Sao Tom and Principe - Multiple Indicator Cluster Survey - 2014

Publication date: 2014

Sao Tome and Principe Multiple Indicator Cluster Survey 2014 MINISTÉRIO DA SAÚDE CENTRO NACIONAL DE ENDEMIAS Empowered lives. Resilient nations. Final Report borob Sticky Note Update 23 January 2017: This English version replaces the previously posted and matches the Portuguese version also available. The current version now includes a cover and also differs with slight improvements to design as well as an update to Appendix B. Sao Tome and Principe Multiple Indicator Cluster Survey 2014 Final Report MINISTÉRIO DA SAÚDE CENTRO NACIONAL DE ENDEMIAS The Sao Tome and Principe Multiple Indicator Cluster Survey (MICS) was carried out in 2014 by the National Institute of Statistics (INE) in collaboration with the National Centre for Endemic Diseases (CNE) and the UNDP/Global Fund project, as part of the global MICS programme. Technical support was provided by the United Nations Children’s Fund (UNICEF) and ICF International. UNICEF, the Global Fund and the Government of the Democratic Republic of Sao Tome and Principe provided financial and logistical support. 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. Suggested citation: National Institute of Statistics, 2016. Sao Tome and Principe Multiple Indicator Cluster Survey 2014, Final Report. São Tomé, Sao Tome and Principe. Sao Tome and Principe 2014 MICS, Final Report P a g e | iii Summary Table of Survey Implementation and the Survey Population, Sao Tome and Principe, 2014 Survey implementation Sample frame - Updated 2012 General Population and Habitat Census January 2014 Questionnaires Household Women (age 15-49) Men (age 15-49) Children under five Interviewer training March 2014 Fieldwork April to June 2014 Survey sample Households - Sampled - Occupied - Interviewed - Response rate (Per cent) 3,930 3,625 3,492 96.3 Children under five - Eligible - Mothers/caretakers interviewed - Response rate (Per cent) 2,062 2,030 98.4 Women - Eligible for interviews - Interviewed - Response rate (Per cent) 3,101 2,935 94.6 Men - Eligible for interviews - Interviewed - Response rate (Per cent) 2,772 2,267 81.8 Survey population Average household size 3.9 Percentage of population living in - Urban areas - Rural areas - Region Centre East - Region North West - Region South East - Autonomous Region of Principe 66.6 33.4 65.4 18.7 12.3 3.7 Percentage of population under: - Age 5 - Age 18 14.9 50.8 Percentage of women age 15-49 years with at least one live birth in the last 2 years 25.7 Housing characteristics Household or personal assets Percentage of households with - Electricity - Finished floor - Finished roofing - Finished walls 68.6 36.4 99.8 98.1 Percentage of households that own - A television - A refrigerator/freezer - Agricultural land - Farm animals/livestock 68.3 42.8 25.8 40.6 Mean number of persons per room used for sleeping 2.18 Percentage of households where at least a member has or owns a - Mobile phone - Car or truck 82.2 9.7 Sao Tome and Principe 2014 MICS, Final Report P a g e | iv Summary Table of Findingsi Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Sao Tome and Principe, 2014 CHILD MORTALITY Early childhood mortalitya MICS Indicator Indicator Description Value 1.1 Neonatal mortality rate Probability of dying within the first month of life 22 1.2 MDG 4.2 Infant mortality rate Probability of dying between birth and the first birthday 38 1.3 Post-neonatal mortality rate Difference between infant and neonatal mortality rates 16 1.4 Child mortality rate Probability of dying between the first and the fifth birthdays 7 1.5 MDG 4.1 Under-five mortality rate Probability of dying between birth and the fifth birthday 45 a Rates refer to the 5-year period preceding the survey. NUTRITION Nutritional status MICS Indicator Indicator Description Value 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 8.8 1.8 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 17.2 4.5 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 4.0 0.8 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 2.4 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 97.4 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 38.3 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 73.8 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 85.1 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 85.9 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 24.1 i See Appendix E for a detailed description of MICS indicators Sao Tome and Principe 2014 MICS, Final Report P a g e | v 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 17.0 2.12 Age-appropriate breastfeeding Percentage of children age 0-23 months appropriately fed during the previous day 62.3 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 74.1 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 26.4 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 58.2 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 46.8 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 28.5 10.9 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 15.3 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodine 88.1 Low-birthweight 2.20 Low-birthweight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 8.4 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 94.0 CHILD HEALTH Vaccinations MICS Indicator Indicator Description Value 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 97.3 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 88.8 3.3, 3.5, 3.6 Diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenzae type B (penta) immunization coverage Percentage of children age 12-23 months who received the third dose of diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenzae type B (penta3) by their first birthday 93.0 3.S1i Pneumococcal conjugate vaccine (PCV) Percentage of children age 12-23 months who received the third dose of PCV vaccine (PCV3) by their first birthday 82.0 3.4 MDG 4.3 Measles immunization coverage Percentage of children age 12-23 months who received measles vaccine by their first birthday 89.0 3.7 Yellow fever immunization coverage Percentage of children age 12-23 months who received yellow fever vaccine by their first birthday 89.3 3.8ii Full immunization coverage Percentage of children age 12-23 months who received all vaccinations recommended in the national immunization schedule by their first birthday 65.8 i Specific indicator for Sao Tome and Principe ii Includes BCG, OPV3, penta3, PCV3, yellow fever and measles Sao Tome and Principe 2014 MICS, Final Report P a g e | vi 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 72.1 Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 17.7 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 54.2 3.S2i Diarrhoea treatment with oral rehydration salts (ORS) Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS 49.1 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 61.7 Acute Respiratory Infection (ARI) symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 7.1 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 68.9 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 47.6 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 41.8 Malaria / Fever MICS Indicator Indicator Description Value - Children with fever Percentage of children under age 5 with fever in the last 2 weeks 26.3 3.16a 3.16b Household availability of insecticide-treated nets (ITNs) Percentage of households with (a) at least one ITN (b) at least one ITN for every two people 77.8 55.1 3.17a 3.17b Household vector control Percentage of households (a) with at least one ITN or that have been sprayed by IRS in the last 12 months (b) with at least one ITN for every two people or that have been sprayed by IRS in the last 12 months 96.7 94.8 3.18 MDG 6.7 Children under age 5 who slept under an ITN Percentage of children under age 5 who slept under an ITN the previous night 61.1 3.19 Population that slept under an ITN Percentage of household members who slept under an ITN the previous night 56.1 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 65.8 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 42.0 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 1.4 i Specific indicator for Sao Tome and Principe Sao Tome and Principe 2014 MICS, Final Report P a g e | vii 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) (*) 3.24 Pregnant women who slept under an ITN Percentage of pregnant women who slept under an ITN the previous night 60.9 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 12.3 (*) Figures that are based on fewer than 25 unweighted cases WATER AND SANITATION MICS Indicator Indicator Description Value 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 93.9 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 9.1 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 40.9 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 28.9 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 40.5 4.6 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent 76.5 REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Value - Total fertility rate Total fertility rate for women age 15-49 years 4.4 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rate for women age 15-19 years 92 5.2 Early childbearing Percentage of women age 20-24 years who had at least one live birth before age 18 27.3 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women age 15-49 years currently married or in union who are using (or whose partner is using) a (modern or traditional) contraceptive method 40.6 5.4 MDG 5.6 Unmet need Percentage of women age 15-49 years who are currently married or in union who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 32.7 Maternal and newborn health 5.5a 5.5b 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 97.5 83.6 Sao Tome and Principe 2014 MICS, Final Report P a g e | viii 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 94.2 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 92.5 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 91.0 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 5.6 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 98.8 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 90.7 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 86.8 Maternal mortality 5.13 MDG 5.1 Maternal mortality ratio Deaths during pregnancy, childbirth, or within two months after delivery or termination of pregnancy, per 100,000 births within the 7-year period preceding the survey (74) ( ) Unreliable estimate due to small sample size CHILD DEVELOPMENT MICS Indicator Indicator Description Value 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 36.4 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 62.7 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 3.0 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 15.7 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 5.8 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 64.7 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 15.5 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 54.5 Sao Tome and Principe 2014 MICS, Final Report P a g e | ix LITERACY AND EDUCATION MICS Indicator Indicator Description Value 7.1 “ “ MDG 2.3 “ “ Literacy rate among young people Percentage of young people age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education (a) women (b) men 89.6 87.5 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 57.9 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 77.1 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school 94.1 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 60.4 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 91.6 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) 111.9 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 53.7 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 1.00 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 1.18 CHILD PROTECTION Birth registration MICS Indicator Indicator Description Value 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 95.2 Child labour 8.2 Child labour Percentage of children age 5-17 years who are involved in child labour 26.0 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 79.6 Early marriage and polygyny 8.4 “ “ Marriage before age 15 Percentage of people age 15-49 years who were first married or in union before age 15 (a) Women (b) Men 5.1 1.4 Sao Tome and Principe 2014 MICS, Final Report P a g e | x 8.5 “ “ Marriage before age 18 Percentage of people age 20-49 years who were first married or in union before age 18 (a) Women (b) Men 32.2 7.5 8.6 “ “ Young people age 15-19 years currently married or in union Percentage of young people age 15-19 years who are married or in union (a) Women (b) Men 15.3 1.3 8.7 “ “ Polygyny Percentage of people age 15-49 years who are in a polygynous union (a) Women (b) Men 22.4 13.0 8.8a 8.8b Spousal age difference Percentage of young women who are married or in union and whose spouse is 10 or more years older, (a) among women age 15-19 years, (b) among women age 20-24 years 23.1 17.3 Attitudes towards domestic violence 8.12 “ “ Attitudes towards domestic violence Percentage of people 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 (a) Women (b) Men 19.1 13.8 Children’s living arrangements 8.13 Children’s living arrangements Percentage of children age 0-17 years living with neither biological parent 14.7 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 5.4 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 15.7 HIV/AIDS AND SEXUAL BEHAVIOUR HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Value - - Have heard of AIDS Percentage of people age 15-49 years who have heard of AIDS (a) Women (b) Men 99.2 99.5 9.1 “ “ MDG 6.3 “ “ Knowledge about HIV prevention among young people Percentage of young people age 15-24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission (a) Women (b) Men 42.2 43.2 9.2 “ “ Knowledge of mother-to- child transmission of HIV Percentage of people age 15-49 years who correctly identify all three means of mother-to-child transmission of HIV (a) Women (b) Men 47.1 39.9 9.3 “ “ Accepting attitudes towards people living with HIV Percentage of people age 15-49 years expressing accepting attitudes on all four questions toward people living with HIV (a) Women (b) Men 13.4 22.5 Sao Tome and Principe 2014 MICS, Final Report P a g e | xi HIV testing 9.4 “ “ People who know where to be tested for HIV Percentage of people age 15-49 years who state knowledge of a place to be tested for HIV (a) Women (b) Men 92.3 89.9 9.5 “ “ People who have been tested for HIV and know the results Percentage of people age 15-49 years who have been tested for HIV in the last 12 months and who know their results (a) Women (b) Men 38.5 27.3 9.6 “ “ Sexually active young people who have been tested for HIV and know the results Percentage of young people age 15-24 years who have had sex in the last 12 months, who have been tested for HIV in the last 12 months and who know their results (a) Women (b) Men 48.0 21.6 9.7 HIV counselling during antenatal care Percentage of 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 77.2 9.8 HIV testing during antenatal care Percentage of 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 86.1 Sexual behaviour 9.9 “ “ Young people who have never had sex Percentage of never married young people age 15-24 years who have never had sex (a) Women (b) Men 58.2 41.2 9.10 “ “ Sex before age 15 among young people Percentage of young people age 15-24 years who had sexual intercourse before age 15 (a) Women (b) Men 9.2 18.2 9.11 Age-mixing among sexual partners Percentage of women age 15-24 years who had sex in the last 12 months with a partner who was 10 or more years older 17.6 9.12 “ “ Multiple sexual partnerships Percentage of people age 15-49 years who had sexual intercourse with more than one partner in the last 12 months (a) Women (b) Men 2.9 29.1 9.13 “ “ Condom use at last sex among people with multiple sexual partnerships Percentage of people age 15-49 years who report having had more than one sexual partner in the last 12 months who also reported that a condom was used the last time they had sex (a) Women (b) Men 46.0 49.0 9.14 “ “ Sex with non-regular partners Percentage of sexually active young people age 15-24 years who had sex with a non-marital, non-cohabitating partner in the last 12 months (a) Women (b) Men 24.7 46.9 9.15 “ “ MDG 6.2 “ “ Condom use with non- regular partners Percentage of young people age 15-24 years reporting the use of a condom during the last sexual intercourse with a non-marital, non-cohabiting sex partner in the last 12 months (a) Women (b) Men 65.2 82.5 Orphans Sao Tome and Principe 2014 MICS, Final Report P a g e | xii 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 (*) Male circumcision 9.17 Male circumcision Percentage of men age 15-49 years who report having been circumcised 3.2 (*) Figures that are based on fewer than 25 unweighted cases ACCESS TO MASS MEDIA AND ICT Access to mass media MICS Indicator Indicator Description Value 10.1 “ “ Exposure to mass media Percentage of people age 15-49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television (a) Women (b) Men 15.9 28.4 Use of information/communication technology 10.2 “ “ Use of computers Percentage of young people age 15-24 years who used a computer during the last 12 months (a) Women (b) Men 37.2 48.3 10.3 “ “ Use of internet Percentage of young people age 15-24 years who used the internet during the last 12 months (a) Women (b) Men 32.3 42.9 SUBJECTIVE WELL-BEING MICS Indicator Indicator Description Value 11.1 “ “ Life satisfaction Percentage of young people age 15-24 years who are very or somewhat satisfied with their life, overall (a) Women (b) Men 75.6 84.2 11.2 “ “ Happiness Percentage of young people age 15-24 years who are very or somewhat happy (a) Women (b) Men 74.4 77.3 11.3 “ “ Perception of a better life Percentage of young people age 15-24 years whose life improved during the last one year, and who expect that their life will be better after one year (a) Women (b) Men 59.4 63.4 TOBACCO AND ALCOHOL USE Tobacco use MICS Indicator Indicator Description Value 12.1 “ “ Tobacco use Percentage of people age 15-49 years who smoked cigarettes, or used smoked or smokeless tobacco products at any time during the last one month (a) Women (b) Men 1.1 8.9 Sao Tome and Principe 2014 MICS, Final Report P a g e | xiii 12.2 “ “ Smoking before age 15 Percentage of people age 15-49 years who smoked a whole cigarette before age 15 (a) Women (b) Men 0.4 1.4 Alcohol use 12.3 “ “ Use of alcohol Percentage of people age 15-49 years who had at least one alcoholic drink at any time during the last one month (a) Women (b) Men 53.2 67.1 12.4 “ “ Use of alcohol before age 15 Percentage of people age 15-49 years who had at least one alcoholic drink before age 15 (a) Women (b) Men 7.5 11.9 Sao Tome and Principe 2014 MICS, Final Report P a g e | xiv Table of Contents Summary Table of Survey Implementation and the Survey Population, Sao Tome and Principe, 2014iii Summary Table of Findings . iv Table of Contents .xiv List of Tables . xvii List of Figures . xxiii List of Abbreviations . xxiv Acknowledgements . xxv Executive Summary . xxvi I. Introduction 1 Background . 1 Survey Objectives . 2 II. Sample and Survey Methodology . 3 Sample Design . 3 Questionnaires . 3 Methodology and processes used when taking blood samples for anaemia, malaria and HIV testing . 5 Training and Fieldwork . 6 Data Processing . 6 III. Sample Coverage and the Characteristics of Households and Respondents . 7 Sample Coverage . 7 Characteristics of Households . 8 Characteristics of Female and Male Respondents 15-49 Years of Age and Children Under-5 . 12 Housing characteristics, asset ownership, and wealth quintiles . 16 IV. Child Mortality . 20 V. Nutrition . 26 Low Birth Weight . 26 Nutritional Status . 28 Breastfeeding and Infant and Young Child Feeding . 31 Salt Iodization . 43 VI. Child Health . 46 Vaccinations . 46 Neonatal Tetanus Protection . 50 Care of Illness . 51 Prevalence of malaria in children . 80 Prevalence of anaemia in children . 83 VII. Water and Sanitation . 85 Use of Improved Water Sources . 85 Use of Improved Sanitation . 91 Handwashing . 101 Sao Tome and Principe 2014 MICS, Final Report P a g e | xv VIII. Reproductive Health . 104 Fertility . 104 Contraception . 109 Unmet Need . 111 Antenatal Care . 114 Assistance at Delivery . 118 Place of Delivery . 122 Post-natal Health Checks . 123 Adult Mortality Rates . 131 Maternal Mortality . 132 Prevalence of anaemia in women . 134 IX. Early Childhood Development . 137 Early Childhood Care and Education . 137 Quality of Care . 138 Developmental Status of Children . 144 X. Literacy and Education . 147 Literacy among Young Women and Men. 147 School Readiness . 148 Primary and Secondary School Participation . 149 XI. Child Protection . 160 Birth Registration . 160 Child Labour . 161 Child Discipline . 166 Early Marriage and Polygyny . 169 Attitudes toward Domestic Violence . 176 Children’s Living Arrangements . 179 XII. HIV/AIDS and Sexual Behaviour . 182 Knowledge about HIV Transmission and Misconceptions about HIV . 182 Accepting Attitudes toward People Living with HIV . 189 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care. 192 Sexual Behaviour Related to HIV Transmission . 196 HIV Indicators for Young Women and Young Men . 198 Orphans . 203 Male circumcision . 205 Prevalence of HIV in men and women . 206 XIII. Access to Mass Media and Use of Information/Communication Technology. 215 Access to Mass Media . 215 Use of Information/Communication Technology . 218 XIV. Subjective well-being . 221 XV. Tobacco and Alcohol Use . 229 Tobacco Use . 229 Alcohol Use . 234 Sao Tome and Principe 2014 MICS, Final Report P a g e | xvi Appendices: Appendix A. Sample Design . 237 Appendix B. List of Personnel Involved in the Survey . 245 Appendix C. Estimates of Sampling Errors . 251 Appendix D. Data Quality Tables . 266 Appendix E. Sao Tome and Principe MICS5 Indicators: Numerators and Denominators . 286 Sao Tome and Principe 2014 MICS, Final Report P a g e | xvii List of Tables Table HH.1: Results of household, women's, men's and under-5 interviews . 8 Table HH.2: Age distribution of household population by sex . 9 Table HH.3: Household composition . 11 Table HH.4: Women's background characteristics . 13 Table HH.4M: Men's background characteristics . 14 Table HH.5: Under-5's background characteristics . 16 Table HH.6: Housing characteristics . 17 Table HH.7: Household and personal assets . 18 Table HH.8: Wealth quintiles . 19 Table CM.1: Early childhood mortality rates . 20 Table CM.2: Early childhood mortality rates by socioeconomic characteristics . 22 Table CM.3: Early childhood mortality rates by demographic characteristics . 23 Table NU.1: Low birth weight infants . 27 Table NU.2: Nutritional status of children . 29 Table NU.3: Initial breastfeeding . 34 Table NU.4: Breastfeeding . 36 Table NU.5: Duration of breastfeeding . 38 Table NU.6: Age-appropriate breastfeeding . 39 Table NU.7: Introduction of solid, semi-solid, or soft foods . 39 Table NU.8: Infant and young child feeding (IYCF) practices by sex, age and area . 41 Table NU.8 (second part): Infant and young child feeding (IYCF) practices, by region, mother’s education and wealth index quintile . 42 Table NU.9: Bottle feeding . 43 Table NU.10: Iodized salt consumption . 44 Table CH.1: Vaccinations in the first years of life . 47 Table CH.2: Vaccinations by background characteristics . 49 Table CH.3: Neonatal tetanus protection . 51 Table CH.4: Reported disease episodes . 53 Table CH.5: Care-seeking during diarrhoea . 55 Table CH.6: Feeding practices during diarrhoea . 56 Table CH.7: Oral rehydration solutions, recommended homemade fluids, and zinc . 57 Table CH.8: Oral rehydration therapy with continued feeding and other treatments . 59 Table CH.9: Source of ORS . 61 Table CH.10: Care-seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI) . 62 Table CH.11: Knowledge of the two danger signs of pneumonia . 63 Table CH.12: Solid fuel use . 65 Table CH.13: Solid fuel use by place of cooking . 66 Table CH.14: Household availability of insecticide treated nets and protection by a vector control method . 68 Sao Tome and Principe 2014 MICS, Final Report P a g e | xviii Table CH.15: Access to an insecticide treated net (ITN) - number of household members . 69 Table CH.16: Access to an insecticide treated net (ITN) - background characteristics . 69 Table CH.17: Use of ITNs . 71 Table CH.18: Children sleeping under mosquito nets . 72 Table CH.19: Use of mosquito nets by the household population . 73 Table CH.20: Care-seeking during fever . 74 Table CH.21: Treatment of children with fever . 76 Table CH.22: Diagnostics and anti-malarial treatment of children. 77 Table CH.23: Pregnant women sleeping under mosquito nets . 78 Table CH.24: Intermittent preventive treatment for malaria . 80 Table CH.25: Coverage of testing for malaria in children (unweighted) . 81 Table CH.26: Results of the Rapid Diagnostic Test (RDT) and thick smear for the detection of malaria in children . 82 Table CH.27: Prevalence of anaemia in children . 84 Table WS.1: Use of improved water sources . 86 Table WS.2: Household water treatment . 88 Table WS.3: Time to source of drinking water . 90 Table WS.4: Person collecting water . 91 Table WS.5: Types of sanitation facilities . 93 Table WS.6: Use and sharing of sanitation facilities . 94 Table WS.7: Drinking water and sanitation ladders . 98 Table WS.8: Disposal of child's faeces . 100 Table WS.9: Water and soap at place for handwashing . 102 Table WS.10: Availability of soap or other cleansing agent . 103 Table RH.1: Fertility rates . 104 Table RH.2: Adolescent birth rate and total fertility rate . 106 Table RH.3: Early childbearing . 107 Table RH.4: Trends in early childbearing . 108 Table RH.5: Use of contraception . 110 Table RH.6: Unmet need for contraception . 113 Table RH.7: Antenatal care coverage . 115 Table RH.8: Number of antenatal care visits and timing of first visit . 116 Table RH.9: Content of antenatal care. 118 Table RH.10: Assistance during delivery and caesarian section . 120 Table RH.11: Place of delivery . 123 Table RH.12: Post-partum stay in health facility. 125 Table RH.13: Post-natal health checks for newborns . 126 Table RH.14: Post-natal care visits for newborns within one week of birth . 127 Table RH.15: Post-natal health checks for mothers . 129 Table RH.16: Post-natal care visits for mothers within one week of birth . 130 Table RH.17: Post-natal health checks for mothers and newborns . 131 Table RH.18: Adult mortality rates . 132 Sao Tome and Principe 2014 MICS, Final Report P a g e | xix Table RH.19: Adult mortality probabilities . 132 Table RH.21: Prevalence of anaemia in women . 135 Table CD.1: Early childhood education . 138 Table CD.2: Support for learning, by sex, region and area . 140 Table CD.2 (second part): Support for learning, by age, mother’s education, father’s education and wealth index . 141 Table CD.3: Learning materials . 142 Table CD.4: Inadequate care . 144 Table CD.5: Early child development index . 146 Table ED.1: Literacy (young women) . 147 Table ED.1M: Literacy (young men) . 148 Table ED.2: School readiness . 149 Table ED.3: Primary school entry . 150 Table ED.4: Primary school attendance and out of school children . 152 Table ED.5: Secondary school attendance and out of school children . 153 Table ED.6: Children reaching last grade of primary school . 155 Table ED.7: Primary school completion and transition to secondary school . 156 Table ED.8: Education gender parity . 157 Table ED.9: Out of school gender parity . 158 Table CP.1: Birth registration . 161 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.7M: Early marriage and polygyny (men) . 172 Table CP.8: Trends in early marriage (women) . 173 Table CP.8M: Trends in early marriage (men) . 173 Table CP.9: Spousal age difference . 175 Table CP.10: Attitudes toward domestic violence (women) . 177 Table CP.10M: Attitudes toward domestic violence (men) . 178 Table CP.11: Children's living arrangements and orphanhood . 180 Table CP.12: Children with parents living abroad . 181 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (women) . 183 Table HA.1M: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (men) . 184 Table HA.2: Knowledge of mother-to-child HIV transmission (women) . 187 Table HA.2M: Knowledge of mother-to-child HIV transmission (men) . 188 Table HA.3: Accepting attitudes toward people living with HIV (women) . 190 Table HA.3M: Accepting attitudes toward people living with HIV (men) . 191 Table HA.4: Knowledge of a place for HIV testing (women) . 193 Sao Tome and Principe 2014 MICS, Final Report P a g e | xx Table HA.4M: Knowledge of a place for HIV testing (men) . 194 Table HA.5: HIV counselling and testing during antenatal care . 195 Table HA.6: Sex with multiple partners (women) . 196 Table HA.6M: Sex with multiple partners (men) . 197 Table HA.7: Key HIV and AIDS indicators (young women) . 199 Table HA.7M: Key HIV and AIDS indicators (young men) . 200 Table HA.8: Key sexual behaviour indicators (young women) . 201 Table HA.8M: Key sexual behaviour indicators (young men) . 202 Table HA.9: School attendance of orphans and non-orphans . 204 Table HA.10: Male circumcision . 205 Table HA.11: Coverage of HIV test by area and region . 208 Table HA.13: Prevalence of HIV by age . 211 Table HA.14: Prevalence of HIV by socio-economic characteristics . 212 Table HA.15: Prevalence of HIV by socio-demographic characteristics . 213 Table HA.16: Prevalence of HIV by sexual behaviour and prior HIV test . 214 Table MT.1: Exposure to mass media (women) . 216 Table MT.1M: Exposure to mass media (men) . 217 Table MT.2: Use of computers and internet (women) . 219 Table MT.2M: Use of computers and internet (men) . 220 Table SW.1: Domains of life satisfaction (women) . 222 Table SW.1M: Domains of life satisfaction (men). 223 Table SW.2: Overall life satisfaction and happiness (women) . 225 Table SW.2M: Overall life satisfaction and happiness (men) . 226 Table SW.3: Perception of a better life (women) . 227 Table SW.3M: Perception of a better life (men) . 228 Table TA.1: Current and ever use of tobacco (women) . 230 Table TA.1M: Current and ever use of tobacco (men) . 231 Table TA.2: Age at first use of cigarettes and frequency of use . 233 Table TA.2M: Age at first use of cigarettes and frequency of use . 234 Table TA.3: Use of alcohol (women) . 235 Table TA.3M: Use of alcohol (men). 236 Appendices: Table SD.1: Definition of study domains and strata . 238 Table SD.2: Calculation of the minimum required size of the household sample per study domain 239 Table SD.3: Distribution of the sample by study domain and stratum . 240 Table SD.4: Structure of the sampling frame and sample per study domain . 240 Table SD.5: List of EAs with a selection probability superior to 1 . 241 Table SD.6: Distribution of EAs purposely selected and of remaining EAs to be selected by stratum . 241 Table SE.1: Indicators selected for sampling error calculations . 252 Table SE.2: Sampling errors: Total sample . 253 Sao Tome and Principe 2014 MICS, Final Report P a g e | xxi Table SE.3: Sampling errors: Urban . 254 Table SE.4: Sampling errors: Rural . 255 Table SE.5: Sampling errors: Region Centre East . 256 Table SE.6: Sampling errors: Region North West . 257 Table SE.7: Sampling errors: Region South East . 258 Table SE.8: Sampling errors: Autonomous Region of Principe . 259 Table SE.9: Sampling errors: Education of household head – None . 260 Table SE.10: Sampling errors: Education of household head – Primary . 260 Table SE.11: Sampling errors: Education of household head – Secondary . 260 Table SE.12: Sampling errors: Education of household head – Higher . 261 Table SE.13: Sampling errors: Poorest . 261 Table SE.14: Sampling errors: Second wealth quintile . 262 Table SE.15: Sampling errors: Middle wealth quintile . 263 Table SE.16: Sampling errors: Fourth wealth quintile . 264 Table SE.17: Sampling errors: Wealthiest . 265 Table DQ.1: Age distribution of household population . 266 Table DQ.2: Age distribution of eligible and interviewed women . 267 Table DQ.3: Age distribution of eligible and interviewed men. 268 Table DQ.4: Age distribution of children in household and under-5 questionnaires . 268 Table DQ.5: Birth date reporting: Household population . 269 Table DQ.6: Birth date and age reporting: Women . 269 Table DQ.7: Birth date and age reporting: Men . 270 Table DQ.8: Birth date and age reporting: Under-5s . 270 Table DQ.9: Birth date reporting: Children, adolescents and young people . 271 Table DQ.10: Birth date reporting: First and last births . 272 Table DQ.11: Completeness of reporting . 273 Table DQ.12: Completeness of information for anthropometric indicators: Underweight . 274 Table DQ.13: Completeness of information for anthropometric indicators: Stunting . 274 Table DQ.14: Completeness of information for anthropometric indicators: Wasting . 275 Table DQ.15: Heaping in anthropometric measurements . 276 Table DQ.16: Observation of birth certificates . 277 Table DQ.17: Observation of vaccination cards . 277 Table DQ.18: Observation of women's health cards . 278 Table DQ.19: Observation of bednets and places for handwashing . 278 Table DQ.20: Respondent to the under-5 questionnaire . 279 Table DQ.21: Selection of children age 1-17 years for the child labour and child discipline modules . 279 Table DQ.22: School attendance by single age . 280 Table DQ.23: Sex ratio at birth among children ever born and living . 281 Table DQ.24: Births by periods preceding the survey . 282 Table DQ.25: Reporting of age at death in days . 283 Table DQ.26: Reporting of age at death in months . 284 Sao Tome and Principe 2014 MICS, Final Report P a g e | xxii Table DQ.27: Completeness of information on siblings . 285 Table DQ.28: Sibship size and sex ratio of siblings . 285 Sao Tome and Principe 2014 MICS, Final Report P a g e | xxiii List of Figures F i g u r e H H . 1 : A g e a n d s e x d i s t r i b u t i o n o f h o u s e h o l d p o p u l a t i o n . 10 F i g u r e C M . 1 : E a r l y c h i l d h o o d m o r t a l i t y r a t e s . 21 F i g u r e C M . 3 : T r e n d i n u n d e r - 5 m o r t a l i t y r a t e s . 25 F i g u r e N U . 1 : U n d e r w e i g h t , s t u n t e d , w a s t e d a n d o v e r w e i g h t c h i l d r e n u n d e r a g e 5 ( m o d e r a t e a n d s e v e r e ) . 31 F i g u r e N U . 2 : I n i t i a t i o n o f b r e a s t f e e d i n g . 35 F i g u r e N U . 3 : I n f a n t f e e d i n g p a t t e r n s b y a g e . 37 F i g u r e N U . 4 : C o n s u m p t i o n o f i o d i z e d s a l t . 45 F i g u r e C H . 1 : V a c c i n a t i o n s b y a g e 1 2 m o n t h s . 48 F i g u r e C H . 2 : C h i l d r e n u n d e r - 5 w i t h d i a r r h o e a w h o r e c e i v e d O R S o r r e c o m m e n d e d h o m e m a d e l i q u i d s . 58 F i g u r e C H . 3 : C h i l d r e n u n d e r - 5 w i t h d i a r r h o e a r e c e i v i n g o r a l r e h y d r a t i o n t h e r a p y ( O R T ) a n d c o n t i n u e d f e e d i n g . 60 F i g u r e C H . 4 : P e r c e n t a g e o f h o u s e h o l d p o p u l a t i o n w i t h a c c e s s t o a n I T N i n t h e h o u s e h o l d . 70 F i g u r e W S . 1 : P e r c e n t d i s t r i b u t i o n o f h o u s e h o l d m e m b e r s b y s o u r c e o f d r i n k i n g w a t e r . 87 F i g u r e W S . 2 : P e r c e n t d i s t r i b u t i o n o f h o u s e h o l d m e m b e r s b y u s e a n d s h a r i n g o f s a n i t a t i o n f a c i l i t i e s . 96 F i g u r e W S . 3 : U s e o f i m p r o v e d d r i n k i n g w a t e r s o u r c e s a n d i m p r o v e d s a n i t a t i o n f a c i l i t i e s b y h o u s e h o l d m e m b e r s . 99 F i g u r e R H . 1 : A g e - s p e c i f i c f e r t i l i t y r a t e s b y a r e a . 105 F i g u r e R H . 2 : D i f f e r e n t i a l s i n c o n t r a c e p t i v e u s e . 111 F i g u r e R H . 3 : P e r s o n a s s i s t i n g a t d e l i v e r y . 122 F i g u r e E D . 1 : E d u c a t i o n i n d i c a t o r s b y s e x . 159 F i g u r e C P . 1 : C h i l d d i s c i p l i n i n g m e t h o d s , c h i l d r e n a g e 1 - 1 4 y e a r s . 168 F i g u r e H A . 1 : W o m e n a n d m e n w i t h c o m p r e h e n s i v e k n o w l e d g e o f H I V t r a n s m i s s i o n . 186 F i g u r e H A . 2 : A c c e p t i n g a t t i t u d e s t o w a r d p e o p l e l i v i n g w i t h H I V / A I D S . 192 F i g u r e H A . 3 : S e x u a l b e h a v i o u r t h a t i n c r e a s e s t h e r i s k o f H I V i n f e c t i o n , y o u n g p e o p l e a g e 1 5 - 2 4 . 203 F i g u r e T A . 1 : E v e r a n d c u r r e n t s m o k e r s . 232 Appendices: F i g u r e D Q . 1 : H o u s e h o l d p o p u l a t i o n b y s i n g l e a g e s . 267 F i g u r e D Q . 2 : W e i g h t a n d h e i g h t / l e n g t h m e a s u r e m e n t s b y d i g i t s r e p o r t e d f o r t h e d e c i m a l p o i n t s . 276 Sao Tome and Principe 2014 MICS, Final Report P a g e | xxiv List of Abbreviations AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care BCG Bacillus Calmette-Guérin (Tuberculosis) CNE Centro Nacional de Endemias (National Centre for Endemic Diseases) CRC Convention on the Rights of the Child CSPro Census and Survey Processing System DHS Demographic and Health Survey DPT Diphtheria Pertussis Tetanus ECDI Early Child Development Index EPI Expanded Programme on Immunization GPI Gender Parity Index HIV Human Immunodeficiency Virus ICF ICF International IDD Iodine Deficiency Disorders INE Instituto Nacional de Estatísticas (National Institute of Statistics) IRS Indoor Residual Spraying ITN Insecticide Treated Net IUD Intrauterine Device MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS5 Fifth global round of Multiple Indicator Clusters Surveys programme NAR Net Attendance Rate NGO Non-Governmental Organization ORS Oral Rehydration Salts ORT Oral Rehydration Treatment PCV Pneumococcal Conjugate Vaccine Penta Pentavalent vaccine, which includes antigens for diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenzae type B RDT Rapid Diagnostic Test RHF Recommended Home Fluid ppm Parts Per Million SPSS Statistical Package for Social Sciences UNDP United Nations Development Programme 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 Sao Tome and Principe 2014 MICS, Final Report P a g e | xxv Acknowledgements It is with great pleasure that the Government of the Democratic Republic of Sao Tome and Principe, through the National Institute of Statistics (INE) and the National Centre for Endemic Diseases (CNE), presents the main results of the Multiple Indicator Cluster Survey (MICS) technically coordinated by UNICEF. The Multiple Indicator Cluster Survey (MICS5) of Sao Tome and Principe was implemented in 2014 by the National Institute of Statistics of Sao Tome and Principe in collaboration with the UNDP/Global Fund project. MICS5 is an instrument of utmost importance for the monitoring of programmes in Sao Tome and Principe as it gives access to the country to statistical information to orient policies and programmes implemented by the Government as well as other international commitments. 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. Beside the estimation of socio-demographic and health variables, this survey also helps to shed some light on the social phenomenon of domestic violence against women or children. MICS revealed that the percentage of registered children below five years of age passed from 68.8 percent in 2006 to 95.2 percent in 2014. Infant mortality rates decreased from 45 per 1000 in 2006 to 36 per 1000 in 2014, and maternal mortality ratio from 267 per 100,000 to 74 per 100,000. An Ethics Committee was put in place to oversee ethical aspects that such a survey entails and to ensure the preservation of the rights of the users of this research. The Ethics Committee is an independent and multisectoral entity that was charged to preserve and guarantee the dignity of the rights, security and well-being of the survey participants who tested for HIV. The National Institute of Statistics expresses its sincere thanks to the Government of the Democratic Republic of Sao Tome and Principe, to UNICEF and to the UNDP/Global Fund. It is also grateful to the technicians of the National Institute of Statistics and of the Ministry of Health, as well as to the supervisors, editors, data typists and families who contributed towards the realization of this work. _____________________ ELSA MARIA CARDOSO (General Director) Sao Tome and Principe 2014 MICS, Final Report P a g e | xxvi Executive Summary This report is based on the Sao Tome and Principe Multiple Indicator Cluster Survey (MICS), conducted in 2014 by the National Institute of Statistics. The survey provides statistically sound and internationally comparable data essential for developing evidence-based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating 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). The objective of the 2014 MICS is to update some of the results of previous surveys, to evaluate the progress made with the various programmes of cooperation, and to identify remaining challenges. The survey also permitted to get an update on the sero-prevalence of HIV among men and women, anaemia among children and women, and malaria among children, measurements that were added to the standard MICS. Methodology The sample was designed to provide estimates for a large number of indicators on the situation of children and women at the national level, for urban and rural areas, and for four regions of the country later on recast into: Region Centre East, Region North West, Region South East, and Autonomous Region of Principe. Five sets of questionnaires were used in the survey. The Household Questionnaire included the following modules: o List of Household Members o Education o Child Labour o Child Discipline o Household Characteristics o Insecticide Treated Nets o Indoor Residual Spraying o Water and Sanitation o Handwashing o Salt Iodization The Questionnaire for Individual Women was administered to all women age 15-49 years living in the households, and included the following modules: o Woman’s Background o Access to Mass Media and Use of Information/Communication Technology o Fertility/Birth History o Desire for Last Birth o Maternal and Newborn Health o Post-natal Health Checks o Illness Symptoms o Contraception Sao Tome and Principe 2014 MICS, Final Report P a g e | xxvii o Unmet Need o Attitudes Toward Domestic Violence o Marriage/Union o Sexual Behaviour o HIV/AIDS o Maternal Mortality o Tobacco and Alcohol Use o Life Satisfaction The Questionnaire for Individual Men was administered to all men age 15-49 years living in the households, and included the following modules: o Man’s Background o Access to Mass Media and Use of Information/Communication Technology o Fertility o Attitudes Toward Domestic Violence o Marriage/Union o Sexual Behaviour o HIV/AIDS o Circumcision o Tobacco and Alcohol Use o Life Satisfaction The Questionnaire for Children Under Five was administered to mothers (or caretakers) of children under 5 years of age living in the households, and 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 The Blood Test Questionnaire was administered to all households and included the following modules: o Anaemia and malaria test for children age 6-59 months o Anaemia and HIV test for women age 15-49 years o HIV test for men age 15-49 years The implementation of blood testing in this survey provided a public health opportunity for the provision of information on malaria symptoms to mothers of young children, including sensitisation on the need to take the child to the nearest health facility in case of symptoms. Further, referral cards to Voluntary Counselling and Testing services were handed-over to all respondents, including those who refused to be tested for HIV. The protocol for HIV anonymous testing was approved by the International Review Board of ICF International as well as the MICS Ethics Committee. Analysis of the HIV blood samples-related data was only carried out once the MICS data had been “scrambled” and anonymized. Sao Tome and Principe 2014 MICS, Final Report P a g e | xxviii Sample coverage and characteristics of households and respondents Of the 3,930 households selected for the sample, 3,625 were found to be occupied. Of these, 3,492 were successfully interviewed which leads to a household response rate of 96 percent. The women’s response rate was 95 percent, the men’s response rate 82 percent, and the children’s response rate 98 percent. According to the results of this survey, children and youth less than 18 years of age constitute over half of the population of Sao Tome and Principe (51 percent), while 44 percent are below 15 and only 4 percent 65 or older, characterizing the nation’s population as predominantly young. These results are nearly identical to those of the 2012 census. Two-thirds of households (66 percent) are found in urban areas; one third (35 percent) are female headed. The mean household size is 3.9. The majority (56 percent) of women age 15-49 years are currently married or in union, but a notable proportion (18 percent) are separated. Nearly three- quarters (73 percent) of women in this age group have started child bearing, and 48 percent gave birth in the last two years. Nearly half (48 percent) of men age 15-49 years are currently married or in union, while 10 percent are separated. Overall, 93 percent of children below five years of age live with their biological mother. Over three-quarters of households (76 percent) have electricity in urban areas, compared with 55 percent in rural areas. Finished roofing (mostly corrugated iron) and walls (mostly wood planks) are nearly universal in Sao Tome and Principe. However, a majority of households (57 percent) have a floor made of rudimentary material (mostly wood planks). Mobile phones are very common in both urban (82 percent) and rural (78 percent) households. On the other hand, ownership of computers is still relatively rare even in urban households (15 percent). About two rural households in five (42 percent) own agricultural land. Child mortality For the most recent 5-year period neonatal mortality is estimated at 22 per 1,000 live births, post- neonatal mortality at 16 per 1,000 live births, infant mortality at 38 per 1,000 live births, and under- five mortality at 45 deaths per 1,000 live births. Comparing these findings with those of previous surveys (2000 MICS, 2006 MICS and 2008-2009 DHS), a smooth declining trend is observed over the last 15 to 20 years with a tendency to stabilize in most recent years. Nutrition Low birth weight Overall, 94 percent of newborns were weighed at birth and approximately 8 percent of infants are estimated to weigh less than 2,500 grams at birth (low birth weight). There is no evidence of meaningful differences in the prevalence of low birth weight by region, urban and rural areas or by mother’s education. Sao Tome and Principe 2014 MICS, Final Report P a g e | xxix Malnutrition It is estimated that 9 percent of children under age five in Sao Tome and Principe are underweight (2 percent are severely so), while 17 percent are stunted or too short for their age (5 percent are severely so). In addition, 4 percent are moderately or severely wasted or too thin for their height. A small proportion (2 percent) of children are overweight or too heavy for their height. There are no meaningful differences between urban and rural areas. Regions are also fairly similar with respect to these four indicators, except for stunting where the differences are larger, ranging from 11 percent in Region Autónoma de Principe to 23 percent in Region South East. Breastfeeding While 97 percent of children born in the last two years were breastfed, only 38 percent of babies are breastfed for the first time within one hour of birth, and 86 percent of newborns start breastfeeding within one day. Approximately three-quarters (74 percent) of children age less than six months are exclusively breastfed, while 85 percent are predominantly breastfed. At age 12-15 months, 86 percent of children are still being breastfed, which is remarkable, but breastfeeding drops drastically from that point to a mere 24 percent by age 20-23 months. As a result of feeding patterns, only 59 percent of children age 6-23 months are considered as being appropriately breastfed. Age- appropriate breastfeeding among all children age 0-23 months is of 62 percent, with a declining trend from the poorest quintile (71 percent) to the richest (58 percent). Feeding frequency and dietary diversity Overall, 74 percent of infants age 6-8 months received solid, semi-solid, or soft foods at least once the previous day, while 58 percent of the children age 6-23 months did so the minimum number of times. The proportion of children receiving the minimum dietary diversity, or foods from at least 4 food groups, is 47 percent, suggesting the need to focus on improving diet quality and nutrient intake. The overall assessment using the indicator of minimum acceptable diet reveals that only 22 percent of children age 6-23 months are benefitting from a diet sufficient in both diversity and frequency. Bottle-feeding The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Of the children under 6 months, 10 percent are fed using a bottle with a nipple, but the proportion rises to 21 percent among children age 6-11 months. The prevalence is much higher in the children of mothers with secondary or higher education (25 percent) than with no formal or only primary education (10 percent), and in the wealthiest (32 percent) than the poorest (9 percent) households. Salt iodization In 88 percent of households, salt was found to contain 15 parts per million or more of iodine, the recommended proportion. Use of iodized salt ranges from 82 percent in Region South East to 93 percent in Autonomous Region of Principe. The difference between the richest (95 percent) and poorest (81 percent) households is significant. Sao Tome and Principe 2014 MICS, Final Report P a g e | xxx Child health Immunization The vaccination schedule followed by the Sao Tome and Principe’s National Immunization Programme includes birth doses of BCG and Polio, three doses of the Pentavalent vaccine , four doses of Polio vaccine, three doses of the Pneumococcal vaccine, two doses of the measles vaccine, and one dose of vaccine against yellow fever. All vaccinations should be received during the first year of life except the fourth dose of Polio (one year after the third dose) and the second dose of measles (between 18 and 23 months). The estimates for full immunization coverage are based on children age 12-23 months and exclude the fourth dose of Polio and the second dose of measles. Approximately 97 percent of children age 12-23 months received a BCG vaccination by the age of 12 months. The first dose of Penta was given to 95 percent and the third to 93 percent. For polio, the difference between the first and third dose is somewhat larger (95 and 89 percent respectively). As the pneumococcal conjugate vaccine (PCV), coverage for the first dose by the age of 12 months is notably lower at 87 percent and declines further to 82 percent for the third dose. The coverage is of 89 percent for both yellow fever and measles. There is a rather large gap between the antigen with the lowest coverage (82 percent for PCV3) and the percentage of children who had all the recommended vaccinations by their first birthday which is only 66 percent. This suggests that for a notable proportion of children there are one or several missed immunization opportunities before the age of 12 months. A total of 72 percent women who have had a live birth within the last 2 years and their newborns were protected against tetanus. Diarrhoea The percentage of children with diarrhoea in the two weeks preceding the survey is 18 percent. A health facility or provider was seen in 54 percent of cases. Advice or treatment was sought for a higher proportion of rural (64 percent) than urban (46 percent) children. As for drinking and feeding practices during diarrhoea, 42 percent of under five children with diarrhoea were given more to drink than usual while 56 percent were given the same quantity or less. The majority (87 percent) were given somewhat less, the same or more to eat (continued feeding), while 13 percent were given much less or almost nothing. Half of the children (49 percent) who had an episode of diarrhoea in the two weeks preceding the survey received fluids from ORS packets and one quarter (25 percent) of them received recommended homemade fluids (a water, sugar and salt mixture, and/or rice water). Overall, 73 percent of children with diarrhoea received oral rehydration therapy (ORT) (ORS or recommended homemade fluids or increased fluids). It is observed that 62 percent of children received ORT and, at the same time, feeding was continued, as is the recommendation. Acute respiratory infections (ARI) Overall, 69 percent of children age 0-59 months with symptoms of ARI in the two weeks preceding the survey were taken to a qualified provider and 48 percent received antibiotics. It appears that the use of antibiotics in such circumstances is more prevalent in rural (68 percent) than in urban (38 percent) areas. Overall, 33 percent of women know at least one of the two danger signs of pneumonia – fast and/or difficult breathing. This ranges from 28 percent in Region South East to 55 percent in Autonomous Region of Principe, but is otherwise fairly uniform among urban and rural, more or less educated, and poorer and wealthier mothers. Sao Tome and Principe 2014 MICS, Final Report P a g e | xxxi Solid fuel use Overall, 42 percent of the household population in Sao Tome and Principe uses solid fuels for cooking, consisting mainly of wood (33 percent). Use of solid fuels is substantial even in urban areas (33 percent), and predominant in rural areas, where they are used by 59 percent of household members. The findings show that use of solid fuels ranges from 27 percent in Region Centre East to 76 percent in Autonomous Region of Principe. Malaria and fever The results indicate that 78 percent of households have at least one insecticide treated net (ITN), and 55 percent at least one ITN for every two household members. Overall, 91 percent of households received indoor residual spraying during the last 12 months. Urban areas have higher coverage of ITN than their rural counterparts (82 and 69 percent respectively), and so do wealthiest households in relation to poorest ones (87 versus 65 percent respectively). Coverage of ITN by region ranges from 70 percent in Region South East to 86 percent in Autonomous Region of Principe. Overall, 31 percent of individuals are estimated to have access to ITNs, i.e. they could sleep under an ITN if each ITN in the household was used by two people. Access is higher in urban (34 percent) than in rural (24 percent) areas. Access decreases with poverty and ranges from 45 percent among the wealthiest to 20 percent among the poorest. Overall, 70 percent of ITNs were used during the night preceding the survey. As for children under the age of five years, 61 percent slept under an ITN the night preceding the survey. Of note is the very high proportion (96 percent) of children under five who the previous night slept either under an ITN or in a house that had indoor residual spraying (IRS) in the last 12 months. In terms of care-seeking behaviour during an episode of fever in the past two weeks, advice was sought from a health facility or a qualified health care provider for 66 percent of children with fever. However, no advice or treatment was sought in 33 percent of the cases. Figures also indicate that seeking advice in the case of fever is more likely for children of a younger age than older ones (73 and 62 percent respectively), and for children living in the wealthiest than in the poorest households (77 and 59 percent respectively). Overall, 42 percent of children with a fever in the previous two weeks had blood taken from a finger or heel for testing. Further, 0.2 percent of children with fever in the last two weeks were treated with an artemisinin-based combination therapy (ACT) and 1.4 percent received an antimalarial. Interpretation of these results must take into consideration the low prevalence of malaria in Sao Tome and Principe. The proportion of pregnant women who slept under a mosquito net during the previous night is 62 percent. It varies from 45 percent in Region South East to 65 percent in Region Centre East. It tends to be higher in urban (66 percent) than in rural (50 percent) areas. Of note is the very high proportion (94 percent) of pregnant women who the previous night slept either under an ITN or in a house that had indoor residual spraying (IRS) in the last 12 months. Overall, 90 percent of pregnant women who had a live birth in the two years preceding the survey, and who received antenatal care, took medicine at least once to prevent malaria at any of ANC visit; however, only 12 percent took medicine three or more times as recommended. Sao Tome and Principe 2014 MICS, Final Report P a g e | xxxii The results of blood tests show a low prevalence of malaria in children. Only 0.5 percent of the rapid diagnostic test (RDT) and 0.2 percent of the thick blood smears implemented in children gave positive results, which leads to the conclusion that the prevalence of malaria was extremely low in Sao Tome and Principe during the time of the survey (mid-2014). Anaemia in children Blood was also collected for the haemoglobin test from children age 6-59 months. Over six children in ten (67 percent) in the 6-59 months age group suffer from anaemia: light anaemia in 33 percent of cases, moderate in another 33 percent and severe in 1 percent. In the 6-23 months age group, over four children in five suffer from anaemia. The Region South East and Autonomous Region of Principe have a somewhat higher prevalence (74 and 72 percent respectively) than the rest of the country. With respect to the wealth quintiles, it can be seen that the lowest prevalence is in children from the wealthiest households. The prevalence of severe anaemia in children is low (1 percent). Water and sanitation Water Improved sources of drinking water include: piped water (into dwelling, compound, yard or plot, to neighbour, public tap/standpipe), tube well/borehole, protected well, protected spring, and rainwater collection. Overall, 94 percent of the population uses an improved source of drinking water98 percent in urban areas and 86 percent in rural areas. While such results are admirable, some areas require additional efforts, such as Autonomous Region of Principe where the indicator is considerably lower (74 percent). Countrywide, the indicator ranges from 91 percent among the poorest to nearly 100 percent among the wealthiest. The source of drinking water for the population varies strongly by region. Access to drinking water that is piped into the yard or dwelling ranges from 33 percent in Region Centre East to 13 percent in Region South East. Accessing drinking water through public taps ranges from 71 percent in Region South East to 39 percent in Autonomous Region of Principe. Drinking water mainly from rivers and streams (an unimproved source) is still prevalent in some regions, notably Autonomous Region of Principe (12 percent) and Region North West (8 percent), while unprotected springs are commonly used in Autonomous Region of Principe (13 percent). For 42 percent of the household population, the drinking water source is on premises. While 92 percent of the wealthiest have water on premises, only 10 percent of the poorest have this benefit. For nearly a quarter of the household population (23 percent), it takes the household more than 30 minutes to get to the water source and bring water. One finding of note is the comparatively high percentage of household members in Region South East (28 percent), who live in households spending 30 minutes or more to go to source of drinking water. For over two-thirds of households (69 percent), an adult female usually collects drinking water when the source is not on the premises. Adult men collect water in only 19 percent of cases, while for the rest of the households, female or male children under age 15 collect water (11 percent). Sao Tome and Principe 2014 MICS, Final Report P a g e | xxxiii Sanitation Improved sanitation facilities for excreta disposal include flush or pour flush to a piped sewer system, septic tank, or pit latrine; ventilated improved pit latrine, pit latrine with slab, and use of a composting toilet. Nearly half of the population (47 percent) lives in households using improved sanitation facilities, 53 percent in urban and 36 percent in rural areas. Residents of Region North West are less likely than others to use improved facilities (27 percent). Open defecation is prevalent, and is used by 61 percent of the rural and 42 percent of the urban population. After that, improved latrines with toilets are the most common sanitation facilities, used by 27 percent of the urban and 23 percent of the rural population. Modern bathrooms are used by 17 percent of the population, mostly in urban areas. The expression “use of improved sanitation” is used to refer to improved sanitation facilities, which are not public or shared. The survey found that 41 percent of the household population is using an improved sanitation facility, ranging from 25 percent in Region North West to 51 percent in Autonomous Region of Principe, and from 8 percent among the poorest to 89 percent among the wealthiest. Jointly, 40 percent of the household population has access to both improved drinking water and improved sanitation, 46 percent in urban and 27 percent in rural areas, and 89 percent of the wealthiest but only 7 percent of the poorest. Safe disposal of a child’s faeces is disposing of the stool, by the child using a toilet or by rinsing the stool into a toilet or latrine. Overall, only 29 percent of last stools of children age 0-2 years were disposed safely according to the current criteria. Handwashing In Sao Tome and Principe, a specific place for handwashing was observed in about half of the households (51 percent). Overall, 40 percent of householdsi had a specific place for handwashing supplied with water and soap (or another cleansing agent). Soap or another cleansing agen could be observed anywhere in the dwelling In 76 percent of households. The percentage was similar in urban and rural areas, but ranged from 55 to 94 percent between the poorest and wealthiest households. The differences between regions were also substantial, ranging from 57 percent in Region South East to 88 percent in Autonomous Region of Principe. Reproductive health Fertility Age-specific fertility rates (ASFRs), expressed as the number of births per 1,000 women in a specified age group, show the age pattern of fertility. The total fertility rate (TFR) is a synthetic measure that denotes the number of live births a woman would have if she were subject to the current age- specific fertility rates throughout her reproductive years (15-49 years). i Households with a specific place for handwashing that was not observed by the interviewers are not included in the denominator. Sao Tome and Principe 2014 MICS, Final Report P a g e | xxxiv The overall age pattern of fertility, as reflected in the ASFRs, indicates that childbearing begins early in Sao Tome and Principe. Fertility is low among adolescents, increases to a peak of 221 births per 1,000 among women age 20-24, and declines thereafter. The adolescent birth rate (age-specific fertility rate for women age 15-19) is estimated at 92 and shows a large variation between the wealth quintiles, from 29 among the wealthiest to 154 among the poorest. A similar trend is seen in the total fertility rate which ranges from 3.7 among the wealthiest to 5.3 among the poorest, from 2.5 among women with higher education to 7.1 among women with no formal education. It is estimated that 16 percent of women age 15-19 have already had a birth, 5 percent are pregnant with their first child, and nearly 1 percent has had a live birth before age 15. The latter cases are almost exclusively seen among the 40 percent poorest. Results indicate that 27 percent of women age 20-24 have had a live birth before age 18. Here again, the poorest are more affected (35 percent) than the wealthiest (12 percent), as are those with no formal education or only primary level (42 percent) compared with those with secondary or higher education (18 percent). Contraception Current use of contraception was reported by 41 percent of women currently married (or in union). The most popular method is the pill which is used by 15 percent of married women. The next most popular method is injectables, used by 12 percent of married women, while male condom is used by 5 percent of them. Any of the other methods accounts for less than 3 percent individually. Contraceptive prevalence ranges from 38 percent in Region Centre East to 57 percent in Autonomous Region of Principe. About 46 percent of married women in urban and 38 percent in rural areas use a method of contraception. Women’s education level is strongly associated with contraceptive prevalence. The percentage of married women using any method of contraception rises from 25 percent among those with no education, to 39 percent among those with primary education, 43 percent among those with secondary education, and then 59 percent among those with higher education. Unmet need Unmet need for contraception refers to fecund women who are married or in union and are not using any method of contraception, but who wish to postpone the next birth (spacing) or who wish to stop childbearing altogether (limiting). Unmet need for contraception stands at 33 percent overall, and ranges from 21 percent in Autonomous Region of Principe to 36 percent in Region Centre East. There are no marked differences between women living in urban or rural areas, and the levels are roughly comparable as well between those of different education or wealth levels. Met need for limiting includes women married or in union who are using (or whose partner is using) a contraceptive method, and who want no more children, are using male or female sterilization, or declare themselves as infecund. Met need for spacing includes women who are using (or whose partner is using) a contraceptive method, and who want to have another child, or are undecided whether to have another child. The total of met need is estimated at 41 percent countrywide, with differences between regions ranging from 38 percent in Region Centre East to 57 percent in Autonomous Region of Principe. Using information on contraception and unmet need, the percentage of demand for contraception satisfied can be estimated. The total demand for contraception is estimated to be around 55 percent Sao Tome and Principe 2014 MICS, Final Report P a g e | xxxv countrywide, and ranges from 51 percent in Region Centre East to 73 percent in Autonomous Region of Principe. Antenatal care Antenatal care coverage indicators (at least one visit with a skilled provider and 4 or more visits with any providers) are used to track progress toward the Millennium Development Goal 5 of improving maternal health. Only a small percentage (2 percent) of women do not receive antenatal care in Sao Tome and Principe. The majority of antenatal care services are provided by nurses and midwives while a minority of women receive care from a medical doctor, both in urban and rural areas. Over nine in ten mothers (91 percent) received antenatal care more than once and 84 percent of mothers received antenatal care at least four times. Mothers from the poorest households and those with primary education are less likely than more advantaged mothers to receive antenatal care four or more times. For example, 73 percent of the women living in poorest households reported four or more antenatal care visits compared with 93 percent among those living in richest households. For 67 percent of women with a live birth in the last two years, their first antenatal care visit was during the first trimester of their last pregnancy. A larger proportion of women from wealthiest households had their first antenatal care visit during the first trimester than those from the poorest households (84 and 52 percent respectively). Assistance at delivery About 92 percent of births occurring in the two years preceding the MICS survey were delivered by skilled personnel. This percentage is fairly constant across regions except Region South East estimated at 82 percent; this is also the only region with a substantial proportion of deliveries assisted by traditional birth attendants (13 percent). The likelihood to be delivered by a skilled attendant increases with education and wealth, and is higher in the urban (95 percent) than in the rural (88 percent) areas. Deliveries are predominantly assisted by midwives and nurses (81 percent) and a much smaller proportion (12 percent) by medical doctors. Place of delivery About 91 percent of births are delivered in a health facility, nearly all of which are in public sector facilities. Home deliveries account for about 8 percent. The proportion of institutional deliveries is above 90 percent in all regions except Region South East where it is estimated at 77 percent and where 21 percent of deliveries take place at home. The proportion of births occurring in a health facility increases steadily with wealth, from 82 percent in the lowest wealth quintile to nearly 100 percent in the highest. Post-natal health checks Overall, 99 percent of women who gave birth in a health facility stay 12 hours or more in the facility after delivery. Three-quarters of women stay three days or more, and in Region North West this value increases to 88 percent. Overall, 89 percent of newborns receive a health check following birth while in a facility or at home. With regards to post-natal care visits (PNC), these predominantly occur after the first week following birth (60 percent). These results must be interpreted in the context of an environment in which three-quarters of the mothers stay 3 or more days at the health facility with their babies after Sao Tome and Principe 2014 MICS, Final Report P a g e | xxxvi delivery. Eventually, a total of 91 percent of all newborns receive a post-natal health check. Health checks following birth occur mainly in health facility deliveries (93 percent). It is estimated that 85 percent of mothers receive a health check following birth while in a facility or at home, not dissimilar to the 89 percent registered for newborns. With regards to PNC visits, they mostly occur after the first week following birth (44 percent), even though a small proportion occurs at different times over the first week. Overall, a total of 87 percent of all mothers receive a post- natal health check. With respect to the proportion of mothers and newborns who do not receive a PNC visit, the percentage is more than twice as high for mothers (46 percent) as for newborns (20 percent). Adult mortality rates Adult mortality rates are based on information collected in the Maternal Mortality module in the Women's Questionnaire. Overall mortality rates for adults age 15-49 years are estimated at 1.32 per 1,000 population in the case of males, and 1.35 per 1,000 population in the case of females. The probability of dying between exact ages 15 and 50 is estimated at 52 per 1,000 person-years in the case of males, and 49 per 1,000 person-years in the case of females. Maternal mortality The 2014 Sao Tome and Principe MICS asked women age 15-49 a series of questions designed with the explicit purpose of providing the necessary information to make direct estimates of maternal mortality. This estimation of maternal mortality is done using the direct sisterhood method. The maternal mortality ratio for Sao Tome and Principe for the 7-year period preceding the survey is estimated at 74 maternal deaths per 100,000 live births, while the maternal mortality rate is estimated at 0.11 per 1000 women-years of exposure. It must be taken into consideration however that in the 2014 MICS sample, only 3 cases of maternal deaths were identified in nearly 38,000 women-years of exposure. While the small number of maternal deaths is an encouraging finding, a larger number of cases would have been necessary for the calculation of reliable maternal mortality estimates. It is thus recommended that the estimates arrived at in this survey be considered only as indicative. Prevalence of anaemia in women Blood was collected for the haemoglobin test from women age 15-49 years living in the household who agreed voluntarily to the test. Results indicate that almost half of women (47 percent) are anaemic: light anaemia in 35 percent of cases, moderate in 10 percent, and severe in 1 percent. There is a higher prevalence of anaemia in pregnant (61 percent) than in non-pregnant women (46 percent). Over three pregnant women in ten (32 percent) have moderate anaemia, as compared with 8 percent in non-pregnant women. The prevalence of anaemia differs between age groups. In the 15-19 years group 55 percent are anaemic, as compared with 44 percent in the 40-49 years group. Between regions, prevalence ranges from 42 percent in Autonomous Region of Principe to 51 percent in Region North West. There are large differentials between educational levels, with a prevalence of 57 percent among those without formal education and of 32 percent among those with secondary education. Finally, anaemia ranges from 45 percent in women belonging to the poorest wealth quintile to 51 percent in the wealthiest. Sao Tome and Principe 2014 MICS, Final Report P a g e | xxxvii Early childhood development Early childhood care and education Overall, 36 percent of children age 36-59 months are attending an organised early childhood education programme. Boys and girls have similar opportunities, and the level of attendance is comparable in urban and rural areas. There are, however, large differences between children of wealthiest and poorest households (63 and 21 percent respectively), and those whose mothers have secondary education or higher as compared with their less privileged counterparts (52 and 29 percent respectively). Attendance between regions ranges from 34 percent in Region Centre East to 53 percent in Autonomous Region of Principe. Quality of care Information on a number of activities that support early learning was collected in the survey. These included the involvement of adults with children in the following activities: reading books or looking at picture books, telling stories, singing songs, taking children outside the home, compound or yard, playing with children, and spending time with children naming, counting, or drawing things. For almost two-thirds (63 percent) of children age 36-59 months, an adult household member engaged in four or more activities that promote learning and school readiness during the 3 days preceding the survey. The mean number of activities that adults engage with children is 4. Father’s involvement in four or more activities is merely 3 percent. Only a little over half (56 percent) of children age 36-59 months live with their biological father. Adult engagement in activities with children ranges from 78 percent in Autonomous Region of Principe to 56 percent in Region North West, while the proportion is 74 percent for children living in the richest households, against 48 percent for those living in the poorest. Only 6 percent of children age 0-59 months live in households where at least 3 children’s books are present for the child. The proportion of children with 10 or more books declines to less than 1 percent. Urban and rural areas are comparable. Further, 65 percent of children age 0-59 months have 2 or more types of playthings to play with in their homes. The types of playthings included in the questionnaires were homemade toys (such as dolls and cars, or other toys made at home), toys that came from a store, and household objects (such as pots and bowls) or objects and materials found outside the home (such as sticks, rocks, animal shells, or leaves). It is interesting to note that the proportion of children who play with household objects (66 percent) is similar to that of those who play with toys that come from a store (70 percent), while 55 percent of them play with homemade toys. It appears that in terms of proportion of children with 2 or more types of playthings, those of rural areas are at a slight advantage compared to those of urban areas (70 and 62 percent respectively). Overall, 13 percent of children age 0-59 months were left in the care of other children, while 7 percent were left alone during the week preceding the interview. Combining the two care indicators, it is estimated that a total of 16 percent of children were left with inadequate care during the past week, either by being left alone or in the care of another child. There are marked differences by socio-economic status as children from the poorest households are three times more exposed to inadequate care than those of the wealthiest households (26 and 8 percent respectively). Sao Tome and Principe 2014 MICS, Final Report P a g e | xxxviii Developmental status of children A 10-item module was used to calculate the Early Child Development Index (ECDI). The index is based on selected milestones that children are expected to achieve by ages 3 and 4. The results indicate that 55 percent of children age 36-59 months are developmentally on track. As expected, ECDI is substantially higher in the 48-59 months age group than in the younger children (61 and 48 percent respectively), since children mature more skills with increasing age. A higher ECDI of 64 percent is seen in children attending an early childhood education programme compared to 49 percent among those who are not attending. Children living in poorest households have a lower ECDI (51 percent) compared to children living in richest households (62 percent of children developmentally on track). The analysis shows that 94 percent of children are on track in the physical, 79 percent in the learning and 62 percent in the social-emotional domains. However, only 16 percent are on track in the literacy-numeracy domain. Literacy and education Literacy among young women and men Results indicate that 90 percent of young women in Sao Tome and Principe are literate. Of women who stated that primary school was their highest level of education (and the very few who declared to never have attended school), only 64 percent were actually able to read the statement shown to them. The situation, however, appears to be improving since 92 percent of young women age 15-19 are literate against 86 percent of those age 20-24. The literacy profile of young men is very similar to that of young women. School readiness Overall, 58 percent of children who are currently attending the first grade of primary school were attending pre-school the previous year. There is no gender difference and children from urban and rural areas have similar values. Socioeconomic status is correlated with school readiness; while the indicator is only 37 percent among the poorest households, it increases to 82 percent among those children living in the richest households. Primary and secondary school participation Of children who are of primary school entry age (age 6), 77 percent are attending the first grade of primary school. Attendance levels of children of both sexes, as well as those from urban and rural areas, are similar. The great majority of children of primary school age are attending school (94 percent). The net attendance ratio is similar for children of urban and rural areas and of the various regions. The secondary school net attendance ratio is only 60 percent. Of the remaining 40 percent, most are attending primary school, but 12 percent of children of secondary school age are completely out of school. The net attendance ratio for boys is lower (55 percent) than that of the girls (65 percent), mainly because a higher proportion of boys are still attending primary school. The percentage of children entering first grade who eventually reach the last grade of primary school is 92 percent. The data suggest that boys drop out more from primary school than girls, since 87 percent of boys reach the last grade compared to 96 percent of girls. Similarly, a smaller proportion of children from rural areas reach grade 6 than their urban counterparts (87 and 94 percent respectively). Finally, only 85 percent of children from the poorest households reach grade 6 Sao Tome and Principe 2014 MICS, Final Report P a g e | xxxix compared with 97 percent of those coming from the wealthiest households. The primary school completion rate is 112 percent. Gender parity for primary school is exactly 1.00, indicating no difference in the attendance of girls and boys to primary school. However, the indicator increases to 1.18 for secondary education. Girls are generally at an advantage in urban areas, with a gender parity index (GPI) of 1.24, while rural areas are closer to gender parity, with a GPI of 1.04. Child protection Birth registration The births of 95 percent of children under five years have been registered and less than one percent of children do not have a birth certificate. On the other hand, while virtually all children from wealthiest households are registered, that proportion goes down to 87 percent among the poorest. Child labour Nineteen percent of children age 5-11 years are engaged in any economic activities, while 6 percent of those age 12-14 years are engaged in such activities for at least 14 hours a week, and 3 percent of those age 15-17 years for at least 43 hours a week. With respect to household chores, girls are generally more likely to perform them than boys, and rural children tend to be more involved than their urban counterparts. Overall, 26 percent of children age 5-17 years are estimated to be in child labour, including 16 percent working in hazardous conditions. Rural children are more exposed to child labour (32 percent) than their urban counterparts (23 percent), and so are they to hazardous conditions of work (21 and 13 percent respectively). Child labour increases with age, from 24 percent in the 5-11 years to 32 percent in the 15-17 years; this last group also suffers the heaviest risk of exposure to hazardous conditions (30 percent). Child discipline For the most part, households employ a combination of violent disciplinary practices. While 64 percent of children experienced psychological aggression, more than 2 out of 3 (69 percent) experienced physical punishment during the past month. The most severe forms of physical punishment (hitting the child on the head, ears or face or hitting the child hard and repeatedly), if less common, are not rare: 10 percent of children were subjected to severe punishment the month prior to the survey. While violent methods are extremely common forms of discipline, only 6 percent of respondents believe that physical punishment is a necessary part of child-rearing. Early marriage and polygyny The percentage of women married before age 15 is 5 percent; among women age 20-49 years, about one third (32 percent) was married before age 18. Overall, 15 percent of young women age 15-19 years are currently married or in union. This proportion tends to be higher in rural (21 percent) than in urban (13 percent) areas, and is strongly related to the level of education and to the socio- economic status. Among all women age 15-49 years who are in union, 22 percent are in polygynous union. This condition is somewhat more prevalent in urban (24 percent) than in rural (19 percent) areas, and is less likely among the poorest (13 percent) than the wealthiest (25 percent). Sao Tome and Principe 2014 MICS, Final Report P a g e | xl The percentage of men married before age 15 is only 1 percent (8 percent before age 18). Only 1 percent of young men age 15-19 years are currently married or in union. Among currently married/in union women age 20-24 years, about 17 percent are married/in union with a man who is older by ten years or more. For currently married/in union women age 15-19 years, the corresponding figure is 23 percent. Attitudes toward domestic violence Overall, 19 percent of women in Sao Tome and Principe feel that a husband/partner is justified in hitting or beating his wife in at least one of the five situations presented: if she goes out without telling him, if she neglects the children, if she argues with him, if she refuses sex with him, or if she burns the food. Justification in any of the five situations is more present among those living in poorest households, and less educated. Men are less likely to justify violence than women. Overall, 14 percent of men justify wife-beating for any of the same five reasons. Men living in the poorest households are much more likely to agree with one of the five reasons (21 percent) than men living in the richest households (7 percent). Children’s living arrangements Overall, 46 percent of children age 0-17 years in Sao Tome and Principe live with both their parents, while 34 percent live with mothers only and 4 percent live with fathers only; the rest live with neither biological parents. Very few children (0.4 percent) have lost both parents, while 4 percent of children have only their mother alive and 1 percent of children have only their father alive. Overall, 16 per cent of children age 0-17 have one or both parents living abroad. The percentage of at least one parent abroad varies between 7 percent in Region South East and 19 percent in Region Centre East. It is more likely for a child living in an urban area to have at least one parent living abroad than for one living in a rural area (17 and 13 percent respectively), and there is a large difference in this indicator between children from the poorest (8 percent) and the wealthiest households (22 percent). HIV/AIDS and sexual behaviour Knowledge about HIV transmission and misconception about HIV Nearly all women and men age 15-49 years (over 99 percent) have heard of AIDS. However, the percentage of those who know of both main ways of preventing HIV transmissionhaving only one faithful uninfected partner and using a condom every timeis only 67percent for women and 73 percent for men. Overall, 55 percent of women and 62 percent of men reject the two most common misconceptions (that HIV can be transmitted by sharing food with someone with HIV or through mosquito bites) and know that a healthy-looking person can be HIV-positive. Comprehensive knowledge of HIV prevention methods and transmission is fairly low. Overall, 41 percent of women and 47 percent of men were found to have comprehensive knowledge, with little differences between the urban and rural areas. Overall, 91 percent of both women and men know that HIV can be transmitted from mother to child. The percentage of women and men who know all three ways of mother-to-child transmission is 47 percent and 40 percent, respectively, while 8 percent of women and men did not know of any specific way. Sao Tome and Principe 2014 MICS, Final Report P a g e | xli Accepting attitudes toward people living with HIV The indicators on attitudes toward people living with HIV measure stigma and discrimination in the community. Stigma and discrimination are considered low if respondents report an accepting attitude on the following four questions: 1) would care for a family member with AIDS in own home; 2) would buy fresh vegetables from a vendor who is HIV-positive; 3) thinks that a female teacher who is HIV-positive should be allowed to teach in school; and 4) would not want to keep it a secret if a family member is HIV-positive. Over 95 percent of women and men who have heard of AIDS agree with at least one accepting statement. The less commonly accepted attitude is buying fresh vegetables from a person who is HIV-positive (65 percent and 68 percent, respectively for women and men). Knowledge of a place for HIV testing, counselling and testing during antenatal care Overall, 92 percent of women and 90 percent of men knew where to be tested, while 74 percent and 52 percent, respectively, have actually been tested. Only 40 percent of women and 29 percent of men have been tested within the last 12 months. The highest proportion of tests is found in Autonomous Region of Principe. Among women who had given birth within the two years preceding the survey, 77 percent received counselling during their last pregnancy and 89 percent were offered an HIV test and were tested. There is generally a correlation between these interventions, education and socio-economic status. Sexual behaviour related to HIV transmission Overall, 3 percent of women and 29 percent of men 15-49 years of age report having sex with more than one partner in the last 12 months. Of those, only 46 percent of women and 49 percent of men reported using a condom when they had sex the last time. Among men who had sex with more than one partner in the last 12 months, a larger proportion of younger men age 15-24 years reported using a condom last time they had sex (71 percent) than older men (32 to 41 percent), and a larger proportion of wealthiest (60 percent) than poorest men (44 percent). HIV indicators for young women and young men In young women and young men age 15-24, results with respect to comprehensive knowledge (42 percent of young women and 43 percent of young men), knowledge of mother-to-child transmission (46 percent of young women and 38 of young men), and knowledge of a place to get tested (88 percent of young women and 85 of young men) are generally similar to that of the population age 15-49 years as a whole. Accepting attitudes towards people living with HIV with respect to the same four indicators that were previously discussed are also comparable in this age group (13 percent of young women and 19 percent of young men). Overall, 48 percent of young women and 22 percent of young men in this age group, who are sexually active, have been tested for HIV in the last 12 months and know the result. Overall, 65 percent of young women and 64 percent of young men age 15-24 years reported ever having sex; 9 percent and 18 percent, respectively, reported having sex for the first time before the age of 15. Further, 4 percent of young women and 22 percent of young men had sex with more than one partner in the last 12 months; of those approximately 58 percent of women and 71 percent of men reported using a condom the last time. On the other hand, 25 percent of the young women and 47 percent of the young men who had sex in the last 12 months reported that it involved a non- Sao Tome and Principe 2014 MICS, Final Report P a g e | xlii marital non-cohabiting partner; of those 65 percent of women and 83 percent of men used a condom the last time. About 18 percent of women age 15-24 years had sex with a man 10 or more years older in the last 12 months. Traditionally, circumcision does not form part of cultural practices in Sao Tome and Principe. However, an indicator on circumcision was introduced in the 2014 MICS as part of the CNE’s interest in promoting safe male circumcision as an HIV prevention method. According to the results of this survey, only 3 percent of men age 15-49 are circumcised. Prevalence of HIV in men and women Blood samples were taken from all eligible men and women who voluntarily accepted to be tested for HIV, with an effective coverage of 80 percent: 89 percent among women and 70 percent among men. The results indicate that the prevalence of HIV infection in the 15-49 years population is 0.5 percent in both men and women. They suggest a slight upward trend from the youngest to the oldest in both sexes. With such low HIV prevalence in both men and women, the differentials between various background characteristics are generally small. There seems to be a slightly higher prevalence among divorced or separated individuals (1.5 percent), while it is of 0.4 percent among those who are married or in union, and 0.2 percent among those who are single. HIV prevalence in the 15-24 age group is only 0.1 percent. Access to mass media and use of information/communication technology Access to mass media About 18 percent of women in Sao Tome and Principe read a newspaper or magazine, 77 percent listen to the radio, and 85 percent watch television at least once a week. Overall, 9 percent do not have regular exposure to any of the three media, while 91 percent are exposed to at least one and 16 to all the three types of media on a weekly basis. Men age 15-49 years report a notably higher level of exposure to all types of media than women. At least once a week, 32 percent of men read a newspaper or magazine, 83 percent listen to the radio, and 90 percent watch television. About 5 percent do not have regular exposure to any of the three media, while 95 percent are exposed to at least one and 28 to all the three types of media on a weekly basis. Use of information/communication technology It is estimated that 48 percent of 15-24 year old women ever used a computer, 37 percent used a computer during the last year, and 27 percent used one at least once a week during the last month. Overall, 37 percent of women age 15-24 ever used the internet, while 32 percent used it during the last year. The proportion of young women who used the internet more frequently, at least once a week during the last month, is smaller, at 24 percent. As expected, both the computer and internet use during the last 12 months is more widespread among the 15-19 year old women, but not by much. Higher utilisation of the internet last year is observed among young women in urban areas (36 percent) compared to those in rural areas (24 percent). The use of the internet during the last year ranges from 16 percent in Region North West to 39 percent in Region Centre East, while the Sao Tome and Principe 2014 MICS, Final Report P a g e | xliii proportion is 64 percent for young women in the richest households, as opposed to 10 percent in those living in the poorest households. It is estimated that 48 percent of 15-24 year old men used a computer during the last year while 43 percent used the internet in the same period. The differentials in terms of background characteristics generally go in the same direction as those observed among young women. For example, 12 percent of young men in the poorest households used the internet during the last year compared to 76 percent among the young men in the richest households. Subjective well-being Life satisfaction is a measure of an individual’s perceived level of well-being. Understanding young women and young men’s satisfaction in different areas of their lives can help to gain a comprehensive picture of young people’s life situations. Of the different domains, young women are the most satisfied with their look (82 percent), their family life (80 percent), and their friendships (79 percent). The results for young men are somewhat higher; they are the most satisfied with the way they look (89 percent,) their health (86 percent) and their friendships and family life (both 84 percent). Among the domains, both young women and young men are the least satisfied with their current income, with 71 percent of young women and 46 percent of young men not having an income at all. Overall, 76 percent of 15-24 year old women are satisfied with their life overall; the figures are remarkably similar between the various categories of wealth, but vary between regions from 73 percent, for Region Centre East, to 85 percent in Region North West. Urban and rural areas are similar. Young men are somewhat more satisfied with their life (84 percent) than young women (76 percent), and there is some evidence that life satisfaction is highest among the poorest (91 percent). It is estimated that 74 percent of women and 77 percent of men age 15-24 years are very or somewhat happy. Differences by wealth quintiles can be observed for this indicator and favour the poorest. The proportion of women age 15-24 years who think that their lives improved during the last one year and who expect that their lives will get better after one year, is 59 percent. The corresponding indicator for men age 15-24 years is similar at 63 percent. Tobacco and alcohol use Tobacco use In Sao Tome and Principe, ever and current use of tobacco products is more common among men than among women. Overall, 33 percent of men and 8 percent of women reported to have ever used a tobacco product, while 9 percent of men and only 1 percent of women smoked cigarettes, or used smoked or smokeless tobacco products on one or more days during the last one month. Results show that less than 1 percent of women and 1 percent of men 15-49 years old smoked a cigarette for the first time before age 15. Alcohol use Overall, 53 percent of women age 15-49 years had at least one drink of alcohol on one or more days during the last one month, 7 percent of women of the same age group first drank alcohol before the Sao Tome and Principe 2014 MICS, Final Report P a g e | xliv age of 15, and 21 percent of women never had an alcoholic drink. Among the younger age groups, the proportion of women who had at least one drink of alcohol before age 15 is higher (15 percent) than among the older age groups. The proportion of men that consume alcohol is considerably higher than that of women. Overall 67 percent of men 15-49 years old had at least one drink of alcohol on one or more days during the last one month. Use of alcohol before the age of 15 is also more common among men (12 percent) than among women (7 percent). As for young women, the proportion among young men who had at least one drink of alcohol before age 15 is higher among the younger age groups. Sao Tome and Principe 2014 MICS, Final Report P a g e | 1 I. Introduction Background This report is based on the Sao Tome and Principe Multiple Indicator Cluster Survey (MICS), conducted in 2014 by the National Institute of Statistics. The survey provides statistically sound and internationally comparable data essential for developing evidence-based policies and programmes, and for monitoring progress toward national goals and global commitments. Among these global commitments are those emanating 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). 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, analyze 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.” The national statistical system experienced large reforms in the last decade with the adoption of the statutory law (law 5/98, decree 17/2001) of the National Institute of Statistics (INE). The implementation of the first Demographic and Health Survey (DHS) in 2008-2009 provided critical information to monitor and evaluate the impact of social programmes put into action by the government, including in the area of public health. In addition to measuring a range of socio- Sao Tome and Principe 2014 MICS, Final Report P a g e | 2 demographic indicators, particularly those related to reproductive health and child survival, it provided the opportunity to measure the prevalence of anaemia, the sero-prevalence of HIV in the sexually active population, as well as the prevalence of the hepatitis B virus. In addition to the DHS, the government of Sao Tome and Principe implemented, between 2009 and 2010, a national household survey to evaluate poverty (IOF), in view of a redefinition of the direction of its economic and social development policies, and to address existing constraints and challenges in terms of data availability. The results are being used to elaborate the report on the PRSP and the Millennium Development Goals (MDG). Statistics are available on a total of 51 indicators related to the National Strategy for the Reduction of Poverty and the MDG. The objective of the 2014 MICS is to update some of the results of previous surveys, to evaluate the progress made with the various programmes of cooperation, and to identify remaining challenges. The survey also permitted to get an update on the sero-prevalence of HIV, anaemia and malaria, measurements that were added to the standard MICS. The 2014 Sao Tome and Principe MICS 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. In relation to HIV and malaria, this report provides evidence to inform the country’s efforts towards AIDS and malaria elimination. It also contains up-to-date data required to support the country’s resource mobilization efforts vis-à-vis the Global Fund to fight AIDS, tuberculosis and malaria. This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The 2014 Sao Tome and Principe MICS has as its primary objectives:  To provide up-to-date information for assessing the situation of children and women in Sao Tome and Principe;  To generate data for the critical assessment of the progress made in various areas, and to highlight the need for additional efforts in those areas that require more attention;  To furnish data needed for monitoring progress toward goals established in the Millennium Declaration and other internationally agreed upon goals, as a basis for future action;  To 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;  To validate data from other sources and the results of focused interventions. Sao Tome and Principe 2014 MICS, Final Report P a g e | 3 II. Sample and Survey Methodology Sample Design The sample for the 2014 Sao Tome and Principe Multiple Indicator Cluster Survey was designed to provide estimates for a large number of indicators on the situation of children and women at the national level, for urban and rural areas, and for four regions: Água Grande, Mè Zochi, a southern region composed of the districts of Cantagalo and Cauée, and a northern region composed of the districts of Lembá and Lobata. The sampling frame was stratified by urban and rural areas within each region; a total of 13 strata were defined. The sample was selected in two stages. Within each stratum, a specified number of census enumeration areas were selected systematically with probability proportional to size. After a household listing was carried out within the selected enumeration areas, a systematic sample of 30 households was drawn in each sample enumeration area. All the selected enumeration areas were visited during the fieldwork period. The overall sampling probabilities vary by stratum, and the sample is not self-weighting. For reporting all survey results, sample weights are used. A more detailed description of the sample design can be found in Appendix A, Sample Design. Questionnaires Five sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect basic demographic information on all de jure household members (usual residents), the household, and the dwelling; 2) a questionnaire for individual women administered in each household to all women age 15-49 years; 3) a questionnaire for individual men administered in each household to all men age 15-49 years; 4) an under-5 questionnaire, administered to mothers (or caretakers) for all children under 5 living in the household; and 5) a blood test questionnaire used to collect information in each household on children, women and men eligible for blood testing. The questionnaires included the following modules: The Household Questionnaire included the following modules: o List of Household Members o Education o Child Labour o Child Discipline o Household Characteristics o Insecticide Treated Nets o Indoor Residual Spraying o Water and Sanitation o Handwashing o Salt Iodization The Questionnaire for Individual Women was administered to all women age 15-49 years living in the households, and included the following modules: o Woman’s Background o Access to Mass Media and Use of Information/Communication Technology Sao Tome and Principe 2014 MICS, Final Report P a g e | 4 o Fertility/Birth History o Desire for Last Birth o Maternal and Newborn Health o Post-natal Health Checks o Illness Symptoms o Contraception o Unmet Need o Attitudes Toward Domestic Violence o Marriage/Union o Sexual Behaviour o HIV/AIDS o Maternal Mortality o Tobacco and Alcohol Use o Life Satisfaction The Questionnaire for Individual Men was administered to all men age 15-49 years living in the households, and included the following modules: o Man’s Background o Access to Mass Media and Use of Information/Communication Technology o Fertility o Attitudes Toward Domestic Violence o Marriage/Union o Sexual Behaviour o HIV/AIDS o Circumcision o Tobacco and Alcohol Use o Life Satisfaction The Questionnaire for Children Under Five was administered to mothers (or caretakers) of children under 5 years of agei living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Age o Birth Registration o Early Childhood Development o Breastfeeding and Dietary Intake o Immunization o Care of Illness o Anthropometry i The terms “children under 5”, “children age 0-4 years”, and “children age 0-59 months” are used interchangeably in this report. Sao Tome and Principe 2014 MICS, Final Report P a g e | 5 The Blood Test Questionnaire was administered to all households and included the following modules: o Anaemia and malaria test for children 6-59 months of age o Anaemia and HIV test for women age 15-49 years o HIV test for men age 15-49 years All the questionnaires except that for the blood test are based on the MICS5 model questionnairei. From the MICS5 model versions, the questionnaires were customised and translated into Portuguese and were pre-tested in the city of Sao Tome during December 2013. Based on the results of the pre- test, modifications were made to the wording and translation of the questionnaires. A copy of the 2014 Sao Tome and Principe MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the place for handwashing, measured the weights and heights of children age under 5 years, and took blood samples from children under 5 years, as well as women and men age 15-49 years . Methodology and processes used when taking blood samples for anaemia, malaria and HIV testing Fieldwork teams took blood samples for haemoglobin tests of anaemia from all women age 15-49 years old who voluntarily accepted to do the test, as well as from all children age 6-59 months who lived in the household surveyed. Teams registered the test value in the questionnaire and communicated the test result to the respondent or to the parent in case of minors. Respondents with low levels of anaemia were advised to seek medical attention. Blood samples were also tested for malaria parasitaemia using both rapid diagnostic test (Paramax 3 test kit) and thick smear for laboratory-based microscopy. In the case of children testing positive with RDT and who were not presenting severe malaria symptoms, free ACT treatment was provided, according to the national treatment protocol. Mothers were provided information on malaria symptoms and were advised to go immediately to the nearest health facility in case of symptoms. Field work teams collected blood samples for HIV testing from all eligible respondents who voluntarily accepted to take the test. All women and men aged 15-49 years old surveyed were eligible for the test. The HIV testing protocol was based on an anonymous protocol, approved by ICF International Ethics Committee and the MICS Ethics Committee. A reference card to Voluntary Counselling and Testing services was provided to all respondents, including those who refused to be tested for HIV. A consent form was signed by the eligible respondent once the fieldworker has explained the blood sampling process, and confirmed the confidentiality and anonymity of the HIV testing. i The model MICS5 questionnaires can be found at http://www.mics.unicef.org/mics5_questionnaire.html Sao Tome and Principe 2014 MICS, Final Report P a g e | 6 Training and Fieldwork Training for the fieldwork was conducted for 15 days between 3 and 21 March 2014. The training included lectures on interviewing techniques and the contents of the questionnaires, and mock interviews between trainees to gain practice in asking questions. Towards the end of the training period, trainees spent 7 days practicing interviewing in the district of Água Grande and Mè Zochi. The training also provided guidelines for the field-level collection and analysis of blood samples and biomarkers data, using a specifically designed manual and questionnaire. The data were collected by eight teams; each was comprised of four interviewers, two health technicians (for anthropometry and blood sample collection), one driver, one editor and a supervisor. Fieldwork began on 7 April 2014 and was concluded on 18 June of the same year. Data Processing Data were entered using the CSPro software, Version 5.0. The data were entered on ten desktop computers, procured specifically for the purposes of the 2014 MICS, and carried out by 20 data entry operators and two data entry supervisors working in two shifts (morning and afternoon). For quality assurance purposes, all questionnaires were double-entered and internal consistency checks were performed. Procedures and standard programmes developed under the global MICS programme and adapted to the 2014 Sao Tome and Principe questionnaires were used throughout. Data processing followed rapidly the start of data collection on 14 April and was completed on 28 June 2014. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software, Version 21. Model syntax and tabulation plans developed by UNICEF were customized and used for this purpose. The processing of the blood samples was conducted from August to September 2014 for the malaria samples and from January to February 2015 for the HIV samples. The processing of the HIV samples was initiated after the scrambling and anonymization of the MICS data collected through the questionnaires. Blood samples were analyzed at the Hospital Ayres de Menezes Laboratory in Sao Tome and Principe. For HIV testing in particular, Elisa (Vironostika® VIH Ag/Ab) was used for all samples as a first test. Negative samples from this first testing were classified as negative whereas positive samples were subjected to a second ELISA test (Enzygnost® VIH Integral II). Positive samples from this second test were classified as positive. Discordant cases between the first and second ELISA test were reanalyzed using the two tests. Discordant cases were analyzed once again using Western Blot 2.2. Ten percent of negative cases were also subjected to another ELISA test for quality control purposes. At the end of the process, 261 samples, including all positive cases, were sent to the Centre Pasteur in Cameroon for external quality control (EQC). The results of the EQC, communicated in May 2014, coincided with those obtained in Sao Tome and Principe. Sao Tome and Principe 2014 MICS, Final Report P a g e | 7 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 3,930 households selected for the sample, 3,625 were found to be occupied. Of these, 3,492 were successfully interviewed for a household response rate of 96 percent. In the interviewed households, 3,101 women (age 15-49 years) were identified. Of these, 2,935 were successfully interviewed, yielding a response rate of 95 percent within the interviewed households. The survey also sampled men (age 15-49). All men (age 15-49) in all selected households were identified. A total of 2,772 men (age 15-49 years) were listed in the household questionnaires. Questionnaires were completed for 2,267 men, which corresponds to a response rate of 82 percent within interviewed households. There were 2,062 children under age five listed in the household questionnaires. Questionnaires were completed for 2,030 of these children, which corresponds to a response rate of 98 percent within interviewed households. Overall response rates of 91, 79 and 95 percent are calculated for the individual interviews of women, men, and under-5s, respectively (Table HH.1). Sao Tome and Principe 2014 MICS, Final Report P a g e | 8 Table HH.1:1 Results of household, women's, men's and under-5 interviews Number of households, women, men, and children under 5 by interview results, and household, women's, men's and under- 5's response rates, Sao Tome and Principe, 2014 Total Area Region Urban Rural Region Centre East Region North West Region South East Autonomous Region of Principe Households Sampled 3,930 2,340 1,590 1,800 900 900 330 Occupied 3,625 2,145 1,480 1,672 858 805 290 Interviewed 3,492 2,054 1,438 1,626 840 740 286 Household response rate 96.3 95.8 97.2 97.2 97.9 91.9 98.6 Women Eligible 3,101 1,895 1,206 1,482 774 636 209 Interviewed 2,935 1,810 1,125 1,389 756 582 208 Women's response rate 94.6 95.5 93.3 93.7 97.7 91.5 99.5 Women's overall response rate 91.2 91.5 90.6 91.1 95.6 84.1 98.1 Men Eligible 2,772 1,644 1,128 1,220 684 661 207 Interviewed 2,267 1,360 907 924 598 539 206 Men's response rate 81.8 82.7 80.4 75.7 87.4 81.5 99.5 Men's overall response rate 78.8 79.2 78.1 73.7 85.6 75.0 98.1 Children under 5 Eligible 2,062 1,225 837 937 531 442 152 Mothers/caretakers interviewed 2,030 1,210 820 916 526 436 152 Under-5's response rate 98.4 98.8 98.0 97.8 99.1 98.6 100.0 Under-5's overall response rate 94.8 94.6 95.2 95.1 97.0 90.7 98.6 Coverage rates in urban and rural areas are very similar. Most response rates are above 90 percent, and several above 95 percent, which generally reassures us with respect to the representativeness of the results of this survey. The overall men’s response rate, however, is 79 percent, and the reader should thus interpret men’s statistics in this report with some degree of caution. Many household surveys have struggled to achieve higher response rates for this group because men tend to be absent from home more often than women. It is noteworthy that the Autonomous Region of Principe managed coverage rates above 98 percent in all categories, including a surprising 100 percent for children under age five which may in part have to do with the relatively small sample for that region. Even with such high coverage, confidence intervals for the statistics of that region will tend to be wider than those for the other regions, given the smaller sample size, something that the reader will do well to keep in mind. 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 3,492 households successfully interviewed in the survey, 13,455 household members were listed. Of these, 6,423 were males, and 7,032 were females. Sao Tome and Principe 2014 MICS, Final Report P a g e | 9 Table HH.2:2 Age distribution of household population 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, Sao Tome and Principe, 2014 Total Males Females Number Percent Number Percent Number Percent Total 13,455 100.0 6,423 100.0 7,032 100.0 Age 0-4 2,010 14.9 1,010 15.7 1,001 14.2 5-9 2,151 16.0 1,111 17.3 1,040 14.8 10-14 1,815 13.5 859 13.4 956 13.6 15-19 1,382 10.3 641 10.0 741 10.5 20-24 947 7.0 456 7.1 491 7.0 25-29 953 7.1 435 6.8 518 7.4 30-34 898 6.7 423 6.6 475 6.8 35-39 721 5.4 343 5.3 378 5.4 40-44 545 4.1 235 3.7 310 4.4 45-49 410 3.0 199 3.1 211 3.0 50-54 501 3.7 220 3.4 281 4.0 55-59 325 2.4 131 2.0 194 2.8 60-64 257 1.9 130 2.0 127 1.8 65-69 155 1.1 66 1.0 89 1.3 70-74 130 1.0 56 0.9 74 1.1 75-79 147 1.1 64 1.0 83 1.2 80-84 63 0.5 28 0.4 35 0.5 85+ 38 0.3 14 0.2 24 0.3 DK/Missing 6 0.0 3 0.0 3 0.0 Dependency age groups 0-14 5,977 44.4 2,980 46.4 2,997 42.6 15-64 6,939 51.6 3,212 50.0 3,727 53.0 65+ 533 4.0 228 3.6 305 4.3 DK/Missing 6 0.0 3 0.0 3 0.0 Child and adult populations Children age 0-17 years 6,838 50.8 3,370 52.5 3,469 49.3 Adults age 18+ years 6,610 49.1 3,051 47.5 3,559 50.6 DK/Missing 6 0.0 3 0.0 3 0.0 According to the results of this survey, children and youth less than 18 years of age constitute over half of the population of Sao Tome and Principe (51 percent), while 44 percent are below 15 and only 4 percent 65 or older, characterizing the nation’s population as predominantly young. These results are nearly identical to those of the 2012 census. On the other hand, the fact that the 5-9 years age group is somewhat larger than the youngest, contrary to census results, suggests that children under five years of age might be under-reported in our data. This pattern is not infrequent in surveys with large children’s questionnaires and could be the result of out-transference of a number of eligible children to an older non-eligible age, potentially in addition to under-recording of very young children. Out-transference is also likely to be responsible for the steep downward step between age 14 and 15 observable in Table DQ.1 in Sao Tome and Principe 2014 MICS, Final Report P a g e | 10 Appendix D, related this time to women’s and men’s questionnaires, and similarly at the upper end of age eligibility as seen in Figure HH.1, particularly for women. Figure HH.1: 1 Age and sex d istr ibut ion of household populat ion , Sao Tome and Pr inc ipe , 2014 Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15-49, male respondents 15-49, and children under-5. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in the report and provides background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers.i Table HH.3 provides basic background information on the households, including the sex of the household head, region, area, 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 numbers of observations by major categories of analysis in the report. i See Appendix A: Sample Design, for more details on sample weights. 10 8 6 4 2 0 2 4 6 8 10 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+ Per cent Age Males Females Note: 6 household members with missing age and/or sex are excluded Sao Tome and Principe 2014 MICS, Final Report P a g e | 11 Table HH.3:3 Household composition Percent and frequency distribution of households by selected characteristics, Sao Tome and Principe, 2014 Weighted percent Number of households Weighted Unweighted Total 100.0 3,492 3,492 Sex of household head Male 65.2 2,278 2,362 Female 34.8 1,214 1,130 Region Centre East 66.2 2,311 1,626 North West 17.5 612 840 South East 11.9 417 740 Autonomous of Principe 4.3 152 286 Area Urban 66.0 2,306 2,054 Rural 34.0 1,186 1,438 Number of household members 1 16.1 564 577 2 13.3 465 441 3 16.2 564 542 4 17.0 595 601 5 16.4 573 571 6 10.9 382 398 7 5.6 195 198 8 2.5 87 95 9 0.9 30 32 10+ 1.0 36 37 Education of household head 9.1 319 344 None 9.1 319 344 Primary 54.1 1,891 1,981 Secondary 31.9 1,113 1,038 Higher 4.2 148 109 DK/Missing 0.6 21 20 Mean household size 3.9 3,492 3,492 The weighted and unweighted total number of households are equal, since sample weights were normalized.i The table also shows the weighted mean household size estimated by the survey. It can be seen that the less populous regions of the country were over-sampled in order to provide better precision for their estimates; even so, the sample size of Autonomous Region of Principe remains relatively small as previously noted. Two-thirds of households (66 percent) are found in urban areas; one third (35 percent) are female headed. The mean household size is 3.9. The majority of household heads (54 percent) have only attended primary school, and merely 4 percent have higher education. i See Appendix A: Sample Design, for more details on sample weights. Sao Tome and Principe 2014 MICS, Final Report P a g e | 12 Characteristics of Female and Male Respondents 15-49 Years of Age and Children Under-5 Tables HH.4, HH.4M and HH.5 provide information on the background characteristics of female and male respondents 15-49 years of age and of children under age 5. In all three tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized).i In addition to providing useful information on the background characteristics of women, men, and children under age five, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. Table HH.4 provides background characteristics of female respondents, age 15-49 years. The table includes information on the distribution of women according to region, area, age, marital/union status, motherhood status, births in last two years, educationii, and wealth index quintilesiii, iv. i See Appendix A: Sample Design, for more details on sample weights. ii 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. iii 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 the 2014 Sao Tome and Principe MICS, the following assets were used in these calculations: number of persons per sleeping room; main material of which the roof, walls and floor are made; main cooking fuel; household has electricity, a radio, a television, a non-mobile telephone, a refrigerator or a freezer, a computer, a satellite dish, air conditioning, a wooden bed with a mattress, a plastic chair; household member owns a watch, a mobile phone, a bicycle, a motorcycle, a car or a pick-up truck, a boat with a motor, a boat without a motor, agricultural land, cattle, goats, sheep, chicken, pigs, other farm animals, a bank account; main source of water for cooking; location of the main source of water; type of toilet facility; shared or unshared toilet facility; water at the place used for handwashing; soap for handwashing; a household member living abroad. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels. The wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Filmer, D and Pritchett, L. 2001. Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India. Demography 38(1): 115-132; Rutstein, SO and Johnson, K. 2004. The DHS Wealth Index. DHS Comparative Reports No. 6; and Rutstein, SO. 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. iv 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 richest population wealth quintile”, and similar. Sao Tome and Principe 2014 MICS, Final Report P a g e | 13 Table HH.4:4 Women's background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Sao Tome and Principe, 2014 Weighted percent Number of women Weighted Unweighted Total 100.0 2,935 2,935 Region Centre East 67.6 1,983 1,389 North West 17.8 524 756 South East 11.1 326 582 Autonomous of Principe 3.5 103 208 Area Urban 68.0 1,997 1,810 Rural 32.0 938 1,125 Age 15-19 23.9 702 688 20-24 15.9 467 462 25-29 16.5 484 486 30-34 15.2 446 459 35-39 11.9 349 341 40-44 9.9 290 293 45-49 6.7 198 206 Marital/Union status Currently married/in union 55.5 1,629 1,671 Widowed 0.5 15 13 Divorced 0.1 3 4 Separated 17.7 518 513 Never married/in union 26.1 767 733 DK/Missing 0.1 2 1 Motherhood and recent births Never gave birth 26.7 783 746 Ever gave birth 73.3 2,152 2,189 Gave birth in last two years 25.7 756 758 No birth in last two years 47.6 1,398 1,432 Education None 3.1 91 110 Primary 48.6 1,426 1,520 Secondary 44.9 1,318 1,234 Higher 3.4 99 71 Wealth index quintile Poorest 17.8 524 637 Second 19.8 581 625 Middle 19.3 566 595 Fourth 20.4 598 558 Richest 22.7 666 520 The majority (56 percent) of women age 15-49 years are currently married or in union, but a notable proportion (18 percent) are separated. Nearly three-quarters (73 percent) of women in this age group have started child bearing, and 48 percent gave birth in the last two years. Education patterns are similar to those of the heads of households. Table HH.4 shows that in our sample of 2,935 Sao Tome and Principe 2014 MICS, Final Report P a g e | 14 women age 15-49, the education status of one of them is unknown; this “DK/Missing” category will generally be omitted from the relevant tables of this report. Table HH.4M:5 Men's background characteristics Percent and frequency distribution of men age 15-49 years by selected background characteristics, Sao Tome and Principe, 2014 Weighted percent Number of men Weighted Unweighted Total 100.0 2,267 2,267 Region Centre East 63.9 1,449 924 North West 18.3 415 598 South East 13.6 309 539 Autonomous of Principe 4.1 93 206 Area Urban 66.5 1,508 1,360 Rural 33.5 759 907 Age 15-19 26.0 588 563 20-24 16.7 378 382 25-29 15.6 354 339 30-34 14.4 327 353 35-39 12.5 284 283 40-44 7.7 175 186 45-49 7.1 161 161 Marital/Union status Currently married/in union 47.7 1,081 1,106 Widowed 0.1 2 3 Divorced 0.0 1 1 Separated 10.1 229 231 Never married/in union 42.0 953 925 DK/Missing 0.0 1 1 Fatherhood status Has at least one living child 53.7 1,217 1,247 Has no living children 45.5 1,031 1,003 DK/Missing 0.9 20 17 Education None 1.0 22 28 Primary 42.0 951 1,043 Secondary 52.5 1,189 1,123 Higher 4.6 105 73 Wealth index quintile Poorest 20.4 462 560 Second 20.2 458 503 Middle 19.2 435 456 Fourth 20.1 455 396 Richest 20.1 456 352 Sao Tome and Principe 2014 MICS, Final Report P a g e | 15 Similarly, Table HH.4M provides background characteristics of male respondents 15-49 years of age. The table shows information on the distribution of men according to region, area, age, marital status, fatherhood status, education, and wealth index quintiles. Nearly half (48 percent) of men age 15-49 years are currently married or in union, while 10 percent are separated. Fifty-four percent have at least one living child; 57 percent have secondary or higher education. Table HH.4M shows that in our sample of 2,267 men age 15-49, the marital status of one of them is unknown; this “DK/Missing” category will generally be omitted from the relevant tables of this report; the same will apply to the 3 cases of widowed men. Background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, region and area, age in months, respondent type, mother’s (or caretaker’s) education, and wealth. Overall, 93 percent of children below five years of age live with their biological mother. The average level of education of the mothers/caretakers of under-five children is lower than that of the overall population of women age 15-49 years (66 and 52 percent respectively with primary or no education), and there is some suggestion that a larger proportion of children may live in poorest as opposed to wealthiest households. Sao Tome and Principe 2014 MICS, Final Report P a g e | 16 Table HH.5:6 Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Sao Tome and Principe, 2014 Weighted percent Number of under-5 children Weighted Unweighted Total 100.0 2,030 2,030 Sex Male 50.4 1,023 1,027 Female 49.6 1,007 1,003 Region Centre East 64.9 1,317 916 North West 19.0 386 526 South East 12.1 245 436 Autonomous of Principe 4.0 82 152 Area Urban 65.9 1,339 1,210 Rural 34.1 691 820 Age 0-5 months 8.8 178 169 6-11 months 8.5 172 180 12-23 months 19.9 403 391 24-35 months 20.3 412 423 36-47 months 21.4 434 429 48-59 months 21.2 430 438 Respondent to the under-5 questionnaire Mother 93.2 1,893 1,893 Other primary caretaker 6.8 137 137 Mother’s educationa None 4.2 84 107 Primary 61.7 1,253 1,312 Secondary 31.9 647 578 Higher 2.2 46 33 Wealth index quintile Poorest 21.9 444 541 Second 21.1 428 462 Middle 20.3 411 404 Fourth 20.8 423 375 Richest 16.0 324 248 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. HH.6 presents characteristics of housing, disaggregated by area and region, distributed by whether the dwelling has electricity, the main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. Sao Tome and Principe 2014 MICS, Final Report P a g e | 17 Over three-quarters of households (76 percent) have electricity in urban areas, compared with 55 percent in rural areas. Finished roofing (mostly corrugated iron) and walls (mostly wood planks) are nearly universal in Sao Tome and Principe. However, a majority of households (57 percent) have a floor made of rudimentary material, more so urban (61 percent) than rural (49 percent) households. What is here referred to as rudimentary floor is mostly wood planks, the commonest floor material in urban areas, while finished floors are most often made of cement (data not shown). Table HH.6:7 Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and regions, Sao Tome and Principe, 2014 Total Area Region Urban Rural Region Centre East Region North West Region South East Autonomous Region of Principe Electricity Yes 68.6 75.8 54.8 74.8 54.8 51.8 76.2 No 31.3 24.2 45.1 25.2 45.0 48.2 23.8 DK/Missing 0.0 0.0 0.1 0.0 0.2 0.0 0.0 Flooring Natural floor 0.8 0.2 2.0 0.2 0.4 4.1 1.4 Rudimentary floor 56.7 60.7 49.0 59.8 49.9 58.1 34.1 Finished floor 42.4 39.0 49.0 39.9 49.7 37.4 64.6 Other 0.1 0.1 0.0 0.1 0.0 0.1 0.0 DK/Missing 0.0 0.0 0.0 0.0 0.0 0.3 0.0 Roof Natural roofing 0.0 0.0 0.1 0.0 0.1 0.0 0.4 Rudimentary roofing 0.2 0.2 0.2 0.1 0.0 0.4 1.3 Finished roofing 99.7 99.7 99.6 99.9 99.9 98.8 98.3 Other 0.1 0.1 0.2 0.0 0.0 0.6 0.0 DK/Missing 0.0 0.0 0.0 0.0 0.0 0.1 0.0 Exterior walls Rudimentary walls 1.5 1.8 1.0 1.6 2.0 0.5 1.5 Finished walls 98.1 97.7 98.7 98.0 97.9 99.3 95.7 Other 0.3 0.3 0.2 0.2 0.1 0.1 2.9 DK/Missing 0.1 0.2 0.0 0.2 0.0 0.1 0.0 Rooms used for sleeping 1 35.0 32.3 40.3 34.1 38.7 32.3 42.1 2 38.4 37.9 39.4 38.0 38.2 41.1 38.7 3 or more 22.9 25.7 17.2 24.2 21.5 19.5 17.3 DK/Missing 3.7 4.0 3.1 3.7 1.7 7.0 2.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 3,492 2,306 1,186 2,311 612 417 152 Mean number of persons per room used for sleeping 2.18 2.14 2.26 2.13 2.38 2.25 2.01 In Table HH.7 households are distributed according to ownership of assets by households and by individual household members. This also includes ownership of dwelling. Sao Tome and Principe 2014 MICS, Final Report P a g e | 18 Table HH.7 is a testimony of the phenomenal spread of mobile phones in both urban (82 percent) and rural (78 percent) households. One the other hand, ownership of computers is still relatively rare even in urban households (15 percent). About two rural households in five (42 percent) own agricultural land. Table HH.7:8 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, Sao Tome and Principe, 2014 Total Area Region Urban Rural Region Centre East Region North West Region South East Autonomous Region of Principe Percentage of households that own a Radio 60.8 64.9 52.9 65.4 49.3 50.4 64.8 Television 68.3 73.2 58.6 74.4 55.5 52.5 69.7 Non-mobile telephone 7.3 9.9 2.2 9.4 2.5 3.4 5.4 Refrigerator/freezer 42.8 49.9 28.9 49.8 28.0 24.8 44.4 Computer 11.6 14.7 5.6 14.8 4.1 4.3 12.7 Satellite dish 25.8 30.8 16.1 29.7 14.9 15.7 37.9 Air conditioning 2.0 2.8 0.5 2.8 0.6 0.1 1.0 Wooden bed with a mattress 96.6 97.0 95.8 97.0 96.7 94.9 95.4 Dining table with wooden chairs 94.2 94.6 93.3 95.0 92.8 92.1 93.0 Plastic chair 10.6 12.6 6.7 12.1 8.8 6.3 7.4 Percentage of households that own Agricultural land 25.8 17.7 41.5 17.5 43.1 38.5 47.4 Farm animals/Livestock 40.6 36.9 47.9 34.9 48.9 52.6 61.3 Percentage of households where at least one member owns or has a Watch 36.1 39.0 30.5 38.7 28.7 34.1 31.7 Mobile telephone 82.2 84.4 77.8 87.8 69.7 69.5 82.7 Bicycle 8.6 10.0 6.0 10.3 4.6 5.5 7.0 Motorcycle 15.8 15.7 16.0 17.0 12.0 11.8 24.6 Animal-drawn cart 0.0 0.0 0.0 0.0 0.1 0.0 0.0 Car or pick-up truck 9.7 11.4 6.3 12.1 6.4 3.6 3.1 Boat with a motor 1.7 2.0 0.9 0.5 4.2 3.0 5.0 Boat without a motor 3.1 3.6 2.2 0.4 11.3 4.8 6.5 Bank account 44.2 49.0 34.8 49.7 31.0 22.7 73.2 Ownership of dwelling Owned by a household member 76.5 73.9 81.6 72.2 87.1 84.7 76.1 Not owned 23.5 26.1 18.4 27.8 12.9 15.2 23.9 Rented 14.2 16.1 10.6 17.0 6.1 10.5 15.4 Other 9.3 10.0 7.8 10.8 6.7 4.6 8.5 DK/Missing 0.0 0.0 0.0 0.0 0.0 0.1 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 3,492 2,306 1,186 2,311 612 417 152 Table HH.8 shows how the household populations in areas and regions are distributed according to household wealth quintiles. Sao Tome and Principe 2014 MICS, Final Report P a g e | 19 As expected, rural areas have a higher proportion of household members in the poorest quintile (27 percent) than the urban (17 percent). At the other end of the distribution, we find 26 percent of household members of urban areas in the richest quintile, but only 7 percent of those living in rural areas. At the regional level, the highest concentration of poorest population is found in Region North West and Region South East (37 percent each). Table HH.8:9 Wealth quintiles Percent distribution of the household population by wealth index quintile, according to area of residence and regions, Sao Tome and Principe, 2014 Wealth index quintile Total Number of household members Poorest Second Middle Fourth Richest Total 20.0 20.0 20.0 20.0 20.0 100.0 13,455 Area Urban 16.6 16.5 18.9 21.6 26.4 100.0 8,960 Rural 26.8 26.9 22.2 16.8 7.3 100.0 4,495 Region Centre East 12.4 18.1 20.6 22.7 26.2 100.0 8,799 North West 37.0 24.4 17.4 14.0 7.2 100.0 2,510 South East 37.0 25.4 18.4 11.5 7.7 100.0 1,651 Autonomous of Principe 12.7 13.5 26.7 30.2 16.9 100.0 495 Sao Tome and Principe 2014 MICS, Final Report P a g e | 20 IV. Child Mortality One of the overarching goals of the Millennium Development Goals (MDGs) is to reduce infant and under-five mortality. Specifically, the MDGs call for the reduction of under-five mortality by two- thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Mortality rates presented in this chapter are calculated from information collected in the birth histories of the Women’s Questionnaires. All interviewed women were asked whether they had ever given birth, and if yes, they were asked to report the number of sons and daughters who live with them, the number of those who live elsewhere, and the number of those who have died. In addition, they were asked to provide a detailed birth history of live births of children in chronological order starting with the firstborn. Women were asked whether births were single or multiple, the sex of the children, the date of birth (month and year), and survival status. Further, for children still alive, they were asked the current age of the child and, if not alive, the age at death. Childhood mortality rates are expressed by conventional age categories and are defined as follows: • Neonatal mortality (NN): probability of dying within the first month of life • Post-neonatal mortality (PNN): difference between infant and neonatal mortality rates • Infant mortality (1q0): probability of dying between birth and the first birthday • Child mortality (4q1): probability of dying between the first and the fifth birthdays • Under-five mortality (5q0): the probability of dying between birth and the fifth birthday Rates are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age one, and post-neonatal mortality, which is the difference between infant and neonatal mortality rates. Table CM.1:10Early childhood mortality rates Neonatal, post-neonatal, Infant, child and under-five mortality rates for five year periods preceding the survey, Sao Tome and Principe, 2014 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Years preceding the survey 0-4 22 16 38 7 45 5-9 13 11 24 17 41 10-14 17 14 31 29 59 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates Table CM.1 and Figure CM.1 present neonatal, post-neonatal, infant, child, and under-five mortality rates for the three most recent five-year periods before the survey. Neonatal mortality in the most recent 5-year period is estimated at 22 per 1,000 live births, while the post-neonatal mortality rate is estimated at 16 per 1,000 live births. Sao Tome and Principe 2014 MICS, Final Report P a g e | 21 Figure CM.1: 2 Ear ly chi ldhood mortal i t y rates Sao Tome and Pr inc ipe , 2014 The infant mortality rate in the five years preceding the survey is 38 per 1,000 live births and under- five mortality is 45 deaths per 1,000 live births for the same period, indicating that 853 out of 1,000 under-five deaths are infant deaths. The point estimate for under-five mortality is 59 per 1,000 live births during the 10-14 year period preceding the survey (centered on October 2001), which is 14 points higher than the estimate for the 0-4 year period preceding the survey (centered on October 2011). While this is reassuring, the width of the confidence intervals for these estimates does not allow us to categorically state that a decline in under-five mortality has actually taken place over that period. For a similar reason, it would be statistically incorrect, on the basis of the results of this survey alone, to speak of an increase in either neonatal or infant mortality. We can however be affirmative with respect to an actual decline in child mortality over the same period. The fluctuations seen in these indicators, particularly those related to the first year of life, may be the reflection of actual fluctuations in mortality patterns in the population over the referred periods, sampling variations, and/or data quality issues such as the likely under-reporting of young children discussed in the previous chapter of this report. Another aspect of data quality relates to heaping of age at death reported as 1 year (see DQ.26 in Appendix D), a rather common problem in birth histories, which may affect to some extent post-neonatal, infant and child mortality estimates. 17 14 31 29 59 13 11 24 17 41 22 16 38 7 45 Neonatal mortality rate Post-neonatal mortality rate Infant mortality rate Child mortality rate Under-five mortality rate Years preceding the survey Note: Indicator values are per 1,000 live births Whiskers represent confidence intervals ( standard error  2) 10-14 5-9 0-4 Sao Tome and Principe 2014 MICS, Final Report P a g e | 22 Table CM.2:11Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, Infant, child and under-five mortality rates for the ten year period preceding the survey, by socioeconomic characteristics, Sao Tome and Principe, 2014 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total 18 14 32 12 43 Region Centre East 15 14 30 11 41 North West 29 13 42 14 56 South East 10 15 25 11 36 Autonomous of Principe (25) 6 31 4 35 Area Urban 17 15 32 10 42 Rural 19 11 30 15 44 Mother's education None/Primary 16 15 31 15 45 Secondary/Higher 23 11 33 3 37 Wealth index quintile 60 percent poorest 18 16 35 15 50 40 percent richest 17 9 26 4 30 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates ( ) Figures that are based on 250-499 unweighted exposed persons Sao Tome and Principe 2014 MICS, Final Report P a g e | 23 Table CM.3:12Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, Infant, child and under-five mortality rates for the ten year period preceding the survey, by demographic characteristics, Sao Tome and Principe, 2014 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total 18 14 32 12 43 Sex of child Male 23 13 36 14 50 Female 12 14 27 9 35 Mother's age at birth Less than 20 10 20 30 11 41 20-34 14 9 23 11 34 35-49 47 30 77 13 89 Birth order 1 12 14 26 8 34 2-3 15 12 27 5 32 4+ 26 16 42 24 64 Previous birth intervalb < 2 years 20 19 39 17 55 2 years 25 15 40 10 50 3 years 6 8 14 6 19 4+ years 17 10 28 8 35 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates b Excludes first order births Tables CM.2 and CM.3 provide estimates of child mortality by socioeconomic and demographic characteristics. In order to improve the stability and precision of the estimates, these two tables have been produced for a 10-year period preceding the survey. Even so, as can be seen in Figure CM.2 which provides a graphical presentation of some of the results, the confidence intervals of these estimates are still relatively wide and interpretation of differences between point estimates should be cautious. Many of the differences seen in these tables are in the expected direction. Under-five mortality estimates are higher:  for males (50) than for females (35) (not statistically significant)  for children from mothers age 35-49 years (89) than 20-34 years (34) (statistically significant)  for children from mothers with no more than primary education (45) than secondary or higher education (37) (not statistically significant)  for birth intervals of less than 2 years (55) than of 3 years (19) (statistically significant)  for children of a high birth order (64) than for second or third children (32) (statistically significant). Sao Tome and Principe 2014 MICS, Final Report P a g e | 24 Figure CM.2: Under -5 mortal i t y rates by area and regions , 10 year per iod preceding the survey, Sao Tome and Pr inc ipe , 2014 Figure CM.3 compares the national under-five mortality rates presented above with those from other data sources: the 2000 MICS, the 2006 MICS and the 2008-2009 DHS for Sao Tome and Principe. The results from the three most recent surveys are in broad agreement in terms of trend, although the 2008-2009 DHS results are considerably higher than those of the 2006 and 2014 MICS for the same years. Overall, these results show a smooth declining trend over the last 15 to 20 years with a tendency to stabilize in most recent years. Further qualification of these apparent declines and differences as well as its determinants should be taken up in a separate, more detailed, analysis. 43 41 56 36 35 42 44 0 20 40 60 80 100 Sao Tome and Principe Region Region Centre East Region North West Region South East Autonomous Region of Principe Area Urban Rural Under-5 Mortality Rates per 1,000 Births Note: Indicator values are per 1,000 live births Whiskers represent confidence intervals (± standard error  2) Sao Tome and Principe 2014 MICS, Final Report P a g e | 25 F igure CM.3: 3 Tr end in under -5 mortal i ty rates Sao Tome and Pr inc ipe , 2014 0 20 40 60 80 100 120 140 160 1986 1990 1994 1998 2002 2006 2010 2014 Per 1,000 live births Year MICS 2000 MICS 2006 DHS 2008-2009 MICS 2014 Sao Tome and Principe 2014 MICS, Final Report 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 the newborn'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 intellectual quotient (IQ) and cognitive disabilities, affecting their performance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother's poor health and nutrition. Three factors have 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 the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run 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 developing world 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.i i For a detailed description of the methodology, see Boerma, JT et al. 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization 74(2): 209-16. Sao Tome and Principe 2014 MICS, Final Report P a g e | 27 Table NU.1:13Low 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, Sao Tome and Principe, 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 Total 3.4 8.9 70.1 16.5 1.1 100.0 8.4 94.0 756 Mother's age at birth Less than 20 years 5.0 18.7 64.1 11.8 0.5 100.0 12.5 97.6 120 20-34 years 2.2 7.0 73.1 16.8 0.9 100.0 7.2 93.9 519 35-49 years 7.1 7.2 63.0 20.2 2.6 100.0 9.6 90.7 116 Birth order 1 2.2 15.9 66.7 14.9 0.3 100.0 10.2 99.0 171 2-3 3.3 5.2 75.2 15.1 1.2 100.0 7.2 93.3 328 4-5 2.9 9.6 67.4 19.1 0.9 100.0 8.4 93.8 175 6+ 7.2 7.4 63.0 20.3 2.2 100.0 9.8 86.6 82 Region Centre East 3.2 8.8 67.9 19.5 0.6 100.0 8.3 95.9 514 North West 2.3 7.8 81.5 7.7 0.6 100.0 7.8 91.3 131 South East 5.6 12.5 65.2 11.8 4.9 100.0 10.8 84.7 86 Aut. of Principe (4.8) (3.2) (74.1) (17.9) (0.0) 100.0 (7.2) (100.0) 25 Area Urban 3.7 8.6 67.8 19.3 0.6 100.0 8.4 94.9 496 Rural 2.8 9.4 74.6 11.2 2.0 100.0 8.5 92.2 260 Mother’s education None/Primary 4.2 9.1 72.6 12.6 1.4 100.0 9.0 91.6 468 Secondary/Higher 2.0 8.5 66.1 22.9 0.5 100.0 7.5 97.9 288 Wealth index quintile Poorest 6.2 14.0 67.8 11.6 0.4 100.0 11.6 87.7 161 Second 1.2 7.4 73.2 15.0 3.4 100.0 6.9 93.0 158 Middle 3.7 9.3 73.9 12.0 1.1 100.0 8.8 93.9 149 Fourth 1.5 5.9 73.7 18.6 0.3 100.0 6.5 96.6 161 Richest 4.5 7.7 60.3 27.5 0.0 100.0 8.4 100.0 126 1 MICS indicator 2.20 - Low-birthweight infants 2 MICS indicator 2.21 - Infants weighed at birth ( ) Figures that are based on 25-49 unweighted cases Overall, 94 percent of newborns were weighed at birth and approximately 8 percent of infants are estimated to weigh less than 2,500 grams at birth (Table NU.1). There is no evidence of meaningful differences in the prevalence of low birth weight by, region, urban and rural areas or by mother’s education. Sao Tome and Principe 2014 MICS, Final Report 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. Undernutrition 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 Millennium Development Goal 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 standardsi. 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 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 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 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. i http://www.who.int/childgrowth/standards/technical_report Sao Tome and Principe 2014 MICS, Final Report P a g e | 29 Table NU.2:14Nutritional 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, Sao Tome and Principe, 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 SD 3 - 3 SD4 - 2 SD 5 - 3 SD6 + 2 SD 7 Total 8.8 1.8 -0.6 1,938 17.2 4.5 -0.9 1,929 4.0 0.8 2.4 -0.1 1,935 Sex Male 10.6 2.7 -0.6 963 20.5 6.1 -1.0 960 4.7 0.7 2.6 -0.1 962 Female 6.9 1.0 -0.5 976 13.9 3.0 -0.8 969 3.3 0.8 2.2 -0.1 973 Region Centre East 8.4 1.5 -0.5 1,245 15.6 3.4 -0.8 1,238 3.9 0.7 2.5 -0.1 1,242 North West 9.6 2.0 -0.6 380 20.0 7.0 -1.1 379 4.0 1.0 2.4 0.0 379 South East 9.7 2.8 -0.7 232 23.3 6.3 -1.2 232 5.4 1.0 2.4 -0.1 233 Aut. of Principe 7.5 2.7 -0.6 81 10.5 4.9 -0.8 80 1.2 0.0 0.9 -0.3 81 Area Urban 8.3 1.7 -0.6 1,269 16.3 4.1 -0.9 1,267 4.1 0.7 2.8 -0.1 1,270 Rural 9.6 2.0 -0.6 669 18.9 5.3 -1.0 662 3.9 0.9 1.7 -0.1 665 Age 0-5 months 7.5 1.2 -0.1 163 13.8 2.2 -0.2 161 6.0 2.4 4.9 0.1 165 6-11 months 13.1 2.6 -0.6 168 13.8 1.5 -0.5 167 11.4 0.6 3.0 -0.4 169 12-17 months 14.5 2.8 -0.7 214 14.6 3.4 -0.9 213 5.3 1.9 2.5 -0.4 213 18-23 months 12.7 3.5 -0.6 170 24.2 11.3 -1.2 168 5.0 0.5 1.7 -0.1 168 24-35 months 8.9 1.9 -0.7 400 24.7 7.6 -1.3 396 1.6 0.4 3.1 0.0 396 36-47 months 6.8 1.0 -0.5 411 15.9 4.5 -0.9 411 2.4 0.0 2.0 0.1 411 48-59 months 4.8 1.2 -0.6 413 12.3 1.6 -0.8 413 3.0 0.9 1.2 -0.2 413 Mother’s education None 7.8 1.8 -0.7 83 18.1 2.0 -1.0 83 5.5 1.0 3.5 -0.2 83 Primary 9.7 1.9 -0.7 1,191 19.5 5.3 -1.0 1,184 4.1 0.8 1.6 -0.1 1,186 Secondary/Higher 7.2 1.6 -0.4 664 12.9 3.5 -0.7 662 3.6 0.7 3.7 -0.1 666 Wealth index quintile Poorest 12.6 2.7 -0.9 429 25.5 7.0 -1.3 428 5.8 1.5 1.9 -0.2 429 Second 9.4 1.5 -0.7 405 20.2 4.0 -1.1 404 3.0 0.6 1.8 -0.1 405 Middle 7.5 2.1 -0.5 397 18.3 6.8 -0.9 392 2.3 0.7 2.5 0.0 392 Fourth 5.9 1.1 -0.4 403 12.0 2.0 -0.7 401 4.1 0.4 3.4 0.0 403 Richest 8.0 1.5 -0.4 304 6.8 2.1 -0.4 303 4.9 0.6 2.4 -0.2 305 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 Sao Tome and Principe 2014 MICS, Final Report P a g e | 30 In MICS, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommendedi 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, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes mean z-scores for all three anthropometric indicators. Children whose measurements are 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.12, DQ.13, and DQ.14 in Appendix D. The tables show that due to implausible measurements, and/or missing weight and/or height, 4 percent of children have been excluded from calculations of the weight-for-age, height-for-age and weight-for-height indicators. Further, Table DQ.15 shows that measurers had a tendency in some cases to round height measurements to the nearest centimetre (decimal 0) or half centimetre (decimal 5), but the extent to which this took place is unlikely to have had much impact on the quality of the results. We already referred in Chapter 3 to the issue of out-transference and the likely under-recording of young children which may affect to some extent the representativity of the anthropometric results. Table NU.2 shows that 9 percent of children under age five in Sao Tome and Principe are underweight (2 percent are severely so), while 17 percent are stunted or too short for their age (5 percent are severely so). In addition, 4 percent are moderately or severely wasted or too thin for their height. A small proportion (2 percent) of children are overweight or too heavy for their height. There are no meaningful differences between urban and rural areas, nor between various levels of education of the mother, except in the case of stunting where children of mothers having secondary or higher education tend to be less affected (13 percent) than those whose mothers have primary or no formal education (20 and 18 percent respectively). Regions are also fairly similar with respect to these four indicators, except once again for stunting where the differences are larger, ranging from 11 percent in Region Autónoma de Principe to 23 percent in Region South East. Boys tend to suffer more from underweight and stunting (11 and 21 percent respectively) than girls (7 and 14 percent respectively). However, the widest differences are seen between wealth categories in relation to stunting which ranges from 7 percent among the wealthiest to 26 percent amongst the poorest. The age pattern shows increasing levels of underweight becoming evident during the second half of the first year of life and then increasing levels of stunting manifesting themselves around 18 months of age. The same trends are visible in Figure NU.1. In addition, as will be seen later in Figure NU.3, for many infants complementary foods are initiated well before the recommended age of 6 months, and the proportion of weaned children increases rapidly after the age of 12 months. While it is not possible to demonstrate relationships of causality in such a study, it nonetheless seems plausible i See MICS Supply Procurement Instructions: http://www.mics.unicef.org/mics5_planning.html Sao Tome and Principe 2014 MICS, Final Report P a g e | 31 that the increasing proportions of undernourished children at the two periods indicated above are at least partly related to those two sets of events: the premature initiation of complementary feeding, followed by weaning at a later stage. As children cease to be breastfeed, they tend to be exposed to contamination in water, food, and environment which can lead to undernutrition. F igure NU.1: 4 Under weight , s tunted, wasted and overweight ch i ldren under age 5 (moderat e and sever e) Sao Tome and Pr inc ipe , 2014 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.i i 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. Underweight Stunted Wasted Overweight 0 5 10 15 20 25 30 0 12 24 36 48 60 P e r ce n t Age in months Sao Tome and Principe 2014 MICS, Final Report P a g e | 32 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.i Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods.ii A summary of key guiding principlesiii, iv for feeding 6-23 month olds is provided in the table below along with proximate measures for these guidelines collected in this survey. 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).v 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). i WHO. 2003. Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February, 2003. ii WHO. 2003. Global Strategy for Infant and Young Child Feeding. iii PAHO. 2003. Guiding principles for complementary feeding of the breastfed child. iv WHO. 2005. Guiding principles for feeding non-breastfed children 6-24 months of age. v WHO. 2008. Indicators for assessing infant and young child feeding practices. Part 1: Definitions. Sao Tome and Principe 2014 MICS, Final Report P a g e | 33 Guiding Principle (age 6-23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 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 groupsi eaten in the last 24 hours NU.6 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 na 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 NU.9 Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists na i 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. Sao Tome and Principe 2014 MICS, Final Report P a g e | 34 Table NU.3:15Initial 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, Sao Tome and Principe, 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 Total 97.4 38.3 85.7 7.7 756 Region Centre East 97.8 35.3 85.1 7.4 514 North West 97.3 64.1 87.9 7.4 131 South East 97.1 10.4 84.7 12.4 86 Aut. of Principe (91.8) (58.6) (89.3) (0.0) 25 Area Urban 97.3 35.3 85.2 7.9 496 Rural 97.6 43.8 86.5 7.4 260 Months since last birth 0-11 months 97.3 39.1 83.9 6.6 351 12-23 months 97.5 37.1 87.0 8.9 375 Assistance at delivery Skilled attendant 98.0 38.0 86.6 6.5 699 Traditional birth attendant (94.5) (41.7) (75.9) (26.0) 35 Other/DK/Missing (83.6) (42.3) (70.9) (16.5) 22 Place of delivery Home 96.8 50.1 80.1 21.1 60 Health facilitya 98.0 37.5 86.5 6.7 687 Other/DK/Missing (*) (*) (*) (*) 8 Mother’s education None/Primary 97.0 39.7 84.6 7.1 468 Secondary/Higher 98.2 35.8 87.4 8.8 288 Wealth index quintile Poorest 100.0 48.4 87.6 7.6 161 Second 96.9 35.6 83.8 8.7 158 Middle 97.3 38.7 87.1 5.7 149 Fourth 95.6 36.3 84.0 6.1 161 Richest 97.3 30.7 85.9 11.2 126 1 MICS indicator 2.5 - Children ever breastfed 2 MICS indicator 2.6 - Early initiation of breastfeeding a Since only 1 case was from a private health facility, all health facilities have been merged into one single category ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Table NU.3 is based on mothers’ reports 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.i Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 38 percent of babies are breastfed for the first time within one hour of birth, while 86 percent of newborns in Sao Tome and Principe i 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). Sao Tome and Principe 2014 MICS, Final Report P a g e | 35 start breastfeeding within one day of birth. The findings are presented in Figure NU.2 by region and area. Initiation of breastfeeding within one hour varies widely between regions, from 10 percent in Region South East to 64 percent in Region North West; it is higher among the poorest (48 percent) than the wealthiest (31 percent), among those giving birth at home (50 percent) than in a health facility (38 percent), and among rural dwellers (44 percent) than urban dwellers (35 percent). On the other hand, initiation with one day is nearly uniform throughout the country and the various groups. About 8 percent of newborns receive a prelacteal feed; the practice appears to be more prevalent when the delivery occurs at home than in a health facility. Various fluids may be given to the newborn during the first three days, the most frequents being simple water, water mixed with sugar, water mixed with sugar and salt, herbal infusions, and the like (data not shown). F igure NU. 2: 5 In i t iat ion of breastfeeding Sao Tome and Pr inc ipe , 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 being interviewed. 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 infants 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 85 88 85 89 85 86 86 35 64 10 59 35 44 38 0 20 40 60 80 100 P er c en t Within one day Within one hour Sao Tome and Principe 2014 MICS, Final Report P a g e | 36 and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. Table NU.4:16Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Sao Tome and Principe, 2014 Children age 0-5 months Children age 12-15 months Children age 20-23 months Percent exclusivel y breastfed1 Percent predominantl y breastfed2 Numbe r of children Percent breastfed (Continued breastfeedin g at 1 year)3 Numbe r of children Percent breastfed (Continued breastfeedin g at 2 years)4 Numbe r of children Total 73.8 85.1 178 85.9 139 24.1 124 Sex Male 77.6 87.6 90 84.3 64 17.9 57 Female 70.1 82.6 89 87.2 75 29.3 67 Region Centre East 73.4 84.3 128 82.6 90 21.4 77 North West (69.1) (85.9) 29 (89.9) 31 (22.5) 20 South East (82.2) (90.4) 14 (96.3) 15 (35.7) 23 Aut. of Principe (*) (*) 6 (*) 3 (*) 4 Area Urban 76.3 88.8 112 85.1 98 27.8 83 Rural 69.7 78.9 66 (87.7) 41 (16.4) 41 Mother’s education None/Primary 72.6 86.9 99 86.3 96 25.4 78 Second./Highe r 75.3 82.8 79 (84.8) 44 (21.7) 46 Wealth index quintile 60% poorest 71.2 83.2 119 94.9 82 22.9 73 40% richest 79.2 89.0 59 72.8 57 (25.8) 51 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 ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Some caution is required when interpreting the results of Table NU.4 due to the generally small sample sizes. For this reason, we will focus only on the overall results. In Sao Tome and Principe, approximately three-quarters (74 percent) of children age less than six months are exclusively breastfed, while 85 percent are predominantly breastfed. At age 12-15 months, 86 percent of children are still being breastfed, which is remarkable, but breastfeeding drops drastically from that point to a mere 24 percent by age 20-23 months. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. One of the most salient features is the early initiation of complementary feeding, as commented earlier. At age 4-5 months, only about half of the children are exclusively breastfed and nearly 20 percent are already receiving complementary foods, while recommendations are for children to be exclusively breastfed until they reach 6 months of age. Sao Tome and Principe 2014 MICS, Final Report P a g e | 37 Figure NU.3: 6 Infant feeding patterns by age Sao To me and Pr inc ipe , 2014 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3, the median duration is 17.0 months for any breastfeeding, 4.8 months for exclusive breastfeeding, and 5.7 months for predominant breastfeeding. Variations between the various background characteristics are generally small, but worthy of note is the gradual shortening of the duration of any breastfeeding from the poorest quintile (18.1 months) to the wealthiest (14.7 months). 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) Sao Tome and Principe 2014 MICS, Final Report P a g e | 38 Table NU.5:17Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Sao Tome and Principe, 2014 Median duration (in months) of: Number of children age 0-35 months Any breastfeeding1 Exclusive breastfeeding Predominant breastfeeding Median 17.0 4.8 5.7 1,166 Sex Male 16.5 5.0 6.0 588 Female 17.7 4.6 5.4 578 Region Centre East 16.2 4.9 5.8 762 North West 18.0 4.1 5.3 222 South East 19.2 5.0 5.9 135 Autonomous of Principe 17.9 5.0 5.7 47 Area Urban 17.0 4.7 5.6 765 Rural 17.0 4.8 5.9 401 Mother’s education None/Primary 17.4 4.2 5.5 736 Secondary/Higher 16.4 5.5 6.1 430 Wealth index quintile Poorest 18.1 4.3 5.1 258 Second 18.6 4.8 6.8 245 Middle 16.4 4.8 5.6 227 Fourth 16.9 4.9 5.9 236 Richest 14.7 5.0 5.0 201 Mean 17.6 4.6 5.9 1,166 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 59 percent of children age 6-23 months are being appropriately breastfed. Age-appropriate breastfeeding among all children age 0-23 months is of 62 percent, with a declining trend from the poorest quintile (71 percent) to the richest (58 percent). Region Centre East, the most populous, is at the lowest end of the 59 to 70 percent range between the regions. Sao Tome and Principe 2014 MICS, Final Report P a g e | 39 Table NU.6:18Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Sao Tome and Principe, 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 Total 73.8 178 58.8 576 62.3 754 Sex Male 77.6 90 55.7 277 61.1 366 Female 70.1 89 61.6 299 63.5 388 Region Centre East 73.4 128 54.6 383 59.3 512 North West (69.1) 29 67.9 105 68.2 134 South East (82.2) 14 67.9 67 70.4 82 Aut. of Principe (*) 6 (58.8) 21 (65.2) 27 Area Urban 76.3 112 59.5 385 63.2 497 Rural 69.7 66 57.3 191 60.5 257 Mother’s education None/Primary 72.6 99 61.6 375 63.9 473 Secondary/Higher 75.3 79 53.4 201 59.6 281 Wealth index quintile Poorest (73.1) 34 69.8 132 70.5 166 Second (66.3) 38 58.8 118 60.6 156 Middle (73.7) 47 54.9 95 61.2 142 Fourth (80.0) 38 53.8 119 60.1 156 Richest (*) 22 54.1 112 58.0 134 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.12 - Age-appropriate breastfeeding ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases Overall, 74 percent of infants age 6-8 months received solid, semi-solid, or soft foods at least once during the previous day (Table NU.7). Since only a very small proportion of children of this age group in Sao Tome and Principe are not breastfeeding, it is not meaningful in this case to present these results separately for breastfeeding and not breastfeeding children. Table NU.7:19Introduction 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, Sao Tome and Principe All Percent receiving solid, semi- solid or soft foods1 Number of children age 6- 8 months Total 74.1 81 Area Urban 74.6 55 Rural (73.1) 26 1 MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods ( ) Figures that are based on 25-49 unweighted cases Sao Tome and Principe 2014 MICS, Final Report P a g e | 40 As seen in Table NU.8, 58 percent of the children age 6-23 months are receiving solid, semi-solid and soft foods the minimum number of times. Children from wealthiest households are more likely to have the required number of daily meals than those from poorest households (67 and 53 percent respectively). The proportion of children receiving the minimum dietary diversity, or foods from at least 4 food groups, is 47 percent, somewhat lower than that for minimum meal frequency, indicating the need to focus on improving diet quality and nutrient intake among this vulnerable group. The proportion of children with minimum dietary diversity improves with age, passing from 17 percent in the 6-8 month old to 60 percent in the 18-23 month old; a similar trend is found among children from the poorest (38 percent) to the wealthiest (54 percent) households. The overall assessment using the indicator of minimum acceptable diet reveals that only 22 percent are benefitting from a diet sufficient in both diversity and frequency. While the tables provide information for both breastfeeding and not breastfeeding children, the sample size in the latter group is rather small and should lead to cautious interpretation. Statistics for all children are based on a larger sample and have thus a better precision. Sao Tome and Principe 2014 MICS, Final Report P a g e | 41 Table NU.8:20Infant and young child feeding (IYCF) practices by sex, age and area 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, Sao Tome and Principe, 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 diversi- ty4, a Minimum meal frequen- cy5, b Minimum accepta- ble dietc Total 40.4 60.6 28.5 372 60.7 53.5 10.9 26.4 195 46.8 58.2 22.5 576 Sex Male 40.1 55.8 25.8 174 55.3 54.5 10.8 24.2 98 44.9 55.3 20.4 277 Female 40.6 64.9 30.8 198 66.1 52.5 11.0 28.6 97 48.6 60.8 24.3 299 Age 6-8 months 18.2 54.1 12.8 74 (*) (*) (*) (*) 6 16.8 51.2 11.9 81 9-11 months 41.0 59.2 29.6 89 (*) (*) (*) (*) 2 42.5 60.3 28.9 92 12-17 months 46.2 65.3 32.2 157 (58.9) (59.9) (9.8) (31.3) 63 49.3 63.7 25.7 223 18-23 months 53.9 58.4 38.1 50 63.9 51.2 12.3 22.7 123 59.5 53.3 19.8 180 Area Urban 41.2 61.1 29.1 251 63.6 58.2 9.4 28.2 125 47.9 60.1 22.5 385 Rural 38.7 59.7 27.2 121 55.4 45.2 13.8 23.1 70 44.7 54.4 22.3 191 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 ( ) Figures that are based on 25-49 unweighted cases (*) Figures that are based on fewer than 25 unweighted cases 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. 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. Sao Tome and Principe 2014 MICS, Final Report P a g e | 42 Table NU.8 (second part):21Infant and young child feeding (IYCF) practices, by region, mother’s education and wealth index quintile 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, Sao Tome and Principe, 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 6-2

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