' .

Towards the Year 2000 Goals of the World Summit for Children:

Report on achievement of mid-decade goals in Oman

Paul Milligan October 1996

For further information contact: Company Co-ordinator Liverpool Associates in Tropical Health Limited Liverpool School of Tropical Medicine Pembroke Place Liverpool L3 5QA, U.K.

Tel: +44 (0)151 708 9359 direct +44 (0)151 708 9393 ext 2259 Fax: +44 (0)151 707 1766 e-mail: [email protected] Towards the Year 2000 Goals of the World Summit for Children:

Report on achievement of mid-decade goals in Oman

P Milligan Liverpool School of Tropical Medicine June 1996

1. Executive Summary 3 2. Sampling design 5 2.1. The Gulf Family Health Sunrey 5 3. Questionnaire 5 4. Description offield work etc. 6 4.1. Pilot sunrey: 6 4.2. Main sunrey: 6 4.3. Sampling frame: 7 4.4. Coding and checking 7 4.5. Quality control 7 4.6. Data entry procedures: 8 5. Extraction of data for mid-decade indicators: 8 6. Indicators for mid-decade goals 9 7. 1995 Mid-Decade Goals: 12 7.1. Goal1: Elevation of immunization coverage of six antigens of the Expanded Programme on Immunization to 80% or more. 12 7.2. Goa12: Elimination of neonatal tetanus. 13 7.3. Goa13: Reduction of the number of measles deaths by 95%, and of the number of measles cases by 90%, compared with pre-immunization levels. 15 7 .4. Goal 4: Elimination of polio. 15 7.5. GoalS: Virtual elimination ofvitamin A deficiency: at least 80% of all children under 24 months of age in areas with vitamin A deficiency receive adequate vitamin A. 16 7.6. Goa16: Universal iodization ofsalt. ______16 7.6. I. Survey methodology: 16

1 7.6.2. Survey results: ______17 7.7. Goal7: 80% usage ofORT (increased fluids) and continued feeding in diarrhoea._18 7.8. GoalS: Ending and preventing free and low-cost supplies of breast milk substitutes in all hospitals and maternity facilities. Have target hospitals and maternity facilities achieve 'baby friendly' status in accordance with BFHI global criteria. 19 7.8.1. Musaiger's results: 21 7.9. Goal 9: Interrupt dracunculiasis transmission. ______21 7.10. Goa110: Ratification of the Convention on the Rights of the Child. 21 7 .11. Goalll: Reduction of1990 levels of severe and moderate malnutrition by 115 or more ______22

7 .11.1. Results for 1-yr-olds from recent surveys: ------:------~28 7 .11.2. 198911990 Oman Child Health Survey follow-up study: 29 7.11.3. Health and nutritional status ofOmani Families survey 1991 (Musaiger, 1992). 29 7 .11.4. National Study on the Prevalence of Vitamin A Deficiency, 199415: 30 7.1 1.5. MOH Annual Statistical Report for 1994: 30 7.12. Goal12: Strengthen Basic Education: 31 7.12.1. Education indicator: Girls 33 7.12.2. Education indicators: Boys 35 7.12.3. Education indicators: Boys and Girls: 36 7 .12.4. Estimates of education indicators from 1993 Census: 3 7 7.13. Goa113: Increase water supply and sanitation: ______38 7.13.1. Water: ______38 7.13 .2.Sanitation: 42 7.14. Goal14: Strengthening health facilities' capability for case management of pneumonia. ------43 8. Recommendations 43 9. References ------44 I 0. Acknowledgements 44 Appendix 1: Sample Designfor GulfFamily Health Survey in Oman 45 Appendix 2: 2-stage cluster sampling plan ofthe GulfFamily Health Survey ofOman. 48 Appendix 3: Mid-Decade Goals Table 55 Appendix 4: Acronyms and Abbreviations 59

Maps following page Map of Regions of Oman 2 MOH Primary Health Care through Wilayat Health Services 2 Population distribution (Omani and non-Omani) 2 Number ofOmani children under 5 yrs 2 Number ofnon-Omani children under 5 yrs 2 % households using iodised salt 17 Weight for age malnutrition, under Syr olds 24 Households with safe and convenient water supply (by region) 40 Households with safe and convenient water supply (by Wilayat) 40

2 • Musandam rm~m~ A'Dhahirah D N AI Batinah D S AI Botinah • Muscat

~ A'Dokliyah • S A'Shorqiyah m N A'Sharqiyoh D AI Wusta • Dhofar I Ministry of Health Primary Health Care through Wi/ayat Health Services 1

GULF OF OMAN

SAUDI ARABIA

ARABIAN SEA

• •• •

YEMEN • Hospital • Exhc • He I i, d AL DAKHLIYAH ~ ~~it l AL DHAHIRAH I ,,; j AL WUSTA r. DHOFAR l .ci\J~r!i d MUSANDAM 1*11 MUSCAT l t'$1;~' 1 NORTH BATINAH IA>i6~ 1 NORTH SHARQIYA CJ SOUTH BATINAH [Z] SOUTH SHARQIYA Population distribution (Omani and non-Omani),. 1993 (1 dot = 2000 people) ~·)~ .'· / ·\ Number of Omani children under Syrs 1993 No under 5's i I < 1 5ooo [. ...·:::><.·] 1 5000-30000 k::.::~:.::j 30000-45000 ~ 45000-60000 • 60000-90000 Number of non-Omani children under Syrs 1993 No under 5's D <1000 [2] 1000 2000 ~. 2000 3000 ~ 3000 to 4000 • 4000 to 15000 1. Executive Summary In 1990 at the World Summit for Children, heads of state pledged themselves to a Declaration and Plan of Action for Children. Countries around the world proceeded to develop their own National Programmes for Action for Children. The Government of Oman began preparing a National Programme for Action in November 1992. Working groups were established to prepare National Programmes of Action for health and nutrition, education, social services and childhood disability. In 1992 and 1993 UNICEF held a series of regional consultations at which consensus was reached about a set of goals that could be achieved by mid-decade, 1995 (see Appendix 3), as stepping-stones to the goals for the year 2000.

The Gulf Family Health Survey (GFHS) was planned and executed in all GCC countries for nationals and was supported in Oman by the Government of Oman, Executive Board of the Council of Health Ministers of GCC States, Arab Gulf Programme for the United Nations Development Organizations (AGFUND), United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF) and World Health Organization (WHO). It is a national survey of Omani families with emphasis on women of child bearing age and children under 5yrs in 6250 households selected to be representative of the whole Omani population. The scope of the GFHS was only Omani households; non­ Omani households were excluded. Nine per cent of children under 5 in Oman are non­ Omani, but we are unable to report on this section of the community.

The GFHS was planned as a four-year follow-up to the Gulf Child Health Survey, 1988/89 and was designed to provide planners and policy makers with a reliable information base to formulate family health and development policies and programmes in Bahrain, Oman, United Arab Emirates (survey activities started in 1995), Kuwait, Saudi Arabia and Qatar (survey work to start in 1996). In Oman, the GFHS consisted of 4 questionnaires: family health, household living conditions, reproductive health and child health.

To compile this report on Mid-Decade Goals, data was extracted from the GFHS of Oman which was conducted from September to December 1995, and from a household salt survey conducted in 1995/96, in order to assess achievement of mid-decade goals in the country. The GFHS questionnaire was updated to include the questions from Multiple Indicator Cluster Survey handbook and appropriate coding was provided for it. The data extraction and compilation of report from GFHS was done by the Liverpool School of Hygiene and Tropical Medicine with support from the Ministry of Health and UNICEF.

The main results are as follows:

Vaccination coverage of 1-yr.-olds for the 6 main antigens (Polio, Diphtheria, Pertussis, Tetanus, Measles, BCG) is 98-99%.

3 . -.;

81% of households have access to convenient water supply generally considered to be safe. Safe water is defined as piped water or water obtained from: an outside tap; a well with a pump; from a tanker or bottled water. Convenient water supply is defined as time up to 30 minutes required to obtain the water. However, there are regional and urban/rural disparities (87% of households have access in urban areas, 70% in rural. Water quality is variable; applying Ministry of Health (MOH) estimates of the proportion of water samples from different sources that were considered fit to drink, based on chemical and bacteriological tests, only 69% of households have access to safe water. In some districts access is much lower than the regional average (see maps).

77% of households have access to safe and convenient sanitation (safe was defined as flush to main sewerage or toilets flushing to a tank; convenient was defined as location of the toilet within the household or outside the house but within the compound), but there are marked regional and urban/rural disparities. In rural areas (settlement population size <2500) the figure is 56% and in urban areas it is as high as 88%.

Prevalence of malnutrition is high: 23% of boys and girls under 5yrs are moderately or severely underweight (weight for age), and 23% moderately or severely stunted (height for age). 13% are moderately or severely wasted (weight for height). These estimates are comparable with results from a number of independent surveys. In certain communities the prevalence is much higher than the national average: in Dhakilyah, 32% of under-5's are underweight, 25% stunted, and 23% wasted.

The average net enrollment rate (NER: % of primary-school-age children attending school) has risen in recent years, and the gender gap has narrowed. The NER is 93% for both boys and girls. However, many children are not in the correct grade for their age, and there are regional disparities.

35% ofhouseholds use iodized salt.

Use of oral rehydration therapy is common, 82% of children with diarrhoea received ORS solution, 89% received increased fluids with continued feeding.

All 51 hospitals were certified as baby friendly in December 1994, one year ahead of target date. Distribution of free and low cost breast milk substitutes has been banned. 86% of children continue to be breastfed at 1yr. 28% of 0-3-month-old children are exclusively breastfed.

Many indicators show the same geographical pattern; there are large regional disparities, with Dhahirah, Dhakiliya and Sharqiya consistently showing the poorest figures for most indicators, particularly access to water and malnutrition.

4 2. Sampling design

2.1. The Gulf Family Health Survey The sampling design for the Gulf Family Health Survey in Oman was a two-stage PPS (probability proportional to size) cluster sample design. The first stage consisted of 264 primary sampling units (PSUs), defined as Enumeration Areas of the 1993 Census of Oman. PSUs were selected with probability proportional to the number of households in the 1993 Census. Within each sample PSU, a current listing of all the Omani households was made from which 25 households were to be selected by systematic sampling. In each household, all women of child-bearing age were to be interviewed, and information obtained about their children (health information for all under 5s; educational information for all children of primary school age). Details of the sampling plan are given in Appendix 3.

6600 households were to be visited (264 PSU's x 25 households); 6250 households were selected and 6103 households were actually sampled, from 52 of the 59 Wilayats (districts) of the country. (A different sampling design was used for assessing household consumption of iodized salt).

3. Questionnaire Four questionnaires were used. In each questionnaire there were a number of modules of related questions on the following topics:

Questionnaire 1: Family health. 1 - list of households 2 - general module for disease prevalence 3 - chronic diseases 4 - other health status indicators 5 - general mortality patterns

Questionnaire II: Household living conditions 1 -housing 2 - type of kitchen and fuel used 3 - drinking water 4 -lighting 5 - sanitation 6 - disposal of household refuse 7 - availability of household equipment: fridge, TV, radio etc. 8 - hygiene of the area surrounding the house

Questionnaire III: Reproductive health 1 - background of the interviewee 2- marriage

5 3 - births and infant mortality 4 - maternal care: current pregnancy 5 - maternal care: past 3 years 6 - child nutrition 7 - birth spacing

Questionnaire IV: Child health 1 - child care 2 - health status of child 3 - immunization status of the child 4 - anthropometry

4. Description of field work etc.

4.1. Pilot survey: A pilot survey was conducted prior to the main survey. Three regions were selected for this: Muscat, South Batinah and Dakhliyah. Eight interviewers were recruited in each region and workshops were conducted between 20-25 May 1995 to orient staff and train them. Immediately after the training, the interviewers spent the next two weeks collecting data from a total of 300 Omani families from the pilot survey regions. UNICEF supported this activity.

With the experience of the pilot survey, some questions were reviewed and revised to suit Omani conditions and to be in line with the health cards that are used, e.g. the child health card. The pre-test also helped to plan the logistics of the main survey, for example to estimate the number of interviewers that would be required and the time needed to complete the field work.

4.2. Main survey: A workshop was held 16-28 September 1995 for training interviewers and supervisors on how to use the questionnaire, how to conduct the interview, division of labour, supervision and reviewing. The programme also included; lectures on theory, role playing and practical demonstrations of data collection from the field.

The central team trained 40 data collectors as well as 10 supervisors, 10 coordinators and 10 officials from the regions within two weeks of the training workshop. An expert from UNFPA contributed to the training in the first week ofthe workshop. UNICEF supported the training workshop as well as the printing of questionnaires and supervisors' training manual.

One survey team was formed in each of the 10 regions. The teams consisted of the official responsible for the region, a supervisor, a reviewer, and the interviewers. After training each group was given assignments to be done during the survey.

6 At the central level, a central team was formed consisting of the Executive Director of the project, coordinators, administrators, supervisors and reviewers for each step and for the survey operations. The central team visited the regions several times at the beginning and in the middle of data collection to follow up the work in the field and to evaluate the data collectors' performance and to submit their observations and comments.

The field teams worked mornings and evenings every day for two weeks, each interviewer covering 2 to 3 families per day. Data collection from the field took three months (October to December 1995).

Field teams found no difficulty reaching remote areas and were able to reach all regions. Therefore all the families within the sample could potentially be reached despite the fact that some ofthem lived in difficult geographical areas (e.g. mountainous areas). With the exception of anthropometric measurement which was to be done at health institutions, the compliance was high.

4.3. Sampling frame: To draw up the sampling frame, maps of selected Enumeration Areas of the 1993 Census were updated in collaboration with the Ministry of Development. The Ministry trained 36 Census workers from all the regions in a training programme held 21-23 August 1995 on how to update the maps, drawings, codings, numbering of houses and listing of Omani families. The training programme included practical field experience.

Updating of the maps and sample selection took about 3 months from the end of August 1995 until the end ofNovember 1995.

4.4. Coding and che~king Fifteen government officials were trained on how to code and check the survey questionnaires. The training took about one week (4-9 November 1995) and implementation started on 11 November 1995. Coding and checking was completed by the end of March 1996.

4.5. Quality control The questionnaires were subject to different stages of quality control to ensure data quality; they were checked by the interviewer, the field supervisor, and the regional coordinator. In cases where there were inconsistencies in the data, the families concerned were re-interviewed. At the centre, questionnaires were reviewed by the reviewer, coders, and then the central coordinators. In cases where answers were inconsistent, the family questionnaires were sent back to the regions for re-interviewing

7 4.6. Data entry procedures: A consultant visited MOH to advise on data entry at the end of November 1995; following this, 20 people received one week's training (9-14 December 1995); they were taught the basics of computing and file management, and how to enter the data. These 20 people did data entry in two shifts. Data entry was completed in three months at the end of March 1996.

Data was entered into the package ISSA (Integrated Social Statistical Analysis); this enabled range checks and logical consistency checks to be made when data were entered (e.g. checks on date of birth of child and date of marriage of the mother, or date of marriage of the mother and the number of children). A data cleaning procedure was designed by a consultant who visited the country for two weeks starting 26 April 1996. A computer printout was produced showing the inconsistencies and the household number and enumeration area; the questionnaire was then reviewed and data entry errors rectified. MOH staff were trained to edit these errors.

5. Extraction of data for mid-decade indicators: To extract data for mid-decade indicators, Liverpool School of Hygiene and Tropical Medicine was contracted by UNICEF in consultation with the Ministry of Health. The data checking and cleaning process had not been completed when this report was being prepared. The report is based on analysis of data for a subset of variables in files prepared in May by the visiting consultant, before the data had been cleaned. Staff experienced problems using the ISSA package and did not have access to documentation so it was not possible to refer back to the main dataset. The results in this report should therefore be regarded as preliminary. Furthermore, not all the questions in the MICS handbook had equivalents in the GFHS questionnaire, so it was not always possible to estimate indicators according to the definitions in the handbook. This applies to education indicators, tetanus immunization of mothers, and exclusive breastfeeding.

Throughout the report, the quoted confidence intervals for the indicator estimates, and for the relative risks, were computed using the CSAMPLE program of EPIINFO, which takes account of the cluster sample design.

8 6. Indicators for mid-decade goals

Immunization coverage

%of 12-23 month-olds that 95.6% 94.6,99.6 1801 1% 1.2 have immunization card

BCG 99.9% 99.7,100 1798 1% 1.0 DPT3 98.4% 97.6,98.9 1798 1% 1.1 OPV3 99.6% 99.2,99.8 1798 1% 1.0 Measles 98.5% 97.7,99.0 1798 1% 1.0 Tetanus toxoid1 69.5% 66.9,72.0 1616 1.3 Vitamin A and salt: VitA 2 45%

VitA fortification & Oman has hea~ edRcation and communi)\ mob~iza~on/ . programmes. orti IcatlOn With VItamm IS un er tscusston education Salt iodization 35% (30,39) 2788 3% 7.23

ORTuse: ORT use (1993 definition) 82% 78,86 445 19% 1.2 ORT use (increased fluids) 89% 85,92 425 24% 1.1

1 Mothers were asked, for each child under 3, if they received a TT shot during the pregnancy. Numerator is number of mothers immunized in at least one of these pregnancies.

2 Vitamin A supplementation programme was introduced in August 1995, tied to the EPI: All children get 100,000 IU at 9 months with the measles vaccination and 200,000 IU at 15 months with the MR vaccination. Coverage is expected to be same as measles and MR vaccination which is expected to reach over 90% oftarget group by July 1996.

3 The sampling design for salt iodization is different from the other indicators, see main text.

9 ' -..

Anthropometry: 4

Weight-for-age <-2SD 23% 22,25 3920 4% (55%)5 2.0

Weight-for-age <-3SD 3% 2,4 3920 4% (55%) 1.4 I Height-for-age <-2SD 21,26 23% 3920 4% (55%) 3.6 I ; Height-for-age <-3SD 8% 6,10 3920 4% (55%) 4.0 I Weight-for-height <-2SD 13% 11,15 3920 4% (55%) 3.3 I

! Weight-for-height <-3SD 1.5% 1,2 3920 4% (55%) 2.1 I

Education: I

Retention rate to grade 56 95% --- - Net enrollment rate 7 93% - 10352 1.5% ' Primary school entry 8 rate 85% - 1588 1.5% - Gross enrollment rate 109%

Water and sanitation: 9

'Safe and convenient' 77% 5308 13% 4.3 sanitation Safe and Convenient water 81% supply

4 Estimates based on under-estimation of children's ages, see main text.

5 4% missing, 55% non-response to request to attend for measurement. Response rate varied regionally.

6 Cohort information not available; this figure is an MOE estimate for 1994/5.

7 Rough approximation, childrens ages on September 1st not available.

8 See note 6.

9 Estimator based on number of households, not number of residents: this information not available at time of writing.

10 x· Breastfeeding:

Mainly breastfed 0-3 28% 23,31 525 % 1.2 months10

Timely complementary 85% 81,88 540 1% 1.0 fiee d"mg II

Continued breastfeeding at 1yr 86% 82,89 576 0% 1.3

Continued breastfeeding at 64% 61 ,71 348 0% 1.1 2yrs

Bottle feeding rate 26% 24,39 1616 1% 2.0 Ever breastfed rate 99% 99,100 1633 0.1% 1.3 ARI: knowledge of signs 12

1° Children who were breastfed, who were not bottle fed, and who were not regularly given other liquids or solids. Data on occasional water not available.

11 Of all children 6-9months, % breastfed and started solids.

12 Question was asked but information not available at time of writing.

11 L_ 1995 Mid-Decade Goals:

7.1. Goa/1: Elevation of immunization coverage of six antigens of the Expanded Programme on Immunization to 80% or more.

The EPI programme in Oman began in 1981; coverage increased from 10% in 1981 to 97% in 1994 (MOH Annual Statistical Report 1994). In the present survey, 95.6% (margin of error 94.6% to 99.6%) of children aged 12-23 months have immunization cards. Amongst these children, coverage of all vaccinations is over 98%. For those without an immunization card, coverage is lower for DPT and for measles (71% and 90% respectively). The coverage for those with and without cards combined is presented in the list of indicators at the start of this report. Children under 1yr receive BCG, diphtheria, pertussis, tetanus, poliomyelitis, measles Birth BCG/OPV/HBV -1 and hepatitis-B vaccinations. In January 6 weeks OPV/HBV-2 1994 the programme was expanded to 3 months DPT/OPV include measles and rubella vaccine at 15 5 months DPT/OPV months. The current schedule is shown on 7 months DPT/OPV/HBV-3 the right. Coverage in Oman is slightly 9 months Measles higher than in neighbouring countries 15 months Measles/Rubella (Saudi Arabia, coverage 92%-94% for the 19 months DPT/OPV (booster) main antigens; UAE 90%-98%).

Conclusion: MDG Achieved

Immunization coverage in children aged 12-23 months (95%CI): Children with card (n=1722) Children without card (n=76) BCG 99.9% (99.8,100) 100% (100,96.1) DPT3 99.6% (99.3,99.9) 71.1% (61.2,80.9) OPV (5 doses) 99.6% (99.3,99.9) 100% (100,96.1) measles 98.9% (98.4,99.9) 89.5% (82.6,96.4)

Coverage of booster at 19 months (95%CI)

Children with card 76.3% (73.0,79.6) n=716 valid (5% missing) without card 81.5% (66.8,96.0) n=25

Total 77.1% (74.1,79.9)

12 7.2. Goa/2: Elimination of neonatal tetanus.

Mothers of O-Il-month-old children were asked whether they received a tetanus vaccination during % pregnant women fully recent pregnancies ("When you were pregnant with immunized against tetanus during this child, were you given any injection to prevent pregnancy the baby from getting convulsions after birth, i.e. 30% anti-tetanus shot?"), of all children under 3 yrs. 69.5% had had at least one dose recently. Women ~ 20% +-.;.....;.;...... ;.,.--.....,._...... ,._...-1 t--11----1 who were pregnant at the time of the survey were E ~ asked if they had been vaccinated since the ~ 10% +----....___---! beginning of this pregnancy, and if so how many doses they received. 2 3 4 5 6 7 8 9 However, since in Oman women of child-bearing duration of pregnancy in months age may be offered tetanus immunization whenever they visit health centres, not just when they are pregnant, the data from these questions may be misleading: the % immunized during % mothers of 0-11-mnth-old pregnancy is less than the % protected. children who received at least 1 Information on this coverage is not available in the dose of TT during recent present survey; according to UNICEF figures, 27% pregnancies (children born in last of pregnant women were protected in 1981, and 3 yrs). 97% in 1989-90. There were no cases of neonatal 0 20 40 60 80 tetanus in 1994 (MOH Annual Statistical Report for 1994) and only one case was reported in 1995. Muscat However, according to WHO/UNICEF criteria, Batinah NNT has been eliminated from Oman. Musandam

Conclusion: MDG Achieved Dhahirah

Dhakilyah

Sharqiyah

AI Wusta

Dhofar

Total:

13 Immunization against tetanus during pregnancy: Region: % mothers who have received at 95% CI (n) least 1 TT shot in the last 3 years

Muscat 79.7 74.3,85.1 (281)

Batinah 62.7 58.4,67.0 (584)

Musandam 70 41,99 (10)

Dhahirah 67.1 59.7,74.6 (146)

Dhakilyah 69.8 64.1,75.5 (252)

Sharqiyah 73.0 66.2,79.8 (226)

Al Wusta 66 4 out of6

Dhofar 74.8 65.7,83.9 (111)

Total: 69.5 66.9,72.0 (1616)

Tetanus immunizations during current pregnancyu:

Duration of 1 dose 2 dose none no. of pregnancy women (months) --- 1 0

2 94% 6% 0 17

3 92% 8% 0 25

4 92% 8% 0 25 58 5 76% 24% 0

6 79% 21% 0 53 71 7 82% 17% 1% 61 8 75% 22% 3%

9 66% 29% 5% 67

13 A pregnant woman who has received 5 doses of TT is protected throughout her child-bearing age period and does not require any additional booster doses of TT eventhough she may be pregnant.

14 7.3. Goal 3: Reduction of the number of measles deaths by 95%, and of the number of measles cases by 90%, compared with pre-immunization levels.

Measles cases 7000r------6000 +------5000 +------4000 +------...... ---:---- 3000 2000 1000 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994

7.4. Goal 4: Elimination of polio.

Acute poliomyelitis cases

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994

15 7.5. Goal 5: Virtual elimination of vitamin A deficiency: at least 80% of all children under 24 months of age in areas with vitamin A deficiency receive adequate vitamin A.

A supplementation programme linked to the EPI was started in August 1995. Children receive 100,000 IU vitamin A at 9 months, with the measles vaccination, and 200,000 IU vitamin A at 15 months with MR vaccination. Coverage is therefore expected to be the same as the measles and MR vaccination coverage, but as yet no data is available. There is no food fortification programme in Oman.

Educational materials on micronutrient deficiencies (vitamin A, iodine and iron) have been developed and used through the School Health Programme and community support group network. These materials promote dietary diversification as well as supplementation.

Conclusion: MDG not achieved

7.6. Goal6: Universal iodization of salt in iodine deficiency disorders affected countries.

To determine if Iodine Deficiency Disorders (IDD) were problems of public health significance in Oman, the Ministry of Health (MOH), in collaboration with Sultan Qaboos University (SQU), WHO and UNICEF, surveyed primary school children aged 8- 11 years to assess urinary iodine levels. The survey was carried out between September 1993 and July 1994. The overall national median urinary iodine concentration was 9-10 mg/dl indicating a mild IDD problem according to the WHO criteria (> 1Omg/dl is normal). The Sultanate of Oman adopted the strategy of Universal Salt Iodization by a ministerial decree passed on 3 June 1995, giving a 6-months period during which all salt for human consumption produced locally or imported had to be iodized. The provision became effective on 3 December 1995. To estimate the proportion of households consuming adequately iodized salt, MOH, WHO and UNICEF conducted a survey in March/April 1996.

7.6.1. Survey methodology:

A PPS sample of 100 primary schools was selected; from each school, one 6th grade class was randomly selected. All children in the class were asked to bring in 2 tablespoonfuls of salt from home. The study nurse tested the salt for the level of iodine using a rapid assessment test kits, and recorded the result on a form. The principal and class teachers of the selected schools were contacted one day before to explain the study to them.

The brands of salt available shops in the catchment area of each school in the survey were listed by field staff who visited 5 to 10 shops in each area. A sample of each brand was tested for level of iodine/iodate

16 7.6.2. Survey results: Results showed that 35% of school students came from households using iodized salt; but in certain regions the use of iodized salt is much lower than the national average: in South Sharqiyah and Dhahirah the figures are only 12% and 13%; in Musandam, there was almost no iodized salt used (2% of students).

0/o students whose households use iodized salt

Region % using margin of no. of iodized salt error students Muscat 19% (28,44) 496 N Batinah 55% (42,67) 623 S Batinah 41% (32,50) 318 Dhakliya 28% (24,32) 464

N Sharqiyah 24% ; (19,29) 204 S Sharqiyah 12% (4,20) 161 Dhahirah 13% (9,17) 242 Dhofar 38% (25,50) 225 Musandam 2% (0,4) 55 Total 35% (30,39) 2788

While effective 3 December 1995, all imported and locally produced salt is iodized, the stock of uniodized salt previously imported had not been fully depleted by the time of survey. Since introduction of this legislation, two Omani companies have started producing edible salt, all iodized, and many new brands of iodized salt are being imported. It is expected that by end 1996, this transitional phase of full switch to iodized salt will be complett:!d.

Conclusion: MDG Achieved

17 % households us1ng iodized salt

% households

• <10% ~ 10%-20% ~ 20%-30% ~ 30%-40% EZd 40%-50% D 50%-60% 7.7. Goa/7: Achievement of 80% usage of ORT (increased fluids) and continued feeding as part of the programme to control diarrhoeal diseases.

6.7% (6.0,7.3) of children under 5 had had diarrhoea in the 2 weeks preceding the survey. Diarrhoea treatments mJ packet ORT 88% of these children had been treated with increased solution 100 • antibiotics fluids and continued feeding; 83% received ORS 80 solution. The mid-decade goal has been achieved. 60 mJ other % 40 tablets/syrup The 1988 Child Health Survey in Oman indicated that 20 0 injections prevalence of knowledge and use of ORT was 72%. 0 • other Musaiger's (1989) study showed that 35% of infants treatment had diarrhoea in the 2 weeks preceding the study, a much higher figure than the present survey, but there may be seasonal differences. Treatments for diarrhoea: (children under 5 with diarrhoea in the 2 weeks preceding the survey interview; n=445). Use of ORS solution in treatment of diarrhoea(% receiving ORT of under 5's with diarrheoa in the % 95% CI 2 weeks preceding survey interview): children under 5 % (95% CI) children (n=sample) packet ORS solution 82.0 (78.2,85.9) under 5 antibiotics 18.4 (14.3,22.5) Packet ORS solution: other tablets/syrup 9.9 (6.6,13.2) Urban 79.9 (75.0,84.7) injections 2.2 (0.9,3.6) (n=283) ...... :...._---1

Rural 85.8 (79.5,92.1) other treatment 7.4 (4.7,10.2) (n=162)

Relative risk 1.4 (0.9,2.3) Conclusion: MDG Achieved. Increased fluids and continued feeding:

Urban 86.6 (82.1,91.0) (n=268)

Rural 91.7 (87.5,96.0) (n=157)

Relative risk 1.6 (0.9,3.0)

18 7.8. Goa/8: Ending and preventing free and low-cost supplies of breast milk substitutes in all hospitals and maternity facilities. Have target hospitals and maternity facilities achieve 'baby friendly' status in accordance with BFHI global criteria.

All 51 hospitals in Oman have been certified "baby friendly" since December 1994 according % 0-3 month-<>lds exclusively breastfed to the global BFHI criteria. While free and low 0 20 40 60 cost samples of breast milk substitutes are not distributed, the Ministry of Health receives its Mmi. limited supply of breast milk substitutes free c.-.1:-+.o::&JI t:1 I pli~iii!-~[il ~l'W1 from infant formula companies. The survey to Dmrch ?it!l~~·' determine exclusive breastfeeding and u.,....,~kd'l t::r\1,1..,, ...... ~--~mg-ii) " !WillffiM!I '"r,l complementary feeding practices showed that s-a-qya, ""~- 28% (9 5%CI 23,31) of children aged 0-3 months were being exclusively breastfed. Boys (30%) were more likely to be exclusively breastfed than girls (23% ).

86% of children age 12-15 months were % breastfed breastfed (continued breastfeeding at lyr), and 64% of those aged 20-23 months (continued breastfeeding at 2yrs). The 100 80 proportion of children still breastfed 60 decreases sharply after 23 months. The 40 median duration of breastfeeding was 24 20 months. The median age for starting solid 0 food was 5 months. 85% of 6-9-month-olds 0 5 10 15 20 25 30 35 were breastfed and had complementary age (months) feeding.

Mothers were asked whether they still breastfed their child; whether they had % children started solids started regular feeding with milk or powder; whether they bottle-fed their child; 100 whether they regularly gave the child 80 water, vitamins, full milk, pasteurised milk, 60 % canned or powdered milk, or other liquids 40 (not by bottle), or foods. They were not 20 asked about occasional water nor what they 0 1 2 3 4 5 6 7 8 9 10 11 12 had given the child in the preceding 24hrs; Age, months the results on 'exclusive ' breastfeeding are therefore not directly comparable with other surveys. Combining information from 20

19 - - -. questionnaire variables, the % of children 0-3 months on ly receiving breastmilk was calculated as the exclusive breastfeeding rate, 28%. Timely complementary feeding: There was no evidence that the breastfeeding indicators I %breastfed and complementary I differed between urban and rural areas, though there are food, 6-9month olds I regional differences: 'exclusive' breastfeeding is commonest in Dhakiliya (47%) , and lowest in Muscat % 6-9 84.8% (81.4,87.5) 540 I (6%). Boys were more likely to be exclusively breastfed month than girls (exclusive breastfed rate 12% greater in boys olds I than girls).

Exclusively breastfed for 4 months (%children aged 0-3 months):

% 95%CI n

%children 0-3 months exclusively breastfed 28% (23 ,31) 525 Sexes: (difference is significant)

boys 30% (25,36) 286 girls 23% (17,28) 239

I Relative risk 0.89 (0.81,0.99) I ' Urban/rural (difference not significant) i

urban 26% (21 ,30) 340 rural 30% (22,37) 185 Regions:

Muscat 6% (1,10) 90

Batinah 31% (25,37) 209 Musandam 2 out of6 6 Dhahirah 43% (28,59) 53 Dhakilyah 47% (37,57) 60

Sharqiyah 22% (10,33) 65 I AI Wusta 0 out of3 3

Dhofar 13% (1 ,24) 39 I '

20 Continued breastfeeding and 1yr and 2 yrs:

%children 95%CI (sample size) % 12-15-month olds breastfed 85.6% (82.4,88.8) (n=576)

% 20-23-month-olds breastfed 64.3% (61.0,71.2) (n=348)

7.8.1. Musaiger's results: According to Musaiger's survey14 of 1991 (published in 1992), 73% of mothers introduced water or water and sugar to the infant during the first three days after delivery. 13% exclusively breastfed their children for one week, 4% for 3 weeks. 30% of mothers 'predominantly exclusive breastfed their infants (breast + water)' for 1-3 weeks; the percentage declined to 18% for 4-6 weeks, and 13% for 7-9 weeks.

Of217 mothers who had completed breastfeeding at the time ofMusaiger's survey, 38% breastfed their infants for 1-2 months, 17% for 3-4 months, 21% for 5-6 months, and the rest for more than 6 months. The mean duration of breastfeeding from these data was 9. 7 months (but note that this will be an underestimate because the calculation (unnecessarily) excludes women still breastfeeding their children at the time of that survey).

Conclusion: MDG for BFHI achieved, but exclusive breastfeeding and complementary feeding practices need to be improved. MDG for cessation of free and low-cost supplies partially achieved

7.9. Goa/9: Interrupt dracunculiasis transmission.

There is no guinea worm transmission in Oman.

7.1 0. Goal 10: Ratification of the Convention on the Rights of the Child. A Royal Decree (No. 54/96) was issued on 11 June 1996 approving the Sultanate of Oman's joining the CRC. The Decree authorizes the competent authorities to follow the necessary procedures to join the Convention according to its provisions taking into account the accompanied reservations. The Decree is effective from the date of issue. The instruments of ratification are being deposited with t~e·UN Legal Office.

Conclusion: MDG not achieved

14 The results are difficult to compare with those ofGFHS as the sample size in Musaigar' s survey is small and not statistically significant.

21 7.11. Goa/11: Reduction of 1990 levels of severe and moderate Response rate for anthropometry malnutrition by 1/5 or more. 0% 20% 40% 60% 80%

1. 23% of children under 5yrs were below minus 2SD from median (WF A) weight for age of NCHS/WHO reference population (z scores <-2SD); 23% were stunted (height for age (HF A) z score <-2SD); and 13% were wasted (weight for height (WFH) z score <-2SD). 3% were severely underweight for age. These estimates are consistent with earlier surveys. According to Health and Nutritional Status of Omani Families 1992, the PEM rate in under fives ranged from 16-30%.

There is no evidence in the present survey of a difference between boys and girls overall, nor within any age group. This conclusion of earlier studies is therefore not borne out by the % of under S's present, larger survey. 30T-______2. The prevalence of malnutrition is up to 30% higher in rural than urban areas. 25 +------20 BUnderwt 3. In certain areas, nearly 1/3 of children under 15 •stunting 5yrs are underweight (Dhakliyah: 32%). 10 DWasting Prevalence of malnutrition is lowest in Dhofar 5 (14%). (see map). 0 Urban Rural

22 .. 4. In this survey, interviewers gave mothers a form to take to their health centre where the % anthropometry measurements would be done. 0 20 40 Response rate was 45%, but varied considerably from region to region. Furthermore, the child's age was entered in the form by the interviewer; some mothers may have taken their children to their health centre straight away, but the delay between interview and anthropometry DlakilyahDlahirah==-=1 measurement could have been as long as 2 or 3 months; the recorded age is therefore too young. Sharqiyah -----' This can be corrected later by using the date of lllofar measurement and the date of interview, but these El!Underwt data were not available at the time of writing •stunting (June 1996). A consequence is that the quoted OWasting estimates of percentage underweight for age and underheight for age may be underestimates, the effects of this may be most marked in the youngest age groups.

Conclusion: MDG not achieved

23 • Weight for age, % of under S's moderately and severely under weight (WFA) 0-6-- 6-12-- 12-60-- Total (n=3920) months months months (n=305) (n=380) (n=3235) moderate and 2.0 16.1 26.2 23.3 (21.5,25.2) severe (<-2SD) (0.4,3.5) (11.8,20.3) (24.1,28.3) severe (<-3SD) 0 (0,0.9) 2.9 3.6 3.3 (2.6,3.9) (0.8,5.0) (2.9,4.3)

Height for age: % of under S's moderately and severely stunted (HFA) 0-6- 6-12-- 12-60-- Total months months months moderate and 5.9 23.4 24.5 23.0 (20.5,25.5) severe (<-2SD) (3.5,8.4) (18.9,27.9) (21.8,27.3) severe (<-3SD) 1.3 5.5 (3.0,8.1) 8.9 8.0 (6.3,9.7) (0.0,2.6) (7 .0, 10.9)

Weight for height: % of under S's moderately and severely wasted (WFH) 0-6-- 6-12-- 12-60- Total months months months moderate and 6.2 12.1 13.5 12.8 (10.9,14.7) severe (<-2SD) (3.2,9.3) (8.0,16.2) (11.5,15.5) severe (<-3SD) 1.0 1.8 (0.3,3.3) 1.5 (1.0,2.1) 1.5 (1.0,2.1) (0.0,2.1)

24 Weight for age malnutrition, under 5 yr olds c;; <-2 so 0 5.0 to 10.0 .. · C22J 1 0.1 to 1 5.0 !2S] 1 5.1 to 20.0 ~ 20.1 to 25.0 ~ 25.1 to 30.0 • 30.1 to 35.0 .. Girls 0 6 0 0 0 0 0 0 a

0 0 0 0 0 0 0 00 4 0 0 ~ 0 0 0 0 0 0 a '"'0 oo 0 Co 0 0 0 (.) 0 0 0 0 {/) 0 00 0 0 I ~8 0 0 0 0 N 2 0 ss 0 ...., coco ...c: ...... QD ~ ::c

~ Do ol:l ;.:::: 0 oo 0 0 0 0 0 0 0 co -4 0 0 0 0 0 0 0 0 0 0 0 10 20 30 40 50 Age (months)

Boys 6 0

0 0 0 0

0 0~ 0 4 0 0 0 0 ~ 0 0 0 0 '"'0 0 0 oB 0 (.) 0 0 {/) coo 0 I co 0 0 N 2 00 .., 0 ...c: .....QD ::c~

0'"' ..,...... c: -2 ....QD ~ ;.:::: 0 00 0 oo 08 co 0 0 00 oO 0 -4 0 0 0 0 0 0 0

0 0 0 10 20 30 40 50 Age (months) Weight for Age z-score Weight for Age z-score I I I I ..... N 0 N ~ CJ) ..... N 0 N ..... CJ) 0 0 0 0 co 0 co 0 0 OOIIIIDOOO 0 [X]IJJ[I] ammoo 0 0 D []IJDCIIJ 0 IIIIIIJJD 0 0 OCDOCDI [1]1 CD CDOO a Gl D 0 0 an 0 D a CDCJ:ID Ill a a:liJI 0 0 a aDm o a a OOCDIJ 0 0 a ..... 0 0 co 0 a oan:nm OOlD llD 0 ~I 0 0 0 0 0 0 a IDJCIJ] 0 [I] IIIIIll 0 0 aoo 0 I [X]~ [X] 0 0 [XI 0 0 0 llDO OODIDO 0 OJ] IJIIIlCID 0 0 0 0 0 00 0 0 0 0 ...... 0 0 0 0 0 0 0 ~I 0 0 a liD 0 0 0 0 ~L 0 > > 0 O'Q 0'<:1 0 0 co ~ D 0 0 0 ~ co 0 0 to ,--.. 00 0 ,--.. 0 DO 0 0 c..J c..J 0 0 3 0 0 0 3 0 [XI 0 0 0 0 0 0 ~ 0 0 o rn 0 1--1-· ;:l 0 ~ ;:l ~ 0 (/) ~ [XI 0 (/) :::r' :::r' 0 Ul 0 Ul 00 0 O=OCD CD 0 - - o ooo ao liD o co 0 rn 0 of>. ~J 0 0 0 0 I 0 0 0 0 0 0 0 0 0 I 0 0 0 c.n 0 OO~a:Da:IlCD 0 ~J 0 I:ID [1]1 0 DIIID CD 0 0 00 0 0 0 0 00 0 0 0 0 000 0 0 0 0 0 0 0 --- 0 0 0 Girls [J 6 D D [J [J

[J [J [J 4 [J [J [J D [J D D

-4 [J [J [J [J [J [J D 0 0 0 [J 10 20 30 40 50 Age (months)

Boys 6 [J 0 [J [J

[J [J [J [J [J [J [J [J co [J [J 0 [J [J 4 [J [J 0 [J [J [J [J 4> 0 D D [J s.. [J 0 0 (,) Cll I N

(I) tlD <

[J [J -4 [J [J [J [J 0 [J [J 10 20 30 40 50 Age (months) .,

0/o under S's under weight (WFA) Urban Rural Relative risk moderate and severe (<-2SD) 20.6 (18.5,22.8) 27.5 (24.4,30.6) 1.33 (1.15,1.56) severe (<-3SD) 2.8 (2.0,3.6) 4.0 (2.8,5.1) 1.43 (0.95,2.13)

0/o of under S's stunted (HFA) Urban Rural Relative risk moderate and severe (<-2SD) 21.2 (18.1 ,24.4) 25.6 (21.8,29.5) 1.21 (0.97,1.49) severe (<-3SD) 8.3 (5.7,10.9) 7.6 (5.8,9.4) 0.93 (0.63,1.37)

0/o of under S's wasted (WFH) Urban Rural Relative risk moderate and severe (<-2SD) 11.8 (9.5,14.1) 14.3 (11.0,17.6) 1.03 (0.98, 1.08) severe (<-3SD) 1.7 (0.9,2.4) 1.3 (0.6,2.1) 1.0 (0.99,1.01)

% children moderately and severely under-weight (WFA) (z-score <- 250), (95% Cl). 0-6- 6-12- 12-24- 24-36- 36-48- 48-60- Total months months months months months months boys 1.2 16.7 24.I 26.8 26.5 27.I 23.1 (0.0,2.8) (11.2,22 .I) (19.0,29.I) (22.6,3I.O) (22.0,30.9) (23 .I ,3 l.l) (20.9,25.3) (n=17I) (n=I92) (n=378) (n=429) (n=408) (n=406) (n=I984) girls 3.0 I5.4 23.6 28.4 30.0 23.0 23.6 (0.1,5.8) (9.6,21.2) (18.9,28.4) (24.0,32.9) (25.6,34.5) ( 18.7,27 .3) (21.3,25.9) (n=I34) (n=188) (n=415) (n=415) (n=393) (n=39I) (n=1936)

25 ' 0 /o children moderately and severely wasted (WFH) (z-score <-250). I 0-6- 6-12- 12-24- 24-36- 36-48- 48-60- Total months months months months months months

' 6.4 12.5 14.3 13.8 16.4 14.0 13.7 i boys (2.5,10.4) (7.2,17.8) (10.5,18.1) (9.9, 17.6) (12.5,20.4) (10.1,18.0) (11.3,16.1, 6.0 11.7 11.3 12.3 13.7 12.0 12.8 I girls (1.5,10.4) (6.8,16.6) (7.3,15.3) (8.9,15.7) (10.3,17.2) (8.7,15.3) (10.9,14.~

Regional variation in % moderate and severe malnutrition

Weight for age, Height for age, (HFA) Weight for height (WFA)% <-2SD % <-2SD (WFH) % <-2SD 1 Muscat (n=280) 19.3 23.9 (18.4,29.5) 7.1 (13.9,24.6) (4.1,10.1) 2 Al-Batinah (n=1628) 20.3 21.9 10.6 (17.7,22.9) (18.6,25.3) (8.6,12.6) 3 Musandam (n=6) 4 A'Dhahirah (n=427) 25.1 24.8 13.1 (19.8,30.3) (19.0,30.7) (9.1,17.1) 5 A'Dhakhliyah (n=813) 31.7 24.8 23.1 (27.4,36.1) (16.6,33.1) (16.7,29.6) 6 A'Sharqiya (n=567) 24.0 24.7 7.6 (19.8,28.1) (20.3,29.1) (5.3,9.8) 7 AI Wusta (n=O) - - - 8 Dhofar (n=199) 13.6 13.6 10.1 (5.4,21.7) (6.8,20.4) (4.9,15.2)

26 Response rate1s for anthropometric measurements, by region: %children no. children taken for whose measurement mother was issued with form

Muscat 21% 1534

Batinah 53% 3256

Musandam 9% 67 Dhahirah 51% 882

Dhakilyah 65% 1327

Sharqiyah 47% 1245

Al Wusta 0% 54

Dhofar 32% 673

15 The response rate is perhaps low because initially the intention of GFHS was to weigh and measure 3,000 children only. Therefore, no aggressive follow up of the remaining children who did not come to the weighing sessions was done.

27 Comparative data from other surveys of nutritional status:

The results of the Gulf Family Health Survey are in line with those of surveys conducted since 1988. These include the 1989/1990 Oman Child Health Survey Follow-up study; the study conducted by Abdul Rahman Musaiger in 1991 (published 1992); and the National Study ofVitamin A Deficiency of 1994/95. The results ofthis last survey included children under 7 years of age, leading to a national estimate of 12.5% for malnutrition in Oman. However, when data for children under fives is taken, the results are comparable.

7.11.1. Results for 1-yr-oldsfrom recent surveys: (note the age groups do not exactly correspond; they were 11-18 months, 1989/90; 1-2yrs (midpoint 1.5yrs), 1991; 18-19 months, 1994/5; 12-24 months, 1995).

% 1-yr-olds underweight for age % 1-yr-olds underheight for age

30 ~------=-~ 25'~~--~~--~.---- 20 % 15 % 10 5 0

% 1-yr-olds underweight for height

%

28 7.11.2.1989/1990 Oman Child Health Survey follow-up study: Sample size: 759 boys and 655 girls aged 11-18 months. The differences between %'s for boys and girls are statistically significant.

% children with z scores more than 2 SD below the reference median boys girls relative risk weight for age 23% 18% 1.3 (1.04,1.6) height for age 22% 17% 1.3 (1.05, 1.6) weight for height 7% 9% 1.3 (0.9,1.9)

(The estimates may be somewhat unreliable as they were derived from the mean and standard deviation of weight or height, by assuming a normal distribution, rather than from individual z-scores).

7.11.3. Health and nutritional status ofOmani Families survey 1991 (Musaiger, 1992). 376 boys and 388 girls under 5. National PPS sample. The results were as follows:

% children with z-scores over 2SD below the reference median girls boys Girls Boys Girls Boys Girls Boys Age N N Weight for age Height for age Weight for height midpt 1.5 76 79 13.5% 19.0% 12.4% 9.2% 11.3% 9.8% 2.5 72 72 16.6% 26.2% 11.9% 17.3% 6.7% 6.1% 3.5 120 100 26.4% 23.8% 22.9% 25.2% 6.0% 7.1% 4.5 120 125 30.3% 30.0% 29.4% 25.8% 5.8% 6.8%

The differences between %' s for boys and girls were not statistically significant. The sample size is also small (less than 900 children).

29 7.1 1.4. National Study on tlte Prevalence of Vitamin A Deficiency, 199415:

A national PPS sample of three age classes was drawn comprising 644 children (258 6- 7-month-olds;260 18-19-month-olds; and 126 35-36-month-olds) was drawn (another group of children under 7 were also sampled). Re-analysis of the anthropometry data for the under-5's is shown below. The sex difference was statistically significant and was similar in each of the age groups. Note that a simple average of these data would be misleading because the age distribution of the sample is not the same as the general population. The low figures for the 6-7 -month-olds would have undue weight.

Girls Boys 5-6 18-19 35-36 5-6 18-19 35-36 months months months months months months Weight for age 3.6% 13% 18% 2.5% 27% 24% Height for age 6.5% 20% 13% 11% 26% 20% Weight for height 0% 10% 20% 2.5% 17% 11%

7.11.5. MOH Annual Statistical Report for 1994: MOH national figures are surprisingly low and are not consistent with recent independent surveys. Figures are given for "PEM Attendances", with 13.7% of children under 5yrs "attended" for "mild, moderate or severe" protein-energy malnutrition. Apparently only 1/4 of these are moderate or severe, but the definition used for severity categories is not given in the report. When the regional breakdown of these national figures is examined, the largest discrepancy between the MOH figures and GFHS in Dhahirah, with a rate of 7% in the MOH report and 25% in the GFHS.

Conclusion: MDG not achieved

30 7.12. Goa/12: Strengthen Basic Education so as to achieve reduction by 1/3 of the gap between: a) primary school enrollment and retention rates in 1990 and universal enrollment and retention in primary education of at least 80% of school-age children; and b) primary school enrollment and retention rates of boys and girls in 1990.

Primary school enrollment (PER): enrollment rates at grade 1 are 85% (82%-86% for girls; 87%-89% for boys). Net enrollment (NER): the estimated proportion of children of primary-school age who are attending primary school is 93%. Gross enrollment (GER): If children aged 12-14 are also included in the numerator of the above estimate, the figure (gross enrollment) becomes 109% (107% for girls, 112% for boys). Retention to grade 5: 95% (MOE estimate 1994/5).

Comparison with figures for 1986-89 (below) show that the net enrollment gap has been reduced to 1/2 of what it was then for boys, and to 113 for girls. This goal has been achieved. Primary retention rates already exceed the goal of 80%, and have improved slightly from 1986/89 estimates. The disparity between NER of boys and girls has been reduced; this goal has been achieved. The retention rates in 1995 are similar; 1990 estimates not available for sexes separately.

Conclusion: MDG Achieved

31 Education indicators and gaps 1995 1995 gap 1986-89 gap, 1986/89 Primary enrollment rate: 85% boys 87% 13 girls 82% 18 difference 5

Net enrollment rate 93% boys 93% 7 85% 15 girls 93% 7 77% 23 difference 0 8

Gross enrollment rate 109% boys 112% 105% girls 107% 95%

% Retention to grade 5 95% 5 92% 8 (MOE estimates only} boys 96% girls 94%. . These md1cators follow the defimtwns m the MICS handbook. The MOE quote a 'Gross primary school enrollment ratio' of 94%, and a 'Net primary school enrollment ratio' of 82%. Estimation of education indicators using data from the GFHS is difficult because the age of children over 5 was recorded only as integer years, so their age on September 1st is unknown. A rough correction has been used and is described below. Furthennore, no cohort information was available, so retention Grade-age distribution of girls in primary school rates could not be estimated. Mothers were asked the grade achieved by each child, and whether they were still in school, had left, or had never been in school. We do not know what grade children were in last year, nor, if they have dropped out of school, when they dropped out. The MOE estimate of the % children reaching grade 5 (primary retention rate) is 95% (94% for girls, 96% for boys). Many children are not in the correct grade for their age. For example, there are about twice as many 7-yr-olds in grade 1 as one would expect from a uniform distribution of birth month, and there are some 8 and 9 yr olds in grade 1. According to the MOE, only 60% children enter grade 1 at the recommended age.

7 .12.1. Education indicator: girls

Surveyed no. of girls in primary school, by grade and age, Oct-Dec 1995: Age: grade 6 7 8 9 10 11 12 13 14 Total 1 492 305 74 15 3 3 3 6 1 902 2 24 477 285 88 25 8 8 7 4 926 3 2 17 439 283 106 46 15 3 5 916 4 0 6 21 433 301 111 51 21 19 963 5 1 2 4 26 354 277 133 45 11 853 6 0 1 2 4 24 340 248 107 55 781 Total 519 808 825 849 813 785 458 189 95 5351 Interview month: Oct 312 Nov 316 Dec 221

Total no. girls of surveyed: Age: 6 7 8 9 10 11 12 13 14 Total 785 880 881 891 848 859 817 795 728 7484 Interview month: Oct 272 320 Nov 283 332 Dec 230 228

33 7.12.1.1.Adjustment for birth date: Children enter school in the September following their 6th birthday. Estimates of enrollment rates must therefore take account of the child's birth date. In the GFHS, age at the interview was recorded only as an integer number of years. Assuming unifonn distribution of birth month, of272 girls interviewed in Oct who were 6 yrs old at interview, an expected fraction of 1112 will have had their 6th birthday in September, and therefore should not be in school, they will not start school until the following September. We know the month, but not the day of the interview; we assume the day of interview is unifonnly distributed through the month; then the expected fraction of 6-yr-olds which had their 6th birthday in the month of the interview, October, is approximately 1/24. So an expected fraction (1112)+(1124) of those 6yrs-olds interviewed in October were not due to start school until the following year, because they were not six until after September 1st. Similarly, of those 6-yr olds interviewed in November, an expected fraction of (2/12)+(1/24) were not six until after the start of September, and of those who were six at interview in December, a fraction (3/12)+(1/24) should not be considered to be of school age. No interviews were conducted after December. Using the numbers interviewed in each month given in the table, the expected number of children aged 6 in the sample who should be in school is 272*(1-(l!J2)-(l/24)) + 283*(1-(2/12)-(1/24)) + 230*(1-(3/12)-(1/24)) = 625. All those aged 7 at interview should be in school. If their birthday was before September 1st, they should be in grade 2; if their birthday was in September, October, November or December, they should be in grade 1. With the same assumptions as before, the expected number of 7-year-olds in grade 1 is calculated as: 312 (l!J2+ 1/24)+ 316 (2/12+ 1/24)+ 221 ( 3112+ I /24) = 169. The actual number is 305. This implies many children either repeat year 1, or enter school late.

The expected total no. of 7 years olds, both in school and out, who are of school-entry age, is 320*(1/J2+ 1/24)+332*(2/12+ 1124)+228*(3/12+ 1/24) = 40+69.2+66.5=176.

The primary-school entry rate is therefore: 6-yr-olds: 519/625=83% (the unadjusted estimate is 519/785=66%) 6- and 7-yr-olds: (5 I 9+ 169)/(625+ 176)=86%

Net enrollment rate: No. of primary-school

34 7.12.2. Education indicators: Boys

Surveyed no. of boys in primary school, by grade and age: Age: Grade 6 7 8 9 10 11 12 13 14 Total 1 541 319 56 9 5 5 5 5 1 946 2 IS 442 3I8 81 29 7 5 3 3 903 3 1 22 461 270 115 43 14 3 6 935 4 3 0 31 45I 308 I 56 77 37 17 1080 5 0 2 2 23 367 284 147 60 32 917 6 0 0 2 1 32 314 277 144 74 844 Total 560 785 870 835 856 809 525 252 133 5625 Interview month: Oct 322 Nov 304 Dec I92

Surveyed no. of boys in primary school: Age: 6 7 8 9 IO II 12 I3 14 Total 803 845 9I3 868 906 873 884 844 767 7703 Interview month: Oct 299 334 Nov 279 3I2 Dec 225 199

No. 6-yr-olds of school age: 299*(1-1112-l/24)+279*(1-2/12-l/24)+225*(1-3/12-l/24) = 261.6+220.9+ 159.4=642 No. 7-yr-olds in school who should be in grade I: · 322x (1/12+1/24) + 304x{2/12+1/24) + 192x(3/12+1/24) = 160 Total 7-yr-olds of school-entry age: 334x (1/12+ 1/24) + 312x(2/12+ 1/24) + 199x(3/12+ 1/24) = 165

Primary enrollment rate: 6 yrs olds: 560/642 = 87% (unadjusted estimate is 560/803 = 67%) 6&7-yr-olds: (560+160)/(642+165) = 89% Net enrollment rate: 4715/5047=93% (No. in school of primary age= 560+785+870+835+856+809 = 4715 Total no. of primary age= 642+845+913+868+906+873 = 5047) Gross enrollment: 5625/5047 = 111.5%

35 7.12.3.Education indicators: boys and girls:

Surveyed no. of children in primary school by age and grade: Age: Grade 6 7 8 9 10 11 12 13 14 Total 1 1033 624 130 24 8 8 8 11 2 1848 2 39 919 603 169 54 15 13 10 7 1829 3 3 39 900 553 221 89 29 6 11 1851 4 3 6 52 884 609 267 128 58 36 2043 5 1 4 6 49 721 561 280 105 43 1770 6 0 1 4 5 56 654 525 251 129 1625 Total 1079 1593 1695 1684 1669 1594 983 441 228 10966 Interview month Oct 634 Nov 620 Dec 413

Total number of children surveyed: Age: 6 7 8 9 10 11 12 13 14 Total 1588 1725 1794 1759 1754 1732 1701 1639 1493 15187 Interview month: Oct 571 654 Nov 562 644 Dec 455 427

No. 6-yr-olds of school age: 1267 No. 7-yr-olds in school who should be in grade I: 329 Total no. 7-yr-olds who are of school-entry age: 340

Primary-school entry rate is: 6 yr olds: 1079/1267 = 85.2% 6&7-yr-olds: (329+ 1079)/(340+ 1267) = 87.6% TheNER is: (1079+1593+ 1695+ 1684+ 1669+ 1594)/(1267+ 1725+ 1794+1759+ 1754+ 1732) = 9314/10031 =93% uncorrected estimate ofNER: 9314/10352 = 90% Gross enrollment: 10966/1003 1 = 109%

36 7.12.4. Estimates of education indicators from 1993 Census (Source: Statistical Profile ofOmani Women, Ministry of Development and UNICEF 1996)

Primary Net enrollment rate: Region Girls Boys Total Muscat 88.5 89.9 89.2 Batinah 86.6 87.6 87.1 Musandam 82.5 88.9 85.8 Dhahirah 89.7 90.7 90.2 Dhakilyah 84.4 87.3 85.8 Sharqiyah 80.6 84.9 82.8 AI Wusta 41.6 66.5 54.4 Dhofar 86.2 87.3 86.8

Primary net enrollment, 1993 100,------~------~ 90 -t-;:;::__,---==------80 70 60 50 40 30 20 10 0

Primary Gross enrollment rate: Region Girls Boys Total Muscat I09.7 II3.8 III.8 Batinah 109.3 112.7 111.0 Musandam 97.0 109.1 I03.2 Dhahirah I07.9 II2.3 I1 O.I Dhakilyah I03.9 III.O 107.5 Sharqiyah 99.8 110.2 105.1 AI Wusta 48.4 87.3 68.5 Dhofar II 0.5 1I4.6 112.6

37 7.13. Goal13: Increase water supply and sanitation so as to narrow the gap between the 1990 levels and universal access by the year 2000 of water supply by one-fourth and sanitation by one­ tenth:

7.13.l.Water: 81% of households had access to safe and convenient water supply defined as access, within Water supply(% households) 30 minutes, from piped supply, outside tap, indoor well, tanker or used bottled water. 70% of the households have this access in rural areas compared to 87% in urban areas. (These estimates are not weighted by number of Piped (outside) household residents as this information was not available at the time of writing). In some districts, less than 50% of households have access to safe and convenient water supply; the worst areas for water access are the north of Dhahirah, Dhakilyah and Sharqiyah regions (see maps).

Rainwater

I'!Hotal%

[J Urban,% households

[J Rural,% households

38 However, according to the MOH Annual Statistical Report of 1994, water from tankers, wells, taps and storage tanks is of variable quality. 36% of samples from Government and private wells were bacteriologica:lly unfit. If these results are applied to the various sources of water, the national percentage of households with access to safe and convenient water reduces to 69%. Furthermore, the Child Health Survey showed incidence of diarrhoea in children according to water supply was highest Water quality in 1994 (MOH Annual among those who used well or tanker Statistical Report):% samples unfit water, followed in order by bottled water, spring/falaj, and lastly piped. 35+----- In 1990, according to the State of the 30+----- World's Children Report 1993, 55% of 25+----- the population was estimated to have access to safe water. 15+----- Conclusion: MDG Achieved 10 5 0 Wlter W:lls taps tanks bottled tankers

li3chemically unift •bacteriologically unfit

39 Time to water, %households

El <30 mins Access to safe & convenient water I • 30-60 mins supply 0 60-90mins Urban(n=3887) 86.7 (83.4,90.1) ' 0 >1.5 hrs

Rural(n=2214) 69.5 (63.6,75.3) I

Relative risk 1.25 (1.14,1.37) I

Water quality: % samples unfit (MOH Annual Statistical Report, 1994). Chemical tests:% Bacteriological tests: % samples unfit samples unfit

Water tankers 0.7 (0.2,1.7) 10.5 (8.4, 13.0)

Government and private wells 8.1 (6.7,9.6) 35.8 (28.0,43.4)

Government and private taps 7.5 (4.8,10.9) 13.5 (5.6,25.8)

Government and private storage 9.0 (6.1 '12.6) 28.4 (22.1,34.9) tanks # Bottled mineral water 0 (0,9.5) * 0 (0,9.5) m 1993, 2.6% of samples of bottled mmeral water was chemically unfit #in 1993, 11.1% of sample of bottled mineral water was bacteriologically unfit (MOH Annual Statistical Report, 1994).

Time to water:

% of households no. of households

<30 mins 86.6% 1349

30-60 8.0% 124 mins

60-90 3.5% 55 mms

> 1.5 hrs 1.9% 30

40 Households with safe & convenient water supply

% households

~ 60%-70% ~ 70%-80% EZ3 80%-90% D 90%-100% Access to safe & convenient water supply Wilayats

% households

0.0 to 15.0

~ 15.1 to 30.0

~ 30.1 to 45.0

• 45.1 to 60.0

60.1 to 75.0

~75.1 to 85.0

~85.1 to 90.0

090.1 to 95.0

095.1 to 100.0

''

------Access to convenient water supply % (95% Cl) (n=sample households size) with access

Muscat 96.2 (93.6,98.8) (n=l230)

Batinah 79.5 (73.7,85.4) (n=1909) Musandam 73.8 (45.2,100) (n=80)

Dhahirah 77.6 (66.8,88.3) (n=526) Dhakilyah 61.0 (51.4,70.7) (n=813) Sharqiyah 75.6 (67.2,84.0) (n=1016)

Al Wusta 97.8 (94.2, 100) (n=46)

Dhofar 90.0 (82.9,97.1) (n=481)

Main drinking water supply

% no. of Urban,% Rural,% households households households households surveyed

Piped (indoor) 21.7 1326 30.1 7.1 Piped (outside) 7.3 448 4.1 13.1 Well (indoor) 9.0 550 9.0 9.1

Tanker 40.4 2466 39.5 42.0

Bottled 3.0 183 4.4 0.6

Well (outside) 6.1 370 4.6 8.6 Stream 6.2 381 4.2 9.8

Rainwater 0.4 25 0 1.1 Other 5.8 352 4.1 8.6

Total 100 6101 100 •. 100

41 Water supplier:

o/o no. Urban,% Rural,% households households households households surveyed

Government 26.9 1641 32.4 17.3

Private 38.1 2322 44.5 26.8

Free 35.0 2138 23.2 55.9

7.13.2. Sanitation: In Oman 57% of rural households and 90% of urban households had flush toilet with waste flushed to sewage system. Overall, around 78% oftotal households surveyed had a flush to sewage system and 77% of the population had access to safe and convenient sanitation. During the period 1988-90, 48% of the population had access to adequate sanitation according to 1993 State of the World's Children Report. The Child Health Survey showed incidence of diarrhoea in children was highest among those using flushpits or toilets without flush. The 1993 census showed 78% of the population lives in houses equipped with toilets, but these figures hide the fact that many septic tanks are health hazards because they are not properly built or maintained (see Situation Analysis of Children and Women in Oman: Ministry ofDevelopment!UNICEF, 1995).

Type of toilet

0/o no. Urban, 0/o Rural,% households households households households surveyed

Flush to sewage 77.8 4748 89.6 57.1 system

Non-flush toilet 7.6 462 6.7 9.1

Pit 1.2 76 1.2 1.4

Open field 13.0 793 2.2 32.0

Other 0.4 22 0.3 I 0.5

Conclusion: MDG Achieved

42 7.14. Goal14: Strengthening health facilities' capability for case management of pneumonia. ARI diseases have been the most common cause of out-patient attendance in Oman in recent years, accounting for 33% of all out-patient attendance, 25%-40% of all hospital admissions of children, and 10% of all in-patient infant deaths. In 1993 and 1994, respiratory problems were the leading cause of in-patient morbidity in hospitals. Of all respiratory ailments, the single most common problem among in-patients was acute upper respiratory infections. In 1994 there were 2446 ARI cases per 1000 population, ofwhich 77% were mild and 22% moderate. In 1994 there were 27 deaths from ARI.

A nationally standardised ARI programme now in effect aims to improve public awareness of preventive measures and to enhance quality and availability of treatment in health centres. The programme includes health staff training, provision of diagnosis and treatment information for health staff and the public, and a series of TV spots and half-hour TV programmes.

The 1989 Child Health Survey found that 38% of children suffered from ARI in the previous month, and 74% of these had been taken to a health facility. 51% of women believed a cough was "normal", 40% thought it was "serious", 2% thought it "insignificant".

Information on mother's knowledge of symptoms of ARI was obtained in the survey but the data was not available at the time of writing.

8. Recommendations

Malnutrition indicators are high and have not improved in recent years. Earlier recommendations to address malnutrition in children by exclusive breastfeeding, complementary feeding, control of infection and promotion of good food habits remain appropriate. Existing programmes should be evaluated and their impact assessed to identify priority problems and needs. Nutrition surveys should be conducted regularly to monitor the situation and to identify trends. On the basis of surveys and programme evaluations, new interventions/programmes should be launched.

There are regional disparities in most of the mid-decade indicators; the regions Dhahirah, Dhakilya and Sharqiya are consistently worst off, and include districts (wilayats) with the poorest access to water and the highest prevalences of malnutrition. Priority attention and programme interventions should be targetted to these regions and wilayats. Urban and rural disparities also need to be addressed. Gender differentials needed to be further studied and better understood to devise appropriate actions in order to reduce remaining gaps.

It is highly desirable that future surveys included non-Ornani households, as data would then become available for the entire population to facilitate planning for services. This would aid comparison with other countries and simplify the sampling scheme. Certain questions in the present questionnaire could be modified, (e.g. about exclusive breastfeeding and education indicators) following the examples in the MICS handbook.

43 9. References

Ministry of Health (1995) Annual Statistical Report, 1994. Ministry of Health, Sultanate of Oman.

Ministry of Health (1992) Oman Child Health Survey. Ministry of Health, Sultanate of Oman. Ministry of Development (1994) General Census of Population, Housing and Establishments 1993. Ministry of Development, Sultanate of Oman.

Ministry of Development!UNI CEF ( 1996) Statistical Profile of Omani Women

Musaiger, AO (1992) Health and nutritional status of Omai families. Unicef Muscat, 1992.

Ministry of Health!UNICEF/WHO National Study on the Prevalence of Vitamin A Deficiency (V AD) among children 6 months to 7 years

UNICEF (1995) Monitoring progress towards the goals of the world summit for children: A practical handbookfor multiple-indicator surveys. UNICEF, New York. (The MICS handbook).

UNICEF (1995) Situation Analysis of Children and Women in the Sultanate of Oman. Ministry of Development Sultanate of Oman/UNICEF Muscat.

Dean et al (1994) Epilnfo 6. CDC, Atlanta, Georgia, USA.

Dean et al. (1995) EpiMap 2: A mapping program for IBM-compatible microcomputers. CDC, Atlanta, Georgia, USA.

Turner, AG ( 1995) Sample Design for Gulf Family Health Survey - Sultanate of Oman. Statistical Division, United Nations, New York.

10. Acknowledgements The Gulf Family Health Survey in Oman was carried out by the Ministry of Health in collaboration with UNICEF. I am grateful to the following for help during preparation of this report: Dr. Ali Jaffar Mohammed, Director General of Health Services, Mrs Shahnaz Kianian Firouzgar, UNICEF Representative, Dr Asya Al-Riyami, Executive Director of the Gulf Family Health Survey in Oman and her staff; Dr . Mahendra Sheth, UNICEF Programme Officer, Dr. Carol Watson, UNICEF Project Officer-Social Policy & Planning. I am also grateful for the results of Household Salt Survey conducted by the staff of Ministry of Health - Dr. Pradeep Malankar from the Department of Disease Surveillance and Disease Control, Dr. Sahar Abdul Khalik from the Department of School Health, Mr. Ramesh Srivastava , Directorate General of Planning, and Mrs. Nitya Prakash, Head of Follow-Up Section and Mrs. Sawsan Rawas, UNICEF Project Officer for Health and Nutrition

44 .. Appendix 1: Sample Design for Gulf Family Health Survey in Oman (by A Turner)

The sample for the Gulf Family Health Survey (GFHS) of Oman is a two-stage, stratified probability sample. The first stage consists of 264 primary sampling units (PSU's). These are defined as Census enumeration areas (EA's), or combinations of EAs. Within each sample PSU, 25 Omani households will be selected for interview, as described below. Altogether 6600 households are to be designated for the GFHS (264PSUs x 25 households).

The sample frame for the GFHS is the 1993 Population Census. Before selecting the first stage units, the Census Organization of the Ministry of Development provided a computer file of the EAs sorted in geographical sequence - by governorate/region and within governorate by wilayat (district); EAs within wilayat were sorted in numerical order, which is approximately geographic. The average size, though variable, of an EA is 100 households - Omani plus non-Omani. Since only Omani households are in scope for the survey, some EAs naturally contain only a few Omani households. The minimum size for a PSU is 25 Omani households, so EAs containing fewer than 25 Omani households were combined to form PSUs.

From the geographically sorted file a systematic PPS (probability proportional to size) sample of 264 PSUs was chosen, thus achieving an implicit geographic stratification. The measure of size used for the PPS selection was the number of Omani households in the EA as of the 1993 Census. The sampling interval for the PPS selection was equal to the number of Omani households, as of 1993, divided by 264, that is, 185844/264, or 704; the random start was 212.

The selection method yields a proportionate allocation of the sample among 52 of the 59 wilayat of the Sultanate. (See end of this section for treatment of the other 7 wilayat).

Within each selected PSU the sample of Omani households must be selected. The preferred method of doing this entails, first, making an up-dated listing of current Omani households in the sample PSUs. The listing workload will be of the order of 20000 households. After the listing operation is completed, a fixed sample of 25 households is to be selected in each sample PSU, using systematic selection. As mentioned, it will yield a total sample of 6600 households, although it is expected that some of them - perhaps 10% - may noninterview for various reasons.

The sample will be self-weighting. This means that no weights need to be used in the analysis, provided distributions only will be produced (as opposed to estimated totals or aggregates). The overall probability of selection will be 0.0355 (that is, 25/704, or 6600/185844). In the event that weights are used in the analysis, the weight is equal to the reciprocal of the probability, or 110.0355 = 28.16; as mentioned all households will have the same weight.

45 Finally, seven of the wilayat are so small that they were missed in the systematic PPS selection of 264 PSUs. There is a need to have some sample of households from every wilayat. Accordingly, a supplemental sample of one EA in each of the following wilayats was selected at random. Carrying out the listing and subsequently selecting 25 households from each ofthese EAs for interview will add 175 households to the sample.

Region Wilayat EA Selection Omani non-Omani probability households households ofEA 3-Musandam 70-Madha 11341 1/3 80 39 71-Bukha 11163 118 64 19 7-Al Wusta 72-A'Duqm 13322 115 110 28 73-Haima 13412 1/3 130 21 8-Dhofar 74-Thumrait 14022 1/6 75 35 75-Rakhyut 14055 1/14 40 10 76-Sudh 14015 1/6 94 18

When the national data are produced by combining the results from the 264 national PSUs, the data from these 7 areas must be excluded; otherwise the probabilities of selection will be wrong and the national estimate will be biased.

Sampling at the second stage is complicated by the requirement to restrict the GFHS to Omani households only, It is not known in advance of the field work which households are Omani and which are not. A current listing has to be made of the Omani households in the selected PSUs, and then a fixed sample of 25 households selected from each PSU. This procedure provides for an up-date of the sample frame at the second stage, or, in other words, this procedure will represent the current Omani population of the Sultanate, as opposed to the population as it existed in 1993. The procedure will control the sample size exactly, that is exactly 6600 Omani households will be selected. Each interviewer's workload will be the same, since each EA will contain exactly 25 sample households. The sample is a probability method and is self-weighting. The method is unbiased. However, every sample EA will have to be listed, which is expensive and time consuming. It is estimated that it will add 3 weeks to the field work, plus 2-3 days for training.

Selection ofhouseholds: 1. Obtain the description and location of the sample EAs, along with the corresponding EA maps from the Census Organisation of the Development Council. Obtain also, if possible, the EA listing books used in the 1993 Census which provide the names of the households at that time. Note that while there are 264 PSUs, there are 272 EAs because 7 of the small sample PSUs consist of combinations of2 or 3 EAs.

46 2. Organize field visits to each of the sample EAs for the purpose of (a) updating the listing of households, since changes will have occurred since 1993, and (b) identifying the locations of Omani households, since non-Omani households are to be excluded from the survey.

3. Within each sample EA, make a current listing of the households- Omani only- with the aid of the 1993 Census listing books, if available. If the 1993 listing books cannot be made available, make a fresh listing of Omani households for each sample EA; this will be used for the GFHS second-stage sample selection. The listing should include the name of the head of the household, the address and/or location and telephone number, if applicable.

4. After the updating has been completed in the field, return the new listings of Omani households to a central office for sample selection. Note that the selection of the particular households to be included in the GFHS should not be done by the field staff which completes the listing but by office (supervisory) personnel who were not involved in listing.

5. Within each sample EA, select exactly 25 households by calculating the sampling interval and choosing a random start. An example is given to illustrate. Suppose the number of Omani households in the new listing of PSU007 in Muscat (EA2624) is 139. Divide this number by 25, which gives 5.56 as the sampling interval; choose a random start between 0.01 and 5.56 to designate the first sample household on the new listing and then select every 5.56th household thereafter, yielding 25 households for interview.

In this illustration if the random start is, say, 1.34, then the sample selection numbers would be 1.34 6.90 12.46 18.02 23.58 29.14 34.70 etc. and the corresponding households selected are 1,6,12,18,23,29,34 and so on (ignoring the decimal here, but not in the accumulations).

6. Repeat step 5 for each of the 264 PSUs, since each PSU will have a different sampling interval depending upon the current number ofOmani households living in the PSU, as well as a different random start.

7. Then, conduct the GFHS interview with the selected households in each sample PSU.

This was the original design; in practice, only 6101 households were interviewed in the main survey, as follows:

47 Appendix 2: 2-stage cluster sampling plan of the Gulf Family Health Survey of • Oman. Region Wilayat EA No. of Cluster households number surveyed 1 Muscat 1 Muttrah 1132 23 1 1 Muscat 1 Muttrah 1212 24 2 1 Muscat 1 Muttrah 1226 24 3 1 Muscat 1 Muttrah 1314 18 4 1 Muscat 1 Muttrah 1413 23 5 1 Muscat 1 Muttrah 1443 7 6 1 Muscat 1 Muttrah 1552 22 7 1 Muscat 1 Muttrah 1634 22 8 1 Muscat 1 Muttrah 1711 20 9 1 Muscat 1 Muttrah 1733 25 10 1 Muscat 1 Muttrah 2521 24 11 1 Muscat 1 Muttrah 2552 23 12 1 Muscat 2 Bausher 2132 22 13 1 Muscat 2 Bausher 2221 23 14 1 Muscat 2 Bausher 2244 21 15 1 Muscat 2 Bausher 2263 25 16 1 Muscat 2 Bausher 2333 21 17 I Muscat 2 Bausher 2351 23 18 I Muscat 2 Bausher 2454 25 19 1 Muscat 3 A'Seeb 15111 25 20 1 Muscat 3 A'Seeb 15124 24 21 I Muscat 3 A'Seeb 15134 23 22 1 Muscat 3 A'Seeb 15151 19 23 1 Muscat 3 A'Seeb 15162 25 24 1 Muscat 3 A'Seeb 15171 25 25 1 Muscat 3 A'Seeb 15181 22 26 1 Muscat 3 A'Seeb 15213 21 27 1 Muscat 3 A'Seeb 15231 25 28 1 Muscat 3 A'Seeb 15243 24 29 1 Muscat 3 A'Seeb 15255 21 30 1 Muscat 3 A'Seeb 15271 24 31 1 Muscat 3 A'Seeb 153.13 25 32 1 Muscat 3 A'Seeb 15324 24 33 1 Muscat 3 A'Seeb 15335 22 34 1 Muscat 3 A'Seeb 15351 21 35 1 Muscat 3 A'Seeb 15363 23 36 1 Muscat 3 A'Seeb 15374 24 37 1 Muscat 4 Al-Amrat 3314 23 38 1 Muscat 4 Al-Amrat 3325 23 39

48 " 1 Muscat 4 Al-Amrat 3.341 23 40 1 Muscat 4 Al-Amrat 3353 25 41 1 Muscat 4 Al-Amrat 3421 23 42 1 Muscat 4 Al-Amrat 3434 19 43 1 Muscat 5 Muscat 2624 25 44 1 Muscat 5 Muscat 2633 23 45 1 Muscat 5 Muscat 2645 23 46 1 Muscat 5 Muscat 2655 25 47 1 Muscat 5 Muscat 2672 24 48 1 Muscat 6 Quriyat 3112 23 49 1 Muscat 6 Quriyat 3123 23 50 1 Muscat 6 Quriyat 3141 22 51 1 Muscat 6 Quriyat 3153 24 52 1 Muscat 6 Quriyat 3224 24 53 1 Muscat 6 Quriyat 10345 25 54 2 Al-Batinah 7 Sohar 6113 25 55 2 Al-Batinah 7 Sohar 6124 25 56 2 Al-Batinah 7 Sohar 6142 24 57 2 Al-Batinah 7 Sohar 6161 25 58 2 Al-Batinah 7 Sohar 6211 25 59 2 Al-Batinah 7 Sohar 6223 21 60 2 Al-Batinah 7 Sohar 6235 25 61 2 Al-Batinah 7 Sohar 6256 23 62 2 Al-Batinah 7 Sohar 6321 25 63 2 Al-Batinah 7 Sohar 6342 19 64 2 Al-Batinah 7 Sohar 6356 25 65 2 Al-Batinah 7 Sohar 6372 24 66 2 Al-Batinah 7 Sohar 6391 25 67 2 Al-Batinah 8 A'Rustaq 4521 24 68 2 Al-Batinah 8 A'Rustaq 4532 23 69 2 Al-Batinah 8 A'Rustaq 4544 25 70 2 Al-Batinah 8 A'Rustaq 4556 23 71 2 Al-Batinah 8 A'Rustaq 4574 24 72 2 Al-Batinah 8 A'Rustaq 4591 25 73 2 Al-Batinah 8 A'Rustaq 4614 24 74 2 Al-Batinah 8 A'Rustaq 4626 25 75 2 Al-Batinah 8 A'Rustaq 4643 19 76 2 Al-Batinah 9 Shinas 6514 24 77 2 A1-Batinah 9 Shinas 6525 25 78 2 Al-Batinah 9 Shinas 6541 25 79 2 Al-Batinah 9 Shinas 6556 14 80 2 Al-Batinah 9 Shinas 6623 25 81 2 Al-Batinah 9 Shinas 6641 25 82 2 Al-Batinah 9 Shinas 6654 25 83 2 Al-Batinah 10 Liwa 6423 24 84

49 2 Al-Batinah 10 Liwa 6436 25 85 2 Al-Batinah 10 Liwa 6455 24 86 2 Al-Batinah 11 Saham 5313 25 87 2 Al-Batinah 11 Saham 5331 24 88 2 Al-Batinah 11 Saham 5344 25 89 2 Al-Batinah 11 Saham 5354 24 90 2 Al-Batinah 11 Saham 5411 21 91 2 Al-Batinah 11 Saham 5422 24 92 2 Al-Batinah 11 Saham 5435 24 93 2 Al-Batinah 11 Saham 5452 25 94 2 Al-Batinah 11 Saham 5515 25 95 2 Al-Batinah 11 Saham 5533 25 96 2 Al-Batinah 12 Al-Khabura 5113 23 97 2 Al-Batinah 12 Al-Khabura 5125 25 98 2 Al-Batinah 12 Al-Khabura 5143 23 99 2 Al-Batinah 12 Al-Khabura 5161 25 100 2 Al-Batinah 12 Al-Khabura 5212 25 101 2 Al-Batinah 12 Al-Khabura 5234 19 102 2 Al-Batinah 13 A'Suwaiq 5613 25 103 2 Al-Batinah 13 A'Suwaiq 5625 24 104 2 Al-Batinah 13 A'Suwaiq 5641 25 105 2 Al-Batinah 13 A'Suwaiq 5652 25 106 2 Al-Batinah 13 A'Suwaiq 5665 25 107 2 Al-Batinah 13 A'Suwaiq 5682 24 108 2 Al-Batinah 13 A'Suwaiq 5714 25 109 2 Al-Batinah 13 A'Suwaiq 5725 24 110 2 Al-Batinah 13 A'Suwaiq 5742 24 Ill 2 Al-Batinah 13 A'Suwaiq 5752 25 112 2 Al-Batinah 13 A'Suwaiq 5765 24 113 2 Al-Batinah 13 A'Suwaiq 5774 25 114 2 Al-Batinah 14 Nakhal 4111 23 115 2 Al-Batinah 14 Nakhal 4123 21 116 2 Al-Batinah 14 Nakhal 4135 24 117 2 Al-Batinah 15 Wadi Ma'awil 4151 25 118 2 Al-Batinah 16 Al-Awabi 4181 24 119 2 Al-Batinah 17 Al-Musanna 4213 23 120 2 Al-Batinah 17 Al-Musanna 4224 25 121 2 Al-Batinah 17 Al-Musanna 4235 25 122 2 Al-Batinah 17 Al-Musanna 4252 22 123 2 Al-Batinah 17 Al-Musanna 4262 25 124 2 Al-Batinah 17 Al-Musanna 4273 24 125 2 Al-Batinah 17 Al-Musanna 4284 23 126 2 Al-Batinah 18 Barka 4321 25 127 2 Al-B atinah 18 Barka 4336 24 128 2 Al-Batinah 18 Barka 4353 24 129

50 2 Al-Batinah 18 Barka 4373 20 130 2 Al-Batinah 18 Barka 4421 23 131 2 Al-Batinah 18 Bar~p 4435 24 132 2 Al-Batinah 18 Barka 4455 24 133 2 Al-Batinah 18 Barka 4473 24 134 3 Musandam 19 Kasab 11114 19 135 3 Musandam 19 Kasab 11143 22 136 3 Musandam 19 Kasab 11232 19 137 3 Musandam 21 Diba Al-Biya 11315 20 138 4 A'Dhahirah 23 Al-Buraimi 12613 25 139 4 A'Dhahirah 23 Al-Buraimi 12642 24 140 4 A'Dhahirah 23 Al-Buraimi 12662 25 141 4 A'Dhahirah 23 Al-Buraimi 12713 21 142 4 A'Dhahirah 23 Al-Buraimi 12731 25 143 4 A'Dhahirah 24 Ibri 12121 24 144 4 A'Dhahirah 24 lbri 12141 24 145 4 A'Dhahirah 24 lbri 12156 25 146 4 A'Dhahirah 24 lbri 12174 25 147 4 A'Dhahirah 24 lbri 12223 23 148 4 A'Dhahirah 24 lbri 12234 24 149 4 A'Dhahirah 24 lbri 12251 23 150 4 A'Dhahirah 24 lbri 12263 25 151 4 A'Dhahirah 24 lbri 12313 24 152 4 A'Dhahirah 24 lbri 12332 25 153 4 A'Dhahirah 24 lbri 12352 23 154 4 A'Dhahirah 25 Mahadha 12812 21 155 4 A'Dhahirah 26 Yanqui 12424 25 156 4 A'Dhahirah 26 Yanqui 12443 23 157 4 A'Dhahirah 27 Dhank 12511 24 158 4 A'Dhahirah 27 Dhank 12526 24 159 4 A'Dhahirah 27 Dhank 12545 24 160 5 A'Dakliyah 28 Nizwa 8116 22 161 5 A'Dakliyah 28 Nizwa 8133 24 162 5 A'Dakliyah 28 Nizwa 8152 24 163 5 A'Dakliyah 28 Nizwa 8162 24 164 5 A'Dakliyah 28 Nizwa 8212 21 165 5 A'Dakliyah 28 Nizwa 8222 25 166 5 A'Dakliyah 28 Nizwa 8234 24 167 5 A'Dakliyah 28 Nizwa 8253 23 168 5 A'Dakliyah 29 Samail 7122 24 169 5 A'Dakliyah 29 Samail 7134 24 170 5 A'Dakliyah 29 Samail 7152 25 171 5 A'Dakliyah 29 Samail 7214 22 172 5 A'Dakliyah 29 Samail 7224 20 173 5 A'Dakliyah 29 Samail 7243 24 174

51 5 A'Dakliyah 30 Bahia 8311 24 175 5 A'Dakiiyah 30 Bahia 8323 24 176 5 A'Dakiiyah 30 Bahia 8335 23 177 5 A'Dakiiyah 30 Bahia 8412 25 178 5 A'Dakiiyah 30 Bahia 8424 24 179 5 A'Dakiiyah 30 Bahia 8443 20 180 5 A'Dakiiyah 30 Bahia 8454 24 181 5 A'Dakliyah 31 Adam 8511 21 182 5 A'Dakiiyah 31 Adam 8541 24 183 5 A'Dakiiyah 31 Adam 8554 22 184 5 A'Dakiiyah 32 AI-Hamra 8612 24 185 5 A'Dakiiyah 32 AI-Hamra 8622 19 186 5 A'Dakiiyah 32 AI-Hamra 8636 22 187 5 A'Dakiiyah 33 Manah 8565 25 188 5 A'Dakiiyah 34 Izki 7412 25 189 5 A'Dakiiyah 34 Izki 7431 22 190 5 A'Dakiiyah 34 Izki 7444 24 191 5 A'Dakiiyah 34 Izki 7462 25 192 5 A'Dakiiyah 34 Izki 7476 23 193 5 A'Dakiiyah 35 Bid Bid 7316 24 194 5 A'Dakiiyah 35 Bid Bid 7333 23 195 6 A'Sharqiya 36 Sur 10122 23 196 6 A'Sharqiya 36 Sur 10142 21 197 6 A'Sharqiya 36 Sur 10153 24 198 6 A'Sharqiya 36 Sur 10221 24 199 6 A'Sharqiya 36 Sur 10234 24 200 6 A'Sharqiya 36 Sur 10254 23 201 6 A'Sharqiya 36 Sur 10312 25 202 6 A'Sharqiya 36 Sur 10331 20 203 6 A'Sharqiya 37 Ibra 9124 23 204 6 A'Sharqiya 37 Ibra 9143 24 205 6 A'Sharqiya 37 Ibra 9163 22 206 6 A'Sharqiya 38 Biddiya 9514 20 207 6 A'Sharqiya 38 Biddiya 9533 22 208 6 A'Sharqiya 38 Biddiya 9545 20 209 6 A'Sharqiya 38 Biddiya 9563 24 210 6 A'Sharqiya 39 AI-Qabii 9424 20 211 6 A'Sharqiya 39 AI-Qabii 9442 23 212 6 A'Sharqiya 40 AI-Mudhaibi 9214 23 213 6 A'Sharqiya 40 AI-Mudhaibi 9225 24 214 6 A'Sharqiya 40 AI-Mudhaibi 9241 25 215 6 A'Sharqiya 40 AI-Mudhaibi 9255 20 216 6 A'Sharqiya 40 AI-Mudhaibi 9272 24 217 6 A'Sharqiya 40 AI-Mudhaibi 9284 18 218 6 A'Sharqiya 40 AI-Mudhaibi 9311 23 219

52

... 6 A'Sharqiya 40 Al-Mudhaibi 9332 21 220 6 A'Sharqiya 40 Al-Mudhaibi 9354 23 221 6 A'Sharqiya 41 Dima wa A'Tayeen 9622 20 222 6 A'Sharqiya 41 Dima wa A'Tayeen 9641 23 223 6 A'Sharqiya 42 Al-Kbmil wa Al-Wafi 10713 25 224 6 A'Sharqiya 42 Al-Kbmil wa Al-Wafi 10732 22 225 6 A'Sharqiya 42 Al-Kbmil wa Al-Wafi 10752 24 226 6 A'Sharqiya 43 JBB Ali 10413 16 227 6 A'Sharqiya 43 JBB Ali 10432 25 228 6 A'Sharqiya 43 JBB Ali 10464 25 229 6 A'Sharqiya 43 JBB Ali 10524 21 230 6 A'Sharqiya 43 JBB Ali 10543 25 231 6 A'Sharqiya 43 JBB Ali 10556 25 232 6 A'Sharqiya 43 JBB Ali 10571 23 233 6 A'Sharqiya 43 JBB Ali 10583 22 234 6 A'Sharqiya 44 JBB Hassan 10611 24 235 6 A'Sharqiya 44 JBB Hassan 10624 23 236 6 A'Sharqiya 44 JBB Hassan 10644 24 237 6 A'Sharqiya 44 JBB Hassan 10662 17 238 6 A'Sharqiya 45 Wadi Bani Khalid 9584 24 239 6 A'Sharqiya 46 Masirah 10822 25 240 7 Al Wusta 48 Mahoot 13121 16 241 7 AI Wusta 48 Mahoot 13151 14 242 7 Al Wusta 50 Al-Jazar 13221 16 243 8 Dhofar 51 Salalah 14114 25 244 8 Dhofar 51 Salalah 14135 25 245 8 Dhofar 51 Salalah 14161 24 246 8 Dhofar 51 Salalah 14221 23 247 8 Dhofar 51 Salalah 14244 22 248 8 Dhofar 51 Salalah 14311 22 249 8 Dhofar 51 Salalah 14352 25 250 8 Dhofar 51 Salalah 14413 23 251 8 Dhofar 51 Salalah 14442 25 252 8 Dhofar 51 Salalah 14523 25 253 8 Dhofar 51 Salalah 14554 25 254 8 Dhofar 51 Salalah f46:23 24 255 8 Dhofar 51 Salalah 14651 11 256 8 Dhofar 53 Taqah 14812 23 257 8 Dhofar 53 Taqah 14841 25 258 8 Dhofar 53 Taqah 14864 19 259 8 Dhofar 54 Mirbat 14932 25 260 8 Dhofar 54 Mirbat 14976 24 261 8 Dhofar 57 Dhalkut 14083 22 262 8 Dhofar 58 Muqshin 14044 14 263 8 Dhofar 59 AI Hallaniyah 14035 25 264

53 TOTAL: 6101

The following samples are not part of the cluster sampling plan and data for these households are excluded from national estimates: 3 Musandam 70 Madha 11341 23 3 Musandam 71 Bukha 11163 21 7 Al Wusta 72 A'Duqm 13322 17 7 Al Wusta 73 Haima 13412 16 8 Dhofar 74 Thumrait 14022 23 8 Dhofar 75 Rakhyut 14055 25 8 Dhofar 76 Sudh 14015 24 TOTAL: 149

54 ------

• '' Appendix3

1995 MID DECADE GOALS

1995 MID-DECADE GOALS INDICATORS 1. Elevation of immunization coverage of six - Proportion of children immunized against diphtheria, pertussis and antigens of the Expanded Programme on tetanus (DPT3) before their first birthday. Immunization to 80% or more in all countries. - Proportion of children immunized against measles before their first birthday. - Proportion of children immunized against poliomyelitis (OPV3) before their first birthday. - Proportion of children immunized against tuberculosis before their first birthday - Proportion of pregnant women immunized against tetanus - Proportion of children protected against neonatal tetanus through immunization of their mother. 2. Elimination ofneonatal tetanus by 1995. - Annual number of cases of neonatal tetanus - Proportion of districts reporting neonatal tetanus cases 3. Reduction by 95% in measles deaths and - Annual number of under-five deaths due to measles reduction by 90% of measles cases compared Annual number of cases of measles with pre-immunization levels by 1995, as a - major step to the global eradication of measles in the longer run. 4. Elimination of polio in selected countries and - Annual number of cases of polio regions. - Proportion of districts reporting polio cases

55 1995 MID-DECADE GOALS INDICATORS 5. Virtual elimination of vitamin A deficiency. (At - Proportion of children under 24 months of age receiving adequate least 80% of all children under 24 months of age vitamin A (in vitamin A-deficient areas) in areas with vitamin A deficiency receive adequate vitamin A) 6. Universal iodization of salt in IDD affected - Proportion of households consuming adequately iodized salt countries. according to agreed criteria: 1) in the whole country and 2) in areas known to be at high risk ofiDD

7. Achievement of80% usage ofORT (increased - Proportion of diarrhoea episodes in under-fives treated with oral . ! fluids) and continued feeding as part of the rehydration salts (ORS) and/or recommended home fluids (pre-1993 programme to control diarrhoeal diseases. ORT definition) - Proportion of diarrhoea episodes in under-fives treated with ORT (increased fluids) and continued feeding - Proportion of population that has a regular supply ofORS available in their community 8. Ending and preventing free and low-cost - Proportion of hospitals and maternity facilities targeted for BFID by supplies of breast milk substitutes in all end of 1995 hospitals and maternity facilities. Having - Proportion of hospitals and maternity facilities that have been target hospitals and maternity facilities officially designated as "baby friendly" in accordance with global achieve "baby friendly" status in accordance criteria with BFHI global criteria. 9. Interrupt guinea-worm disease - Annual number of cases of dracunculiasis in the total population (dracunculiasis) transmission in all affected - Number of villages with any cases of dracunculiasis in the last year villages by the end of 1995. 10. Ratification of the Convention on the Rights - Depositing the instruments of Ratification with the United Nations of the Child (CRC) by all countries. Legal Office

' ' 56 • • ' '

1995 MID-DECADE GOALS INDICATORS 11. Reduction of 1990 levels of severe and - Proportion of under-fives who fall below minus 2 standard deviations moderate malnutrition by one-fifth (1/5) or from median weight for age ofNCHS/WHO reference population more - Proportion of under-fives who fall below minus 3 standard deviation from median weight for age ofNCHS/WHO reference population - Proportion of under-fives who fall below minus 2 standard deviations from median height for age ofNCHS/WHO reference population - Proportion of under-fives who fall below minus 3 standard deviations from median height for age ofNCHS/WHO reference population 12. Strengthen basic education so as to achieve - Proportion of children entering first grade of primary school who reduction by one-third of the gap between: a) eventually reach grade 5 primary school enrollment and retention rates ·~ Number of children enrolled in primary school who belong in the in 1990 and universal enrollment and retention - relevant age group, expressed as a percentage of the total number in in primary education of at least 80% of that age group (net enrollment) school-age children, and b) primary school enrollment and retention rates of boys and - Proportion of children of primary-school-entry age who enter grade 1 girls in 1990. at that age - Number of children enrolled in primary school expressed as a percentage of the total number of children of primary-school age (gross enrollment) 13. Increase water supply and sanitation so as to - Proportion of population with access to an adequate amount of safe narrow the gap between the 1990 levels and drinking water located within a convenient distance from the user's universal access by the year 2000 of water dwelling supply by one-fourth and of sanitation by one- Proportion of population with access to a sanitation facility for human tenth. - excreta disposal in the dwelling or located within a convenient distance from the user's dwelling

57 1995 MID-DECADE GOALS INDICATORS 14. Strengthening health facilities capability for - Proportion of children under five years of age, with an acute case management of pneumonia respiratory infection needing assessment, who are taken to an appropriate health provider - Proportion of all health facilities that have a regular supply of free or affordable antibiotics and a trained worker and are thus able to give correct penumonia case management

. ·'

• ' ' 58 ~---:-. ·- ---

¥ Appendix 4

Acronyms and Abbreviations

ARI Acute Respiratory Infection AGFUND Arab Gulf Programme for the United Nations Development Organization BCG Bacillus Calmette Guerine BFHI Baby Friendly Hospital Initiative CRC Convention on the Rights of the Child OPT Diphtheria, Pertussis, Tetanus EA Enumeration Area EPI Expanded Programme of Immunization GER Gross Enrollment Ratio GFHS Gulf Family Health Survey HBV Hepatitis B Vaccine IDD Iodine Deficiency Disorders ISS Integrated Social Statistical Analysis MICS Multiple Indicator Cluster Survey MOH Ministry of Health NER Net Enrollment Ratio OPV Oral Polio Vaccine ORT Oral Rehydration Therapy PER Primary Enrollment Rate PPS Probability Proportional to Size PSU Primary Sampling Unit SQU Sultan Qaboos University TT Tetanus Toxoid UNFPA United Nations Population Fund UNICEF United Nations Children's Fund WHO World Health Organization

59