Pakistan - Multiple Indicator Cluster Survey - 2014

Publication date: 2014

Punjab Final Report Monitoring the situation of children and women Multiple Indicator Cluster Survey 2014 Bureau of Statistics Planning & Development Department Government of the Punjab United Nations Children’s Fund Title page picture is taken by Ms. Shagufta (UNICEF) with the permission from Ms. Rukhsana with her one month daughter Mahnoor, in her house at basti nandanpura near Kacha Pakka in Kasur district, Punjab. Punjab Multiple Indicator Cluster Survey 2014 Final Report December, 2015* *Report was endorsed by MICS Steering Committee, Punjab in December, 2015 and disseminated in March, 2016 The Multiple Indicator Cluster Survey (MICS) Punjab, 2014 [Pakistan] was carried out in 2014 by Bureau of Statistics Punjab in collaboration with United Nations Children’s Fund (UNICEF). It was conducted as part of the fifth global round of MICS. Major funding was provided by Government of the Punjab through Annual Development Programme 2014-15 and the technical support was provided by the UNICEF. The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to support countries in the collection of internationally comparable data on a wide range of indicators on the situation of children and women. MICS surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. MICS Punjab, 2014 is the fourth MICS in Punjab since 2004. Information on the global MICS may be obtained from mics.unicef.org and information about Bureau of Statistics, Punjab from bos.gop.pk and pndpunjab.gov.pk Suggested citation Bureau of Statistics Punjab, Planning & Development Department, Government of the Punjab and UNICEF Punjab. Year of publication 2016. Multiple Indicator Cluster Survey, Punjab 2014, Final Report. Lahore, Pakistan. Bureau of Statistics Punjab, Planning & Development Department, Government of the Punjab and UNICEF Punjab. P a g e | iii SUMMARY TABLE OF SURVEY IMPLEMENTATION AND THE SURVEY POPULATION, MICS PUNJAB, 2014 Survey implementation Sample frame - Updated 1998 census 2010 Questionnaires Household Women (age 15-49) Children under five Interviewer training June-July, 2014 Fieldwork June to September 2014 Survey sample Households - Sampled - Occupied - Interviewed - Response rate (Percent) 41,413 39,333 38,405 97.6 Children under five - Eligible - Mothers/caretakers interviewed - Response rate (Percent) 31,083 27,495 88.5 Women - Eligible for interviews - Interviewed - Response rate (Percent) 61,286 53,668 87.6 Survey population Average household size 6.4 Percentage of population living in - Urban areas - Rural areas - Bahawalpur - D.G. Khan - Faisalabad - Gujranwala - Lahore - Multan - Sahiwal - Rawalpindi - Sargodha 33.4 66.6 10.7 8.9 12.7 14.5 17.3 12.1 6.9 9.4 7.5 Percentage of population under: - Age 5 - Age 18 12.7 43.3 Percentage of ever married women age 15-49 years with at least one live birth in the last 2 years 30.6 Housing characteristics Household or personal assets Percentage of households with - Electricity - Finished floor - Finished roofing - Finished walls 95.4 63.3 82.2 86.6 Percentage of households that own - A television - A refrigerator - Agricultural land - Farm animals/livestock 67.6 53.1 30.5 45.5 Mean number of persons per room used for sleeping 3.91 Percentage of households where at least a member has or owns a - Mobile phone - Car or Van 92.6 5.8 P a g e | iv SUMMARY TABLE OF FINDINGS1 Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDGs) Indicators, Punjab, 2014 Indicator No. Indicator Description ValueA MICS MDG CHILD MORTALITY Early childhood mortality 1.2 MDG 4.2 Infant mortality rate Probability of dying between birth and the first birthday 75.0 1.5 MDG 4.1 Under-five mortality rate Probability of dying between birth and the fifth birthday 93.0 A Indicator values are per 1,000 live births and rates refer to April, 2011. The East Model was assumed to approximate the age pattern of mortality in Punjab, Pakistan and calculations are based on the Time Since First Birth (TSFB) version of the indirect children ever born/children surviving method. Indicator No. Indicator Description Value MICS MDG NUTRITION Nutritional status 2.1a 2.1b MDG 1.8 Underweight prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard 33.7 11.3 2.2a 2.2b Stunting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height for age of the WHO standard 33.5 13.3 2.3a 2.3b Wasting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard 17.5 4.4 2.4 Overweight prevalence Percentage of children under age 5 who are above two standard deviations of the median weight for height of the WHO standard 0.8 Breastfeeding and infant feeding 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 93.7 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last newborn to the breast within one hour of birth 10.6 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 16.8 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 47.8 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 65.6 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 34.5 2.11 Median duration of breastfeeding The age in months when 50 percent of children age 0-35 months did not receive breast milk during the previous day 17.4 months 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fed during the previous day 41.2 1 See Appendix F for a detailed description of MICS indicators P a g e | v Indicator No. Indicator Description Value MICS MDG 2.13 Introduction of solid, semi- solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day 61.1 2.14 Milk feeding frequency for non-breastfed children Percentage of non-breastfed children age 6-23 months who received at least 2 milk feedings during the previous day 90.8 2.15 Minimum meal frequency Percentage of children age 6-23 months who received solid, semi-solid and soft foods (plus milk feeds for non- breastfed children) the minimum number of times or more during the previous day 65.3 2.16 Minimum dietary diversity Percentage of children age 6–23 months who received foods from 4 or more food groups during the previous day 17.3 2.17a 2.17b Minimum acceptable diet (a) Percentage of breastfed children age 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day (b) Percentage of non-breastfed children age 6–23 months who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day 11.2 7.3 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 57.7 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodate 49.2 Low-birthweight 2.20 Low-birth weight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 29.4 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 25.6 Vitamin A 2.S1 Vitamin A supplementation Percentage of children age 6-59 months who received at least one high-dose vitamin A supplement in the 6 months preceding the survey 64.8 CHILD HEALTH Vaccinations 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 92.8 3.2 Polio immunization coverage Percentage of children age 12-23 months who received the third dose of OPV vaccine (OPV3) by their first birthday 84.8 3.3 3.5 3.6 Diphtheria, pertussis and tetanus (DPT), hepatitis B (HepB) and haemophilus influenza type B (Hib) (PENTA) immunization coverage Percentage of children age 12-23 months who received the third dose of PENTA vaccine (diphtheria, pertussis, tetanus, hepatitis B and haemophilus influenza B) by their first birthday 71.7 3.4 MDG 4.3 Measles immunization coverage Percentage of children age 12-23 months who received measles vaccine by their first birthday 71.6 3.8 Full immunization coverage Percentage of children age 12-23 months who received all vaccinations recommended in the national immunization schedule by their first birthday 56.6 Tetanus toxoid 3.9 Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years who were given at least two doses of tetanus toxoid vaccine within the appropriate interval prior to the most recent birth 76.4 P a g e | vi Indicator No. Indicator Description Value MICS MDG Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 17.4 3.10 Care-seeking for diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 72.1 3.11 Diarrhoea treatment with oral rehydration salts (ORS) and zinc Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS and zinc 9.7 3.12 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet, pre-packaged ORS fluid, recommended homemade fluid or increased fluids) and continued feeding during the episode of diarrhoea 38.9 Acute Respiratory Infection (ARI) symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 2.5 3.13 Care-seeking for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 77.1 3.14 Antibiotic treatment for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics 39.1 Solid fuel use 3.15 Use of solid fuels for cooking Percentage of household members in households that use solid fuels as the primary source of domestic energy to cook 61.1 Malaria / Fever - Children with fever Percentage of children under age 5 with fever in the last 2 weeks 20.8 3.20 Care-seeking for fever Percentage of children under age 5 with fever in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 79.3 3.21 Malaria diagnostics usage Percentage of children under age 5 with fever in the last 2 weeks who had a finger or heel stick for malaria testing 4.0 3.22 MDG 6.8 Anti-malarial treatment of children under age 5 Percentage of children under age 5 with fever in the last 2 weeks who received any antimalarial treatment 1.3 3.23 Treatment with Artemisinin-based Combination Therapy (ACT) among children who received anti-malarial treatment Percentage of children under age 5 with fever in the last 2 weeks who received ACT (or other first-line treatment according to national policy) 9.4* 3.25 Intermittent preventive treatment for malaria during pregnancy Percentage of women age 15-49 years who received three or more doses of SP/Fansidar, at least one of which was received during an ANC visit, to prevent malaria during their last pregnancy that led to a live birth in the last 2 years 0.4 *Indicator denominator based on 25-49 unweighted cases - only shown here in summary table and not in main report chapter. WATER AND SANITATION 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 94.4 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 2.1 4.3 MDG 7.9 Use of improved sanitation (Not shared) Percentage of household members using improved sanitation facilities which are not shared 66.2 P a g e | vii Indicator No. Indicator Description Value MICS MDG 4.S1 Use of improved sanitation Percentage of household members using improved sanitation facilities whether shared or not shared 75.1 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 71.4 4.5 Place for handwashing Percentage of households with a specific place for hand washing where water and soap or other cleansing agent are present 79.6 4.6 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent available anywhere in the household 92.8 REPRODUCTIVE HEALTH Contraception and unmet need - Total fertility rate Total fertility rateA for women age 15-49 years 3.5 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rateA for women age 15-19 years 34.0 5.2 Early childbearing Percentage of ever married women age 20-24 years who had at least one live birth before age 18 11.8 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women age 15-49 years currently married who are using (or whose partner is using) a (modern or traditional) contraceptive method 38.7 5.4 MDG 5.6 Unmet need Percentage of women age 15-49 years who are currently married who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 17.5 A The age-specific fertility rate is defined as the number of live births to women in a specific age group during a specified period, divided by the average number of women in that age group during the same period, expressed per 1,000 women. The age-specific fertility rate for women age 15-19 years is also termed as the adolescent birth rate. The total fertility rate (TFR) is calculated by summing the age-specific fertility rates calculated for each of the 5-year age groups of women, from age 15 through to age 49. The TFR denotes the average number of children to which a woman will have given birth by the end of her reproductive years (by age 50) if current fertility rates prevailed. Maternal and newborn health 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women age 15-49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 78.8 48.0 5.6 Content of antenatal care Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 45.3 5.S1 Content of antenatal care (All four) Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure measured, weight measured and gave urine and blood samples during the last pregnancy that led to a live birth 36.3 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women age 15-49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 64.7 5.8 Institutional deliveries Percentage of women age 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 60.8 5.9 Caesarean section Percentage of women age 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 23.6 Post-natal health checks 5.10 Post-partum stay in health facility Percentage of women age 15-49 years who stayed in the health facility for 12 hours or more after the delivery of their most recent live birth in the last 2 years 52.0 P a g e | viii Indicator No. Indicator Description Value MICS MDG 5.11 Post-natal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery 88.8 5.12 Post-natal health check for the mother Percentage of women age 15-49 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 86.3 CHILD DEVELOPMENT 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 25.7 6.2 Support for learning Percentage of children age 36-59 months with whom an adult has engaged in four or more activities to promote learning and school readiness in the last 3 days 35.0 6.3 Father’s support for learning Percentage of children age 36-59 months whose biological father has engaged in four or more activities to promote learning and school readiness in the last 3 days 2.6 6.4 Mother’s support for learning Percentage of children age 36-59 months whose biological mother has engaged in four or more activities to promote learning and school readiness in the last 3 days 11.8 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 7.6 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 52.5 6.7 Inadequate care Percentage of children under age 5 left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week 6.8 6.8 Early child development index Percentage of children age 36-59 months who are developmentally on track in at least three of the following four domains: literacy-numeracy, physical, social- emotional, and learning 67.2 LITERACY AND EDUCATION 7.1 MDG 2.3 Literacy rate among young women Percentage of young women age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education 72.6 7.S1 Literacy rate 10+ (reported) Percentage of household members age 10 years or older where it is reported that they are able to both read & write with understanding in any language excluding quranic reading, if this was the only response 60.8 7.S2 Literacy rate 15+ (reported) Percentage of household members age 15 years or older where it is reported that they are able to both read & write with understanding in any language excluding quranic reading, if this was the only response 58.0 7.S3 Literacy rate 15-24 years (reported) Percentage of household members age 15-24 years where it is reported that they are able to both read & write with understanding in any language excluding quranic reading, if this was the only response 75.9 7.2 School readiness Percentage of children in first grade of primary school who attended preschool during the previous school year 92.5 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 23.4 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school 57.9 7.S4 Primary school gross attendance ratio (adjusted) Percentage of children of all age currently attending primary or secondary school 86.1 P a g e | ix Indicator No. Indicator Description Value MICS MDG 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 42.1 7.6 MDG 2.2 Children reaching last grade of primary Percentage of children entering the first grade of primary school who eventually reach last grade 95.8 7.7 Primary completion rate Number of children attending the last grade of primary school (excluding repeaters) divided by number of children of primary school completion age (age appropriate to final grade of primary school) 74.9 7.8 Transition rate to secondary school Number of children attending the last grade of primary school during the previous school year who are in the first grade of secondary school during the current school year divided by number of children attending the last grade of primary school during the previous school year 91.4 7.9 MDG 3.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 0.97 7.10 MDG 3.1 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 0.98 7.S5 Government school attendance rate (primary) Percentage of children aged 5-9 years attending Government primary schools 54.2 CHILD PROTECTION Birth registration 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 72.7 Child labour 8.2 Child labour Percentage of children age 5-17 years who are involved in child labour2 16.4 Child discipline 8.3 Violent discipline Percentage of children age 1-14 years who experienced psychological aggression or physical punishment during the last one month 80.7 Early marriage and polygyny 8.4 Marriage before age 15 Percentage of women age 15-49 years who were first married before age 15 5.2 8.5 Marriage before age 18 Percentage of women age 20-49 years who were first married before age 18 20.8 8.6 Young women age 15-19 years currently married Percentage of women age 15-19 years who are married 9.2 8.7 Polygyny Percentage of women age 15-49 years who are in a polygynous marriage 2.5 8.8a 8.8b Spousal age difference Percentage of young women who are married and whose spouse is 10 or more years older, (a) among women age 15-19 years, (b) among women age 20-24 years 18.8 14.6 Attitudes towards domestic violence 8.12 Attitudes towards domestic violence Percentage of women age 15-49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food 39.8 2 Children involved in child labour are defined as children involved in economic activities at or above the age-specific thresholds, children involved in household chores at or above the age-specific thresholds, and children involved in hazardous work P a g e | x Indicator No. Indicator Description Value MICS MDG Children’s living arrangements 8.13 Children’s living arrangements Percentage of children age 0-17 years living with neither biological parent 1.4 8.14 Prevalence of children with one or both parents dead Percentage of children age 0-17 years with one or both biological parents dead 4.8 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 3.9 HIV/AIDS HIV/AIDS knowledge and attitudes - Have heard of AIDS Percentage of ever married3 women age 15-49 years who have heard of AIDS 39.0 9.S1 Knowledge about HIV prevention among young women Percentage of ever married young women age 15-24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission 3.3 9.S2 Knowledge of mother-to- child transmission of HIV Percentage of ever married women age 15-49 years who correctly identify all three means of mother-to-child transmission of HIV 23.6 9.S3 Accepting attitudes towards people living with HIV Percentage of ever married women age 15-49 years expressing accepting attitudes on all four questions toward people living with HIV 19.0 HIV testing 9.S4 Women who know where to be tested for HIV Percentage of ever married women age 15-49 years who state knowledge of a place to be tested for HIV 8.5 9.S5 Women who have been tested for HIV and know the results Percentage of ever married women age 15-49 years who have been tested for HIV in the last 12 months and who know their results 0.6 9.S7 HIV counselling during antenatal care Percentage of ever married women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they received counselling on HIV during antenatal care 1.3 9.S8 HIV testing during antenatal care Percentage of ever married women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they were offered and accepted an HIV test during antenatal care and received their results 1.1 9.16 MDG 6.4 Ratio of school attendance of orphans to school attendance of non- orphans Proportion attending school among children age 10-14 years who have lost both parents divided by proportion attending school among children age 10-14 years whose parents are alive and who are living with one or both parents (0.83)* *Indicator denominator based on 25-49 unweighted cases - only shown here in summary table and not in main report chapter. ACCESS TO MASS MEDIA AND ICT Access to mass media 10.1 Exposure to mass media Percentage of women age 15-49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television 1.3 Use of information/communication technology 10.2 Use of computers Percentage of women age 15-24 years who used a computer during the last 12 months 21.4 3 The modules of “Individual questionnaire for women” i.e. “Fertility”, “Desire for last birth”, “Maternal and newborn health”, “Post-natal health checks”, “Contraception”, “Unmet Need” &“HIV/AIDS” were asked to ever married women (age 15-49 years) only. P a g e | xi Indicator No. Indicator Description Value MICS MDG 10.3 Use of internet Percentage of women age 15-24 years who used the internet during the last 12 months 12.4 SUBJECTIVE WELL-BEING 11.1 Life satisfaction Percentage of young women age 15-24 years who are very or somewhat satisfied with their life, overall 90.5 11.2 Happiness Percentage of young women age 15-24 years who are very or somewhat happy 90.9 11.3 Perception of a better life Percentage of young women age 15-24 years whose life improved during the last one year, and who expect that their life will be better after one year 59.2 TOBACCO USE Tobacco use 12.1 Tobacco use Percentage of women age 15-49 years who smoked cigarettes, or used smoked or smokeless tobacco products at any time during the last one month 4.1 12.2 Smoking before age 15 Percentage of women age 15-49 years who smoked a whole cigarette before age 15 0.2 ADULT HEALTH AND HEALTH CARE Adult health care 13.S1 Care provided by Lady Health Worker (LHW) Number of ever married women aged 15–49 years who have given birth in the previous 2 years and were visited by a Lady Health Worker (LHW) in the last month 37.6 13.S2 Prevalence of chronic cough Number of household members with cough that lasted for the past 3 weeks 3.2 13.S3 Reported tuberculosis Number of household members that were diagnosed with tuberculosis in the past year 0.5 13.S4 Reported hepatitis Number of household members that were diagnosed with hepatitis in the past year 1.5 SOCIO-ECONOMIC DEVELOPMENT Assets 14.S1 Ownership of assets: House, land, livestock Percentage of household members living in a household that own a house, land or livestock a) House b) Agriculture land c) Livestock 87.0 30.5 45.5 Unemployment 14.S2 Unemployment rate (10+ years) Percent of household members aged 10 years or older who are unemployed and are seeking jobs 7.1 Housing4 14.S10 Mean household size Average members in a household 6.4 14.S11 Currently married population Percentage of household members of age 10 years and above currently married 51.4 14.S12 Mean number of persons per room Average members sleeping in one room 3.91 14.S13a 14.S13b 14.S13c Household characteristics Main material of floor, roof and wall a) finished floor (pacca) b) finished roof (pacca) c) finished wall (pacca)] 63.4 82.2 86.6 4 The information related to provincial indicator 14.S10 and 14.S12 & 14.S13 is given in chapter III “sample coverage and the characteristics of households and respondents” at Table HH.3 and HH.6 respectively. P a g e | xii Indicator No. Indicator Description Value MICS MDG Remittances and zakat 14.S3 Population working outside village/city/country Percentage of family members working outside village/city/country 12.0 14.S4 Receiving remittances from within Pakistan Percentage of household members who received remittances from within Pakistan during the year preceding the survey 3.1 14.S5 Receiving remittances from abroad Percentage of household members living in a household that received remittances from abroad during the year preceding the survey 7.3 14.S6 Receiving cash donation Percentage of household members living in a household that received cash donation such as zakat or other means during the year preceding the survey 1.2 Social benefits and Subsidies 14.S7 Safety nets (getting benefits from government schemes of social protection) Percentage of household members living in a household that got benefits from government schemes of social protection [Benefits include: zakat, dearness allowance, health subsidy, education subsidy, marriage grant, subsidized food, others] 7.2 14.S8a Purchasing goods from government utility stores Percentage of household members living in a household that purchase goods from government utility stores 18.0 14.S8b Regular purchase from utility stores Percentage of household members who purchase goods from government utility stores regularly 29.5 14.S9 Receiving pensions Percentage of household who received pension during the year preceding the survey 8.1 P a g e | xiii Table of Contents SUMMARY TABLE OF SURVEY IMPLEMENTATION AND THE SURVEY POPULATION, MICS PUNJAB, 2014 . iii SUMMARY TABLE OF FINDINGS . iv LIST OF TABLES . xvi LIST OF FIGURES . xx LIST OF ABBREVIATIONS . xxi FOREWORD . xxii ACKNOWLEDGEMENTS . xxiii EXECUTIVE SUMMARY . xxiv MAP OF THE PUNJAB . xxx I. INTRODUCTION . 1 Background . 1 Survey Objectives . 2 Report Structure . 2 II. SAMPLE AND SURVEY METHODOLOGY . 3 Sample Design . 3 List of Indicators . 3 Questionnaires . 4 Pretesting of Questionnaires . 5 Appointment of Regional Supervisors . 5 Training . 5 Field Work . 6 Monitoring Mechanism . 6 Data Processing . 7 International Review . 8 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS . 9 Sample Coverage . 9 Characteristics of Households . 11 Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 . 13 Housing Characteristics, Asset Ownership, and Wealth Quintiles . 17 IV. CHILD MORTALITY . 21 V. NUTRITION . 26 Low Birth Weight . 26 Nutritional Status . 28 Breastfeeding and Infant and Young Child Feeding . 33 Salt Iodization . 45 Children’s Vitamin A Supplementation. 47 VI. CHILD HEALTH . 50 Vaccinations . 50 Neonatal Tetanus Protection . 53 Care of Illness. 55 Diarrhoea . 57 P a g e | xiv Acute Respiratory Infections . 68 Solid Fuel Use. 71 Malaria/Fever . 73 VII. WATER AND SANITATION . 80 Use of Improved Water Sources . 80 Use of Improved Sanitation . 86 Handwashing . 95 VIII. REPRODUCTIVE HEALTH . 98 Fertility . 98 Contraception . 103 Unmet Need . 106 Antenatal Care . 108 Assistance at Delivery . 113 Place of Delivery . 116 Post-natal Health Checks . 118 IX. EARLY CHILDHOOD DEVELOPMENT . 128 Early Childhood Care and Education . 128 Quality of Care . 129 Developmental Status of Children . 135 X. LITERACY AND EDUCATION . 138 Literacy among Young Women . 138 School Readiness . 139 Preschool Attendance. 140 Primary and Secondary School Participation . 141 Literacy Rate . 153 Literacy Rate (10+ years) . 153 Literacy Rate (15+ years) . 155 Literacy Rate (15-24 years) . 156 Public and private primary school attendance rate . 157 XI. CHILD PROTECTION . 159 Birth Registration . 159 Child Labour . 161 Child Discipline. 166 Early Marriage and Polygyny . 170 Attitudes toward Domestic Violence . 176 Children’s Living Arrangements . 178 XII. HIV/AIDS . 181 Knowledge about HIV Transmission and Misconceptions about HIV . 181 Accepting Attitudes toward People Living with HIV . 185 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care . 186 HIV Indicators for Young Women . 189 XIII. ACCESS TO MASS MEDIA AND USE OF INFORMATION/COMMUNICATION TECHNOLOGY . 191 Access to Mass Media . 191 Use of Information/Communication Technology . 192 XIV. SUBJECTIVE WELL-BEING. 194 XV. TOBACCO USE . 200 Tobacco Use . 200 P a g e | xv XVI. ADULT HEALTH AND HEALTH CARE . 204 Chronic Cough, Tuberculosis and Hepatitis . 204 Lady Health Worker Visits. 205 XVII. SOCIO ECONOMIC DEVELOPMENT . 206 Introduction . 206 Ownership Status of Household . 206 Remittances and Cash Donations . 207 Remittances . 208 Cash Donations . 211 Social Benefits, Subsidies and Family Support Programmes . 212 Possession of Bank Account . 215 Marital Status . 215 Unemployment . 217 APPENDICES . 219-480 Appendix A. District Tables . 219 Appendix B. Sample Design . 350 Appendix C. List of Personnel Involved in the Survey/survey committees . 356 Appendix D. Estimates of Sampling Errors . 366 Appendix E. Data Quality Tables . 380 Appendix F. MICS5 Indicators: Numerators and Denominators . 398 Appendix G. Questionnaires . 410 P a g e | xvi LIST OF TABLES Table HH.1: Results of household, women's and children under-5 interviews . 10 Table HH.2: Household age distribution by sex . 11 Table HH.3: Household composition . 13 Table HH.4: Women's background characteristics . 14 Table HH.5: Under-5's background characteristics . 16 Table HH.6: Housing characteristics . 18 Table HH.7: Household and personal assets . 19 Table HH.8: Wealth quintiles . 20 Table CM.1: Children ever born, children surviving and proportion dead . 21 Table CM.2: Infant and under-5 mortality rates by age groups of women . 22 Table CM.3: Infant and under-5 mortality rates by background characteristics . 22 Table NU.1: Low birth weight infants . 27 Table NU.2: Nutritional status of children . 31 Table NU.3: Initial breastfeeding . 35 Table NU.4: Breastfeeding. 37 Table NU.5: Duration of breastfeeding . 39 Table NU.6: Age-appropriate breastfeeding . 40 Table NU.7: Introduction of solid, semi-solid, or soft foods . 41 Table NU.8: Infant and young child feeding (IYCF) practices . 42 Table NU.9: Bottle feeding . 44 Table NU.10: Iodized salt consumption . 45 Table NU.11: Children's vitamin A supplementation . 48 Table CH.1: Vaccinations in the first years of life. 51 Table CH.2: Vaccinations by background characteristics . 53 Table CH.3: Neonatal tetanus protection . 54 Table CH.4: Reported disease episodes . 56 Table CH.5: Care-seeking during diarrhoea . 58 Table CH.6: Feeding practices during diarrhoea . 59 Table CH.7: Oral rehydration solutions, recommended homemade fluids, and zinc . 61 Table CH.8: Oral rehydration therapy with continued feeding and other treatments . 63 Table CH.9: Source of ORS and zinc . 66 Table CH.10: Care-seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI) . 69 Table CH.11: Knowledge of the two danger signs of pneumonia . 70 Table CH.12: Solid fuel use. 72 Table CH.13: Solid fuel use by place of cooking . 73 Table CH.14: Care-seeking during fever . 74 Table CH.15: Treatment of children with fever . 76 Table CH.16: Diagnostics and anti-malarial treatment of children . 77 Table CH.17: Source of anti-malarial . 78 Table CH.18: Intermittent preventive treatment for malaria . 79 Table WS.1: Use of improved water sources . 81 Table WS.2: Household water treatment . 84 Table WS.3: Time to source of drinking water . 85 Table WS.4: Person collecting water . 86 Table WS.5: Types of sanitation facilities . 88 Table WS.6: Use and sharing of sanitation facilities . 90 Table WS.7: Drinking water and sanitation ladders . 93 Table WS.8: Disposal of child's faeces . 94 Table WS.9: Water and soap at place for handwashing . 96 Table WS.10: Availability of soap or other cleansing agent. 97 Table RH.1: Fertility rates. 98 P a g e | xvii Table RH.2: Adolescent birth rate and total fertility rate . 100 Table RH.3: Early childbearing . 101 Table RH.4: Trends in early childbearing . 102 Table RH.5: Use of contraception . 104 Table RH.6: Unmet need for contraception . 107 Table RH.7: Antenatal care coverage . 110 Table RH.8: Number of antenatal care visits and timing of first visit . 111 Table RH.9: Content of antenatal care . 112 Table RH.10: Assistance during delivery and cesarean section . 114 Table RH.11: Place of delivery. 117 Table RH.12: Post-partum stay in health facility . 119 Table RH.13: Post-natal health checks for newborns . 120 Table RH.14: Post-natal care visits for newborns within one week of birth . 122 Table RH.15: Post-natal health checks for mothers . 123 Table RH.16: Post-natal care visits for mothers within one week of birth . 125 Table RH.17: Post-natal health checks for mothers and newborns . 127 Table CD.1: Early childhood education . 128 Table CD.2: Support for learning . 130 Table CD.3: Learning materials . 133 Table CD.4: Inadequate care . 135 Table CD.5: Early child development index . 137 Table ED.1: Literacy (young women) . 138 Table ED.2: School readiness . 139 Table ED.2A: Pre-school attendance . 140 Table ED.3: Primary school entry . 142 Table ED.4: Primary school net attendance and out of school children . 143 Table ED.4B: Primary school gross attendance ratio of school children (5-9) years . 145 Table ED.5: Secondary school attendance and out of school children . 146 Table ED.6: Children reaching last grade of primary school . 148 Table ED.7: Primary school completion and transition to secondary school . 149 Table ED.8: Education gender parity index (GPI) . 151 Table ED.9: Out of school gender parity . 152 Table ED.10: Literacy rate 10+ . 154 Table ED.11: Literacy rate 15+ . 155 Table ED.12: Literacy rate 15-24 years . 157 Table ED.13: Public and private primary school attendance rate . 158 Table CP.1: Birth registration . 159 Table CP.2: Children's involvement in economic activities . 163 Table CP.3: Children's involvement in household chores. 164 Table CP.4: Child labour . 165 Table CP.5: Child discipline . 167 Table CP.6: Attitudes toward physical punishment . 169 Table CP.7: Early marriage and polygyny (women) . 171 Table CP.8: Trends in early marriage (women) . 173 Table CP.9: Spousal age difference . 175 Table CP.10: Attitudes toward domestic violence (women) . 177 Table CP.11: Children's living arrangements and orphanhood . 179 Table CP.12: Children with parents living abroad . 180 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV/AIDS, and comprehensive knowledge about HIV transmission (women) . 182 Table HA.2: Knowledge of mother-to-child HIV transmission (women) . 184 Table HA.3: Accepting attitudes toward people living with HIV/AIDS (women) . 185 Table HA.4: Knowledge of a place for HIV testing (women) . 187 P a g e | xviii Table HA.5: HIV counselling and testing during antenatal care . 188 Table HA.6: Key HIV/AIDS indicators (young women) . 190 Table MT.1: Exposure to mass media (women) . 191 Table MT.2: Use of computers and internet (women) . 193 Table SW.1: Domains of life satisfaction (women) . 195 Table SW.2: Overall life satisfaction and happiness (women) . 198 Table SW.3: Perception of a better life (women) . 199 Table TA.1: Current and ever use of tobacco (women) . 201 Table TA.2: Age at first use of cigarettes and frequency of use (women) . 203 Table HC.1: Prevalence of Cough, TB and Hepatitis . 204 Table HC.2: Care provided by lady health worker (LHW) . 205 Table SED.1: House, agricultural land and livestock ownership . 206 Table SED.2: Working outside village / city/country . 208 Table SED.3: Receiving remittance from within Pakistan . 209 Table SED.4: Receiving remittance from abroad . 210 Table SED.5: Received zakat/donations . 211 Table SED.6: Pension Benefits . 212 Table SED.7: Safety nets (social protection) . 213 Table SED.8: Safety nets (utility store) . 214 Table SED.9: Possession of Bank Account . 215 Table SED.10: Marital status of household members . 216 Table SED.11: Un-employment rate 10 years and above . 218 Tables in Appendices: District Tables . 219 Table SD.1: Allocation of Sample Clusters (Primary Sampling Units) to Sampling Strata . 352 Table SE.1: Indicators selected for sampling error calculations. 367 Table SE.2: Sampling errors: Total sample . 368 Table SE.3: Sampling errors: Urban . 369 Table SE.4: Sampling errors: Rural . 370 Table SE.5: Sampling errors: Bahawalpur division . 371 Table SE.6: Sampling errors: DG Khan division . 372 Table SE.7: Sampling errors: Faisalabad division . 373 Table SE.8: Sampling errors: Gujranwala division . 374 Table SE.9: Sampling errors: Lahore division . 375 Table SE.10: Sampling errors: Multan division . 376 Table SE.11: Sampling errors: Rawalpindi division . 377 Table SE.12: Sampling errors: Sahiwal division . 378 Table SE.13: Sampling errors: Sargodha division . 379 Table DQ.1: Age distribution of household population . 380 Table DQ.2: Age distribution of eligible and interviewed women . 381 Table DQ.3: Age distribution of children in household and under-5 questionnaires . 381 Table DQ.4: Birth date reporting: Household population . 382 Table DQ.5: Birth date and age reporting: Women . 383 Table DQ.6: Birth date and age reporting: Under-5s . 384 Table DQ.7: Birth date reporting: Children, adolescents and young people . 385 Table DQ.8: Birth date reporting: First and last births . 386 Table DQ.9: Completeness of reporting . 387 P a g e | xix Table DQ.10: Completeness of information for anthropometric indicators: Underweight . 387 Table DQ.11: Completeness of information for anthropometric indicators: Stunting . 388 Table DQ.12: Completeness of information for anthropometric indicators: Wasting . 388 Table DQ.13: Heaping in anthropometric measurements . 388 Table DQ.14: Observation of birth certificates . 389 Table DQ.15: Observation of vaccination cards . 390 Table DQ.16: Observation of women's health cards . 391 Table DQ.17: Observation of the place for handwashing . 392 Table DQ.18: Respondent to the under-5 questionnaire . 393 Table DQ.19: Selection of children age 1-17 years for the child labour and child discipline modules . 394 Table DQ.20: School attendance by single age . 395 Table DQ.21: Sex ratio at birth among children ever born and living . 396 P a g e | xx LIST OF FIGURES Figure HH.1: Age and sex distribution of household population. 12 Figure CM.1: Under-5 mortality rates by area and region . 24 Figure CM.2: Trend in under-5 mortality and Infant Mortality rates . 25 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe) . 30 Figure NU.2: Initiation of breastfeeding . 36 Figure NU.3: Infant feeding patterns by age . 38 Figure NU.4: Consumption of iodized salt . 47 Figure CH.1: Vaccinations by age 12 months (measles by 24 months) . 52 Figure CH.2: Children under-5 with diarrhoea who received ORS or recommended homemade liquids . 62 Figure CH.3: Children under-5 with diarrhoea receiving oral rehydration therapy (ORT) and continued feeding . 65 Figure WS.1: Percent distribution of household members by source of drinking water . 83 Figure WS.2: Percent distribution of household members by use and sharing of sanitation facilities . 89 Figure WS.3: Use of improved drinking water sources and improved sanitation facilities by household members . 92 Figure RH.1: Age-specific fertility rates by area . 99 Figure RH.2: Differentials in contraceptive use . 103 Figure RH.3: Person assisting at delivery . 116 Figure ED.1: Education indicators by sex . 153 Figure CP.1: Children under-5 whose births are registered . 161 Figure CP.2: Child disciplining methods, children age 1-14 years . 168 Figure CP.3: Early marriage among women . 172 Figure HA.1: Women and men with comprehensive knowledge of HIV transmission . 183 Figure HA.2: Accepting attitudes toward people living with HIV/AIDS . 186 Figure TA.1: Ever and current smokers by age group . 201 Figures in Appendix: Figure DQ.1: Household population by single ages . 397 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points . 397 P a g e | xxi LIST OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome BCG Bacillus-Calmette-Guerin (Tuberculosis) BHU Basic Health Unit BoS Bureau of Statistics CSPro Census and Survey Processing System DPT Diphtheria Pertussis Tetanus ECDI Early Child Development Index EOBI Employees Old-Age Benefits Institution EPI Expanded Programme on Immunization GPI Gender Parity Index GAR Gross Attendance Rate HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders IMR Infant Mortality Rate IUD Intrauterine Device LAM Lactational Amenorrhea Method LHV Lady Health Visitor LHW Lady Health Worker MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS5 Fifth global round of Multiple Indicator Clusters Surveys programme NAR Net Attendance Rate ORT Oral Rehydration Treatment PBS Pakistan Bureau of Statistics P&DD Planning and Development Department PENTA Combination of 5 Vaccines (Diphtheria, Pertussis, Tetanus, Haemophilu influenzae B (HIB) and Hepatitis B) PNC Post-natal Care PNHC Post-natal Health Checks ppm Parts Per Million PSUs Primary Sampling Units ROSA Regional Office for South Asia – UNICEF SDGs Sustainable Development Goals SPSS Statistical Package for Social Sciences SSUs Secondary Sampling Units TBAs Traditional Birth Attendants TFR Total Fertility Rate U5MR Under 5 Mortality Rate UN United Nations UNAIDS United Nations Programme on HIV/AIDS UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit for Children WHO World Health Organization ASFR Age Specific Fertility Rate P a g e | xxii FOREWORD Social sector has remained a priority area for the Government of Punjab. Development outlays for the sector have grown manifold over the last few years. Government of the Punjab, along with the national and international partners, is committed to achieve the Sustainable Development Goals (SDGs)/Millennium Development Goals (MDGs) vis-a-vis education, health, water supply, sanitation, poverty etc. This would require not only provision of adequate resources but also a very robust system for ascertaining the area specific needs, efficient use of resources and regular monitoring of the results and impacts. The first district based Multiple Indicator Cluster Survey (MICS) was conducted 2003-04. This survey provided benchmark for a number of indicators at district level and created a culture for using data for planning purposes. The raw data was shared with academia, research organizations and development partners for carrying out further research. Second and third round of MICS Punjab took place in 2007-08 and 2011. These surveys proved to be the most imperative tools in determining government budgetary outlays, particularly for the social sector. Besides many international papers, various students have completed their M.Phil/Ph.D theses by using the MICS data. MICS Punjab, 2014 is a district based survey covering 125 indicators, and is the largest on this account. It is a matter of immense satisfaction that the survey has been completed within a stipulated time period. The results of MICS Punjab, 2014 will enable the government to measure progress made on key social indicators. It also provides a baseline for a number of new social indicators which were not covered earlier. Planning & Development Department, UNICEF, and other stakeholders at the provincial and district level richly deserve all the credit for coming up with an excellent report. Special credit goes to Bureau of Statistics (BoS) Punjab for their untiring efforts and hard work. This present round of MICS, like the other three rounds, allows the provincial and district governments to monitor their respective status of human and social development with precise data on variety of key indicators. It will assist the decision-makers to move towards new avenues of human and social development. I am confident that this report will prove to be a valuable source for planning efforts of Government of Punjab and development partners, and a reference for academia and research organizations. MOHAMMAD JEHANZEB KHAN Chairman Planning and Development Board, Punjab P a g e | xxiii ACKNOWLEDGEMENTS The Punjab Multiple Indicator Cluster Survey (MICS) 2014 is the result of devoted efforts of different departments and organisations. Major funding for the survey was provided by Government of the Punjab through the Punjab Annual Development Programme (ADP) and a moderate contribution by UNICEF. Field work was conducted by the Bureau of Statistics (BoS), like in all previous rounds of MICS in Punjab. It is remarkable that for the first time, data processing of the current MICS Punjab which was outsourced in all previous rounds was carried out by BOS. This really was an exceptional achievement and the staff involved deserves special appreciation. The Global MICS team provided technical support throughout the survey process. Pakistan Bureau of Statistics (PBS) provided the sample design which was reviewed by an international expert on sampling engaged by UNICEF. The Chairman, Planning & Development Board who heads the Provincial Steering Committee extended his fullest support throughout the process. Mr. Shamim Rafique, the Director General of BoS and his team worked hard for the timely completion of the survey. Keen interest and contribution made by members of the Steering Committee, Technical and Planning and Coordination groups are also acknowledged. The continuous coordination efforts of Mr. Khalid Sultan, focal person from Planning & Development Department, are commendable. Ms. Pashmina Naz Ali (Ex-Chief Planning, Monitoring, Evaluation and Reporting, UNICEF, Islamabad), Mr. Nouman Ghani (Planning, Monitoring, Evaluation and Reporting Specialist), Rana Muhammad Sarwar (UNICEF MICS Consultant) and Mr. Faateh ud din Ahmad (Data Processing Consultant) played an active role in the process of MICS Punjab, 2014. All district governments and administrative departments provided valuable support and facilitation in the field work. Communities, local leaders and members of the selected households devoted their precious time. They need to be applauded for their confidence in sharing personal information and enriching this survey. The information provided by respondents remains in trust and will not be used for any purposes other than for their own benefit. IFTIKHAR ALI SAHOO Secretary Planning & Development Department, Punjab P a g e | xxiv EXECUTIVE SUMMARY The Punjab Multiple Indicator Cluster Survey (MICS), 2014 is a household survey covering 38,405 households to provide estimates of around 125 indicators for the province, 9 divisions and 36 districts. The results will be used to update indicators used for monitoring the situation of children and women in Punjab. MICS Punjab, 2014 was conducted as part of the fifth global round of MICS. The survey was planned, designed and implemented by Punjab Bureau of Statistics. The sample design was provided by Pakistan Bureau of Statistics. Technical support was provided by UNICEF through the Global MICS team. Fieldwork was carried out from June to September 2014. The survey collected information on standard MICS topics such as housing characteristics, child and maternal health, HIV/AIDS, domestic violence, child discipline, child protection and use of Information/Communication Technology among other topics. Additional information was also collected on income and employment, remittances, safety nets, tuberculosis, hepatitis and life satisfaction. The findings on most of the indicators presented in this summary show significant variations by some of the background characteristics. Infant and Under-five Child Mortality Under-five child mortality rate is estimated at 93 deaths per thousand live births and the Infant mortality rate at 75 deaths per thousand live births. Among divisions, infant mortality rates and under- 5 mortality rates are lowest in Rawalpindi division (72 and 59 deaths per thousand live births respectively) and highest in DG Khan division (118 and 91 deaths per thousand live births respectively). By wealth quintile, the data show that the probability of dying before age 5 for children living in the households in the highest quintile is lower at 53 deaths per thousand live births and this rises to 137 deaths per thousand live births in the lowest quintile. Nutritional Status Information collected on nutrition of children shows that 34 percent of children under 5 are underweight. The same proportion of children is stunted while 18 percent are wasted. The three anthropometric indicators vary by household wealth. Nearly half of children living in the households in the lowest quintile are stunted (49%) and 48 percent are underweight compared to 17 percent for stunting and underweight in the highest quintile. Underweight, stunting and wasting is less common among children in Rawalpindi division compared to the other divisions. Breastfeeding Ninety-four percent of the children under 2 years have are ever been breastfed. Early initiation of the breastfeeding is only 11 percent that is children that were put to breast within one hour of birth. Only 17 percent of children aged 0–5 months are exclusively breastfed as recommended by WHO guidelines while 48 percent of children age 6-23 months are predominantly breastfed. The median duration of any breastfeeding is 17.4 months and this declines to 0.6 months for exclusive breastfeeding. Sixty- one percent of the infants age 6-8 months have been introduced to solid, semi-solid and soft food. Overall, 65 percent of the children age 6-23 months are receiving solid, semi-solid and soft foods the minimum number of times. However, only 10 percent of these children are benefitting from a diet sufficient in both diversity and frequency. P a g e | xxv The findings also show that 58 percent of the children age 0-23 months are being fed through a bottle with a nipple. By education of the mother, 72 percent of children whose mothers have higher education are bottle fed compared to 49 percent of children whose mother have pre-school or no education. The findings further show that the practice of bottle feeding with a nipple among children age under six months is not uncommon even though it is discouraged, as 45 percent of the children are fed using a bottle with a nipple. Results from MICS Punjab, 2014 show that 49 percent of the households are found to be using adequately iodized salt. Use of iodized salt is lowest in Sargodha division (33%) and highest in Gujranwala division (63%). Child Health Information on child vaccination shows that 62 percent of the children are fully vaccinated and only 56 percent of children were vaccinated by their first birthday as recommended. About three in four children living in the households in the highest quintile are fully vaccinated (74%) compared to 42 percent living in the households in lowest quintile. Approximately 93 percent of children age 12-23 months received a BCG vaccination by their first birthday and the first dose of PENTA vaccine was given to 85 percent of children. The percentage declines to 81 percent for the second dose of PENTA, and to 72 percent for the third dose. Similarly, 95 percent of children received Polio 1 by first birthday and this declines to 85 percent by the third dose. For the first dose of measles vaccine, 72 percent of children received the vaccine by first birthday. In Punjab, 65 percent of children aged 6–59 months received a high dose Vitamin A supplement in the 6 months preceding the survey. Information collected on childhood diseases shows that 17 percent of children under 5 had diarrhoea in the 2 weeks preceding the survey. Out of these children, 47 percent were given Oral Rehydration Therapy (ORT) whereas 39 percent were treated with ORT with continued feeding. About 3 percent of the children had symptoms of ARI in the two weeks preceding the survey. Of these, 77 percent were taken to a health facility or provider, and 39 percent of the children were given antibiotics. The results also show that 21 percent of children were found to have an episode of fever, of which 79 percent were taken to a health facility or provider. Only 1 percent of children with fever were treated with anti-malarial drug; Of these, 9 percent were given Artemisinin-based Combination Therapy. Use of solid fuel is of concern regarding health as it increases risk of diseases such as acute respiratory illness. The findings reveal that 61 percent of the households use solid fuels for cooking, most of which is wood (33%). Majority (83%) of the households in rural areas use solid fuel compared to only 17 percent in urban areas. All of the population living in the households in the lowest quintile use solid fuel for cooking compared to only 4 percent of population in the highest quintile. Water and Sanitation In Punjab, 94 percent of the population is using improved sources of drinking water and 81 percent have water in their premises. The main sources of improved drinking water are motorized pump (42%) and hand pump (31%). Seventy five percent of the population is using improved sanitation facilities; higher in urban (92%) and lower in rural (67%). Most commonly used facilities are flush toilets connected to septic tanks (44%) and facilities connected to a sewerage system (21%). In Punjab, 18 percent of the population still has no access to toilet facilities and this proportion rises to 25 percent in rural areas. P a g e | xxvi One other issue of interest is disposal of children’s stool. The results show that stools of 71 percent of the children under 2 years were disposed of safely. The most commonly reported method of children’s stool disposal was rinsing into toilet or latrine (65%). For 17 percent of children, stool was thrown into garbage. Safe disposal of child’s faeces is found to be higher in urban (89%) compared to rural areas (64%). Information collected on handwashing shows that at the time of the survey, 80 percent of households with a place for handwashing had both water and soap (or another cleansing agent) present at the handwashing place. In 17 percent of the households, only water was available at the handwashing place. However 93 percent of households had soap or other cleansing agent available somewhere in the household. Reproductive Health Total Fertility Rate (TFR) as a measure of current fertility is estimated at 3.5 children per woman. Fertility is slightly higher in rural areas compared to urban areas. TFR among women having pre-school or no education is 4.2 and declines to 2.7 children per woman among women with higher education. Current use of a contraceptive method is reported by 39 percent of currently married women. The most popular modern method is the male condom (11%) followed by female sterilization (10%). Unmet need for contraception is 17 percent. Out of the total women with a live birth in the last two years, 79 percent received antenatal care at least once during their pregnancy from a skilled personnel whereas 17 percent received no antenatal care. Further to that, 48 percent of the women had at least four antenatal care visits. During the antenatal visits, 45 percent of the women had their blood pressure measured, urine and blood sample taken. Sixty-five percent of deliveries were attended by skilled personnel. Sixty-one percent of the births were delivered in a health facility: mostly (43%) in private health facility compared to 18 percent in public health facility. Traditional birth attendants delivered 33 percent of the babies; 40 percent in rural and 19 percent in urban. Eighty-six percent of the mothers had a postnatal check-up and 41 percent of the first PNC visits occurred in a private facility. MICS Punjab, 2014 also collected information on visits by Lady Health Workers. About 38 percent of women aged 15-49 years, who had given birth in two years preceding the survey, reported having been visited by a Lady Health Worker (LHW). The proportion of women visited by a LHW is higher in rural (43%) than urban areas (26%). More than half of the women visited by LHW reported that they received health education or advice. Child Development Among children aged 36-59 months, 26 percent were attending an early childhood education programme. Children who got support for learning from their father was 3 percent while 12 percent of children got support from the mother. Among children under 5, only 8 percent had at least three children's books and 53 percent had two or more types of playthings in their homes. Early Child Development Index was calculated to measure the developmental status of children within four domains namely: literacy-numeracy, physical, social-emotional development and learning. Overall, 67 percent of children age 36-59 months were developmentally on track in at least three of the four domains. P a g e | xxvii Literacy and Education In Punjab, 61 percent of the population age 10 years and above is able to read and write. Literacy rate among young women age 15-24 is 76 percent. Literacy is higher among males than females. By age, only 19 percent of population age 75 years or older is literate compared to 78 percent of population age 15-19. School readiness, that is percentage of children attending first grade at the time of the survey who attended pre-school in previous year is 93 percent and 26 percent of children of primary school entry age have entered the first grade. The Net Attendance Rate (NAR) i.e. children age 5-9 years who attend primary or secondary school, is 58 percent. Four percent of children age 5-9 years are attending government schools and 46 percent private schools. It is interesting to note that of all children starting grade 1, the majority (96%) eventually reach the last grade of primary school. In case of secondary school children (10–14 years), 42 percent are attending secondary school, with a lower percentage in rural areas (36%) compared to urban (54%). There is only a small difference in the attendance of girls and boys in primary and secondary schools. The Gender Parity Index (GPI), that is the ratio of girls to boys attending school is 0.97 for primary school and 0.98 for secondary school. The GPI is lower in rural areas, 0.94 for primary and 0.88 for secondary schools. Child Protection The findings from MICS Punjab, 2014 show that 73 percent of children under 5 years were registered at birth. Birth registration ranges from 31 percent in D.G Khan division to 90 percent in Gujranwala division. There is variation by wealth quintile; 90 percent of children living in the households in the highest quintile are registered compared to 46 percent of children living in the households in the lowest quintile. Sixteen percent of children age 5–17 years are involved in child labour. A higher proportion of male children (20%) is involved in child labour compared to female children (12%). Similarly, child labour is more prevalent in rural (20%) than urban areas (8%). As a form of child discipline, 81 percent of children age 1-14 experienced violent discipline in form of psychological aggression or physical punishment, during the last one month. The most severe forms of physical punishment which include hitting the child on the head, ears or face or hitting the child hard and repeatedly were given to 27 percent of children. Information collected on early marriages shows that 5 percent of the women age 15-49 were married before age 15 while 21 percent of women age 20-49 were married before age 18. There is a decline in early marriage over the years as 31 percent of women age 45-49 reported being first married by age 18 compared to 15 percent of women age 20-24. The data further show that 19 percent of the currently married women age 15-19 are married to a man that is older by 10 years or more. MICS Punjab, 2014 results on attitudes towards domestic violence show that 40 percent of women believe that a husband is justified in hitting or beating his wife if she goes out without telling him, neglects the children, argues with him, refuses sex with him or burns the food. Twenty seven percent of women agree and justify violence in instances when a wife neglects the children and 26 percent of women justify violence if a wife goes out without telling her husband or argues with him. P a g e | xxviii HIV/ AIDS In Punjab, 39 percent of the ever married women have heard of AIDS and it drops to 28 percent in rural areas compared to 60 percent in urban. Only 16 percent of women know that using a condom every time during sexual intercourse and having only one faithful uninfected are the main ways of HIV prevention. Comprehensive knowledge among the women about HIV transmission is even lower (5%) and it falls to 3 percent among young women age 15-24. About 24 percent of ever married women age 15-49 years know that the HIV can be transmitted from mother to child during pregnancy, delivery and breastfeeding. Out of the ever married women who have heard about HIV/AIDS, 19 percent express accepting attitude towards people living with HIV/AIDS. While 9 percent of ever married women know a place where one can get tested for HIV, almost 2 percent of women have actually been tested and about the same proportion of women know the result of their most recent test. Access to mass media and ICT Information collected on access to mass media shows that 11 percent of the women read newspapers, 5 percent listen to the radio and 64 percent watch television at least once a week. While 66 percent of women use any of the three media types at least once a week, 34 percent do not have regular exposure to any of the three types of media. Twenty-one percent of young women age 15-24 used a computer during the last 12 months and fewer women (14 percent) used a computer during the last month. Use of internet is lower, with 12 percent of young women reporting use of internet during the last 12 months. At division level, only 9 percent of young women in DG Khan division used a computer during the last year compared with 32 percent of women in Lahore division during that same period. Subjective well-being The survey included a module on life satisfaction for women age 15-24 years to understand how satisfied this group of young people is in different areas of their lives, such as their family life, friendships, school, current job, health, where they live, how they are treated by others, how they look, and their current income. The data show that 91 percent of the women age 15-24 are satisfied on overall with their lives and about the same proportion of women is happy with their life. Six out of ten young women (59%) think that their life has improved over the last one year and expect that life will get better in the coming year. Overall, only 8 percent of young women have an income and of those with income, 67 percent are satisfied with their current income. Tobacco Use Four percent of women smoked cigarettes or used smoked or smokeless tobacco products at any time in the last one month. In D.G Khan division, 13 percent of women used tobacco, a proportion much higher than the other divisions. There is also notable variation by age, with a higher proportion of older women using tobacco compared to younger women; 13 percent among women age 45-49 compared to less than 1 percent among women age 15-19. The proportion of women who smoked a cigarette before age 15 is less than 1 percent. P a g e | xxix Adult health Three percent of household members were reported to have had a cough for the past 3 weeks. Almost 6 percent of the population in Sahiwal division was reported to have had a cough, a proportion much higher than the other divisions. Furthermore, less than 1 percent of the household population was reported to have been diagnosed with tuberculosis and 2 percent was diagnosed with hepatitis. Socio-economic development The unemployment rate among population age 10 years and over is 7 percent. In Punjab, 87 percent of the population is living in a household that owns a house, 30 percent own agricultural land and 45 percent own livestock. Ownership of agricultural land and livestock is higher amongst the rural population. The survey also collected information on remittances. The results reveal that 3 percent of the respondents reported having received remittances from within the country while 7 percent reported receiving remittances from outside the country. In addition, 7 percent of household members are living in a household that received benefits such as zakat, dearness allowance, health and education subsidy from government schemes of social protection P a g e | xxx MAP OF THE PUNJAB P a g e | 1 I. INTRODUCTION Background This report is based on the Multiple Indicator Cluster Survey (MICS), conducted in 2014 by the Bureau of Statistics (BoS) Punjab, Planning and Development Department (P&DD), Government of the Punjab, in collaboration with UNICEF. It is the fourth report in the MICS series since 2004 in Punjab. These surveys provide statistically sound and internationally comparable data essential for developing evidence-based policies and programmes and for monitoring progress towards national goals and global commitments. These commitments emanate from the World Fit for Children Declaration and Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs) (See box below). The MICS Punjab, 2014 results will be critically important for final MDG reporting in 2015, and are expected to form part of the baseline data for the post 2015 era. MICS Punjab, 2014 is expected to contribute to the evidence base of several other important initiatives, including Committing to Child Survival: A Promise Renewed, a global movement to end child deaths from preventable causes, and the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women's and Children's Health. A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child- focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the national and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action of the World Fit for Children (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agencies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” P a g e | 2 Survey Objectives The MICS Punjab, 2014 has as its primary objectives:  To provide up-to-date information for assessing the situation of children and women  To generate data for the critical assessment of the progress made in various areas, and to put additional efforts in those areas that require more attention;  To furnish data needed for monitoring progress towards goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action;  To collect disaggregated data for the identification of disparities, to allow for evidence based policy-making aimed at social inclusion of the most vulnerable;  To contribute to the generation of baseline data for the post 2015 agenda; Report Structure This final report presents the results of the indicators and topics covered in the survey. Preliminary findings of MICS Punjab, 2014 were shared with the government in May, 2015. The description for each chapter is based on tables within the text that contain provincial level results by background characteristics including divisional level results. District level tables are placed in Appendix – A of the report. The report comprises 17 chapters, focusing on different socio-economic features of the survey. The first three chapters explain about the survey background and objective, methodology (sample design, questionnaires, training and fieldwork) and sample coverage, characteristics of the households, asset ownership, and wealth quintiles. The remaining 14 chapters present the findings on child mortality, nutrition, child health, water and sanitation, reproductive health, early child development, literacy and education, child protection, HIV/AIDS knowledge, access to mass media and use of information/communication technology, subjective wellbeing, tobacco use, adult health and health care and socio economic development. P a g e | 3 II. SAMPLE AND SURVEY METHODOLOGY Sample Design The sample for the MICS Punjab, 2014 was designed by the Pakistan Bureau of Statistics (PBS) to provide estimates for a large number of indicators, on the situation of women and children including the socio-economic indicators at the provincial level, 9 divisions, 36 districts, and urban and rural areas at the provincial level. The total sample size was 41,000 households, located in 2050 sample clusters (enumeration areas). For the calculation of the sample size, the key indicator used was the underweight prevalence among children age 0-4 years. The detail of districts under each division is as follows: Bahawalpur: Bahawalpur, Bahawalnagar and Rahim Yar Khan DG Khan: DG Khan, Layyah, Muzaffargarh and Rajanpur Faisalabad: Faisalabad, Chiniot, Jhang and TT Singh Gujranwala: Gujranwala, Gujrat, Hafizabad, Mandi Bahauddin, Narowal and Sialkot Lahore: Lahore, Kasur, Nankana Sahib and Sheikhupura Multan: Multan, Khanewal, Lodhran and Vehari Sahiwal: Sahiwal, Pakpattan and Okara Rawalpindi: Rawalpindi, Attock, Chakwal and Jhelum Sargodha: Sargodha, Bhakkar, Khushab and Mianwali The urban and rural areas within each district were identified as the main sampling strata and the sample was selected in two stages. Eight large cities (Lahore, Faisalabad, Rawalpindi, Gujranwala, Multan, Sargodha, Sialkot and Bahawalpur) were also treated as separate strata within their respective districts. Within each stratum, a specified number of census enumeration areas were selected systematically with probability proportional to size. After a households listing in the selected urban and rural enumeration areas, a systematic sample of 20 households was drawn in each sample enumeration area. All sample enumeration areas were covered except for three enumeration areas which were substituted for technical reasons in consultation with PBS. Within each district the sample was proportionally allocated to urban and rural areas. The sampling rates vary by stratum and cluster, so the sample is not self-weighting. For reporting all results from the survey data, sample weights are used. The sample design including weights were reviewed for adequacy and soundness by an international consultant engaged by UNICEF Pakistan. The sample design and weighting procedures are described in more detail in Appendix B, which includes a summary of the sample size by divisions and districts. List of Indicators The fifth round of the Multiple Indicator Cluster Survey (MICS5), being a standard methodology, has limited space for additional indicators but is flexible enough to adapt indicators to local environment. The Punjab MICS Technical Group followed a comprehensive plan for the finalization of list of indicators for the Punjab MICS, 2014. The group held sectoral consultations with key social sector departments and development partners. Based on these consultations, the group made recommendations to finalize the list of indicators. The recommendations were approved by the Punjab MICS Steering Committee. The final list of indicators approved by the Steering Committee is presented in Appendix – F. P a g e | 4 Questionnaires A set of the following three questionnaires was used in the survey instead of the four available with the MICS5 methodology. 1. Household Questionnaire which was used to collect basic demographic information on all de jure household members (usual residents), the household, and the dwelling with the following modules; o List of Household Members5 o Education6 o Child Discipline o Child Labour o Child Discipline o Household Characteristics o Water and Sanitation o Handwashing o Salt Iodization Non-Global Standard MICS Modules o Income and Employment o Remittances o Pension Benefits o Safety Nets 2. Questionnaire for Individual Women administered in each household to all women age 15- 49 years and included the following modules; o Woman’s Background o Access to Mass Media and Use of Information/Communication Technology o Marriage o Fertility o Desire for Last Birth o Maternal and Newborn Health7 o Post-natal Health Checks o Illness Symptoms o Contraception o Unmet Need o Attitudes Toward Domestic Violence o HIV/AIDS o Tobacco Use o Life Satisfaction 3. Questionnaire for Children Under-Five, administered to mothers (or caretakers) for all children under 5 years of age8 living in the household. Normally, the questionnaire was administered to mothers of children; in cases when the mother was not listed in the 5 The module also includes non-standard MICS questions on cough, TB and Hepatitis 6 It also includes non-MICS questions on type of schools 7 It also includes non-MICS questions on Lady Health Worker (LHW) 8 The terms “children under 5”, “children age 0-4 years”, and “children age 0-59 months” are used interchangeably in this report for children age less than 5 years. P a g e | 5 household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Age o Birth Registration o Early Childhood Development o Breastfeeding and Dietary Intake o Immunization o Care of Illness o Anthropometry Non-Global Standard MICS Modules o Vitamin A Supplementation The questionnaires were based on the MICS5 model questionnaires and translated from English to Urdu language for data collection and again retranslated into English to ensure accuracy and quality of the translation. Pretesting of Questionnaires The Questionnaires were pretested in Southern, Central and Northern zones of the Punjab. For this purpose, one district was selected randomly in each zone and within it, one urban site and one rural site (20 households), called cluster, was enumerated as per guidelines of MICS5 methodology. Based on findings from the pretest, modifications were made to the wording and translation of the questionnaires. A copy of the MICS questionnaires is provided in Appendix – G. In addition to the administration of questionnaires, field teams tested salt used for cooking in the households for iodine content, observed the place for handwashing, and measured the weights and heights of children under 5 years. Findings of these observations and measurements are provided in the respective sections of this report. Appointment of Regional Supervisors To manage huge fieldwork operation while assuring quality and proper supervision, the province was divided into 10 regions of 3–5 districts each: Bahawalpur, DG Khan, Faisalabad, Gujranwala, Lahore I, Lahore II, Multan, Rawalpindi, Sahiwal and Sargodha. Ten senior officers of BOS were designated as regional supervisors - one for each region. They were responsible for all aspects of the field work in their respective regions (See list of field staff in Appendix – C). Training Training of Trainers (ToT) was conducted for 10 days in Lahore including two days of field practice. A total of 35 field teams were recruited for field data collection, each team comprising one team supervisor, two field editors (one male and one female), two measurers (both female), three male interviewers, and five female interviewers. The field teams were given 18 days training in two phases. In the first phase, the trainings were held at Multan, Faisalabad and Rawalpindi for field teams belonging to Multan, Bahawalpur, DG Khan, Faisalabad, Sargodha, Rawalpindi and Gujranwala divisions. During this phase, 312 field staff including regional supervisors, team supervisors, field P a g e | 6 editors, measurers and interviewers were trained at Multan (126), Faisalabad (99), and Rawalpindi (97). The rest of the teams were trained in second phase, wherein trainings were held at Sahiwal (51) and Lahore (104). During this phase, altogether 155 field staff were trained. During the trainings, about 9 percent additional staff were also trained to be deployed in case of dropout during the field work. Trainings included sessions on contents of the questionnaires along with the survey theoretical concepts, survey ethics, interviewing techniques, and mock interviews to practice in asking questions. The whole training took 18 days, including three days of practice in the field. All trained staff overwhelmingly participated in the hands on sessions. Moreover, measurers received three days exclusive hands on training for height and weight measurement of children at Basic Health Units (BHUs). Field Work The field teams who received training in the first phase started field work in their respective divisions immediately after the completion of training session in June 2014. The rest of the teams, however were deployed into the field in July 2014 after the completion of the second phase of training. A total of 33 teams were deployed into the field to collect the information on prescribed questionnaire (Household, Woman and Child). Each team was comprised of one supervisor, two field editors (male and female), two measurers, and eight interviewers (3 males and 5 females). Twenty households were interviewed from an urban or rural cluster by each team in a day. One android cellular was provided to each team supervisor for the purpose of sending key information (i.e. GPS Coordinates, Cluster Control Sheet) of the enumerated cluster. The information was compiled at BoS office headquarters and shared with Secretary, Director General/Project Director through a dash board. The field monitoring was also carried out extensively by the technical team, Deputy Project Director, Project Director and representative of UNICEF to achieve the quality milestone. During the field visits, necessary support and feedback was provided to each field team by the technical monitors. In addition, consistency tables were examined and evaluated weekly in respect of each field team and in case of any issue, the concerned team supervisor was notified immediately. The whole field work exercise was completed in about three months. Monitoring Mechanism The monitoring of field work for quality data included conventional as well as innovative system known as Online Monitoring Mechanism (OMM). Under the conventional method, the nominated monitors from BoS and other stakeholders visited field teams. All the monitoring activities were planned in such a way that each field team could be visited more than once. As regards to the innovative method (OMM), a GPS device was given to each team supervisor through which they sent GPS coordinates of the cluster to BoS headquarters in Lahore twice a day, firstly when the team reached the cluster and secondly at the time of leaving the cluster. To share the latest information received from the field with the stakeholders, a dashboard was designed. The information sent by the field supervisors was used not only to observe duration of their stay in the cluster, but also to update the dashboard on daily basis. The dashboard was shared with all concerned stakeholders on a daily basis to give updates on progress on the cluster completion. P a g e | 7 Another monitoring tool was the use of field check tables. These tables were produced on weekly basis using latest field data entered in computers. These tables were regularly shared with the regional supervisors who in turn had discussions with the team supervisors in their respective regions. In this way, a number of data collection weaknesses were addressed before it is too late. The field check tables were also shared with operational teams who then issued instructions immediately to the concerned regional supervisors/ team supervisors through email, text messages, telephone calls and personal visits. These tables included descriptive statistics on key variables for each team. Moreover, to enhance data quality, other corrective steps were also taken including reshuffling of team(s) member(s) reporting inadequately and conducting additional trainings in the field where felt necessary. Data Processing Data were entered using the CSPro software version 5.0 on 22 desktop computers by 44 data entry operators under the supervision of 2 data entry (DE) supervisors. There were four assistant DE supervisors who were monitoring the data entry process and helping data entry operators (DEOs) in rectifying the problems. For quality assurance purposes, all questionnaires were double-entered and the differences thereof resolved by referring back to the questionnaires. Internal consistency checks were also performed and the secondary editors fixed those inconsistencies according to the secondary editing manual. Procedures and standard programs developed under the global MICS programme and adapted to the MICS Punjab, 2014 questionnaire were used throughout. Data processing began simultaneously with data collection at the beginning of July 2014 (after one week of data collection) and was completed in October 2014 (one week after completion of field work). Data were analysed using the Statistical Package for Social Sciences (SPSS) software, version 22. Model syntax and tabulation plans developed by UNICEF were customized and used for this purpose. Initial analysis, for cleaning purpose, was carried out by examining frequency distribution of all variables and looking at possible errors in data entry and otherwise. Dummy tables reflecting cross- tables between dependent and independent variables were generated focusing on presenting frequencies and simple bivariate tables. After cleaning, the final data was exported from CSPro to SPSS software tabulation programme for construction of analysis files (comprising HH: Household, HL: Online Monitoring Mechanism Online Monitoring Mechanism (OMM) was especially designed and implemented for effective online monitoring of field teams. It was used to detect:  Location of survey teams through Global Positioning System (GPS)  Entering and leaving time in the Cluster  Time spent in the Cluster Open Data Kit (ODK) Aggregate server (https://bos-punjab.appspot.com) was set-up at google. Two ODK forms were programmed for updating data about GPS coordinates and cluster summary information. Android based smart phones with internet connectivity through U fone SIM were provided to team supervisors. By using the above facility following, two reports were generated on daily basis:  Time spent in the field by survey team  Dash board for easy review/monitoring of the field work P a g e | 8 Household listing, WM: Women and CH: Children), production of tabulations, analysis of sampling errors/ confidence intervals; and production of datasets and tabulations for report writing. International Review All stages of the survey were closely monitored by the UNICEF global MICS team. Before the start of survey, UNICEF reviewed the sample design, survey tools and trainings through international consultants. The software used for data entry and analysis was adapted from the MICS5 recommended methodology which was also reviewed by the national and international consultants. The data files, syntax files and tabulations were shared with the global MICS team. The data and software review inputs received from these organizations were addressed before the finalization of the tables and report. P a g e | 9 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Sample Coverage Initially 41,000 households were selected for the sample and distributed equally in 2050 selected clusters. Following MICS5 guidelines, if a selected household was untraceable or unreachable or refused to be interviewed, there was no replacement. Further to that, if there was more than one household identified in the selected dwelling at the time of data collection and these households were not listed then all of them were to be interviewed. As a result, the final sample size was 41,413 households. Of the 41,413 households selected for the sample, 39,333 were found to be occupied. Of these, 38,405 were successfully interviewed achieving household response rate of 98 percent. In the interviewed households, 61,286 eligible women (age 15-49 years) were identified. Of these, 53,668 were successfully interviewed, yielding a response rate of 88 percent within the interviewed households. There were 31,083 children under age five listed in the household questionnaires. Questionnaires were completed for 27,495 of these children, which corresponds to a response rate of 89 percent within interviewed households. Overall response rate of households i.e. 98 percent is 12 percent higher than the response rates of individual women and children under 5s (85.5 and 86.4 percent) due to the reason that the children and women were not at home at the time of interview (Table HH.1). P a g e | 10 Table HH.1: Results of household, women's and under-5 interviews Number of households, women and children under 5 by results of the household, women's and under-5's interviews, and household and women's and under-5's response rates, Punjab, 2014. Punjab Area of residence Division Rural All Urban Major Cities Other Urban Bahawalpur D.G. Khan Faisalabad Gujranwala Lahore Multan Rawalpindi Sahiwal Sargodha Households Sampled 41,413 25,769 15,644 4,847 10,797 4,016 4,356 4,830 6,715 5,564 4,745 4,092 3,316 3,779 Occupied 39,333 24,617 14,716 4,554 10,162 3,801 4,127 4,689 6,381 5,137 4,596 3,891 3,127 3,584 Interviewed 38,405 24,241 14,164 4,295 9,869 3,690 4,051 4,647 6,254 4,874 4,526 3,756 3,054 3,553 Household response rate 97.6 98.5 96.2 94.3 97.1 97.1 98.2 99.1 98.0 94.9 98.5 96.5 97.7 99.1 Women Eligible 61,286 38,002 23,284 7,015 16,269 5,575 6,180 7,303 10,582 8,064 6,675 5,932 4,883 6,092 Interviewed 53,668 33,584 20,084 5,786 14,298 4,847 5,446 6,724 9,232 6,630 5,953 5,169 4,347 5,320 Women's response rate 87.6 88.4 86.3 82.5 87.9 86.9 88.1 92.1 87.2 82.2 89.2 87.1 89.0 87.3 Women's overall response rate 85.5 87.0 83.0 77.8 85.4 84.4 86.5 91.2 85.5 78.0 87.8 84.1 86.9 86.6 Children under 5 Eligible 31,083 20,486 10,597 3,147 7,450 3,112 4,085 3,443 5,145 4,016 3,300 2,527 2,587 2,868 Mothers/caretakers interviewed 27,495 18,220 9,275 2,663 6,612 2,705 3,700 3,067 4,504 3,449 2,934 2,264 2,345 2,527 Under-5's response rate 88.5. 88.9 87.5 84.6 88.8 86.9 90.6 89.1 87.5 85.9 88.9 89.6 90.6 88.1 Under-5's overall response rate 86.4 87.6 84.2 79.8 86.2 84.4 88.9 88.3 85.8 81.5 87.6 86.5 88.5 87.3 P a g e | 11 Response rates were higher in rural than urban areas. Across divisions, the household response rate was found to be lowest in Lahore division (95%), which is highly urban. In this division, non-availability of eligible women at home at the time of the survey resulted in low response rates for both women and children under 5 (78% and 82% respectively). Characteristics of Households The weighted age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 38,405 households successfully interviewed, 246,396 household members were listed. Of these, 124,711 are males, and 121,684 are females. Table HH.2: Household age distribution by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Punjab, 2014. Total Males Females Number Percent Number Percent Number Percent Punjab 246,396 100.0 124,711 100.0 121,684 100.0 Age 0-4 31,324 12.7 15,861 12.7 15,463 12.7 5-9 31,473 12.8 16,203 13.0 15,270 12.5 10-14 28,665 11.6 14,815 11.9 13,849 11.4 15-19 25,999 10.6 13,284 10.7 12,715 10.4 20-24 22,985 9.3 11,399 9.1 11,586 9.5 25-29 20,194 8.2 9,483 7.6 10,711 8.8 30-34 16,764 6.8 8,305 6.7 8,458 7.0 35-39 13,580 5.5 6,632 5.3 6,948 5.7 40-44 11,392 4.6 5,752 4.6 5,640 4.6 45-49 10,685 4.3 5,578 4.5 5,107 4.2 50-54 9,099 3.7 4,388 3.5 4,711 3.9 55-59 7,078 2.9 3,544 2.8 3,533 2.9 60-64 6,023 2.4 3,146 2.5 2,877 2.4 65-69 4,254 1.7 2,418 1.9 1,836 1.5 70-74 3,180 1.3 1,816 1.5 1,363 1.1 75-79 1,608 0.7 903 0.7 706 0.6 80-84 1,192 0.5 674 0.5 518 0.4 85+ 891 0.4 504 0.4 387 0.3 Missing/DK 13 0.0 7 0.0 6 0.0 Dependency age groups 0-14 91,461 37.1 46,879 37.6 44,582 36.6 15-64 143,797 58.4 71,511 57.3 72,286 59.4 65+ 11,124 4.5 6,314 5.1 4,810 4.0 Missing/DK 13 0.0 7 0.0 6 0.0 Child and adult populations Children age 0-17 years 106,585 43.3 54,610 43.8 51,975 42.7 Adults age 18+ years 139,798 56.7 70,094 56.2 69,703 57.3 Missing/DK 13 0.0 7 0.0 6 0.0 Table HH.2 shows that 37 percent of the population is under 15 years and 4 percent is age 65 or over, showing a high dependent population. The largest age cohorts are the following age groups: 5 – 9 and 0 – 4 (13% each). As expected, the proportion of the population in the 5 year age group decreases with increase in age. In MICS Punjab, 2014, particular efforts were made to minimise age reporting errors by training interviewers in age probing techniques. Reference calendars of major local and P a g e | 12 national events were provided to assist in determining approximate age of respondents who could not recall accurate age or date of birth. Resultantly, errors in recording ages and date of births were controlled to a great extent, however, some age heaping still remains at ages ending with digits zero and five (Table DQ.1 in Appendix – E). The population pyramid is presented in Figure HH.1. Figure HH.1: Age and sex d istr ibut ion of household populat ion , MICS Punjab , 2014 Tables HH.3, HH.4 and HH.5 provide basic information on the households, eligible women age 15-49 years, and children under 5. Both unweighted and weighted numbers are presented in the tables. Such information is essential for the interpretation of findings presented later in the report and provide background information on the representativeness of the survey sample. The remaining tables in this report show only weighted numbers.9 Table HH.3 presents basic background information on the households, including sex of the household head, division, area of residence, number of household members and education of household head. These background characteristics are used in subsequent tables in this report. The figures in the table are also intended to show the number of observations by major categories of analysis in the report. The weighted and unweighted total number of households are equal, since sample weights were normalized.10 The table also shows the weighted mean household size estimated by the survey which is 6.4 persons. In Punjab, 92 percent of households are headed by males and the rest are headed by females. About 67 percent of households are in rural areas, while the rest are in urban. More than half of households 9 See Appendix B: Sample Design, for more details on sample weights. 10 ibid 8 6 4 2 0 2 4 6 8 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Percent Age Males Females P a g e | 13 (59%) have 4 to 7 members, while one-member households are at about 1 percent. Forty percent of the household heads have no education or only have pre-school followed by those with secondary education (18%) and primary education (17%). Table HH.3: Household composition Percent and frequency distribution of households by selected characteristics, Punjab, 2014. Weighted percent Number of households Weighted Unweighted Punjab 100.0 38,405 38,405 Area of residence Rural 66.6 25,577 24,241 All Urban 33.4 12,828 14,164 Major Cities 52.4 6,717 4,295 Other Urban 47.6 6,111 9,869 Sex of household head Male 92.1 35,375 35,341 Female 7.9 3,030 3,064 Number of household members 1 1.0 372 389 2 4.6 1,762 1,749 3 7.5 2,866 2,891 4 11.8 4,518 4,516 5 16.1 6,193 6,175 6 17.0 6,527 6,504 7 14.1 5,410 5,359 8 9.7 3,722 3,756 9 6.5 2,479 2,461 10+ 11.9 4,555 4,605 Education of household head None/pre-school 40.1 15,399 15,179 Primary 17.3 6,639 6,671 Middle 12.7 4,863 4,964 Secondary 18.3 7,022 7,058 Higher 11.6 4,472 4,522 Missing/DK 0.0 10 11 At least one child age < 5 years 48.5 38,405 38,405 At least one child age 0-17 years 84.7 38,405 38,405 At least one woman age 15-49 years 93.1 38,405 38,405 Division Bahawalpur 10.7 4,091 3,690 D.G. Khan 8.9 3,436 4,051 Faisalabad 12.7 4,889 4,647 Gujranwala 14.5 5,569 6,254 Lahore 17.3 6,631 4,874 Multan 12.1 4,633 4,526 Rawalpindi 9.5 3,633 3,756 Sahiwal 6.9 2,638 3,054 Sargodha 7.5 2,885 3,553 Mean household size1 6.4 38,405 38,405 1 MICS indicator 14.S10 - Mean household size Characteristics of Female Respondents 15-49 Years of Age and Children Under-5 Tables HH.4 and HH.5 show information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In both tables, total number of weighted and unweighted observations are equal, since sample weights have been normalized. In addition to providing useful information on the background characteristics of women and children under age five, P a g e | 14 the tables are also showing the number of observations in each background category. These categories are used in the subsequent tables of this report. Table HH.4: Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Punjab, 2014. Weighted percent Number of women Weighted Unweighted Punjab 100.0 53,668 53,668 Area of residence Rural 65.3 35,043 33,584 All Urban 34.7 18,625 20,084 Major Cities 52.5 9,781 5,786 Other Urban 47.5 8,844 14,298 Age 15-19 20.8 11,158 11,298 20-24 18.6 9,960 9,943 25-29 17.0 9,114 9,106 30-34 14.1 7,558 7,513 35-39 11.6 6,251 6,158 40-44 9.5 5,078 5,028 45-49 8.5 4,548 4,622 Marital status Currently married 61.6 33,047 32,854 Widowed 2.0 1,047 1,014 Divorced 0.8 451 465 Separated 0.6 310 320 Never married 35.1 18,813 19,015 Motherhood and recent births Never gave birth 42.6 22,888 23,127 Ever gave birth 57.4 30,780 30,541 Gave birth in last two years 19.9 10,653 10,602 No birth in last two years 37.5 20,130 19,942 Women’s education None/pre-school 38.9 20,887 20,878 Primary 17.3 9,296 9,427 Middle 10.6 5,714 5,613 Secondary 16.5 8,837 8,656 Higher 16.6 8,916 9,079 Missing/DK 0.0 19 15 Wealth index quintile Lowest 17.3 9,271 9,265 Second 19.3 10,353 10,456 Middle 20.3 10,898 11,478 Fourth 21.5 11,528 11,859 Highest 21.6 11,617 10,610 Division Bahawalpur 10.0 5,369 4,847 D.G. Khan 8.5 4,563 5,446 Faisalabad 12.7 6,796 6,724 Gujranwala 15.5 8,328 9,232 Lahore 18.0 9,685 6,630 Multan 11.0 5,887 5,953 Rawalpindi 9.5 5,086 5,169 Sahiwal 6.9 3,685 4,347 Sargodha 8.0 4,270 5,320 P a g e | 15 Table HH.4 includes information on the distribution of women according to area, age, marital status, motherhood status, births in last two years, education11, and wealth index quintiles12, 13. The area of residence of eligible women is almost similar to the household, as expected. The highest proportion of the women, i.e., 21 percent, is of age group 15-19 years, which declines with increase in age. About 62 percent of the women are currently married and 35 percent have never married. Fifty seven percent of ever married women have ever given birth, of which 20 percent gave birth during last 2 years. About 39 percent of women have only pre-school or no education followed by primary education (17%), secondary education (16%) and higher education (17%). There is, however, only small difference based on household wealth. 11 Throughout this report, unless otherwise stated, “education” refers to highest educational level ever attended by the respondent when it is used as a background variable. 12 The wealth index is a composite indicator of wealth. To construct the wealth index, principal components analysis is performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth, to generate weights (factor scores) for each of the items used. First, initial factor scores are calculated for the total sample. Then, separate factor scores are calculated for households in urban and rural areas. Finally, the urban and rural factor scores are regressed on the initial factor scores to obtain the combined, final factor scores for the total sample. This is carried out to minimize the urban bias in the wealth index values. Each household in the total sample is then assigned a wealth score based on the assets owned by that household and on the final factor scores obtained as described above. The survey household population is then ranked according to the wealth score of the household they are living in, and is finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). In MICS Punjab, 2014 the following assets are used in these calculations: Main material of the dwelling floor, Main material of the roof, Main material of the exterior walls, type of fuel used for cocking, Household possessions (Electricity, Radio, Television, Non-mobile telephone, Refrigerator/Freezer, Gas, Computer, Air conditioner, Washing machine/Dryer, Air cooler/ Fan, Cooking Range/Micro wave, Sewing/knitting machine, Iron, Water Filter and Dunky pump/Turbine), utilities owned by household members (Watch, Mobile telephone, Bicycle, Motorcycle / Scooter, Animal drawn-cart, Bus / Truck, Boat with motor, Car / Van, Tractor/Trolley), household ownership, ownership of land, having animals (Cattle, milk cows, Buffaloes or bulls, Horses, donkeys, mules or camels, Goats, Sheep and Chickens/ Ducks/ Turkey), possession of bank account, main source of drinking water and type of toilet. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from lowest to highest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Filmer, D. and Pritchett, L., 2001. “Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in mstates of India”. Demography 38(1): 115-132. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro and Rutstein, S.O., 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. Calverton, Maryland: Macro International Inc. 13 When describing survey results by wealth quintiles, appropriate terminology is used when referring to individual household members, such as for instance “women in the richest population quintile”, which is used interchangeably with “women in the wealthiest survey population”, “women living in households in the highest population wealth quintile”, and similar. P a g e | 16 Table HH.5 provides the distribution of children by several attributes including sex, area of residence, division, age in months, respondent type, mother’s (or caretaker’s) education, and wealth quintiles. The proportion of boys under 5 is 51 percent against 49 percent for girls, which is similar to the total population composition in the selected households. Sixty nine percent of these children reside in rural areas. As regards the share of various age groups, the smallest proportion (9%) is in age group of 0-5 months which increases in each subsequent five months age group with the highest (21%) in age group of 36–47 months. Majority of the children under 5 years (48%) have mothers with only pre-school or no education followed by 18 percent whose mothers have primary education and 24 percent have mothers with secondary education or higher. About 1 percent of children are looked after by primary caretakers and the rest by their mothers. As regards to distribution of children with respect to household wealth, there are more children living in the households in the lowest quintile (23%) compared to 18 percent in the highest quintile. Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Punjab, 2014. Weighted percent Number of under-5 children Weighted Unweighted Punjab 100.0 27,495 27,495 Area of residence Rural 69.1 19,002 18,220 All Urban 30.9 8,493 9,275 Major Cities 51.4 4,364 2,663 Other Urban 48.6 4,129 6,612 Sex Male 50.6 13,915 14,003 Female 49.4 13,580 13,492 Age 0-5 months 8.5 2,333 2,302 6-11 months 10.9 3,010 3,008 12-23 months 19.3 5,300 5,350 24-35 months 19.4 5,326 5,302 36-47 months 21.4 5,894 5,908 48-59 months 20.5 5,633 5,625 Respondent to the under-5 questionnaire Mother 98.8 27,170 27,158 Other primary caretaker 1.2 325 337 Mother’s educationa None/pre-school 47.8 13,140 13,133 Primary 18.2 4,991 5,106 Middle 10.0 2,740 2,687 Secondary 13.0 3,563 3,449 Higher 11.1 3,062 3,120 Wealth index quintile Lowest 23.0 6,316 6,286 Second 20.2 5,560 5,612 Middle 19.4 5,335 5,621 Fourth 19.6 5,380 5,496 Highest 17.8 4,904 4,480 P a g e | 17 Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Punjab, 2014. Weighted percent Number of under-5 children Weighted Unweighted Division Bahawalpur 11.2 3,080 2,705 D.G. Khan 11.5 3,151 3,700 Faisalabad 11.9 3,272 3,067 Gujranwala 14.9 4,100 4,504 Lahore 17.0 4,670 3,449 Multan 11.0 3,019 2,934 Rawalpindi 7.9 2,165 2,264 Sahiwal 7.4 2,032 2,345 Sargodha 7.3 2,005 2,527 a In this table and throughout the report, mother's education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. Housing Characteristics, Asset Ownership, and Wealth Quintiles Tables HH.6, HH.7 and HH.8 provide further details on household level characteristics. Table HH.6 presents characteristics of housing by area of residence and divisions. The characteristics include the availability of electricity, main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. It can be observed from Table HH.6 that 95 percent of households have electricity (100% in urban and 93% in rural). Sixty-three percent of households have finished (pacca) floor and 36 percent have rudimentary/natural (katcha) floor. More houses have “pacca” roofing (82%) than “pacca” floors (63%). Eighty-seven percent of households have “pacca” walls; urban houses are more likely to have pacca walls (97%) than rural houses (81%). Forty-one percent of households have one room for sleeping, whereas the mean number of persons per sleeping room is 3.9. In Table HH.7 households are distributed according to ownership of assets and dwelling. Sixty-eight percent of the households have a television, 53 percent have a refrigerator, 16 percent have a computer and 55 percent have a washing machine or dryer. Thirty one percent of households own agricultural land and 46 percent own livestock, while 87 percent own a house. Ownership of agricultural land and livestock is mostly in the rural areas. Ninety-three percent of households have at least a member owning a mobile phone and about 46 percent own a watch. Thirty-three percent of households have a member who owns a bicycle, 48 percent own a motorcycle or scooter, 6 percent have a car or van and 11 percent own an animal cart. P a g e | 18 Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and regions, Punjab, 2014. Punjab Area Division Rural All Urban Major Cities Other Urban Bahawalpur D.G. Khan Faisalabad Gujranwala Lahore Multan Rawalpindi Sahiwal Sargodha Electricity Yes 95.4 93.3 99.5 99.7 99.3 91.9 79.6 96.8 99.7 99.3 95.0 99.3 95.6 95.2 No 4.5 6.6 0.4 0.2 0.6 8.0 20.4 3.2 0.3 0.5 4.9 0.7 4.4 4.8 Missing/DK 0.0 0.0 0.1 0.1 0.1 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 0.0 Flooring Natural floor 36.4 51.4 6.5 2.4 11.0 49.1 67.6 36.2 21.1 14.9 48.2 12.7 53.5 55.7 Finished floor1 63.4 48.4 93.3 97.3 88.9 50.8 31.5 63.6 78.8 84.7 51.7 87.2 46.3 44.3 Other 0.2 0.2 0.1 0.1 0.0 0.1 0.9 0.2 0.1 0.2 0.0 0.1 0.1 0.0 Missing/DK 0.1 0.0 0.1 0.2 0.1 0.0 0.0 0.1 0.0 0.2 0.0 0.0 0.0 0.1 Roof Natural roofing 0.2 0.3 0.0 0.0 0.1 0.5 0.9 0.1 0.0 0.0 0.1 0.1 0.0 0.1 Rudimentary roofing 17.0 21.8 7.3 3.9 11.1 16.3 32.6 12.1 24.0 11.6 17.0 8.2 13.9 20.1 Finished roofing1 82.2 77.4 91.9 95.4 88.0 83.0 64.3 87.4 75.4 87.8 82.6 91.3 85.1 79.6 Other 0.5 0.5 0.7 0.5 0.8 0.2 2.2 0.5 0.5 0.3 0.2 0.4 1.0 0.1 Missing/DK 0.0 0.0 0.1 0.2 0.1 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.1 Exterior walls Natural walls 11.4 16.7 0.8 0.1 1.5 17.5 38.5 7.4 1.5 1.6 15.0 7.6 8.4 20.5 Rudimentary walls 1.3 1.8 0.3 0.4 0.3 2.5 2.7 0.7 0.2 1.2 2.0 1.5 1.0 0.4 Finished walls1 86.6 81.2 97.4 97.2 97.6 80.0 58.4 91.5 98.1 94.8 83.1 90.5 89.7 78.8 Other 0.6 0.2 1.5 2.3 0.6 0.0 0.4 0.4 0.2 2.3 0.0 0.4 1.0 0.2 Missing/DK 0.0 0.0 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 Rooms used for sleeping 1 41.1 43.5 36.3 34.8 38.0 47.6 54.2 35.6 32.9 39.9 49.2 27.0 50.4 40.5 2 40.6 39.9 42.1 41.9 42.3 38.1 34.5 43.5 43.1 40.9 38.4 47.1 35.7 41.0 3 or more 18.1 16.4 21.4 23.1 19.5 14.1 10.8 20.6 23.9 18.9 12.1 25.5 13.9 18.5 Missing/DK 0.2 0.3 0.2 0.2 0.2 0.2 0.5 0.3 0.1 0.3 0.3 0.4 0.1 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 38,405 25,577 12,828 6,717 6,111 4,091 3,436 4,889 5,569 6,631 4,633 3,633 2,638 2,885 Mean number of persons per room used for sleeping2 3.91 4.03 3.67 3.58 3.78 4.19 4.66 3.69 3.61 3.96 4.03 3.14 4.26 3.89 1 MICS indicator 14.S13 - Household characteristics 2 MICS indicator 14.S12 - Mean number of persons per room P a g e | 19 Table HH.7: Household and personal assets Percentage of households by ownership of selected household and personal assets, and percent distribution by ownership of dwelling, according to area of residence and regions, Punjab, 2014. Punjab Area Division Rural All Urban Major Cities Other Urban Bahawalpur D.G. Khan Faisalabad Gujranwala Lahore Multan Rawalpindi Sahiwal Sargodha Percentage of households that own a Radio 4.4 4.8 3.7 3.8 3.6 4.1 8.3 3.3 2.7 2.7 4.7 9.9 1.9 4.7 Television 67.6 58.0 86.9 91.0 82.5 52.3 39.2 70.2 79.4 82.7 56.8 81.0 63.9 65.9 Non-mobile telephone 6.2 2.6 13.2 17.5 8.6 3.3 1.9 5.9 7.9 11.0 2.3 12.4 2.3 3.2 Refrigerator 53.1 42.8 73.7 79.3 67.6 38.7 26.7 53.4 65.3 67.9 42.9 75.7 41.6 45.8 Computer 16.1 8.6 31.1 36.9 24.8 9.1 5.4 16.1 18.8 26.5 9.7 26.4 10.0 12.6 Washing machine/ Dryer 54.8 41.1 82.0 87.3 76.3 34.3 26.0 56.4 76.1 73.5 42.7 69.7 38.2 46.7 Air conditioner 7.7 2.6 17.7 23.4 11.5 3.1 2.7 7.1 8.0 17.4 5.4 8.1 4.5 3.9 Percentage of households that own Agricultural land 30.5 41.1 9.3 6.2 12.6 37.8 43.7 29.3 31.4 15.3 30.1 30.9 33.0 37.3 Farm animals/ Livestock 45.5 62.5 11.6 6.4 17.4 60.4 71.9 40.1 39.3 23.4 49.3 37.8 54.2 60.4 Percentage of households where at least one member owns or has a Watch 46.4 42.3 54.4 56.7 51.8 36.2 53.9 44.5 49.6 48.1 48.7 67.5 29.1 30.2 Mobile telephone 92.6 90.6 96.7 97.2 96.1 89.2 86.4 93.8 95.7 94.8 91.1 96.7 87.9 93.3 Bicycle 32.8 34.9 28.6 26.8 30.7 29.4 33.4 44.5 31.2 25.0 42.3 17.2 37.5 37.7 Motorcycle or scooter 48.5 44.3 56.9 63.3 49.8 48.2 41.4 49.7 51.2 55.4 49.1 39.9 46.2 46.3 Animal-drawn cart 10.8 15.1 2.4 1.2 3.6 10.1 9.9 14.7 8.7 8.7 8.2 2.3 23.0 19.3 Bus or truck 0.4 0.3 0.4 0.5 0.3 0.2 0.4 0.3 0.2 0.5 0.3 0.3 0.4 0.5 Boat with a motor 0.1 0.1 0.1 0.2 0.0 0.0 0.1 0.1 0.0 0.2 0.1 0.0 0.0 0.0 Car / van 5.8 3.6 10.2 13.4 6.7 3.2 2.2 4.9 5.5 9.4 4.4 11.7 3.7 4.3 Bank account 31.6 25.3 44.4 46.8 41.8 20.3 18.2 32.8 36.9 37.7 25.8 44.9 25.4 36.0 Ownership of dwelling Owned by a household member 87.0 91.6 77.9 73.8 82.4 90.0 93.0 86.3 91.1 82.9 87.9 79.2 84.7 88.9 Not owned 12.9 8.4 22.0 26.0 17.5 9.9 7.0 13.6 8.9 16.9 12.1 20.6 15.3 11.1 Rented 7.8 3.0 17.5 20.9 13.8 3.5 2.7 7.6 6.6 13.1 6.0 16.1 5.4 5.5 Other 5.1 5.4 4.4 5.1 3.7 6.5 4.3 6.1 2.3 3.8 6.1 4.5 9.9 5.6 Missing/DK 0.1 0.0 0.2 0.2 0.1 0.0 0.0 0.1 0.0 0.2 0.0 0.2 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 38,405 25,577 12,828 6,717 6,111 4,091 3,436 4,889 5,569 6,631 4,633 3,633 2,638 2,885 P a g e | 20 Table HH.8 shows the distribution of household population according to household wealth quintiles. In urban population positive correlation can be observed with wealth quintiles; the highest proportion of population is living in households in the highest quintile. In contrast, a higher proportion of rural population is living in the households in the lowest quintile. Lahore division which is highly urban, has 40 percent of its population living in the households in the highest quintile and less than 5 percent living in the households in the lowest quintile. In contrast, 57 percent of the population in DG Khan division is living in the households in the lowest quintile compared to 3 percent of population living in the households in the highest quintile. Table HH.8: Wealth quintiles Percent distribution of the household population by wealth index quintiles, according to area of residence and regions, Punjab, 2014. Wealth index quintiles Total Number of household members Lowest Second Middle Fourth Highest Total 20.0 20.0 20.0 20.0 20.0 100.0 246,396 Area Rural 28.5 26.8 23.0 15.4 6.3 100.0 165,174 All Urban 2.7 6.2 13.9 29.4 47.8 100.0 81,222 Major Cities 0.5 1.9 8.7 27.8 61.0 100.0 42,289 Other Urban 5.0 10.9 19.6 31.2 33.4 100.0 38,933 Division Bahawalpur 37.6 25.6 17.8 10.9 8.2 100.0 25,956 D.G. Khan 56.6 22.0 11.1 6.9 3.4 100.0 23,418 Faisalabad 16.4 19.7 21.6 23.2 19.1 100.0 30,970 Gujranwala 4.7 14.1 25.5 29.9 25.7 100.0 36,313 Lahore 4.6 12.6 17.5 25.5 39.8 100.0 43,847 Multan 24.6 25.2 22.5 16.3 11.3 100.0 27,788 Rawalpindi 5.9 13.9 20.6 26.9 32.7 100.0 21,767 Sahiwal 19.9 30.4 22.8 16.5 10.4 100.0 17,255 Sargodha 31.0 28.6 19.6 12.5 8.3 100.0 19,082 P a g e | 21 IV. CHILD MORTALITY One of the overarching goals of the Millennium Development Goals (MDGs) is the reduction of infant and under-five mortality. The infant mortality rate is the probability of dying before the first birthday, while the under-five mortality rate is the probability of dying before the fifth birthday. The MDGs call for the reduction in under-five mortality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. In MICS Punjab, 2014 an indirect method, known as the Brass method14, was used. Robust estimates of the aforementioned indicators are produced by this method, and generally are comparable with those obtained by applying direct methods. The data used by the indirect method are: the mean number of children ever born for the five-year time-since-first-birth (TSFB) groups of women age 15 to 49 years, and the proportion of these children who are dead, also for five-year time-since-first-birth groups of women (Table CM.1). The technique converts the proportions dead among children of women in each time-since-first-birth group into probabilities of dying by taking into account the approximate length of exposure of children to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in Pakistan, the “East Model” life table was selected as most appropriate. Table CM.1: Children ever born, children surviving and proportion dead Mean and total numbers of children ever born, children surviving and proportion dead by age of women, Punjab, 2014. Children ever born Children surviving Proportion dead Number of women age 15-49 years Mean Total Mean Total Punjab 3.7 104,444 3.4 94,193 0.1 28,106 Time since first birth 0-4 1.7 11,636 1.5 10,773 0.1 6,996 5-9 3.2 21,681 2.9 19,838 0.1 6,775 10-14 4.3 25,158 3.9 22,769 0.1 5,794 15-19 5.1 24,596 4.6 22,012 0.1 4,803 20-24 5.7 21,374 5.0 18,800 0.1 3,738 Table CM.2 provides estimates of infant and under-five mortality rates derived from proportion dead among children of women in various time-since-first-birth groups from 0-4 to 20-24. This table provides estimates of infant and under-5 mortality rates for various points in time prior to the survey. These estimates are later used in Figure CM.2 to compare the trend indicated by these rates with those from other data sources. 14 United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations publication, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Pop Division. United Nations, 1990b. Step-by-step Guide to the Estimation of Child Mortality. New York, UN. International Union for the Scientific Study of Population, 2013. Tools for Demographic Estimation. Paris, UNFPA. P a g e | 22 Table CM.2: Infant and under-5 mortality rates by age groups of women Indirect estimates of infant and under-5 mortality rates by age of women, and reference dates for estimates, East model, Punjab 2014. Reference date Infant mortality rate Under-5 mortality rate Time since first birth 0-4 2012.7 76 95 5-9 2010.2 74 92 10-14 2007.3 76 95 15-19 2004.1 79 100 20-24 2000.5 84 107 To obtain the most recent single estimates of the two indicators by background characteristics, estimates from time since first birth groups 0-4 and 5-9 are averaged and presented in Table CM.3. Table CM.3: Infant and under-5 mortality rates by background characteristics Indirect estimates of infant and under-five mortality rates by selected background characteristics, age version, (by using East Model), Punjab, 2014. Infant mortality rate1 Under-five mortality rate2 Punjab 75 93 Area of residence Rural 83 105 All Urban 57 69 Major Cities 46 55 Other Urban 68 85 Sex Male 84 104 Female 65 82 Mother's education None/pre-school 96 124 Primary 73 91 Middle 58 71 Secondary 50 60 Higher 46 54 Wealth index quintile Lowest 105 137 Second 88 112 Middle 73 91 Fourth 61 75 Highest 45 53 Division Bahawalpur 91 116 D.G. Khan 91 118 Faisalabad 74 92 Gujranwala 68 85 Lahore 64 79 Multan 74 92 Rawalpindi 59 72 Sahiwal 89 114 Sargodha 72 89 1 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 2 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate Rates refer to April 2011. The East Model was assumed to approximate the age pattern of mortality in Pakistan. The infant mortality rate is estimated at 75 deaths per thousand live births, while the probability of dying under age 5 (U5MR) is 93 deaths per thousand live births. Probability of dying during childhood among males is higher than females. The infant mortality rate for males is 84 deaths per thousand live births compared to 65 deaths per thousand for females, similarly the child mortality for males is 104 P a g e | 23 deaths per thousand live births compared with 82 deaths per thousand for females (Table CM.3). Among divisions, infant mortality rates and under-5 mortality rates are lowest in Rawalpindi division (72 and 59 deaths per thousand live births respectively) and highest in DG Khan division (118 and 91 deaths per thousand live births respectively). Infant mortality rate in rural areas is 83 deaths per thousand live births compared to 57 deaths per thousand live births in urban areas. Similarly, under-5 mortality rate is higher in rural areas compared to urban areas (105 and 69 deaths per thousand live births respectively). There is a considerable difference in child mortality in terms of mother's educational levels and wealth. Under-5 mortality for children whose mothers have pre-school or no education is high (124 deaths per thousand live births) and the rates decline as the mother’s educational level increases. Similarly, infant mortality rate for children whose mothers have pre-school or no education is much higher compared to children whose mothers have higher secondary education (96 versus 46 deaths per thousand live births). Furthermore, the probability of dying before age 5 for children living in households in the highest quintile is much lower (53 deaths per thousand live births) compared to children living in the households in the lowest quintile (137 deaths per thousand live births). Similarly, infant mortality rate is 105 deaths per thousand live births for children living in the households in the lowest quintile compared to 45 deaths per thousand live births for those living in the households in the highest quintile. Figure CM.1 provides a graphical presentation of the differences of child mortality rates. P a g e | 24 Figure CM.1: Under -5 mortal i t y rates by area and div is ion , MICS Punjab , 2014 Figure CM.2 compares the findings of the current MICS Punjab, 2014 with MICS Punjab, 2011 and Pakistan Demographic and Health Survey (PDHS) 2012-13. The MICS estimates indicate a decline in mortality during the last four years. 53 75 91 112 137 54 60 71 91 124 69 105 116 118 92 85 79 92 72 114 89 93 0 50 100 150 Wealth index quintile Highest Fourth Middle Second Lowest Mother's education Higher Secondary Middle Primary None/pre-school Area Urban Rural Division Bahawalpur D.G.Khan Faisalabad Gujranwala Lahore Multan Rawalpindi Sahiwal Sargodha Punjab Under-5 Mortality Rates per 1,000 Births P a g e | 25 Figure CM.2: Trend in under -5 mortal i ty and In fant mortal i ty rates , 1990-2014 133 97 104 105 9591 78 82 74 75 0 20 40 60 80 100 120 140 PDHS 1990-91 PDHS 2006-07 MICS 2011 PDHS 2012-13 MICS 2014 Deaths per 1,000 live births Under-5 mortality Infant mortality P a g e | 26 V. NUTRITION Low Birth Weight Weight at birth is a good indicator not only of a mother's health and nutritional status but also for the new-born’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (defined as less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early days, months and years. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born with low birth weight also risk a lower IQ and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight shoots primarily from the mother's poor health and nutrition. Three factors have most impact:  the mother's poor nutritional status before conception,  short stature (due mostly to under nutrition and infections during her childhood), and  poor nutrition during pregnancy, Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In developing countries like Pakistan, teenagers who give birth when their own bodies have yet to finish growing, run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the countries like Pakistan (developing countries) are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth.15 15 For a detailed description of the methodology, see Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. Source of Data on Birth Weight in Developing Countries in “Bulletin of the World Health Organization”, P a g e | 27 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Punjab, 2014. Percent distribution of births by mother's assessment of size at birth Total Percentage of live births: Number of last live-born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams1 Weighed at birth2 Punjab 3.9 16.6 70.2 8.4 0.8 100.0 29.4 25.6 10,653 Area of residence Rural 3.9 17.7 69.9 7.5 1.1 100.0 29.9 18.8 7,369 All Urban 4.1 14.4 70.9 10.3 0.3 100.0 28.3 41.0 3,284 Major Cities 4.1 12.6 71.9 11.2 0.2 100.0 27.4 49.1 1,692 Other Urban 4.1 16.3 69.9 9.3 0.5 100.0 29.3 32.3 1,592 Mother’s age at birth Less than 20 years 4.2 17.5 69.5 7.7 1.1 100.0 30.1 19.0 694 20-34 years 3.9 16.2 70.5 8.6 0.8 100.0 29.2 26.9 8,660 35-49 years 4.1 19.1 68.5 7.5 0.9 100.0 30.8 20.3 1,299 Birth order 1 4.2 15.9 70.8 8.3 0.8 100.0 29.3 32.5 2,431 2-3 3.9 16.1 71.2 8.2 0.7 100.0 29.2 28.3 4,392 4-5 3.7 17.2 69.5 8.6 1.1 100.0 29.5 21.0 2,448 6+ 4.1 18.8 67.3 8.8 1.1 100.0 30.4 13.0 1,382 Mother’s educationa None/pre-school 4.1 19.0 68.7 7.2 1.0 100.0 30.8 10.5 4,816 Primary 4.1 16.8 70.9 7.4 0.7 100.0 29.7 20.4 1,961 Middle 3.8 16.0 71.7 7.6 0.8 100.0 29.1 35.8 1,096 Secondary 4.0 11.8 72.7 10.9 0.6 100.0 27.0 42.8 1,467 Higher 3.0 13.7 70.6 12.1 0.6 100.0 27.1 61.2 1,311 Wealth index quintile Lowest 3.7 22.2 67.4 5.6 1.1 100.0 32.2 6.0 2,327 Second 4.4 18.0 68.8 8.0 0.9 100.0 30.4 12.3 2,166 Middle 4.1 15.1 72.0 7.6 1.1 100.0 28.8 21.6 2,144 Fourth 4.5 13.6 72.4 8.9 0.6 100.0 28.3 35.2 2,065 Highest 2.9 13.5 70.7 12.5 0.4 100.0 27.0 58.0 1,951 Division Bahawalpur 4.7 21.5 61.4 10.3 1.9 100.0 31.9 15.5 1,068 D.G. Khan 3.6 28.0 62.1 5.9 0.4 100.0 34.8 6.0 1,181 Faisalabad 2.7 11.6 77.9 7.4 0.4 100.0 26.5 22.2 1,237 Gujranwala 4.8 15.4 72.3 7.3 0.2 100.0 29.6 30.7 1,578 Lahore 6.1 14.8 66.2 12.1 0.8 100.0 29.5 35.8 1,914 Multan 1.6 13.8 75.4 7.9 1.4 100.0 26.6 20.7 1,162 Rawalpindi 3.9 14.1 70.5 9.9 1.6 100.0 27.9 50.8 882 Sahiwal 3.7 16.9 72.0 7.2 0.3 100.0 29.5 21.4 827 Sargodha 1.8 14.9 77.5 4.5 1.2 100.0 27.8 22.7 804 1 MICS indicator 2.20 - Low-birthweight infants 2 MICS indicator 2.21 - Infants weighed at birth a Total includes 2 unweighted cases of mother's education missing Overall, about 26 percent of births were weighed at birth and approximately 29 percent of infants are estimated to weigh less than 2,500 grams at birth (Table NU.1). Among divisions, Rawalpindi had the lowest proportion of low birth weight babies (27%) and the highest proportion was in DG Khan division (35%). The prevalence of low birth weight does not vary considerably by urban and rural areas or mother’s education. P a g e | 28 Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Under nutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The MDG target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the WHO growth standards16. Each of the three nutritional status indicators – weight-for-age, height-for-age, and weight-for-height – can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median weight of the reference population are considered moderately or severely underweight, while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two standard deviations below the median height of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Weight-for-height can be used to assess wasting and overweight status. Children whose weight-for- height is more than two standard deviations below the median weight of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are classified as severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator of wasting may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. In MICS5, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommended17 by UNICEF. Findings in this section are based on the results of these measurements. Table NU.2 shows percentages of children classified into each of the above described categories and mean z-scores for all three anthropometric indicators. 16 http://www.who.int/childgrowth/standards/technical_report 17 MICS Supply Procurement Instructions: http://mics.unicef.org/tools#survey-design P a g e | 29 Children whose full birth date (month and year) were not obtained, and children whose measurements were outside a plausible range are excluded from Table NU.2. Children are excluded from one or more of the anthropometric indicators when their weights and heights have not been measured, whichever applicable. For example, if a child has been weighed but his/her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. Percentages of children by age and reasons for exclusion are shown in the data quality Tables DQ.10, DQ.11, and DQ.12 in Appendix – E. These tables show that due to incomplete dates of birth, implausible measurements, and/or missing weight and/or height, 3.4 percent of children have been excluded from calculations of the weight-for-age, 4.2 percent from the height-for- age, and 3.8 percent for the weight-for-height. Percentage of interviews completed for eligible children is shown in Table DQ.3. The completeness of reporting of both year and month is 99 percent for interviews conducted for children under 5 (Table DQ.4). There was no heaping in the weight measurements, however, a slight heaping was observed in the height measurements where interviewers preferred the digits zero, two and five (DQ.13). Almost one in three children under age five are moderately or severely underweight (34%) and 11 percent are classified as severely underweight (Table NU.2). Thirty four percent of children are moderately or severely stunted or too short for their age and 18 percent of children are moderately or severely wasted or too thin for their height, whereas less than 1 percent are overweight or too heavy for their height. Boys appear to be slightly more likely to be underweight, stunted, and wasted than girls. Children in rural areas are more likely to be underweight and stunted than in other urban areas and major cities. Among divisions, children in DG Khan division are twice more likely to be underweight and stunted (44% and 47%) than children in Rawalpindi division (21% respectively). All three anthropometric indicators are found to be better in Rawalpindi division. Underweight, stunting and wasting indicators are inversely correlated with mother’s education and wealth. Among women with higher education, 13 percent of children are stunted, 15 percent are underweight and 12 percent are wasted compared to more than 40 percent for stunting and underweight among children whose mother have pre-school or no education. Nearly half of children living in the households in the lowest quintile are stunted and the same proportion of children is underweight compared to 17 percent of children living in the households in the highest quintile that are stunted and underweight. The age pattern shows that a higher percentage of children age 36-47 months are undernourished as prevalence of underweight and stunting is higher in this age group in comparison to children who are younger (Figure NU.1). P a g e | 30 Figure NU.1: Under weight , s tunted, wasted and overweight ch i ldren under age 5 (moderate and severe) , MICS Punjab , 2014 Underweight Stunted Wasted Overweight 0 5 10 15 20 25 30 35 40 45 0 12 24 36 48 60 P e rc e n t Age in months P a g e | 31 Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Punjab, 2014. Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z- Score (SD) Stunted Mean Z- Score (SD) Wasted Overweight Mean Z- Score (SD) Percent below Percent below Percent below Percent above - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD7 Punjaba 33.7 11.3 -1.6 26,490 33.5 13.3 -1.4 26,280 17.5 4.4 0.8 -1.0 26,421 Area of residence Rural 36.3 12.9 -1.6 18,343 36.7 15.1 -1.6 18,195 18.2 4.8 0.8 -1.0 18,284 All Urban 27.7 7.7 -1.3 8,147 26.3 9.2 -1.2 8,085 16.1 3.6 1.0 -0.9 8,137 Major Cities 26.3 6.9 -1.3 4,162 25.0 8.4 -1.1 4,143 15.5 3.3 1.1 -0.9 4,166 Other Urban 29.2 8.7 -1.4 3,985 27.7 10.2 -1.2 3,942 16.6 4.0 0.9 -1.0 3,971 Sex Male 33.9 11.4 -1.6 13,410 33.9 13.5 -1.4 13,290 18.8 5.0 0.9 -1.0 13,356 Female 33.4 11.1 -1.6 13,080 33.1 13.2 -1.4 12,990 16.2 3.8 0.7 -1.0 13,065 Age 0-5 months 30.9 12.8 -1.5 2,263 17.5 6.8 -0.7 2,238 30.6 11.9 1.6 -1.3 2,165 6-11 months 30.8 11.0 -1.4 2,947 22.0 7.9 -1.0 2,926 22.6 6.6 1.4 -1.1 2,941 12-23 months 33.8 12.3 -1.6 5,170 33.0 13.2 -1.4 5,116 20.7 5.5 0.7 -1.1 5,159 12-17 months 32.9 11.7 -1.5 2,583 30.3 11.3 -1.3 2,562 22.4 5.9 0.6 -1.2 2,580 18-23 months 34.7 12.9 -1.6 2,587 35.7 15.0 -1.6 2,554 18.9 5.1 0.8 -1.1 2,580 24-35 months 35.4 12.3 -1.6 5,150 38.6 16.5 -1.7 5,101 16.2 3.9 0.6 -1.0 5,132 36-47 months 35.8 11.5 -1.6 5,637 41.6 16.1 -1.7 5,601 13.0 2.0 0.8 -0.9 5,688 48-59 months 32.3 8.6 -1.5 5,324 33.7 13.2 -1.5 5,298 12.6 2.2 0.6 -0.9 5,336 Mother’s education None/pre-school 42.2 16.2 -1.8 12,646 43.0 19.2 -1.8 12,529 20.0 5.4 0.7 -1.1 12,639 Primary 33.8 10.2 -1.6 4,820 33.3 11.5 -1.4 4,782 17.7 3.9 0.5 -1.0 4,798 Middle 26.9 6.7 -1.4 2,658 27.4 8.9 -1.3 2,642 15.2 4.3 1.0 -0.9 2,658 Secondary 23.3 5.4 -1.2 3,440 21.2 6.2 -1.0 3,414 14.5 3.1 1.1 -0.9 3,418 Higher 14.8 3.0 -0.9 2,927 12.9 3.2 -0.7 2,914 12.3 2.6 1.5 -0.7 2,908 Wealth index quintile Lowest 47.7 20.3 -2.0 6,072 49.4 24.1 -2.0 5,993 21.4 6.1 0.6 -1.2 6,045 Second 39.0 13.3 -1.7 5,362 39.4 15.9 -1.7 5,323 18.7 5.1 0.6 -1.1 5,350 Middle 32.2 9.5 -1.5 5,162 31.1 10.9 -1.4 5,126 18.5 4.1 0.7 -1.0 5,153 Fourth 28.0 7.0 -1.4 5,212 26.3 8.3 -1.2 5,186 15.7 3.9 1.0 -0.9 5,199 Highest 17.3 4.1 -1.0 4,682 16.9 4.7 -0.8 4,652 12.2 2.4 1.4 -0.7 4,673 P a g e | 32 Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Punjab, 2014. Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z- Score (SD) Stunted Mean Z- Score (SD) Wasted Overweight Mean Z- Score (SD) Percent below Percent below Percent below Percent above - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD7 Division Bahawalpur 42.6 16.6 -1.8 2,940 41.3 19.2 -1.7 2,900 20.8 6.0 1.0 -1.2 2,932 D.G. Khan 43.9 17.3 -1.9 3,012 46.6 23.0 -1.9 2,977 18.8 4.4 1.0 -1.1 3,017 Faisalabad 33.8 10.7 -1.5 3,210 29.5 10.7 -1.3 3,193 21.0 6.7 1.2 -1.1 3,173 Gujranwala 24.5 6.8 -1.3 4,006 28.5 8.8 -1.3 3,985 13.2 3.2 0.8 -0.8 3,984 Lahore 31.2 9.6 -1.5 4,452 31.7 11.8 -1.4 4,414 15.2 3.4 0.8 -0.9 4,465 Multan 36.8 12.6 -1.7 2,884 34.7 14.8 -1.5 2,856 20.5 5.0 0.9 -1.1 2,878 Rawalpindi 21.4 5.5 -1.2 2,079 21.4 6.6 -1.0 2,069 13.3 2.6 1.1 -0.8 2,076 Sahiwal 36.0 12.2 -1.6 1,980 34.0 13.2 -1.5 1,971 18.3 4.3 0.2 -1.1 1,977 Sargodha 34.8 11.3 -1.6 1,927 33.3 11.8 -1.5 1,916 18.5 4.1 0.3 -1.1 1,919 Punjaba 33.7 11.3 -1.6 26,490 33.5 13.3 -1.4 26,280 17.5 4.4 0.8 -1.0 26,421 1 MICS indicator 2.1a and MDG indicator 1.8 - Underweight prevalence (moderate and severe) 2 MICS indicator 2.1b - Underweight prevalence (severe) 3 MICS indicator 2.2a - Stunting prevalence (moderate and severe) 4 MICS indicator 2.2b - Stunting prevalence (severe) 5 MICS indicator 2.3a - Wasting prevalence (moderate and severe) 6 MICS indicator 2.3b - Wasting prevalence (severe) 7 MICS indicator 2.4 - Overweight prevalence a Number of children under age 5 in each case differ as children are excluded from one or more anthropometric indicators when their weights or heights have not been measured P a g e | 33 Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival. It can also promote optimal growth and development, especially in the critical window from birth to 2 years of age. Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers don’t start to breastfeed early enough, do not breastfeed exclusively for the recommended 6 months or stop breastfeeding too soon. There are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and can be unsafe if hygienic conditions, including safe drinking water, are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of appropriate, adequate and safe solid, semi-solid and soft foods from the age of 6 months onwards leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life.18 UNICEF and WHO recommend that infants be breastfed within one hour of birth, breastfed exclusively for the first six months of life and continue to be breastfed up to 2 years of age and beyond.19 Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods.20 A summary of key guiding principles21, 22 for feeding 6-23 month olds is provided in the table on next page along with proximate measures for these guidelines. The guiding principles for which proximate measures and indicators exist, are: (i) continued breastfeeding; (ii) appropriate frequency of meals (but not energy density); and (iii) appropriate nutrient content of food. Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds for non-breastfed children) for their age. Dietary diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For dietary diversity, seven food groups were created for which a child consuming at least four of these is considered to have a better quality diet. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber).23 These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of “minimum acceptable diet”. To have a minimum acceptable diet in the previous day, a child must have received: (i) the appropriate number of meals/snacks/milk feeds; (ii) food items from at least 4 food groups; and (iii) breastmilk or at least 2 milk feeds (for non-breastfed children). 18 Bhuta Z. et al. (2013). Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet June 6, 2013. 19 WHO (2003). Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February 2003. 20 WHO (2003). Global Strategy for Infant and Young Child Feeding. 21 PAHO (2003). Guiding principles for complementary feeding of the breastfed child. 22 WHO (2005). Guiding principles for feeding non-breastfed children 6-24 months of age 23 WHO (2008). Indicators for assessing infant and young child feeding practices. Part 1: Definitions. P a g e | 34 Table Guiding Principle (age 6-23 months) Proximate measures NU.4 Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.6 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content of food Four food groups24 eaten in the last 24 hours na Appropriate amount of food No standard indicator exists na Appropriate consistency of food No standard indicator exists na Use of vitamin-mineral supplements or fortified products for infant and mother No standard indicator exists NU.9 Practice good hygiene and proper food handling While it was not possible to develop indicators to fully capture programme guidance, one standard indicator does cover part of the principle: Not feeding with a bottle with a nipple na Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists Table NU.3 is based on mothers’ report of what their last-born child, born in the last two years, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were first breastfed within one hour and one day of birth, and those who received a prelacteal feed.25 Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 11 percent of babies are breastfed for the first time within one hour of birth, while 45 percent of newborns start breastfeeding within one day of birth. By division, 66 percent of babies in Rawalpindi division were breastfed within one day of birth compared to only 28 percent of babies in Sahiwal. The data also show that 75 percent of newborns receive prelacteal feed. The findings are presented in Figure NU.2 by division and area of residence. 24 Food groups used for assessment of this indicator are 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. 25 Prelacteal feed refers to the provision any liquid or food, other than breastmilk, to a newborn during the period when breastmilk flow is generally being established (estimated here as the first 3 days of life). P a g e | 35 Table NU.3: Initial breastfeeding Percentage of last live-born children in the last two years who were ever breastfed, breastfed within one hour of birth and within one day of birth, and percentage who received a prelacteal feed, Punjab, 2014. Percentage who were ever breastfed1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last live- born children in the last two years Within one hour of birth2 Within one day of birth Punjab 93.7 10.6 45.2 74.5 10,653 Area of residence Rural 93.9 10.3 44.3 74.4 7,369 All Urban 93.3 11.2 47.3 74.8 3,284 Major Cities 93.8 11.9 50.3 73.2 1,692 Other Urban 92.8 10.5 44.1 76.5 1,592 Months since last birth 0-11 months 93.4 10.0 42.5 74.6 5,546 12-23 months 94.0 11.3 48.2 74.4 5,107 Assistance at delivery Skilled attendant 93.4 9.8 42.3 75.9 6,894 Traditional birth attendant 95.4 11.9 50.9 73.3 3,535 Other 97.3 19.5 59.5 65.5 173 No one/Missing (7.3) (0.0) (3.6) (7.3) 52 Place of delivery Home 95.6 12.9 51.8 73.3 4,125 Health facility 93.2 9.2 41.4 75.9 6,473 Public 93.7 11.8 49.9 70.9 1,909 Private 93.0 8.1 37.8 77.9 4,565 Other/DK/Missing 12.7 4.0 8.6 9.0 55 Mother’s educationa None/pre-school 93.7 11.5 45.4 71.7 4,816 Primary 94.6 9.1 45.0 77.7 1,961 Middle 93.0 8.7 45.9 77.4 1,096 Secondary 93.8 10.4 45.8 76.4 1,467 Higher 93.1 11.3 43.8 75.6 1,311 Wealth index quintile Lowest 94.2 12.4 45.5 69.2 2,327 Second 94.7 10.9 45.3 75.2 2,166 Middle 93.6 8.8 44.9 77.6 2,144 Fourth 92.8 8.4 44.0 76.2 2,065 Highest 93.0 12.4 46.5 74.8 1,951 Division Bahawalpur 95.1 11.2 39.7 69.4 1,068 D.G. Khan 95.7 22.2 56.4 57.6 1,181 Faisalabad 93.6 6.2 40.8 82.7 1,237 Gujranwala 91.8 5.5 42.4 85.4 1,578 Lahore 92.8 10.4 42.0 74.9 1,914 Multan 94.2 9.5 47.4 63.9 1,162 Rawalpindi 92.8 17.6 66.4 69.8 882 Sahiwal 93.8 4.5 27.5 84.1 827 Sargodha 95.1 10.2 48.3 81.9 804 1 MICS indicator 2.5 - Children ever breastfed 2 MICS indicator 2.6 - Early initiation of breastfeeding ( ) Figures that are based on 25-49 unweighted cases a Total includes 2 unweighted cases of mother's education missing P a g e | 36 Figure NU.2: In i t iat ion of breastfeeding, MICS Punjab, 2014 The set of Infant and Young Child Feeding indicators reported in Tables NU.4 through NU.8 are based on the mother’s report of consumption of food and fluids during the day or night prior to the interview. Data are subject to a number of limitations, some related to the respondent’s ability to provide a full report on the child’s liquid and food intake due to recall errors as well as lack of knowledge in cases where the child was fed by other individuals. In Table NU.4, breastfeeding status is presented for both Exclusively breastfed and Predominantly breastfed; referring to infant’s age less than 6 months who are breastfed, distinguished by the former only allowing vitamins, mineral supplements, and medicine and the latter allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. Approximately 17 percent of children age less than six months are exclusively breastfed. With 48 percent predominantly breastfed, it is evident that water-based liquids are displacing feeding of breastmilk to the greatest degree. By age 12-15 months, 66 percent of children are breastfed, and by age 20-23 months, 35 percent continue to be breastfed. Exclusive breastfeeding for children age less than six months is slightly higher in rural areas than urban areas. In Bahawalpur division, fewer children (7%) are exclusively breastfed compared to children in the other divisions. Predominant breastfeeding ranges from 37 percent in Gujranwala division to 60 percent in Multan division. 40 56 41 42 42 47 66 27 48 47 44 45 11 22 6 6 10 9 18 4 10 11 10 11 0 20 40 60 80 100 P er ce n t Within one day Within one hour P a g e | 37 Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Punjab, 2014. Children age 0-3 months Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent ever breastfed Percent exclusively breastfed1 Percent predominantly breastfed2 Number of children Percent ever breastfed Percent exclusively breastfed1 Percent predominantly breastfed2 Number of children Percent breastfed (Continued breastfeeding at 1 year)3 Number of children Percent breastfed (Continued breastfeeding at 2 years)4 Number of children Punjab 96.6 22.6 55.5 1,583 96.5 16.8 47.8 2,333 65.6 1,854 34.5 1,728 Area of residence Rural 96.3 24.6 59.9 1,113 96.3 18.3 51.1 1,627 67.3 1,299 34.0 1,188 All Urban 97.5 17.8 45.0 470 96.9 13.4 40.0 706 61.5 555 35.7 540 Major Cities 99.1 14.8 41.7 236 98.4 11.5 38.6 373 56.9 251 33.3 284 Other Urban 95.9 20.8 48.4 234 95.2 15.4 41.5 333 65.4 304 38.3 256 Sex Male 95.7 22.9 55.9 757 95.7 16.7 47.8 1,138 64.4 963 35.4 903 Female 97.5 22.3 55.1 825 97.3 16.9 47.7 1,195 66.9 891 33.5 825 Mother’s education None/pre-school 96.2 22.6 63.1 727 96.1 16.6 54.4 1,075 68.9 839 40.2 738 Primary 96.8 23.4 56.6 277 96.9 18.6 50.7 391 66.7 369 33.9 309 Middle 96.2 22.1 47.0 155 96.4 16.3 39.5 229 62.5 192 28.5 210 Secondary 96.9 21.6 45.3 231 96.5 16.0 38.7 330 60.6 249 32.7 237 Higher 97.8 22.9 44.2 192 97.6 16.5 36.5 307 58.9 205 24.6 234 Wealth index quintile Lowest 95.3 20.5 66.2 356 96.4 15.0 56.8 515 72.9 406 37.8 336 Second 97.1 24.0 60.8 350 96.9 17.4 51.9 527 69.5 382 36.8 340 Middle 96.9 23.8 56.5 307 97.4 18.3 50.1 431 63.5 395 39.5 351 Fourth 95.7 25.4 50.3 309 94.7 19.2 44.4 460 62.0 347 30.5 344 Highest 98.5 18.7 38.6 262 97.4 13.8 32.0 400 58.2 323 28.3 358 Division Bahawalpur 99.7 9.8 56.6 149 99.8 7.4 49.5 224 71.3 201 34.5 151 D.G. Khan 95.6 21.3 62.5 170 96.4 15.3 51.0 257 72.0 205 43.1 153 Faisalabad 94.7 15.2 47.3 168 95.6 10.0 42.3 277 68.7 200 34.5 228 Gujranwala 94.6 26.4 45.8 216 95.2 19.3 37.3 323 61.4 297 27.0 302 Lahore 97.9 18.9 48.9 290 97.1 14.1 43.2 406 55.2 315 32.3 268 Multan 96.0 24.3 66.6 210 96.5 20.1 60.2 286 64.0 203 36.3 203 Rawalpindi 97.0 34.4 57.6 120 94.6 24.1 46.9 194 63.1 128 34.5 138 Sahiwal 97.4 30.9 56.7 130 96.3 24.3 49.2 175 69.6 164 39.3 150 Sargodha 97.4 28.2 65.2 130 97.3 21.5 57.7 192 75.7 142 38.1 133 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.8 - Predominant breastfeeding under 6 months 3 MICS indicator 2.9 - Continued breastfeeding at 1 year 4 MICS indicator 2.10 - Continued breastfeeding at 2 years P a g e | 38 Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, the majority of children are receiving liquids or foods other than breastmilk, with other milk formula being of highest prevalence, even at the early age of 0-1 months. At age 4-5 months old, the percentage of children exclusively breastfed is only 5 percent. About 30 percent of children are receiving breastmilk at age 2 years. Figure NU.3: Infant feeding patterns by age, MICS Punjab, 2014 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3, the median duration is 17.4 months for any breastfeeding, 0.6 months for exclusive breastfeeding, and 2.2 months for predominant breastfeeding. There is no difference in median duration of exclusive breastfeeding according to background characteristics, while slight differentials are observed for predominant breastfeeding. Exclusively breastfed Breastfed and complementary foods Weaned (not breastfed) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0-1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age in months Exclusively breastfed Breastfed and plain water only Breastfed and non-milk liquids Breastfed and other milk / formula Breastfed and complementary foods Weaned (not breastfed) P a g e | 39 Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Punjab, 2014. Median duration (in months) of: Number of children age 0-35 months Any breastfeeding1 Exclusive breastfeeding Predominant breastfeeding Median (Punjab) 17.4 0.6 2.2 15,968 Area of residence Rural 17.6 0.6 2.6 11,061 All Urban 16.8 0.5 0.7 4,908 Major Cities 16.0 0.5 0.6 2,524 Other Urban 17.7 0.5 1.4 2,384 Sex Male 17.5 0.6 2.2 8,106 Female 17.3 0.6 2.2 7,863 Mother’s education None/pre-school 18.2 0.5 3.1 7,277 Primary 18.3 0.6 2.6 2,960 Middle 15.1 0.5 1.5 1,657 Secondary 17.9 0.6 0.7 2,164 Higher 15.7 0.6 0.8 1,910 Wealth index quintile Lowest 18.9 0.5 3.4 3,480 Second 18.1 0.6 2.8 3,246 Middle 17.4 0.6 2.5 3,216 Fourth 16.6 0.6 1.9 3,149 Highest 15.8 0.5 0.6 2,877 Division Bahawalpur 18.7 0.5 2.5 1,682 D.G. Khan 20.0 0.5 2.6 1,767 Faisalabad 17.0 0.5 1.4 1,920 Gujranwala 15.8 0.6 1.1 2,398 Lahore 14.8 0.6 1.1 2,739 Multan 18.6 0.5 3.8 1,771 Rawalpindi 19.2 0.8 2.2 1,267 Sahiwal 16.9 0.6 2.4 1,218 Sargodha 18.2 0.6 3.4 1,206 Mean (Punjab) 16.7 1.0 3.6 15,968 1 MICS indicator 2.11 - Duration of breastfeeding The age-appropriateness of breastfeeding of children under age 24 months is provided in Table NU.6. Different criteria of feeding are used depending on the age of the child. For infants age 0-5 months, exclusive breastfeeding is considered as age-appropriate feeding, while children age 6-23 months are considered to be appropriately fed if they are receiving breastmilk and solid, semi-solid or soft food. As a result of feeding patterns, only 48 percent of children age 6-23 months are being appropriately breastfed and age-appropriate breastfeeding among all children age 0-23 months, drops to 41 percent. At divisional level, age-appropriate breastfeeding among all children age 0-23 months ranges from 36 percent in Bahawalpur to 49 percent in Rawalpindi. P a g e | 40 Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Punjab, 2014. Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed1 Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed2 Number of children Punjab 16.8 2,333 48.0 8,310 41.2 10,642 Area of residence Rural 18.3 1,627 48.2 5,756 41.6 7,383 All Urban 13.4 706 47.6 2,553 40.2 3,259 Major Cities 11.5 373 44.9 1,298 37.5 1,671 Other Urban 15.4 333 50.4 1,255 43.1 1,588 Sex Male 16.7 1,138 48.0 4,254 41.4 5,392 Female 16.9 1,195 48.0 4,056 40.9 5,251 Mother’s education None/pre-school 16.6 1,075 47.7 3,730 40.7 4,806 Primary 18.6 391 49.5 1,529 43.2 1,921 Middle 16.3 229 44.0 887 38.3 1,116 Secondary 16.0 330 50.1 1,139 42.4 1,469 Higher 16.5 307 48.3 1,024 41.0 1,331 Wealth index quintile Lowest 15.0 515 47.3 1,794 40.1 2,308 Second 17.4 527 48.9 1,646 41.2 2,173 Middle 18.3 431 49.7 1,690 43.3 2,122 Fourth 19.2 460 46.7 1,634 40.7 2,094 Highest 13.8 400 47.5 1,546 40.6 1,946 Division Bahawalpur 7.4 224 43.0 849 35.6 1,073 D.G. Khan 15.3 257 54.5 906 45.9 1,163 Faisalabad 10.0 277 50.6 1,033 42.0 1,310 Gujranwala 19.3 323 45.2 1,296 40.0 1,620 Lahore 14.1 406 43.9 1,418 37.3 1,824 Multan 20.1 286 46.9 892 40.4 1,177 Rawalpindi 24.1 194 56.4 656 49.0 850 Sahiwal 24.3 175 46.2 651 41.6 825 Sargodha 21.5 192 51.3 609 44.1 801 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.12 - Age-appropriate breastfeeding Overall, 61 percent of infants age 6-8 months received solid, semi-solid, or soft foods at least once during the previous day (Table NU.7). Among currently breastfeeding infants this percentage is 59 while it is 72 among infants currently not breastfeeding. The proportion is higher (70%) in urban compared to 58 percent in rural areas. Similarly, the percentage of children receiving solid, semi-solid or soft food shows a positive relation with household wealth. P a g e | 41 Table NU.7: Introduction of solid, semi-solid, or soft foods Percentage of infants age 6-8 months who received solid, semi-solid, or soft foods during the previous day, Punjab, 2014. Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi- solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods1 Number of children age 6-8 months Punjab 58.7 1,295 72.4 282 61.1 1,577 Area of residence Rural 56.4 948 64.5 172 57.7 1,120 All Urban 64.7 347 84.6 110 69.5 457 Major Cities 63.2 157 (87.4) 63 70.2 220 Other Urban 66.0 190 81.0 47 69.0 238 Sex Male 58.7 645 70.9 134 60.8 779 Female 58.7 650 73.7 149 61.5 799 Mother’s education None/pre-school 49.1 629 54.9 101 49.9 730 Primary 60.0 229 70.7 51 61.9 280 Middle 61.8 135 (74.1) 34 64.3 169 Secondary 67.0 162 (89.0) 41 71.4 203 Higher 86.6 140 92.7 55 88.3 195 Wealth index quintile Lowest 44.6 336 (54.0) 50 45.9 386 Second 56.9 259 (58.7) 41 57.1 301 Middle 59.2 274 70.2 58 61.1 332 Fourth 63.4 237 76.5 55 65.8 292 Highest 79.3 189 90.1 78 82.5 267 Division Bahawalpur 44.9 147 (*) 22 48.4 168 D.G. Khan 55.1 172 (63.8) 23 56.2 196 Faisalabad 65.3 173 (83.1) 42 68.8 215 Gujranwala 66.7 169 (69.4) 49 67.3 218 Lahore 53.0 213 76.1 61 58.1 274 Multan 54.8 150 (*) 24 55.9 174 Rawalpindi 83.9 98 (*) 26 83.8 123 Sahiwal 52.3 83 (*) 22 55.2 105 Sargodha 58.6 90 (*) 13 57.7 103 1 MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Overall, 65 percent of the children age 6-23 months are receiving solid, semi-solid and soft foods the minimum number of times (Table NU.8). A slightly higher proportion of children in urban areas (71%) were achieving the minimum meal frequency compared to children in rural areas (63%). The proportion of children (17%), receiving the minimum dietary diversity or foods from at least 4 food groups, was much lower than that for minimum meal frequency indicating the need to focus on improving diet quality and nutrients intake among this vulnerable group. A higher proportion of older (18-23 month) children (26%) were achieving the minimum dietary diversity compared to younger (6-8 month old) children (6%). The overall assessment using the indicator of minimum acceptable diet revealed that only 10 percent of children are benefitting from a diet sufficient in both diversity and frequency. The proportion is slightly higher in urban areas (14%) compared to rural areas (8%). Children living in the households in highest wealth quintile, those whose mothers have higher education and from Rawalpindi division are most likely to receive as recommended the minimum meal frequency, minimum dietary diversity, and minimum acceptable diet. P a g e | 42 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Punjab, 2014. Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet1, c Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet2, c At least 2 milk feeds3 Minimum dietary diversity4, a Minimum meal frequency5, b Minimum acceptable dietc Punjab 12.5 49.8 11.2 4,992 25.2 92.2 7.3 90.8 2,866 17.3 65.3 9.7 8,310 Area of residence Rural 9.8 47.3 8.9 3,558 22.7 91.7 6.0 90.5 1,930 14.6 62.9 7.9 5,756 All Urban 19.0 56.1 16.7 1,434 30.5 93.2 9.9 91.4 937 23.6 70.8 14.0 2,553 Major Cities 20.7 55.9 17.6 687 33.1 91.9 12.2 90.3 501 26.3 71.1 15.3 1,298 Other Urban 17.5 56.3 15.8 748 27.4 94.8 7.3 92.6 435 20.8 70.5 12.7 1,255 Sex Male 12.7 49.3 11.1 2,546 27.3 91.8 9.1 90.8 1,484 18.3 64.9 10.4 4,254 Female 12.2 50.4 11.3 2,446 23.0 92.6 5.3 90.8 1,382 16.3 65.6 9.1 4,056 Age 6-8 months 5.0 44.4 4.6 1,295 7.6 84.5 2.3 90.4 209 5.6 49.9 4.3 1,577 9-11 months 8.3 39.9 7.1 1,035 16.6 93.1 4.9 96.6 323 10.2 52.6 6.5 1,433 12-17 months 16.3 53.9 14.8 1,606 22.9 93.3 7.3 92.8 890 19.1 67.9 12.1 2,640 18-23 months 19.8 60.1 17.6 1,056 31.1 92.4 8.5 88.3 1,445 26.4 78.8 12.3 2,660 Mother’s education None/pre-school 7.9 42.9 7.1 2,397 17.7 88.8 3.8 87.4 1,158 11.3 57.9 6.0 3,730 Primary 12.5 49.9 11.9 934 23.4 94.9 4.8 91.7 527 16.4 66.1 9.3 1,529 Middle 12.5 54.2 11.9 486 27.4 94.9 9.7 92.8 336 18.8 70.8 11.0 887 Secondary 18.2 56.4 13.9 656 29.7 94.6 7.8 94.2 427 23.1 71.5 11.5 1,139 Higher 26.0 69.3 24.3 519 41.9 93.3 17.5 93.9 419 33.0 80.0 21.3 1,024 Wealth index quintile Lowest 6.4 37.9 5.5 1,204 14.6 85.0 3.5 85.1 516 8.9 52.0 4.9 1,794 Second 8.1 45.1 7.4 1,043 18.5 90.8 3.8 88.7 540 11.6 60.7 6.2 1,646 Middle 11.5 52.6 10.7 1,029 22.9 95.2 6.4 92.0 583 15.8 68.0 9.1 1,690 Fourth 16.3 56.2 14.3 915 30.5 95.1 8.5 94.3 607 21.7 71.7 12.0 1,634 Highest 24.2 62.9 21.6 801 36.9 93.7 13.0 92.7 621 30.3 76.3 17.8 1,546 P a g e | 43 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Punjab, 2014. Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Percent of children who received: Number of children age 6-23 months Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet1, c Minimum dietary diversitya Minimum meal frequencyb Minimum acceptable diet2, c At least 2 milk feeds3 Minimum dietary diversity4, a Minimum meal frequency5, b Minimum acceptable dietc Division Bahawalpur 5.3 32.1 4.4 546 12.6 82.5 2.1 85.3 271 7.6 48.8 3.7 849 D.G. Khan 11.8 44.1 9.6 639 26.9 88.9 8.7 87.8 239 15.9 56.3 9.3 906 Faisalabad 13.9 62.7 13.6 623 24.7 97.7 8.3 94.6 348 18.0 75.2 11.7 1,033 Gujranwala 11.3 58.6 10.2 682 24.1 94.9 6.2 92.1 514 17.7 74.2 8.5 1,296 Lahore 16.0 52.7 15.2 773 34.5 93.9 9.1 91.3 556 23.5 69.9 12.6 1,418 Multan 5.8 38.8 5.1 553 19.7 88.1 3.8 93.0 296 11.1 56.0 4.6 892 Rawalpindi 25.9 57.8 20.5 399 35.6 92.8 15.2 86.4 214 29.4 70.0 18.7 656 Sahiwal 10.8 52.7 10.6 389 20.6 92.9 7.4 88.9 231 14.3 67.6 9.4 651 Sargodha 13.8 47.1 12.6 388 20.9 92.3 5.3 93.9 199 16.1 62.4 10.2 609 Punjab 12.5 49.8 11.2 4,992 25.2 92.2 7.3 90.8 2,866 17.3 65.3 9.7 8,310 1 MICS indicator 2.17a - Minimum acceptable diet (breastfed) 2 MICS indicator 2.17b - Minimum acceptable diet (non-breastfed) 3 MICS indicator 2.14 - Milk feeding frequency for non-breastfed children 4 MICS indicator 2.16 - Minimum dietary diversity 5 MICS indicator 2.15 - Minimum meal frequency a Minimum dietary diversity is defined as receiving foods from at least 4 of 7 food groups: 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. b Minimum meal frequency among currently breastfeeding children is defined as children who also received solid, semi-solid, or soft foods 2 times or more daily for children age 6-8 months and 3 times or more daily for children age 9-23 months. For non-breastfeeding children age 6-23 months it is defined as receiving solid, semi-solid or soft foods, or milk feeds, at least 4 times daily. c The minimum acceptable diet for breastfed children age 6-23 months is defined as receiving the minimum dietary diversity and the minimum meal frequency, while it for non-breastfed children further requires at least 2 milk feedings and that the minimum dietary diversity is achieved without counting milk feeds. P a g e | 44 The continued practice of bottle-feeding is a matter of concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.9 shows that 58 percent of children under 2 years are fed using a bottle with a nipple. More than two-third (68%) of the children under 2 years are bottle fed in Gujranwala division compared to 44 percent in Bahawalpur division. The practice of bottle feeding is higher in urban (66%) compared to rural areas (54%). Bottle feeding has a positive relation with education of the mother and household wealth. For example, bottle feeding is 49 percent for children whose mother have pre-school or no education compared to 72 percent of children whose mothers have higher education. The data further show that 45 percent of children age less than six months are fed using a bottle with a nipple even though the children are expected to be exclusively breastfed at that age. Table NU.9: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Punjab, 2014. Percentage of children age 0-23 months fed with a bottle with a nipple1 Number of children age 0- 23 months Punjab 57.7 10,642 Area of residence Rural 54.1 7,383 All Urban 65.7 3,259 Major Cities 68.2 1,671 Other Urban 63.1 1,588 Sex Male 58.0 5,392 Female 57.3 5,251 Age 0-5 months 45.0 2,333 6-11 months 58.3 3,010 12-23 months 62.9 5,300 Mother’s education None/pre-school 49.1 4,806 Primary 58.5 1,921 Middle 64.8 1,116 Secondary 66.3 1,469 Higher 71.8 1,331 Wealth index quintile Lowest 44.1 2,308 Second 50.8 2,173 Middle 60.6 2,122 Fourth 63.1 2,094 Highest 72.4 1,946 Division Bahawalpur 44.4 1,073 D.G. Khan 51.1 1,163 Faisalabad 57.6 1,310 Gujranwala 68.4 1,620 Lahore 66.5 1,824 Multan 53.0 1,177 Rawalpindi 61.3 850 Sahiwal 54.3 825 Sargodha 49.4 801 1 MICS indicator 2.18 - Bottle feeding P a g e | 45 Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. The IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). In Pakistan iodine deficiency disorders have been recognized as a public health problem for nearly 50 years. Various surveys have reflected that Pakistan is a country with more than half of the population estimated to be at risk for IDD (Iodine Deficiency Disorders). The situation is worse especially in the northern districts of Pakistan which is considered to be one of the most severely endemic areas in the world for IDD. A National IDD Control Program was initiated in 1989 with a focus on elimination of IDD through Universal Salt Iodization (USI). The Program has been implemented by Government of Pakistan with the support for national USI partners including UNICEF, the Micronutrient Initiative and GAIN (Global Alliance for Improved Nutrition). The Program is being implemented in all provinces with the objective to improve the availability and accessibility of adequately iodized salt to the entire population including the most vulnerable. Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Punjab, 2014. Percentage of households in which salt was tested Number of households Percent of households with: Total Number of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 PPM >0 and <15 PPM 15+ PPM1 Punjab 98.2 38,405 1.1 30.2 19.6 49.2 100.0 38,119 Area of residence Rural 98.4 25,577 1.1 32.5 20.8 45.6 100.0 25,445 All Urban 97.7 12,828 1.1 25.4 17.1 56.3 100.0 12,675 Major Cities 97.2 6,717 1.1 27.9 16.2 54.8 100.0 6,605 Other Urban 98.2 6,111 1.1 22.8 18.2 57.9 100.0 6,070 Education of household heada None/pre-school 98.2 15,399 1.3 34.2 20.8 43.7 100.0 15,311 Primary 98.4 6,639 1.2 31.7 20.0 47.1 100.0 6,607 Middle 98.5 4,863 0.8 30.4 20.4 48.3 100.0 4,829 Secondary 98.0 7,022 1.0 26.5 18.9 53.6 100.0 6,953 Higher 97.8 4,472 0.8 19.2 14.9 65.0 100.0 4,410 Wealth index quintile Lowest 97.7 8,027 1.9 39.3 22.5 36.3 100.0 7,991 Second 98.4 7,721 1.1 33.7 21.1 44.0 100.0 7,687 Middle 98.6 7,508 0.9 30.6 20.2 48.3 100.0 7,469 Fourth 98.3 7,551 0.8 27.7 19.2 52.4 100.0 7,479 Highest 97.9 7,598 0.8 18.8 14.7 65.8 100.0 7,494 P a g e | 46 Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Punjab, 2014. Percentage of households in which salt was tested Number of households Percent of households with: Total Number of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 PPM >0 and <15 PPM 15+ PPM1 Division Bahawalpur 98.2 4,091 1.4 33.1 21.6 43.8 100.0 4,077 D.G.Khan 98.5 3,436 1.2 41.0 24.0 33.9 100.0 3,424 Faisalabad 98.8 4,889 0.8 29.0 17.9 52.3 100.0 4,867 Gujranwala 98.4 5,569 0.9 19.6 16.9 62.6 100.0 5,527 Lahore 97.5 6,631 1.1 26.4 16.4 56.1 100.0 6,537 Multan 97.6 4,633 1.6 38.7 15.0 44.6 100.0 4,596 Rawalpindi 97.4 3,633 1.1 24.4 29.0 45.5 100.0 3,579 Sahiwal 98.6 2,638 1.3 22.1 19.6 57.0 100.0 2,636 Sargodha 99.1 2,885 0.6 44.7 22.2 32.6 100.0 2,874 Punjab 98.2 38,405 1.1 30.2 19.6 49.2 100.0 38,119 1 MICS indicator 2.19 - Iodized salt consumption a Total includes 11 unweighted cases of household head's education missing In 98 percent of households, salt used for cooking was tested for iodine content by using salt test kits to test the presence of potassium iodate content in the salt. Table NU.10 shows that in about 1 percent of households, there is no salt available. These households are, however, included in the denominator of the indicator. In 49 percent of households, salt is found to contain 15 parts per million (ppm) or more of iodine. Use of iodized salt was lowest in Sargodha division (33%) and highest in Gujranwala division (63%). More urban households (56%) were found to be using adequately iodized salt compared to 46 percent in rural areas. Similarly, 66 percent of households in the highest wealth quintile are using adequately iodized salt compared to 36 percent of households in the lowest quintile. The consumption of adequately iodized salt is graphically presented in Figure NU.4. P a g e | 47 Figure NU.4: Consumption of iodized sa lt , MICS Punjab, 2014 Children’s Vitamin A Supplementation Vitamin A is essential for eye health and proper functioning of the immune system. It is found in foods such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables, although the amount of vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, vitamin A deficiency is quite prevalent in developing world and particularly in countries with highest burden of under-five deaths. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly's Special Session on Children in 2002. The critical role of vitamin A in child health and immune function makes control of deficiency a primary component of child survival efforts, and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. 65 58 70 80 73 60 74 77 55 73 66 59 65 69 72 80 69 44 34 52 63 56 45 45 57 33 56 46 36 44 48 52 66 49 0 20 40 60 80 100 P er ce n t Any iodine 15+ PPM of iodine P a g e | 48 For countries where vitamin A deficiency is common, current international recommendations call for high- dose supplementation every 4–6 months for all children aged 6–59 months living in affected areas. Providing young children with two high-dose vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating vitamin A deficiency and improving child survival. Giving vitamin A to new mothers helps protect their children during the first months of life and helps to replenish the mother's own stores of vitamin A which are depleted during pregnancy and lactation. Under Pakistan's National Health Policy 2001, vitamin A supplements are to be provided annually to all children aged 6-59 months on National Immunisation Days through the Expanded Programme on Immunization (EPI) network. This survey uses as an indicator the percentage of children 6–35 months of age who receive at least one high-dose of vitamin A supplement in the preceding 6 months. MICS Punjab, 2014 finds that about 65 percent of children aged 6–59 months received at least one dose of vitamin A supplement during the 6 months period prior to the interview (Table NU.11). Children age 6– 11 months have least coverage (53%) compared to older children age 36-47 months who have highest coverage (67%). Among divisions, nine in ten children (91%) in Bahawalpur division received Vitamin A dose during the last 6months compared to only four in ten children in Multan division (45%). Table NU.11: Children's vitamin A supplementation Percent distribution of children age 6-59 months by receipt of a high dose vitamin A supplement in the last 6 months, Punjab, 2014. Percentage of children who received Vitamin A during the last 6 months1 Number of children age 6-59 months Punjab 64.8 24,706 Area of residence Rural 65.2 17,086 All Urban 64.0 7,620 Major Cities 57.9 3,896 Other Urban 70.4 3,723 Sex Male 65.2 12,533 Female 64.4 12,172 Age 6-11 months 52.9 3,010 12-23 months 65.0 5,300 24-35 months 66.5 5,326 36-47 months 67.3 5,894 48-59 months 67.1 5,176 Mother’s education None/pre-school 63.9 11,885 Primary 66.6 4,508 Middle 64.6 2,471 Secondary 64.5 3,139 Higher 66.9 2,703 Wealth index quintile Lowest 63.2 5,728 Second 66.8 4,966 Middle 67.1 4,821 Fourth 63.8 4,810 Highest 63.4 4,381 P a g e | 49 Table NU.11: Children's vitamin A supplementation Percent distribution of children age 6-59 months by receipt of a high dose vitamin A supplement in the last 6 months, Punjab, 2014. Percentage of children who received Vitamin A during the last 6 months1 Number of children age 6-59 months Division Bahawalpur 90.9 2,807 D.G. Khan 46.9 2,859 Faisalabad 70.7 2,937 Gujranwala 69.4 3,673 Lahore 59.0 4,191 Multan 44.8 2,691 Rawalpindi 60.4 1,924 Sahiwal 73.8 1,837 Sargodha 72.9 1,787 Punjab 64.8 24,706 1 MICS indicator 2.S1 - Vitamin A supplementation P a g e | 50 VI. CHILD HEALTH Vaccinations The Millennium Development Goal 4 (MDG 4) is to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in achieving this goal. In addition, the Global Vaccine Action Plan (GVAP) was endorsed by the 194 Member States of the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. Immunization has saved the lives of millions of children in the four decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide, there are still millions of children not reached by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. The WHO Recommended Routine Immunizations for Children26 aims at all children to be vaccinated against tuberculosis, diphtheria, pertussis, tetanus, polio, measles, hepatitis B, haemophilus influenzae type b, pneumonia/meningitis, rotavirus, and rubella. All doses in the primary series are recommended to be completed before the child’s first birthday, although depending on the epidemiology of disease in a country, the first doses of measles and rubella containing vaccines may be recommended at 12 months or later. The recommended number and timing of most other doses also vary slightly with local epidemiology and may include booster doses later in childhood. Pakistan National Immunization Programme provides all the above mentioned vaccinations with birth doses of BCG, Polio, and Hepatitis B vaccines, three doses of the Pentavalent vaccine containing DPT, Hepatitis B, and Haemophilus influenzae type b (Hib) antigens, three doses of Polio vaccine, three doses of Pneumococcal (conjugate) vaccine, two or three doses of rotavirus vaccine (depending on vaccine used), two doses of the MMR vaccine containing measles, mumps, and rubella antigens. All vaccinations should be received during the first year of life except the doses of MMR at 12 and 15 months. Taking into consideration this vaccination schedule, the estimates for full immunization coverage from the MICS Punjab, 2014 are based on children age 12-23 months. Information on vaccination coverage was collected for all children under three years of age. All mothers or caretakers were asked to provide vaccination cards. If the vaccination card for a child was available, interviewers copied vaccination information from the cards onto the MICS questionnaire. If no vaccination card was available for the child, the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccinations, and for Polio, DPT/HEPB/HIB and PENTA, how many doses were received. The final vaccination coverage estimates are based on information obtained from the vaccination card and the mother’s report of vaccinations received by the child. 26 http://www.who.int/immunization/diseases/en. Table 2 includes recommendations for all children and additional antigens recommended only for children residing in certain regions of the world or living in certain high-risk population groups. P a g e | 51 Table CH.1: Vaccinations in the first years of life Percentage of children age 12-23 months and 24-35 months vaccinated against vaccine preventable childhood diseases at any time before the survey and by their first birthday, Punjab, 2014. Children age 12-23 months: Children age 24-35 months: Vaccinated at any time before the survey according to: Vaccinated by 12 months of agea Vaccinated at any time before the survey according to: Vaccinated by 12 months of age Vaccination card Mother's report Either Vaccination card Mother's report Either Antigen BCG1 58.4 34.7 93.1 92.8 36.7 55.3 92.0 90.3 Polio At birth 57.6 33.8 91.4 91.2 36.2 52.3 88.6 87.2 1 58.0 37.4 95.3 94.7 36.4 57.2 93.6 91.1 2 56.9 33.9 90.8 89.7 35.9 53.1 89.0 85.5 32 55.3 31.2 86.6 84.8 35.2 49.9 85.1 80.8 PENTA 1 58.2 27.5 85.7 85.2 36.7 45.3 82.0 79.8 2 57.1 24.8 81.8 80.9 36.2 41.4 77.6 74.7 33,4,5 55.6 17.7 73.3 71.7 35.5 31.8 67.3 63.9 Measles 16 50.9 26.9 77.8 71.6 33.9 49.1 83.0 71.8 2 28.7 0.5 29.2 na 29.8 0.0 0.0 na Fully vaccinated7, b 50.3 11.9 62.3 56.0 33.9 24.8 58.7 48.7 No vaccinations 0.0 3.5 3.5 3.5 0.0 4.5 4.5 5.2 Number of children 5,300 5,300 5,300 5,300 5,326 5,326 5,326 5,326 1 MICS indicator 3.1 - Tuberculosis immunization coverage 2 MICS indicator 3.2 - Polio immunization coverage 3 MICS indicator 3.3 - Diphtheria, pertussis and tetanus (DPT) immunization coverage 4 MICS indicator 3.5 - Hepatitis B immunization coverage 5 MICS indicator 3.6 - Haemophilus influenzae type B (Hib) immunization coverage 6 MICS indicator 3.4; MDG indicator 4.3 - Measles immunization coverage 7 MICS indicator 3.8 - Full immunization coverage a All MICS indicators refer to results in this column b Includes: BCG, Polio3, PENTA3, and Measles-1 (MCV1) as per the vaccination schedule in Punjab na: not applicable The percentage of children age 12-23 months and 24-35 months who have received each of the specific vaccinations by source of information (vaccination card, mother’s recall or either) is shown in Table CH.1 and Figure CH.1. The denominators for the table are number of children age 12-23 months and 24-35 months so that only those children who are old enough to be fully vaccinated are counted. In the first three columns in each panel of the table, the numerator includes all children who were vaccinated at any time before the survey according to the vaccination card, mother’s recall or either. In the last column in each panel, only those children who were vaccinated before their first birthday, as recommended, are included. For children without vaccination cards, the proportion of vaccinations given before the first birthday is assumed to be the same as for children with vaccination cards. Approximately 93 percent of children age 12-23 months received a BCG vaccination by the age of 12 months and the first dose of PENTA vaccine was given to 85 percent. The percentage declines to 81 percent for the second dose of PENTA, and to 72 percent for the third dose. Similarly, 95 percent of P a g e | 52 children received Polio 1 by age 12 months and this declines to 85 percent by the third dose. The coverage for the first dose of measles vaccine by 12 months is 72 percent although 78 percent of children 12-23 months received the measles vaccine. As a result, the percentage of children who had all the recommended vaccinations by their first birthday is low at 56 percent. The coverage figures for children age 24-35 months are generally similar to those age 12-23 months suggesting that immunization coverage has been on average stagnant in Punjab between 2012 and 201427. Figure CH.1: Vacc inat ions by age 12 months (measles by 24 months) MICS Punjab, 2014 Table CH.2 presents vaccination coverage estimates among children age 12-23 months by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey, and are based on information from both the vaccination cards and mothers’/caretakers’ report. Vaccination cards have been seen by the interviewer for 59 percent of children age 12-23 months. About 62 percent of the children aged 12-23 months are fully vaccinated, the rates being higher in urban (68%) compared to rural (60%). At division level, children age 12-23 months that are fully vaccinated are lowest (39%) in DG Khan division and highest (75%) in Gujranwala division. Vaccination is positively associated with mother’s education as it is highest (76%) for the children whose mothers have higher education and lowest (51%) for those whose mothers have only pre-school or no education. About three 27 It is important to note that data recorded on the vaccination cards was not universally endorsed by the mothers/ caretakers. In some places the field teams received comments from the mothers that sometimes cards were filled without vaccination to show progress. Since this was not in the scope of the survey, it is therefore suggested that health department may initiate a study through a neutral agency to find out the extent of such happenings. It is important to achieve 100 percent coverage of immunization in real. 93 91 95 90 85 85 81 72 72 56 4 BCG Polio at birth Polio1 Polio2 Polio3 PENTA-1 PENTA-2 PENTA-3 Measles-I Fully vaccinated No vaccinations Percent Children Age 12-23 months 90 87 91 86 81 80 75 64 72 30 49 5 BCG Polio at birth Polio1 Polio2 Polio3 PENTA-1 PENTA-2 PENTA-3 Measles-I Measles-II Fully vaccinated No vaccinations Children Age 24-35 months P a g e | 53 in four children living in the households in the highest quintile are fully vaccinated (74%) compared to 42 percent of children living in the households in lowest quintile. Table CH.2: Vaccinations by background characteristics Percentage of children age 12-23 months currently vaccinated against vaccine preventable childhood diseases, Punjab, 2014. Percentage of children age 12-23 months who received: Percentage with vaccination card seen Number of children age 12-23 months BCG Polio PENTA Measles-1 (MCV1) Fulla None At birth 1 2 3 1 2 3 Punjab 93.1 91.4 95.3 90.8 86.6 85.7 81.8 73.3 77.8 62.3 3.5 58.5 5,300 Area of residence Rural 92.4 90.4 95.3 91.1 86.6 83.8 79.8 70.9 76.7 59.8 3.5 57.7 3,682 All Urban 94.4 93.6 95.3 89.9 86.4 90.1 86.5 78.7 80.3 68.0 3.6 60.4 1,618 Major Cities 94.1 93.8 94.6 86.0 83.1 93.2 88.3 78.2 79.1 68.1 3.9 59.5 813 Other Urban 94.8 93.4 96.1 93.9 89.8 86.9 84.7 79.2 81.5 67.8 3.2 61.4 804 Sex Male 93.2 92.3 95.5 90.5 86.9 86.7 83.0 74.0 79.1 63.7 3.4 58.3 2,766 Female 92.9 90.5 95.1 91.0 86.1 84.7 80.6 72.5 76.4 60.7 3.7 58.7 2,534 Mother’s education None/pre-school 88.9 87.3 93.4 88.8 83.7 78.8 74.2 63.5 68.2 51.2 5.1 50.4 2,388 Primary 96.4 94.6 96.4 94.0 89.9 89.2 85.9 80.2 84.2 70.1 2.3 66.3 978 Middle 94.6 93.1 96.5 90.6 87.0 91.3 87.4 79.7 82.4 67.9 2.7 66.3 581 Secondary 96.2 93.9 96.9 92.3 89.2 92.6 89.7 83.4 83.7 71.8 2.8 64.9 725 Higher 98.6 97.7 97.8 91.7 88.7 93.8 90.3 82.4 93.4 75.9 0.8 62.7 628 Wealth index quintile Lowest 85.2 83.4 92.4 87.0 81.1 73.0 67.1 55.4 59.2 42.2 6.0 42.3 1,136 Second 93.5 91.3 95.0 90.8 86.6 84.2 79.7 70.5 76.4 58.8 3.5 60.8 1,047 Middle 94.8 92.7 95.6 92.7 88.4 88.5 86.1 77.7 82.6 67.8 3.2 63.4 1,084 Fourth 95.5 94.1 96.5 92.3 88.9 90.7 88.2 82.5 84.6 70.5 2.8 64.1 1,040 Highest 97.0 96.4 97.5 91.3 88.3 93.7 89.5 82.3 88.3 74.1 1.7 63.4 993 Division Bahawalpur 89.4 88.0 95.3 90.6 84.6 85.9 81.1 67.7 64.0 51.6 2.6 44.5 544 D.G. Khan 81.2 81.3 89.1 84.7 80.1 75.6 67.0 52.1 56.1 38.6 8.9 42.7 557 Faisalabad 93.8 91.9 95.5 91.1 87.4 91.4 88.8 78.4 78.6 66.2 3.5 58.3 617 Gujranwala 97.1 96.0 96.5 93.2 88.7 91.7 88.9 84.3 89.8 75.2 2.2 70.8 851 Lahore 93.5 92.1 95.9 89.0 83.8 85.7 82.4 71.0 76.0 61.3 3.4 54.9 886 Multan 93.6 90.0 95.0 91.6 89.6 90.1 86.9 78.2 78.3 66.7 4.2 57.8 581 Rawalpindi 96.5 96.2 96.4 87.5 82.9 94.3 87.2 82.5 86.7 70.4 2.2 64.9 422 Sahiwal 97.9 95.8 98.5 96.6 93.7 75.4 73.4 71.6 86.4 65.1 1.0 69.8 433 Sargodha 94.1 90.4 95.8 93.6 90.2 73.9 72.8 69.1 84.4 60.4 3.3 63.7 408 a Includes: BCG, Polio3, PENTA3 and Measles-1 (MCV1) as per the vaccination schedule in Punjab Neonatal Tetanus Protection One of the MDGs is to reduce by three quarters the maternal mortality ratio, with one strategy to eliminate maternal tetanus. Following on the 42nd and 44th World Health Assembly calls for elimination of neonatal tetanus, the global community continues to work to reduce the incidence of neonatal tetanus to less than one case of neonatal tetanus per 1,000 live births by 2015. The strategy for preventing maternal and neonatal tetanus is to ensure that all pregnant women receive at least two doses of tetanus toxoid vaccine. If a woman has not received at least two doses of tetanus toxoid during a particular pregnancy, she (and her newborn) are also considered to be protected against tetanus if the woman: P a g e | 54  Received at least two doses of tetanus toxoid vaccine, the last within the previous 3 years;  Received at least 3 doses, the last within the previous 5 years;  Received at least 4 doses, the last within the previous 10 years;  Received 5 or more doses anytime during her life. 28 To assess the status of tetanus vaccination coverage, women who had a live birth during the two years before the survey were asked if they had received tetanus toxoid injections during the pregnancy for their most recent birth, and if so, how many. Women who did not receive two or more tetanus toxoid vaccinations during this recent pregnancy were then asked about tetanus toxoid vaccinations they may have previously received. Interviewers also asked women to present their vaccination card on which dates of tetanus toxoid are recorded and referred to information from the cards when available. Table CH.3: Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus, Punjab, 2014. Percentage of women who received at least 2 doses during last pregnancy Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus1 Number of women with a live birth in the last 2 years 2 doses, the last within prior 3 years 3 doses, the last within prior 5 years 4 doses, the last within prior 10 years 5 or more doses during lifetime Punjab 70.5 4.7 0.8 0.4 0.1 76.4 10,653 Area of residence Rural 69.0 4.1 0.7 0.3 0.1 74.2 7,369 All Urban 73.6 5.9 1.2 0.6 0.1 81.4 3,284 Major Cities 74.4 5.9 1.4 0.3 0.1 82.3 1,692 Other Urban 72.8 5.8 0.9 0.8 0.1 80.4 1,592 Mother’s educationa None/pre-school 59.0 4.7 0.9 0.4 0.2 65.1 4,816 Primary 75.7 3.9 1.0 0.6 0.0 81.3 1,961 Middle 78.4 5.6 0.6 0.1 0.2 84.9 1,096 Secondary 81.5 5.1 0.9 0.4 0.0 87.9 1,467 Higher 85.7 4.4 0.3 0.2 0.1 90.7 1,311 Wealth index quintile Lowest 56.2 4.6 1.1 0.4 0.1 62.5 2,321 Second 64.3 4.1 0.8 0.3 0.2 69.8 2,198 Middle 74.0 5.3 0.5 0.5 0.1 80.4 2,118 Fourth 77.6 3.9 1.0 0.3 0.1 83.0 2,094 Highest 82.9 5.4 0.7 0.4 0.0 89.4 1,922 Division Bahawalpur 63.2 2.2 1.0 0.2 0.1 66.7 1,068 D.G. Khan 59.8 5.4 0.5 0.5 0.1 66.2 1,181 Faisalabad 71.4 5.0 0.8 0.3 0.1 77.6 1,237 Gujranwala 81.5 4.9 0.5 0.5 0.1 87.4 1,578 Lahore 69.3 4.9 1.5 0.6 0.2 76.4 1,914 Multan 68.4 2.9 0.6 0.2 0.2 72.3 1,162 Rawalpindi 79.4 5.1 0.5 0.1 0.1 85.1 882 Sahiwal 70.0 4.0 0.6 0.8 0.0 75.5 827 Sargodha 69.2 7.9 0.8 0.2 0.4 78.5 804 1 MICS indicator 3.9 - Neonatal tetanus protection a Total includes 2 unweighted cases of mother's education missing 28 Deming, M.S. et al. 2002. Tetanus toxoid coverage as an indicator of serological protection against neonatal tetanus. Bulletin of the World Health Organization 80(9):696-703 P a g e | 55 Table CH.3 shows the protection status from tetanus of women who have had a live birth within the last 2 years. Seventy six percent of the women are reported to be protected against tetanus, the proportion being higher in urban (81%) compared to rural (74%). At the divisional level, DG Khan had the lowest proportion of women protected against tetanus (60%) compared to Gujranwala (82%). Women with higher education are more likely to be protected against tetanus (91%) compared to women with only pre-school or no education (65%). Similarly, protection against tetanus is positively correlated with household wealth. Care of Illness A key strategy for accelerating progress toward MDG 4 is to tackle the diseases that are the leading killers of children under 5. Diarrhoea and pneumonia are two such diseases. The Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) aims to end preventable deaths from pneumonia and diarrhoea by reducing mortality from pneumonia to 3 deaths per 1000 live births and mortality from diarrhoea to 1 death per 1000 live births by 2025. Malaria is also a major killer of children under 5, killing about 900 children every day, especially in sub- Saharan Africa. The Global Malaria Action Plan (GMAP) aims to reduce deaths from malaria to near zero by 2015. Table CH.4 presents the percentage of children under 5 years of age who were reported against an episode of diarrhoea, symptoms of acute respiratory infection (ARI), or fever during the 2 weeks preceding the survey. These results are not measures of true prevalence, and should not be used as such, but rather the period-prevalence of these illnesses over a two-week time period. P a g e | 56 Table CH.4: Reported disease episodes Percentage of children age 0-59 months for whom the mother/caretaker reported an episode of diarrhoea, symptoms of acute respiratory infection (ARI), and/or fever in the last two weeks, Punjab, 2014. Percentage of children who in the last two weeks had: Number of children age 0-59 months An episode of diarrhoea Symptoms of ARI An episode of fever Punjab 17.4 2.5 20.8 27,495 Area of residence Rural 17.4 2.8 20.8 19,002 All Urban 17.5 1.8 20.7 8,493 Major Cities 18.3 1.3 21.4 4,364 Other Urban 16.6 2.4 20.0 4,129 Sex Male 17.9 2.8 21.5 13,915 Female 16.9 2.1 20.1 13,580 Age 0-11 months 23.7 3.2 25.7 5,343 12-23 months 25.4 2.4 26.0 5,300 24-35 months 17.9 2.5 19.9 5,326 36-47 months 12.6 2.5 18.2 5,894 48-59 months 8.5 1.9 14.8 5,633 Mother’s education None/pre-school 17.5 3.1 21.0 13,140 Primary 18.5 2.7 22.9 4,991 Middle 18.7 1.7 21.5 2,740 Secondary 17.0 1.5 19.6 3,563 Higher 14.2 1.2 17.3 3,062 Wealth index quintile Lowest 18.7 4.2 21.7 6,316 Second 18.7 2.7 22.5 5,560 Middle 17.4 2.2 21.0 5,335 Fourth 16.1 1.8 20.2 5,380 Highest 15.7 1.0 18.2 4,904 Division Bahawalpur 12.5 2.7 14.8 3,080 D.G. Khan 19.2 4.8 24.0 3,151 Faisalabad 15.3 2.0 19.7 3,272 Gujranwala 18.9 2.1 23.7 4,100 Lahore 19.7 1.9 22.2 4,670 Multan 17.9 1.8 17.9 3,019 Rawalpindi 13.2 1.4 16.2 2,165 Sahiwal 20.5 3.2 24.4 2,032 Sargodha 17.9 2.9 23.2 2,005 The definition of a case of diarrhoea or fever, in this survey, was the mother’s (or caretaker’s) report that the child had such symptoms over the specified period; no other evidence were sought beside the opinion of the mother. A child was considered to have had an episode of ARI if the mother or caretaker reported that the child had, over the specified period, an illness with a cough with rapid or difficult breathing, and whose symptoms were perceived to be due to a problem in the chest or both a problem in the chest and a blocked nose. While this approach is reasonable in the context of a MICS survey, these basically simple case definitions must be kept in mind when interpreting the results, as well as the potential for reporting and recall biases. Further, diarrhoea, fever and ARI are not only seasonal but are also characterized by the often rapid spread of localized outbreaks from one area to another at different points in time. The timing of the survey and the location of the teams might thus considerably affect the results, which must P a g e | 57 consequently be interpreted with caution. For these reasons, although the period-prevalence over a two- week time window is reported, these data should not be used to assess the epidemiological characteristics of these diseases but rather to obtain denominators for the indicators related to use of health services and treatment. Overall, 17 percent of under five children were reported to have had diarrhoea in the two weeks preceding the survey, 3 percent of children had symptoms of ARI, and 21 percent had an episode of fever (Table CH.4). Children age 12-23 months had the highest prevalence of diarrhoea (25%) and diarrhoea was reported to be lowest (9%) for children age 48-59 months. Similarly, the prevalence of an episode of fever was 26 percent for children age 0-11 month compared to 15 percent of children age 48-59 months. Diarrhoea Diarrhoea is a leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recommended home fluid (RHF) – can prevent many of these deaths. In addition, provision of zinc supplements has been shown to reduce the duration and severity of the illness as well as the risk of future episodes within the next two or three months. Preventing dehydration and malnutrition by increasing fluid intake and con

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