1 FINAL REPORT Government of Ghana Ghana Statistical Service Ghana Health Service United Nations Children’s Fund United Nations Population Fund Japan Ocial Development Assistance USAID GHANA Multiple Indicator Cluster Survey with an enhanced Malaria Module and Biomarker 2011 MONITORING THE SITUATION OF CHILDREN AND WOMEN IN GHANA GHANA STATISTICAL SERVICE 4 Acknowledgements 5 Multiple Indicator Cluster Survey with an enhanced Malaria Module and Biomarker number of organizations and individuals contributed to the development and implementation of 2011 this survey with their professional knowledge, personal enthusiasm and commitment to ensure a Abetter life for all children and women in Ghana. The Ghana Statistical Service would particularly like to acknowledge the technical and financial assistance received from the United Nations Children’s Fund (UNICEF) at various stages of this survey. UNICEF staff from Publisher: Ghana Statistical Service the Ghana Office, Regional Office and Headquarters, as well as UNICEF Consultants, supported the Ghana MICS from the planning stage to the sample design, training, data collection, and the data processing Proofreading: Marie Melocco phases to ensure that the final report was of high quality. Design and Layout: Art Excel Ghana The US Government for International Development (USAID), the Japanese Government, the United Nations Population Fund (UNFPA), and the Center for Disease Control (CDC) also deserve special mention. Without Cover photo: c UNICEF/Nyani Quarmyne, 2012 their financial and technical support, the objectives of this survey would not have been achieved. The National Malaria Control Programme (NMCP) and the Navrongo Health Research Centre of the Ghana Printed by: Redbow Investment Limited Health Service and ICF/Macro were mainly responsible for the implementation of the enhanced Malaria Module and Biomarker component of the survey. NMCP provided financial and technical assistance towards these critical aspects of the survey and their support is highly appreciated and acknowledged. The Published in December, 2012 Navrongo Health Research Centre (NHRC) implemented the biomarker component of the survey on behalf of the Malaria Partners – this included collecting blood smears from the field, and conducting the malaria The Ghana Multiple Indicator Cluster Survey (MICS) was carried out in 2011 by the Ghana Statistical Service microscopy, laboratory analysis of the results and preparation of the report writing on this component. (GSS). Financial and technical support was provided by UNICEF, USAID, UNFPA, the Japanese Government, The ICF/Macro provided technical support towards the development and implementation of the malaria ICF/MACRO, the Ministry of Health/National Malaria Control Programme, and the Navrongo Health Research module and biomarker component – from questionnaire design, training, field monitoring, data analysis Centre. and report writing. MICS is an international household survey programme developed by UNICEF. The Ghana MICS was conducted The titration of salt samples was carried out by the Nutrition and Food Science Department of the University as part of the fourth global round of MICS surveys (MICS4). MICS provides up-to-date information on the of Ghana, Legon, and we are very grateful for their assistance. situation of children and women and measures key indicators that allow countries to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. We would also like to express our sincere gratitude to Consultants and Experts from relevant government Additional information on the global MICS project may be obtained from www.childinfo.org. ministries and agencies, other UN agencies, and international partners who were part of the Steering and Technical Committees for the MICS survey. The invaluable advice, comments and inputs received from Suggested citation: them during the organization of the survey, questionnaire development and report writing has helped to Ghana Statistical Service, 2011. Ghana Multiple Indicator Cluster Survey with an Enhanced Malaria Module improve the quality of the final output derived from the survey. and Biomarker, 2011, Final Report. Accra, Ghana. Furthermore, we would like to commend the hard work and dedication of Ghana Statistical Service staff, both at the Headquarters and the regions, for successfully completing this survey and making the results available to users on a timely basis. Special thanks also go to all the interviewers, editors, supervisors and other participants in the survey for their hard work and the long working hours they committed towards the completion of the survey. The names of those who supported the survey in various ways are included in Appendix C. Finally, the data collection would not have been possible without the respondents in the selected households in Ghana who generously opened their homes to the field officers and gave their time to the realization of this survey. Dr. Philomena Nyarko Ag. Government Statistician Table of Content iv Table of Content v TABLE OF CONTENT VI. CHILD HEALTH 65 Acknowledgement iii Vaccinations 65 List of Tables vii Neonatal Tetanus Protection 68 List of Figures xi Oral Rehydration Treatment 71 List of Abbreviations xiii Care Seeking and Antibiotic Treatment of Pneumonia 77 Executive Summary xxi Solid Fuel Use 80 I. INTRODUCTION 1 VII. MALARIA AND BIOMARKER 85 Background 1 Background of Malaria in Ghana 85 Survey Objectives 2 Malaria: Causes and Transmission 85 National strategies for Malaria Control 86 II. SAMPLE AND SURVEY METHODOLOGY 5 Malaria PRevention 88 Sample Design 5 Insectiside Treated Mosquito Nets (ITNs) 88 Questionnaires 5 Brief History of ITN Distribution in Ghana 89 Training and Fieldwork 7 Household Ownership Mosquito Nets 90 Data Processing 7 USe of Mosquito Nets by Persons on the Household 93 USe of Mosquito Nets by Children Under Five Years 95 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF USe of Mosquito Nets by Pregnant Women 98 HOUSEHOLDS AND RESPONDENTS 9 Source, Cost and Disposal of ITNs 101 Sample Coverage 9 Indoor Residual Spraying Against Mosquitoes 101 Characteristics of Households 10 Intermitent Preventive Treatment of Malaria in Pregnancy 103 Characteristics of Female Respondents 15-49 Years of Age, Male 15-59 years and Children Under-5 15 Prevalence, Diagnosis, and Treatment of Fever in Children Under-Five 105 Type and Timing of Antimalarial Drug Use for Children 109 IV. CHILD MORTALITY 23 Knowledge of Malaria Symptoms 111 Assessment of Data Quality in childhood mortality 24 Knowledge of Causes of Malaria 112 Levels and Trends of Early Childhood Mortality 25 Knowledge of ways to avoid Malaria 114 Early childhood mortality rates by region, residence and socio-economic characteristics 27 Specific Messages Seen or Heard about Malaria 116 Residence and Socio-economic Differentials in Childhood Mortality 30 Malaria Biomarkers: Anaemia and Malaria in Children Aged 6-59 Months 120 Demographic Characteristics and Childhood Mortality 31 Anaemia Prevalence in Children 122 VIII. WATER AND SANITATION 131 V. NUTRITION 35 Water 131 Nutritional Status 35 Sanitation 131 Breastfeeding and Infant and Young Child Feeding 38 Use of Improved Water Sources 131 Salt Iodization 52 Use of Improved Sanitation Facilities 140 Rapid Test Kits Results 53 Handwashing 147 Salt Sample for analysis 54 Agreement between Rapid Test Kits and Titration in identifying IX. REPRODUCTIVE HEALTH 153 adequately and inadequately Iodized salts 56 Fertility 153 Children’s Vitamin A Supplementation 57 Contraception 156 Low Birth Weight 60 Unmet Need 156 Anaemia and Diet Diversity in Children aged 6-59 months 63 Antenatal Care 161 Assistance at Delivery 167 Place of Delivery 168 Post-Natal checks 170 Table of Content vi List of Tables vii X. CHILD DEVELOPMENT 183 Table HH.1: Results of household, women’s and under-5 interviews Early Childhood Education and Learning 183 Table HH.2: Household age distribution by sex Early Childhood Development 190 Table HH.3: Household composition Table HH.3: Household composition XI. LITERACY AND EDUCATION 195 Table HH.3: Household composition y residence Literacy among Young Women 195 Table HH.4: Women’s background characteristics School Readiness 196 Table HH.4M: Men’s background characteristics Primary and Secondary School Participation 198 Table HH.5: Under-5’s background characteristics Table HH.A1: Household age distribution by sex and residence XII. CHILD PROTECTION 213 Table HH.A2: Housing Characteristics Birth Registration 213 Child Discipline 216 Table NU.1: Nutritional status of children Types of Disciplinary Methods 218 Table NU.2: Initial breastfeeding Early Marriage and Polygyny 218 Table NU.3: Breastfeeding Female Genital Mutilation/Cutting 226 Table NU.3A: Infant feeding patterns by age Attitudes toward Domestic Violence 230 Table NU.4: Duration of breastfeeding Children’s living arrangements and Orphanhood 234 Table NU.5: Age-appropriate breastfeeding Table NU.6: Introduction of solid, semi-solid or soft food XIII. HIV/AIDS, SEXUAL BEHAVIOUR 239 Table NU.7: Minimum meal frequency Knowledge about HIV Transmission and Misconceptions about HIV/AIDS 239 Table NU.8: Bottle feeding Comprehensive knowledge of HIV methods and transmission 240 Table NU.9: Iodized salt consumption Knowledge of Mother to Child Transmission of HIV 246 Table NU.9A: Iodized salt consumption using titration method Accepting Attitudes toward People Living with HIV & AIDS (PLHIV) 249 Table NU.9B: Iodized salt consumption.