Syria Multiple Indicator Cluster Survey 1995

Publication date: 1996

Syrian Arab Republic Prime Minister's Council Central Bureau of Statistics Multiple Indicator Cluster Survey in The Syrian Arab Republic Damascus December 1996 • United Nations Children's Fund (UNICEF) Syrian Arab Republic Prime Minister's Council Central Bureau of Statistics in cooperation with ~IN., 1'-· c r I trd ·· United Nations Children's Fund (UNICEF) Multiple Indicator Cluster Survey in The Syrian Arab Republic Damascus December 1996 Multiple Indicator Cluster Survey in the Syrian Arab Republic Survey objectives . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Survey methodology . . . . . . . . . . . . . . . . . . . . . . . . 1 Water and sanitation facilities results . . . . . . . . . . . 3 Access to health services results . . . . . . . . . . . . . . . 4 Salt iodization results . . . . . . . . . . . . . . . . . . . . . . . 5 ORS availability results . . . . . . . . . . . . . . . . . . . . . 6 Mother's knowledge of diarrhoea management results 7 Prevalence and management of diarrhoea results . . 9 Breast-feeding results . . . . . . . . . . . . . . . . . . . . . . . 11 Nutrition results . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Vaccination coverage results . . . . . . . . . . . . . . . . . 13 Basic education results . . . . . . . . . . . . . . . . . . . . . . 15 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Annex: Methodology in detail . . . . . . . . . . . . . . . . 18 - 1 - Survey objectives The Multiple Indicator Cluster Survey (MICS) was broadly aimed at providing information to policy-makers and other concerned parties for use in addressing the priority health concerns of women and children in Syria and improving the quality of health care. In more specific terms, it aimed at: o augmenting baseline data made available by the 1993 PAPCHILD survey, particularly in the areas of water and sanitation, health facilities, salt iodization, oral rehydration therapy, diarrhoeal disease, breast-feeding and basic education; o monitoring and assessing the changes in some basic child health indicators between 1993 and 1995; and o obtaining more detailed information concerning health services and health conditions at the sub-national level, both by region and by settlement type. Survey methodology The study covered a total of 2,200 families chosen through multi-stage cluster sampling, 1,230 from urban areas and 970 from rural areas. The 1994 population census provided a recent and reliable sample frame for the households. Data were collected on the following items, using a survey questionnaire that was administered by trained field workers: o water and sanitation facilities; o access to health services; o salt iodization; o availability of ORS in the health facilities; o mothers' knowledge of diarrhoea management; o prevalence and management of diarrhoea among under-fives; o breast-feeding patterns; o nutritional status; o vaccination coverage; and o basic education enrollment. Each item was analyzed according to the country's six regions (Damascus, Middle, Coastline, North, East, and South) and according to different types of settlements (urban, peri-urban, and rural). - 2- Fig.1/1 Administrative devisions Turkey Homs Jordan 0 Iraq 100 KM . Damascus D Middle • Coastline D North • East D South Water and sanitation facilities results Tables 1 (a) and (b) show household water and sanitation facilities by region and settlement type. The tables suggest that access to water supplies is generally good in Syria; almost three-quarters of households are connected to a water network and over 95 percent of households are connected to a water network or a well. Reliance on water tankers or other water sources is widespread only in the East (28 percent) and in rural locations (23 .5 percent). Seventy-five percent of households connected to a water network and 85.8 percent of households dependent on well report receiving water continuously, with little variance by region or settlement type. Sixty-five percent of household dependent on wells had inside water connections, 34.3 percent received water less than 500 meters away, and only 0.7 percent ofhouseholds depended on wells further than 1 000 meters away. The tables indicate, however, that substantial numbers of households remain without access to adequate facilities for excreta disposal. Only two-thirds of households nationally, and only 43.3 percent of East households and 31.2 percent of rural households, are connected to a piped sewerage system. One-quarter of East households and 17.2 percent of rural households are completely lacking sanitation facilities, posing an important environmental health concern. Table 1 (a). Water and sanitation facilities by region (% ). Damascus Middle Coastline North East South Source of drinking water Network 76.7 73.8 73 74 58 94 Well 6.6 13.6 13.5 21 .3 14 0 Water tanker 16.3 4.4 2.2 1 16 0.7 Other 0.4 8.2 11 .3 3.7 12 5.3 Excreta Disposal Piped sewerage system 88.8 63.5 65.2 68.3 43.3 52 Pit latrines 7.3 34.3 24.8 16.4 31.2 47.3 Open drain 3.7 0.2 0.4 0.6 0.7 0.7 Nothing 0.2 2 9.6 14.7 24.8 0 Table 1(b). Water and sanitation facilities by settlement type(%). Urban Peri-urban Rural All Source of Drinking Water Water network 92.7 85.7 51 .6 73.7 Well 2.5 4.4 24.9 12.7 Water tankers 4.1 7.8 11 .3 7.7 Other 0.7 2.1 12.2 5.9 Excreta Disposal Piped sewerage 96.4 96.1 31.2 67 .3 system 2 0.4 50.2 23 .3 Pit latrine 1.3 0.4 1.4 1.3 Open drain 0.3 3.1 17.2 8.1 Nothing - 3 - Fig.2/1 Percentage of households connected to the main water system or to the piped sewerage system Turkey Jordan )'~ll•·l~ . ;'~!'' Iraq water supply system ;-. • • Sewerage A system 0 . Damascus 0 Middle • Coastline 0 North • East 0 South 100 KM Fig 2/2 A : Distribution of families according to the source of drinking water • Urban • Peri -urban • Rural Other Water Tanker Fountain Well Network Fig 2/2 B : Distribution of families according to the source of drinking water • Damascus D Middle • Coastline D North • East D South Other Water Tanker Fountain Well Network 100 90 80 70 60 50 40 30 20 10 0 100 90 80 70 60 50 40 30 20 10 0 Fig. 2/3 A II Urban • Peri ·urban liii Rural Fig. 2/3 B I Damascus 0 Middle l coastline North I East 11\9 South Distribution of families according to sanitation facilities 100 90 80 70 60 50 40 30 20 10 0 Nothing Open drain Piped sewerage system Distribution of families according to sanitation facilities Nothing Open drain Pit latrines Piped sewerage system 90 80 70 60 50 40 30 20 10 0 Access to health services results Tables 2 (a) and (b) indicate that almost all households have relatively easy physical access to non-tertiary health facilities . Only 3.2 of total households have to travel more than 30 minutes to reach a health centre, although this proportion rises to 11.4 percent for East households and 6.6 percent for rural households. Seventy-nine percent of total households have a health centre within five kilometers. Tertiary care facilities are fewer in number and therefore more spread out, but still almost three- quarters of households have a Government hospital within 30 minutes ' travel time. Table 2(a). Percentage of households normally travelling over 30 minutes to reach a health facility, by region . Type of facility Damascu Middle Coastline Northern Eastern Southern s Health centre 0.6 0.6 4.3 3.8 11.4 2.7 Private doctor 0.4 0 4.3 3.8 12.1 2.7 Governmental Hospital 12.3 39.2 33 29.2 42.8 42.5 Private Hospital 12.5 15.6 30.9 21.3 44.5 45.4 Pharmacy 0 2.2 8.7 3.3 15.4 1.4 Table 2(b). Percentage of households normally travelling for more than 30 minutes to reach a health facility, by settlement type. Type of facility Urban Peri-urban Rural All Health Centre 0.6 0.4 6.6 3.2 Private Doctor 0.7 6.4 3.2 Government Hospital 10.9 1.3 51 27.8 Private Hospital 12.3 40.6 23.6 Pharmacy 0.7 9.1 4.4 - 4- - ~- -- Fig.3/1 Percentage of households with access to any health facility within 5 km distance Turkey Jordan Iraq No health facility within 5 km 0 100 KM . Damascus D Middle • Coastline D North • East D South Fig 3/2 A -111·~- Urban 1---- Peri- urban --- Rural Availability of health facilities within less than 5 Kms distance ~~-----------------=~~~~100 90 80 70 r---- 60 / 50 / ' / ~ ', / ~ ' / 20 ' .--/ 10 , __ .- ~-------r------,_-------+--------TO Pharmacy Private hospital Public hospital Private clinic Health center Fig 3/2 B Availability of health facilities less than 5 Kms distance -~ Helath center Private clinic - o-- Public hosp . ----- Private hosp. -{)-- Pharmacy 50 40 30 20 10 ~------+-------+-------;-------;--------+0 South East North Coast Mi"ddle Damascus Fig 3/3 A : Distribution of families according to the number of health facilities within less than 5 Kms. ~-----------------------------------------rao • Urban • Peri-urban • Rural 70 60 50 40 30 20 10 ___, _ __._ 0 5 3-4 1-2 0 Number of health facilities Fig 3/3 B : Distribution of families according to the number of health facilities within less than 5 Kms . • Damascus 0 Middle II Coastline D No rth • East • South 5 3-4 1-2 0 Number of health facilities Salt iodization results Tables 3 (a) and (b) suggest that actual usage of iodized salt lags somewhat behind awareness of its importance. Almost three-quarters ofhouseholds nationally are aware of iodized salt, but only 58 percent of aware households, and 35.6 percent oftotal households, actually use iodized salt. Awareness and usage are lowest in North, peri- urban and rural households. Table 3(a). Salt iodization by region . Damascus Middle % of families aware of iodized salt 83.7 73.4 % of aware families using iodized salt 72.9 48.1 % of families with +ve iodized salt test 57.7 23.5 Table 3(b). Salt iodization by settlement type. % of families aware of iodized salt % of aware families using iodized % of families with +ve iodized salt test - 5- Urban 82.9 63.6 45.9 Coastline North East 86.2 56.2 66.4 70.8 39.1 48.7 58.6 11.4 26.3 Peri-urban Rural 69.1 49.4 27.1 63 52.6 27 .4 South 74 71.2 58.4 All 72.6 58 35.6 ----~-------------------- - ----- - -- ~ Fig.4/1 Percentage of families with positive results of the testing for iodized salt Turkey Iraq . Datnascus Iodized Salt D Middle 60°/o • Coastline II Ill D North Ill • East II 24°/o D South I Jordan 12°/o 0 100 KM Fig 4/2 A : Distribution of families according to ~he results of iodized salt test • Urban • Peri -urban • Rural Negative test Positive test Fig 4/2 B : Distribution of families according to the results of iodized salt test Ill Damascus 0 Middle Ill Coastline North East South Availability of oral rehydration salts (ORS) results Tables 4 (a) and (b) indicate that oral rehydration salts still are not universally available in Syrian health care facilities. One-quarter of total public health centres and 22 percent of total government hospitals did not have ORS supplies at the time of the survey, despite the central importance ofORS to the Ministry ofHealth's national control of diarrhoeal diseases programme. ORS supplies in public health care facilities also appear to vary widely from region to region; 91.7 percent ofEast public health centres reported having ORS compared to only 43.5 percent of Coastline public health centres. Eight percent of households, most situated in rural areas, report having no access to a health facility providing ORS. Availability ofORS is particularly low in the private sector- less than one-third of private doctors and private hospitals report usual availability of oral rehydration salts, with little variance by region or settlement type. Rates of reported ORS wastage were also highest among private sector doctors and hospitals, at 75.7 percent and 72.5 percent respectively. Table 4(a) . Availability of ORS in health facilities by region(%). Damascus Middle Coastline Northern Eastern Southern Availability of ORS Health centre 83.7 76.5 43.5 64.2 91.7 99.3 Private doctor 21.6 20.2 8.3 19.2 71 .3 59.1 Governmental hospital 80.9 99.5 46.1 64.2 85.7 99.3 Private hospital 19.2 16.2 4.3 16.8 85 99.3 Pharmacy 94 100 100 98.1 99.6 99.3 ORS wastage* Health centre 31.4 62.3 87 85.2 12.9 0.7 Private doctor 90.5 78.3 88.8 93.4 29.2 40.3 Governmental hospital 21 .1 45.2 53.9 54.7 16.2 0 Private hospital 89.3 79.8 92.7 99.7 15.5 0 Pharmacy 16.1 5.6 0 7.3 7 0 • Wastage for the period lasting from January 1995 to December 1995 Table 4(b). Availability of ORS in health facilities by settlement type(%). Urban Peri-urban Rural All Availability of ORS Health centre 80.4 73.9 69.2 75.1 Private doctor 30.8 17.8 27 27.8 Governmental hospital 76.4 86.5 77.9 78.1 Private Hospital 30.4 26.2 27.8 28.9 Pharmacy 97.8 100 97.4 97.9 ORS wastage* Health centre 44 66.8 51.2 49.4 Private doctor 78 89.5 69.3 75.7 Governmental hospital 37.9 31.6 30.8 34.4 Private hospital 75.1 84.1 65.3 72.5 Pharmacy 7.9 1.6 9.5 7.9 Wastage for the period lasting from January 1995 to December 1995 - 6- Fig.S/1 Percentage of health centers with ORS available at the time of the survey Turkey Jordan Iraq ORS available 0 100 KM . Damascus D Middle • Coastline D North • East D South Fig 5/2 A • Urban • Rural Fig 5/2 B . Damascus 0Middle .Coastline 0 North • East 0 South .-- L. Availability of ORS at the time of the survey Pharmacy Private hospital Public hospital Private clinic Health center 100 90 80 70 60 50 40 30 20 10 0 Availability of ORS at the time of the survey L. Pharmacy • Private hospital 4- Public hospital 4- I Private clinic 100 90 80 70 60 50 ' 40 30 20 10 4- 0 Health center Mothers' knowledge of diarrhoea management results 1'ables 5 (a) and (b) indicate that there is still room for improvement in terms of mothers' knowledge of proper diarrhoea case management, particularly in the North region, underscoring the continued importance ofthe commu_rrications component of the national control of diarrhoeal diseases programme. Thirty-eight percent of total mothers, and 53.5 percent of North mothers, report stopping or reducing food during diarrhoea. Seven percent of total mothers, and 14.4 percent of North mothers, report decreasing their child's fluid intake diarrhoea. However, more than 95 percent of all mothers sought medical care if their children got an episode of diarrhoea, 77.1 percent as soon as possible, and 92.9 percent ofmothers report a knowledge ofORS. Table 5 (a). Mothers' reported management of childhood diarrhoea cases by region(%). Damascus Middle Coastline North East South Feeding practices Stop or reduce food 34.8 32.7 29 53.5 38.1 23.6 No change 61.7 56.2 60.9 37.6 58.9 73.9 Unknown 3.5 11 .1 10.1 8.9 3 2.5 Fluid intake No change 20.9 11 .3 26.4 20.8 26.9 19.5 Increased 69.9 78.4 63.5 57.9 55.8 74.8 Reduced 5.2 1.3 4.1 14.4 10 3.3 Unknown 4 9 6 6.9 7.3 2.4 Seeking medical care Yes 91 86.3 92.6 93.9 86.2 95.9 No 5.5 9 2 4.7 12.3 1.6 Unknown 3.5 4.7 5.4 1.4 1.5 2.5 Timing of medical care As soon as possible 57.4 66.9 49.6 54.9 48.7 77.1 If symptoms persisted 3 35.2 29.7 43.1 34.2 44.6 22.9 days 7.4 3.4 7.3 10.6 6.3 0 If danger signs appeared 0 0 0 0.3 0.4 0 Unknown Knowledge of ORS 89.1 91.8 93.2 95.6 95 96.7 - 7 - Table 5(b). Mothers' reported management of childhood diarrhoea cases by settlement. Urban Peri-urban Rural All Feeding practices Stop or reduce food 43.5 42.0 30.8 37.5 No change 49.8 51.7 62.1 55.7 Unknown 6.7 6.3 7.1 6.8 Fluid intake No change 16.5 21.8 23.0 20.0 Increased 72.7 65.5 61.5 66.8 Reduced 4.9 8.6 8.2 6.8 Unknown 5.9 4.1 7.3 6.4 Seeking medical care Yes 89.5 89.7 91 .3 90.3 No 6.8 6.9 6.3 6.6 Unknown 3.7 3.4 2.4 3.1 Timing of medical care seeking As soon as possible 62.2 55.1 55.6 58.4 If symptoms persisted 3 days 31 .9 37.8 37.2 34.9 If danger signs appeared 5.9 7.1 6.9 6.5 Unknown 0.3 0.2 0.3 0.2 Knowledge of ORS 93.6 92.5 92.4 92.9 - 8 - 6/1 Percentage of mothers who reduce fluids or foods when the child has diarrhoea. Turkey Jordan 0 Reduce fluid Reduce food 100 KM Iraq . Damascus 0 Middle • Coastline 0 North • East 0 South • urban Fig 6/2 A: Distribution of mothers who seek medical care when their child has diarrhoea !!!! Peri-urban • Rural . Damascus 0Middle . Coastline []North . East osouth If danger signs appeared If symptoms persisted 3 days As soon as possible Fig 6/2 B: Distribution of mothers who seek medical care when their child has diarrhoea If danger signs appeared If symptoms persisted 3 days As soon as possible 80 70 60 50 40 30 20 10 0 Prevalence and management of diarrhoea results A total of 263 cases of diarrhoea were reported among the 3,065 under-fives covered during the two weeks preceding the survey, for a prevalence rate of 8.6 percent. Prevalence was highest in the East region, at 21.1 percent. Just under 62 percent of diarrhoea cases occurred among children under two years of age. By comparison, the diarrhoea prevalence rate estimated in the 1993 P APCHILD survey was 15.8 percent, but the much of the difference is likely attributable to the timing of the two surveys. The 1993 P APCHILD survey was conducted during the summer (June-July, 1992) and the current survey during the winter (January, 1996) . Tables 6 (a) and (b) also suggest there remains room for improvement in terms of parent's management of diarrhoea cases. Only 27 percent of parents of children who had an episode of diarrhoea in the past two weeks preceding the survey used oral rehydration therapy (i.e. ORS, fluids, or both ORS and fluids), while 35.4 percent reduced food intake and 11 percent reduced fluid intake. More than one-third of cases were managed by medicine and ORS, and another third treated exclusively with medicines. Twenty-two percent of breast-feeding mothers reported stopping when their child suffered an episode of diarrhoea. Table 6 (a). Parents' reported management of diarrhoeal cases occurring in the two weeks preceding the study, by region(%). Damascus Middle Coastline Northern Eastern Southern Treatment provided ORS 0 12.5 18.7 4.2 1.7 40 Home fluids 4.9 12.5 50 12.5 8.6 0 Both ORS & fluids 2.4 8.9 0 0 14.7 10 Medicines 43.9 30.4 6.3 41 .7 26.7 10 Medicines & ORS 36.6 28.6 18.7 8.3 44 30 Nothing 12.2 7.1 6.3 33.3 4.3 10 Fluid intake No change 34.1 50 50 50 39.7 30 Increased 56.1 46.4 43.8 41 .7 44 60 Reduced 9.8 3.6 6.2 8.3 16.3 10 Food intake No change 53.7 55.4 50 62.5 33.6 40 Increased 26.8 21.4 12.5 12.5 16.4 40 Reduced 19.5 23.2 37.5 25 50 20 Referral Point Private doctor 58.5 44.6 31 .2 29.2 45.7 40 Pharmacy 4.9 10.7 0 20.8 6.9 10 Government hospital 4.9 0 6.3 0 14.6 0 Health centre 9.8 14.3 12.5 0 5.2 10 Private hospital 0 0 0 0 2.6 0 Nothing 21 .9 30.4 50 50 25 40 - 9 - Table 6 (b) . Parents' reported management of diarrhoea cases existed in the two weeks preceding the study, by settlement type (%). Urban Peri-urban Rural All Treatment provided ORS 6.2 7.1 6.6 6.5 Home fluids 14.3 7.1 9.5 11.4 Both ORS & Fluids 10.7 7.1 8 9.1 Medicines 25.9 42.9 31.4 29.7 Madicines & ORS 33.9 14.3 36.5 34.2 None 8.9 21 .4 8 9.1 Fluid Intake No change 42 35.7 43.1 42.2 Increased 49.1 57.1 43.8 46.8 Reduced 8.9 7.2 13.1 11 Food Intake No change 54.5 50 37.2 45.2 Increased 12.5 21.4 24.8 19.4 Reduced 30 28.6 38 35.4 Referral Point Private doctor 35.7 64.3 50.4 44.9 Pharmacy 7.1 21.4 8.0 8.4 Governmental hospital 7.1 8.8 7.6 Health centre 8.9 8.0 8.0 Private hospital 1.8 0.7 1.1 None 39.3 14.3 24.1 30 - 10- Fig.7/1 The prevalence of Diarrhoea in the past two weeks Turkey Iraq . Damascus D Middle • Coastline 7.9 D North • East • 6.4 D South • 3.7 Jordan 0 100 KM Fig 7/3 A : Percentage of children who had diarrhoea during two weeks brfore the survey 38% Peri-urban 31% 41% Fig 7/3 B : Percentage of children who had diarrhoea during two weeks brfore the survey East 43% South 8% Damascus 12% North 8% Middle 16% 13% Fig 7/4 A : Percentage of children who had diarrhoea and been given less fluids & less food • Less fluids • Less food Fig 7/4 B : Percentage of children who had diarrhoea and been given less fluids & less food 0 10 20 30 40 50 I Damascus Less fluids O Middle I Coastline North South Less food Fig.7/2 Percentage of mothers who stopped breast-feeding when the child had diarrhoea Turkey Jordan Iraq mothers who stopped breast-feeding 0 100 KM . Damascus D Middle • Coastline D North • East D South Fig 7/5 A Percentage of mothers who stopped breast feeding when their child had diarrhoea Fig 7/5 B Rural Peri -urban 48% Urban Percentage of mothers who stopped breast feeding when their child had diarrhoea East 20% 20% Sout h 10% Damascus Coastline 7'1. Middle 24% Breast-feeding results Table 7 (a) shows that the practice of breast-feeding is almost universal among mothers in Syria. Ninety -three percent of all mothers reported breast-feeding their youngest child, ranging from 99.2 percent in the South to 90.2 percent in the East. Of total mothers who had breast-fed, 76.2 percent did so for at least four months, and 33 percent continued breast-feeding for at least 12 months. The most important reasons cited for not breast-feeding were insufficient milk (3 7.1 percent), mother's illness (18.6 percent ), and baby's refusal (16.8 percent). Mother's work was not a significant explanatory factor despite the relatively high female labour force participation rates in Syria. Table 7(a). Breast-feeding patterns by region. Damascus Middle Coastline North East South % breast fed her youngest child 93 92.9 90.5 94.7 90.2 99.2 % breast feed her youngest child for 4 65.1 79.1 86 80 80 75.4 months % of women not breast-feeding due to 29.6 48.1 42.9 4:<:.1 24 100* insufficiency of milk * Only one woman Table 7 (b). Reasons given by mothers for not breast-feeding by settlement type (%). Urban Peri-urban Rural All Insufficiency of milk 25.9 33.3 53.3 37.1 Mother's illness 19.0 16.7 18.6 18.6 Baby's refusal 19.0 33.3 9.3 16.8 Child's illness 10.3 8.3 4.7 8.0 Problem in breast/nipples 8.6 8.3 5.3 Mother's work 3.4 1.8 Other causes 13.8 13.9 12.4 - 11 - - -- - - ~ - - - ---- --- --- ------ - --- - - Fig.B/1 Percentage of mothers who breast-fed their youngest child Turkey Jordan mothers who breast -fed their youngest child Iraq . Damascus D Middle • Coastline D North • East D South 0 100 KM Child nutrition results Table 8 indicates that child nutrition remains an area of concern in Syria. Nationally, the percentage of under-fives below average height-for-age, i.e. suffering from linear growth retardation, or "stunting", typically the product of chronic under- nourishment, is 20.8 percent. The proportion of under-fives below average weight-for- age (male/female), or "under-weight", reflecting both chronic and acute under-nutrition, is 12.9 percent. The percentage of under-fives below average weight-for-height, i.e. suffering from below average body mass relative to body length, or "wasting", a result of current and acute under-nutrition, is 8.7 percent. National rates of severe stunting, under-weight, and wasting are 10.1 percent, 3.7 percent and 2.5 percent respectively. Severe malnutrition is by far the highest in the East region, where 16.4 percent of under-fives are severely stunted, 11.9 percent are severely under-weight and 5.3 percent are severely wasted. Severe malnutrition is also more prevalent among boys than girls, older age groups, and in urban and rural areas compared to peri-urban areas. Table 8. Anthropometric indicators for under-fives, by age, sex, settlement type and region (%). No. height-for-age weight-for-age weight-for-height -2>%>-3 <-3 SDs -2>%>-3 <-3 SDs -2>%>-3 <-3 SDs SDs SDs SDs Age group (months) 0-5 228 1.3 3.5 1.9 0.9 4 1.3 6-11 281 7.9 7.9 6.1 2.5 4 1.4 12-23 471 12.4 12 9.6 2.8 4.2 1.8 24-35 507 10.9 13.7 11 .1 6.2 6.9 2.2 36-47 480 13.9 8.2 10.3 2.9 7.6 1.9 48-59 458 11.6 9.9 11 .4 4.2 7.2 4.4 Sex Male 1283 11 .5 11 .6 10 3.9 6.5 2.9 Female 1142 9.8 8.5 8.3 3.4 5.9 2.1 settlement type Urban 941 9.4 10.9 8.3 3.8 6.8 2.7 259 10.4 6.2 8.9 1.1 5.4 0.8 Peri-urban 1225 11 .8 10.4 9.9 4.1 5.9 2.8 Rural Region Damascus 514 10.1 12.5 12.3 2.7 7.4 1.2 Middle 576 8.7 6.9 7.4 1.6 4.5 2.1 Coastline 205 10.7 4.9 2.9 0 1.5 0.5 North 551 12.5 8.3 10.9 3.4 7.4 3.3 East 379 9.8 16.4 7.4 11 .9 8.7 5.3 South 200 14.5 12 11 .5 1 5 2 Total 2425 10.7 10.1 9.2 3.7 6.2 2.5 - 12- Fig.9/1 Percentage of wasted children Turkey Iraq weight for height Jordan 0 100 KM . Datnascus D Middle • Coastline D North • East D South ---- - - - Fig.9/1 Percentage of stunted or under-weight children Turkey Iraq under-weight 2.9%. 19.3%. height for age 15.6% . 26.5% . Jordan . Damascus 0 Middle • Coastline 0 North • East 0 South 100 KM Fig 9/ 2 A : Anthropometric indic ato rs for under-fives IJasted 20% Stunted 50% Under-weight 30% Fig 9 / 2 B Ant hropometri c indicator s for under-fives • Urban 1!!!1 Peri -urban • Rural (%)Wasted (%)Under - weight <%>Stunted Fig 9 / 2 C Anthropometric indicat o r s for under-f i ves .----------------------------------------r30 -0--Damascus Middle --coastl ine North 10 East 5 South L-------------------------------------+0 (%)\lasted (%)Under -weight <%>Stunted Vaccination coverage results Tables 9 (a) and (b) indicate that substantial numbers of under-fives lack a vaccination card, a critical part of the system to keep track of children's vaccination status. Over one-third of under-fives and over one-quarter of children aged 12-23 months did not have a card available at the time the survey, and cards could only be produced for inspection for only 37 percent of under-fives and 48.7 percent of children aged 12-23 months. Card unavailability for under-fives was highest in the North region (56.9 percent) and in peri-urban locations (50.5 percent). Table 9(a). Availability of vaccination cards by region (%). Damascus Middle Coastline North East South Children <5 Cards available & seen 46.7 37.9 48.9 31 20 51.4 Cards available but not seen 40.8 14.5 29.7 12.1 46.2 14 Cards not available 12.5 47.6 21 .4 56.9 33.8 34.6 Children 12·23 months Cards available & seen 60.7 49.1 60 36.8 32.1 64.3 Cards available but not seen 31 .1 12.1 25.5 12.8 41.7 11.9 Cards not available 8.2 38.8 14.5 50.4 26.2 23.8 Table 9(b). Availability of vaccination cards by settlement type(%). Urban Peri-urban Rural All Children< 5 Cards available & seen 43.1 34.4 32.6 36.9 Cards available but not seen 27.5 15.1 27 .9 26.5 Cards not available 29.4 50.5 39.5 36.6 Children 12-23 months Cards available & seen 56 44.2 44 48.7 Cards available but not seen 20.8 13.5 25.6 22.6 Card not available 23.2 42.3 30.4 28.7 Tables 9 (c) and (d), providing the vaccination status of those children with vaccination cards that were seen by the survey field workers, indicates that raising coverage levels remains a challenge in some areas and for some antigens. BCG coverage for children aged 12-23 months is 95.4 percent nationally, but only 81 percent in the East region. Coverage among children aged 12-23 months for the first dose ofDPT is 93.1 percent nationally, but only 78 percent in the East region, and the drop-out rate nationally between the first and third doses ofDPT is seven percent. For OPV, the drop-out rate between the first and third doses was also high, at 14.9 percent among under-fives and 8.2 percent among children 12-23 months, and OPVO coverage is only 81 percent. Measles coverage among children aged 24-35 months is 91.9 percent for the first dose but only 59.4 for the second. In general, coverage rates among children 12-23 months were lowest in the East region and then North regions; there were no major differences in coverage by settlement type. - 13- The vaccination status of children whose vaccination cards were not available or not seen was investigated through proxy reporting, i.e., mothers were asked to report the history of vaccination. Eighty-five percent of mothers reported a history of vaccination in the deltoid, 8'i .3 percent reported a history of intramuscular vaccination and 92.5 percent reported a history of oral vaccination. These rates were higher than those reported by the PAPCHILD survey in 1993. Table 9(c). Vaccination coverage among children aged 12-23 months with vaccination cards by region. Damascus Middle Coastline North East South BCG 100 96 100 91 81 96 DPT1 97 95 85 95 78 100 DPT2 96 95 85 84 70 93 DPT3 93 91 82 79 70 85 OPVO 93 82 97" 60 67 74 OPV1 97 91 97 91 78 93 OPV2 96 89 91 84 74 85 OPV3 92 88 91 77 67 81 Measles1 89 88 88 77 67 85 Measles2 45 33 42 42 33 33 HB1 97 95 91 60 81 89 HB2 93 86 91 49 67 78 HB3 78 72 67 30 63 70 Table 9(d). Vaccination coverage(%) among children with vaccination cards by settlement type. Children aged i2-23 months Children All children ayed 24-35 aged <5 months Urban Peri-urban Rural Total Total Total BCG 95.7 95.7 95.1 95.4 89.8 92.4 DPT1 97.4 91.3 89.3 93.1 96.4 89.9 DPT2 94.8 91 .3 83.6 89.3 94.9 82.8 DFT3 91.4 82.6 81.1 85.8 91.9 75.7 OPVO 85.3 73.9 78.7 81.2 76.1 74.1 OPV1 94.8 91.3 90.2 92.3 95.4 87.4 OPV2 91.4 91.3 85.2 88.5 92.9 81.4 OPV3 87.1 82.6 8~.8 84.7 90.4 74.4 Measles1 85.3 87 82 83.9 91 .9 68.6 Measles2 37.9 39.1 40.2 39.1 59.4 34.6 HB1 8G.3 78.3 91 87.4 82.2 68.9 HB2 76.7 69.6 84.4 79.7 76.6 57.5 HB3 62.1 43.5 72.1 65.1 68.5 37.9 - 14- ~ - - - - --~------------- Fig.10/1 Percentage coverage with EPI vaccines Children 12-23 months Turkey Iii Urban • Per 1 ~urban Iii Rural I Damascus D Middle I Coastline D North I East D South Fig 10/2 A : Coverage with EPI vaccines Children 12-23 months who had cards ,., ,., s . . tl > > ~ "- "- "' ~ 0 0 ro "' "" Fig 10/2 B : Coverage with EPI vaccines Children 12-23 months who had cards 20 40 60 80 BCG OPV/3§~~ HBV/3 100 90 80 70 60 50 40 30 20 10 0 100 Basic education results Tables 10 (a) and (b) indicate that primary cycle enrollment (children aged 6-11 years) is almost universal in Syria but that enrollment falls off considerably as students move to the secondary cycle (children aged 12-14 years). Primary net enrollment nationally is 96.5 percent, varying slightly by settlement type from 98.6 percent in urban areas to 91.6 percent in peri-urban areas, and by region from 99.6 percent in the Coastline region to 92.6 percent in the North region. Enrollment is 2.7 percentage points higher for males nationally, but is 7.2 points higher in peri-urban areas and 5.7 points higher in the East region. At the secondary level, net enrollment falls to 71.6 percent nationally, and to only 47 percent in peri-urban areas and 49.5 percent in the North region. Secondary level enrollment is slightly higher for girls and boys. Eighty-two percent of children successfully complete six years of primary education, and 53.8 percent of children complete three years of secondary education. Table 10 (a) . Primary and secondary enrollment ratios by region. Damascus Middle Coastline North East South Primary education (6-11 years) 99.3 97.5 99.2 95.5 98.1 100 Male 98 95.9 100 89.1 92.4 100 Female 98.7 96.8 99.6 92.6 95.5 100 Total Secondary education (12-14 years) Male 71.8 77.4 80 54 74 87.8 Female 77.5 69.4 98.7 44.5 82.3 92 Total 74.5 73.7 89.2 49.5 78.2 89.9 Table 10 (b) . Primary and secondary enrollment ratios by settlement type. Urban Peri-urban Rural All Primary education (6-11 years) Male 98.5 95 97.9 97.8 Female 98.8 87.8 93.4 95.1 Total 98.6 91.6 95.7 96.5 Secondary education (12-14 years) Male 72.8 47 75.6 71 Female 79.4 63.8 68 72.2 Total 76 55.2 72 71 .6 - 15- Fig.11/1 The primary and preparatory net enrollment ratio Turkey Jordan Iraq . Damascus ~ Preparatory D Middle • Coastline D North " Primary • East D South 0 100 KM I D Ill Ill • ~ Fig 11/2 A Enrollment ratios iii Urban iiiil Peri-urban iiiil Rural Damascus Middle Coastline North East South Preparatory (Females) Fig 11/2 B 0 Elementary (Males) + Elementary (Females) -+- Preparatory ·(Males) - f- Preparatory (Females) 20 I Preparatory <Males) ~~~--~=-~ 100 Elementary (Females) Elementary (Males) 90 80 70 60 50 40 30 20 10 0 : Enrollment ratios 40 60 80 100 I _l _l_ - Conclusion This study provided a host of data of use to policy-makers in their efforts to improve the quality of health care in Syria and address the priority health concerns of women and children. Among the major findings were the following: o Water supplies: Access to water supplies is generally good in Syria, with almost three-quarters of households connected to a water network and over 95 percent of households are connected to a water network or a well. But reliance on water tankers or other water sources is widespread in the East (28 percent of households) and in rural locations (23 .5 percent). o Sanitation facilities: Substantial numbers of households remain without access to adequate facilities for excreta disposal. Only two-thirds of households nationally, and only 43 .3 percent of East households and 31.2 percent of rural households, are connected to a piped sewerage system. One-quarter of East households and 17.2 percent of rural households are completely lacking sanitation facilities, posing an important environmental health concern. o Access to health services: Almost all households have relatively easy physical access to non-tertiary health facilities. Only 3.2 oftotal households have to travel more than 30 minutes to reach a health centre, although this proportion rises to 11.4 percent for East households and 6.6 percent for rural households. Tertiary care facilities are fewer in number but still almost three-quarters of households have a Government hospital within 30 minutes' travel time. o Salt iodization: Actual usage of iodized salt lags somewhat behind awareness of its importance. Almost three-quarters of households nationally are aware of iodized salt, but only 58 percent of aware households, and 35.6 percent of total households, actually use iodized salt. Awareness and usage are lowest in North, peri-urban and rural households. o Availability of oral rehydration salts: Oral rehydration salts still are not universally available in Syrian health care facilities . One-quarter of total public health centres and 22 percent of total government hospitals did not have ORS supplies at the time of the survey, despite the central importance of ORS to the Ministry of Health's national control of diarrhoeal diseases programme. Eight percent of households, most situated in rural areas, report having no access to a health facility providing ORS. o Management of diarrhoea episodes: There remains room for improvement in terms of parent's management of diarrhoea cases, pointing to the importance of the communications component of the national control of diarrhoeal disease programme. - 16- Only 27 percent of parents of children who had an episode of diarrhoea in the past two weeks preceding the survey used oral rehydration therapy (i.e. ORS, fluids, or both ORS and fluids), while 35.4 percent reduced food intake and 11 percent reduced fluid intake. Twenty-two percent ofbreast-feeding mothers reported stopping when their child suffered an episode of diarrhoea. o Breast-feeding patterns: The practice of breast-feeding is almost universal among mothers in Syria. Ninety -three percent of all mothers reported breast- feeding their youngest child, ranging from 99.2 percent in the South to 90.2 percent in the East. Oftotal mothers who had breast-fed, 76.2 percent did so for at least four months, and 33 percent continued breast-feeding for at least 12 months. The most important reasons cited for not breast-feeding were insufficient milk (37.1 percent) and mother's illness (18.6 percent). o Child nutrition: Child nutrition remains an area of concern in Syria. The percentage of under-fives below average height-for-age, i.e. suffering from stunting, typically the product of chronic under-nourishment, is 20.8 percent. The proportion of under-fives below average weight-for-age (male/female), or "under- weight", reflecting both chronic and acute under-nutrition, is 12.9 percent. The percentage ofunder-fives below average weight-for-height, i.e. suffering from wasting, a result of current and acute under-nutrition, is 8. 7 percent. Rates of severe stunting, under-weight, and wasting are 10.1 percent, 3.7 percent and 2.5 percent respectively; severe malnutrition is by far the highest in the East region, where 16.4 percent of under-fives are severely stunted, 11.9 percent are severely under-weight and 5.3 percent are severely wasted. o Vaccination coverage: Raising coverage levels remains a challenge in some areas and for some antigens. BCG coverage for children aged 12-23 months is 95.4 percent nationally, but only 81 percent in the East region. Coverage among children aged 12-23 months for the first dose ofDPT is 93.1 percent nationally, but only 78 percent in the East region. For OPV, the drop-out rate between the first and third doses is high, at 14.9 percent among under-fives and 8.2 percent among children 12-23 months, and OPVO coverage is only 81 percent. Measles coverage among children aged 24-35 months is 91.9 percent for the first dose but only 59.4 for the second. Substantial numbers of under-fives lack a vaccination card, a critical part of the system to keep track of children's vaccination status. o Basic education results: Primary cycle enrollment (children aged 6-11 years) is almost universal in Syria but enrollment falls off considerably as students move to the secondary cycle (children aged 12-14 years). The net enrollment is 96.5 percent at the primary level compared to only 71.6 percent at the secondary level. Secondary enrollment is particularly low in peri-urban areas and the North region, at 47 percent 49.5 percent respectively. Enrollment is slightly higher among boys at the primary level and slightly higher among girls at the secondary level. - 17- 1. Organization of the survel' Annex Methodolo2y in detail The Central Bureau of Statistics (CBS), in cooperation with other concerned bodies, started work on the-various elements of the survey during the second half of 1995. A technical committee was set up, comprising representatives of the State Planning Commission, Ministry of Health, CBS and UNICEF, to plan and prepare for the survey, adopt the sampling scheme, design the questionnaires, decide on the outcome tables and data processing , train the field workers and agree on the time schedule. Another committee comprising representatives from the MOH and CBS was set up to assist in the sampling and questionnaire design, adopt variable definitions and training instructions. The field work was carried out under the supervision of the directors of statistics departments and health in the provinces. The field team included women field workers from the Ministry of Health. 2. Questionnaire Design The survey questionnaire was designed to collect information on the following: Introductory data; covered 13 variables concerned with the household address, distribution of children according to age, sex and date of birth. • Data on water and sanitation; covered 4 items concerned with the source of drinking water, the continuity of the water in its source, the distance from the source and the type of sanitation • Data related to the accessibility of health services, which included the distance between the household and the nearest type of health facility, the common method of transport and the time of travel to the health facility. • The type of salt used at home; for which three questions were asked about the knowledge ofhousewife ofthe iodized salt, the use of iodized salt and the result of testing samples of the used salt. • Data on the availability of ORS in the health facilities. This included information on the availability of ORS at the time of study and also information on the loss of ORS in the previous year. • Data related to mothers' knowledge of diarrhoea management. This included questions on the food and fluid intake usually given to the child with diarrhoea, the timing of seeking medical advice, knowledge of danger signs and of ORS. • Data on the existence of diarrhoea episodes and its management. This included questions on the occurrence of any diarrhoeal episode among the under five in the two weeks preceding the study, type of treatment given to the child, type of referral point and whether breast feeding was stopped or not. • Data on breast feeding, where information was gathered on the prevalence of the practice of breast feeding, reasons for non breast feeding the child, duration of breast feeding and reasons for stopping breast feeding. • Data on anthropometric measurement, which included weight and height. - 18- • Data on vaccination. This included questions on the availability of vaccination cards, the type of vaccine and date of vaccination. • Data on basic education. This included questions on the enrollment of children in the schools, the level of schooling. The questionnaire was structured to facilitate computer coding and processing. The questions were of all types -close-ended, open-ended and semi-open-ended. 3. Sample design 3.1. Sampling frame The 1994 census provided a frame for the households. The established frame was recent and reliable, so it could be a valid frame for social and demographic investigations. The census unit used was considered to be the smallest statistical unit that could be relied on to reach the households. The maps that were made available after the 1994 census were used in reaching the census units and the census records used in preparing household lists. The size of census unit was 108 families in rural locations, 144 in small towns and 180 in large towns. 3.2. Sample size It was decided to cover urban and rural locations in all provinces. The study unit was considered to be the child under the age of five. Thus it was estimated that a sample of2,200 families would be enough to meet the study's objectives. On the basis of the 1993 PAPCHILD survey, it was expected to find 1,600 child under the age of five in the chosen sample. 3.3. Selection of sampling units Multi-stage cluster sampling was used in order to select the sampling units. The size of cluster was limited to 100 families. The method of systematic sampling was used to select the required number of clusters from the different types of settlement, so as to choose 10 families from each chosen cluster. This made a total of 220 clusters to satisfy the sample size. The distribution of clusters and families in each type of settlement, was as follows:. No. of clusters No. of families Urban 123 1230 Rural 97 970 Total 220 2200 In more detail, the sample was selected as follows: The whole country was considered as one administrative location ( one stratification), and the sampling fraction was estimated by dividing the total number of families by the number of required clusters (i.e. 220). - 19- Thus an estimation of the number of clusters and its distribution in different types of settlement was made. This ensured that the sample size was distributed equally with the number of people in each type of settlement, which meant that the sample was internally homogenous. According to the above. the settlements were selected at the first stage of sampling and also the number of clusters was decided on. In the second stage, the clusters were chosen in each type of settlement. This was done as follows: • In rural locations: Since the cluster size was 100 families, and because the census unit included 108 families, it was felt that those units should be of use in selecting the required number of clusters. It was satisfactory to divide the number of families in each settlement by 100 and to select the desired number using random method (approximately one cluster). • In urban locations: The number of population in the settlement was divided by 100 giving the number of clusters in the settlement. This is different from the census units which included 144 families in small towns and 180 in large towns. Thus it was necessary to reallocate the town or the location to clusters, each including 100 families. The maps were used to do that and to select the required number of clusters at random. The third stage of sampling included the selection of families, which was done using the systematic random sampling. A number between 1 and 10 was randomly chosen at the starting point in the cluster. The next family would be chosen by adding 10 to the previous number and so on until the total desired number of families was chosen. No allowance was made for the non-response, which was expected to be extremely low. -20-

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