African Medical and Research Foundation (AMREF)

HEALTH AND HEALTH RELATED ISSUES IN FOUR WOREDAS IN SOUTH OMO, SNNPR,

ETHIOPIA: FINDINGS OF A BASELINE SURVEY, 2008

Conducted

Birhan Research and Development Consultancy (BRDC)

PHYSICAL LOCATION

KIRKOS SUBCITY, KEBELE 07, HOUSE NO. 227B ETHIOPIAN EVANGELICAL CHURCH MEKANE YESUS BUILDING 6TH FLOOR, GUINEA CONAKRY ST.

Telephone 251-1-53-84-95 OR 95 Mobile 251-91-122-96-21 Fax: 251-1-53-84-95 P. O. Box 20653 Code 1000 Addis Ababa, Ethiopia

February 2007 Addis Ababa

1 Table of Contents

LIST OF TABLES 5 LIST OF FIGURES 7 CHAPTER I ...... 8 INTRODUCTION ...... 8 1.1 BACKGROUND 8 1.2 Objectives 9 1.3 Research design 10 Methodology 10 Study Population ...... 10 Quantitative Approach ...... 10 Sampling 10 Sample Size Determination ...... 10 Sampling Frame ¡Error! Marcador no definido. Qualitative Approach...... 11 Key Informant Interviews ...... ¡Error! Marcador no definido. Focus Group Discussions ...... ¡Error! Marcador no definido. Protocol Visits ¡Error! Marcador no definido. Study Instruments ...... 12 1.4 Recruiting and Training of Field Staff 13 1.5 Field Data Collection 15 1.6 Data Management 15 Key Informant Interviews 15 Individual household questionnaire 15 Focus Groups Discussion 16 1.7 Data Analysis 16 1.8. Organization of the Report 16 Part I- Benna Tsemay and Selamago Project Woredas 17 CHAPTER II ...... 18 BACKGROUND CHARACTERISTICS OF THE STUDY POPULATION ..... 18 2.1 Socioeconomic Background 18 2.2 Demographic Background 13 CHAPTER III...... 34 HOUSEHOLD WATER SOURCES, PERSONAL HEALTH AND SANITATION ...... 32 3.1 Water Sources 32 3.2 Health and Sanitation 36 3.3 Personal Hygiene 38 CHAPTER IV ...... 41 MALARIA ...... 41

4.1 Major health problem in the study area 41 4.2 Symptoms Of Malaria 42 4.3 Knowledge Of Means Of Getting Malaria 43 4.4 Knowledge of Preventing Malaria 44 4.5 Malaria related sickness 45 4.6 Knowledge And Use Of Mosquito Net 47 CHAPTER V ...... 50 KNOWLEDGE, ATTITUDE AND BEHAVIOR (KAB) OF HIV/AIDS ...... 50 5.1 Knowledge of STIs 50 5.2 Knowledge and source of information about HIV/AIDS 51 5.3 Voluntary Counseling and Testing (VCT) 57 5.4 Risk Perception 60 5.5 Action Taken To Prevent Getting HIV/AIDS 61 5.7 Knowledge of PMTCT 62 5.8 Knowledge of ART 63 5.9 Extramarital Sex 63 5.10 Age At Fist Sexual Debut 64 CHAPTER VI ...... 65 REPRODUCTIVE HEALTH ...... 65 6.1 Pregnancy and childbearing 65 6.1.2 Fertility 66 6.1.3 Age at first birth 69 6.1.4 Desire For More Children 69 6.2 Family Planning 71 6.2.1 Knowledge of FP 72 6.2.2 Ever Use Of Family Planning 74 6.2.3 Current Use Of Family Planning 75 6.2.4 Reason For Not Using Family Planning 76 6.3 Use of Antenatal and postnatal care 77 6.3.1 Facility based delivery 77 6.3.2 Use Of Postnatal Care 78 CHAPTER 7 80 HARMFUL TRADITIONAL PRACTICES 78 7.1 Major Harmful Traditional Practices 80 7.2 Experience of Harmful Traditional Practices 83 7.3 Support For the Discontinuation Of HTPs 83 7.4 Knowledge and experience About Fistula 84 CHAPTER 8 ...... 87 GENDER ISSUES ...... 87 8.1 Decision making 87 8.2 Wife Beating 89 CHAPTER 9 ...... 90 CHILD HEALTH ...... 90 9.1 Knowledge of and Source Of information about Vaccination 90 9.2 Last Child Vaccinated 91

9.3 Reason For Not Vaccinating Last Child 91 9.4 Child Morbidity 92 CHAPTER 10...... 94 TUBERCULOSIS ...... 94 10.1 Knowledge about TB 94 10.2 Presence of TB patient in household 95 CHAPTER XI 98 SUMMARY, CONCLUSION AND RECOMMENDATION 98 11.1 SUMMARY 98 11.2 Conclusion 103 11.3 Recommendation 107

Part II- Malle and South Ari Project Woredas------109

CHAPTER II ...... 111 BACKGROUND CHARACTERISTICS OF THE STUDY POPULATION ...... 111 2.1 Socioeconomic Background 111 2.2 Demographic Background 116 CHAPTER III ...... 126 HOUSEHOLD WATER SOURCES, PERSONAL HEALTH AND SANITATION ...... 126 3.1 Water Sources 126 3.2 Health and Sanitation 128 3.3 Personal Hygiene 130 CHAPTER IV ...... 133 MALARIA ...... 133 4.1 Major health problem in the study area 133 4.2 Symptoms Of Malaria 133 4.3 Knowledge Of Means Of Getting Malaria 134 4.4 Knowledge of Preventing Malaria 135 4.5 Malaria related sickness 136 4.6 Knowledge And Use Of Mosquito Net 139 CHAPTER V ...... 142 KNOWLEDGE, ATTITUDE AND BEHAVIOR (KAB) OF HIV/AIDS ...... 142 5.1 Knowledge of STIs 142 5.2 Knowledge and source of information about HIV/AIDS 143 5.3 Voluntary Counseling and Testing (VCT) 148 5.4 Risk Perception 151 5.5 Action Taken To Prevent Getting HIV/AIDS 152 5.7 Knowledge of PMTCT 153 5.8 Knowledge of ART 154 5.9 Extramarital Sex 154 5.10 Age At Fist Sexual Debut 155 CHAPTER VI ...... 157

REPRODUCTIVE HEALTH ...... 157 6.1 Pregnancy and childbearing 157 6.2.1 Fertility 158 6.1.3 Age at first birth 161 6.1.4 Desire For More Children 161 6.2 Family Planning 69 6.2.1 Knowledge of FP 70 6.2.2 Ever Use Of Family Planning 72 6.2.3 Current Use Of Family Planning 166 6.2.4 Reason For Not Using Family Planning 74 6.3 Use of Antenatal and postnatal care 75 6.3.2 Facility based delivery 76 6.3.4 Use Of Postnatal Care 77 CHAPTER 7 78 HARMFUL TRADITIONAL PRACTICES 78 7.1 Major Harmful Traditional Practices 78 7.2 Experience of Harmful Traditional Practices 81 7.3 Support For the Discontinuation Of HTPs 82 7.4 Knowledge and experience About Fistula 82 CHAPTER 8 ...... 85 GENDER ISSUES ...... 85 8.1 Decision making 85 8.2 Wife Beating 87 CHAPTER 9 ...... 88 CHILD HEALTH ...... 88 9.1 Knowledge of and Source Of information about Vaccination 88 9.2 Last Child Vaccinated 89 9.3 Reason For Not Vaccinating Last Child 89 9.4 Child Morbidity 90 CHAPTER 10 ...... 92 TUBERCULOSIS ...... 92 10.1 Knowledge about TB 92 10.2 Presence of TB patient in household 93 CHAPTER XI 95 SUMMARY, CONCLUSION AND RECOMMENDATION 96 11.1 SUMMARY 96 11.2 Conclusion 103 11.3 Recommendation 105

LIST OF TABLES

Table 2.1.1 Religion and Ethnicity composition: Percent distribution of women by religion, ethnicity …………………………………………………………………………………………...19 Table 2.1.2 Work Status of Women and husband: Percent distribution of women by type of work/occupation, Husbands’ occupation……………………………………………………….….20 Table 2.1.3 Educational Status of women: Percentage of women by educational status ….... 21 Table 2.1.4 Women exposure to mass media: Percentage of women who have access to radio media………………………………………………………………………………………..……..22 Table 2.2.1 Women by Age distribution: Percent distribution of Women by age group……………………………………………………………………………………………….24 Table 2.2.2 Marital Status of Women: Percent distribution of women by marital status…………………………………………………………………………………………...…..27 Table 2.2.3 Household composition: Percent distribution of women by household composition…………………………………………………………………………………...…....28 Table 2.2.4 Mortality differentials: Percent distribution of women by mortality differentials and residence……………………………………………………………………………………...……30 Table 3 Sources of drinking water: Percent distribution of women by source of drinking water, time to fetch water, water ……………………………………………………………….…………35 Table 4.1A Availability of toilet: Percent distribution of women according to availability of and type of toilet/ latrine ……………………………………………………………………………….37 Table 4.1B Use and non-use of toilet: Percent distribution of women according to use and reason for not using toilet/ latrine …………………………………………………………………….…. 37 Table 4.3: Personal sanitation: Percent of women practicing personal sanitation ………………………………………………………………………………………………….….38 Table 4.4 Community’s health problem: Percent distribution of women who have knowledge on community’s health problem, by residence ………………………………………………..……. 39 Table 4.5 Symptoms of Malaria: percent distribution of women by symptom of malaria and residence ………………………………………………………………………………………… 42 Table 4.6 Knowledge of acquiring malaria: Percent distribution of women according to knowledge of acquiring malaria, by residence ……………………………………………..……. 42 Table 4.7 Knowledge of preventing Malaria: Percentage of women who have knowledge about prevention of malaria, by residence ……………………………………………………………….43 Table 4.8 Malaria related disease: percent distribution of women according to malaria related sickness and residence …………………………………………………………………………….44 Table 4.9 Knowledge and use of mosquito net: Percentage of women who have knowledge about the use of mosquito net, by residence ………………………………………………………….….46 Table 5.1 Knowledge and infection of STIs: Percent distribution of women by STIs knowledge and residence ……………………………………………………………………………………. 48 Table 5.2 HIV AIDS knowledge and source of information: Percent distribution of women by knowledge of HIV/AIDS, sources of information, means HIV/AIDS prevention and transmission ……………………………………………………………………………………………….….….51 Table 5.3 Knowledge of VCT: Percent distribution of women who have perception about the use of testing HIV/AIDS by residence …………………………………………………………..…….56 Table 5.4 HIV/AIDS risk perception: Percent distribution of women who have perception about the risk of HIV/AIDS, by residence …………………………………………………………..…. 58

Table 5.5 Type of Action to prevent HIV/AIDS: percentage of women who have taken action to prevent HIV/AIDS, by residence …………………………………………………………..…….61 Table 5.6 Knowledge of PMTCT: percentage of women who have knowledge on PMTCT, by residence ………………………………………………………………………………………….62 Table 5.7 Knowledge of ART: Percentage of women who have knowledge on ART, by residence …………………………………………………………………………………………………….62 Table 5.8 Extramarital sex: percentage of women who had sex before marriage, by residence ………………………………………………………………………………….……………….…63 Table 5.9: Age at sexual debut: Percent distribution of women by age at first sexual practice and residence ……………………………………………………………………………………..…...64 Table 6.1 Pregnancy and childbearing Experience: Percentage of women according to pregnancy and childbearing experiences, by residence …………………………………………….………..65 Table 6.2 Fertility differentials by residence: Number of women, children ever born and died children by residence ………………………………………………………………….…..……....68 Table 6.3 Age of women at first birth: Percent distribution of women by age at first birth and residence ………………………………………………………………………………..………...69 Table 6.4 Women’s desire for additional children: Percent distribution of women who want additional children by when to have the next child and preferred sex of the next child …………………………………………………………………………………………...…………70 Table 6.5: knowledge of family planning: Percentage of women who have knowledge of family planning, by residence …………………………………………………………………………….74 Table 6.6: Ever use of family planning: percentage of women by ever use of family planning and residence ……………………………………………………………………………….………….75 Table 6.7: Reasons for not using family planning: percentage of women who provide reasons for not using family planning, residence ……………………………………………………………...77 Table 6.8: Antenatal Care Services: percentage of women by use of Antenatal care and residence ……………………………………………………………………………………..…. 78 Table 6.9: Facility based delivery: percentage of women by type of facility based delivery and residence …………………………………………………………………………………...…..….79 Table 6.10: Use of postnatal care: percentage of women by use of postnatal care and residence ……………………………………………………………………………………………….……..79 Table 7.1: Major harm full traditional practices: percentage of women who reported major harmful traditional practices, by residence …………………………………………………………...…….80 Table 7.2: Experience of harmful traditional practices: percentage of women who practiced harmful traditional practices, by residence ………………………………………………….…….83 Table 7.3: Discontinuation of HTPs: percentage of women who want to discontinue harmful traditional practices and residence ……………………………………………………….….…….84 Table 7.4: Knowledge and experiences of fistula: percentage of women who have knowledge and experience of fistula, by residence ……………………………………………………………..….85 Table 8.1: Women in decision-making: percentage of women who have perception about decision making, by residence …………………………………………………………………………..….88 Table 8.2: Wife beating perceptions: percentage of women who believe about wife beating during conflict, by residence………………………………………………………………………….… 89 Table 9.1: Knowledge and source of information about vaccination: percent distribution of women who have knowledge and source of child vaccination …………………………………………….91

Table 9.2 Percentage of women with at least one Child who had vaccinated the last child ……………………………………………………………………………………………………...91 Table 9.3: Reasons not vaccinating last child: percentage of women who reported reasons for not vaccinating child, by residence………………………………………………………………….…92 Table 9.4 Child morbidity and treatment: percentage of women according to child morbidity and treatment, by residence……………………………………………………………………...……..93 Table 10.1 Knowledge about TB: percent distribution of women about TB knowledge, transmission, prevention and treatment, by residence……………………………………….…….95 Table 10.2 Presence of TB patients in the household: percent distribution of women by TB patients in the household and residence…………………………………………………...……….96

LIST OF FIGURES

Figure 1: Percent distribution of women by level of school grading………………………….....21 Figure 2: Median age of women by residence ……………………………………………….….24 Figure 3: Percentage of Women by age at first marriage ……………………………………….26 Figure 4A: Percent Distribution of women by mortality differentials …………………………..30 Figure 4B: Causes of Death by Woreda ………………………………………………………...31 Figure 5: Median time in hour to fetch water. …………………………………………………..35 Figure 6: Percent distribution of women by malaria patient age group …………………………46 Figure 7: Knowledge level of women by HIV/AIDS prevention methods ………………………... 55 Figure8: Trends in mean number of children ever borne, dead and sex ratio …………………..67 Figure 9: Mean Number of Children Ever born per woman by age and Woreda ………….……68 Figure 10: Percent distribution of women by knowledge of contraception method………….….73 Figure 11A: Current use of Contraceptives ……………………………………………………. 75 Figure.11B: Contraceptive methods used by Woreda …………………………………………..76 Figure 12: Percentage of women by level of vaccination knowledge …………………………..90 Figure 13: Percentage of women by types of childhood disease ……………………………….93

CHAPTER I

INTRODUCTION

1.1 BACKGROUND

South Omo Zone is one of the zones in SNNPR. It is bordered by Kenya on the south, the Bench Maji Zone on the West, Keficho Shekicho on the North West, North Omo on the North, Derashe and Konso special Woredas on the North East and by Oromia Region on the East . Jinka is the capital city and administrative Center of the Zone. It is relatively a large zone covering an area of about 22,361 square kilometers and inhabited by pastoralist and semi-pastoralist population. According to the CSA projection, its population in 2005 was 470,751. It is a very sparsely inhabited zone with an estimated population density of only 21 persons per square kilometer, which is one third of the the national average was (65 persons per square kilometer) in 2005 (CSA 2005). Its infrastructure is weak and for the most part non-existent; which is a disadvantage inherited from historical neglect of a typical marginal region.

The Zone is one of Ethiopia's socially most diverse zones containing as many as 21 ethnic groups. These are Arbore, Ari, Banna, Bashada, Bodi, Borena, Dassanech, Dime, Gawada, Hamar, Kara, Konso, Maale, Mago, Mogudji, Murssi, Nyangatom, Ongota, Tsamai, Suma and Woito (South Omo Research Center,.. Social diversity, therefore, compounds the existing problems of isolation, acute shortage of basic infrastructure as well as scarcity of professional and technical human resources. Only 4% of the inhabitants of South Omo have access to electricity and access to road is much lower than the national average. The zone has a road density of 22.7 kilometers per 1000 square kilometers (compared to the national average of 30 kilometers. Only 37% of all eligible children are enrolled in primary school, and 7% in secondary schools. 77% of the zone is exposed to malaria, and 61% to Tsetse fly (World Bank, 2004).

The African Medical & Research Foundation (AMREF) is one of the International NGOs working in the Zone. It works in community health development focusing on three thematic areas – community partnering, capacity building and health systems research for policy and practice. One of its project areas in Ethiopia is in South Omo. Recently, AMREF began implementing a health

8 program, which covers four Woredas, namely, Bena-Tsemay, Malle, Selamago and South Ari. In order to monitor progress and measure project impact, AMREF intends to conduct a baseline survey on health and health related issues in its project Woredas.

The purpose of this study was to generate cultural and socio-economic information to be used as baseline data for monitoring progress and measuring the impact of the project on the health and wellbeing of the population in the four project woredas.

1.2 Objectives

The objectives of the survey are to:

(i) Provide appropriate bench mark indicators on MCH, HIV/AIDS, HTP, gender issues, personal and environmental hygiene as well as health seeking behavior of the population in the project areas for program monitoring and evaluation (ii) Identify major causes of morbidity and mortality in the area (iii) Establish social causality of health and diseases (iv) Map local institutions and assess their capacity to mobilize resources and enhance service provision and utilization (v) Establish migratory pattern of pastoral communities

1.3 Research design

Methodology

The survey utilized both quantitative and qualitative research methods to collect primary data. Quantitative measures were obtained using structured questionnaires with a representative sample of the female population, while qualitative information was collected using focus group discussions and in-depth interviews using semi-structured questionnaires with female and male participants.

A Household Survey using structured interviews with a random sample of female respondents was used to collect quantitative individual and household level information, while Key Informant Interviews using semi-structured interviews with influential people, opinion leaders and religious

9 leaders, Focus Group Discussions involving men, women and male and female adolescents and In- depth Interviews were employed to gather qualitative information.

Study Population As the purpose of the survey was to provide baseline benchmark indicators on the MCH, HIV/AIDS, HTPs, gender roles as well as heath seeking behaviour and personal and environmental hygiene, the target population for the survey was the general population (male, female and adolescents). As the main purpose of the study was to generate health related information at the household level, it was believed that female respondents could provide the required information. Thus, females in the reproductive age group were interviewed using the structured questionnaire.

Quantitative Approach Sampling In any study, the primary concern is to include representative and adequate number of cases in order to perform a meaningful analysis. In this survey, the four project Woredas, namely, Bena Tsemay, Selamago, Malle and South Ari, were covered. All kebeles in each woreda were included and a representative sample of households from each Kebele taken.

Sample Size Determination Sample size is the pivotal feature that governs the overall design of the study. In this study, an appropriate sample size is the minimum number of women age 15-49 which will allow core indictors to be calculated with a reasonable level of precision. The factors and parameters that must be considered in determining sample size are many but they revolve primarily around the measurement objectives of the survey. They are key estimates desired, target populations, precision and confidence level wanted, estimation domains, whether measuring level or change, clustering effect, allowance for non-response and available budget.

The baseline survey is expected to yield a number of indicators that can help successful project monitoring and evaluation. The percentage of households with latrine for the household and percentage of persons washing hand with soap after defecation or before eating food can be taken as the core ones. For this survey, the proportion of households with latrine is used to determine the

10 sample size. There is no previous survey that measured the percentage of households with latrine. Hence, in the absence of any previous information, we assumed the proportion (p) to be 50%. Thus, the sample size was determined for each Woreda using 95% confidence interval, 5% margin of error and a p (magnitude of effect) value of 50%. In the following formula..

z 2 p(1 p)deff  n   / 2  2

Where n is the required minimum sample size, deff = the design effect (2 is commonly used), Zα/2 =1.96,  =0.05 and p=0.5.

Substituting the respective values into the above formula, a minimum sample of 768 households was obtained for each project site. The sample size was increased by 10% to take into account non- response (vacant households or refusal). Thus, the actual sample size used in the baseline survey was 845 households per project site. This is assumed to be large enough to attain a 95% confidence in estimating the expected changes in the indicators. The total sample was distributed to each of the kebeles using uniform allocation.

Regarding the selection of respondents, Kebeles and villages were selected randomly. Then certain households were randomly picked and the questionnaire was administered. No listing of households was made as this was found to be difficult and time consuming.

Qualitative Approach

The qualitative approach, as pointed out earlier, involved focus group discussions, key informant interviews and direct observations.

Most of the focus group discussions and key informants interviews were organized by AMREF staff by arranging and fixing the place, date and time. in advance. Both focus group discussions and key informants interviews were conducted with people who represent various demographic and socioeconomic categories and who have rich experience and broad knowledge about health and health related issues in the communities. These include the elderly, K’ebele administrators, community leaders, local inhabitants and government functionaries composed of men, women and youth living in the area.

A total of 14 FGDs were conducted in different settings in the four Woredas (Bena-Tsemay, Malle, South Arri and Salamago). As the following table indicates, 5 FGDs were conducted in South Arri Woreda with members of Arri ethnic group, 3 FGDs in Bena-Themay Woreda (2 with members of Benna ethic group and 1 with members of Tsamay ethnic group), 4 in Maalle woreda with members of Maalle ethnic group, and 2 in salamago Woreda (1 with members of Mursi ethnic group and 1 with members of Boddi ethnic group).

No. Woreda No. of FGDs Kebeles were Remark Carried out FGDs were conducted 1 Arri 5 Aykamir & Geza Three FGDs in Aykamir and 2 FGDs in Geza

2 Bena-Themay 3 Alduba, & Argo 2 FGDs in Alduba, 1 in K’ako & 1 FGD in Argo 3 Maalle 4 Beneta & Two FGDs in Beneta & 2 FGDs in Golobarando Golobarando

4 Salamago 2 1 with members of Mursi ethic groups & 1 with members of Boddi ethnic groups

Ten key informants interviews were conducted in the four Woredas (3 three in South Arri, three in Benna-Tsemay, two in Maalle and two in Salamago). Moreover, ddirect and indirect observation was made regarding the existing condition of health and water facilities, personal hygiene and environmental sanitation in the area as well as the overall economic condition of the zone.

Study Instruments The main data collection instruments (the semi-structured questionnaire for the key informant interviews, the structured questionnaire for the quantitative baseline survey, and the focus group discussion guide) were prepared on the basis of the findings of the literature review. In addition, other instruments used in the 2005 Ethiopia DHS, and other survey instruments were used as sources when developing the instruments to be used in the research.

1.4 Recruiting and Training of Field Staff

A total of 20 interviewers, 5 supervisors, 4 moderators and 4 note takers were identified from the project staff and selected. The team leaders, note takers, supervisors and interviewers were given a three-day training that covered methods of sampling, recruiting participants (including informed consent), conducting interviews, and taking interview notes (for semi-structured interviews and FGDs). Recruitment and training of data collectors was conducted at Jinka, the zonal capital.

1.5 Field Data Collection

Fieldwork was conducted using 20 interviewers, 4 supervisors, 4 moderators and 4 note takers (5 interviewers, one supervisor, one moderator and one note taker per Woreda). The supervisors served as team leaders and the principal researchers/investigators coordinated the entire fieldwork.

After the training of interviewers and supervisors, the field staff was deployed to their respective sites to start data collection. The structured questionnaire was administered to a sample of 25 households on average in each segment/block. Supervisors were responsible for the quality of the work of each data collector and ensured that the data collection was done as planned and the information was recorded in the questionnaire as expected. The supervisor had duties other than supervision of the interviewers, such as coordination of the focus group discussions (FGDs) and performing key informant interviews. A moderator guided the FGDs and a note taker assisted taking notes and recording the discussion on audiotapes during the focus group discussion.

1.6 Data Management

Key Informant Interviews The supervisors interviewed the key informants and take notes on the semi-structure questionnaire. After the interview, they reviewed their notes to ensure clarity and completeness. They will then turn in completed interview forms to the team leaders at the end of data collection.

Individual household questionnaire

Interviewers will turn in completed interview forms to the supervisor at the end of each day and the supervisor will check the questionnaire for completeness, consistency and validity of the data.

These forms will then be rechecked for consistency, open-ended questions will be recoded in the office and then the data will be entered into a computer using a data entry program such as CSPro. Data will be cleaned and analysis will be carried out using SPSS.

Focus Groups Discussion

Focus group discussions were audio taped. The moderator moderated the focus group, while the note taker took notes and at the same time recorded the discussion. After the focus group discussion was finished, the note taker and moderator reviewed the notes and made reasonable summaries of the focus group discussion, which were finally used in the production of the report.

1.7 Data Analysis

Data gathered from the key informant interviews and focus group discussions were analyzed using text analysis, while data from the household survey was analyzed using descriptive statistics (percentages and frequencies) and cross-tabulations.

1.8. Organization of the Report

Including this introductory chapter, the report is divided into eleven chapters. The following chapter discusses the Socio-economic and Demographic Characteristics of the respondents. . Chapter Three discusses issues related to sources of water and personal and environmental hygiene. In Chapter Four, Malaria is addressed and Chapter Five deals with HIV/ASIDS Knowledge, Attitude and Behavior. Chapter Six deals with Reproductive Health including family planning. Chapter VII and VIII address harmful traditional practices and Gender issues, respectively, while Chapter Nine discusses Child Health and Chapter Ten deals with knowledge about Tuberculosis. Chapter Eleven Summarizes major findings and put together key recommendations.

Part I

HEALTH AND HEALTH RELATED ISSUES IN BENNA TSEMAY AND SELAMAGO WOREDAS IN SOUTH OMO, SNNPR, ETHIOPIA: FINDINGS OF A BASELINE SURVEY, 2008

CHAPTER II

BACKGROUND CHARACTERISTICS OF THE STUDY POPULATION

This section attempts to give an overview of the socio-economic and demographic characteristics of the study population. In other words, the report considers respondents’ religious affiliation, ethnic background, employment/ occupation, educational attainment and access to mass media. It also presents women’s age structure, marital status, mortality differentials and household compositions. In this regard, the report synthesizes and highlights important background characteristics of women of reproductive age Woreda administration.

2.1 Socioeconomic Background

Religion and Ethnicity Religion and Ethnicity are important variables to affect fertility differentials, marital arrangement, health care and other demographic events. Accordingly, this survey collected information from all 1,657 sampled women on ethnicity and religious affiliation; in particular, the survey interviewed 435 women from Bena Tsemay Woreda, 374 women from Selamgo Wereda. The distribution of women by religion and ethnicity is shown in Table 2.1.1. The result indicate that 62.5 and 54.3 percent of the entire women in Bena Tsemay and Selemago Woredas respectively believe in traditional/customary religious practices, 14.7 percent from Bena Tsemay and 22.5 from Selamago were Protestant Christians, 13.6 and 18.2 percent of respondents in Bena Tsemay and Selamago respectively were Orthodox Christian and a small proportion, 0.2 percent and 2.1 percent from Bena Tsemay were Muslims and Catholic Christians respectively.

The survey identified diversified ethnic compositions in the two Woredas. It seems that Woreda administration demarcated on the basis of ethnicity. For instance, in Bena Tsemay Wereda, 83.5 percent of women belonged to Bena (40.7 percent) and Tsemay

(42.8 percent) ethnic groups. However, other ethnic groups are also observed in Selamgo Woreda. In this Woreda, close to 100 percent of women are composed of various ethnic groups, namely, Birayle, Bodi, Dime, Mursi, Bacha and Konso, amongst others.

Table 2.1.1 Religion and Ethnicity composition: Percent distribution of women by religion, ethnicity

Background Wereda Characteristics Bena Selamgo Tsemay Religion Orthodox Christian 13.6 18.2 Muslim .2 0 Protestant 14.7 22.5 Catholic 2.1 1.9 Tradition 62.5 54.3 Others 6.9 3.2 Total 100 100

Ethnicity Ari 7.6 0 Bena 40.7 0 Malle .9 .5 Tsemay 42.8 .3 Others* 8.0 99.2 Total 100 100

Number of Women (n) 435 374 * includes Birayle, Bodi, Dime, Mursi, Bacha, Konso, etc

Work status and occupation

In Ethiopia, women perform miscellaneous economic activities, such as household chores/domestic work, farm labor, petty trade or working in the formal sector (factories and offices). From this point of view, the survey asked all women to provide information on types of women’s current occupation and husband’s work status.

The highest proportion of women (27 percent) in Bena Tsemay Woreda is engaged in agro pastoralist sector; about 30 percent of women in Selamgo Wereda are farmers. Likewise, the majority of Women in Bena Tsemay Woreda reported that their husbands are engaged in agro pastoralism; while women in Selamgo Woreda reported that their husbands are farmers.

Table 2.1.2 Work Status of Women and husband: Percent distribution of women by type of work/occupation, Husbands’ occupation Woreda Current Bena Selamgo Work/Occupation Tsemay

Women occupation Farmer 18.9 29.9 Pastorals 6.4 11 Agro Pastorals 27.4 13.4 Housewife 15.6 12.6 Farmer & housewife 21.4 25.4 Others 9.7 5.1 Not stated .7 2.7 Total 100 100

Husbands’ occupation Farmer 18.4 43.0 Pastoralist 12.2 12.3 Agro Pastoralist 42.1 23.8 Not stated 1.6 .8 Total 100 100

Number of women (n) 435 374 Educational Status

It is well known that education is the gateway to women’s empowerment. Education enhances women awareness to fight against poverty, build confidence, empower them in decision making, influences their reproductive patterns, increases child survival chances through antenatal and postnatal care utilization. It is also a means to prevent violence against women, amongst others.

The survey asked each woman about access to formal schooling women’s literacy status and highest grade achieved among those who had formal education. As indicated in Table 2.1.3, the majority of women in both Woredas (86% in Benna- Tsemay and 84.6% in Selamago) did not have any education. Only 13.8 and 15.5 percent in Benna-Tsemay and Selamago respectively reported that they had attended

18 formal education. Among these women, some 9.9 and 13.1 percent from Benna- Tsemay and Selamago respectively had attended primary education (from grade 1-8).

Surprisingly, almost all Women in Selamgo Wereda are illiterate. For details refer to Figure1 and Table 2.1.3.

Figure 1: Percent distribution of women by level of school grading

100

80 70

50 No education/grade

percen Grade 1-8 40 Grade 9-12 30 Higher grade 13+ 20

0 Bena Tsemay Selamgo Mali South Ari Total Werda

Table 2.1.3 Educational Status of women: Percentage of women by educational status

Educational Status Woreda Bena Selamgo Tsemay Attending Formal education Yes 13.8 15.5 No 86.0 84.5 Not stated .2 0 Total percent 100 100 Number of Women (n) 435 374

Read and Write Yes .5 0 No 99.5 100.0 Total 100 100 Number of Women (n) 368 314

Completed highest grade No education/grade 87.4 85.0 Grade 1-8 9.9 13.1 Grade 9-12 2.8 1.9 Higher grade 13+ 0 0 Total 100 100 Number of Women (n) 435 374

Exposure to mass media

Access to information through radio, television, newspapers, magazines and other informal channels influence women behaviors. A woman who has access to information from these sources is more likely to understand the importance of family planning, HIV/AIDS prevention, child care, primary health care practices, fighting harmful traditional practices and others.

Women were asked to provide information on availability and functionality of household radios, frequencies of listening radio and interest of listening particular radio programs. The result is shown in Table 2.1.4. As indicated in this table, radios are relatively uncommon in all Woredas. About 75 percent of women in Bena Tsemay, 84 percent in Selamgo Wereda have no working radio in their households.

Among women who have access to radios, the largest proportions of women (77.8 percent) in Selamgo Wereda did not listen to radio programs. In Benna-Tsemay also, 72.4 percent of women have not exposure to listening radios. Most women (37.4 and 40.3 percent in Benna-Tsemay and Selamago Woredas respectively) have interest to listen all radio programs. Moreover, there were notable variations in listening news, entertainment and other radio programs across Weredas.

Table 2.1.4 Women exposure to mass media: Percentage of women who have access to radio media

Wereda Exposure to mass media Bena Tsemay Selamgo

Having working radio Yes 25.1 16.0 No 74.9 84.0 Not stated 0 0

Total 100 100 Number of women (n) 435 374 Frequency of listening radio Always 9.4 8.0 Once a day 2.8 .8 Twice a day 1.4 .8 Rarely/sometimes 10.8 8.3 Never listen 72.4 77.8 2.2 Total 100 100 Number of women 435 374 (n) Types of listening Program News only 21.5 16.4 Entertainment 30.8 38.8 All programs 37.4 40.3 Others 10.3 4.5 Total 100 100 Number of women 107 67 (n) Demographic Background

Age Distribution

Age is an important demographic variable to influence women’s fertility, marriage, sexual practices, labor force participation and other vital events. In demography, a population with a large proportion under 15 years of age is considered to be a young population. Age is also an important demographic variable as it affects social status and opportunity to participate in labor force, among others. All women were asked to report their age at last birthday. Table 2.2.1 displays the distribution of the surveyed women by five years interval age groups. Bena- Tsemay Wereda comprises higher old age women (2.3 percent) than Selamago Woreda. In contrast, Selamgo Woreda has larger young women (4.5 percent) than the Benna- Tsemay Woreda. In both Woredas, the highest proportions of women fall to age 25 to 29 years, which ranges from 21.8 percent to 25.9 percent. In this survey, the median age of women is estimated at 28 years for the whole studied women population.

Similarly, the median age of women in Benna- Tsemay and Selamgo Weredas are estimated to be 26 and 25 years respectively. For details refer to Figure 2 and Table 2.2.1.

Figure 2: Median age of women by residence

Years26 Median age

23 Bena Selamgo Mall South Ari Total e Tsemay

Wereda

Table 2.2.1 Women by Age distribution: Percent distribution of Women by age group

Wereda Age group Bena Selamgo Tsemay Age in years 15-19 17.7 20.0 20-24 19.5 23.0 25-29 21.8 25.9 30-34 14.3 10.7 35-39 13.8 13.6 40-44 7.4 3.2 45-49 5.5 2.2 Total 100 100 Median age 26 25 Average age 29 26.3 Number of women 435 374 (n)

Marriage

Marriage is a key proximate determinant of fertility. According to United Nations classification, marital status is classified into single or never married, married and not legally separated, widowed and not remarried, divorced and not remarried, married but legally separated and consensual union (establishment of marital union without recorded legal sanction). In this survey, information on marital status was collected by asking respondents about their current marital status. In addition women were also asked to provide information on their marital arrangement and whether or not they are married to monogamous or polygamous marriage.

The distribution of women by their marital characteristics is depicted in Table 2.2.2. The result shows that about 80 percent of women in Benna Tsemay and 83.7 percent of women in Selamago were currently married, 8.5 and 5.1 percent in Benna Tsemay and Selamago respectively were widowed, 2.1 percent in Benna Tsemay and 1.6 percent in Selamago were divorced and only 8.5 and 9.1 percent of women in Benna Tsemay and Selamago respectively were single.

Consensual union marital arrangement is common in both Woredas. Marriage through family and abduction are also pronounced. The largest proportion of women (15.3 percent) who formed marriage through abduction is found in Selamgo Wereda.

The table also clearly shows the distribution of women by age at first marriage. About 44.6 percent of women in Bena Tsemay Wereda started married life at age 18 years and above. Only 9.1 percent of women in Selamgo Wereda contracted marriage at early teens (age below 15 years. In addition, the median age at first marriage is estimated at 17 years, which is about one year higher than the national average, suggesting that women in these woredas marry relatively late.

Polygamy appears to be common in these Woredas. There is no substantial difference in polygamous marriage arrangements between the two Woredas. 30 percent in Bena Tsemay, Woreda reported that their husbands had more than one wife, while 31.4 percent in Salamago. (For details refer to Table 2.2.2 and figure 3).

Figure3: percentage of women by age at first marriage, residences

100

60 <15 years 15-17 years

percent 40 18+ years

0 Bena Tsemay Selamgo Mali South Ari Woreda

Table 2.2.2 Marital Status of Women: Percent distribution of women by marital status Wereda Background characteristics Bena Tsemay Selamgo Marital status Never married 8.5 9.1 Currently married 80.0 83.7 Divorced 2.1 1.6 Widowed 8.5 5.1 Separated .2 .3 Not stated .7 .3 Total 100 100 Number of women (n) 435 374

Marriage arrangement Family 26.6 10.3 Abduction 7.8 15.3 Consensual 65.3 74.3 Inheritance .0 .0 Adoption .3 .0 Other .0 .0 Total 100 100 Number of women (n) 398 339

Age at first marriage in years <15 8.6 9.1 15-17 44.2 46.3 18+ 47.2 44.5 Total 100 100 Average age at first marriage 19.3 18.8 Median age at first marriage 17 17 Number of women (n) 396 339

Polygamy (husband has additional wives) Yes 30.0 36.9 No 70.0 63.1 Total 100 100 Number of women (n) 397 339 Number of husband’s additional wives 1 wife 71.1 68.6 2 and more wives 28.9 31.4 Total 100 100 Number of women (n) 114 118

Household composition

Data on household composition was collected in this survey. In order to arrive at household size, the survey asked women to report the number of family members who lived together and shared household resources/ eating from the same pot. The household members include children, wife, husband, grand parents, blood relatives and

25 non-relatives. Collecting this information has paramount importance to give insight utilization about household resources.

Table 2.2.3 presents the distribution of women by size of household. The majority of women (about 54.7 and 50.3 percent in Benna Tsemay and Selamago) Woredas respectively reported that they have more than 5 members in their household. The average household size was found to be 5 members each in Bena Tsemay and Selamgo Weredas. A high proportion of the interviewed women reported that their households comprised of under five children and women of reproductive aged (15-49 years).

Table 2.2.3 Household composition: Percent distribution of women by household composition

Wereda Household composition Bena Selamgo Tsemay Household size 1 family member 2.3 1.1 2 family members 8.0 8.7 3 family members 14.8 18.9 4 family members 19.0 20.2 5+ family members 54.7 50.3 Not stated 1.2 .8 Total 100 100 Average household size 5.2 5 Number of women (n) 435 374 Number of under 5 children in the family 0 child 2.1 2.1 1 children 2.3 1.1 2 children 7.8 8.6 3+ children 86.7 87.4 Not stated 1.1 .8 Total 100 100 Number of women (n) 435 374 Number of women age 15-49 years who are members of family 0 no women 16.6 13.6 1 woman 50.6 62.6 2 woman 17.7 14.7 3+ woman 11.7 8.0 Not stated 3.4 1.1 Total 100 100 Number of women (n) 435 374

Mortality

Mortality is one of the measures of population change. Information on mortality is used to indicate the development of socio-economic status as well as the provision of quality health care for communities. Infectious disease including HIV/AIDS, parasitic disease, prolonged labour and disasters are considered to be main causes of death for infants, women and men who live in rudimentary living conditions. This survey collected information on deaths in the household in the last 12 months prior to the survey by asking all women whether they encountered death in their household in the past twelve months and if so the sex and age of the deceased. .

Table 2.2.4 presents the percent distribution of women reporting death in the last 12 months by Woreda and age. As indicated in this table, 9.9 percent of women in Benna- Tsemay and 10.4 percent of women in Selamago reported that they did have deaths in the household in the last 12 months.

The data shows that there is heavy under five mortality in the population. Most of the deaths in both Woredas were among children under 5 years. About 42 percent of women in Bena Tsemay Woreda had under-five mortality. In Salamago, about a quarter of the deaths were among the under five children. The table also shows that mortality was higher for males than females (For details refer Figure 4 and Table 2.2.4)

Figure 4A: Cause of Death

Figure 4: percent distribution of women by mortality diferentials, age gorup, residence

Under 5 years 5-9 years 10-19 years 20-29 years 100 30-39 years 40-49 years 50+ years 90 80 70 60 50

percent 40 30 20 10 0 Bena Tsemay Selamgo Mali South Ari Total woreda

Table 2.2.4 Mortality differentials: Percent distribution of women by mortality differentials and residence Wereda Mortality differentials Bena Tsemay Selamgo Occurrence of death in the last 12 months Yes 9.9 10.4 No 89.4 89.0 Not stated .7 .5 Total 100 100 Number of women (n) 435 374

Mortality by Age group in years Under 5 years 42.5 24.4 5-9 years 10.0 13.3 10-19 years 12.5 13.3 20-29 years 15.0 17.8 30-39 years 7.5 11.1 40-49 years 2.5 8.9 50+ years 10.0 11.1 Total 100 100 Number of women (n) 40 45

Sex of dead persons Male 52.0 49.0 Female 48.0 51.0 Total 100 100 Number of women (n) 50 49

Cause of Death

The main cause of death in these woredas is malaria followed by diarrhea. About 49% and 47% of the deaths in Benna-Tsemay and Salamago respectively were reported to be due to malaria while about a fifth in both Woredas was due to diarrheal diseases and a little over 10% was due to respiratory diseases or TB and another 10% was due to malnutrition or food shortages. HIV/AIDS was also reported to be the cause of death in both woredas. As Fig. 4B show, the causes of death are more or less similar in all woredas.

Fig 4B Causes of Death by Woreda

Percent 20

Don't Know Malaria Diarrhoea HIV/AIDS Malnutrition Other causes Respiratory/TB Cause of Death

Bena Salamago Malle South Ari All 4 Woredas

According to the participants of FGDs and KIIs, there have been a number of factors that adversely affect the health of the communities under this study. Similar to the findings of quantitative survey, the major cause of death in the study area seem to be malaria and

29 followed by diarrhea. The other causes of death listed down by most of the informants were typhoid, typhus, internal worms and parasites, stomach-ache, TB, common cold, coughing, pneumonia, headache, cold, meningitis, measles and hepatitis. Meanwhile, a considerable number of them were not aware of the causes of certain diseases. Consequently, they have no adequate knowledge that these diseases can be preventable. For instance, some them believe that the cause of Tuberculosis is eating cold food, and it can be cured by slaughtering animals and by eating their meat.

In terms of perception towards modern health service, most of the participants of FGDs and KIIs had positive attitude, and felt comfortable when they had been treated by health practitioners. In other words, they had no hatred towards modern health service. Nevertheless, the major reasons for not going to modern health institutions shortly after their illness had been due to ignorance, lack of adequate knowledge and awareness regarding the cause and transmission of many diseases as well as their inability to afford for the expense of medication. As a result, some of the local inhabitants prefer to stay at home for certain days instead of going to modern health institutions for medication hoping that they would be recovered from their illness as a day went on.

If staying at home for certain days could not bring any improvement towards their illness, they resort to traditional healers and witchdoctors who would treat them with small amount of money as compared to the amount of money paid for medication in modern health institutions. Because of that, the inhabitants who faces financial problem are forced to spend a number of days without going to modern health institutions. In other words, they visit to modern health institutions only after the hope of being recovered by staying at home or by using traditional medicines could not bring any improvement. As a consequence, some patients die on the way to health institutions, or as soon as they reached to health institutions because their health situation has already been complicated and seriously jeopardized before they have been treated. On the contrary, however, one of the participants of FGD said that “our previous consultation to local herbalists and witch doctors after illness has declined significantly especially since the last few years.

Currently, we mostly consult them not for our health problems, but to predict us the future, to bring us rain and to have abundant crops and cattle”.

CHAPTER III

HOUSEHOLD WATER SOURCES, PERSONAL HEALTH AND SANITATION

3.1 Water Sources The availability and quality of household drinking water influences the human health. It is well known that pure water is health and contaminated water is death. Studies showed that lack of access to safe drinking water and sanitation is related to poverty and the inability of governments to invest in these systems. WHO estimated that ‘’about 1.7 million deaths a year worldwide are attributed to unsafe water, sanitation and hygiene, mainly through infectious diarrhea. Nine out of ten deaths are in children, and virtually all of the deaths are in developing countries (WHO, 2002). By 2025 there will be 5 million deaths among children under 5 years of age and 97% of these will occur in developing countries (WHO, 1998b).’’

Data on sources of household drinking water, continuity and availability of water was collected in this survey. The results are presented in Table 3. Some 31 percent of Bena Tsemay women have access to surface water. Over one third (36 percent) of women in Selamgo Woreda reported that river is the main source of water for household consumption and drinking.

According to the participants of FGDs, KIIs and from the researcher’s observation, a significant number of inhabitants have been heavily dependent on unprotected water sources like wells, ponds and rivers due to lack of adequate access to safe water. As they confirmed, there had been many cases in which they were exposed to various types of water born diseases. Besides that, the frequent eruption of various epidemics in the area such as malaria, diarrhea, meningitis, measles, typhoid and viral hepatitis have been adversely affecting their health and making them vulnerable to death.

Furthermore, most of the water sources in these Woredas have been located at a far distance from their localities. Accordingly, a considerable number of women are forced to

32 spend more than two hour in fetching water on average without including those living in urban centres and who have access to pipe water. Generally speaking, the inhabitants of Salamago and Bena Tsemay Woredas seem to make more travel to fetch water and to water their animals than the inhabitants of Arri and Maalle Woredas. As the participants of FGD from Tsemay community confirmed, some of them even travel three to four hours per day to fetch water especially during the dry season. This has been due to small number of water points in Salmago and Benna-Tsemay Woredas which might be the outcome of low altitude, semiarid climate and by-modal type of rainfall.

The table clearly reveals that water interruption is the major problem for households. The result indicated that water interruption is a serious problem for Bena Tsemay and Selamgo Weredas.

As indicated in this table, 62.9 percent of women in Benna- Tsemay woreda travel more than 2 hours to fetch drinking water. The majority of women in Selamgo (81.8%) Wereda take more than 2 hours to fetch drinking water. The median length of time required to fetch drinking water is estimated at 15 hours (for details refer Figure 5 and Table 3)

Figure 5: Media time in hour to fetch water ( round trip)

16 14 12 10 8 Media time in hour hour 6 4 2 0 Bena Selamgo Mali South Total Tsemay Ari Wereda

Table 3 Sources of drinking water: Percent distribution of women by source of drinking water, time to fetch water, water Wereda Access to water Bena Tsemay Selamgo Source of drinking water Narrow/borehole 1.6 .8 Well/borehole .7 .3 Untreated spring 5.3 20.1 Treated spring 2.3 .8 River 26.7 36.4 Pipe water 27.6 31.8

Pond 4.4 7.8 Surface water 30.6 .5 Others .7 1.3 Not stated .2 .3 Total 100 100 Number of women (n) 435 374

Have you experienced Water interruption 76.3 61.2 Frequency of water interruption Sometimes 74.2 83.8 Frequently 20.0 11.8 Usually 5.8 4.4 Total 100 100 Number of women (n) 330 228 Time taken to fetch water (round trip) < 1 hour 32.6 15.2 1 hour to 2 hour 4.6 3.0 Over 2 hour 62.8 81.8 Total 100 100 Median time in hours 10 15 Number of women (n) 371 335 Not stated (n) 64 39

3.2 Health and Sanitation

Availability of latrine

Information on latrine availability, type, sanitation and users are presented in Table 4.1. The result shows that 85.5 percent of Bena Tsemay women and 67.6 percent of Selamgo Women have no access to toilet. Among latrine owners, the majority of women have traditional pit latrine with slab covers (81 percent for Benna Tsemay and 84.3 percent in Selamago).

According to the findings of the information obtained through FGDs and KIIs, the number of people who have access to toilets reached to such high percentage due to the construction of several toilets especially in rural areas through campaign organized by the Health Bureau of South Omo zone and some NGOs in the last three years. As these informants further confirmed, most of these toilets have not yet been used by the households except few toilets that have been started to be used by some educated people. In the existing condition, a significant number of rural inhabitants from all Woredas rarely use the toilets, and most of them defecate inside the bush, inside their crops or in any open place roughly 50 to 100 meters away from their residence.

Table 4.1A Availability of toilet: Percent distribution of women according to availability of and type of toilet/ latrine Wereda Toilet/ latrine facility Bena Tsemay Selamgo Having latrine Yes 14.5 32.4 No 85.5 67.6 Not stated 0 0 Total 100 100 Number of women (n) 435 374 Type of toilet/latrine Traditional pit latrine with slab 81.0 84.3 Traditional pit latrine with out slab 9.5 15.7 Ventilated improved latrine 6.3 0 Other 3.2 0 Total 100 100 Number of women (n) 63 121

Cleanliness of latrine/based on observation Used but clean 54.1 35.5 Unused clean 13.1 9.1 Unused but unclean 31.1 55.4 Other 1.6 0 Total 100 100 Number of women (n) 61 121

Women with some type of latrine were asked who uses the latrine and whether or not there is any discrimination by sex in using the latrine. More than sixty percent of women in both Woredas said that there is no gender disparity in using latrine (all family members have the right to use latrines) in their community.

Table 4.1B Use and non-use of toilet: Percent distribution of women according to use and reason for not using toilet/ latrine

Usual latrine users Bena Salamago Tsemay Adult male only 1.6 2.5 Adult female only 0 1.7 Both adult male & female 29.0 28.9 Children 0 0 All family member 61.3 62.8 No one uses 8.1 4.1 Total 63 121 Number of women (n) 63 121 Reasons for not using latrine Smelling

Yes 16.7 20 No 83.3 80 Number of women (n) 6 5 Human faucal waste should not be

buried Yes 16.7 0 No 83.3 100 Number of women (n) 6 5 Male should not be seen during defecation Yes 16.7 0 No 83.3 100 Number of women (n) 6 5

Regarding reason for not using latrine, 20 percent of women in Selamgo Wereda believe that latrine has bad smell. This argument was also confirmed by the participants of FGDs and KIIs. About 16.7 percent of women in Benna Tsemay said that human faucal waste should not be buried and another 16.7 percent reported that males should not be seen during defecation (Table 4.1B).

The participants of FGDs from Benna Tsemay argued as follows: “Our K’ebele chairman who is expected to be a model to us did not start to use the toilet constructed around his homestead. In such condition, how can we, ordinary people start to use the toilets in our homesteads?” However, some informants argued that they do not feel comfortable to use the toilets constructed around their homestead is to protect their children from any danger of falling into toilets.

3.3 Personal Hygiene

It is known that primary health care, including personal hygienic practices help to attain good health and proper sanitation reduces the risk of transmissions of contagious diseases. Personal hygiene includes washing hands, body, clothes, cleaning cooking utensils, cleaning houses and compounds, amongst others. Thus, this survey collected data on basic personal hygienic practices.

Table 4.2 demonstrates that more than 44 percent of women in Benna Tsemay and 63.9 percent of women in Selamago have the habit to wash hands before eating food. Most (40.4 percent to 63.9 percent) of women in Selamago Wereda washed their hands after

36 defecation, before handling cooking utensils, before eating food and after eating food. On the other hand, women in Bena Tsemay Woreda have poor hand washing practices. In both woredas the majority of women reported that soap is not used for washing hands.

According to the information obtained from FGDs and KIIs, most of the informants seem to have very low level of awareness concerning personal hygiene and environmental sanitation. In fact, many of them feel comfortable to wash their hands before eating food as far as water is available within their home. However, there had been many occasions in which they are forced even to eat their food without washing their hands due to shortage of water especially during the dry season. For some of them who have been living in very hot and arid areas eating food without washing one’ own hand, taking shower and washing their clothes is not a serious issue because the scarcity of drinking water is their major problem than anything else. They are heavily depend on one or two big rivers for water supply. Some of the participants of FGDs and KIIs argue that they stay even more than a month without washing their body. In comparison with men, women have no time to wash their body because they have many responsibilities and they are highly confined to their household cores. Therefore, the majority of women wash their body during certain occasions related to rituals, festivals and New Year’s celebrations within their community.

Table 4.2: Personal sanitation: Percent of women practicing personal sanitation Wereda Practices of personal hygiene Bena Selamgo Tsemay Washing hands After defecation 22.8 40.4 Before handling cooking utensils 29.2 41.4 Before eating food 44.8 63.9 After eating food 33.3 44.7 After cleaning babies 15.6 20.9 Occasional 43.0 48.1 Others 14.5 8.3 Number of women (n) 435 374 Use of soap to wash hand Yes 22.1 20.1 No 77.0 79.4 Not stated .9 .5 Total 100 100 Number of women (n) 435 374 Frequencies of washing body/women

Twice a week 18.9 34.5 Weekly 18.4 17.6 Every two weeks 26.2 10.2 Others 36.1 37.7 Not stated .5 0 Total 100 100 Number of women (n) 435 374 Frequencies of washing body/ family members Twice a week 15.2 35.3 Weekly 19.3 19.0 Every two weeks 27.1 9.9 Others 38.2 35.0 Not stated .2 .8 Total 100 100 Number of women (n) 435 374 Frequencies of washing clothes/ family members Usually 1.8 5.1 Sometimes 31.3 29.9 As need arises 43.7 54.0 Not at all 13.8 5.6 Not applicable 9.2 5.3 Not stated .2 0 Total 100 100 Number of women (n) 435 374

CHAPTER IV

MALARIA

Malaria affects persons in all age groups. It is life-threatening disease for under-five children and pregnant women. It causes fetal losses or abortion for pregnant women. The Federal Health Ministry of Ethiopia and WHO (2007) acknowledged the challenge of malaria for the Ethiopia population in the following statement: “Malaria constitutes a major public health problem and impediment to socioeconomic development in Ethiopia. It is estimated that about 75% of the total area of the country and 65% of the population is estimated to be at risk of infection. Malaria transmission in Ethiopia depends substantially on Anopheles arabiensis Patton, a member of the An. gambaie Giles complex, in the intermediate highlands of Ethiopia. Anopheles funestus Giles is the second most important malaria vector in Ethiopia. Anopheles nili Theobald is an important local malaria vector in the low land region of south West Ethiopia”

4.1 Major health problem in the study area

Information was collected from individual women on what they think is the major health problems in the community. As indicated in Table 4.3, more than 90 percent of the respondents in both woredas perceived that malaria is the leading health problems in their community. In addition, 64.6 and 82.2 percent of women in Benna Tsemay and Selamago respectively believe that diarrheal diseases as the second leading cause of morbidity followed by respiratory disease/TB/reported by 30 percent of respondents in Benna Tsemay and 42.1 percent in Selamago. On the other hand, a small proportion of women reported that HIV/AIDS has low contribution to community health problems.

Table 4.3 Community’s health problem: Percent distribution of women who have knowledge on community’s health problem, by residence

Wereda Types of health problems Bena Selamgo Tsemay Health problems Malaria 92.0 96.7 Diarrhea 64.6 82.2 Respiratory disease including 30.0 42.1 TB Gastro intestinal diseases 14.1 24.9 Malnutrition 9.2 16.1 HIV/AIDS 4.5 3.0 Skin disease 10.8 17.2 Other disease 23.0 19.1 Do not know/not sure 5.3 7.7 Number of women (n) 435 374

4.2 Symptoms of Malaria

Table 4.2 presents the distribution of women according to their knowledge towards malaria symptoms. Women in Bena Tsemay Woreda know that malaria causes headache (78.5 percent) and vomiting (51.3 percent). The majority of Selamago women identified several symptoms, among these, 87.9 percent of them said fever and 86.2 percent reported headache (for details refer to Table 4.4).

Table 4.4 Symptoms of Malaria: percent distribution of women by symptom of malaria and residence Wereda Malaria symptoms Bena Tsemay Selamgo Kind of symptoms Fever 80.2 87.9 Shivering/chills 75.7 78.8 Sweating 23.9 32.5 Headache 78.5 86.2 Vomiting 51.3 61.6 Loss of appetite 37.0 37.3 Bitterness in the mouth 19.8 33.6 Weakness/tiredness 22.9 34.5 Splenomegaly 14.8 23.7 Backache 35.6 39.0 Convolution 5.0 19.8 Joint pain 17.7 28.2 Other symptoms 4.5 5.1 Do not know 5.0 0 Number of women (n) 435 374

4.3 Knowledge of Means of Getting Malaria

Table 4.5 displays data on knowledge of women about malaria transmissions. As shown in this table, 84.8 and 86.9 percent of women in Benna Tsemay and Selamago Woredas respectively perceive that malaria is a major health problem of the villages. More than 40 percent of women in both Woredas said that malaria is transmitted from person to percent. Most women (more than 88 percent) in both Woredas also reported that malaria is a treatable disease. The overwhelming majority of women in each Wereda know that malaria infection is transmitted through mosquito bite (90.2 percent in Benna Tsemay and 83.4 percent in Selamago). Surprisingly, a small proportion of women in Bana Tsemay and Selamgo Woreda believe that witchcraft is a means through which malaria is transmitted from one person to the other.

Table 4.5 Knowledge of acquiring malaria: Percent distribution of women according to knowledge of acquiring malaria, by residence Wereda Knowledge of getting malaria Bena Selamgo Tsemay Malaria is a major health problem Yes 84.8 86.9 No 9.9 9.9 Do not know 5.3 3.2 Total 100 100 Number of women (n) 435 374 Malaria is transmitted from one person to another Yes 40.9 46.8 No 33.6 25.9 Do not know 25.5 27.3 Total 100 100 Number of women (n) 435 374 Malaria is treatable disease Yes 88.5 89.0 No 4.1 2.4 Do not know 7.4 8.6 Total 100 100 Number of women (n) 435 374 Malaria infection transmitted through Breathing 20.0 19.1 Mosquito bite 90.2 83.4 Sleeping together with a malaria 12.5 17.2 patient Drinking dirty water 21.5 30.2

Being exposed to cold water 15.2 28.6 Exposure to dirty swampy areas 22.0 32.0 Witchcraft 4.9 4.9 Eating sweet food/maize 36.7 40.6 Other 3.2 7.7 Do not know 4.2 3.9 Number of women (n) 409 325

4.4 Knowledge of Preventing Malaria

This survey includes information on the knowledge of respondents about ways of malaria prevention. Table 4.6 depicts that 46 percent of women in Selamgo and 49.4 percent of women in Benna Tsemay Woredas appear to have knowledge on prevention of malaria.

The result clearly shows that 83.7 and 85.5 percent of women in Benna Tsemay and Selamago respectively know that sleeping under mosquito net can prevent malaria. DDT/ spraying insecticide is also considered to be malaria-controlling mechanism. Respondents were asked whether it is better to treat malaria at home or at health facility. The majority (about 80 percent) of women in both woredas reported that they preferred to treat malaria in health facility. A few women preferred to treat malaria at home. For details refer Table 4.6.

Table 4.6: Knowledge of preventing Malaria: Percentage of women who have knowledge about prevention of malaria, by residence Wereda Knowledge of preventing malaria Bena Tsemay Selamgo

Malaria is preventable disease 49.4 46.0 Number of women (n) 435 374 Means of Controlling Malaria Eating good food 25.8 15.2 Keep house clean 24.4 27.3 Remain indoors at night 7.2 10.3 To sleep under a mosquito net 83.7 85.5 To spray house with insecticide/DDT/ 28.7 27.9 To spray house with aerosols 3.3 9.7 Smoking the house 8.6 20.0 Apply ointment/repellents on the skin 6.2 4.2 Drain mosquito breeding site 18.7 40.0 Window screening 2.9 6.7 Other 3.3 8.5 Do not know 18.8 18.2 Number of women (n) 209 165 Not stated 226 209 Measures taken to treat malaria Treat at home 7.4 9.1

Take to health facility 79.8 80.7 Take to traditional healer 7.6 6.1 Buy drug from pharmacy 3.7 2.4 Other 1.6 1.3 Not stated 0 .3 Total 100 100 Number of women (n) 435 374

4.5 Malaria related sickness

The distribution of women in relation to malaria related sickness is presented in Table 4.7. As indicated in this table, some 19.3 and 20.3 percent of women in Benna Tsemay and Selamago respectively reported that febrile illness is more related to malaria sickness. More than 67 percent of women in Benna Tsemay and 57.9 percent in Selamago Woredas reported that households had more female malaria patient than male patients. The table shows that under-five children are more susceptible to malaria than any other age groups (look at figure 6). The majority of women reported that malaria patients had access to medical treatment within 8 days after the onset of symptoms.

Figure 6: percent distribution of women by malaria patients age groups

100

80 Under 5 years 5-9 years

70 10-19 years 20-29 years

60 30+ years

Percent 40

0 Bena Tsemay Selamgo Mali South Ari Total Wereda

Table 4.7 Malaria related disease: percent distribution of women according to malaria related sickness and residence Wereda Malaria related sickness Bena Selamgo Tsemay Febrile illness Yes 19.3 20.3 No 80.0 78.3 Not stated .7 1.3 Total 100 100 Number of women (n) 435 374 Sex of malaria patients Male 32.1 42.1 Female 67.9 57.9 Total 100 100 Number of women (n) 84 76 Malaria patient in age group Under 5 years 30.1 26.3 5-9 years 28.9 23.7 10-19 years 9.6 13.2

20-29 years 13.3 15.8 30+ years 18.1 21.1 Total 100 100 Number of women (n) 83 76 Malaria patients sought treatment Yes 51.8 40.8 No 47.0 59.2 Do not know 1 0 Total 100 100 Number of women (n) 83 76 Number of days took between symptoms & first treatment < 8 days 71.4 83.3 8-30 days or more 21.4 16.7 More than 30 days 7.1 0 Total 100 100 Number of women (n) 42 30

4.6 Knowledge and Use of Mosquito Net

It is observed from Table 4.8 that the great majority of women in both Woredas have knowledge about malaria (88.3 percent in Benna Tsemay and 82 percent in Selamago). About 18 percent of women in Selamgo Woreda reported that they had not heard about malaria. Moreover, 91.1 percent of women in Bena Tsemay and 88.9 percent of those in Selamgo Wereda have knowledge about the prevention of mosquito using mosquito net.

More than two-third of women in both woredas reported that mosquito nets are available in their households. Among these women, 35.9 percent in Benna Tsemay and 25.1 percent in Selamago said that their mosquito net has anti mosquito medicine. A little more than half (about 55 percent) of women reported having 1 mosquito net in their households. Most women reported that all household members have used mosquito net to prevent malaria. On the other hand, women also reported the use of mosquito net for other household purposes. As the table shows, some women use mosquito net for clothes and ornament.

Table 4.8 Knowledge and use of mosquito net: Percentage of women who have knowledge about the use of mosquito net, by residence Wereda Knowledge and use of mosquito net Bena Selamgo Tsemay Heard about mosquito net 88.3 82.1 Sleeping under mosquito net prevent malaria 91.1 88.9 Mosquito net is available in the household 77.6 66.3 Mosquito net has anti mosquito medicine 35.9 25.1 Number of mosquito nets in the household 0 0 0 1 54.7 55.9 2 37.6 32.7 3 or more 7.7 11.4 Total 100 100 Average mosquito net 1.6 1.6 Number of women (n) 298 203 Sleeping mostly under mosquito net Babies 29.5 35.1 Adult men 21.5 19.3 Adult women 28.2 27.2 Pregnant women 12.8 15.3 Guests 2.0 2.5 All family member 58.1 60.9 Husband and wife 25.5 37.1 Others 6.4 4.0 Number of women (n) 298 203 Other uses of mosquito net For cloth and ornament 5.5 12.8 To prevent from bites 43.0 23.6 For door and window protection 5.5 3.9 Others 34.1 40.5 Number of women (n) 298 203

In connection to malaria, the qualitative result also shows that there is no adequate knowledge and awareness regarding its cause and transmission among some members of the community. On the contrary, misconceptions and erroneous assumptions still dominate the perception of some inhabitants. For some of them, malaria is mainly caused by eating sweet food stuffs such as sugar cane, the stalk of sorghum/maize and ripens maize/corn. For a few others, it is believed to be caused by evil eye, by the punishment from God and as a result of heavy rain. These people use the fruit of “Enqoqo” (Embelia Schimperi), “Kosso” (Hygienea Abyssinika), and other trees as a medicine. In general, however, a large number of local inhabitants have started to go to modern health institutions when they are infected with malaria especially since the last few years.

On the other hand, a significant number of inhabitants have no adequate knowledge that mosquito net can protect them from malaria infection. As a result of such misconceptions and lack of adequate awareness concerning the cause and transmission of malaria, a considerable number of inhabitants still pay little attention to use mosquito net. Even those who started to use the mosquito net did not use it regularly.

What is surprising is that some of them are using the mosquito net for other purposes such as to cover their rooms as curtain, to cover their widows and to wear as tulle and mattress of their bed. However, most of the participants of FGDs and KIIs underlined that the epidemics of malaria has decreased since they have been provided with mosquito nets. Consequently, many of them were aware that the presence of lice, beetles, “mujäle” (small insect burrows into human toes) and other vermin/insects of house had been reduced after the inhabitants had been provided with mosquito net soaked in chemicals. Accordingly, the desire to use the mosquito net during the survey time was much higher than some years ago even though a significant number of inhabitants have not yet been provided with mosquito net. Therefore, educating the local inhabitants concerning the cause, transmission and prevention of malaria seem to be very essential before the distribution of mosquito net.

CHAPTER V

KNOWLEDGE, ATTITUDE AND BEHAVIOR (KAB) OF HIV/AIDS

This section provides information on women’s knowledge, attitude and behavior towards HIV/AIDS, sexual behavior and practice, risk behavior with infection of sexual transmitted diseases, practices of voluntary counseling tests, knowledge of ART and prevention from mother to child transmission and exposure to extra marital sexes. The information on these issues helps to understand the spread of HIV/AIDS in the study areas/Woredas.

5.1 Knowledge of STIs

Sexually transmitted infections (STIs) are major health problem in developing countries including Ethiopia. Sexually transmitted infections such as gonorrhea, human papiloma virus, genital warts, syphilis, trichomoniasis, etc increase the risk of HIV/AIDS transmission. Studies indicated that STIs is transmitted unsafe sexual intercourse, which causes more complications for women and children than men. In addition to other complications, STIs cause infertility (primary or secondary). From these aspects, data was collected from all women about the practice and knowledge of STIs.

As Table 5.1 shows, 56.3 percent of women in Benna Tsemay Woreda have heard of STIs. About 51 percent of Selamgo women reported that they do not know STIs. The highest percent of women who reported having been infected with STIs was observed in Selamgo Woreda (9.4 percent) followed by Bena Tsemay Wereda (5.7 percent).

Table 5.1 Knowledge and infection of STIs: Percent distribution of women by STIs knowledge and residence

Wereda Knowledge of STIs Bena Tsemay Selamgo Heard of STIs 56.3 48.7 Infected with STI 5.7 9.4 Number of women (n) 244 180

5.2 Knowledge and source of information about HIV/AIDS

Data on Knowledge, prevention, transmission, causes and sources of HIV/AIDS information is illustrated in Table 5.2. As indicated in this table, the majority of women (69.5 percent of women in Selamago and 69.2 percent in Benna Tsemay) are knowledgeable about HIV/AIDS.

The table clearly reveals that the women received HIV/AIDS information mainly from health professionals. Moreover, meetings and health messengers are reported as sources of HIV/AIDS information. About 63.7 percent of women in Benna Tsemay and 60.6 percent of women in Selamago reported that they do not know the causes of HIV/AIDS. Only 13 percent of Benna Tsemay women and 29.3 percent of Selamago women perceive that virus causes HIV/AIDS. Most women have an understanding about the mode of HIV/AIDS transmission. More than 87 percent of the women in both Woredas reported that unsafe sexual intercourse and 71.3 of women in Benna Tsemay and 84.4 percent of women in Selamago Woredas reported that sharing sharp objects are means through which HIV virus can be transmitted from person to person. Surprisingly, more than 12.2 percent of women in Benna Tsemay and 22 percent of women in Selamago perceive that mosquito can transmit HIV/AIDS virus.

The findings also indicate that more than 95 percent of women in both Woredas believed HIV/AIDS is not a curable disease. About 42 percent and 50 percent of the women in Benna Tsemay and Selamago Woredas respectively reported that HIV/AIDS is a preventable disease. The majority of women perceive that abstinence, being faithful to

49 partners and avoiding sharing needles are the best ways of preventing HIV/AIDS.(refer to Figure 7).

According to the information obtained from the participants of FGDs and KIIs, the knowledge concerning the causes of HIV virus, the modes of its transmission and the prevention methods have been really low and inadequate because a significant number of inhabitants have not yet been adequately synthesized except the information that HIV is a disease with no cure so far. In relation to this, the awareness level towards HIV/AIDS steadily declines one goes from urban areas to rural areas. On the other hand, there has been a big gap between the youth and adults in grasping the prevention methods from HIV infection. In accordance with this, some adult informants of both sexes could not able to adequately grasp the prevention methods like abstinence, faithfulness to the partner and using condoms. As a result, some informants largely remained non-conversant about HIV issue during the FGDs and KIIs. Because their attitude is dominated by misconceptions, erroneous assumptions and myths created towards HIV/AIDS. The following are some of the misconceptions that had been widely circulating around the inhabitants with regard to the mode of HIV transmission and the disease it self.

1. Washing one’ own body around the river bed. 2. Swimming and taking shower together with HIV positive person. 3. Casual contacts such as shaking hand, hugging and other social kissing as well as making conversation with patients of AIDS. 4. Buying food stuffs and sharing food/drinks, materials and living in the same room with HIV infected people could transmit the disease. 5. HIV/AIDS is not a disease that actually exists. 6. HIV/AIDS can be transmitted from animals to human beings by eating raw meat. 7. Traditional healers, herbalists and sorcerers or witchdoctors can treat HIV/AIDS. 8. People, who have been emaciated, thin and skinny as well as with low body weight, are perceived as carriers of HIV/AIDS or victims of the virus.

9. HIV/AIDS is perceived as the disease of urban inhabitants, and largely confined to urban settings. Therefore, infection can be prevented by avoiding sexual relations with people living in urban areas. 10. Chat traders, people often go to urban centres and pass the night in towns are perceived as the ones who can be contracted with HIV/AIDS, potential carriers and transmitters of HIV/AIDS.

In spite of that, some informants have certain knowledge about HIV/AIDS. According to the participants of FGDs and KIIs, heterosexual relations constitute a principal means for the spread of the HIV virus. They also understand that HIV can be transmitted from mother to child during pregnancy, and by the unsterilized sharp objects. Some informants suggest that marriage can be one of the preventive methods of HIV pandemic if the couples remain faithful to each other, and if they take blood test before marriage. They further indicate that they started to avoid sharing objects that pierce the skin, such as razors and needles. But unprotected premarital sex and sexual intercourse out of marriage had been widely practiced in almost all societies under in study area. They further argued that there had been certain death cases, which have had similar symptoms with HIV/AIDS.

According to the participants of FGDs and KIIs, the major sources of information and education in most of the rural K’ebeles of survey Woredas had been the staff of Health Bureau and some NGOs. Meanwhile, some of them are complaining that most of the sensitization workshops and training sessions that were organized at a Woreda level had been attended by K’ebele administrators and their kinsmen. Some K’ebele administrators mostly assign themselves on behalf of other inhabitants of the K’ebele. As a result, a limited number of people seem to be reached out through sensitization workshops conducted for certain years.

51 centres and some other rural areas. This situation coupled with very low literacy rate, inaccessibility of many localities, remoteness and harsh climate of the area; makes the implementation of activities to be more cumbersome than the efforts that might be made in other places. Apart from this, some informants are not comfortable with vaccination service given to their children because they have no adequate knowledge and awareness concerning its relevance. Nonetheless, most of the families bring their children to vaccination service because they are enforced by K’ebele administrators and fearing the punishment.

Figure 7: Knowledge level of women by HIV/AIDS prevention methods

100 90 80 70 60 Percent50 40 30 20 10 0 Bena Tsemay Selamgo Mall South Ari Total Woredae

Abstinence Being faithful to on partner

UsingAvoid condom sharing needles Avoid unsafe blood transfusion Avoid circumcision at unauthorized place

Table 5.2 HIV AIDS knowledge and source of information: Percent distribution of women by knowledge of HIV/AIDS, sources of information, means HIV/AIDS prevention and transmission

Wereda HIV/AIDS characteristics/ background Bena Selamgo Tsemay Heard about HIV/AIDS 69.2 69.5 Source of HIV/AIDS information Friends 0 0 Church/ Mosque 6.6 12.7 Health professional 62.1 79.6 Radio/Television 15.3 10.8 Pamphlets 5.0 6.9 Meetings 42.5 56.9 Health messengers 54.2 48.1 Others 9.0 4.2 Number of women (n) 301 260 Perception about causes of HIV/AIDS Punishment from God 11.0 5.4 Caused by virus 13.0 29.3 Food problem 1.0 .4 Other 11.3 4.2 Do not know 63.7 60.6 Total 100 100 Number of women (n) 300 259 Knowledge about transmission of HIV/AIDS Unsafe sexual intercourse/made sex with 87.8 88.5 any people Sharing sharp object 71.3 84.4 Mother to child during pregnancy 30.8 43.4 Mother to child during birth 28.7 42.2 Mother to child during breastfeeding 28.7 43.4 Blood transfusion 53.1 67.6 Kissing/shaving 17.5 16.0 Living with HIV+ people 15.0 19.3 Mosquito bit 12.2 22.1 Other 1.4 10.7 Number of women (n) 286 244 HIV/AIDS is curable disease 4.4 3.9 HIV/AIDS is preventable disease 42.2 50.4 Mode of prevention of HIV/AIDS Abstinence 84.1 77.5 Being faithful to on partner 73.8 86.0 Using condom 53.2 59.7 Avoid sharing needles 71.4 88.4 Avoid unsafe blood transfusion 38.1 59.7 Avoid circumcision at unauthorized 29.4 50.4 place Other 2.4 7.0 Number of women (n) 126 129

5.3 Voluntary Counseling and Testing (VCT)

Voluntary HIV counseling and testing (VCT) is a major HIV/AIDS prevention and care strategy. It is the ways of provision of counseling for persons to make an informed choice before being tested for HIV. The data from this survey show that forty percent of women in Selamgo Woreda and 37.6 percent of women in Benna Tsemay Woreda have no knowledge about VCT. Only 11 and 6.2 percent of the sampled women in Benna Tsemay and Selamago respectively had obtained HIV/AIDS test.

Table 5.3 shows that a little more than half of women (54.7 percent) in Benna Tsemay and 66.2 percent in Selamago have interest to know about their HIV/AIDS status. Among women who did not get HIV/AIDS test 78.4 percent of then in Benna Tsemay and 76.1 percent of them in Selamago believe that they are not at risk for HIV, 20 percent and 7.5 percent of them in Selamago and Benna Tsemay respectively said that VCT service is not available, the remaining 7.5 percent in Benna Tsemay and 11.4 percent in Selamago reported that they fear stigma. The majority (79.7 percent of them in Benna Tsemay and 81.5 percent of them in Selamago) perceives that the HIV/AIDS virus is not found inside a healthy looking person. For details refer to Table 5.3

According to the participants of FGDs and KIIs, the magnitude of stigma and discrimination had not been clearly known because no one has revealed himself to the public so far about his health status, and there is no VCT centre in close distance of many K’ebeles except in few places in other Woredas. Therefore, it was not possible to know which category of people had been more exposed to HIV infection than the other, and whether its prevalence rate is reducing or not. Surprisingly enough, most of the inhabitants have not yet informed regarding the availability of VCT centres even in the capitals of some of the Woredas. In this connection, almost all of the people in South Omo Zone have not yet tested for HIV/AIDS except a few in some urban centres and certain efforts made by some protestant church leaders to enforce the engaged couples to produce their certificates before their wedding day.

Table 5.3 Knowledge of VCT: Percent distribution of women who have perception about the use of testing HIV/AIDS by residence

Wereda Knowledge of HIV test Bena Selamgo Tsemay

Know the usefulness of HIV test 62.4 60.0 Had tested HIV/AIDS 11.0 6.2 Need/plan to test HIV/AIDS 54.7 66.2 Reasons for not testing HIV/AIDS No services available 7.5 20.5 Fear of stigma 7.5 11.4 No risk of HIV infection 78.4 76.1 Others 12.7 12.5 Number of women (n) 134 88 Believe that a healthy looking 20.3 18.5 person can have HIV/AIDS

However, most of the participants of FGD expressed that they are willing to be tested for the sake of knowing themselves and marriage purposes if the VCT centre is available in their area. In fact, a few of them expressed that they were not ready to be tasted even the service was available in the area. The major reasons proposed by these informants were lack of self-confidence, suspecting one self to be positive (if one happens to be HIV positive, life would become boring, meaningless and hopeless to him/her), not being ready for marriage, being practicing safer sex, and didn’t practice sexual intercourse with opposite sex. When asked whether to keep it secrete if he/she were happen to be HIV positive, most of the participants of FGD confirmed that they would feel a sort of discomfort to come out, and disclose their health status because they are afraid of neglect, blame, insult, stigma and discrimination. Only few informants expressed that they do not know what would happen if they found to be HIV positive.

Whereas some informants who participated in the training of HIV/AIDS confidently underlined that they would not keep secrete because it is possible to live by taking ART. A considerable number of informants argued that they are not ready to treat, and take care of the HIV patient even someone would be their family member. This indicates that the level of stigma and discrimination might be very high among the trained people. In relation to this, however, almost all forms of marriages that have been taking place in the

56 study area have still been performed without blood test, except very few cases in urban centers in the area.

In relation to this, the participants of FGDs and KIIs had different feelings towards infected people with HIV/AIDS. Some of them felt that being infected with HIV/AIDS is the effect of promiscuity. A few others argued that he must be ostracized from his family and the inhabitants of the K’ebele, and must be resettled in other place prepared for HIV patients. This kind of attitude may be due to inadequate training, or being contracted with HIV/AIDS is considered as a shame and curse by the wider community. There is also another misconception of attributing illness for a long period of time, and being physically emaciated or stunted to HIV infection, and vice versa. In general, the situation indicates the level of stigma and discrimination might be very high if someone is identified to be HIV positive.

5.4 Risk Perception

Information on HIV/AIDS risk perception was collected from HIV/AIDS knowledgeable women. As shown in Table 5.4, the majority of women (91 percent of women in Benna Tsemay and 96.2 percent of women in Selamago) believe that they are not at risk of HIV/AIDS. Women also asked to provide reasons for the fear of HIV/AIDS. Accordingly, 48.1 and 70 percent of the Benna Tsemay and Selamago women said that they fear it because of sharing common sharp objects; followed by 33.3 percent in Benna Tsemay and 40 percent of women in Selamago who reported that their husbands have had sex with other partners.

The data also indicate that the majority of the sample women in Benna Tsemay (77.8 percent) did not use condoms to prevent HIV/AIDS. However, half (50 percent) of women in Selamgo Woreda reported that they used condoms. Eighteen percent of Selamgo and 14 percent of Benna Tsemay women suspect that their husbands made sex with other women.

According to the findings from the participants of FGDs and KIIs, most of the young boys and girls seem to be exposed to risk conditions due to various factors. For instance, premarital sex has been widely practiced because girls seem to be culturally allowed to have unprotected sex with any body before they got married particularly among the Banna and the rest of the communities. Among the Benna, a girl who stays virgin until her wedding day and found to be virgin during her honey moon is considered to be unwanted, and she may be divorced. However, a girl is expected and oriented by married women to avoid pregnancy before marriage. If pregnancy happens before marriage, a girl will necessarily abort by using a local medicine provided by married women. If she could not able to abort, she marries him or the child will be killed after her delivery.

On top of that, unprotected sex practiced in weddings and dancing places have been some of the occasions that might expose a number of young generations of the study area to HIV infection because most of the people have yet started to use condoms. For instance, “Evangadi” (the local dance among the Benna) that takes place at every night

58 for a consecutive three and half months from the beginning of September to mid of December has been one of the risk conditions that paves the way to unprotected sex and makes many of them vulnerable to HIV/AIDS.

Furthermore, one may have several sexual partners especially among the Banna, Tsemay, and other ethnic groups whether he is married or not. Even this trend has been started to be adopted by members of the neighboring ethnic groups in the area. There are also several cases of pregnancy out of wedlock, and dozens of induced abortion cases which would expose the inhabitants to risk condition of being infected with HIV/AIDS

Table 5.4 HIV/AIDS risk perception: Percent distribution of women who have perception about the risk of HIV/AIDS, by residence Wereda HIV/AIDS risk perception Bena Selamgo Tsemay Believe that the risk of HIV/AIDS at the present Never at risk 91.0 96.2 To some extent at risk 5.3 1.2 At risk highly 0 0 Other 3.7 2.7 Total 100 100 Number of women (n) 300 260 Reasons for risk of HIV/HIDS Always make sexual intercourse 22.2 10.0 Received blood transfusion 3.7 10.0 Husband made sex with other women 33.3 40.0 Not faithful to partner 29.6 20.0 Sharing sharp object 48.1 70.0 Other 18.5 20.0 Number of women (n) 27 10 Used condom 22.2 50.0 Suspecting husband can have sex with other 14.0 18.1 woman

5.5 Action Taken To Prevent Getting HIV/AIDS

59 respectively prefer to be faithful to partners, followed by avoiding sharing needles (68.1 percent for Benna Tsemay and 74 percent for Selamago) and abstinence (55.3 percent for Benna Tsemay and 68.7 percent for Selamago). Only 22.3 percent and 18.3 percent of women in Benna Tsemay and Selamago respectively used condom to prevent HIV/AIDS transmission.

Table 5.5 Type of Action to prevent HIV/AIDS: percentage of women who have taken action to prevent HIV/AIDS, by residence

Wereda Type of actions Bena Tsemay Selamgo Prevention methods Avoid sex completely 55.3 68.7 Stay faithful to partner 68.1 87.8 Used condoms in every act of sexual intercourse 22.3 18.3 Avoid sharing of needles 68.1 74.0 Others 1.1 4.6 Number of women (n) 94 131

5.7 Knowledge of PMTCT

Prevention of mother to child transmission (PMTCT) is the best strategy to reduce the transmission of HIV/AIDS from HIV infected mother to her baby. Babies are at risk for HIV during pregnancy and lactation/breastfeeding. Therefore, antenatal and postnatal VCT service is an important approach to save the newborn infants. This survey gathered data on knowledge of women towards PMTCT service. As Table 5.6 shows, only 34.6 percent of the women in Benna Tsemay and 19.2 percent of women in Selamago Woreda have knowledge on PMTCT services.

Table 5.6 Knowledge of PMTCT: percentage of women who have knowledge on PMTCT, by residence

Wereda Knowledge of PMTCT Bena Selamgo Tsemay

Heard of information on PMTCT Yes 34.6 19.2 No 65.4 80.8 Total 100 100

Number of women 301 260

5.8 Knowledge of ART

Antiretroviral therapy (ART) is a drug, which is used to increase survival, improving quality of life and reduce morbidity of people living with HIV/AIDS. Table 5.7 presents information on women who have ART knowledge. The result illustrates smaller proportion of women in Benna Tsemay (27.9 percent) and Selamago Woreda (29.6) has ART knowledge.

Table 5.7 Knowledge of ART: Percentage of women who have knowledge on ART, by residence

Wereda Knowledge of ART Bena Selamgo Tsemay Heard about ART information Yes 27.9 29.6 No 72.1 70.4 Total 100 100 Number of women 301 260

5.9 Extramarital Sex

Extramarital sex is a window of hop for the spread of sexually transmitted infectious disease, including HIV/AIDS. Besides, women who exercised extramarital sex are at risk of abortion and unintended birth. Information on extramarital sex was collected from women by asking whether they had had sexual intercourse before marriage. Table 5.8 shows that a little less than a quarter of women in Bena Tsemay and 16 percent in Selamgo Woredas said that they had practiced sex before marriage.

Table 5.8 Extramarital sex: percentage of women who had sex before marriage, by residence

Wereda Extra marital sex Bena Selamgo Tsemay Sexual practices before marriage Yes 23.1 15.8 No 76.9 84.2 Total 100 100 Number of women (n) 299 259

5.10 Age at Fist Sexual Debut

Table 5.9 displays percent distribution of women by age at first sexual debut. As indicated in this table, about 13 percent of women in Benna Tsemay Woreda had first sex while under age 15 years. Moreover, 41.7 percent of Selamago women said that they started the first sex while they were aged between 15 to 19 years. On the other hand, more than 40 percent of the sample women did not know the age they started sexual intercourse.

Table 5.9: Age at sexual debut: Percent distribution of women by age at first sexual practice and residence Wereda Age at first sexual debut Bena Selamgo Tsemay Age groups in years Under 15 years 13.2 6.2 15-19 years 35.1 41.7 20- 29 years 9.1 3.5 30+ years 0 0 Do not know 42.6 48.6 Total 100 100 Average age at first sex 16.3 16.3 Number of women 296 259

CHAPTER VI

REPRODUCTIVE HEALTH

6.1 Pregnancy and childbearing

Collecting information on pregnancy and childbearing is useful to understand the health conditions of women in relation to pregnancy. Several studies show that women who have had many pregnancies/ more than five/ are at high risk of pregnancy related morbidity and mortality.

Information on women’s pregnancy and childbearing practices of the study population is presented in Table 6.1. As shown in this table, the majority of women (85.3 percent in Benna Tsemay and 86.1 percent in Selamago) experienced pregnancies. Among those who experienced pregnancy, 98.1 and 96.9 percent of Benna Tsemay and Selamago women respectively had given live births. Most women (about 34 percent) reported that they did have five or more pregnancies, followed by 22.3 percent in Benna Tsemay and 19.3 percent in Selamago who reported experiencing only two pregnancies and 13.9 percent in Benna Tsemay and 20.2 percent in Selamago had only one pregnancy. The average number of conceptions was estimated to be 4 pregnancies for both woredas.

Table 6.1 Pregnancy and childbearing Experience: Percentage of women according to pregnancy and childbearing experiences, by residence Wereda Pregnancy and birth Bena Selamgo Tsemay

Have ever been pregnant 85.3 86.1 Have given live birth 98.1 96.9 Frequency of pregnancy 1 pregnancy 13.9 20.2 2 two pregnancies 22.3 19.3 3 pregnancies 14.9 12.4 4 pregnancies 14.1 13.7 5+pregnancies 34.8 34.5 Total 100 100 Average number of 3.9 3.7 pregnancy Number of women (n) 368 322

6.1.2. Fertility

Fertility is the key demographic variable that influences population change. In order to have some insight about the reproductive behavior of the population was collected by asking each woman to report the number of live births she had ever borne/. Women were also asked to provide information on the number of died children. Figure 8.

As indicated in this table, a total of 302 and 262 women in Benna Tsemay and Selamago respectively had given birth to 1325 and 1138 children respectively. The mean number of children ever born per woman was 4.5 children for Benna Tsemay and 5.4 children for Selamago (450 and 540 children ever borne per 100 women).

Overall, the sex ratio at birth (male to female) is estimated to be 1.02 in Benna Tsemay. This indicates that there were 102 male births per 100 female births. In Selamago it is 0.92. This means there were 92 male births per 100 female births. For human populations Sex ratio at birth ranges between 102 and 107. There is considerable deviation from the expected sex ratio at birth in Selamago and this is likely to be due to errors of reporting the sex of children who might have died.

Figure 8: Trends inSex mean ratio number of children ever borne, dead and

6 2.45 4.7 2.4 4.8 5 2.35

2.3 4.3 3.8 2.3 4 Numbe 3.1 3.0 2.25 Numbe 2.3 r r 3 2.2 2.2 2.15 2 2.1 2.1

1.08 2.05 1 1.02 0.92 0.99 1.01 2 0 1.95 Bena Tsemay Selamgo Mall South Ari Total e Woreda

Mean number of children ever borne

Sex ratio

Mean number of died children

Fertility in general appears to be high in both Woredas. Figure 9 presents the mean number of children ever born by five-year age group and Woreda. As the data show, women in Benna Tsemay Woreda have the highest fertility than Selamago woreda.

Figure 9: Mean Number of Children Ever born per woman by age and Woreda

9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 15-19 20-24 25-29 30-34 35-39 40-44 45-49

Bena Tsemay Selamago Malie South Ari

Table 6.2 Fertility differentials by residence: Number of women, children ever born and died children by residence Woreda Bena Selamg Tsemay o Children ever born Number of children ever born 1325 1138 Mean number of children 4.5 5.4 Number of women (n) 302 262 Sex of children ever born Male 669 546 Number of women (n) 293 252 Mean number of children 2.3 2.2 Female 656 592 Number of women (n) 292 257 Mean number of children 2.2 2.3 Sex ratio at birth (male to female) 1.02 0.92 Died children Number of died children 262 181 Number of women (n) 117 88 Mean number of died children 2.2 2.1

6.1.3 Age at first birth

It is well-established fact that age at first birth disrupts the survival of women. Young women (below 18 years) and older women (above 35) years are at greater risk of developing pregnancy complications and death. To give an idea about the age women start giving birth, all women who had at least one live birth were asked to report on the age at which they had their first baby. Table 6.3 shows the distribution of women who had at least one live birth by age at first birth. More than a third of women with at least one live birth in Salamago and 30 percent in Bena Tsemay had their first baby before age 18 years. Most of the women (39.5 percent) in Bena Tsemay Woreda had given first birth at their 20’s age. While most of the women (41.0 percent) in Selamago Woreda had given first birth at their 18-19 age. The median age at first birth among women who had at least one child was estimated to be 19 years for both Woredas.

Table 6.3 Age of women at first birth: Percent distribution of women by age at first birth and residence

Wereda Age at first birth Bena Selamgo Tsemay Age groups in years <15 years 3.6 2.8 15-17 years 26.0 32.0 18-19 years 33.1 41.0 20+ years 39.5 32.0 Total 100 100 Median age at first 19 19 birth Number of women (n) 223 178

6.1.4 Desire For More Children

Data was collected from all eligible women about the number of children desired. As shown in Table 6.4, 72.7 percent of women in Benna Tsemay and 76.2 percent in Selamago said that they wanted to have more children.

The table clearly illustrates sex preference of the next child. About 48.4 and 54.4 percent of women in Benna Tsemay and Selamago do not worry about the sex of the next child. Nevertheless, some 21 percent of women in both Woreda prefer a boy while 15.3 percent in Benna Tsemay and 12.9 in Selamago prefer a girl. Likewise, about 40 percent of women in both woreda said that husbands prefer a son to girl child. From this result, it may be concluded that boys are more preferred than girls in these communities. The data indicate over 7 and 11 percent of the respondents in Benna Tsemay and Selamago respectively do not want additional children. Most of the respondents in Benna Tsemay reported that they do not want additional children mainly because they have already enough children while those women in Selamago said that child rearing is becoming very expensive. About 52.9% of the women in Benna Tsemay who did not want additional children reported that they have already achieved the desired number.

Table 6.4 Women’s desire for additional children: Percent distribution of women who want additional children by when to have the next child and preferred sex of the next child Wereda Fertility differential Bena Tsemay Selamgo Want additional children Yes 72.7 76.2 No 7.9 11.2 Can not get pregnant 3.2 5.4 Do not know 16.2 7.2 Total 100 100 Number of women (n) 216 223 How long to wait before having the next birth Within a year 31.6 17.5 1-2 years 17.4 28.7 2 years and more 25.2 21.6 Can’t decide 16.8 21.1 Do not know 9.0 11.1 Total 100 100 Number of women (n) 155 171 Sex preference for next child Boy 21.0 21. Girls 15.3 12.9 Either sex/do not worry about sex/ 48.4 54.4 Do not know 15.3 11.1 Total 100 100 Number of women (n) 155 171 Husband’s preference of next child sex Boy 40.1 39.2 Girls 12.1 12.9 Do not know 47.8 48.0

Total 100 100 Number of women (n) 155 171 Reasons for not desiring additional children Already have enough 52.9 36.0 Cannot afford any more 35.3 40.0 Spouse/respondent/ is too old 23.5 0 Spouse/husband/ does not want any 11.8 0 more Others 23.5 33.3 Number of women (n) 17 25

6.2 Family Planning

Studies documented that family planning helps to save women’s and children’s lives and preserves their health by preventing unwanted pregnancies, reducing women’s exposure to the health risks of childbirth and abortion. Ultimately, it contributes to slower population growth and rapid economic development. Collecting such information has paramount importance to assess the health and well being of women, children and communities. From this point of view, this survey gathered data on women’s knowledge of family planning, experiences to modern family planning methods, and reasons for not using contraception.

According to the participants of FGDs and KIIs, sexual issues have not yet discussed openly in most of the societies of the country, the case of the people under this study could not be exceptional. As the young boys and girls (adolescents) from rural areas who participated in FGDs remarked, they have never discussed the sexual issues such as menstruation, sexual intercourse, sexuality and sexual preferences with their parents, and even rarely discuss with adults older than themselves. They learn such issues from their friends, peer groups, the mass media and schools. In most cases, they get information about sexual issues from their friends and peers of the same sex. In fact, some of the young girls did not deny that they have got the first information especially about menstruation from their older sisters, cousins and young neighbours of the same sex.

6.2.1 Knowledge of FP

Women were asked if they have ever heard about modern family planning methods. Table 6.5 presents the responses to these questions. Smaller proportion of women (about 31 percent) in Bena Tsemay and Selamgo Woredas appear to have some knowledge about family planning knowledge.

The most important source of family planning methods is health professional (more than 79 percent of women in Benna Tsemay and 86.6 percent in Selamago responded it), followed by Health messengers in Benna Tsemay (54 percent) while meeting in Selamago (52.1 percent). The overwhelming majority of women (76.6 percent in Benna Tsemay and 77.3 percent in Selamago) reported that they know more about injection contraception. About 73 and 71.4 percent of women in Benna Tsemay and Selamago Woredas respectively responded that they have knowledge of the pill. The result reveals that most women do not have Norplant and IUD (Intrauterine Device) knowledge. It is also found that a relatively high proportion of women (60.3 percent in Benna Tsemay and 52.9 percent in Selamago) do not know emergency contraception. For Details refer figure 10.

Figure 10: Percent distribution of women by type of contraception knowledge

100 90 80 70 Bena Tsemay 60 Selamgo 50 Mali percent 40 South Ari 30 20 10 0 Pill IUD Injection Norplant Condom Type of modern contraception

Table 6.5: knowledge of family planning: Percentage of women who have knowledge of family planning, by residence Wereda Knowledge of family planning Bena Selamgo Tsemay Heard of family planning (FP) Yes 31.5 31.8 No 67.6 68.2 Not stated .9 0 Total 100 100 Number of women (n) 435 374 Source of information about FP Friends 21.2 21.0 Church/mosque 5.1 5.0 Radio/television 9.5 10.9 Health professional 79.6 86.6 Pamphlets 5.8 7.6 Meeting 21.9 52.1 Health messengers 54.0 49.6 Others 4.4 5.0 Number of women (n) 137 119 Knowledge of contraception/family

planning methods/ Pill 73.0 71.4 IUD 18.2 8.4 Injection 76.6 77.3 Norplant 17.5 5.9 Condom 26.3 13.4 Others 12.0 6.0 Number of women (n) 137 119 Heard of emergency contraception Yes 39.7 47.1 No 60.3 52.9 Total 100 100 Number of women (n) 137 119

6.2.2 Ever Use Of Family Planning

The data of this survey indicate that among all women, only 38 and 35.3 percent in Benna Tsemay and Selamago respectively have ever used modern contraception. (Table 6.6).

Table 6.6: Ever use of family planning: percentage of women by ever use of family planning and residence

Use of family planning Wereda Bena Selamgo Tsemay Ever use of family planning Yes 38.0 35.3 No 60.6 62.2 Never made sex 1.5 2.5 Total 100 100 Number of women (n) 137 119

6.2.3 Current Use Of Family Planning

Figure 10 presents current use of family planning methods at the time of the survey. As shown in the figure, only 8.5 percent and 7.0 percent of women in Bena Tsemay and Salamago respectively were using contraception at the time of the fieldwork. (Figure 11A).

Figure 11A: Current use of Contraceptives

25.0

20.0 20.0

15.0 12.9 12.3

10.0 8.5 7.0

5.0

Percent using Contraceptives using Percent

0.0 Bena Salamago Malle South Ari Total Tsemay Woreda

The most common method of contraception used by women in both Woredas is injection followed by Pill. About 1.6 percent of women in Bena Tsemay and 1.1 percent in Salamago using IUDS. Condom use was reported by less than a quarter of a percent in both woredas. Very few women reported using EOC in Bena Tsemay Woreda. In general,

73 like in many parts of Ethiopia, long term or permanent methods of contraceptives are not practiced in these Woredas Figure 11B)

Figure.11B: Contraceptive methods used by Woreda:

20 18 16 14 12 10 8

Percent Using Percent 6 4 2 0 Pill IUD injection Norplant Condom EOC Other Contraceptive Method

Bena Tsemay Salamago Malle South Ari

6.2.4 Reason For Not Using Family Planning

Women who were not using family planning methods at the time of the survey were asked why they were not using. The most common reason reported by the respondents is different in two Woredas. In Benna Tsemay the most common reason reported was they are pregnant (40 percent).While in Selamago they belief that contraceptive have side effects/ affects health and wants to have more children (each 21.4%). About 13.3% in Benna Tsemay reported that they were not using it because they wanted to have children. (Table 6.7)

Table 6.7: Reasons for not using family planning: percentage of women who provide reasons for not using family planning, residence Wereda Reasons Bena Selamgo Tsemay Reasons for not using family planning currently No service 6.7 0 Pregnant 40.0 7.1 Not suitable/health problem 6.7 21.4 No appropriate FP for respondent 6.7 14.3 Want to have child 13.3 21.4 Husband does not allow to use FP 0 7.1 Respondents do not support use of FP 0 0 Other 26.7 28.6 Number of women (n) 388 343

6.3 Use of Antenatal and postnatal care

6.3.1 Use of Antenatal Care

Antenatal care service including pregnancy checkup and immunization has a significant effect on the health of women and their newborn babies. The survey collected information on the use of antenatal care services at the time of pregnancy. As indicated in Table 6.8, over forty percent (42 percent in Benna Tsemay and 46.2 percent in Selamago) of pregnant women reported that they had visited health facilities for checkups and immunization services.

The data shows that that about half of women in Bena Tsemay and Selamgo Woredas did not receive TT immunization. The majority of women (60.7 percent in Benna Tsemay and 56.4 percent in Selamago) received three or more TT injection.

Table 6.8: Antenatal Care Services: percentage of women by use of Antenatal care and residence Wereda ANC Bena Selamgo Tsemay Attending health facility during last pregnancy Yes 42.0 46.2 No 58.0 53.8 Total 100 100 Number of women (n) 219 221 Not stated (n) 1 2 Received TT immunization Yes 52.3 52.9 No 47.7 47.1 Total 100 100 Number of women (n) 216 223 Not stated (n) 4 0 Number of TT injection received 1 TT injection 15.2 12.8 2 TT injections 24.1 30.8 3+ injections 60.7 56.4 Total 100 100

Median time of receiving TT injection 3 3 Number of women (n) 112 117 Not stated (n) 1 1

6.3.2 Facility based delivery

Women were asked about the place where they gave births. Table 6.9 shows that close to 50 percent of women in Selamago and 41.4 percent of women in Benna Tsemay Woreda delivered at home alone with no assistance and 38.9 percent in Benna Tsemay and 28.4 in Selamago assisted by untrained traditional birth attendant). Health facility based deliveries are very low in both Woredas (6.8 percent in Benna Tsemay and 5.1 percent in Selamago). Surprisingly, In Salamago Woreda, about 6 percent women reported delivering in the forest with out any assistance. The highest percentage of women (6 percent) who gave birth at forest is observed in Selamgo Woreda.

Table 6.9: Facility based delivery: percentage of women by type of facility based delivery and residence Wereda Type of facilities Bena Selamgo Tsemay Type of delivery place for last birth Health facility 6.8 5.1 Home with skilled traditional midwife 8.4 7.9 Home with unskilled traditional midwife 38.9 28.4 Home with health extension workers 1.6 4.2 Home-lonely 41.1 48.4 Forest-lonely 2.6 6.0 Other .5 0 Total 100 190 Number of women (n) 190 215

6.3.3 Use Of Postnatal Care

Data on postnatal care (care after birth) was collected in this survey. Table 7.6.3 presents the percentage of women who visited health facilities after birth. 60 percent of women in Salamago and 48.4 percent in Bena Tsemay did not receive postnatal care services (Table 6.10). Table 6.10: Use of postnatal care: percentage of women by use of postnatal care and residence

Wereda Use of Postnatal care Bena Selamgo Tsemay Receiving postnatal care for recent birth Yes 51.1 40.0 No 48.4 60.0 Not stated .5 0 Total 100 100 Number of women (n) 190 215

CHAPTER 7 HARMFUL TRADITIONAL PRACTICES

In Ethiopia, there are tremendous traditional, cultural and religious practices that have direct negative impact on women’s health and well-being. Early marriage, abduction, son preference, bride price, women hitting, female genital mutilation are among the harmful traditional practices common in Ethiopia. In order to have an idea about the dimension and existences of harmful traditional practices in the study area, women were asked to provide information on some major harmful practices.

7.1 Major Harmful Traditional Practices

Women were asked to identify the major traditional practices, which have given values and beliefs, by members of the community. Table 7.1 presents major harmful practices as reported by the respondents.

Table 7.1: Major harm full traditional practices: percentage of women who reported major harmful traditional practices, by residence

Wereda Common Harmful Traditional Practices/HTP Bena Selamgo Tsemay Type of HTP in the community Early marriage 53.4 63.6 Abduction 48.7 69.8 Tonsilectomy/univlictomy 26.7 47.9 Rape 34.1 45.5 Stigmas of women during birth 20.0 24.6 Thrown of child /Mingi 42.2 17.6 Killing of a child if it is born with out the custom 34.8 12.3 Women hitting 42.2 26.2 Inheritance marriage 52.2 68.2 Polygamy 57.8 79.7 Giving higher payment to bride groom/family 49.4 62.3 Prevention of eating with men 26.0 36.1 Lip cutting 3.0 43.0 Teeth extraction 25.8 42.2 Washing of milk material with cattle urine 3.9 36.6 Not washing female body 18.6 8.0 Chick image alteration when people dead 2.8 15.8 Prevent women not to eat honey and milk for 3 2.3 7.2 months Others 6.7 17.4 Number of women (n) 435 374

As indicated in this table, in Bena Tsemay Woreda, polygamy, early marriage and marriage by inheritance are the major practices. Likewise, Abduction and early marriage are also major harmful practices in Selamgo Woreda. For details refer to Table 7.1.

According to the participants of FGDs and KIIs, there have been a number of harmful customary practices in the study area except female genital mutilation. The only two ethnic groups that have been widely practicing female genital mutilation in South Omo zone are Dasenetch and Arbore. The following are some of the harmful customary practices that have been widely practiced by most of the ethnic groups: polygamy, tonsillectomy, early marriage, milk teeth extraction, rape, abduction, high bride price, infanticide, widow inheritance, lip- plate and others. Nevertheless, lip- plate is practiced only by Mursi ethnic group under this study. All women are expected to have lip- plates among the Mursi because it is a symbol of beauty and gaining acceptance by a wider community. Viewed from gender perspective, the custom may be regarded as a design made to dominate woman and render them vulnerable. A woman or a girl without a lip- plate is subject to a serious of sanctions, mockery and alienation by the community.

On the other hand, the practices of abduction, rape and infanticide have been declining since the last few years as a result of serious legal measures taken by law enforcing bodies though they have not yet been totally eradicated from the area. There has been a rumour that infanticide is presently practiced by people living in peripheral areas near the borders between Ethiopia and Kenya as well as Ethiopia and Sudan. In the former time, infants whose incisors/teeth of the upper jaw started to grow before the lower jaw were immediately thrown in the bush among Benna, Tsemay, Mursi, and other ethnic groups. Such children are designated by the term “Minggi”, which implies that they are the ones who would bring catastrophe, misfortune, curse, lack of rain, drought and famine in the area.

Apart from this, women are not allowed to give birth within their own house among the Benna and many other ethnic groups in the study area. Among the Benna, women mostly isolated from their home and give birth in the bush nearby their houses. The informants from Tsemay ethnic group alleged that women of their community started to deliver within their own house since the last few years though the argument was not confirmed by other sources. On the contrary, women give birth in their own house among the Boddi ethnic group, but they have no leisure time until the day of their delivery.

Apart from this, milk teeth extraction and uvula cutting are the most widely practiced harmful customary practices among all ethnic groups in the area. They believe that children would be exposed to sudden death and frequent diarrhea if their teeth are not extracted and their uvula would not be cut down. The participants of FGDs admitted that a single instrument is mostly used for different children during uvula cutting and milk teeth extraction by local practitioners, and this may resulted in health hazards including HIV/AIDS.

Subsequently, the problem of early marriage has been started to be practiced among a number of ethnic groups such ad Benna, Tsemay and others mainly since the last one decade. Among these ethnic groups, girls are getting married beginning from the age of

12 to 14 years on average. Early marriage has continued to exist mainly parents justify it by saying that they want to see their children’s ceremony before they die. Besides this, parents are afraid of negative cultural rebelling if their children could not perform their marriage at the right time. Furthermore, parents want to secure economic advantage through the marriage relationship. As a result, a number of female children seem to perform marriage at their early age and seem to be exposed to early pregnancy, early death related to pregnancy, and giving birth to immature and/or unhealthy child. In connection to this issue, however, slight change has been taking place that school girls are performing their marriage at a later age than in the former time in some urban centres.

7.2 Experience of Harmful Traditional Practices

Table 7.2 presents information on women’s exposures towards harmful practices. As can be seen from the table about a quarter (26.6 percent) of the women in Bena Tsemay Woreda reported that they had encountered physical violence. The Majority of women in Selamgo Woreda had experienced high bridegroom prices and are in polygamous marriages.

Table 7.2: Experience of harmful traditional practices: percentage of women who practiced harmful traditional practices, by residence Wereda HTP experience/practices Bena Selamgo Tsemay Type of HTP experiences/ practices exists Early marriage 18.1 17.6 Abduction 12.7 17.4 Tonsilectomy/univlictomy 5.4 14.2 Rape 6.6 5.6 Stigmas of women during birth 4.5 5.3 Thrown of child /Mingi 6.8 .5 Killing of a child if it is born with out the custom 6.1 1.3 Women beating 26.6 8.6 Inheritance marriage 14.4 9.1 Polygamy 19.5 25.9 Giving higher payment to bride groom/family 24.5 46.5 Prevention of eating with men 15.1 25.1 Lip cutting 2.8 26.2 Teeth extraction 12.5 31.0 Washing of milk material with cattle urine 2.6 26.5 Not washing female body 11.1 2.4

Chick image alteration when people dead 1.4 2.7 Prevent women not to eat honey & milk for 3 1.4 2.1 months Others 11.8 16.0 Number of women (n) 425 374

7.3 Support for the Discontinuation of HTPs

Data was collected on women opinions about the discontinuation of harmful traditional practices. As shown in Table 7.3, about nine out of ten women in both woredas are against the practices. Only 37.4 percent of women in Selamgo and 32.2 percent of women in Benna Tsemay want to continue the practices bridegroom price.

Table 7.3: Discontinuation of HTPs: percentage of women who want to discontinue harmful traditional practices and residence

Wereda Discontinuation of HTP Bena Selamgo Tsemay Type of HTP to be discontinued Early marriage 91.6 92.2 Abduction 93.7 92.8 Tonsilectomy/univlictomy 94.2 92.0 Rap 97.4 97.1 Stigmas of women during birth 97.4 95.7 Thrown of child /Mingi 91.1 97.6 Killing of a child if it is born with out the custom 93.0 97.1 Women hitting 80.6 96.3 Inheritance marriage 71.7 84.0 Polygamy 68.7 70.6 Giving higher payment to bride groom/family 67.8 62.6 Prevention of eating with men 90.4 77.3 Lip cutting 95.3 74.1 Teeth extraction 86.4 70.9 Washing of milk material with cattle urine 97.2 74.1 Not washing female body 92.3 95.5 Chick image alteration when people dead 97.9 97.3 Prevent women not to eat honey and milk for 3 97.7 96.0 months Others practices 86.6 76.7

Number of women (n) 435 374

7.4 Knowledge and experience About Fistula

82 opening between one hollow organ and another, which is between the urinary bladder and the vagina or the rectum and the vagina (WHO, 1997). Accordingly, information was collected from entire women by asking their knowledge and practices to obstetric fistula. As shown in Table 7.4, about nine in ten women in Bena Tsemay Woreda, 85 percent in Salamago reported having not heard about fistula. In contrast, about a quarter of the women in Salamago, 16 percent in Bena Tsemay had themselves experienced fistulas.

Table 7.4: Knowledge and experiences of fistula: percentage of women who have knowledge and experience of fistula, by residence Wereda Knowledge and Bena Selamgo experience of Fistula Tsemay Knowledge of Fistula Yes 11.3 15.2 No 87.8 84.5 Not stated .9 .3 Total 100 100 Number of women 435 374 (n) Experiences/ practices of Fistula Yes 16.3 23.2 No 83.7 76.8 Total 100 100 Number of women 49 56 (n)

CHAPTER 8

GENDER ISSUES

8.1 Decision making

A number of studies defined that gender is a socially constructed difference between women and men in roles and responsibilities, access to resources and decision-making power. Differences in decision making at the household level lead to gender inequalities. In order to assess women decision-making role and women empowerment, the survey collected information from all women by asking their perceptions about on who should be making decision in relation to household activities.

Table 8.1 presents the percentage of women by their opinion regarding whether a man or a women should make decisions regarding some important issues. The data demonstrates that most of the women reported that both husband and wife should jointly make decisions on household activities. For instance, 75 and 83.9 percent of women in Benna Tsemay and Selamago Woredas respectively said that husband and wife together should decided to take a sick child to hospital/health facility, about 67.4 percent of women in Benna Tsemay and 77 percent of women in Selamago perceive that both husband and wife should decide whether or not to have another child.

The table also shows that 55.5 percent of women in Benna Tsemay and 57 percent of women in Selamago believe that men have better leadership capability than women, whereas, 38.2 percent of women in both woredas said that both men and women can fit for public administration. Only 6 and 4.8 percent of women in Benna Tsemay and Selamago respectively reported that women have ability to stand at the leadership position.

Table 8.1: Women in decision-making: percentage of women who have perception about decision making, by residence Wereda Decision making process Bena Selama Tsemay go Take a sick child to a medical facility Husband with out consulting wife 6.8 6.7 Wife without consulting husband 17.7 9.4 Both husband and wife 75. 83.9 Total 100 100 Decision about sending children to school Husband with out consulting wife 24.6 18.0 Wife without consulting husband 7.7 3.0 Both husband and wife 67.7 79.0 Total 100 100 Spending wife's income for the husband Husband with out consulting wife 31.4 20.9 Wife without consulting husband 12.9 16.0 Both husband and wife 55.7 63.1 Total 100 100 Spending husband's income for the wife Husband with out consulting wife 37.9 36.6 Wife without consulting husband 8.2 2.7 Both husband and wife 54.0 60.7 Total 100 100 Number of children to have Husband with out consulting wife 26.9 20.3 Wife without consulting husband 5.5 2.7 Both husband and wife 67.4 77.0 Total 100 100 Using family planning Husband with out consulting wife 27.8 19.2 Wife without consulting husband 5.5 2.7 Both husband and wife 66.7 78.0 Total 100 100 When daughter can marry Husband with out consulting wife 32.2 21.7 Wife without consulting husband 6.4 3.3 Both husband and wife 61.5 75.1 Total 100 100 Participation of women in meetings Husband with out consulting wife 35.1 19.8 Wife without consulting husband 10.1 6.4 Both husband and wife 54.8 73.7 Total 100 100 Sale of cattle Husband with out consulting wife 36.7 28.3 Wife without consulting husband 6.3 2.9 Both husband and wife 57.0 68.7 Total 100 100 Purchasing clothes for self Husband with out consulting wife 29.3 19.8 Wife without consulting husband 10.7 5.1

Both husband and wife 60.0 75.1 Total 100 100

Visiting friends or relatives Husband with out consulting wife 20.5 13.4 Wife without consulting husband 7.2 3.5 Both husband and wife 72.3 83.2 Total 100 100 Number of women (n) 429 373 Not stated (n) 6 1 Fit for public administration Men 55.6 57.0 Women 6.0 4.8 Both 38.2 38.2 Not stated .2 .0 Total 100 100 Number of women (n) 435 374

8.2 Wife Beating

Women were asked to provide information on their attitudes towards wife beating. As indicated in Table 8.2, women approve partner-induced physical violence in the household.

Table 8.2: Wife beating perceptions: percentage of women who believe about wife beating during conflict, by residence Wereda Wife beating Bena Selamgo Tsemay Believe that husband should punish wife with Killing 6.0 3.2 Beating 32.3 18.2 Shouting 63.0 38.6 Threatening with stick 33.5 17.4 Forced sex 13.2 6.4 Burned /scaled 10.4 4.8 Pushed pulled 17.8 10.2 Others 6.2 16.4 Number of women (n) 435 374

There are considerable differences by Woreda regarding women’s perception about domestic violence. While 63 percent of women in Bena Tsemay approving that a man can shout at his wife, only a little more than a quarter women in Selamago Woreda shared similar views. Moreover, about a third of women in Bena Tsemay approved wife beating, about 18% approved it in Selamago. In general higher proportion of women in Bena Tsemay approve physical violent action against wives in case of any wrong doing. Most women in Selamago woreda appear not to approve any physical violent action against women by their husbands.

CHAPTER 9

CHILD HEALTH

9.1 Knowledge of and Source Of information about Vaccination

Several researches have documented that neonatal tetanus; pertussis, measles with its complications (pneumonia, diarrhoea and systemic infection) and acute respiratory disease are attributed to the death of under-five children. These diseases can be prevented through immunization of pregnant women, newborn infants or children. Thus, this survey collected information on women’s knowledge and sources of information channels regarding vaccination services. Table 10.1 presents the responses of the women included in this survey by Woreda.

As can be seen in Table 9.1, the majority of the women (84.1 percent in Benna Tsemay and 81.1 percent in Selamago) Woredas have heard about vaccination (refer to Figure 12 and Table 10.1)

Table 9.1 and Figure 12 clearly depict that 78.2 percent of the women in Benna Tsemay and 82.1 percent of women in selamago obtained immunization information from health professional and about two-third got it from health messengers.

Figure 12: percentage of women by level of vaccination knowledge

have vaccination knowlede Have not knowledge

91%

Table 9.1: Knowledge and source of information about vaccination: percent distribution of women who have knowledge and source of child vaccination Wereda Knowledge and source of information about child Bena Selamgo vaccination Tsemay Knowledge/ heard of immunization Yes 84.1 81.1 No 15.9 18.9 Total 100 100 Number of women (n) 283 275 Source of vaccination information Friends 12.2 22.0 Church/mosque 2.5 4.0 Radio/television 6.3 6.3 Health professional 78.2 82.1 Pamphlets 1.7 1.8 Meetings 31.5 45.3 Health messengers 66.8 58.3 Others 3.8 3.1 Number of women (n) 238 223

9.2 Last Child Vaccinated

Table 9.2 shows that the majority of women (79.7 percent of women in Benna Tsemay and 73.4 percent in Selamago) had vaccinated their last child.

Table 9.2 Percentage of women with at least one Child who had vaccinated the last child Wereda Vaccination Bena Selamgo Tsemay Last child fully vaccinated Yes 79.7 73.4 No 14.8 24.3 Not applicable 5.5 2.3 Total 100 100 Number of women (n) 237 222 Not stated (n) 1 1

9.3 Reason for Not Vaccinating Last Child

Information was collected from women who did not vaccinate their last child. Lack of access to service was reported by more than 30.9 percent of women in Selamago Woreda, while about a quarter of those in Bena Tsemay reported lack of knowledge.

Table 9.3: Reasons not vaccinating last child: percentage of women who reported reasons for not vaccinating child, by residence Wereda Reasons Bena Selamgo Tsemay Reasons for not vaccinated last child The service is not available 5.7 30.9 Religion/belief is not permitted 0 0 Know that immunized child become sick 5.7 3.6 Do not know the importance of immunization 25.7 21.8 Other 62.9 43.6 Total 100 100 Number of women 35 55

9.4 Child Morbidity

Most under-five children are vulnerable to preventable diseases. In order to identify the causes of illness, information was gathered from individual women on childhood morbidity and mortality conditions. Figure 13 shows the percentage of women who reported about causes of childhood morbidity and means and availability of treatment.

As can be observed from the figure, the majority of the women in both woredas reported that diarrhoea, fever and coughing are the most common childhood diseases. Also, eye problem, skin infections and measles are the important childhood diseases. About 62.5 and 42.7 percent of women in Benna Tsemay and Selamago respectively said that they provided treatment for the sick child. More than nine in ten women in Benna Tsemay and 100 percent of women in Selamago reported that they took the sick child to a health facility to obtain treatment. However, a few women in Bena Tsemay Woreda said that they visited traditional healers, spiritual healers and holy water to cure the sick child (Table 9.4).

Figure 13: percentage of women by type of childhood disease

40 Bena Tsemay Selamgo 30 Mali

percent 20 South Ari

0 Eye Fever Skin Diarrhoea problem Coughing conditions Measles Type of childhood disease

Table 9.4 Child morbidity and treatment: percentage of women according to child morbidity and treatment, by residence Wereda Child morbidity and treatment Bena Tsemay Selamgo Received treatment Yes 62.5 42.7 No 37.5 57.3 Total Number of women (n) 72 74 Type of facility/place that took treatment Health facility 95.6 100 Traditional healer 4.4 0 Spiritual healer 2.2 0 Holy water 2.2 0 Other 2.2 12.5 Number of women (n) 45 32 Number of days took to get treatment The same day (within 12 hours) illness 20.0 18.8 happened The day after the onset of illness 15.6 21.9 After three days of illness 42.2 34.4 After a week of illness 15.6 21.9 Other 6.7 3.1 Total 100 100 Number of women (n) 45 32

CHAPTER 10

TUBERCULOSIS 10.1 Knowledge about TB

Although there has been a steady decline of cases of tuberculosis (TB), worldwide, there are an estimated eight million new cases of TB each year and three million deaths are attributed to this disease annually. The reduction in the incidence of TB will continue only if attention is paid to increasing awareness about the disease, identifying patients with TB, initiating proper treatment and implementing measures to reduce the risk of transmission to others. In order to help assess the level of awareness and incidence of the disease in the four woredas, in this survey, effort was made to collect information about knowledge of TB and its prevalence from all sampled women. Table 10.1 presents the percentage of women according to their knowledge about TB by Woreda.

As shown in the table, in Bena Tsemay, only 2 in five women appear to have heard about TB. While a little more than half of women in Selamago heard about TB. Among those who have heard about TB, almost all women (more than 96%) in both Woredas relate coughing to TB. About 35 and 40 percent in Benna Tsemay and Selamago respectively consider weight loss as a symptom of TB.

The data also show that nine in ten women in Selamago and Three-quarter of women in Benna Tsemay believe that TB can be transmitted from one person to another person. Regarding the means of transmission, more than 94 percent of the women reported that TB can be spread (transmitted) primarily from person to person by breathing infected air during close contact.

Table 10.1 Knowledge about TB: percent distribution of women about TB knowledge, transmission, prevention and treatment, by residence Wereda TB background characteristics Bena Selamgo Tsemay Knowledge/ heard about TB 40.7 53.7 Yes 59.1 46.3 No .2 0 Total 100 100 Number of women (n) 435 374 Symptoms of TB Cough 96.6 96.5 Fever 29.1 32.3 Sweet 19.4 18.9 Lost of weight 35.4 40.3 Other 8.0 16.9 Number of women (n) 177 201 TB transmitted from person to person Yes 75.7 92.8 No 24.3 7.2 Total 100 100 Number of women (n) 177 201 Means of TB transmission Cold air 0 0 Sexual intercourse .9 1.6 In food .9 .8 Breath 95.5 94.4 Other 2.7 3.2 Total 100 100 Number of women (n) 111 125 Not stated (n) 20 55 TB can be prevented Yes 68.9 68.6 No 31.1 31.4 Total 100 100 Number of women (n) 132 185 Not stated (n) 45 16 TB can be cured Yes 68.1 59.4 No 31.9 40.6 Total 100 100 Number of women (n) 135 187 Not stated (n) 42 14

10.2 Presence of TB patient in household

The survey also asked women whether there was a TB patient in their household. Table 10.2 presents the responses. Accordingly, more than one in ten women in both Woredas reported that they had a household member who has been coughing continuously for two weeks before the time of the survey. And among these in Selamago Woreda the

93 majorities are children and men. While in Benna Tsemay the majorities are children and women. The data indicates that under-five children are at high risk of cough in both Woredas. In Benna Tsemay about half (52.6 percent) of women reported that patients visit health facilities to obtain treatment. While most women in Selamago (more than 77 percent) reported that patients did not visit health facilities to obtain treatment. The possible reasons women gave for not visiting a health facility include, among others, traveling long distance to health facility is a barrier to get treatment (33.3 percent in Benna Tsemay and 29.4 percent in Selamago), followed by 22.2 percent of them in Benna Tsemay believes that cough can be cured by itself whereas 29.4 percent of them in Selamago Woreda do not know the presence of medication. Table 10.2 Presence of TB patients in the household: percent distribution of women by TB patients in the household and residence Wereda TB patients in the household Bena Tsemay Selamgo Presence of persons in the household who cough continuously for 2 weeks Yes 14.3 11.8 No 85.7 88.2 Total 100 100 Number of women (n) 140 187 Not stated (n) 37 14 Age of TB patient in years Under 5 years 21.1 36.4 5-9 years 21.1 18.2 10-19 years 15.8 9.1 20-29 years 5.3 18.2 30+ years 36.8 18.2 Total 100 100 Number of women (n) 20 22 Sex of the patient Male 47.4 54.5 Female 52.6 45.5 Total 100 100 Number of women (n) 20 22 Patient took hospital/clinic Yes 52.6 22.7 No 47.4 77.3 Total 100 100 Number of women (n) 20 22 Reasons for not going to hospital/clinic Do not know the presence of 0 17.6 medication No medical services 0 11.8 Too far to go hospital/clinic 33.3 29.4 Can cure itself 22.2 5.9 Cough could not cure with 0 0

94 medication Other 44.4 35.3 Total 100 100 Number of women (n) 9 17

10.3 Need of the Community and Options for Interventions Members of various communities try to list down their felt need and various problems facing their community. Among these problems lack of adequate water and health facilities have been the major ones followed by lack of adequate education, veterinary and infrastructural facilities. From the researcher’ view and confirmed by the local informants, genuine community participation is very important to bring behavioral change and sustainable development in the area. In connection to this, community members recommend persons respected in their community who would further influence others. In this regard, in the community of Benna and Tsemay, persons with title of “Biit” and “Boqoilku” have been very influential respectively. Consequently, using elders effectively in all communities for intervention purpose seem to be very essential.

CHAPTER XI SUMMARY, CONCLUSION AND RECOMMENDATION

11.1 SUMMARY

The main objective of this survey is to provide information on women, children and community’s health in relation to knowledge, attitude and practices of STIs, HIV/AIDS, family planning, availability of water, personal hygiene, malaria, child health, HTPs and gender issues. In order to meet this objective, the survey collected information regarding these issues from a representative sample of women who reside in four woredas of South Omo Zone, namely, Bena Tsemay, Selamgo, Malle and South Ari Woredas. A total of 1,657 women aged 15 to 49 years were included in this survey. Specifically, 435 women were interviewed from Benna Tsemay and 374 women from Selamago Woreda.

Socio-economic and demographic characteristics Religion, culture and ethnicity have direct and indirect impact on women’s health and wellbeing. Accordingly, information was also collected on religious and ethnic background of the sampled women. Survey results reveal that women have various religious affiliations The result indicate that 62.5 and 54.3 percent of the women in Bena Tsemay and Selemago Woredas respectively believe in traditional/customary religious practices, 14.7 percent from Bena Tsemay and 22.5 from Selamago were Protestant Christians.

Regarding ethnicity, respondents belonged to various ethnic origins, including Bena, Tsemay, Malle, , Birayle, Bodi, Dime, Mursi, Bacha and Konso, among others.

Women were engaged in various economic activities, such as the highest proportion of women (27 percent) in Bena Tsemay Woreda is engaged in agro pastoralist sector; about 30 percent of women in Selamgo Wereda are farmers

The survey found that the majority of women in both Woredas (86% in Benna-Tsemay and 84.6% in Selamago) did not have any education. Only 13.8 and 15.5 percent in

Benna-Tsemay and Selamago respectively reported that they had attended formal education. The result shows the level of literacy is extremely low in these woredas compared to that of the region. The 2005 EDHS shows that 31% of women at national level and 22 percent in SNNPR were literate.

Radio message is an important source of information on health and wellbeing. However, in these woredas, access to radio is limited and the majority of women do not listen to radios.

The data of this survey illustrates that the median age of sampled women. There was no significant difference by Woreda in age among women included in the survey. The median age of women in Bena Tsemay and Selamgo Weredas are 26 years and 25 years respectively.

Regarding marital status of the women, the result shows that about 80 percent of women in Benna Tsemay and 83.7 percent of women in Selamago were currently married, 8.5 and 5.1 percent in Benna Tsemay and Selamago respectively were widowed, 2.1 percent in Benna Tsemay and 1.6 percent in Selamago were divorced and only 8.5 and 9.1 percent of women in Benna Tsemay and Selamago respectively were single.

Marriage is relatively late compared to other parts of the country as the mean age at first marriage was found to be 17 year (nationally 16 years). Most women had contracted marriage through Consensus. Marriage by family arrangement and abduction was also reported to be significant. There seems to be high prevalence of polygamous marriages in these woredas. One in three women reported that their husband has more than one wife.

Information on size of household shows that in the majority of cases, there were more than 5 persons in a household. The average household size was found to be 5 members each in Bena Tsemay and Selamgo Weredas. Under five mortality was reported to be highest in both woredas

Household water, health and Sanitation In these Woredas, it is very difficult to get safe drinking water. Some 31 percent Bena Tsemay women and only 0.5 percent of women in Selamago have access to surface water. Over one third (36 percent) of women in Selamgo Woreda reported that river is the main source of water for household consumption and drinking. This is much lower compared to the national level. The 2005 EDHS results reveal that 61 percent of households in Ethiopia have access to safe/improved drinking water.

It is not only the quality of water that is a problem in these communities. Access to any water source is also a problem. About 62.9 percent of women in Benna Tsemay and 81.8 percent of women in Selamago travel more than two hours to fetch water, which is too long compared to the national average. The 2005 DHS found that 44.3 percent of women have access to water within half an hour. The survey result also indicates that the estimated median time to fetch drinking water is 15 hours. Most women also reported that water interruption is the main problem of the community.

About 86 percent of women in Bena Tsemay Woreda and 67.6 percent in Selamago have no toilet facility. The proportion of women with no toilet facility is higher than in the 2005 DHS estimate, which found that 62 percent of households have no access to toilet facility.

Malaria Women were asked to identify the major health problems of the community. The survey result showed that malaria is the leading causes of health problem (more than 90 percent). In addition, 62.1 percent of women and 44.1 percent of women believe that diarrhoea and respiratory disease/TB/ are the second and third common health problems in the community, in that order.

The data indicates that most women have knowledge on transmission and prevention of malaria. Accordingly, most women (more than 88 percent) in both Woredas also reported that malaria is a treatable disease. The overwhelming majority of women in each Wereda

98 know that malaria infection is transmitted through mosquito bite (90.2 percent in Benna Tsemay and 83.4 percent in Selamago). Surprisingly, a small proportion of women in Benna Tsemay and Selamgo Woreda believe that witchcraft is a means through which malaria is transmitted from one person to the other. As the area is predominantly malarious, more than two-third of women in both woredas reported that mosquito nets are available in their households. However, some households do not use the nets for preventing from mosquito bite but for decorating the house.

KAB of HIV/AIDS Knowledge of STIs and HIV/AIDS is lowest as compared to the 2005 DHS estimates. In these Woredas, according to this survey, 56.3 percent of women in Benna Tsemay and 51 percent in Selamgo Woreda have heard of STIs and 69.5 percent of women in Selamago and 69.2 percent in Benna Tsemay ) are knowledgeable about HIV/AIDS. However, the 2005 DHS indicated that 87 .3 percent of SNNPR women and 89.9 percent of entire women have HIV/AIDS Knowledge. The main source of information about HIV/AIDS was health professionals, meetings and health messengers. More than 60 percent of women have heard about VCT and among these, only 11 percent in Benna Tsemay and 6.2 percent in Selamago have received VCT tests and have known their HIV/AIDS status.

The highest prevalence was observed in Selamgo Woreda, in which 9.4 percent of women reported having been infected by an STI.

About a third of women in Benna Tsemay and 19.2 percent of women in Selamago know about PMTCT and a little more than a quarter know about ART, this is much lower than the national average of 69% in 2005. The level of knowledge about means of HIV transmission is high among those who have heard about the disease. More than eight in ten women believe unsafe sexual intercourse and 71.3 of women in Benna Tsemay and 84.4 percent in Selamago believe sharing sharp objects transmit HIV/AIDS. A significant proportion of women have wrong perception about the means of transmission of the virus.

More than a fifth of the women in Selamago and 12.2 percent of women in Benna Tsemay believe that the virus can be transmitted through mosquito bite Among HIV/AIDS knowledgeable women, the majority of women perceive that abstinence, being faithful to partners and avoiding sharing needles are the best ways of preventing HIV/AIDS. However, condom use in Benna Tsemay woreda is relatively low.

The majority of the women (35.1% in Benna Tsemay and 41.7 percent in selamago) started sex while they were aged 15-19 years and only 13.2% and 6.2 percent in Benna Tsemay and Selamago respectively had sex before their fifteenth birth anniversary suggesting early exposure to sex is not common in these Woredas. The average age at first sex in these woredas is 16.3 years.

Fertility The population in these woredas is characterized by high fertility. More than 85 percent of the women had experienced pregnancies and among these, 85.3 percent and 86.1 of them in Benna Tsemay and Selamago respectively had given live births. The average number of pregnancies was ranged from 3.7 to 3.9 pregnancies across Woredas. The median age at first birth was estimated to be 19 years. This estimate is close to that of the 2005 EDHS estimate, which is 19.2 years. At the end of her reproductive life, a woman in these Woreda had more than five live births.

Family Planning Smaller proportion of women (about 31 percent) in Bena Tsemay and Selamgo Woredas appear to have some knowledge about family planning knowledge. The result indicates that the main source of family planning methods is health professional, meeting, and health messengers. The result shows that women do not have knowledge in all types of modern contraception. For instance, 76.6 and 77.3 percent of women in Benna Tsemay and Selamago respectively know about Injectable, 73 percent of women in Benna Tsemay and 71.4 percent in Selamago heard about oral pill contraceptive, however, about Sixty percent of women in Benna Tsemay and more than half of women in Selamago haven’t heard of emergency contraception.

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The data indicate that only 8.5 and 7 percent of women in Benna Tsemay and Selamago respectively have used contraception at the time of interview. This prevalence is lower by 6.2 and 7.7 percent than the contraceptive prevalence estimates of 2005 DHS (CPR=14.7 percent).

Among the method mix of family planning, the most common method of contraception used by women in both Woredas is injection followed by Pill. Condom use was reported by less than a quarter of a percent in both woredas.

Most women do not want to use modern family planning methods. The most common reason reported by the respondents is different in two Woredas. In Benna Tsemay the most common reason reported was they are pregnant (40 percent).While in Selamago they belief that contraceptive have side effects/ affects health and wants to have more children (each 21.4%).

Women were asked about the place where they gave births. The result show that close to 50 percent of women in Selamago and 41.4 percent of women in Benna Tsemay Woreda delivered at home alone with no assistance and 38.9 percent in Benna Tsemay and 28.4 in Selamago assisted by untrained traditional birth attendant). Health facility based deliveries are very low in both Woredas (6.8 percent in Benna Tsemay and 5.1 percent in Selamago). Surprisingly, in Salamago Woreda, about 6 percent women reported delivering in the forest with out any assistance.

Harmful Traditional Practices Women were asked to identify the major traditional practices of communities.In Bena Tsemay Woreda, polygamy, early marriage and marriage by inheritance marriage are the major practices. Likewise, abduction and early marriage are considerable harmful practice for Selamgo Woreda community.

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Obstetric Fistula Because of early marriage and harmful cultural practices, women are vulnerable to obstetric fistula. The result indicates that about nine in ten women in Bena Tsemay Woreda and 85 percent in Salamago having not heard about fistula. The prevalence of women who have heard of fistula is less than the 2005 DHS estimates (23.2 percent of women at national, 19.9 percent of women in SNNP region).

The result indicates that among fistula knowledgeable women, the highest incidence of fistula is observed in Selamgo Woreda (23.2 percent). The data shows that prevalence of obstetric fistula is higher than that of 2005 DHS (National 1 percent; SNNPR 1.5 percent of women)

Gender and wife beating The data shows that in most cases decisions are made jointly in both Woredas. In the majority of cases, husband and wife jointly decide on whether or not to take a sick child to a health facility, spending wife’s income, spending husband’s income, when to have another child, whether or not to use family planning.

More than half (55.6 % in Benna Tsemay and 57% in Selamago) of women agree that men have good leadership ability than women, while 38.2 percent of women in both Woredas said that both men and women are fit for public services. Most women still think that a husband is justified to beat or shout or threat his wife.

Child Health The survey results show that the majority of the women have heard about immunization. Sources of information included health professionals, community health messenger and meetings.

All women perceive that diarrhoea; fever and cough are the common childhood diseases. Besides, eye problem, skin infections and measles are also recognized childhood diseases in these communities. Most women report that they use health facilities to seek

102 treatment for the sick child. However, some women go to traditional healers, spiritual healers and holy water.

Tuberculosis In Bena Tsemay, only 2 in five women appear to have heard about TB. While a little more than half of women in Selamago heard about TB. And nine out of ten among these women in Selamago and three quarter of women in Benna Tsemay, know that TB can be transmitted from one person to another.

11.2 Conclusion

Information on children, women and community’s health has paramount importance for researchers, policy makers and service providers. Accordingly, the results of this survey will serve as a bench mark/baseline for health related program interventions in Bena Tsemay and Selamgo Woreda administrations.

The survey found that women have low educational status in all Woreda administrations. Most studies showed that education and child survival/ household living conditions/ are highly correlated. Thus, educated women are more likely to use family planning, improved personal and environmental sanitation, fight against harmful traditional practices and realized gender equality, amongst others. The findings concluded that enhancing women’s knowledge helps to reduce the environment burden of disease as well as harmful cultural practices.

The wellbeing of household members, especially under five children depends on improved hygienic practices, sanitation and access to potable water. Though, the data showed that communities in the study areas are disadvantageous to live in good environmental health. To maintain good health, it is concluded that communities in particular women should receive environmental health education though adult education systems.

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The findings showed that most women have heard about STIs and HIV/AIDS. Most of them obtained information from health professionals, messengers and participating meeting/ workshops. On the other hand, STIs and HIV/AIDS prevention and control practices are limited in the studied areas.

Awareness about modern family planning methods is significantly noticeable in the study areas; however, contraception prevalence rate is small compared with the 2005 DHS. The findings indicated that women use more on hormonal methods of contraception (Injectable and oral pill contraceptives) than barrier methods. The barrier methods (condom and IUD) are rarely used by women. The reason for low CPR might be women do not have access to method mix such as Norplant and emergency contraception.

The proportion of women who have heard of malaria is very high. However, the findings indicated that women have erroneously employed malaria prevention and control practices, for instance, most women know the exact transmission and modes of malaria prevention, whereas, some women use mosquito net for ornament and other household purposes. Therefore, the results suggest that women have little knowledge on ways of malaria prevention and control methods.

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11.3 Recommendation

Based on the results the following key recommendations are suggested for interventions in order to improve the health and wellbeing of the population in these woredas. 1. Education changes women behaviour. This survey found that women have poor access to education. Therefore, it is suggested that non-formal education systems be introduced and expanded in these communities. . Non-formal education is an alternative education system, which enhances reading and writing skills of people who live in remote areas. 2. Water, sanitation and hygiene are serious problems in both Woredas. Women travel long distance to fetch water for the household and they do have poor personal hygienic and sanitation practices. Therefore, it is suggested that concerned agencies should enhance the capacity of women on primary health care education; creating access to safe drinking water as well as advocate for the provision of safe water supply at reasonable distance 3. More than three fourths of women reported that communities are at risk of malaria, diarrhoea and TB. Intervention on prevention and treatment program helps to reduce the incidences of morbidity and mortality from these diseases. As education on ways of malaria transmission and use of mosquito net has paramount importance to reduce malaria infections, it is also recommended that members of the community be given intensive education on these issues. 4. Women who have formed marriage through abduction as well as those in polygamous union are more susceptible to STIs and HIV/AIDS infections. To minimize the risks and practices, it recommends that concerned organizations focus on raising awareness of elders, clan leaders, religious leaders and broader community members on the issues of harmful marital arrangement through community mobilization process. 5. Women have relatively better knowledge on STIs and HIV/AIDS infections. Nevertheless, they have little practices and knowledge on prevention methods. It is recommended that concerned agencies should increase behavioural change

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communication intervention on STIs and HIV/AIDS with regard to prevention modalities. 6. The survey found that only lees than 32 percent of the women have knowledge on modern family planning methods, which is considerably, lower than the average for SNNPR. It suggests that all Woredas women should need substantial family planning education. 7. The survey indicates that contraceptive prevalence rate is low and the majority of women use temporary or short-term methods. It is recommended that access to family planning services be expanded, awareness about permanent and long term methods be improved and method mix improved. This service can be provided through linkages with government health institutions/ or directly supplying the commodities through outreach services. Or community based reproductive health workers. 8. In order to reduce the morbidity and mortality conditions of under five children and pregnant women, it is suggested that women should be educated to use antenatal and postnatal care services as well as about facility based distribution. Also, intervention is required to prevent childhood infections / diarrhoea, eye problem, skin infection, measles, coughs, respiratory infection/ and use of vaccination services. 9. The survey found that most women suffer from various harmful traditional practices. It is recommended that concerned organizations conduct HTP education to raise awareness of influential persons such as community leaders, religious leaders, traditional healers and respective individuals in order to accelerate the abolition of such practices. 10. The prevalence of obstetric fistula is above the 2005 DHS national prevalence estimate. This shows that women are at risk of obstetric fistula. It suggests that women should receive physiological and psychological treatment by educating communities about causes, prevention, treatment and risks of fistula.

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Part II

HEALTH AND HEALTH RELATED ISSUES IN MALLE AND SOUTH ARI WOREDAS IN SOUTH OMO, SNNPR, ETHIOPIA: FINDINGS OF A BASELINE SURVEY, 2008

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CHAPTER II

BACKGROUND CHARACTERISTICS OF THE STUDY POPULATION

2.1 Socioeconomic Background

The distribution of women by religion and ethnicity is shown in Table 2.1.1. The result indicates that half of women (49.4 percent) in Malle Wereda were believers in traditional faith. In contrast, women in South Ari Wereda were more affiliated to Protestant Christianity.

The survey identified diversified ethnic compositions in two Weredas. It seems that Wereda administration demarcated on the basis of ethnicity. For instance, almost, 97 percent of women in Malle Wereda belong to Malle ethnic groups. Likewise, about 87 percent of women in South Ari Wereda belong to Ari ethnic groups.

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Table 2.1.1 Religion and Ethnicity composition: Percent distribution of women by religion, ethnicity

Background Wereda Characteristics Malle South Ari Religion Orthodox Christian 11.7 37.3 Muslim 2.2 3.4 Protestant 33.3 42.8 Catholic .7 1.4 Tradition 49.4 13.7 Others 2.7 1.4 Total 100 100

Ethnicity Ari .7 86.7 Bena 0 .2 Malle 97.1 0 Tsemay 0 0 Others* 2.2 13.0 Total 100 100

Number of Women (n) 411 437 * includes Birayle, Bodi, Dime, Mursi, Bacha, Konso, etc

Work status and occupation

As indicated in Table 2.1.2, more than half (51 percent) of women in Malle Wereda combine household chores and farming. A little over a third (34 percent) of women in South Ari Wereda are more inclined work as farmers and housewives.

The majority of Women in Malle (47.9 percent) and South Ari (67.7 percent) Weredas reported that their husbands are farmers followed by 44.5 percent in Malle and 13 percent in South Ari who reported that their husbands are agro pastoralist.

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Table 2.1.2 Work Status of Women and husband: Percent distribution of women by type of work/occupation, Husbands’ occupation Wereda Current Malle South Work/Occupation Ari

Women occupation Farmer 22.6 31.8 Pastorals .2 .2 Agro Pastorals 8.5 3.9 Housewife 14.1 18.1 Farmer & housewife 50.9 38.0 Others 3.2 7.3 Not stated .5 .7 Total 100 100

Husbands’ occupation Farmer 47.9 67.7 Pastoralist 1.2 .7 Agro Pastoralist 44.5 13.0 Not stated .2 1.1 Total 100 100

Number of women (n) 411 437 Educational Status

It is well known that education is the gateway to women’s empowerment. Education enhances women awareness to fight against poverty, build confidence, empower them in decision making, influences their reproductive patterns, and increases child survival chances through antenatal and postnatal care utilization. It is also a means to prevent violence against women, amongst others.

The survey asked each woman about access to formal schooling women’s literacy status and highest grade achieved among those who had formal education. As indicated in Table 2.1.3, a remarkable difference in terms of education is also observed between the two Weredas. Women in South Ari Wereda have better educational opportunity (28 percent) than women in Malle Woreda (11.2). This may be because the Zonal Capital Jinka is located in this Woreda. For details refer to Figure1 and Table 2.1.3.

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Figure 1: Percent distribution of women by level of school grading

100

80 70

50 No education/grade

percen Grade 1-8 40 Grade 9-12 30 Higher grade 13+ 20

0 Bena Tsemay Selamgo Mali South Ari Total Werda

Table 2.1.3 Educational Status of women: Percentage of women by educational status

Educational Status Wereda Malle South Ari Attending Formal education Yes 11.2 27.5 No 87.3 70.9 Not stated 1.5 1.6 Total percent 100 100 Number of Women (n) 411 437

Read and Write Yes .9 1.7 No 99.1 98.3 Total 100 100 Number of Women (n) 332 290

Completed highest grade No education/grade 89.1 73.2 Grade 1-8 10.0 23.1 Grade 9-12 .7 3.2 Higher grade 13+ .2 .5 Total 100 100 Number of Women (n) 411 437

Exposure to mass media

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HIV/AIDS prevention, child care, primary health care practices, fighting harmful traditional practices and others.

Women were asked to provide information on availability and functionality of household radios, frequencies of listening radio and interest of listening particular radio programs. The result is shown in Table 2.1.4. As indicated in this table, radios are relatively uncommon in both Woredas. Most women (44.4 percent) in South Ari Woreda have radios. However, 81 percent in Malle Woreda have no working radio in their households.

Among women who have access to radios, 67 percent do not listen to radio messages. The largest proportions of women (91.5 percent) in Malle Wereda did not listen to radio programs. In South Ari, however, some 17 percent of women have exposure to listening radios. Most women (52.4 percent in Malle and 42.2 percent in South Ari) have interest to listen all radio programs. Moreover, there were some variations in listening news, entertainment and other radio programs between the Weredas.

Table 2.1.4 Women exposure to mass media: Percentage of women who have access to radio media

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2.2 Demographic Background Wereda Exposure to mass media Malle South Ari

Having working radio Yes 18.7 44.4 No 81.0 55.4 Not stated .2 .2 Total 100 100 Number of women (n) 411 437 Frequency of listening radio Always 9.5 16.9 Once a day 2.4 4.6 Twice a day .5 1.8 Rarely/sometimes 8.0 23.3 Never listen 72.5 47.4 Total 100 100 Number of women 411 437 (n) Types of listening Program News only 28.6 27.9 Entertainment 19.0 26.5 All programs 52.4 42.2 Others 0 3.4 Total 100 100 Number of women 84 204 (n)

Age Distribution

All women were asked to report their age at last birthday. Table 2.2.1 displays the distribution of the surveyed women by five years interval age groups. The result revealed that in both Woredas, the highest proportions of women fall to age 25 to 29 years, which is 27 percent for South Ari and 34.5 percent for Malle. In this survey, the median age of women is estimated at 28 years for the whole studied women population. Similarly, the median age of women for both Malle and South Ari Weredas are estimated to be 28 years. For details refer to Figure 2 and Table 2.2.1.

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Figure 2: Median age of women by residence

Years26 Median age

23 Bena Selamgo Mall South Ari Total e Tsemay

Wereda

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Table 2.2.1 Women by Age distribution: Percent distribution of Women by age group

Wereda Age group Malle South Ari Age in years 15-19 5.4 8.7 20-24 18.2 16.7 25-29 34.5 27.0 30-34 15.1 15.1 35-39 17.0 18.1 40-44 3.6 8.2 45-49 5.1 6.1 Total 100 100 Median age 28 28 Average age 29.5 29.9 Number of women 411 437 (n)

Marriage

The distribution of women by their marital characteristics is depicted in Table 2.2.2. The result shows that majorities (96.1 percent in Malle and 87.9 percent in South Ari) of women were currently married, 4.6 and 2.2 percent in South Ari and Malle respectively were widowed, 0.5 percent in Malle and 4.3 percent in South Ari were divorced and only 0.5 and 1.8 percent of women in Malle and South Ari respectively were single.

Consensual union marital arrangement is common in both Woredas. Marriage through family and abduction are also pronounced.

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The table also clearly shows the distribution of women by age at first marriage. About 60.7 percent of women in Malle Wereda and 51.2 percent of women in South Ari started married life at age 15-17 years. Only 2.8 percent of women in both woredas contracted marriage at early teens (age below 15 years. In addition, the median age at first marriage is estimated at 17 years, which is about one year higher than the national average, suggesting that women in these woredas marry relatively late.

Polygamy appears to be common in these woredas. There is substantial difference in polygamous marriage arrangements between Woredas. 42.1 percent of women in South Ari Woreda reported that their husbands had more than one wife, while 33 percent in Malle reported same (for details refer to Table 2.2.2 and figure 3).

Figure3: percentage of women by age at first marriage, residences

100

60 <15 years 15-17 years

percent 40 18+ years

0 Bena Tsemay Selamgo Mali South Ari Woreda

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Table 2.2.2 Marital Status of Women: Percent distribution of women by marital status Wereda Background characteristics Malle South Ari Marital status Never married .5 1.8 Currently married 96.1 87.9 Divorced .5 4.3 Widowed 2.2 4.6 Separated .5 1.1 Not stated .2 .2 Total 100 100 Number of women (n) 411 437

Marriage arrangement Family .2 2.1 Abduction 1.2 3.5 Consensual 98.3 93.9 Inheritance .0 .5 Adoption .0 0 Other .2 0 Total 100 100 Number of women (n) 406 427

Age at first marriage in years <15 2.7 2.8 15-17 60.7 51.2 18+ 36.6 46.0 Total 100 100 Average age at first marriage 17 17.4 Median age at first marriage 17 17 Number of women (n) 407 428

Polygamy (husband has additional wives) Yes 23.0 30.4 No 77.0 69.6 Total 100 100 Number of women (n) 405 424 Number of husband’s additional wives 1 wife 66.7 57.9 2 and more wives 33.3 42.1 Total 100 100 Number of women (n) 93 126

Household composition

118 non-relatives. Collecting this information has paramount importance to give insight utilization about household resources.

Table 2.2.3 presents the distribution of women by size of household. The average household size was found to be 5 members in South Ari Woreda. On the other hand, in Malle Woreda higher average household size was reported (6 members per household). A high proportion of the interviewed women reported that their households comprised of under five children and women of reproductive aged (15-49 years).

Table 2.2.3 Household composition: Percent distribution of women by household composition

Wereda Household composition Malle South Ari Household size 1 family member 0 1.9 2 family members 3.2 8.4 3 family members 10.7 15.1 4 family members 13.6 17.2 5+ family members 71.0 55.8 Not stated 1.5 1.6 Total 100 100 Average household size 6.1 5.3 Number of women (n) 411 437

0 child 0 1.6 1 children 0 1.8 2 children 3.2 8.2 3+ children 95.4 86.7 Not stated 1.5 1.6 Total 100 100 Number of women (n) 411 437 Number of women age 15-49 years who are members of family 0 no women 33.6 33.4 1 woman 49.1 43.5 2 woman 12.2 12.8 3+ woman 4.6 9.6 Not stated .5 .7 Total 100 100 Number of women (n) 411 437

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Mortality

Table 2.2.4 presents the percent distribution of women reporting death in the last 12 months by Woreda and age. As indicated in this table, the highest proportion of deaths (14.2 percent) was reported by women in South Ari Wereda. In addition, women in Malle Woredas also reported that they had experienced deaths in the household (9.5 percent).

The data shows that there is heavy under five mortality in the population. About 49 percent of women in Malle Woreda had the highest under-five mortality followed by those in South Ari (29%). The table also shows that in Malle woreda mortality was higher for females than males while in South Ari mortality was higher for males than females. (For details refer Figure 4 and Table 2.2.4)

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Figure 4A: Cause of Death

Figure 4: percent distribution of women by mortality diferentials, age gorup, residence

Under 5 years 5-9 years 10-19 years 20-29 years 100 30-39 years 40-49 years 50+ years 90 80 70 60 50

percent 40 30 20 10 0 Bena Tsemay Selamgo Mali South Ari Total woreda

Table 2.2.4 Mortality differentials: Percent distribution of women by mortality differentials and residence Wereda Mortality differentials Malle South Ari Occurrence of death in the last 12 months Yes 9.7 14.2 No 89.8 85.4 Not stated .5 .5 Total 100 100 Number of women (n) 411 437

Mortality by Age group in years Under 5 years 48.7 29.0 5-9 years 15.4 15.9 10-19 years 17.9 14.5 20-29 years 2.6 15.9 30-39 years 7.7 7.2 40-49 years 5.1 4.3 50+ years 2.6 13.0 Total 100 100 Number of women (n) 39 69

Sex of dead persons Male 43.5 63.0 Female 56.5 37.0 Total 100 100 Number of women (n) 46 73

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Cause of Death

The main cause of death in these woredas is malaria followed by diarrhea. About 45% of the deaths in both woredas were reported to be due to malaria while over a fifth was due to diarrheal diseases and a little over 10% was due to respiratory diseases or TB and another 10% was due to malnutrition or food shortages. HIV/AIDS was also reported to be the cause of death in both woredas. As Fig. 4B show, the causes of death are more or less similar in both woredas.

Fig 4B Causes of Death by Woreda

Percent 20

Don't Know Malaria Diarrhoea HIV/AIDS Malnutrition Other causes Respiratory/TB Cause of Death

Bena Salamago Malle South Ari All 4 Woredas

122 were typhoid, typhus, internal worms and parasites, stomach-ache, TB, common cold, coughing, pneumonia, headache, cold, meningitis, measles and hepatitis. Meanwhile, a considerable number of them were not aware of the causes of certain diseases. Consequently, they have no adequate knowledge that these diseases can be preventable. For instance, some them believe that the cause of Tuberculosis is eating cold food, and it can be cured by slaughtering animals and by eating their meat.

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CHAPTER III

HOUSEHOLD WATER SOURCES, PERSONAL HEALTH AND SANITATION

Data on sources of household drinking water, continuity and availability of water was collected in this survey. The results are presented in Table 3. About 42 percent of South Ari women have access to piped water and 47 percent of Malle women reported that river is the main sources of household drinking water.

Furthermore, most of the water sources in these Woredas have been located at a far distance from their localities. Accordingly, a considerable number of women are forced to

124 spend more than two hour in fetching water on average without including those living in urban centres and who have access to pipe water.

The table clearly reveals that water interruption is the major problem for households. About 54.7 percent of women in Malle and 47.1 percent in South Ari reported that they do not get water as required.

As indicated in this table, the majority of women in Malle (77.9 percent) and South Ari (85 percent) Woredas take more than 2 hours to fetch drinking water. The median length of time required to fetch drinking water is estimated at 15 hours for Malle and 12 hours for South Ari. (for details refer Figure 5 and Table 3)

Figure 5: Media time in hour to fetch water ( round trip)

16 14 12 10 8 Media time in hour hour 6 4 2 0 Bena Selamgo Mali South Total Tsemay Ari Wereda

Table 3 Sources of drinking water: Percent distribution of women by source of drinking water, time to fetch water, water Woreda Access to water Malle South Ari Source of drinking water Narrow/borehole .2 1.1 Well/borehole .5 .7 Untreated spring 18.0 21.3 Treated spring 2.9 8.0 River 47.4 22.9 Pipe water 20.9 42.1 Pond 2.9 1.6 Surface water 0 .5 Others 6.6 1.8 Not stated .5 0 Total 100 100 Number of women (n) 411 437

Have you experienced Water interruption 54.7 47.1 Frequency of water interruption Sometimes 80.4 86.3

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Frequently 8.9 6.9 Usually 10.7 6.9 Total 100 100 Number of women (n) 225 204

< 1 hour 21.6 8.5 1 hour to 2 hour .5 6.5 Over 2 hour 77.9 85.0 Total 100 100 Median time in hours 15 12 Number of women (n) 371 401 Not stated (n) 40 36

3.2 Health and Sanitation

Availability of latrine

Information on latrine availability, type, sanitation and users are presented in Table 4.1. The result shows that Seventy percent of women in Malle Woreda and 79.2 percent of women in South Ari Woreda reported that their households have no latrine. Among latrine owners, the majority of women have traditional pit latrine with slab covers (87.8 percent in Malle and 80.9 percent in South Ari).

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Table 4.1A Availability of toilet: Percent distribution of women according to availability of and type of toilet/ latrine Wereda Toilet/ latrine facility Malle South Ari Having latrine Yes 70.1 79.2 No 29.4 20.6 Not stated .5 .2 Total 100 100 Number of women (n) 411 437 Type of toilet/latrine Traditional pit latrine with slab 87.8 80.9 Traditional pit latrine with out slab 10.4 16.5 Ventilated improved latrine 1.4 2.3 Other .3 .3 Total 100 100 Number of women (n) 288 346

Cleanliness of latrine/based on observation Used but clean 54.7 58.5 Unused clean 5.9 5.3 Unused but unclean 39.4 35.6 Other 0 .6 Total 100 100 Number of women (n) 287 340

Women with some type of latrine were asked who uses the latrine and whether or not there is any discrimination by sex in using the latrine. More than eighty five percent of women said that there is no gender disparity in using latrine (all family members have the right to use latrines) in their community.

Table 4.1B Use and non-use of toilet: Percent distribution of women according to use and reason for not using toilet/ latrine Woreda Usual latrine users Malle South Ari Adult male only .7 1.4 Adult female only 1.0 1.7 Both adult male & female 10.4 10.1 Children 0 .3 All family member 86.5 84.6 No one uses 1.4 1.7 Total 288 346 Number of women (n) 288 346 Reasons for not using latrine Smelling Yes 0 50.0 No 100 50.0 Number of women (n) 4 4 Human faecal waste should not be

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buried Yes 0 25.0 No 100 75.0 Number of women (n) 4 4 Male should not be seen during defecation Yes 0 25.0 No 100 75 Number of women (n) 4 4

Regarding reason for not using latrine, 50 percent of women in South Ari Wereda believe that latrine has bad smell. While about a quarter of Malle women said that human faucal waste should not be buried. Otherwise, serious danger and curse would come upon a person who buried his faucal waste as the participants of FGDs and KIIs underlined and another quarter reported that males should not be seen during defecation (Table 4.1B).

3.3 Personal Hygiene

Table 4.2 demonstrates that most (54 percent to 71 percent) of women in South Ari Wereda washed their hands after defecation, before handling cooking utensils, before eating food and after eating food. Similar hygienic practices are reported in Malle Woreda. In Malle Woreda, the majority of women (74.2 percent) reported that soap is not used for washing hands. While most women (56.3 percent) in South Ari Woreda used soap for hand washing.

128 shortage of water especially during the dry season. For some of them who have been living in very hot and arid areas eating food without washing one’ own hand, taking shower and washing their clothes is not a serious issue because the scarcity of drinking water is their major problem than anything else.

In relative term, the inhabitants in Arri and the Maalle Woredas have better access to water sources like rivers and springs as compared to the Salamago and Bena Tsemay Woredas who heavily depend on one or two big rivers for water supply. Some of the participants of FGDs and KIIs argue that they stay even more than a month without washing their body. In comparison with men, women have no time to wash their body because they have many responsibilities and they are highly confined to their household cores. Therefore, the majority of women wash their body during certain occasions related to rituals, festivals and New Year’s celebrations within their community. The informants from Arri and Maalle Woredas alleged that most of the Christians who regularly attend churches wash their body in the rivers within the interval of two weeks or on weekly basis, especially on Saturdays because they are expected to be clean during the worshiping program on Sundays.

However, a significant number of inhabitants wash their cloth once or twice in a year because of water scarcity in the area, lack of money to buy soap, and lack of education concerning personal hygiene. In relation to this, a large number of inhabitants have only one piece of cloth or no cloth at all because wearing cloths has been a recent phenomenon for most of the communities in south Omo zone. According to the researcher’s observation and confirmed by the participants of FGDs, members of Arri and Maalle ethnic groups seem to be better in clothing, and started to wear cloths before members of any other ethnic group in the study area.

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Table 4.2: Personal sanitation: Percent of women practicing personal sanitation Wereda Practices of personal hygiene Malle South Ari Washing hands After defecation 64.6 70.0 Before handling cooking utensils 61.0 57.6 Before eating food 77.6 71.9 After eating food 63.9 54.6 After cleaning babies 21.0 15.9 Occasional 20.2 13.1 Others 9.8 15.9 Number of women (n) 411 437 Use of soap to wash hand Yes 25.5 56.3 No 74.2 43.2 Not stated .2 .5 Total 100 100 Number of women (n) 411 437 Frequencies of washing body/women Twice a week 42.3 49.2 Weekly 26.3 28.4 Every two weeks 14.8 11.9 Others 15.6 9.8 Not stated 1.0 .7 Total 100 100 Number of women (n) 411 437

Twice a week 39.2 46.9 Weekly 29.4 29.5 Every two weeks 15.8 11.9 Others 14.6 10.5 Not stated 1.0 1.1 Total 100 100 Number of women (n) 411 437

Usually 8.3 8.2 Sometimes 29.7 41.0 As need arises 58.9 48.5 Not at all 1.0 1.1 Not applicable 1.9 .7 Not stated .2 .5 Total 100 100 Number of women (n) 411 437

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CHAPTER IV

MALARIA

4.1 Major health problem in the study area

Information was collected from individual women on what they think is the major health problems in the community. As indicated in Table 4.3, 97.1 percent of the respondents in Malle and 67.3 percent of them in South Ari woreda perceived that malaria is the leading health problems in their community. In addition, 70 and 34.4 percent of women in Malle and South Ari Woredas respectively believe that diarrhoeal diseases and respiratory disease/TB as the second leading cause of morbidity. On the other hand, a small proportion of women in Malle (4.4 percent) reported that HIV/AIDS has low contribution to community health problems. While 21.2 percent of women in South Ari that HIV/AIDS has high contribution to community health problems.

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Table 4.3 Community’s health problem: Percent distribution of women who have knowledge on community’s health problem, by residence

Wereda Types of health problems Malle South Ari Health problems Malaria 97.1 67.3 Diarrhoea 70.0 34.4 Respiratory disease including 70.5 34.4 TB Gastro intestinal diseases 23.1 23.4 Malnutrition 26.8 11.7 HIV/AIDS 4.4 21.2 Skin disease 8.4 6.4 Other disease 41.0 25.5 Do not know/not sure 20.0 15.8 Number of women (n) 411 437

4.2 Symptoms of Malaria

Table 4.2 presents the distribution of women according to their knowledge towards malaria symptoms. The majority of Malle women identified several symptoms, among these, 91.9 percent of them said Shivering/Chills and 89.9 percent reported Fever. About 73.4 and 62.4 percent of women in South Ari reported that malaria has fever and shivering/ chills symptoms respectively (for details refer to Table 4.4).

Table 4.4 Symptoms of Malaria: percent distribution of women by symptom of malaria and residence Wereda Malaria symptoms Malle South Ari Kind of symptoms Fever 89.9 62.4 Shivering/chills 91.9 73.4 Sweating 69.5 31.1 Headache 88.5 59.3 Vomiting 85.3 43.3 Loss of appetite 71.3 39.3 Bitterness in the mouth 67.1 31.8 Weakness/tiredness 66.3 31.3 Splenomegaly 56.8 16.7 Backache 73.0 40.2 Convolution 48.4 20.5 Joint pain 56.8 21.6 Other symptoms 26.0 14.4 Do not know 9.1 4.7 Number of women (n) 411 437

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4.3 Knowledge Of Means Of Getting Malaria

Table 4.5 displays data on knowledge of women about malaria transmissions. As shown in this table, 94.9 percent of women in Malle and 66.1 percent in South Ari perceive that malaria is a major health problem of the villages. Similarly, More than 41 percent of women in South Ari said that malaria is transmitted from person to percent. However, about 50 percent of women in Malle Woreda believe that malaria cannot transmit from one person to the other. Most women (more than 96 percent in Malle and 83.5 percent in South Ari) reported that malaria is a treatable disease. The overwhelming majority of women in each Woreda know that malaria infection is transmitted through mosquito bite (72.8 percent to 92.3 percent). Surprisingly, a small proportion of women in both Woredas believe that witchcraft is a means through which malaria is transmitted from one person to the other.

Table 4.5 Knowledge of acquiring malaria: Percent distribution of women according to knowledge of acquiring malaria, by residence Woreda Knowledge of getting malaria Malle South Ari Malaria is a major health problem Yes 94.9 66.1 No 3.9 22.9 Do not know 1.2 11.0 Total 100 100 Number of women (n) 411 437 Malaria is transmitted from one person to another Yes 45.0 41.9 No 49.6 35.0 Do not know 5.4 23.1 Total 100 100 Number of women (n) 411 437 Malaria is treatable disease Yes 96.1 83.5 No 2.2 5.3 Do not know 1.7 11.2 Total 100 100 Number of women (n) 411 437 Malaria infection transmitted through Breathing 8.1 13.9 Mosquito bite 92.6 72.8 Sleeping together with a malaria 8.8 6.5 patient Drinking dirty water 28.3 17.5

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Being exposed to cold water 24.8 15.6 Exposure to dirty swampy areas 43.0 32.9 Witchcraft 2.2 2.4 Eating sweet food/maize 51.8 27.9 Other 5.9 5.0 Do not know 11.8 11.0 Number of women (n) 407 416

4.4 Knowledge of Preventing Malaria

This survey includes information on the knowledge of respondents about ways of malaria prevention. Table 4.4 depicts that 81 and 71.2 percent of women in Malle and South Ari respectively have knowledge of preventing malaria.

The result clearly shows that 90.2 percent of women in Malle and 71.6 percent in South Ari woreda know that sleeping under mosquito net can prevent malaria. DDT/ spraying insecticide is also considered to be malaria-controlling mechanism. Respondents were asked whether it is better to treat malaria at home or at health facility. The majority (more than 85 percent) of women reported that they preferred to treat malaria in health facility. A few women preferred to treat malaria at home. For details refer Table 4.6.

Table 4.6: Knowledge of preventing Malaria: Percentage of women who have knowledge about prevention of malaria, by residence Wereda Knowledge of preventing malaria Malle South Ari

Malaria is preventable disease 81.0 71.2 Number of women (n) 411 437 Means of Controlling Malaria Eating good food 25.7 22.9 Keep house clean 41.7 44.8 Remain indoors at night 19.3 11.9 To sleep under a mosquito net 90.2 71.6 To spray house with insecticide/DDT/ 40.5 32.3 To spray house with aerosols 13.8 11.9 Smoking the house 33.4 24.8 Apply ointment/repellents on the skin 10.7 8.4 Drain mosquito breeding site 51.8 41.9 Window screening 10.4 10.3 Other 8.9 10.6 Do not know 0 25.0 Number of women (n) 327 310 Not stated 84 127 Measures taken to treat malaria Treat at home 7.8 4.8 Take to health facility 85.2 86.5

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Take to traditional healer .2 1.4 Buy drug from pharmacy 6.1 2.7 Other .5 4.6 Not stated .2 0 Total 100 100 Number of women (n) 411 437

4.5 Malaria related sickness

The distribution of women in relation to malaria related sickness is presented in Table 4.7. As indicated in this table, some 18.2 and 10.8 percent of women in Malle and South Ari respectively reported that febrile illness is more related to malaria sickness. More than 52 percent of women in Malle and 56 percent in South Air Woredas reported that households had more male malaria patient than female patients. The table shows that under-five children are more susceptible to malaria than any other age groups (look at figure 6). The majority of women reported that malaria patients had access to medical treatment within 8 days after the onset of symptoms. Only 3.6 percent of women in Malle Woreda said that malaria patients seek treatment after 30 days of symptoms.

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Figure 6: percent distribution of women by malaria patients age groups

100

80 Under 5 years 5-9 years

70 10-19 years 20-29 years

60 30+ years

Percent 40

0 Bena Tsemay Selamgo Mali South Ari Total Wereda

Table 4.7 Malaria related disease: percent distribution of women according to malaria related sickness and residence Wereda Malaria related sickness Malle South Ari Febrile illness Yes 18.2 10.8 No 81.0 87.9 Not stated .7 1.4 Total 100 100 Number of women (n) 411 437 Sex of malaria patients Male 52.7 56.5 Female 47.3 43.5 Total 100 100 Number of women (n) 74 46 Malaria patient in age group Under 5 years 39.2 10.6 5-9 years 28.4 17.0 10-19 years 13.5 12.8 20-29 years 9.5 21.3 30+ years 9.5 38.3 Total 100 100

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Number of women (n) 74 47 Malaria patients sought treatment Yes 47.3 89.4 No 52.7 10.6 Do not know 0 0 Total 100 100 Number of women (n) 74 47 Number of days took between symptoms & first treatment < 8 days 85.7 73.5 8-30 days or more 10.7 26.5 More than 30 days 3.6 0 Total 100 100 Number of women (n) 28 34

4.6 Knowledge And Use Of Mosquito Net

It is observed from Table 4.8 that the great majority of women in both Woredas have knowledge about mosquito net (98.5 percent in Malle and 88.1 percent in South Ari). Moreover, 98.3 percent of women in Malle, 91.1 percent of women in South Ari Wereda have knowledge about the prevention of mosquito using mosquito net.

Almost all (97.1 percent) of women in Malle said that mosquito nets are available in their households. In addition, Three-fourth of women in South Ari reported that mosquito nets are available in their households. Among these women, more than 40 percent said that their mosquito net has anti mosquito medicine. A little more than half of women in both Woredas reported having 2 mosquito nets in their households. Most women reported that all household members have used mosquito net to prevent malaria. On the other hand, women also reported the use of mosquito net for other household purposes. As the table shows, some women use mosquito net for clothes and ornament.

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Table 4.8 Knowledge and use of mosquito net: Percentage of women who have knowledge about the use of mosquito net, by residence Wereda Knowledge and use of mosquito net Malle South Ari Heard about mosquito net 98.5 88.1 Sleeping under mosquito net prevent malaria 98.3 91.1 Mosquito net is available in the household 97.1 74.0 Mosquito net has anti mosquito medicine 41.4 47.5 Number of mosquito nets in the household 0 0 0 1 31.7 36.4 2 51.5 54.1 3 or more 16.8 9.5 Total 100 100 Average mosquito net 1.9 1.8 Number of women (n) 394 284 Sleeping mostly under mosquito net Babies 37.7 28.9 Adult men 17.5 11.6 Adult women 19.0 16.5 Pregnant women 13.4 7.0 Guests 9.1 5.6 All family member 60.0 50.7 Husband and wife 35.2 45.8 Others 9.6 4.9 Number of women (n) 394 284 Other uses of mosquito net For cloth and ornament 2.5 4.6 To prevent from bites 68.6 67.3 For door and window protection 1.0 3.9 Others 23.0 22.8 Number of women (n) 394 284

In connection to malaria, the qualitative result shows that there is no adequate knowledge and awareness regarding its cause and transmission among some members of the community. On the contrary, misconceptions and erroneous assumptions still dominate the perception of some inhabitants. For some of them, malaria is mainly caused by eating sweet food stuffs such as sugar cane, the stalk of sorghum/maize and ripens maize/corn. For a few others, it is believed to be caused by evil eye, by the punishment from God and as a result of heavy rain. These people use the fruit of “Enqoqo” (Embelia Schimperi), “Kosso” (Hygienea Abyssinika), and other trees as a medicine. In general, however, a large number of local inhabitants have started to go to modern health institutions when they are infected with malaria especially since the last few years.

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CHAPTER V

KNOWLEDGE, ATTITUDE AND BEHAVIOR (KAB) OF HIV/AIDS

5.1 Knowledge of STIs

As Table 5.1 shows, more than 86 percent of women in Malle Woreda and South Ari Woreda have knowledge of STIs. On the other hand, the table illustrates that 8.8 percent of women in South Ari Woreda had experience of STI infection.

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Table 5.1 Knowledge and infection of STIs: Percent distribution of women by STIs knowledge and residence

Wereda Knowledge of STIs Malle South Ari Heard of STIs 86.9 86.5 Infected with STI 1.7 8.8 Number of women (n) 357 375

5.2 Knowledge and source of information about HIV/AIDS

Data on Knowledge, prevention, transmission, causes and sources of HIV/AIDS information is illustrated in Table 5.2. As indicated in this table, higher proportions of women in Malle Woreda (97.1 percent) and South Ari Woreda (97.3 percent) have HIV/AIDS knowledge.

The table clearly reveals that the women received HIV/AIDS information mainly from health professionals. Moreover, meetings and health messengers are reported as sources of HIV/AIDS information. Only 37 percent of Malle women and 31.3 percent of South Ari women perceive that virus causes HIV/AIDS. Most women have an understanding about the mode of HIV/AIDS transmission. More than ninety percent of the women in both Woredas reported that unsafe sexual intercourse is a means through which HIV virus can be transmitted from person to person. Surprisingly, more than 21 percent of women in Malle and 15.2 percent of women in South Ari perceive that mosquito can transmit HIV/AIDS virus.

The findings also indicate that more than 95 percent of women in Malle and 87 percent of women in South Ari Woreda believed HIV/AIDS is not a curable disease. About 65 and 58 percent of the women in Malle and South Ari Woredas respectively reported that HIV/AIDS is a preventable disease. The majority of women perceive that abstinence, being faithful to partners and avoiding sharing needles are the best ways of preventing HIV/AIDS. There seems to be some variation on knowledge of means of HIV/AIDS prevention between the two Woredas (refer to Figure 7).

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11. Washing one’ own body around the river bed. 12. Swimming and taking shower together with HIV positive person. 13. Casual contacts such as shaking hand, hugging and other social kissing as well as making conversation with patients of AIDS. 14. Buying food stuffs and sharing food/drinks, materials and living in the same room with HIV infected people could transmit the disease. 15. HIV/AIDS is not a disease that actually exists. 16. HIV/AIDS can be transmitted from animals to human beings by eating raw meat. 17. Traditional healers, herbalists and sorcerers or witchdoctors can treat HIV/AIDS. 18. People, who have been emaciated, thin and skinny as well as with low body weight, are perceived as carriers of HIV/AIDS or victims of the virus. 19. HIV/AIDS is perceived as the disease of urban inhabitants, and largely confined to urban settings. Therefore, infection can be prevented by avoiding sexual relations with people living in urban areas.

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20. Chat traders, people often go to urban centres and pass the night in towns are perceived as the ones who can be contracted with HIV/AIDS, potential carriers and transmitters of HIV/AIDS.

The other limiting factor in this regard is lack of adequate access to other means of information. For instance, the number of people who have access to electronic media such as radio, television and others seem to be very low as compared to people in urban centres and some other rural areas. This situation coupled with very low literacy rate, inaccessibility of many localities, remoteness and harsh climate of the area; makes the implementation of activities to be more cumbersome than the efforts that might be made

143 in other places. Apart from this, some informants are not comfortable with vaccination service given to their children because they have no adequate knowledge and awareness concerning its relevance. Nonetheless, most of the families bring their children to vaccination service because they are enforced by K’ebele administrators and fearing the punishment.

Figure 7: Knowledge level of women by HIV/AIDS prevention methods

100 90 80 70 60 Percent50 40 30 20 10 0 Bena Tsemay Selamgo Mall South Ari Total Woredae

Abstinence Being faithful to on partner

UsingAvoid condom sharing needles Avoid unsafe blood transfusion Avoid circumcision at unauthorized place

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Table 5.2 HIV AIDS knowledge and source of information: Percent distribution of women by knowledge of HIV/AIDS, sources of information, means HIV/AIDS prevention and transmission

Wereda HIV/AIDS characteristics/ background Malle South Ari Heard about HIV/AIDS 97.1 97.3 Source of HIV/AIDS information Friends 0 0 Church/ Mosque 13.5 21.6 Health professional 88.0 75.8 Radio/Television 8.5 20.7 Pamphlets 4.3 5.6 Meetings 69.7 64.0 Health messengers 40.4 38.6 Others 8.3 11.1 Number of women (n) 399 425 Perception about causes of HIV/AIDS Punishment from God 13.5 26.4 Caused by virus 37.3 31.3 Food problem 0 .5 Other 18.0 8.9 Do not know 31.1 32.9 Total 100 100 Number of women (n) 399 425 Knowledge about transmission of HIV/AIDS Unsafe sexual intercourse/made sex with 94.4 90.7 any people Sharing sharp object 86.4 77.9 Mother to child during pregnancy 60.9 50.0 Mother to child during birth 57.8 48.8 Mother to child during breastfeeding 58.1 44.0 Blood transfusion 77.2 67.9 Kissing/shaving 17.4 14.5 Living with HIV+ people 15.1 10.5 Mosquito bit 21.2 15.2 Other 17.1 11.9 Number of women (n) 391 420 HIV/AIDS is curable disease 4.8 13.0 HIV/AIDS is preventable disease 65.8 58.1 Mode of prevention of HIV/AIDS Abstinence 75.9 79.4 Being faithful to on partner 85.8 70.8 Using condom 46.7 46.1 Avoid sharing needles 87.7 80.2 Avoid unsafe blood transfusion 63.2 48.6 Avoid circumcision at unauthorized 52.1 36.6 place Other 8.8 8.2 Number of women (n) 261 243

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5.3 Voluntary Counseling and Testing (VCT)

Voluntary HIV counseling and testing (VCT) is a major HIV/AIDS prevention and care strategy. It is the ways of provision of counseling for persons to make an informed choice before being tested for HIV. The data from this survey show that 82.4 percent of the women from Malle and 85.9 percent in South Ari Woreda know the usefulness of being tested for HIV (Table 6.3). However, Only 17.6 and 23.6 percent of the sampled women in Malle and South Ari respectively had obtained HIV/AIDS test.

Table 5.3 shows that most women (more than 80 percent) in both Woredas have interest to know about their HIV/AIDS status. Also, women in both Woredas have positive attitude for testing HIV/AIDS. Among women who did not get HIV/AIDS test 62.3 and 56.3 percent in Malle and South Ari respectively believe that they are not at risk for HIV, 30.4 percent of women in Malle said that VCT service is not available, while 17.2 percent of them in South Ari reported that they fear stigma. The majority (75 percent in Malle and 86 percent in South Ari) perceives that the HIV/AIDS virus is not found inside a healthy looking person. For details refer to Table 6.3

According to the participants of FGDs and KIIs, the magnitude of stigma and discrimination had not been clearly known because no one has revealed himself to the public so far about his health status, and there is no VCT centre in close distance of many K’ebeles except in Jinka, capital of the South Omo Zone and in few places in other Woredas. Therefore, it was not possible to know which category of people had been more exposed to HIV infection than the other, and whether its prevalence rate is reducing or not. Surprisingly enough, most of the inhabitants have not yet informed regarding the availability of VCT centres even in the capitals of some of the Woredas. In this connection, almost all of the people in South Omo Zone have not yet tested for HIV/AIDS except a few in some urban centres and certain efforts made by some protestant church leaders to enforce the engaged couples to produce their certificates before their wedding day.

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Table 5.3 Knowledge of VCT: Percent distribution of women who have perception about the use of testing HIV/AIDS by residence

Wereda Knowledge of HIV test Malle South Ari

Know the usefulness of HIV test 82.4 85.9 Had tested HIV/AIDS 17.6 23.6 Need/plan to test HIV/AIDS 82.1 84.2 Reasons for not testing HIV/AIDS No services available 30.4 10.9 Fear of stigma 5.8 17.2 No risk of HIV infection 62.3 56.3 Others 11.6 23.4 Number of women (n) 69 64 Believe that a healthy looking 15.4 24.1 person can have HIV/AIDS

147 study area have still been performed without blood test, except very few cases in and around Jinka other urban centers in the area.

In relation to this, the participants of FGDs and KIIs had different feelings towards infected people with HIV/AIDS. Some of them felt that being infected with HIV/AIDS is the effect of promiscuity. The church leader and participant of FGD from Beneta K’ebele of Malle Woreda shook his head and said, “Those who infected with HIV/AIDS have got what they deserve because they are sinners who transgressed the word of God. Therefore, I am not ready to treat and take care of them even they would be my own family members”. Some informants further underlined that, “we would rather ask him to leave our house, and find his way to any where else immediately we have been informed that he/she is HIV positive”.

A few others argued that he must be ostracized from his family and the inhabitants of the K’ebele, and must be resettled in other place prepared for HIV patients. This kind of attitude may be due to inadequate training, or being contracted with HIV/AIDS is considered as a shame and curse by the wider community. There is also another misconception of attributing illness for a long period of time, and being physically emaciated or stunted to HIV infection, and vice versa. In general, the situation indicates the level of stigma and discrimination might be very high if someone is identified to be HIV positive.

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5.4 Risk Perception

Information on HIV/AIDS risk perception was collected from HIV/AIDS knowledgeable women. As shown in Table 5.4, the majority of women (more than 90 percent) believe that they are not at risk of HIV/AIDS. Some 2 percent of women perceive that they are in fear of HIV/AIDS to some extent. Women also asked to provide reasons for the fear of HIV/AIDS. Accordingly, 57.1 and 36.4 percent of women in Malle and South Ari respectively who reported that their husbands have had sex with other partners followed by 35.7 percent of women in Malle and 27.3 percent in South Ari said that they fear it because of sharing common sharp objects.

The data also indicate that Half (50 percent) of women in South Ari Woreda reported that they used condoms. However, almost all women in Malle Woreda have never habituated condoms. 11.1 and 16.9 percent of women in Malle and South Ari Woredas respectively suspect that their husbands made sex with other women.

According to a tradition of “Zappa” among the Maalle, young boys were practicing unprotected sex with girls by breaking the gate of the girls’ house at late night. Although this tradition has declined since the last couple of years, it is still practiced in some places.

Furthermore, one may have several sexual partners especially among the Maalle and other ethnic groups whether he is married or not. Even this trend has been started to be adopted by members of the neighboring ethnic groups in the area. There are also several cases of pregnancy out of wedlock, and dozens of induced abortion cases which would expose the inhabitants to risk condition of being infected with HIV/AIDS

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Table 5.4 HIV/AIDS risk perception: Percent distribution of women who have perception about the risk of HIV/AIDS, by residence Wereda HIV/AIDS risk perception Malle South Ari Believe that the risk of HIV/AIDS at the present Never at risk 94.9 91.7 To some extent at risk 2.3 1.9 At risk highly .3 .7 Other 2.5 5.7 Total 100 100 Number of women (n) 396 423 Reasons for risk of HIV/HIDS Always make sexual intercourse 7.1 9.1 Received blood transfusion 14.3 9.1 Husband made sex with other women 57.1 36.4 Not faithful to partner 7.1 12.1 Sharing sharp object 35.7 27.3 Other 14.3 18.2 Number of women (n) 14 33 Used condom 0 50.0 Suspecting husband can have sex with other 11.1 16.9 woman

5.5 Action Taken To Prevent Getting HIV/AIDS

In order to halt the spread of HIV/AIDS infection, abstinence, being faithful and consistent condom uses are the recognized HIV/AIDS prevention strategies. To have an insight about this practice, information was collected from individual women to share their HIV/AIDS prevention practices. Table 5.5 shows the distribution of women who prevent them from HIV/AIDS infection by applying possible prevention methods`. As indicated in this table, 89.6 percent of the women from Malle Woreda prefer to be faithful to partners, followed by avoiding sharing needles (88.8 percent) and abstinence (62.7 percent). On the other hand, in South Ari 77.9 percent of the women prefer avoiding sharing needles followed by to be faithful to partners (74.7 percent) and abstinence (68.3 percent). Only 21.3 and 27.3 percent of women in Malle and South Ari respectively used condom to prevent HIV/AIDS transmission.

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Table 5.5 Type of Action to prevent HIV/AIDS: percentage of women who have taken action to prevent HIV/AIDS, by residence

Type of actions Wereda Mall South e Ari Prevention methods Avoid sex completely 62.7 68.3 Stay faithful to partner 89.6 74.7 Used condoms in every act of sexual intercourse 21.3 27.3 Avoid sharing of needles 88.8 77.9 Others .8 5.6 Number of women (n) 249 249

5.7 Knowledge of PMTCT

Prevention of mother to child transmission (PMTCT) is the best strategy to reduce the transmission of HIV/AIDS from HIV infected mother to her baby. Babies are at risk for HIV during pregnancy and lactation/breastfeeding. Therefore, antenatal and postnatal VCT service is an important approach to save the newborn infants. This survey gathered data on knowledge of women towards PMTCT service. As Table 5.6 shows, higher proportion of women in South Ari Woreda (49.5 percent) has knowledge about PMTCT. However, women in Malle Woreda a small proportion (27.5 percent) of women appear to have the knowledge about PMTCT.

Table 5.6 Knowledge of PMTCT: percentage of women who have knowledge on PMTCT, by residence

Wereda Knowledge of PMTCT Malle South Ari

Heard of information on PMTCT Yes 27.5 49.5 No 72.5 50.5 Total 100 100 Number of women 396 426

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5.8 Knowledge of ART

Antiretroviral therapy (ART) is a drug, which is used to increase survival, improving quality of life and reduce morbidity of people living with HIV/AIDS. Table 5.7 presents information on women who have ART knowledge. The result illustrates that most women (65.7 percent) in South Ari Woreda have ART knowledge and a little less than half (45.7 percent) of women in Malle Woreda has ART knowledge.

Table 5.7 Knowledge of ART: Percentage of women who have knowledge on ART, by residence

Wereda Knowledge of ART Malle South Ari Heard about ART information Yes 45.7 65.7 No 54.3 34.3 Total 100 100 Number of women 396 423

5.9 Extramarital Sex Extramarital sex is a window of hop for the spread of sexually transmitted infectious disease, including HIV/AIDS. Besides, women who exercised extramarital sex are at risk of abortion and unintended birth. Information on extramarital sex was collected from women by asking whether they had had sexual intercourse before marriage. Table 5.8 shows that 94 percent of women in Malle Woreda and 92.7 percent in South Ari did not practice sexual intercourse before marriage (Table 5.8). Table 5.8 Extramarital sex: percentage of women who had sex before marriage, by residence

Wereda Extra marital sex Malle South Ari Sexual practices before marriage Yes 6.0 7.3 No 94.0 92.7 Total 100 100 Number of women (n) 397 426

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5.10 Age At Fist Sexual Debut

Table 5.9 displays percent distribution of women by age at first sexual debut. As indicated in this table, 70.1 percent of Malle women and 60.9 percent of South Ari women said that they started the first sex while they were aged between 15 to 19 years. On the other hand, one fifth of the sample women did not know the age they started sexual intercourse.

Table 5.9: Age at sexual debut: Percent distribution of women by age at first sexual practice and residence Wereda Age at first sexual debut Malle South Ari Age groups in years Under 15 years 2.8 10.1 15-19 years 70.1 60.9 20- 29 years 8.6 10.1 30+ years 0 0 Do not know 18.5 18.8 Total 100 100 Average age at first sex 16.9 16.5 Number of women 395 425

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CHAPTER VI REPRODUCTIVE HEALTH

6.1 Pregnancy and childbearing

Information on women’s pregnancy and childbearing practices of the study population is presented in Table 6.1. As shown in this table, the majority of women (97.3 percent in Malle and 94.3 percent in South Ari) experienced pregnancies. Among those who experienced pregnancy, 99 and 98.5 percent in Malle and South Ari respectively had given live births. Most women (56.6 percent in Malle and 53.8 percent in South Ari) reported that they did have five or more pregnancies. The average number of conceptions was estimated to be 5.6 and 5.1 pregnancies for Malle and South Ari Woredas respectively.

Table 6.1 Pregnancy and childbearing Experience: Percentage of women according to pregnancy and childbearing experiences, by residence Wereda Pregnancy and birth Malle South Ari

Have ever been pregnant 97.3 94.3 Have given live birth 99.0 98.5 Frequency of pregnancy 1 pregnancy 8.0 11.4 2 two pregnancies 11.5 12.9 3 pregnancies 10.5 10.5 4 pregnancies 13.5 11.4 5+pregnancies 56.6 53.8 Total 100 100 Average number of 5.6 5.1 pregnancy Number of women (n) 401 412

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6.1.2 Fertility

Table 6.2 shows data on the pattern of children ever born by sex ratio. The sex ratio of children ever born is consistent indicating that there is no sex selective omission in the number of children ever born. As indicated in this table, the highest mean number of children ever borne (8 children per a woman) is observed in Malle Woreda. It is 5 in South Ari Woreda.

The sex ratio at birth (male to female) is estimated to be 1.08 and 0.99 for Malle and South Ari respectively. This indicates that there were 101 male births per 100 female births for Malle and 99 male births per 100 female births for South Ari. For human populations Sex ratio at birth ranges between 102 and 107. There is considerable deviation from the expected sex ratio at birth and this is likely to be due to errors of reporting the sex of children who might have died.

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Figure 8: Trends inSex mean ratio number of children ever borne, dead and

6 2.45 4.7 2.4 4.8 5 2.35

2.3 4.3 3.8 2.3 4 Numbe 3.1 3.0 2.25 Numbe 2.3 r r 3 2.2 2.2 2.15 2 2.1 2.1

1.08 2.05 1 1.02 0.92 0.99 1.01 2 0 1.95 Bena Tsemay Selamgo Mall South Ari Total e Woreda

Mean number of children ever borne

Sex ratio

Mean number of died children

Fertility in general appears to be high in both Woredas. Figure 9 presents the mean number of children ever born by five-year age group and Woreda. As the data show, women in Malle Woreda have the highest fertility. The mean number of children ever born in each age group is highest for women in this Woreda.

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Figure 9: Mean Number of Children Ever born per woman by age and Woreda

9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 15-19 20-24 25-29 30-34 35-39 40-44 45-49

Bena Tsemay Selamago Malie South Ari

Table 6.2 Fertility differentials by residence: Number of women, children ever born and died children by residence Woreda Malle South Ari Children ever born Number of children ever born 1992 1881 Mean number of children 7.8 5.4 Number of women (n) 350 338 Sex of children ever born Male 1034 937 Number of women (n) 369 341 Mean number of children 2.8 2.7 Female 958 944 Number of women (n) 344 348 Mean number of children 2.8 2.7 Sex ratio at birth (male to female) 1.08 0.99 Died children Number of died children 349 473 Number of women (n) 153 199 Mean number of died children 2.3 2.4

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6.1.3 Age at first birth

It is well-established fact that age at first birth disrupts the survival of women. Young women (below 18 years) and older women (above 35) years are at greater risk of developing pregnancy complications and death. To give an idea about the age women start giving birth, all women who had at least one live birth were asked to report on the age at which they had their first baby. Table 6.3 shows the distribution of women who had at least one live birth by age at first birth. 30 percent of women in South Ari had their first baby before age 18 years. In South Ari, only a quarter of had their first baby before age 18. Surprisingly, 2 percent of women had their first child at age below 15 years. Most of the women (39.6 percent) in Malle Woreda had given first birth at their 18-19 ages. The median age at first birth among women who had at least one child was estimated to be 19 years and 18 years in South Ari and Malle Woreda, respectively. The median age was 19 years in Southern Ari and 18 years in Malle.

Table 6.3 Age of women at first birth: Percent distribution of women by age at first birth and residence

Wereda Age at first birth Malle South Ari Age groups in years <15 years .9 1.7 15-17 years 29.1 24.2 18-19 years 39.6 37.2 20+ years 29.1 34.6 Total 100 100 Median age at first birth 18 19 Number of women (n) 327 356

6.1.4 Desire for More Children

Data was collected from all eligible women about the number of children desired. As shown in Table 6.4, 68.1 percent of women in Malle and 43 percent of women in South Ari said that they wanted to have more children.

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The table clearly illustrates sex preference of the next child. About 39.3 percent of women in Malle woreda do not worry about the sex of the next child. Nevertheless, some 43.4 percent of women prefer a boy while 22.1 percent a girl in South Ari Woreda. Likewise, 47 percent of women in Malle and 64.3 percent in South Ari said that husbands prefer a son to girl child. From this result, it may be concluded that boys are more preferred than girls in these communities. The data indicate that most of the respondents do not want additional children. Most of the respondents reported that they do not want additional children mainly because child rearing is becoming very expensive. About 37.8 % and 39.4% of the women in Malle and South Ari respectively who did not want additional children reported that they have already achieved the desired number.

Table 6.4 Women’s desire for additional children: Percent distribution of women who want additional children by when to have the next child and preferred sex of the next child Wereda Fertility differential Malle South Ari Want additional children Yes 68.1 43.0 No 14.5 37.3 Can not get pregnant 5.7 8.7 Do not know 11.7 11.0 Total 100 100 Number of women (n) 317 263 How long to wait before having the next birth Within a year 20.5 21.2 1-2 years 18.6 21.2 2 years and more 33.0 35.4 Can’t decide 23.7 16.8 Do not know 4.2 5.3 Total 100 100 Number of women (n) 215 114 Sex preference for next child Boy 23.8 43.4 Girls 14.0 22.1 Either sex/do not worry about sex/ 39.3 16.8 Do not know 22.9 17.7 Total 100 100 Number of women (n) 215 114 Husband’s preference of next child sex Boy 47.0 64.3 Girls 8.8 16.1 Do not know 44.2 19.6 Total 100 100 Number of women (n) 215 114 Reasons for not desiring additional children Already have enough 37.8 39.4

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Cannot afford any more 57.8 59.6 Spouse/respondent/ is too old 13.3 10.1 Spouse/husband/ does not want any 6.7 13.1 more Others 13.3 12.1 Number of women (n) 45 99

6.2 Family Planning

6.2.1 Knowledge of FP

Women were asked if they have ever heard about modern family planning methods. Table 6.5 presents the responses to these questions. About 76 percent of women in South Ari Woreda and 69.3 percent in Malle have knowledge about family planning.

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The most important source of family planning methods is health professional (95.4 percent of Malle and 89.7 percent of South Ari women responded it), followed by meetings (51.1 percent in Malle and 48.8 percent in South Ari). The overwhelming majority of women (88 percent in Malle and 89.7 percent in South Ari) reported that they know more about injection contraception. About 81.3 and 80.0 percent of women in Malle and South Ari Woredas respectively responded that they have knowledge of the pill. The result reveals that most women do not have IUD (Intrauterine Device) knowledge. It is also found that a relatively high proportion of women (62.7 percent in Malle and 59 percent in South Ari) do not know emergency contraception. For Details refer figure 10.

Figure 10: Percent distribution of women by type of contraception knowledge

100 90 80 70 Bena Tsemay 60 Selamgo 50 Mali percent 40 South Ari 30 20 10 0 Pill IUD Injection Norplant Condom Type of modern contraception

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Table 6.5: knowledge of family planning: Percentage of women who have knowledge of family planning, by residence Wereda Knowledge of family planning Malle South Ari Heard of family planning (FP) Yes 69.3 75.7 No 30.2 24.0 Not stated .5 .2 Total 100 100 Number of women (n) 411 437 Source of information about FP Friends 29.2 19.0 Church/mosque 6.7 10.6 Radio/television 3.9 10.6 Health professional 95.4 89.7 Pamphlets 2.1 3.9 Meeting 51.1 48.8 Health messengers 41.2 35.2 Others 5.6 10.3 Number of women (n) 284 331 Knowledge of contraception/family

planning methods/ Pill 81.3 80.0 IUD 2.5 7.9 Injection 88.0 89.7 Norplant 6.0 9.1 Condom 6.7 14.2 Others 0 0 Number of women (n) 284 331 Heard of emergency contraception Yes 37.3 41.0 No 62.7 59.0 Total 100 100 Number of women (n) 284 331

6.2.2 Ever Use Of Family Planning

The data of this survey indicate that in South Ari Woreda, higher proportion of women (39.5 percent) reported ever use of family planning than women in Malle Woreda. However, 75 percent of women in Malle Woreda had never used any of family planning methods (Table 6.6).

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Table 6.6: Ever use of family planning: percentage of women by ever use of family planning and residence

Use of family planning Wereda

Malle South Ari Ever use of family planning Yes 25.0 39.5 No 75.0 57.4 Never made sex 0 3.0 Total 100 100 Number of women (n) 284 331

6.2.3 Current Use Of Family Planning

Figure 10 presents current use of family planning methods at the time of the survey. As shown in the figure, highest proportion (20.%) of women in South Ari followed by Malle Woreda (12.9%) reported using contraception. (Figure 11A). The high reported contraceptive prevalence in South Ari and Malle Woredas might be due to the high proportion urban population in these Woredas compared to the others, which are relative remote.

Figure 11A: Current use of Contraceptives

25.0

20.0 20.0

15.0 12.9 12.3

10.0 8.5 7.0

5.0

Percent using Contraceptives using Percent

0.0 Bena Salamago Malle South Ari Total Tsemay Woreda

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The most common method of contraception used by women is injection followed by Pill. Only 0.9 percent in South Ari reported using IUDS. Condom use was reported by less than a quarter of a percent in Malle woreda while in South Ari where about half a percent of women reported use of condom. Very few women reported using EOC in South Ari Woreda. In general, like in many parts of Ethiopia, long term or permanent methods of contraceptives are not practiced in these Woredas. Figure 11B)

Figure.11B: Contraceptive methods used by Woreda:

20 18 16 14 12 10 8

Percent Using Percent 6 4 2 0 Pill IUD injection Norplant Condom EOC Other Contraceptive Method

Bena Tsemay Salamago Malle South Ari

6.2.4 Reason For Not Using Family Planning

Women who were not using family planning methods at the time of the survey were asked why they were not using. The most common reason reported was the belief that contraceptive have side effects/ affects health (39%). About 11.1 and 9.8% in Malle and South Ari Woredas respectively reported that they were not using it because they wanted to have children. The same proportion of women in both Woredas also said that they are pregnant. (Table 6.7)

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Table 6.7: Reasons for not using family planning: percentage of women who provide reasons for not using family planning, residence Wereda Reasons Malle South Ari Reasons for not using family planning currently No service 5.6 2.4 Pregnant 11.1 9.8 Not suitable/health problem 38.9 39.0 No appropriate FP for respondent 5.6 2.4 Want to have child 11.1 9.8 Husband does not allow to use FP 0 7.3 Respondents do not support use 5.6 2.4 of FP Other 22.2 26.8 Number of women (n) 338 310

6.3 Use of Antenatal and postnatal care

6.3.1 Use of Antenatal Care

Antenatal care service including pregnancy checkup and immunization has a significant effect on the health of women and their newborn babies. The survey collected information on the use of antenatal care services at the time of pregnancy. As indicated in Table 6.8, more women in South Ari appear to have experience in visiting health facilities for antenatal and postnatal services than women who live in Malle Woredas.

The data shows that that 80.8 percent of women in Malle and 90.2 percent in South Ari received Tetanus Toxoid (TT) immunization. The majority of women (75 percent in Malle and 83.2 percent in South Ari) received three or more TT injection.

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Table 6.8: Antenatal Care Services: percentage of women by use of Antenatal care and residence Wereda ANC Malle South Ari Attending health facility during last pregnancy Yes 54.6 71.4 No 45.4 28.6 Total 100 100 Number of women (n) 313 262 Not stated (n) 4 3 Received TT immunization Yes 80.8 90.2 No 19.2 9.8 Total 100 100 Number of women (n) 317 264 Not stated (n) 0 1 Number of TT injection received 1 TT injection 8.6 1.7 2 TT injections 16.4 15.1 3+ injections 75.0 83.2 Total 100 100 Median time of receiving TT injection 3 3 Number of women (n) 256 238 Not stated (n) 0 0

6.3.2 Facility based delivery

Women were asked about the place where they gave births. Table 6.9 shows that close to 76 percent of women in Malle and 73.6 percent of women in South Ari delivered at home alone with no assistance. Health facility based deliveries are higher in South Ari Woreda than Malle Woreda. Surprisingly, 2.7 percent of women in Malle and 1.8 percent in South Ari delivered in the forest without any assistant.

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Table 6.9: Facility based delivery: percentage of women by type of facility based delivery and residence Wereda Type of facilities Malle South Ari Type of delivery place for last birth Health facility 4.1 8.8 Home with skilled traditional midwife 9.5 5.3 Home with unskilled traditional midwife 2.7 6.6 Home with health extension workers 5.4 4.0 Home-lonely 75.7 73.6 Forest-lonely 2.7 1.8 Other 0 0 Total 215 296 Number of women (n) 296 227

6.3.3 Use Of Postnatal Care

Data on postnatal care (care after birth) was collected in this survey. Table 7.6.3 presents the percentage of women who visited health facilities after birth. Most women in South Ari (71.8 percent) and Malle (66.6 percent) Woredas reported to have received postnatal care services. (Table 6.10).

Table 6.10: Use of postnatal care: percentage of women by use of postnatal care and residence

Wereda Use of Postnatal care Malle South Ari Receiving postnatal care for recent birth Yes 66.6 71.8 No 33.4 28.2 Not stated 0 0 Total 100 100 Number of women (n) 296 227

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CHAPTER 7 HARMFUL TRADITIONAL PRACTICES

7.1 Major Harmful Traditional Practices

Table 7.1: Major harm full traditional practices: percentage of women who reported major harmful traditional practices, by residence Wereda Common Harmful Traditional Practices/HTP Malle South Ari Type of HTP in the community Early marriage 54.0 42.9 Abduction 51.3 41.7 Tonsilectomy/univlictomy 54.0 45.0 Rape 47.7 32.3 Stigmas of women during birth 35.7 21.6 Thrown of child /Mingi 18.6 11.2 Killing of a child if it is born with out the custom 19.8 6.7 Women hitting 7.8 9.2 Inheritance marriage 9.5 45.0 Polygamy 79.0 70.9 Giving higher payment to bride groom/family 40.1 53.4 Prevention of eating with men 21.3 8.9 Lip cutting .2 4.8 Teeth extraction 16.9 13.1 Washing of milk material with cattle urine 16.6 4.6 Not washing female body 7.3 6.9 Chick image alteration when people dead 40.8 7.8 Prevent women not to eat honey and milk for 3 21.5 18.6 months Others 14.9 11.0 Number of women (n) 411 437

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As indicated in this table, Polygamy, tonsillectomy, abduction and early marriage are practiced in Malle Woreda. Women in South Ari Woreda reported that polygamy and high bridegroom prices are considerable harmful practices. For details refer to Table 7.1.

Apart from this, women are not allowed to give birth within their own house among the Arri, and many other ethnic groups in the study area. In the case of Arri, a woman left her house as soon as she starts to labour and taken to the “Däs”/ a place sheltered by poles (pavilion) around the homestead until she gives birth and the age of her child becomes four month. During her stay there, men are not allowed to visit her except the TBAs and other women who would provide her food, drinks and cloths. Among the Arri, a woman is not allowed to eat food stuffs rich in protein like milk, butter, cheese, and others like honey starting from the day of delivery until her child begins to eat other supplementary food stuffs in addition to breast feeding. Because they believe that such food stuffs are not good for the well being of a lactating woman. Instead, she eats the root of Enset, cabbage and other crops and vegetables.

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On the other hand, a woman in a period of menstruation is not allowed to fetch water from any water points like springs, rivers, ponds and wells until her menstruation stops because the Arri believe that the water points would be spoiled if they are touched by a woman in a period. Strictly speaking, the feeding habit of staying the whole day by breakfast insufficiently eaten early in the morning seem to be the other deeply rooted problem that adversely affected the health of women among a number of ethnic groups in the area.

Subsequently, the problem of early marriage has been started to be practiced among a number of ethnic groups such as Arri, and others mainly since the last one decade. Among these ethnic groups, girls are getting married beginning from the age of 12 to 14 years on average. Early marriage has continued to exist mainly parents justify it by saying that they want to see their children’s ceremony before they die. Besides this, parents are afraid of negative cultural rebelling if their children could not perform their marriage at the right time. Furthermore, parents want to secure economic advantage through the marriage relationship. As a result, a number of female children seem to perform marriage at their early age and seem to be exposed to early pregnancy, early death related to pregnancy, and giving birth to immature and/or unhealthy child. In connection to this issue, however, slight change has been taking place that school girls are performing their marriage at a later age than in the former time in some urban centres like Jinka and others.

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7.2 Experience of Harmful Traditional Practices

Table 7.2 presents information on women’s exposures towards harmful practices. As can be seen from the table, The Majority of women in Malle (17.1 percent) and South Ari (22.8 percent) Woredas had experienced high bridegroom prices and are in polygamous marriages; it is 17.1 percent for Malle and 26 percent for South Ari.

Table 7.2: Experience of harmful traditional practices: percentage of women who practiced harmful traditional practices, by residence Wereda HTP experience/practices Malle South Ari Type of HTP experiences/ practices exists Early marriage 6.1 7.1 Abduction 2.2 8.5 Tonsilectomy/univlictomy 4.4 6.2 Rape 2.0 3.0 Stigmas of women during birth 3.7 3.9 Thrown of child /Mingi .2 .7 Killing of a child if it is born with out the custom 1.0 .9 Women beating 1.2 1.1 Inheritance marriage 1.5 5.5 Polygamy 17.1 26.0 Giving higher payment to bride groom/family 17.1 22.8 Prevention of eating with men 3.9 1.4 Lip cutting .5 .7 Teeth extraction 5.4 5.5 Washing of milk material with cattle urine 2.9 2.1 Not washing female body 1.5 .7 Chick image alteration when people dead 7.6 1.4 Prevent women not to eat honey & milk for 3 4.2 5.7 months Others 4.2 3.9 Number of women (n) 409 435

7.3 Support For the Discontinuation Of HTPs

Data was collected on women opinions about the discontinuation of harmful traditional practices. As shown in Table 7.3, about nine out of ten women in both Woredas are against the practices.

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Table 7.3: Discontinuation of HTPs: percentage of women who want to discontinue harmful traditional practices and residence

Wereda Discontinuation of HTP Malle South Ari Type of HTP to be discontinued Early marriage 95.8 95.6 Abduction 97.1 96.3 Tonsilectomy/univlictomy 96.8 96.3 Rap 97.8 97.5 Stigmas of women during birth 97.8 99.1 Thrown of child /Mingi 97.8 99.1 Killing of a child if it is born with out the custom 97.6 99.3 Women hitting 97.8 99.1 Inheritance marriage 98.0 95.2 Polygamy 94.9 91.5 Giving higher payment to bride groom/family 89.5 77.3 Prevention of eating with men 97.1 97.9 Lip cutting 97.6 99.3 Teeth extraction 95.4 94.7 Washing of milk material with cattle urine 95.8 98.4 Not washing female body 97.3 99.5 Chick image alteration when people dead 97.1 99.5 Prevent women not to eat honey and milk for 3 months 97.6 98.2 Others practices 94.6 96.1

Number of women (n) 411 437

7.4 Knowledge and experience About Fistula

Studies show that women who become pregnant before the age of 18 years of age face serious health risks, mainly obstetric fistula. Obstetric fistula refers to “the damage to the tissues of the vagina and supporting structures during obstructed labor that results in an opening between one hollow organ and another, which is between the urinary bladder and the vagina or the rectum and the vagina (WHO, 1997). Accordingly, information was collected from entire women by asking their knowledge and practices to obstetric fistula.

As shown in Table 7.4, two in three women in Malle and 70 percent in South Ari reported having not heard about fistula. In contrast, 11.5 in South Ari had themselves experienced fistulas. In Malle Woreda, however, only 5 percent of the women reported having experienced fistula.

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Table 7.4: Knowledge and experiences of fistula: percentage of women who have knowledge and experience of fistula, by residence Wereda Knowledge and South experience of Fistula Malle Ari Knowledge of Fistula Yes 32.4 30.0 No 66.7 69.1 Not stated 1.0 .9 Total 100 100 Number of women (n) 411 437 Experiences/ practices of Fistula Yes 5.3 11.5 No 94.7 88.5 Total 100 100 Number of women (n) 133 130

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CHAPTER 8

GENDER ISSUES

8.1 Decision making

Table 8.1 presents the percentage of women by their opinion regarding whether a man or a women should make decisions regarding some important issues. The data demonstrates that most of the women reported that both husband and wife should jointly make decisions on household activities. For instance, 87 percent of women in Malle and 90.8 percent of women in South Ari said that husband and wife together should decided to take a sick child to hospital/health facility, about 86 and 88 percent of women in Malle and South Ari Woredas respectively perceive that both husband and wife should decide whether or not to have another child.

The table also shows that 59.4 percent of women in Malle and 52.6 percent of women in South Ari said that both men and women can fit for public administration. Whereas, 36.3 and 44.2 percent of women in Malle and South Ari Woredas respectively believe that men have better leadership capability than women, only 4.1 percent of women in Malle and 3.2 percent of women in South Ari reported that women have ability to stand at the leadership position.

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Table 8.1: Women in decision-making: percentage of women who have perception about decision making, by residence Wereda Decision making process Malle South Ari Take a sick child to a medical facility Husband with out consulting wife 5.6 3.2 Wife without consulting husband 7.3 6.0 Both husband and wife 87.0 90.8 Total 100 100

Decision about sending children to school Husband with out consulting wife 9.8 7.1 Wife without consulting husband 4.4 4.6 Both husband and wife 85.8 88.3 Total 100 100 Spending wife's income for the husband Husband with out consulting wife 8.6 4.6 Wife without consulting husband 18.3 21.3 Both husband and wife 73.1 74.1 Total 100 100 Spending husband's income for the wife Husband with out consulting wife 24.2 20.4 Wife without consulting husband 4.4 5.5 Both husband and wife 71.4 74.1 Total 100 100 Number of children to have Husband with out consulting wife 10.1 7.1 Wife without consulting husband 4.4 5.0 Both husband and wife 85.5 87.8 Total 100 100 Using family planning Husband with out consulting wife 9.1 6.4 Wife without consulting husband 4.4 5.3 Both husband and wife 86.5 88.3 Total 100 100 When daughter can marry Husband with out consulting wife 9.6 6.9 Wife without consulting husband 3.9 6.7 Both husband and wife 86.5 86.4 Total 100 100 Participation of women in meetings Husband with out consulting wife 10.0 5.8 Wife without consulting husband 4.6 9.7 Both husband and wife 85.3 84.6 Total 100 100 Sale of cattle Husband with out consulting wife 14.9 15.9 Wife without consulting husband 3.9 4.8 Both husband and wife 81.2 79.3 Total 100 100 Purchasing clothes for self Husband with out consulting wife 9.8 5.7 Wife without consulting husband 7.8 12.0 Both husband and wife 82.4 82.3

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Total 100 100

Visiting friends or relatives Husband with out consulting wife 8.1 3.4 Wife without consulting husband 6.6 9.2 Both husband and wife 85.3 87.4 Total 100 100 Number of women (n) 409 436 Not stated (n) 2 1 Fit for public administration Men 36.3 44.2 Women 4.1 3.2 Both 59.4 52.6 Not stated .2 0 Total 100 100 Number of women (n) 411 437

8.2 Wife Beating

Women were asked to provide information on their attitudes towards wife beating. As indicated in Table 8.2, women approve partner-induced physical violence in the household.

Table 8.2: Wife beating perceptions: percentage of women who believe about wife beating during conflict, by residence Wereda Wife beating Malle South Ari Believe that husband should punish wife with Killing .5 11.0 Beating 8.1 25.9 Shouting 9.8 26.5 Threatening with stick 9.3 23.1 Forced sex 3.4 16.7 Burned /scaled 1.7 10.3 Pushed pulled 2.7 16.9 Others 11.7 9.8 Number of women (n) 411 437

There are considerable differences by Woreda regarding women’s perception about domestic violence. While 26.5 percent of women in South Ari approving that a man can shout at his wife, only one in ten women in Malle Woreda shared similar views. Moreover, about a quarter of women in South Ari approved wife beating, only 8% approved it in Malle. In general higher proportion of women in South Ari approve physical violent action against wives in case of any wrong doing. Most women in Malle woredas appear not to approve any physical violent action against women by their husbands.

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CHAPTER 9

CHILD HEALTH

9.1 Knowledge of and Source Of information about Vaccination

As can be seen in Table 9.1, almost all women (99.7 percent) in South Ari Woreda are knowledgeable about immunization. Likewise, most of the women in Malle Woreda (98.6 percent) have heard about vaccination (refer to Figure 12 and Table 10.1)

Table 9.1 and Figure 12 clearly depict that 94.1 percent of the women in Malle and 87 percent of women in South Ari obtained immunization information from health professional and about half got it at community meetings.

Figure 12: percentage of women by level of vaccination knowledge

have vaccination knowlede Have not knowledge

91%

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Table 9.1: Knowledge and source of information about vaccination: percent distribution of women who have knowledge and source of child vaccination Wereda Knowledge and source of information about child Malle South vaccination Ari Knowledge/ heard of immunization Yes 98.6 99.7 No 1.4 .3 Total 100 100 Number of women (n) 345 293 Source of vaccination information Friends 28.5 17.1 Church/mosque 8.5 13.0 Radio/television 6.2 12.7 Health professional 94.1 87.0 Pamphlets 2.4 3.8 Meetings 56.8 49.7 Health messengers 37.9 40.4 Others 6.5 8.2 Number of women (n) 340 292

9.2 Last Child Vaccinated

Table 9.2 shows that higher proportion of women in Malle (89.3 percent) and South Ari (87.7 percent) Woredas appear to have vaccinated their last child.

Table 9.2 Percentage of women with at least one Child who had vaccinated the last child Wereda Vaccination Malle South Ari Last child fully vaccinated Yes 89.3 87.7 No 10.7 11.6 Not applicable 0 .7 Total 100 100 Number of women (n) 337 292 Not stated (n) 3 0

9.3 Reason For Not Vaccinating Last Child

Information was collected from women who did not vaccinate their last child. About 17 percent of women in Malle Woreda reported that their last child was not vaccinated because the service is not available in their community and 8.6 percent reported lack of knowledge. About 5.7 percent did not vaccinate their last child due religion/belief is not permitted. While religion/belief is not permitted was reported by 8.8 percent of women in

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South Ari Woreda, while 5.9 percent of them reported lack of knowledge, the service is not available and immunization make a child to be sick.

Table 9.3: Reasons not vaccinating last child: percentage of women who reported reasons for not vaccinating child, by residence Wereda Reasons Malle South Ari Reasons for not vaccinated last child The service is not available 17.1 5.9 Religion/belief is not permitted 5.7 8.8 Know that immunized child become sick 0 5.9 Do not know the importance of immunization 8.6 5.9 Other 68.6 73.5 Total 100 100 Number of women 35 34

9.4 Child Morbidity

As can be observed from the figure, the majority of the women reported that diarrhoea, fever and coughing are the most common childhood diseases. Also, eye problem, skin infections and measles are the important childhood diseases. About 45 percent of women in Malle and 65.4 percent in South Ari said that they provided treatment for the sick child. More than nine in ten women reported that they took the sick child to a health facility to obtain treatment. (Table 9.4).

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Figure 13: percentage of women by type of childhood disease

40 Bena Tsemay Selamgo 30 Mali

percent 20 South Ari

0 Eye Fever Skin Diarrhoea problem Coughing conditions Measles Type of childhood disease

Table 9.4 Child morbidity and treatment: percentage of women according to child morbidity and treatment, by residence Wereda Child morbidity and treatment Malle South Ari Received treatment Yes 44.9 65.4 No 55.1 34.6 Total Number of women (n) 98 52 Type of facility/place that took treatment Health facility 97.7 97.1 Traditional healer 2.3 2.9 Spiritual healer 0 0 Holy water 0 0 Other 6.8 8.8 Number of women (n) 44 34 Number of days took to get treatment The same day (within 12 hours) illness 29.5 2.9 happened The day after the onset of illness 20.5 41.2 After three days of illness 25.0 44.1 After a week of illness 15.9 2.9 Other 9.1 8.8 Total 100 100 Number of women (n) 44 34

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CHAPTER 10

TUBERCULOSIS 10.1 Knowledge about TB

As shown in the table, the proportion of women who had heard about TB was highest in Malle Woreda followed by those in South Ari (86% and 79.6% respectively). Among those who have heard about TB, almost all women (more than 96%) in two Woredas relate coughing to TB. About 71 percent in Malle and 41.7 percent in South Ari woredas consider weight loss as a symptom of TB.

The data also show that nine in ten women believe that TB can be transmitted from one person to the person. Regarding the means of transmission, more than 98 and 97.5 percent of the women in Malle and South Ari respectively reported that TB can be spread (transmitted) primarily from person to person by breathing infected air during close contact.

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Table 10.1 Knowledge about TB: percent distribution of women about TB knowledge, transmission, prevention and treatment, by residence Wereda TB background characteristics Malle South Ari Knowledge/ heard about TB 86.1 79.6 Yes 13.4 20.4 No .5 0 Total 100 100 Number of women (n) 411 437 Symptoms of TB Cough 98.9 95.1 Fever 48.6 36.2 Sweet 46.6 31.0 Lost of weight 71.2 41.7 Other 8.8 12.9 Number of women (n) 354 348 TB transmitted from person to person Yes 94.2 94.2 No 5.8 5.8 Total 100 100 Number of women (n) 354 348 Means of TB transmission Cold air 0 0 Sexual intercourse 0 .4 In food .5 1.1 Breath 98.6 97.5 Other .9 1.1 Total 100 100 Number of women (n) 221 277 Not stated (n) 6 47 TB can be prevented Yes 75.7 76.4 No 24.3 23.6 Total 100 100 Number of women (n) 334 326 Not stated (n) 20 22 TB can be cured Yes 67.3 64.2 No 32.7 35.8 Total 100 100 Number of women (n) 333 327 Not stated (n) 21 21

10.2 Presence of TB patient in household

The survey also asked women whether there was a TB patient in their household. Table 10.2 presents the responses. Accordingly, one in ten women reported that they had a household member who has been coughing continuously for two weeks before the time of the survey. And among these the majorities are children and men in South Ari whereas

183 children and women in Malle.The data indicate that under-five children are at high risk of cough across all Woredas. Most women (48.3 percent in Malle and 69 percent in South Ari) reported that patients did not visit health facilities to obtain treatment. The possible reasons women gave for not visiting a health facility include, no medical service, traveling long distance to health facility and they cough can be cured by itself (each 26.7 percent) in Malle Woreda. While in South Ari traveling long distance to health facility and cough can be cured by itself (each 22.2 percent) are the major reasons given. Table 10.2 Presence of TB patients in the household: percent distribution of women by TB patients in the household and residence Wereda TB patients in the household Malle South Ari Presence of persons in the household who cough continuously for 2 weeks Yes 8.7 8.7 No 91.3 91.3 Total 100 100 Number of women (n) 335 332 Not stated (n) 19 16 Age of TB patient in years Under 5 years 17.2 34.5 5-9 years 20.7 24.1 10-19 years 17.2 17.2 20-29 years 3.4 0 30+ years 41.4 24.1 Total 100 100 Number of women (n) 29 29 Sex of the patient Male 48.3 62.1 Female 51.7 37.9 Total 100 100 Number of women (n) 29 29 Patient took hospital/clinic Yes 48.3 69.0 No 51.7 31.0 Total 100 100 Number of women (n) 29 29 Reasons for not going to hospital/clinic Do not know the presence of 0 0 medication No medical services 26.7 0 Too far to go hospital/clinic 26.7 22.2 Can cure itself 26.7 22.2 Cough could not cure with 6.7 11.1 medication Other 13.3 44.4 Total 100 100 Number of women (n) 15 9

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Need of the Community and Options for Interventions Members of various communities try to list down their felt need and various problems facing their community. Among these problems lack of adequate water and health facilities have been the major ones followed by lack of adequate education, veterinary and infrastructural facilities. From the researcher’ view and confirmed by the local informants, genuine community participation is very important to bring behavioral change and sustainable development in the area. In connection to this, community members recommend persons respected in their community who would further influence others. In this regard, the person called by the name “Babi” elders has been highly regarded among the community of Arri. Among the Maalle, however, persons called by the term “Godda”, “Gatto”, “Anno”, “Toyda” and “Garche” have been very important if they have been used effectively. Consequently, using elders effectively in all communities for intervention purpose seem to be very essential.

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CHAPTER XI SUMMARY, CONCLUSION AND RECOMMENDATION

11.1 SUMMARY

The main objective of this survey is to provide information on women, children and community’s health in relation to knowledge, attitude and practices of STIs, HIV/AIDS, Family Planning, availability of water, personal hygiene, malaria, child health, HTPs and gender issues. In order to meet this objective, the survey collected information regarding these issues from a representative sample of women who reside in four woredas of South Omo Zone, namely, Bena Tsemay, Selamgo, Malle and South Ari Woredas. A total of 1,657 women aged 15 to 49 years were included in this survey. Specifically, 411 from Malle and 437 women from South Ari Woreda.

Socio-economic and demographic characteristics

Religion, culture and ethnicity have direct and indirect impact on women’s health and wellbeing. Accordingly, information was also collected on religious and ethnic background of the sampled women. Survey results reveal that women have various religious affiliations. The result indicates that half of women (49.4 percent) in Malle Wereda were believers in traditional faith. In contrast, women in South Ari Wereda were more affiliated to Protestant Christianity.

Regarding ethnicity, respondents belonged to various ethnic origins; almost 97 percent of women in Malle Wereda belong to Malle ethnic groups. Likewise, about 87 percent of women in South Ari Wereda belong to Ari ethnic groups.

Women were engaged in various economic activities, such as more than half (51 percent) of women in Malle Wereda combine household chores and farming. A little over a third (34 percent) of women in South Ari Wereda are more inclined work as farmers and housewives and the remaining were engaged in miscellaneous economic activities.

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The survey found that Women in South Ari Wereda have better educational opportunity (28 percent) than women in Malle Woreda (11.2). This may be because the Zonal Capital Jinka is located in this Woreda. However, the result shows the level of literacy is extremely low in both woredas compared to that of the national. The result for Malle also less compared to that of the region. The 2005 EDHS shows that 31% of women at national level and 22 percent in SNNPR were literate.

Radio message is an important source of information on health and wellbeing. However, in these woredas, access to radio is limited and the majority of women do not listen to radios.

The data of this survey illustrates that the median age of women in Malle and South Ari Weredas are 28 years.

Regarding marital status of the women, the majority (96.1 percent in Malle and 87.9 percent in South Ari) of women were currently married, 4.6 and 2.2 percent in South Ari and Malle respectively were widowed, 0.5 percent in Malle and 4.3 percent in South Ari were divorced and only 0.5 and 1.8 percent of women in Malle and South Ari respectively were single. Marriage is relatively late compared to other parts of the country as the mean age at first marriage was found to be 17 year (nationally 16 years). There seems to be high prevalence of polygamous marriages in these Woredas. One in three women reported that their husband has more than one wife.

Information on size of household shows that the average household size was found to be 5 members in South Ari Woreda. On the other hand, in Malle Woreda higher average household size was reported (6 members per household). Under five mortality was reported to be highest in both Woredas, but Malle Woreda has the highest.

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Household water, health and Sanitation

In these Woredas, especially in Malle it is very difficult to get safe drinking water. About 42 percent of South Ari women have access to piped water and 47 percent of Malle women reported that river is the main sources of household drinking water. This is much lower compared to the national level. The 2005 EDHS results reveal that 61 percent of households in Ethiopia have access to safe/improved drinking water. It is not only the quality of water that is a problem in these communities. Access to any water source is also a problem. About 77.9 percent of women in Malle and 85 percent of women in South Ari travel more than two hours to fetch water, which is too long compared to the national average. The 2005 DHS found that 44.3 percent of women have access to water within half an hour. The survey result also indicates that the estimated median time to fetch drinking water is 15 hours for Malle and 12 hours for South Ari. Most women also reported that water interruption is the main problem of the community.

Seventy percent of women in Malle Woreda and 79.2 percent of women in South Ari Woreda households have no latrine. The proportion of women with no toilet facility is higher than in the 2005 DHS estimate, which found that 62 percent of households have no access to toilet facility.

Malaria Women were asked to identify the major health problems of the community. 97.1 percent of the respondents in Malle and 67.3 percent of them in South Ari woreda perceived that malaria is the leading health problems in their community. In addition, 70 and 34.4 percent of women in Malle and South Ari Woredas respectively believe that diarrhoeal diseases and respiratory disease/TB as the second leading cause of morbidity

The data indicates that most women (more than 96 percent in Malle and 83.5 percent in South Ari) reported that malaria is a treatable disease. The overwhelming majority of women in each Woreda know that malaria infection is transmitted through mosquito bite (72.8 percent to 92.3 percent). Surprisingly, a small proportion of women in both

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Woredas believe that witchcraft is a means through which malaria is transmitted from one person to the other. As the area is predominantly malarious, almost all (97.1 percent) of women in Malle said that mosquito nets are available in their households. In addition, Three-fourth of women in South Ari reported that mosquito nets are available in their households However; some households do not use the nets for preventing from mosquito bite but for decorating the house.

KAB Of HIV/AIDS

Knowledge of HIV/AIDS is highest as compared to the 2005 DHS estimates. In these Woreda, according to this survey, more than 86 percent of women in both Woreda have knowledge of STIs and higher proportions of women in Malle Woreda (97.1 percent) and South Ari Woreda (97.3 percent) have HIV/AIDS knowledge. However, the 2005 DHS indicated that 87 .3 percent of SNNPR women and 89.9 percent of entire women have HIV/AIDS Knowledge. The main source of information about HIV/AIDS was health professionals, meetings and health messengers. More than four- fifth of women have heard about VCT and among these, Only 17.6 and 23.6 percent of the sampled women in Malle and South Ari respectively had obtained HIV/AIDS test. Moreover, 8.8 percent of women in South Ari Woreda had experience of STI infection.

Higher proportion of women in South Ari Woreda (49.5 percent) has knowledge about PMTCT. However, women in Malle Woreda a small proportion (27.5 percent) of women appear to have the knowledge about PMTCT and most women (65.7 percent) in South Ari Woreda have ART knowledge and a little less than half (45.7 percent) of women in Malle Woreda has ART knowledge. This is lower than the national average of 69% in 2005. The level of knowledge about means of HIV transmission is high among those who have heard about the disease. More than ninety percent of the women in both Woredas reported that unsafe sexual intercourse is a means through which HIV virus can be transmitted from person to person. Surprisingly, more than 21 percent of women in Malle and 15.2 percent of women in South Ari perceive that mosquito can transmit HIV/AIDS virus. Among HIV/AIDS knowledgeable women, the majority of women perceive that

189 abstinence, being faithful to partners and avoiding sharing needles are the best ways of preventing HIV/AIDS. There seems to be some variation on knowledge of means of HIV/AIDS prevention between the two Woredas. However, condom use in Male woreda is 0 percent but it is 50 percent in South Ari.

The majority of the women (70.1% in Malle and 60.9 percent in South Ari) started sex while they were aged 15-19 years and only 2.8 percent of them in Malle and 10 percent in South Ari had sex before their fifteenth birth anniversary suggesting early exposure to sex is not common in these Woredas. The average age at first sex in these woredas is 16.9 years in Malle and 16.5 in South Ari.

Fertility The population in these woredas is characterized by high fertility. The majority of women (97.3 percent in Malle and 94.3 percent in South Ari) experienced pregnancies. Among those who experienced pregnancy, 99 and 98.5 percent in Malle and South Ari respectively had given live births. The median age at first birth was estimated to be 18 years for Malle and 19 years for South Ari. This estimate is close to that of the 2005 EDHS estimate, which is 19.2 years. At the end of her reproductive life, a woman in these Woreda had more than five live births, the highest being Malle with close to 8 live births.

Family Planning About 76 percent of women in South Ari Woreda and 69.3 percent in Malle have knowledge about family planning. The result indicates that the main source of family planning methods is health professional and meetings. The result shows that women do not have knowledge in all types of modern contraception. The overwhelming majority of women (88 percent in Malle and 89.7 percent in South Ari) reported that they know more about injection contraception. About 81.3 and 80.0 percent of women in Malle and South Ari Woredas respectively responded that they have knowledge of the pill. However, about two third of women haven’t heard of emergency contraception.

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The data indicate that highest proportion (20%) of women in South Ari and 12.9 in Malle Woreda using contraception at the time of interview. This prevalence is higher by 5.3 percent in South Ari and lower by 1.8 percent than the contraceptive prevalence estimates of 2005 DHS (CPR=14.7 percent).

Among the method mix of family planning, the most common method of contraception used by women is injection followed by Pill. Only 0.9 percent in South Ari reported using IUDS. Condom use was reported by less than a quarter of a percent in Malle woreda while in South Ari where about half a percent of women reported use of condom. Most women do not want to use modern family planning methods. The most common reason reported was the belief that contraceptive have side effects/ affects health (39%). About 11.1 and 9.8% in Malle and South Ari Woredas respectively reported that they were not using it because they wanted to have children. The same proportion of women in both Woredas also said that they are pregnant.

More women in South Ari appear to have experience in visiting health facilities for antenatal and postnatal services than women who live in Malle Woredas.

However, close to 76 percent of women in Malle and 73.6 percent of women in South Ari delivered at home alone with no assistance. Health facility based deliveries are higher in South Ari Woreda than Malle Woreda. Surprisingly, 2.7 percent of women in Malle and 1.8 percent in South Ari delivered in the forest without any assistant.

Harmful Traditional Practices

Women were asked to identify the major traditional practices of communities. Women in South Ari Woreda reported that polygamy and high bridegroom prices are considerable harmful practices. On the other hand, Polygamy, tonsillectomy, abduction and early marriage are the major harmful practices for Malle Woreda community.

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Obstetric Fistula Because of early marriage and harmful cultural practices, women are vulnerable to obstetric fistula. 32 percent of women in Malle and 30 percent in South Ari heard about fistula. The prevalence of women who have heard of fistula is higher than the 2005 DHS estimates (23.2 percent of women at national, 19.9 percent of women in SNNP region).

The result indicates that among fistula knowledgeable women, 11.5 in South Ari had themselves experienced fistulas. In Malle Woreda, however, only 5 percent of the women reported having experienced fistula. The data shows that prevalence of obstetric fistula is higher than that of 2005 DHS (National 1 percent; SNNPR 1.5 percent of women). Gender and wife beating The data shows that in most cases decisions are made jointly in both woredas. In the majority of cases, husband and wife jointly decide on whether or not to take a sick child to a health facility, spending wife’s income, spending husband’s income, when to have another child, whether or not to use family planning.

59.4 percent of women in Malle and 52.6 percent in South Ari said that both men and women are fit for public services. While 36.3 percent of women in Malle and 44.2 percent in South Ari agree that men have good leadership ability than women, while most women still think that a husband is justified to beat or shout or threat his wife.

Child Health The survey results show that the majority of the women have heard about immunization. Sources of information included health professionals, community health messenger and meetings.

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Tuberculosis The proportion of women who had heard about TB was highest in Malle Woreda followed by those in South Ari (86% and 79.6% respectively). Among these women, nine in ten women believe that TB can be transmitted from one person to the person. Regarding the means of transmission, more than 98 and 97.5 percent of the women in Malle and South Ari respectively reported that TB can be spread (transmitted) primarily from person to person by breathing infected air during close contact.

11.2 Conclusion

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Awareness about modern family planning methods is significantly noticeable in the study areas; however, contraception prevalence rate is small compared with the 2005 DHS only in Malle Woreda; it is better than the 2005 DHS in South Ari. The findings indicated that women use more on hormonal methods of contraception (Injectable and oral pill contraceptives) than barrier methods. The barrier methods (condom and IUD) are rarely used by women. The reason for low CPR might be women do not have access to method mix such as Norplant and emergency contraception.

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11.3 Recommendation

Based on the results the following key recommendations are suggested for interventions in order to improve the health and wellbeing of the population in these Woredas. 1. Education changes women behaviour. This survey found that women have poor access to education. Therefore, it is suggested that non-formal education systems be introduced and expanded in these communities. . Non-formal education is an alternative education system, which enhances reading and writing skills of people who live in remote areas. 2. Water, sanitation and hygiene are serious problems in all Woredas. Women travel long distance to fetch water for the household and they do have poor personal hygienic and sanitation practices. Therefore, it is suggested that concerned agencies should enhance the capacity of women on primary health care education; creating access to safe drinking water as well as advocate for the provision of safe water supply at reasonable distance 3. More than three fourths of women reported that communities are at risk of malaria, diarrhoea and TB. Intervention on prevention and treatment program helps to reduce the incidences of morbidity and mortality from these diseases. As education on ways of malaria transmission and use of mosquito net has paramount importance to reduce malaria infections, it is also recommended that members of the community be given intensive education on these issues. 4. Women who have formed marriage through abduction as well as those in polygamous union are more susceptible to STIs and HIV/AIDS infections. To minimize the risks and practices, it recommends that concerned organizations focus on raising awareness of elders, clan leaders, religious leaders and broader community members on the issues of harmful marital arrangement through community mobilization process. 5. Women have relatively better knowledge on STIs and HIV/AIDS infections. Nevertheless, they have little practices and knowledge on prevention methods. It is recommended that concerned agencies should increase behavioural change

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communication intervention on STIs and HIV/AIDS with regard to prevention modalities. 6. The survey found that more than two third of the women have knowledge on modern family planning methods, which is considerably lower than the average for SNNPR. It suggests that all Woredas women should need substantial family planning education. 7. The survey indicates that contraceptive prevalence rate is low in Malle woreda and the majority of women use temporary or short-term methods. It is recommended that access to family planning services be expanded, awareness about permanent and long term methods be improved and method mix improved. This service can be provided through linkages with government health institutions/ or directly supplying the commodities through outreach services. Or community based reproductive health workers. 8. In order to reduce the morbidity and mortality conditions of under five children and pregnant women, it is suggested that women should be educated to use antenatal and postnatal care services as well as about facility based distribution. Also, intervention is required to prevent childhood infections / diarrhoea, eye problem, skin infection, measles, coughs, respiratory infection/ and use of vaccination services. 9. The survey found that most women suffer from various harmful traditional practices. It is recommended that concerned organizations conduct HTP education to raise awareness of influential persons such as community leaders, religious leaders, traditional healers and respective individuals in order to accelerate the abolition of such practices. 10. The prevalence of obstetric fistula is above the 2005 DHS national prevalence estimate. This shows that women are at risk of obstetric fistula. It suggests that women should receive physiological and psychological treatment by educating communities about causes, prevention, treatment and risks of fistula.

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