VI Child Health Immunisation Millennium Development Goal (MDG) 4 is to reduce child mortality by two-thirds between 1990 and 2015. Immunisation plays a key part in this goal. Immunisation has saved the lives of millions in the three decades since the launch of the Expanded Programme on Immunisation (EPI) in 1974. According to UNICEF data, worldwide there are still 27 million children overlooked by routine immunisation and as a result vaccine preventable diseases cause more than 2 million deaths each year. A World Fit for Children goal is to ensure full immunisation under one year of age at 90 per cent nationally with at least 80 per cent coverage in every administrative unit. According to UNICEF and WHO guidelines a child should receive a BCG vaccination to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and tetanus; three doses of the polio vaccine; three doses of the Hepatitis B (HepB) vaccine and a measles vaccination by the age of 12. In accordance with the UNICEF and WHO guidelines and the recommendations for immunisation against measles rubella and mumps (MMR) outlined in the regulations on immunisations and prophylactics in the FBiH and RS, as well as for purposes of international comparison, estimates on full immunisation based on this survey refer to children aged 18-29 that have received a BCG vaccine, three doses of DPT and the polio vaccine by 12 and the MMR vaccine by 18. Data on immunisation against HepB is not included in the calculation of the percentage aged 18-29 who have received all vaccinations. 24 Information on vaccination coverage was collected for all children under five years of age. Mothers or caretakers were asked to provide vaccination cards or health booklets for all of these children. If the vaccination card for a child was available the interviewers copied the vaccination information from the card onto the questionnaire. If no vaccination card was available then the interviewer proceeded to ask the mother to recall whether or not the child had received each of the vaccinations and for polio and DPT and how many doses the child had received. The final vaccination coverage estimates were based on both the information obtained from the vaccination card and the mother s reports on the vaccinations received by the child. The percentage aged 18-29 who had received each of the specific vaccinations recommended by UNICEF and WHO is shown in Table CH.1. The denominator comprises aged 18-29 so that only children who were old enough to be fully vaccinated with these vaccines were taken into consideration. In the first three columns of the table the numerator includes all children who were vaccinated at any time before the survey; in the last column only those children who were vaccinated by age 12, as recommended, were included (by 18 of age for MMR). For children without vaccination cards the proportion of vaccinations given by 12 was assumed to be the same as for children with vaccination cards. Overall, 41 per cent of Roma children had vaccination cards available at the time of the survey (see Table CH.2). According to the data shown in Table CH.1, 86 per cent aged 18-29 had received a BCG vaccination by the age of 12. Thirty-two per cent had received the first dose of the polio vaccine; however, the percentage decreased with subsequent doses of this vaccine to 24 per cent for the second dose and only 14 per cent for the third. The first dose of the DPT vaccine was given to 30 per cent of Roma children. The percentage declined for subsequent doses of this vaccine to 21 per cent for the second dose and 13 per cent for the third (see Figure CH.1). The first dose of the HepB vaccine was received by 65 per cent, the second dose by 35 per cent and the third dose by 15 per cent. Immunisation coverage against measles rubella and mumps (MMR) by the age of 18 was 22 per cent. The percentage of Roma children who received all of the UNICEF and WHO recommended vaccinations during infancy was low at only 4 per cent. This indicator includes the percentage who received a BCG vaccine and three doses of DPT, and three doses of the polio vaccine by age 12 and an MMR vaccine by age 18 (see Figure CH.1). Data on immunisation to protect against HepB and Hib, both of which are part of the immunisation calendars in FBiH and RS, is not included in the calculation of the percentage with all immunisations. Thirteen per cent of Roma children did not receive any of the vaccines mentioned by age 12. 24 For the purposes of comparing the percentage who had received the UNICEF and WHO recommended vaccines during infancy with data from the BiH MICS3 (2005-2006) data on the Hepatitis B vaccines is not included in the calculation of full immunisation. Data on immunisation against illnesses caused by Haemophilus influenzae type B (Hib), which is a part of the immunisation calendars in the FBiH and RS, are not presented in this report. Monitoring the situation and women 29
Figure CH.1: Percentage aged 18-29 who received the recommended vaccinations by 12 (18 for MMR), BiH Roma Survey 2011 2012 Per cent 100 90 80 70 60 50 40 30 20 10 0 86 BCG 32 Polio1 * The percentage for all vaccines excludes vaccines to prevent Hepatitis B. 24 Polio2 14 Polio3 30 DTP1 Table CH.1: Vaccinations in first year of life Percentage aged 18-29 immunised against childhood diseases at any time before the survey and by age 12 (by 18 for MMR), BiH Roma Survey 2011 2012 Vaccinated at any time before the survey according to: Vaccination card Mother s report Either Vaccinated by 12 of age (by 18 for MMR) BCG 1 37.6 48.1 85.6 85.6 Polio 1 21.7 14.0 35.7 32.4 2 17.4 9.0 26.4 24.2 3 2 12.9 2.3 15.2 14.2 DPT 1 22.1 11.2 33.3 29.9 2 15.4 7.6 23.0 20.9 3 3 9.7 4.0 13.7 12.5 MMR 4 15.7 9.2 24.9 21.8 All vaccinations (BCG, Polio, DPT and MMR) 6.3 1.6 7.9 4.3 No vaccinations (BCG, Polio, DPT and MMR) 1.0 12.3 13.3 13.3 HepB 1 (at birth) 35.6 29.3 64.8 64.8 2 25.8 9.5 35.3 35.3 3 5 13.7 2.4 16.1 14.5 aged 18-29 146 146 146 146 1 MICS indicator 3.1 2 MICS indicator 3.2 3 MICS indicator 3.3 4 MICS indicator 3.4; MDG indicator 4.3 5 MICS indicator 3.5 21 DTP2 Table CH.2 presents immunisation coverage amongst children aged 18-29 by background characteristics. The figures indicate children receiving the vaccinations at any time up to the date of the survey and are based on information from both the vaccination cards and mothers /caretakers reports. The overall percentage who had received all of the recommended vaccinations, apart from the HepB vaccine, at any time before the survey was 8 per cent. Eighty-six per cent had received a BCG vaccine at any time before the survey. The third dose of the polio vaccine was received by 15 per cent, the third dose of DPT was received by 14 per cent, while the third dose of the HepB vaccine was received by 16 per cent. The MMR vaccine had been received by 25 per cent at any time before the survey. 13 DTP3 22 MMR All vaccinations 4 (BCG, polio, P i MRP) (BCG, Polio, DTP and MMR) 65 HepB1 35 HepB2 15 HepB3 Table CH.2: Vaccinations by background characteristics Percentage aged 18-29 currently vaccinated against childhood diseases, BiH Roma Survey 2011 2012 aged 18-29 Percentage with vaccination card seen Percentage who received: Polio DPT No All HepB vaccinations vaccinations MMR 1 2 3 1 2 3 (BCG, Polio, (BCG, Polio, 1 2 3 DPT and MMR) DPT and MMR) BCG Male 87.9 33.3 26.1 13.6 29.7 20.2 10.9 23.9 12.1 6.8 64.0 36.6 14.5 38.0 80 Female 83.0 38.6 26.6 17.1 37.4 26.3 16.9 26.0 14.7 9.1 65.8 33.7 18.1 44.7 66 FBiH 90.0 33.8 25.6 12.8 28.6 20.3 11.5 25.7 10.0 7.0 63.2 34.1 13.8 37.4 105 RS (80.0) (47.7) (32.3) (25.7) (57.1) (40.8) (27.6) (31.5) (14.2) (16.2) (75.4) (43.3) (30.0) (50.2) 27 BD (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 15 No formal education 74.7 26.2 19.6 10.1 21.0 16.1 9.7 14.3 22.2 0.0 56.6 24.5 11.5 30.9 50 Primary 89.9 36.6 24.2 12.1 32.9 20.4 9.6 22.9 10.1 6.9 65.4 36.2 13.3 42.0 83 Secondary+ (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 13 Poorest (88.1) (30.2) (23.0) (11.2) (20.0) (17.1) (5.8) (13.9) (11.9) (5.3) (63.3) (30.5) (14.0) (29.1) 34 Second (84.3) (30.2) (21.4) (15.6) (35.9) (24.6) (14.0) (23.7) (15.7) (6.5) (58.6) (30.4) (13.5) (46.1) 41 Middle (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 23 Fourth (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 23 Richest (93.2) (34.5) (29.9) (26.4) (42.1) (25.7) (22.3) (28.1) (6.8) (18.1) (89.2) (56.3) (33.8) (59.6) 25 Poorest 60 per cent 83.6 32.7 21.8 13.3 27.5 17.7 9.5 20.7 14.8 4.5 58.5 30.0 12.0 37.4 98 Richest 40 per cent (89.8) (41.7) (35.4) (19.0) (44.2) (33.2) (21.7) (33.6) (10.2) (14.6) (77.8) (46.1) (24.6) (48.5) 48 Language of household head Romani 80.4 27.8 18.5 10.4 29.1 17.2 9.3 17.3 17.8 2.8 60.7 27.0 11.3 37.2 90 Other 93.9 48.4 39.0 22.9 40.3 32.6 20.8 35.9 6.1 15.8 71.2 48.1 23.7 47.1 57 85.6 35.7 26.4 15.2 33.3 23.0 13.7 24.9 13.3 7.9 64.8 35.3 16.1 41.0 146 30 Multiple Indicator Cluster Survey 2011 2012 Monitoring the situation and women 31
Oral Rehydration Treatment Diarrhoea is the second leading cause of death amongst children under five worldwide. In the treatment of diarrhoea of particular importance are increased fluid intake, continued adequate feeding of the child and use of oral rehydration salts (ORS). The goal is to reduce by two-thirds the mortality rate amongst children under five by 2015. 25 In addition, A World Fit for Children calls for a reduction in the incidence of diarrhoea by 25 per cent. In MICS the prevalence of diarrhoea was estimated by asking mothers or caretakers whether their child had had an episode of diarrhoea in the two weeks prior to the survey (see Table CH.4). In those cases where mothers reported that a child had had diarrhoea a series of questions were asked about the treatment of the illness, including what the child had to drink and eat during the episode and whether this was more or less than the child usually drank or ate. Table CH.3 also shows the percentage of Roma children who had diarrhoea in the two weeks preceding the survey as well as the percentage who received various types of recommended liquids during the episode of diarrhoea. The data shows that in BiH 15 per cent of Roma children under 5 years of age had suffered diarrhoea in the two weeks prior to the survey. Diarrhoea prevalence amongst these children was highest in the FBiH (18 per cent) and lower in RS and BD (7 per cent and 4 per cent respectively). According to age, the peak diarrhoea prevalence was amongst children aged 12-23 (23 per cent), while the lowest prevalence was amongst children aged 4-5 (7 per cent). Diarrhoea prevalence was similar amongst girls (16 per cent) and boys (14 per cent). Figure CH.2 shows the percentage who had diarrhoea in the two weeks preceding the survey by age groups.fifty-eight per cent with diarrhoea received ORS (fluid from ORS packet or pre-packaged ORS fluid). Figure CH.2: Percentage under age 5 with diarrhoea in the two weeks preceding the survey by age group, BiH Roma Survey 2011 2012 Per cent 25 20 15 10 5 0 19 23 12 14 0-11 12-23 24-35 36-47 48-59 BiH Age () 7 15 Table CH.3: Oral rehydration solutions and recommended homemade fluids Percentage with diarrhoea in the last two weeks, and treatment with oral rehydration solutions and recommended homemade fluids, BiH Roma Survey 2011 2012 Had diarrhoea in last two weeks of children aged 0-59 Children with diarrhoea who received ORS (Fluid from ORS packet or pre-packaged ORS fluid) with diarrhoea in last two weeks Male 14.2 392 62.5 56 Female 15.9 356 53.3 57 FBiH 17.8 570 59.4 101 RS 7.3 123 (*) 9 BD 3.7 56 (*) 2 Age () 0-11 18.8 144 (45.6) 27 12-23 22.5 147 (74.7) 33 24-35 12.0 151 (*) 18 36-47 14.3 170 (*) 24 48-59 7.1 136 (*) 10 No formal education 13.6 247 (57.4) 34 Primary 16.3 427 55.4 69 Secondary+ 12.6 74 (*) 9 Poorest 17.6 216 (60.7) 38 Second 16.6 181 (52.4) 30 Middle 18.0 122 (*) 22 Fourth 11.3 127 (*) 14 Richest 7.9 102 (*) 8 Poorest 60 per cent 17.3 519 56.9 90 Richest 40 per cent 9.8 229 (*) 22 Romani 13.8 454 55.9 63 Other 17.0 293 (60.5) 50 15.0 748 57.9 112 Table CH.4 shows feeding practices for children during the episode of diarrhoea. The data shows that during the episode of diarrhoea only 16 per cent of Roma children under 5 years of were given more than usual to drink and that 84 per cent were given the same or less to drink. With respect to food intake, 11 per cent were given much less to eat than usual and 58 per cent were given somewhat less to eat. Five per cent stopped feeding, while 6 per cent were given more than usual to eat (continued feeding). 25 Compared to 1990 (Millennium Development Goals) 32 Multiple Indicator Cluster Survey 2011 2012 Monitoring the situation and women 33
Male 14.2 392 9.0 51.8 23.8 15.5 100.0 13.1 49.2 23.7 5.9 8.1 100.0 56 Female 15.9 356 13.7 53.2 17.2 16.0 100.0 7.9 66.8 18.3 5.4 1.5 100.0 57 FBiH 17.8 570 11.1 52.9 20.6 15.4 100.0 10.8 57.9 19.8 6.3 5.3 100.0 101 RS 7.3 123 (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 9 BD 3.7 56 (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 2 Age () 0-11 18.8 144 (5.2) (39.5) (33.1) (22.1) 100.0 (12.2) (33.0) (33.9) (12.4) (8.5) 100.0 27 12-23 22.5 147 (20.2) (42.6) (18.8) (18.3) 100.0 (7.2) (75.8) (11.8) (2.6) (2.6) 100.0 33 24-35 12.0 151 (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 18 36-47 14.3 170 (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 24 48-59 7.1 136 (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 10 No formal education 13.6 247 (9.8) (67.4) (16.1) (6.7) 100.0 (11.5) (52.9) (23.3) (9.8) (2.5) 100.0 34 Primary 16.3 427 10.8 48.6 22.0 18.6 100.0 6.2 60.1 22.7 4.4 6.5 100.0 69 Secondary+ 12.6 74 (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 9 Poorest 17.6 216 (3.7) (61.0) (18.4) (16.8) 100.0 (5.3) (57.9) (25.6) (6.0) (5.1) 100.0 38 Second 16.6 181 (16.8) (42.7) (14.1) (26.5) 100.0 (8.0) (60.2) (22.5) (6.5) (2.8) 100.0 30 Middle 18.0 122 (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 22 Fourth 11.3 127 (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 14 Richest 7.9 102 (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 8 Poorest 60 per cent 17.3 519 9.7 54.0 20.3 16.0 100.0 7.2 56.1 24.7 6.1 6.0 100.0 90 Richest 40 per cent 9.8 229 (*) (*) (*) (*) 100.0 (*) (*) (*) (*) (*) 100.0 22 Romani 13.8 454 10.4 55.8 22.2 11.5 100.0 6.7 66.2 20.5 3.3 3.4 100.0 63 Other 17.0 293 (12.5) (48.3) (18.3) (20.9) 100.0 (15.2) (47.9) (21.7) (8.7) (6.5) 100.0 50 15.0 748 11.3 52.5 20.5 15.7 100.0 10.5 58.1 21.0 5.7 4.8 100.0 112 Had diarrhoea in last two weeks much less to drink somewhat less to drink about the same to drink more to drink much less to eat somewhat less to eat about the same to eat more to eat Stopped f ood Drinking practices during diarrhoea Eating practices during diarrhoea with diarrhoea in last two weeks Table CH.4: Feeding practices during diarrhoea Per cent distribution with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, BiH Roma Survey 2011 2012 Table CH.5 provides the proportion with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding and the percentage with diarrhoea who received other treatments. Overall 64 per cent with diarrhoea received oral rehydration salts or increased fluids. It was observed that 52 per cent received oral rehydration therapy (ORT) and, at the same time, feeding was continued, as is the recommendation. Nineteen per cent received antimotility medication in the form of tablets or syrup, 7 per cent received an antibiotic in the form of tablets or syrup, 4 per cent received an injectable antibiotic and 1 per cent received an intravenous infusion. Diarrhoea was treated by home remedies/herbal medicine in 5 per cent, while 19 per cent were treated in some other way. No diarrhoea treatment or medication was received by 25 per cent. 34 Multiple Indicator Cluster Survey 2011 2012 Monitoring the situation and women 35
Male 70.3 54.0 9.5 13.8 0.0 0.0 1.8 6.0 0.0 2.5 1.2 6.9 15.9 24.6 56 Female 58.1 50.1 5.4 23.9 0.0 1.6 0.0 2.2 0.0 0.0 1.2 3.6 21.9 25.1 57 FBiH 65.4 52.9 7.4 15.9 0.0 0.9 1.0 4.5 0.0 1.4 1.3 5.8 20.1 23.2 101 RS (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 9 BD (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 2 Age 0-11 (56.6) (35.8) (14.4) (13.6) (0.0) (3.3) (3.8) (8.5) (0.0) (0.0) (2.5) (4.7) (11.9) (25.5) 27 12-23 (77.8) (73.5) (6.4) (27.4) (0.0) (0.0) (0.0) (3.8) (0.0) (4.3) (2.0) (0.0) (14.3) (16.3) 33 24-35 (*) 56.5 (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 18 36-47 (*) 31.5 (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 24 48-59 (*) 67.3 (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 10 No formal education (59.9) (51.4) (18.5) (10.0) (0.0) (0.0) (0.0) (10.6) (0.0) (0.0) (2.0) (3.8) (10.9) (34.8) 34 Primary 64.3 52.8 3.1 25.7 0.0 1.3 1.5 1.5 0.0 0.0 1.0 6.6 22.0 20.5 69 Secondary+ (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 9 Poorest (68.0) (57.6) (6.0) (23.8) (0.0) (2.4) (0.0) (6.0) (0.0) (0.0) (3.6) (8.7) (19.6) (18.2) 38 Second (66.5) (61.8) (10.0) (17.0) (0.0) (0.0) (3.4) (7.6) (0.0) (0.0) (0.0) (.0) (20.7) (27.2) 30 Middle (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 22 Fourth (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 14 Richest (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 8 Poorest 60 per cent 64.7 53.6 7.3 20.2 0.0 1.0 1.1 5.1 0.0 0.0 1.5 6.5 18.7 23.5 90 Richest 40 per cent (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) (*) 22 Language of household head * Romani 57.5 50.3 9.3 21.2 0.0 0.0 0.0 3.3 0.0 0.0 2.2 2.0 10.2 31.0 63 Other (72.5) (54.3) (5.1) (16.0) (0.0) (1.8) (2.1) (5.1) (0.0) (2.9) (0.0) (9.2) (29.8) (17.2) 50 64.1 52.1 7.4 18.9 0.0 0.8 0.9 4.1 0.0 1.3 1.2 5.2 18.9 24.9 112 1 MICS indicator 3.8 Zinc Other Unknown Antibiotic Intravenous ORT ORS with or increased Antimotility continued Anti-biotic fluids feeding 1 Nonantibiotic Unknown Home remedy, herbal medicine Other Pill or syrup Injection Not given any treatment or drug Children with diarrhoea who received: Other treatments with diarrhoea in last two weeks Table CH.5: Oral rehydration therapy with continued feeding and other treatments Percentage with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding and percentage with diarrhoea who received other treatments, BiH Roma Survey 2011 2012 Care-Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children and the use of antibiotics in under-5 s with suspected pneumonia is a key intervention. A World Fit for Children goal is to reduce by one-third the deaths due to acute respiratory infection. In the MICS survey on Roma in BiH the prevalence of suspected pneumonia was estimated by asking mothers or caretakers whether children under age five had experienced an illness with a cough accompanied by rapid or difficult breathing whose symptoms were due to a problem with the chest or both a problem with the chest and a blocked nose. Table CH.6 present the percentage with suspected pneumonia. During the two weeks that preceded the survey 10 per cent were reported to have had symptoms of suspected pneumonia. Of these children 80 per cent were taken to an appropriate service provider (MICS indicator 3.9 which is not shown in Table CH.6). 26 The largest proportion were taken to a government health centre (68 per cent) or government hospital (12 per cent), while a small proportion were taken to a private medical practice (1 per cent) and or a private pharmacy (2 per cent). The highest percentage with suspected pneumonia was found in the FBiH (11 per cent), followed by RS (6 per cent) and BD (2 per cent). Three quarters under-5 with suspected pneumonia in the two weeks prior to the survey (75 per cent) were treated with antibiotics (MICS indicator 3.10 which is not shown in Table CH.6). 27 Table CH.6: Prevalence of suspected pneumonia by background characteristics Percentage with suspected pneumonia in the last two weeks, BiH Roma Survey 2011 2012 Had suspected pneumonia in the last two weeks Male 9.1 392 Female 10.2 356 FBiH 11.1 570 RS 6.3 123 BD 1.9 56 Age () 0-11 9.4 144 12-23 11.7 147 24-35 8.4 151 36-47 9.5 170 48-59 8.9 136 No formal education 7.7 247 Primary 9.9 427 Secondary+ 14.2 74 Poorest 10.9 216 Second 12.3 181 Middle 8.6 122 Fourth 9.3 127 Richest 3.4 102 Poorest 60 per cent 10.9 519 Richest 40 per cent 6.7 229 Romani 6.6 454 Other 14.2 293 9.6 748 MICS indicator 3.9: Percentage with suspected pneumonia in the last two weeks who were taken to a health provider; the indicator is not shown in Table CH.6 because of the low number of unweighted cases for the background characteristics (less than 25 unweighted cases). MICS indicator 3.10: Percentage with suspected pneumonia who received antibiotics in the last two weeks; the indicator is not shown in Table CH.6 because of the low number of unweighted cases for the background characteristics (less than 25 unweighted cases). 26 MICS indicator 3.9: percentages by basic characteristics are based on fewer than 25 unweighted cases, and are not shown in Table CH.6. 27 MICS indicator 3.10: percentages by basic characteristics are based on fewer than 25 unweighted cases, and are not shown in Table CH.6. 36 Multiple Indicator Cluster Survey 2011 2012 Monitoring the situation and women 37
It is obvious that a mothers knowledge of the danger signs is an important determinant of care-seeking behaviour; issues related to knowledge of the danger signs of pneumonia are presented in Table CH.7. Overall 6 per cent of mothers were aware of the two danger signs of pneumonia: fast and difficult breathing. Twenty-eight per cent of mothers identified difficult breathing and 13 per cent of mothers identified fast breathing as symptoms for immediately taking a child to a health facility. A higher percentage of mothers in RS (40 per cent) believed that a child should be taken immediately to a health facility if the child experienced difficulty breathing than in the FBiH (27 per cent). The highest percentage of mothers believed that a child should immediately be taken to a health facility in the case of fever (81 per cent). Solid Fuel Use More than 3 billion people around the world rely on solid fuel for their basic energy needs, including cooking and heating. Solid fuels include biomass such as wood, charcoal, crop or other agricultural residues, dung, shrubs and straw, and coal. Cooking and heating with solid fuel leads to high levels of indoor smoke, a complex mix of health damaging pollutants. The main problem with the use of solid fuel is incomplete combustion, which produces toxic elements such as, amongst others, carbon monoxide and sulphur oxide (SO 2 ). Use of solid fuel increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease and cancer. The primary indicator of solid fuel use is the proportion of the population using solid fuel as their primary source of domestic energy for cooking. FBiH 5.1 7.1 80.0 14.2 27.2 3.3 4.3 55.2 5.6 404 RS 11.6 4.8 87.4 13.3 39.8 8.1 5.9 74.5 10.1 78 BD (5.9) (0.0) (82.4) (2.9) (5.9) (0.0) (5.9) (70.6) (0.0) 34 No formal education 8.9 5.5 81.9 11.9 28.9 4.3 5.7 59.3 5.1 163 Primary 4.7 6.6 79.5 14.0 27.3 3.1 4.0 60.4 6.7 299 Secondary+ 5.5 7.4 88.7 14.5 26.2 6.5 5.3 51.3 4.1 55 Poorest 2.4 6.3 78.5 7.3 25.9 3.1 3.2 67.8 4.8 135 Second 6.3 6.2 82.9 17.5 25.8 7.5 5.1 55.9 6.3 124 Middle 9.7 10.0 75.4 13.9 33.5 1.4 4.2 58.2 6.4 86 Fourth 5.6 3.7 83.2 19.2 26.5 2.5 2.9 58.9 6.2 95 Richest 9.1 5.6 87.5 9.4 28.9 3.6 9.3 50.4 6.4 76 Poorest 60 per cent 5.6 7.2 79.3 12.6 27.8 4.3 4.1 61.1 5.8 345 Richest 40 per cent 7.2 4.6 85.1 14.8 27.6 3.0 5.8 55.1 6.3 171 Romani 7.0 6.7 78.5 10.0 25.2 3.2 6.8 60.8 4.7 296 Other 4.9 5.9 85.3 18.0 31.2 4.7 1.8 56.6 7.7 219 6.1 6.3 81.2 13.4 27.7 3.8 4.7 59.1 5.9 517 Is not able Becomes to drink worse or breastfeed Develops a fever Has fast breathing Has difficulty breathing Has blood in stool Is drinking poorly Has other symptoms danger signs of pneumonia Percentage of mothers/caretakers who think that a child should be taken immediately to a health facility if the child: Mothers/ caretakers who recognise the two of mothers/ caretakers Table CH.7: Knowledge of the two danger signs of pneumonia Percentage of mothers and caretakers by symptoms that would cause them to take the child immediately to a health facility and percentage of mothers who recognised fast and or difficult breathing as signs to seek immediate care, BiH Roma Survey 2011 2012 Table CH.8 shows that, overall, 92 per cent of Roma households used solid fuel for cooking; solid fuel use was somewhat higher in RS (97 per cent) and BD (95 per cent) than in the FBiH (91 per cent). The highest percentage of households used wood for cooking (84 per cent). Charcoal was used for cooking by 7 per cent of households and coal/lignite by 1 per cent of households. The findings show that the use of solid fuel for cooking was most common amongst households where household heads had no formal education (96 per cent) and least common amongst those with secondary or higher education (88 per cent). A higher percentage of households in the poorest 60 per cent of the population use solid fuels for cooking (84 per cent), compared to those in the richest 40 per cent of the population (98 per cent). Households in the poorest 60 per cent of the population are more likely to use wood for cooking (92 per cent) than households in the richest 40 per cent of the population (73 per cent), whereas the richest households use electricity for cooking more frequently (16 per cent) than poorest households (2 per cent). Table CH.8: Solid fuel use Per cent distribution of household members according to type of cooking fuel used by the household and percentage of household members living in households using solid fuel for cooking, BiH Roma Survey 2011 2012 Electricity Percentage of household members in households using: Solid fuel No food Liquefied petroleum Straw, cooked Coal, Char- Missing in the gas (LPG) Wood shrubs, lignite coal grass household Solid fuel for cooking 1 of household members FBiH 8.7 0.0 0.6 6.2 84.1 0.1 0.0 0.3 100.0 90.9 4,543 RS 1.8 1.0 1.4 7.2 88.1 0.4 0.1 0.0 100.0 97.1 1,027 BD 2.2 0.0 0.0 20.0 74.8 0.0 0.0 3.0 100.0 94.8 282 Education of household head No formal education 3.2 0.2 1.1 7.7 86.9 0.0 0.0 0.9 100.0 95.8 1,478 Primary 7.7 0.2 0.5 6.7 84.4 0.0 0.1 0.3 100.0 91.6 3,560 Secondary+ 11.7 0.0 0.8 7.4 79.2 0.8 0.0 0.0 100.0 88.3 814 Poorest 0.4 0.0 0.6 3.4 94.9 0.0 0.2 0.4 100.0 98.9 1,171 Second 1.2 0.0 0.9 4.8 91.8 0.0 0.0 1.3 100.0 97.5 1,168 Middle 2.8 0.0 0.6 5.7 90.0 0.6 0.0 0.3 100.0 96.8 1,173 Fourth 9.8 0.0 0.5 6.1 83.7 0.0 0.0 0.0 100.0 90.2 1,173 Richest 21.6 0.9 0.9 15.3 61.3 0.0 0.0 0.0 100.0 77.5 1,167 Poorest 60 per cent 1.5 0.0 0.7 4.6 92.2 0.2 0.1 0.7 100.0 97.7 3,512 Richest 40 per cent 15.7 0.5 0.7 10.7 72.5 0.0 0.0 0.0 100.0 83.9 2,340 Romani 4.3 0.1 0.6 9.7 84.8 0.0 0.0 0.5 100.0 95.2 3,373 Other 11.1 0.3 0.8 3.5 83.6 0.3 0.1 0.3 100.0 88.1 2,469 7.2 0.2 0.7 7.0 84.3 0.1 0.0 0.4 100.0 92.2 5,852 1 MICS indicator 3.11 The use of solid fuel is in itself a weak indicator of indoor air pollution, since the concentration of pollutants varies when the same type of fuel is burned in different types of stoves or fireplaces. The use of sealed stoves with chimney flukes minimises indoor air pollution, whereas the use of open stoves or fireplaces without a chimney or smoke extractor provides no protection against the harmful effects of solid fuel combustion. 38 Multiple Indicator Cluster Survey 2011 2012 Monitoring the situation and women 39
Solid fuel use by place of cooking is depicted in Table CH.9. Indoor air pollution depends on cooking practices, the place of cooking and the type of fuel used. The findings of this survey show that, overall, the place of cooking in 41 per cent of Roma households was a room designated to serve solely as a kitchen, while 52 per cent of households cooked somewhere else in the house (no designated room). Two-thirds of households in RS (67 per cent) had a designated room for cooking compared to more than one half in BD (54 per cent) and only one-third of households in the FBiH (34 per cent). The data shows that the percentage of households with a room designated solely for cooking increased with the education level of the household head and household wealth: the highest percentage was amongst those with secondary or higher education (51 per cent) and amongst households in the richest 40 per cent of the population (56 per cent). Table CH.9: Solid fuel use by place of cooking Per cent distribution of household members in households using solid fuel by place of cooking, BiH Roma Survey 2011 2012 In a separate room used as kitchen Elsewhere in the house In a separate building Place of cooking Outdoors At another place Missing of household members in households using solid fuel for cooking FBiH 34.0 57.9 1.0 1.6 4.8 0.7 100.0 4,131 RS 67.2 29.8 1.4 0.7 0.0 0.9 100.0 997 BD 53.9 46.1 0.0 0.0 0.0 0.0 100.0 267 Education of household head No formal education 33.7 56.0 2.1 2.8 4.8 0.6 100.0 1,416 Primary 42.1 52.4 0.7 1.1 3.1 0.6 100.0 3,262 Secondary+ 51.1 43.1 0.5 0.0 3.9 1.4 100.0 718 Poorest 22.3 57.8 2.0 6.4 10.4 1.1 100.0 1,159 Second 36.4 59.6 1.6 0.0 2.2 0.3 100.0 1,138 Middle 38.6 57.0 1.2 0.0 2.9 0.3 100.0 1,136 Fourth 50.3 47.4 0.0 0.0 1.8 0.5 100.0 1,059 Richest 63.4 35.0 0.0 0.0 0.0 1.6 100.0 905 Poorest 60 per cent 32.4 58.1 1.6 2.2 5.2 0.6 100.0 3,433 Richest 40 per cent 56.4 41.7 0.0 0.0 1.0 1.0 100.0 1,963 Romani 38.5 54.6 1.5 2.1 2.4 1.0 100.0 3,210 Other 45.1 48.3 0.4 0.3 5.6 0.3 100.0 2,176 41.1 52.1 1.0 1.4 3.7 0.7 100.0 5,396 40 Multiple Indicator Cluster Survey 2011 2012