.5.2 and Figure 3.2). Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Sierra Leone 2008 Background characteristic Employed in the past 12 months Not employed in the past 12 months Missing Total Number of women Currently employed1 Not currently employed Age 15-19 46.6 4.0 49.2 0.2 100.0 1,198 20-24 60.3 5.0 34.5 0.2 100.0 1,186 25-29 79.3 4.5 15.7 0.5 100.0 1,643 30-34 78.5 7.3 13.9 0.3 100.0 1,043 35-39 81.6 5.5 12.5 0.3 100.0 1,131 40-44 83.2 4.1 12.2 0.4 100.0 652 45-49 84.0 4.4 11.1 0.4 100.0 520 Marital status Never married 41.5 3.3 55.1 0.1 100.0 1,399 Married/ living together 78.9 5.6 15.1 0.4 100.0 5,525 Divorced/separated/widowed 79.7 3.5 16.9 0.0 100.0 450 Number of living children 0 49.2 3.9 46.7 0.2 100.0 1,592 1-2 73.6 5.1 20.9 0.4 100.0 2,639 3-4 80.3 5.6 13.9 0.2 100.0 1,954 5+ 84.5 5.4 9.7 0.4 100.0 1,189 Residence Urban 57.7 4.0 38.1 0.2 100.0 2,655 Rural 79.8 5.6 14.2 0.4 100.0 4,719 Region Eastern 66.4 9.0 24.4 0.3 100.0 1,325 Northern 78.8 4.6 16.2 0.5 100.0 3,001 Southern 75.6 3.9 20.3 0.3 100.0 1,542 Western 59.0 3.6 37.2 0.2 100.0 1,506 Education No education 79.6 5.5 14.5 0.3 100.0 4,860 Primary 68.3 5.0 26.2 0.5 100.0 960 Secondary or higher 49.8 3.5 46.5 0.2 100.0 1,554 Wealth quintile Lowest 80.3 6.7 12.4 0.7 100.0 1,382 Second 81.1 5.3 13.2 0.3 100.0 1,368 Middle 79.1 4.8 15.9 0.2 100.0 1,428 Fourth 69.2 5.2 25.3 0.3 100.0 1,472 Highest 54.0 3.4 42.3 0.2 100.0 1,723 Total 71.9 5.0 22.8 0.3 100.0 7,374 1 ‘Currently employed’ is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Characteristics of Respondents | 41 Figure 3.1 Women’s Employment Status in the Past 12 Months Sierra Leone, 2008 72% 5% 23% Currently employed Not employed in the past 12 months Not currently employed, but worked in the past 12 months Tables 3.5.1 and 3.5.2 show that for both women and men current employment increases with the respondent’s age. Almost all men age 30 or older (97 percent or higher) were employed in the past year. Women who are married or divorced, separated, or widowed are more likely to be currently employed than unmarried women (79-80 percent, compared with 42 percent). Men show a similar pattern; married men are the most likely to be currently employed (97 percent), while never-married men are the least likely to be currently employed (63 percent). The two tables also show that the proportion of women and men who are currently working increases with the number of living children they have. While less than half of women with no children are currently employed, at least 74 percent of women with children are employed. Similarly, at least 91 percent of men with one or more living children are currently employed, compared with 66 percent of men with no living children. The percentage of men and women who are currently employed is substantially higher in rural areas (80 percent for women and 94 percent for men) than in urban areas (58 percent for women and 67 percent for men). There is also a substantial difference in levels of employment by region; the Northern Region has the highest level of employment for men (90 percent) and women (79 percent), while the Western Region has the lowest level of employment for the two sexes (68 percent of men and 59 percent of women). Employment has a negative relationship with education level and wealth status. For example, 97 percent of men and 80 percent of women with no education are employed, compared with 67 percent of men and 50 percent of women with secondary or higher education. 42 | Characteristics of Respondents Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Sierra Leone 2008 Background characteristic Employed in the past 12 months Not employed in the past 12 months Missing Total Number of men Currently employed1 Not currently employed Age 15-19 51.8 3.4 44.8 0.0 100.0 526 20-24 70.6 3.0 26.4 0.0 100.0 403 25-29 90.6 1.3 8.0 0.1 100.0 446 30-34 96.3 1.3 1.9 0.5 100.0 373 35-39 95.3 2.2 2.5 0.0 100.0 525 40-44 95.4 1.9 2.4 0.3 100.0 336 45-49 97.0 0.4 2.6 0.0 100.0 335 Marital status Never married 62.8 3.3 33.9 0.0 100.0 1,085 Married/ living together 96.5 1.2 2.2 0.1 100.0 1,767 Divorced/separated/widowed 86.8 4.0 9.2 0.0 100.0 92 Number of living children 0 66.0 2.9 31.0 0.0 100.0 1,137 1-2 91.1 1.9 6.8 0.1 100.0 715 3-4 96.8 1.6 1.4 0.1 100.0 551 5+ 98.1 0.8 0.9 0.2 100.0 541 Residence Urban 66.9 3.9 28.9 0.2 100.0 1,123 Rural 94.2 0.9 4.9 0.0 100.0 1,822 Region Eastern 89.5 1.5 9.0 0.0 100.0 557 Northern 90.0 1.3 8.6 0.1 100.0 1,131 Southern 83.9 1.3 14.8 0.0 100.0 617 Western 67.6 4.6 27.5 0.4 100.0 639 Education No education 97.2 0.5 2.2 0.1 100.0 1,426 Primary 83.4 2.1 14.4 0.0 100.0 414 Secondary or higher 66.6 4.0 29.3 0.2 100.0 1,104 Wealth quintile Lowest 94.5 0.6 4.7 0.1 100.0 558 Second 95.5 0.0 4.5 0.0 100.0 520 Middle 94.6 1.5 3.9 0.0 100.0 530 Fourth 83.7 3.0 13.0 0.2 100.0 597 Highest 59.7 4.1 36.0 0.1 100.0 739 Total 15-49 83.8 2.0 14.1 0.1 100.0 2,944 50-59 95.1 0.9 3.7 0.3 100.0 336 Total 15-59 84.9 1.9 13.0 0.1 100.0 3,280 1 ‘Currently employed’ is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 3.6 OCCUPATION Tables 3.6.1 and 3.6.2 show the distribution of women and men who were employed in the 12 months preceding the survey by occupation and background characteristics. Data in these tables show that the agriculture sector employs 57 percent of women and 59 percent of men. The next most common occupation for women is sales and services (34 percent). Six percent of women are in professional, technical, and managerial work. Very few women are engaged in other occupations (2 percent or less). Similar proportions of men work in professional, technical, managerial occupations (14 percent) and sales and services jobs (13 percent). Characteristics of Respondents | 43 Women who work in agriculture are more likely to be older, married, live in rural areas, have no education, and live in the poorest households. Professional, technical and managerial sectors are more likely to attract younger women, women who have never married, women with no children, urban women, women with secondary or higher education, and women from the wealthiest households. There are no substantial differences in occupation by region; 66-72 percent of women and men in the Northern, Eastern and Southern regions work in agriculture and 19-27 percent of women work in the sales and services sector. One in three men (33 percent) in the Western Region work in professional, technical and managerial jobs. Women with no education or with primary education work mainly in agricultural jobs (42-69 percent), while 51 percent of women with secondary or higher education work in the sales and services sector. For men, the relationship between education and occupation follows a similar pattern. Tables 3.6.1 and 3.6.2 show that women (85 percent) and men (86 percent) in the lowest wealth quintile are most likely to work in the agriculture sector, while those in the highest wealth quintile (71 and 31 percent, respectively) are most likely to work in the sales and service sector. Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Sierra Leone 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agri- culture Missing Total Number of women Age 15-19 19.6 0.0 24.2 2.5 0.1 1.0 48.9 3.7 100.0 606 20-24 7.0 0.2 36.8 2.3 0.5 0.4 50.8 2.0 100.0 775 25-29 3.2 0.3 34.4 1.9 0.1 0.2 59.0 1.0 100.0 1,377 30-34 3.9 0.4 36.8 1.7 0.3 0.0 56.0 0.8 100.0 895 35-39 4.0 0.3 33.5 0.8 0.0 0.0 60.1 1.2 100.0 986 40-44 5.3 0.6 34.0 0.4 0.2 0.0 58.8 0.7 100.0 570 45-49 3.5 0.3 31.9 0.4 0.0 0.0 63.7 0.2 100.0 460 Marital status Never married 29.9 0.6 36.7 3.5 0.3 0.7 24.2 4.2 100.0 627 Married/ living together 2.9 0.2 32.4 1.3 0.2 0.2 61.9 0.9 100.0 4,668 Divorced/separated/widowed 3.7 0.4 44.0 1.3 0.3 0.0 48.7 1.6 100.0 374 Number of living children 0 20.2 0.5 31.2 2.4 0.4 0.7 41.6 3.0 100.0 845 1-2 4.7 0.5 35.6 2.4 0.1 0.3 55.0 1.4 100.0 2,077 3-4 2.7 0.1 34.2 0.7 0.2 0.0 61.2 0.8 100.0 1,678 5+ 2.3 0.1 30.7 0.2 0.1 0.0 65.7 0.8 100.0 1,069 Residence Urban 13.3 1.0 66.2 3.4 0.1 0.5 13.2 2.4 100.0 1,637 Rural 3.0 0.0 20.4 0.8 0.2 0.1 74.6 0.9 100.0 4,032 Region Eastern 5.7 0.1 18.9 1.6 0.5 0.1 72.3 0.7 100.0 998 Northern 3.8 0.0 27.2 0.8 0.1 0.3 67.0 0.8 100.0 2,502 Southern 3.1 0.1 27.2 1.0 0.2 0.0 65.6 2.8 100.0 1,225 Western 15.6 1.4 74.6 3.9 0.1 0.2 2.5 1.6 100.0 944 Education No education 1.3 0.0 28.0 0.9 0.2 0.2 68.6 0.9 100.0 4,137 Primary 6.1 0.0 46.6 2.7 0.0 0.5 42.4 1.7 100.0 703 Secondary or higher 29.2 2.0 50.8 3.5 0.4 0.2 10.7 3.2 100.0 829 Wealth quintile Lowest 1.5 0.0 11.5 0.3 0.3 0.0 85.3 1.2 100.0 1,201 Second 3.1 0.1 16.9 0.4 0.2 0.0 78.2 1.1 100.0 1,183 Middle 3.1 0.0 26.2 1.2 0.1 0.4 67.6 1.3 100.0 1,199 Fourth 6.1 0.1 50.2 2.0 0.2 0.4 39.4 1.5 100.0 1,095 Highest 18.1 1.5 71.1 4.2 0.1 0.2 3.3 1.5 100.0 990 Total 6.0 0.3 33.6 1.5 0.2 0.2 56.9 1.3 100.0 5,669 44 | Characteristics of Respondents Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Sierra Leone 2008 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agri- culture Missing Total Number of men Age 15-19 33.1 0.3 3.0 3.6 1.4 0.0 55.0 3.4 100.0 290 20-24 22.7 2.7 10.4 9.2 3.6 0.5 48.8 2.2 100.0 296 25-29 11.1 3.0 12.7 9.3 3.8 0.0 58.8 1.4 100.0 410 30-34 9.4 1.7 15.5 8.4 4.4 0.4 59.8 0.3 100.0 364 35-39 7.4 1.5 13.9 6.7 4.4 0.2 65.2 0.7 100.0 512 40-44 15.7 1.2 17.7 5.8 4.9 0.0 54.0 0.8 100.0 327 45-49 9.0 0.7 13.4 8.4 5.0 0.0 62.9 0.6 100.0 326 Marital status Never married 26.6 1.8 8.2 7.1 3.2 0.2 50.2 2.7 100.0 717 Married/ living together 9.3 1.4 14.6 7.3 4.2 0.1 62.4 0.7 100.0 1,726 Divorced/separated/widowed 13.1 3.7 13.2 11.9 7.4 0.0 50.7 0.0 100.0 84 Number of living children 0 23.1 2.0 9.1 5.8 3.4 0.2 54.2 2.2 100.0 784 1-2 12.4 1.9 13.2 11.1 6.2 0.2 53.7 1.3 100.0 665 3-4 9.9 1.7 15.7 6.8 3.4 0.2 61.5 0.8 100.0 543 5+ 8.3 0.6 14.3 5.9 2.8 0.0 68.0 0.1 100.0 535 Residence Urban 29.2 4.3 26.6 16.9 4.4 0.5 15.2 2.8 100.0 796 Rural 7.5 0.4 6.3 3.0 3.8 0.0 78.5 0.5 100.0 1,731 Region Eastern 9.8 0.6 6.1 3.0 10.7 0.0 69.6 0.2 100.0 506 Northern 12.2 0.6 9.4 3.9 1.3 0.1 72.1 0.4 100.0 1,033 Southern 6.3 1.3 13.7 4.3 5.8 0.0 66.5 2.2 100.0 526 Western 33.3 5.4 26.1 23.6 0.6 0.7 7.1 3.1 100.0 462 Education No education 2.7 0.7 9.1 5.7 4.3 0.0 77.1 0.4 100.0 1,393 Primary 11.3 2.0 12.1 10.3 5.2 0.0 57.9 1.2 100.0 354 Secondary or higher 36.5 3.1 19.3 9.2 3.0 0.5 25.6 2.8 100.0 779 Wealth quintile Lowest 4.4 0.1 3.8 1.4 4.3 0.0 85.5 0.6 100.0 530 Second 4.6 0.3 7.8 1.3 2.8 0.0 83.2 0.0 100.0 497 Middle 10.1 0.4 7.9 5.3 4.7 0.0 71.1 0.6 100.0 509 Fourth 18.9 1.4 14.7 10.8 6.9 0.5 45.2 1.7 100.0 518 Highest 35.4 6.2 30.9 19.3 1.0 0.3 3.5 3.4 100.0 472 Total 15-49 14.3 1.6 12.7 7.4 4.0 0.2 58.5 1.2 100.0 2,526 50-59 9.9 1.2 15.1 4.2 4.8 0.0 64.5 0.3 100.0 322 Total 15-59 13.8 1.6 13.0 7.1 4.1 0.1 59.2 1.1 100.0 2,849 3.7 EARNINGS, EMPLOYERS, AND CONTINUITY OF EMPLOYMENT Table 3.7 presents information on women’s employment, including type of earnings, type of employer, and continuity of employment. Because the employment variables in the table are strongly influenced by the sector in which a woman is employed, the table takes into account whether the woman is involved in agricultural or non-agricultural work. The data show that 83 percent of women employed in agricultural work are not paid, 74 percent are self-employed, and 24 percent are employed by a family member; 44 percent work all year and 53 percent work seasonally. Characteristics of Respondents | 45 Women who work in non-agricultural jobs are slightly better off than women employed in agricultural work; 54 percent of these women are not paid, but 37 percent are paid in cash only. Among women who work in agriculture, 84 percent are not paid and 5 percent are paid in cash only. Eighty-one percent of women are self-employed, and most women work all year (71 percent). Table 3.7 Type of employment: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or non-agricultural), Sierra Leone 2008 Employment characteristic Agricultural work Non- agricultural work Total Type of earnings Cash only 4.5 36.8 18.2 Cash and in-kind 5.6 5.0 5.3 In-kind only 5.9 2.9 4.6 Not paid 83.4 54.2 71.0 Missing 0.6 1.1 0.9 Total 100.0 100.0 100.0 Type of employer Employed by family member 24.3 9.8 18.1 Employed by non-family member 1.4 8.3 4.4 Self-employed 74.1 81.3 77.1 Missing 0.2 0.6 0.5 Total 100.0 100.0 100.0 Continuity of employment All year 44.2 70.7 55.1 Seasonal 53.1 17.6 37.8 Occasional 2.0 11.0 6.3 Missing 0.7 0.7 0.8 Total 100.0 100.0 100.0 Number of women employed during the past 12 months 3,225 2,368 5,669 Note: The total column includes women with information missing on type of employment who are not shown separately. 3.8 HEALTH INSURANCE Health insurance is largely unknown in Sierra Leone; almost no one is covered by a health insurance scheme (data not shown). 3.9 KNOWLEDGE AND ATTITUDES CONCERNING TUBERCULOSIS The 2008 SLDHS collected information on the respondent’s knowledge and attitudes concerning tuberculosis (TB). Tables 3.8.1 and 3.8.2 show that knowledge of TB in Sierra Leone is widespread (86 percent of women and 90 percent of men). Younger respondents and those who live in rural areas are less likely than other respondents to have heard of TB. Almost all women and men in the Western Region have heard of TB (99 and 98 percent, respectively). Knowledge of TB increases with education and wealth status. Women and men with less than primary education and in the lowest wealth quintile are the least likely to know about TB. 46 | Characteristics of Respondents Among women and men who have heard of TB, more than half know that TB is spread through the air by coughing (57 percent of women and 68 percent of men). Knowledge that TB can be cured is also widespread (77 percent of women and 85 percent of men). In general, urban residents, more educated respondents, and those in the wealthiest households are more aware that TB is transmitted through the air by coughing and that it can be completely cured. In Sierra Leone, there is little stigma attached to TB. Only about one-quarter of women (24 percent) and 17 percent of men said that they would want to keep secret the fact that a family member had TB. Stigma generally increases with level of education and wealth quintile, and is higher among urban than rural residents. Table 3.8.1 Knowledge and attitudes concerning tuberculosis: Women Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentage who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Sierra Leone 2008 Background characteristic Among all women: Among respondents who have heard of TB: Percentage who have heard of TB Number of women Percentage who reported that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member’s TB kept secret Number of women Age 15-19 81.3 1,198 55.8 72.8 28.9 974 20-24 88.5 1,186 56.9 75.3 28.5 1,050 25-29 85.1 1,643 55.9 77.4 21.1 1,398 30-34 85.7 1,043 58.1 79.1 22.9 894 35-39 86.0 1,131 59.9 79.6 22.7 973 40-44 88.7 652 59.8 80.0 20.2 578 45-49 88.9 520 56.7 81.0 18.3 462 Residence Urban 94.8 2,655 62.7 82.9 33.8 2,518 Rural 80.8 4,719 53.9 73.8 17.1 3,812 Region Eastern 85.2 1,325 56.4 67.9 18.3 1,129 Northern 81.5 3,001 60.4 80.1 15.6 2,445 Southern 82.2 1,542 46.2 72.0 19.0 1,268 Western 98.7 1,506 62.9 84.9 45.3 1,487 Education No education 82.0 4,860 52.6 74.2 18.7 3,985 Primary 89.5 960 60.3 74.2 26.0 859 Secondary or higher 95.6 1,554 68.8 88.1 36.0 1,486 Wealth quintile Lowest 78.7 1,382 53.9 71.1 15.9 1,087 Second 81.2 1,368 53.2 74.3 18.3 1,112 Middle 80.9 1,428 54.0 73.0 17.0 1,155 Fourth 88.7 1,472 58.8 78.6 22.9 1,306 Highest 96.9 1,723 63.7 85.7 37.8 1,670 Total 85.8 7,374 57.4 77.4 23.7 6,330 Characteristics of Respondents | 47 Table 3.8.2 Knowledge and attitudes concerning tuberculosis: Men Percentage of men age 15-49 who have heard of tuberculosis (TB), and among men who have heard of TB, the percentage who know that TB is spread through the air by coughing, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Sierra Leone 2008 Background characteristic Among all men: Among respondents who have heard of TB: Percentage who have heard of TB Number of men Percentage who reported that TB is spread through the air by coughing Percentage who believe that TB can be cured Percentage who would want a family member’s TB kept secret Number of men Age 15-19 80.7 526 71.1 80.5 22.2 424 20-24 90.0 403 73.1 86.1 24.7 362 25-29 90.2 446 62.2 82.9 17.5 402 30-34 91.9 373 65.3 81.7 9.8 343 35-39 92.9 525 63.2 84.3 14.2 488 40-44 93.0 336 72.0 89.3 17.3 313 45-49 93.1 335 71.6 88.8 11.9 312 Residence Urban 96.1 1,123 78.4 88.9 21.7 1,079 Rural 86.0 1,822 60.8 81.5 13.7 1,566 Region Eastern 89.0 557 48.9 75.8 8.5 495 Northern 87.5 1,131 72.5 87.4 11.8 990 Southern 86.0 617 66.9 83.3 18.6 531 Western 98.4 639 76.8 87.8 30.4 629 Education No education 88.1 1,426 57.3 79.5 12.7 1,256 Primary 80.1 414 60.7 81.0 15.2 332 Secondary or higher 95.7 1,104 82.9 91.5 22.6 1,057 Wealth quintile Lowest 83.5 558 52.2 77.0 14.8 466 Second 85.3 520 61.3 80.8 10.6 444 Middle 87.8 530 65.1 84.0 11.7 465 Fourth 92.3 597 72.6 87.4 16.7 551 Highest 97.2 739 80.6 89.7 26.0 719 Total 15-49 89.8 2,944 68.0 84.5 17.0 2,645 50-59 92.1 336 67.1 88.8 12.5 309 Total 15-59 90.1 3,280 67.9 84.9 16.5 2,954 3.10 SMOKING To measure the extent of smoking among Sierra Leonean adults, women and men who were interviewed in the 2008 SLDHS were asked if they currently smoked cigarettes or used other forms of tobacco. Twelve percent of women reported that they use tobacco; 6 percent smoke cigarettes and 6 percent use other types of tobacco (Table 3.9.1). Men are more likely to use tobacco than women. Overall, 37 percent of men age 15-49 smoke cigarettes (Table 3.9.2). Among men, the proportion of smokers is highest in rural areas, among those with no education, and among those in the poorest households. Four in ten men who smoke cigarettes had at least 10 cigarettes in the 24 hours before the survey. While there are large differences in the proportion cigarette smokers by wealth quintile (50 percent for men in the lowest quintile and 17 percent for men in the highest quintile), among men who smoke 10 or more cigarettes there is little variation by wealth status (34-42 percent). 48 | Characteristics of Respondents Table 3.9.1 Use of tobacco: Women Percentage of women age 15-49 who smoke cigarettes or a pipe or use other tobacco products, by background characteristics and maternity status, Sierra Leone 2008 Background characteristic Uses tobacco Does not use tobacco Number of women Cigarettes Pipe Other tobacco Age 15-19 0.8 0.0 0.8 98.2 1,198 20-24 3.4 0.0 2.0 95.2 1,186 25-29 6.5 0.2 4.1 90.3 1,643 30-34 9.2 0.4 7.0 85.0 1,043 35-39 7.8 0.2 8.2 85.0 1,131 40-44 8.5 0.9 10.7 82.2 652 45-49 9.0 0.5 13.6 78.5 520 Maternity status Pregnant 4.5 0.0 5.2 91.3 598 Breastfeeding (not pregnant) 6.0 0.2 4.8 90.2 2,091 Neither 6.2 0.3 5.9 88.6 4,685 Residence Urban 5.0 0.3 1.7 93.4 2,655 Rural 6.6 0.2 7.7 87.0 4,719 Region Eastern 8.5 0.2 6.9 85.4 1,325 Northern 5.0 0.3 3.4 92.6 3,001 Southern 6.2 0.0 13.2 82.3 1,542 Western 5.7 0.5 0.8 93.2 1,506 Education No education 6.9 0.3 7.5 86.7 4,860 Primary 6.1 0.0 3.4 90.6 960 Secondary or higher 3.1 0.1 0.7 96.4 1,554 Wealth quintile Lowest 6.6 0.0 9.9 84.7 1,382 Second 6.5 0.3 8.1 86.5 1,368 Middle 6.2 0.1 6.0 89.0 1,428 Fourth 6.8 0.5 4.0 90.1 1,472 Highest 4.2 0.3 0.8 94.7 1,723 Total 6.0 0.2 5.5 89.3 7,374 Characteristics of Respondents | 49 Table 3.9.2 Use of tobacco: Men Percentage of men age 15-49 who smoke cigarettes or a pipe or use other tobacco products and the percent distribution of cigarette smokers by number of cigarettes smoked in past 24 hours, according to background characteristics, Sierra Leone 2008 Background characteristic Uses tobacco Does not use tobacco Number of men Number of cigarettes in the past 24 hours Total Number of cigarette smokers Cigarettes Pipe Other tobacco 0 1-2 3-5 6-9 10+ Don’t know/ missing Age 15-19 9.0 0.0 0.9 90.9 526 (2.4) (13.2) (41.8) (15.3) (25.4) (2.0) 100.0 47 20-24 25.5 0.0 2.4 74.4 403 0.0 8.6 45.3 14.1 25.7 6.3 100.0 103 25-29 38.6 0.5 5.0 60.2 446 0.9 9.4 38.4 17.7 30.6 3.0 100.0 172 30-34 43.9 0.6 6.2 54.9 373 1.1 6.5 33.2 14.7 43.2 1.3 100.0 164 35-39 47.5 0.1 4.2 51.9 525 0.5 7.1 32.3 13.9 43.1 3.1 100.0 249 40-44 49.6 0.8 3.8 50.0 336 0.4 2.8 27.3 19.8 48.7 1.1 100.0 167 45-49 52.5 1.4 6.1 46.4 335 0.0 6.5 37.7 14.9 39.6 1.3 100.0 176 Residence Urban 22.5 0.1 2.7 76.6 1,123 0.8 8.1 31.4 14.2 43.4 2.1 100.0 253 Rural 45.3 0.6 4.6 54.2 1,822 0.6 6.7 36.3 16.3 37.6 2.5 100.0 825 Region Eastern 42.4 0.2 5.2 56.7 557 0.0 6.9 54.6 19.6 18.1 0.8 100.0 236 Northern 41.3 0.7 1.9 58.4 1,131 0.4 6.5 26.8 14.1 48.6 3.7 100.0 467 Southern 37.6 0.6 6.9 61.3 617 0.4 4.6 31.9 17.5 44.2 1.4 100.0 232 Western 22.3 0.0 3.3 76.9 639 2.7 13.0 35.9 12.3 33.4 2.7 100.0 143 Education No education 50.0 0.8 5.0 49.5 1,426 0.4 5.0 33.7 16.1 42.1 2.7 100.0 713 Primary 31.8 0.0 3.2 67.6 414 0.0 12.3 35.7 18.4 31.5 2.1 100.0 132 Secondary or higher 21.1 0.1 2.8 78.0 1,104 1.6 10.1 39.5 13.4 33.6 1.8 100.0 233 Wealth quintile Lowest 50.2 0.2 5.7 49.0 558 0.4 5.5 38.0 18.5 34.2 3.4 100.0 280 Second 43.0 1.3 5.6 56.2 520 0.4 7.0 35.6 13.6 40.9 2.4 100.0 224 Middle 44.7 0.2 3.7 54.6 530 0.0 7.5 34.1 14.9 41.6 1.9 100.0 237 Fourth 35.1 0.4 2.0 64.8 597 0.3 5.6 34.9 15.9 40.4 2.8 100.0 210 Highest 17.2 0.1 3.0 81.9 739 3.0 11.7 30.6 15.0 38.8 0.8 100.0 127 Total 15-49 36.6 0.4 3.9 62.7 2,944 0.6 7.0 35.2 15.8 39.0 2.5 100.0 1,078 50-59 41.6 1.4 5.0 55.8 336 1.0 4.3 19.8 25.0 46.9 3.0 100.0 140 Total 15-59 37.1 0.5 4.0 62.0 3,280 0.6 6.7 33.4 16.8 39.9 2.5 100.0 1,217 Note: Figures in parentheses are based on 25-49 unweighted cases. Fertility Levels, Trends, and Differentials | 51 FERTILITY LEVELS, TRENDS, AND DIFFERENTIALS 4 Fertility is one of the principal components of population dynamics that determine the size and structure of the population of a country. Fertility, unlike mortality and migration, has remained the most crucial factor associated with population change in Sierra Leone because of its persistent high levels. For over a generation, the total fertility rate (TFR) in Sierra Leone has been six children or more per woman. These high TFR levels are strongly tied to social, economic, and cultural factors that are yet to be fully understood. The UN fertility estimates also indicate that there has been little or no change in fertility levels in Sierra Leone since the early 1950s (United Nations, 2009). The increasing number of births per woman has come to be seen as the driving force behind the country’s population increases. The government of Sierra Leone recognized the potential drawbacks of high levels of fertility on the economy in its First National Development Plan (Sierra Leone Government, 1974). These efforts culminated in the formulation of a National Population Policy in 1988, government’s earliest population policy framework to address development issues, including fertility. The 2008 SLDHS was undertaken at a time when this long-standing trend of high fertility in Sierra Leone was well established. However, the survey provides information on fertility differentials that is essential for understanding the dynamics of fertility in Sierra Leone and the potential impact on population change. This chapter looks at a number of fertility indicators including levels, patterns, and trends in both current and cumulative fertility; the length of birth intervals; and the age at which women initiate childbearing. Information on current and cumulative fertility is essential in monitoring population growth. The data on birth intervals are important because short intervals are strongly associated with childhood mortality. The age at which childbearing begins can also have a major impact on the health and well-being of both the mother and the child. Data on fertility were collected in several ways. Each woman interviewed was asked about all of the births she had had in her lifetime. To ensure completeness of responses, the duration of the pregnancy, the month and year the pregnancy ended, and the result of the pregnancy were recorded for each pregnancy. In addition, questions were asked separately about sons and daughters who live with the mother, those who live elsewhere, and those who have died. Subsequently, a list of all births was recorded along with the name of the child, age if still living, and age at death if dead. Finally, information was collected on whether women were pregnant at the time of the survey. 4.1 CURRENT FERTILITY The level of current fertility is one of the most important demographic indicators for determining the status of women and for health and family planning policy-makers because of its direct relevance to population policy and programmes. Current fertility is measured for the three-year period prior to the survey (mid-2005 to mid-2008). A three-year period was chosen because it reflects the most current information, while having a sufficient number of cases to allow statistical calculation of rates. The results by urban-rural residence are presented in Table 4.1. 52 | Fertility Levels, Trends, and Differentials Several measures of fertility are shown in this chapter. Age-specific fertility rates (ASFRs) are defin

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