A l b a n i a 2 0 0 8 Albania - 0 9 D Demographic and e 2008-09 m Health Survey o g r a p h i c a n d H e a l t h S u r v e y REPUBLIC OF ALBANIA Albania Demographic and Health Survey 2008-09 Institute of Statistics Institute of Public Health Tirana, Albania ICF Macro Calverton, Maryland, USA March 2010 Ministria e Shëndetësisë This report summarizes the findings of the 2008-09 Albania Demographic and Health Survey (2008-09 ADHS), which was conducted by the Institute of Statistics (INSTAT) and the Institute of Public Health (IPH). ICF Macro, an ICF International Company, provided technical assistance to the project through funding from UNICEF and MEASURE DHS, a USAID-funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide. Funding for the 2008-09 ADHS was provided by USAID, UNICEF, UNFPA, the Swiss Cooperation Office in Albania (SCO-A), the World Health Organization (WHO), and the Spanish Agency for International Development Cooperation (AECID). The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID, UNICEF, UNFPA, SCO-A, WHO, or the Government of Albania. Additional information about the 2008-09 ADHS may be obtained from either: The Institute of Statistics Lantona Sado, ADHS Coordinator Street address: Blvd ‘Gergj Fishta’ #3, Tirana, Albania. Telephone: +355 (4) 2222411, Fax: +355 (4) 2228300, Email: [email protected] or The Institute of Public Health Elizana Petrela, ADHS Coordinator Street address: ‘Aleksander Moisiu’ # 80, Tirana, Albania. Telephone: +355 (4) 2363195, Fax: +355 (4) 2370058, Email: [email protected] Additional information about the MEASURE DHS project may be obtained from ICF Macro, MEASURE DHS, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705 USA; Telephone: 301-572-0200, Fax: 301-572-0999, E- mail: [email protected], Internet: http://www.measuredhs.com. Recommended citation: Institute of Statistics, Institute of Public Health [Albania] and ICF Macro. 2010. Albania Demographic and Health Survey 2008-09. Tirana, Albania: Institute of Statistics, Institute of Public Health and ICF Macro. INTRODUCTION In the early-mid 1990s, Albania entered a new phase of major changes, moving from a totalitarian to a democratic system and shifting gradually to the free market economy. This process led, naturally, to changes in various demographic and health characteristics of the Albanian society. The 2008-09 Albania Demographic and Health Survey (ADHS) is a nationally representative study aimed at collecting and providing information on population, demographic, and health characteristics of the country. Population-based studies of this magnitude are a major undertaking that provide information on important indicators which measure the progress of a country. The ADHS results help provide the necessary information to assess, measure, and evaluate the existing programs in the country. They also provide crucial information to policy-makers when drafting new policies and strategies related to the health sector and health services in Albania. The information collected in the 2008-09 Albania Demographic and Health Survey will be used not only by local decision-makers and programme managers, but also by partners and foreign donors involved in various development areas in Albania, as well as by academic institutions to do further analysis with the collected data. The 2008-09 ADHS is the result of hard and good quality work of many Albanian institutions as well as national and international organizations, which have shown a high level of professionalism and dedication to good quality data in the field of health and demographics in Albania. Petrit VASILI Minister of Health Introduction | iii CONTENTS Page INTRODUCTION.........................................................................................................iii TABLES AND FIGURES...........................................................................................................xi PREFACE ................................................................................................................................xix ACKNOWLEDGMENTS........................................................................................................xxi LIST OF CONTRIBUTORS.................................................................................................xxiii SUMMARY OF FINDINGS..................................................................................................xxv MILLENNIUM DEVELOPMENT GOAL INDICATORS................................................xxxi MAP OF ALBANIA...............................................................................................................xxxii CHAPTER 1 INTRODUCTION 1.1 Geography and Population...............................................................................1 1.2 History.............................................................................................................1 1.2.1 The Albanian Language.........................................................................3 1.2.2 The Albanian Flag.................................................................................3 1.3 Economy..........................................................................................................3 1.4 Characteristics of the Health System.................................................................4 1.4.1 Health Care System..............................................................................4 1.4.2 Primary Health Care.............................................................................5 1.4.3 Country Epidemiological Profile............................................................6 1.4.4 Hospital Services..................................................................................7 1.4.5 Pharmaceutical Services........................................................................7 1.4.6 Health Insurance Institute.....................................................................7 1.4.7 Human Resources................................................................................8 1.4.8 Sources of Public Financing for Health..................................................8 1.5 Objectives and Organization of the Survey.......................................................9 1.5.1 Sample Design and Implementation...................................................10 1.5.2 Questionnaires...................................................................................10 1.5.3 Biomarkers.........................................................................................12 1.5.4 Field Staff and Fieldwork....................................................................13 1.5.5 Data Processing..................................................................................14 1.5.6 Response Rates...................................................................................14 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Household Population by Age and Sex...........................................................18 2.2 Household Composition................................................................................19 2.3 Children’s Living Arrangements......................................................................20 2.4 Educational Attainment of Household Members.............................................21 2.5 Preschool Attendance and Primary School Participation.................................26 2.6 Housing Characteristics..................................................................................28 Contents | v 2.6.1 Drinking Water...................................................................................30 2.6.2 Sanitation Facilities.............................................................................32 2.6.3 Household Possessions.......................................................................32 2.7 Wealth Quintiles............................................................................................34 2.8 Birth Registration............................................................................................34 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS 3.1 Background Characteristics of Respondents....................................................37 3.2 Educational Level of Respondents..................................................................39 3.3 Literacy..........................................................................................................41 3.4 Exposure to Mass Media ................................................................................42 3.5 Employment ..................................................................................................44 3.6 Occupation....................................................................................................47 3.7 Employment Characteristics...........................................................................50 CHAPTER 4 FERTILITY 4.1 Current Fertility Level.....................................................................................53 4.2 Fertility Differentials by Background Characteristics........................................55 4.3 Fertility Trends...............................................................................................56 4.4 Children Ever Born and Living........................................................................57 4.5 Birth Intervals.................................................................................................58 4.6 Age at First Birth.............................................................................................60 4.7 Teenage Pregnancy and Motherhood.............................................................61 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods............................................................63 5.2 Ever Use of Contraception.............................................................................66 5.3 Current Use of Contraceptive Methods..........................................................68 5.4 Trends in Contraceptive Use..........................................................................71 5.5 Differentials in Contraceptive Use by Background Characteristics...................71 5.6 Other Forms of Fertility Regulation.................................................................73 5.7 Number of Children at First Use of Contraception..........................................73 5.8 Knowledge of the Fertile Period.....................................................................74 5.9 Source of Contraception................................................................................75 5.10 Cost of Contraception....................................................................................79 5.11 Informed Choice............................................................................................79 5.12 Contraceptive Discontinuation.......................................................................81 5.13 Future Use of Contraception..........................................................................81 5.14 Reasons for Not Intending to Use Contraception............................................82 5.15 Preferred Method for Future Use...................................................................83 5.16 Exposure to Family Planning Messages...........................................................83 5.17 Contact of Non-users with Family Planning Providers.....................................84 5.18 Attitudes of Respondents Towards Family Planning........................................85 CHAPTER 6 OTHER PROXIMATE DETERMINANTS OF FERTILITY 6.1 Introduction...................................................................................................87 vi │ Contents 6.2 Marital Status.................................................................................................87 6.3 Age at First Marriage......................................................................................88 6.4 Age at First Sexual Intercourse........................................................................93 6.5 Recent Sexual Activity....................................................................................96 6.6 Post-partum Amenorrhoea, Abstinence, and Insusceptibility...........................98 6.7 Termination of Exposure to Pregnancy........................................................100 CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children............................................................................101 7.2 Need for Family Planning Services...............................................................104 7.3 Ideal Number of Children...........................................................................107 7.4 Wanted and Unwanted Fertility..................................................................110 7.4.1 Planning Status of Births...................................................................110 7.4.2 Wanted Fertility...............................................................................111 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Definitions and Methodology......................................................................113 8.2 Assessment of Data Quality.........................................................................114 8.3 Levels and Trends in Infant and Child Mortality...........................................115 8.4 Socio-economic Differentials in Childhood Mortality...................................117 8.5 Demographic Differentials in Childhood Mortality......................................118 8.6 Perinatal Mortality.......................................................................................119 8.7 High-risk Fertility Behaviour........................................................................119 CHAPTER 9 MATERNAL HEALTH 9.1 Antenatal Care............................................................................................124 9.1.1 Antenatal Care Provider...................................................................124 9.1.2 Number and Timing of Antenatal Care Visits....................................126 9.1.3 Components of Antenatal Care.........................................................126 9.1.4 Tetanus Toxoid Immunization..........................................................128 9.2 Delivery Care..............................................................................................129 9.2.1 Place of Delivery..............................................................................130 9.2.2 Assistance during Delivery................................................................131 9.3 Postnatal Care.............................................................................................132 CHAPTER 10 CHILD HEALTH 10.1 Child’s Weight and Size at Birth..................................................................135 10.2 Vaccination Coverage.................................................................................137 10.3 Acute Respiratory Infections And Fever.......................................................140 10.4 Diarrhoea...................................................................................................142 10.5 Disposal of Stools........................................................................................146 10.6 Family Support for Learning........................................................................148 10.7 Children Left Alone.....................................................................................150 10.8 Child Discipline..........................................................................................151 Contents | vii CHAPTER 11 NUTRITION 11.1 Breastfeeding and Supplementation............................................................154 11.1.1 Initiation of Breastfeeding.............................................................154 11.1.2 Breastfeeding Status by Age..........................................................156 11.1.3 Duration and Frequency of Breastfeeding.....................................158 11.1.4 Types of Complementary Foods....................................................159 11.1.5 Food and Liquids Consumed by Women......................................162 11.2 Salt Iodization.............................................................................................163 11.3 Micronutrient Intake among Young Children...............................................164 11.4 Micronutrient Intake among Mothers..........................................................167 11.5 Prevalence of Anaemia................................................................................169 11.5.1 Prevalence of Anaemia in Children...............................................169 11.5.2 Prevalence of Anaemia in Women and Men.................................170 11.6 Nutritional Status of Children......................................................................173 11.7 Trends in Child Nutrition............................................................................176 11.8 Nutritional Status of Women and Men........................................................177 CHAPTER 12 HIV AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOUR 12.1 Knowledge of HIV/AIDS..............................................................................182 12.2 Knowledge of Ways to Reduce AIDS Transmission......................................183 12.3 Comprehensive Knowledge about HIV/AIDS...............................................185 12.4 Knowledge about Mother-to-Child Transmission.........................................188 12.5 Accepting Attitudes Towards People Living with HIV/AIDS..........................190 12.6 Attitudes Towards Negotiating Safer Sex......................................................192 12.7 Adult Support of Education About Condom Use to Prevent AIDS................194 12.8 Multiple Sexual Partners and Higher-Risk Sex..............................................195 12.9 Testing for HIV............................................................................................200 12.10 Male Circumcision......................................................................................202 12.11 Reports of Recent Sexually Transmitted Infections.......................................203 12.12 Comprehensive HIV/AIDS Knowledge and Source of Condoms among Youth..............................................................................................205 12.13 Age at First Sexual Intercourse.....................................................................207 12.14 Condom Use at First Sexual Intercourse......................................................209 12.15 Premarital Sex and Condom Use among Young Women and Men..............210 12.16 Higher-Risk Sex and Condom Use among Young Adults..............................211 12.17 Age-Mixing in Sexual Relationships............................................................213 12.18 Drunkenness during Sexual Intercourse among Youth.................................214 12.19 Recent HIV Testing among Youth................................................................215 CHAPTER 13 ADULT HEALTH 13.1 Current Health Status..................................................................................217 13.2 Chronic and Acute Illnesses.........................................................................220 13.3 Knowledge of Cancer Screening..................................................................221 13.4 Use of Tobacco...........................................................................................223 13.5 Alcohol Consumption.................................................................................227 viii │ Contents 13.6 Hypertension..............................................................................................229 13.6.1 Prevalence of Hypertension..........................................................229 13.6.2 Awareness of Hypertension and Treatment Status.........................233 13.7 Problems in Accessing Health Care.............................................................234 13.8 Utilization and Quality of Health Services...................................................236 13.9 Health Insurance.........................................................................................238 13.10 Payments for Health Care...........................................................................241 CHAPTER 14 MIGRATION 14.1 Households With at Least One Former Member Who Has Migrated...........247 14.2 Characteristics of Migrants’ Former Households..........................................249 14.3 Migrant Population.....................................................................................252 14.4 Background Characteristics of Migrants.......................................................254 14.5 Reasons For Migration.................................................................................256 14.6 Trends in Migration.....................................................................................257 14.7 Destination of Migrants...............................................................................258 14.8 Children of Migrants Left Behind.................................................................264 14.9 Money or Goods Sent to Households by Migrants.......................................267 14.10 Short-term Emigration.................................................................................270 CHAPTER 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15.1 Employment and Cash Earnings...................................................................271 15.2 Use of Earnings...........................................................................................272 15.3 Household Decision-making.......................................................................275 15.4 Men’s Attitudes about Household Decision-making....................................276 15.5 Attitudes toward Wife Beating.....................................................................279 15.6 Attitudes towards Refusing Sexual Relations................................................282 15.7 Indicators of Women’s Empowerment........................................................287 15.8 Current Use of Contraception by Women’s Status.......................................288 15.9 Women’s Status and Ideal Family Size and Unmet Need............................289 15.10 Women’s Status and Reproductive Health Care..........................................290 REFERENCES........................................................................................................................299 APPENDIX A SAMPLE IMPLEMENTATION........................................................................ A.1 Introduction...............................................................................................299 A.2 Sampling Frame..........................................................................................299 A.3 Sample Allocation.......................................................................................300 A.4 Sampling Procedure and Updating of the Sampling Frame..........................301 A.5 Men’s Sub-sample......................................................................................302 A.6 Sampling Probabilities................................................................................303 A.7 Weighting And Representativeness.............................................................303 A.8 Special Concerns........................................................................................305 APPENDIX B ESTIMATES OF SAMPLING ERRORS....................................................309 Contents | ix