Albania - Demographic and Health Survey - 2018

Publication date: 2018

Wo.,MuE NN � REPUBLIC OF ALBANIA Albania Demographic and Health Survey 2017-18 Institute of Statistics Institute of Public Health Tirana, Albania The DHS Program ICF Rockville, Maryland, USA October 2018 This report presents the findings of the 2017-18 Albania Demographic and Health Survey (2017-18 ADHS), which was conducted by the Institute of Public Health (IPH) and the Institute of Statistics (INSTAT). ICF provided partial technical assistance to the project. Funding for the 2017-18 ADHS was provided by the Swiss Agency for Development and Cooperation (SDC), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF) and United Nations Entity for Gender Equality and the Empowerment of Women (UN Women). The opinions expressed herein are those of the authors and do not necessarily reflect the views of SDC, UNFPA, UNICEF, and UN Women, or the Government of Albania. Additional information about the ADHS may be obtained from: Institute of Statistics Rr. Vllazën Huta, #35, Tirana, Albania Tel: +355 (4) 2222411, Fax: +355 (4) 2228300, Email: info@instat.gov.al Or Institute of Public Health Blvd Alexander Moisiu # 80, Tirana, Albania Tel.: +355 (4) 2363195, Fax +355 (4) 2370058, Email: ishp@shendetesia.gov.al Information about The DHS Program may be obtained from ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; Telephone: +1-301-407-6500; Fax: +1-301-407-6501; Email: info@DHSprogram.com; Internet: www.DHSprogram.com. Recommended citation: Institute of Statistics, Institute of Public Health, and ICF. 2018. Albania Demographic and Health Survey 2017-18. Tirana, Albania: Institute of Statistics, Institute of Public Health, and ICF. Contents • iii CONTENTS TABLES AND FIGURES . vii PREFACE . xv ACKNOWLEDGMENTS . xvii FOREWORD . xix CONTRIBUTORS TO THE REPORT . xxi ABBREVIATIONS . xxiii READING AND UNDERSTANDING TABLES FROM THE 2017-18 ADHS . xxv MAP OF ALBANIA . xxiv 1 INTRODUCTION AND SURVEY METHODOLOGY . 1 1.1 History, Geography, and Population . 1 1.2 Health Care . 2 1.3 Survey Objectives . 2 1.4 Sample Design and Sample Updating . 2 1.5 Questionnaires and Forms . 3 1.6 Anthropometry, Anemia Testing, and Blood Pressure Measurement . 4 1.7 Pretest . 4 1.8 Training of Field Staff for the Main Fieldwork . 5 1.9 Fieldwork . 5 1.10 Data Processing . 5 1.11 Response Rates . 6 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 7 2.1 Drinking Water Sources and Treatment . 7 2.2 Sanitation . 8 2.3 Household Wealth . 8 2.4 Household Population and Composition . 10 2.5 Children’s Living Arrangements and Parental Survival . 11 2.6 Birth Registration . 12 2.7 Education . 12 2.7.1 Educational Attainment of Women . 12 2.7.2 Educational Attainment of Men . 13 2.7.3 School Attendance . 13 3 CHARACTERISTICS OF RESPONDENTS . 27 3.1 Basic Characteristics of Survey Respondents . 27 3.2 Education and Literacy . 28 3.3 Early Education and Support in Learning . 29 3.4 Mass Media Exposure . 31 3.5 Employment . 32 3.6 Occupation . 33 3.7 Health Insurance Coverage . 35 4 MARRIAGE AND SEXUAL ACTIVITY . 55 4.1 Marital Status . 55 4.2 Age at First Marriage . 56 4.3 Early Marriage . 56 4.4 Age at First Sexual Intercourse . 57 4.5 Recent Sexual Activity . 58 5 FERTILITY . 67 5.1 Current Fertility . 67 5.2 Children Ever Born and Living . 69 5.3 Non-Live Pregnancy Outcomes . 69 5.4 Birth Intervals . 69 iv • Contents 5.5 Insusceptibility to Pregnancy . 71 5.6 Age at First Birth . 72 5.7 Teenage Childbearing . 72 6 FERTILITY PREFERENCES . 83 6.1 Desire for Children. 83 6.2 Ideal Family Size . 84 6.3 Fertility Planning Status . 85 6.4 Wanted Fertility Rates . 86 7 FAMILY PLANNING . 93 7.1 Contraceptive Knowledge and Use . 94 7.2 Source of Modern Contraceptive Methods . 95 7.3 Discontinuation of Contraceptives . 96 7.4 Demand for Family Planning . 96 7.5 Decision-making about Family Planning . 98 7.6 Exposure to Family Planning Messages in the Media. 98 7.7 Contact of Nonusers with Family Planning Providers . 98 8 MATERNAL HEALTH CARE . 111 8.1 Antenatal Care Coverage and Content . 112 8.1.1 Skilled Providers . 112 8.1.2 Timing and Number of ANC Visits . 112 8.2 Components of ANC Visits . 113 8.3 Delivery Services . 114 8.3.1 Institutional Deliveries . 114 8.3.2 Assistance during Delivery . 115 8.3.3 Delivery by Caesarean . 115 8.4 Postnatal Care . 116 8.4.1 Postnatal Health Check for Mothers . 116 8.4.2 Postnatal Health Check for Newborns . 117 8.5 Problems in Accessing Health Care . 118 9 CHILD HEALTH . 131 9.1 Birth Weight . 131 9.2 Vaccination of Children . 132 9.3 Symptoms of Acute Respiratory Infection . 133 9.4 Fever . 134 9.5 Diarrheal Disease . 134 9.5.1 Prevalence of Diarrhea. 134 9.5.2 Feeding Practices . 135 9.5.3 Treatment of Diarrhea . 135 9.6 Disposal of Children’s Stools. 136 9.7 Child Discipline . 136 9.8 Inadequate Care . 138 10 NUTRITION OF CHILDREN AND ADULTS . 155 10.1 Nutritional Status of Children . 155 10.1.1 Measurement of Nutritional Status among Young Children . 155 10.1.2 Data Collection . 157 10.1.3 Levels of Child Malnutrition . 157 10.2 Infant and Young Child Feeding Practices . 158 10.2.1 Breastfeeding . 158 10.2.2 Exclusive Breastfeeding . 159 10.2.3 Median Duration of Breastfeeding . 159 10.2.4 Complementary Feeding . 160 10.2.5 Minimum Acceptable Diet . 160 10.3 Anemia Prevalence in Children . 162 10.4 Presence of Iodized Salt in Households . 163 10.5 Micronutrient Intake and Supplementation among Children . 163 10.6 Adults’ Nutritional Status . 164 Contents • v 10.6.1 Nutritional Status of Women . 164 10.6.2 Nutritional Status of Men . 165 10.7 Anemia Prevalence in Adults . 165 10.8 Micronutrient Intake among Mothers . 166 11 LIFESTYLE HEALTH RISK FACTORS . 183 11.1 Tobacco Smoking . 183 11.2 Alcohol Consumption . 184 11.3 Consumption of Sugary Sodas and Juices . 185 11.4 Consumption of Oils and Fat . 186 11.5 Consumption of Fruits and Vegetables . 187 11.6 Physical Activity . 188 12 NON-COMMUNICABLE DISEASES . 207 12.1 Hypertension . 207 12.2 Self-reported Prevalence of Noncommunicable Diseases . 209 12.3 Self-reported Prevalence of Chronic Disabilities . 210 12.4 Recent Injuries and Ailments . 211 12.5 Assessment of One’s Own Health Evolution . 211 12.6 Awareness of Cancer-screening Tests . 212 12.7 Depression. 213 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 227 13.1 HIV/AIDS Knowledge, Transmission, and Prevention Methods. 227 13.2 Knowledge about Mother-to-Child Transmission (MTCT) . 229 13.3 Discriminatory Attitudes toward People Living with HIV . 229 13.4 Multiple Sexual Partners . 230 13.5 Paid Sex . 230 13.6 Coverage of HIV Testing Services . 231 13.6.1 Awareness of HIV Testing Services and Experience with HIV Testing . 231 13.6.2 HIV Testing of Pregnant Women . 232 13.7 Male Circumcision . 232 13.8 Self-reporting of Sexually Transmitted Infections . 232 13.9 HIV/AIDS-Related Knowledge and Behavior among Young People . 233 13.9.1 Knowledge . 233 13.9.2 Age at First Sex . 233 13.9.3 Premarital Sex . 234 13.9.4 Multiple Sexual Partners . 234 13.9.5 Coverage of HIV Testing Services . 234 14 WOMEN’S EMPOWERMENT. 253 14.1 Employment and Cash Earnings . 254 14.2 Control over Women’s Earnings . 255 14.3 Control over Men’s Earnings . 256 14.4 Ownership of Assets . 257 14.5 Bank Accounts and Mobile Phones . 258 14.6 Participation in Decision Making . 258 14.6 Attitudes toward Wife-Beating . 259 14.7 Experience of Intimate Partner Violence . 260 14.8 Negotiating Sexual Relations . 260 15 REFERENCES . 283 APPENDIX A SAMPLE DESIGN . 285 A.1 Introduction . 285 A.2 Sampling Frame . 285 A.3 Sample Design and Selection . 286 A.4 Sampling Weights . 287 vi • Contents APPENDIX B ESTIMATES OF SAMPLING ERRORS . 293 APPENDIX C DATA QUALITY TABLES . 311 APPENDIX D PERSONS INVOLVED IN THE 2017-18 ALBANIA DHS . 315 APPENDIX E QUESTIONNAIRES . 319 Tables and Figures • vii TABLES AND FIGURES 1 INTRODUCTION AND SURVEY METHODOLOGY . 1 Table 1.1 Results of the household and individual interviews . 6 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 7 Table 2.1 Household drinking water . 16 Table 2.2 Household sanitation facilities . 17 Table 2.3 Household characteristics . 18 Table 2.4 Household possessions . 19 Table 2.5 Wealth quintiles . 19 Table 2.6 Household population by age, sex, and residence . 20 Table 2.7 Household composition . 21 Table 2.8 Children’s living arrangements and orphanhood . 22 Table 2.9 Birth registration of children under age 5 . 23 Table 2.10.1 Educational attainment of the female household population . 24 Table 2.10.2 Educational attainment of the male household population . 25 Table 2.11 School attendance ratios . 26 Figure 2.1 Household drinking water by residence . 8 Figure 2.2 Household toilet facilities by residence . 10 Figure 2.3 Household wealth by residence . 11 Figure 2.4 Population pyramid . 15 3 CHARACTERISTICS OF RESPONDENTS . 27 Table 3.1 Background characteristics of respondents . 36 Table 3.2.1 Educational attainment: Women . 37 Table 3.2.2 Educational attainment: Men . 38 Table 3.3.1 Literacy: Women . 39 Table 3.3.2 Literacy: Men. 40 Table 3.4 Early education . 41 Table 3.5 Support in learning . 42 Table 3.6.1 Exposure to mass media: Women . 43 Table 3.6.2 Exposure to mass media: Men . 44 Table 3.7.1 Internet usage: Women . 45 Table 3.7.2 Internet usage: Men . 46 Table 3.8.1 Employment status: Women . 47 Table 3.8.2 Employment status: Men . 48 Table 3.9.1 Occupation: Women . 49 Table 3.9.2 Occupation: Men . 50 Table 3.10 Type of employment . 51 Table 3.11.1 Health insurance coverage: Women . 52 Table 3.11.2 Health insurance coverage: Men . 53 Figure 3.1 Education of survey respondents . 28 Figure 3.2 More than secondary education . 28 Figure 3.3 More than secondary education by prefecture . 29 Figure 3.4 Exposure to mass media . 31 Figure 3.5 Employment status by education . 33 Figure 3.6 Occupation . 34 Figure 3.7 Type of employment, women . 34 viii • Tables and Figures 4 MARRIAGE AND SEXUAL ACTIVITY . 55 Table 4.1 Current marital status . 59 Table 4.2 Age at first marriage . 59 Table 4.3 Median age at first marriage by background characteristics . 60 Table 4.4 Early marriage by background characteristics . 61 Table 4.5 Age at first sexual intercourse . 62 Table 4.6 Median age at first sexual intercourse by background characteristics . 63 Table 4.7.1 Recent sexual activity: Women . 64 Table 4.7.2 Recent sexual activity: Men . 65 Figure 4.1 Marital status . 55 Figure 4.2 Women’s and men’s median age at first marriage and first sexual intercourse by residence . 56 Figure 4.3 Women’s and men’s median age at first marriage and first sexual intercourse by wealth. 58 5 FERTILITY . 67 Table 5.1 Current fertility . 74 Table 5.2 Fertility by background characteristics . 74 Table 5.3 Trends in age-specific fertility rates . 75 Table 5.4 Children ever born and living . 75 Table 5.5 Non-live pregnancy outcomes . 76 Table 5.6 Birth intervals . 77 Table 5.7 Postpartum amenorrhea, abstinence and insusceptibility . 78 Table 5.8 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 78 Table 5.9 Menopause . 79 Table 5.10 Age at first birth . 79 Table 5.11 Median age at first birth . 80 Table 5.12 Teenage pregnancy and motherhood . 81 Figure 5.1 Trends in fertility by residence . 68 Figure 5.2 Trends in age-specific fertility . 68 Figure 5.3 Fertility by prefecture . 68 Figure 5.4 Fertility by household wealth . 69 Figure 5.5 Non-live pregnancy outcome . 69 Figure 5.6 Birth intervals . 70 Figure 5.7 Median age at first birth by education . 72 Figure 5.8 Teenage pregnancy and motherhood by prefecture . 73 Figure 5.9 Teenage pregnancy and motherhood by household wealth . 73 6 FERTILITY PREFERENCES . 83 Table 6.1 Fertility preferences by number of living children . 87 Table 6.2.1 Desire to limit childbearing: Women . 87 Table 6.2.2 Desire to limit childbearing: Men . 88 Table 6.3 Ideal number of children by number of living children . 89 Table 6.4 Mean ideal number of children . 90 Table 6.5 Fertility planning status . 90 Table 6.6 Wanted fertility rates . 91 Figure 6.1 Trends in desire to limit childbearing by number of living children. 84 Figure 6.2 Desire to limit childbearing by number of living children . 84 Figure 6.3 Ideal family size by education . 85 Figure 6.4 Fertility planning status . 85 Tables and Figures • ix 7 FAMILY PLANNING . 93 Table 7.1 Knowledge of contraceptive methods . 100 Table 7.2 Knowledge of contraceptive methods according to background characteristics . 101 Table 7.3 Current use of contraception by age . 102 Table 7.4 Current use of contraception according to background characteristics . 103 Table 7.5 Knowledge of fertile period . 104 Table 7.6 Knowledge of fertile period by age . 104 Table 7.7 Source of modern contraception methods . 104 Table 7.8 Twelve-month contraceptive discontinuation rates . 105 Table 7.9 Reasons for discontinuation . 105 Table 7.10 Need and demand for family planning among currently married women . 106 Table 7.11 Need and demand for family planning for all women . 107 Table 7.12 Decision-making about family planning . 108 Table 7.13 Future use of contraception . 108 Table 7.14 Exposure to family planning messages . 109 Table 7.15 Contact of nonusers with family planning providers . 110 Figure 7.1 Contraceptive use . 94 Figure 7.2 Trends in contraceptive use . 95 Figure 7.3 Modern contraceptive use by prefecture . 95 Figure 7.4 Source of modern contraceptive methods . 96 Figure 7.5 Demand for family planning . 97 Figure 7.6 Unmet need by prefecture . 97 Figure 7.7 Decision-making about family planning . 98 8 MATERNAL HEALTH CARE . 111 Table 8.1 Antenatal care . 119 Table 8.2 Number of antenatal care visits and timing of first visit . 120 Table 8.3 Components of antenatal care . 121 Table 8.4 Place of delivery . 122 Table 8.5 Assistance during delivery . 123 Table 8.6 Caesarean section . 124 Table 8.7 Timing of first postnatal check for the mother . 125 Table 8.8 Type of provider of first postnatal check for the mother . 126 Table 8.9 Timing of first postnatal check for the newborn . 127 Table 8.10 Type of provider of first postnatal check for the newborn . 128 Table 8.11 Content of postnatal care for newborns . 129 Table 8.12 Problems in accessing health care. 130 Figure 8.1 Trends in antenatal care coverage . 112 Figure 8.2 Components of antenatal care . 113 Figure 8.3 Use of iron supplements . 114 Figure 8.4 Trends in place of birth . 114 Figure 8.5 Assistance during delivery . 115 Figure 8.6 Postnatal care by type of provider for postnatal check . 117 9 CHILD HEALTH . 131 Table 9.1 Child’s size and weight at birth . 139 Table 9.2 Vaccinations . 140 Table 9.3 Vaccinations by background characteristics . 141 Table 9.4 Possession and observation of vaccination cards, according to background characteristics . 142 Table 9.5 Prevalence and treatment of symptoms of ARI . 143 Table 9.6 Source of advice or treatment for children with symptoms of ARI . 144 Table 9.7 Prevalence and treatment of fever . 145 x • Tables and Figures Table 9.8 Prevalence and treatment of diarrhea . 146 Table 9.9 Feeding practices during diarrhea . 147 Table 9.10 Oral rehydration therapy, zinc, and other treatments for diarrhea . 148 Table 9.11 Source of advice or treatment for children with diarrhea . 149 Table 9.12 Disposal of children’s stools . 150 Table 9.13 Child discipline . 151 Table 9.14 Attitudes towards physical punishment . 152 Table 9.15 Inadequate care . 153 Figure 9.1 Childhood vaccinations. 132 Figure 9.2 Trends in childhood vaccinations . 133 Figure 9.3 Vaccination coverage by residence . 133 Figure 9.4 Treatment of diarrhea. 135 Figure 9.5 Treatment of diarrhea. 136 Figure 9.6 Trends in child discipline . 137 10 NUTRITION OF CHILDREN AND ADULTS . 155 Table 10.1 Nutritional status of children . 168 Table 10.2 Initial breastfeeding . 170 Table 10.3 Breastfeeding status by age . 171 Table 10.4 Infant and young child feeding (IYCF) indicators on breastfeeding status . 171 Table 10.5 Median duration of breastfeeding . 172 Table 10.6 Foods and liquids consumed by children in the day or night preceding the interview . 173 Table 10.7 Minimum acceptable diet. 174 Table 10.8 Prevalence of anemia in children . 175 Table 10.9 Presence of iodized salt in household . 176 Table 10.10 Micronutrient intake among children . 177 Table 10.11.1 Nutritional status of women . 178 Table 10.11.2 Nutritional status of men. 179 Table 10.12.1 Prevalence of anemia in women . 180 Table 10.12.2 Prevalence of anemia in men . 181 Table 10.13 Micronutrient intake among mothers . 182 Figure 10.1 Trends in nutritional status of children . 157 Figure 10.2 Trends in stunting . 157 Figure 10.3 Stunting in children by mother’s education . 158 Figure 10.4 Stunting in children by prefecture . 158 Figure 10.5 Breastfeeding practices by age. 159 Figure 10.6 IYCF indicators on minimum acceptable diet . 161 Figure 10.7 Trends in childhood anemia . 162 Figure 10.8 Anemia in children by prefecture . 163 Figure 10.9 Nutritional status of women . 164 Figure 10.10 Trends in women’s nutritional status . 164 Figure 10.11 Trends in anemia status among women . 166 11 LIFESTYLE HEALTH RISK FACTORS . 183 Table 11.1.1 Tobacco smoking: Women . 190 Table 11.1.2 Tobacco smoking: Men . 191 Table 11.2.1 Average number of cigarettes smoked daily: Women . 192 Table 11.2.2 Average number of cigarettes smoked daily: Men . 193 Table 11.3.1 Consumption of alcohol: Women . 194 Table 11.3.2 Consumption of alcohol: Men . 195 Table 11.4.1 Consumption of sugary sodas and juices: Women . 196 Table 11.4.2 Consumption of sugary sodas and juices: Men . 197 Tables and Figures • xi Table 11.5.1 Consumption of oil and fat: Women . 198 Table 11.5.2 Consumption of oil and fat: Men . 199 Table 11.6.1 Consumption of fruits: Women . 200 Table 11.6.2 Consumption of fruits: Men . 201 Table 11.7.1 Consumption of vegetables: Women . 202 Table 11.7.2 Consumption of vegetables: Men . 203 Table 11.8 Consumption of fruit and vegetables . 204 Table 11.9.1 Practice of aerobic exercises: Women . 205 Table 11.9.2 Practice of aerobic exercises: Men . 206 Figure 11.1 Trends in cigarette smoking . 184 Figure 11.2 Smoking of any type of tobacco by prefecture . 184 Figure 11.3 Women’s consumption of alcohol by wealth . 185 Figure 11.4 Consumption of the recommended combination of fruits and vegetables by prefecture . 188 Figure 11.5 Practice of aerobic exercises: Women . 189 Figure 11.6 Practice of aerobic exercises: Men . 189 12 NON-COMMUNICABLE DISEASES . 207 Table 12.1 Self-reported hypertension . 214 Table 12.2.1 Blood pressure status: Women . 215 Table 12.2.2 Blood pressure status: Men . 216 Table 12.3.1 Self-reported prevalence of noncommunicable diseases: Women . 217 Table 12.3.2 Self-reported prevalence of noncommunicable diseases: Men . 217 Table 12.4 Self-reported prevalence of any noncommunicable disease . 218 Table 12.5 Self-reported prevalence of chronic disabilities . 219 Table 12.6 Self-reported prevalence of any chronic disability . 220 Table 12.7 Self-reported injuries and ailments . 221 Table 12.8 Self-assessment of health evolution . 221 Table 12.9.1 Awareness of diagnostic tests: Women . 222 Table 12.9.2 Awareness of diagnostic tests: Men . 223 Table 12.10.1 Recent experience of depression: Women . 224 Table 12.10.2 Recent experience of depression: Men . 225 Table 12.11 Diagnosed depression . 226 Figure 12.1 Measured high blood pressure . 209 Figure 12.2 Self-assessment of health progression . 212 Figure 12.3 Awareness of diagnostic test among women 15-49 . 212 Figure 12.4 Experience of depression . 213 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 227 Table 13.1 Knowledge of HIV or AIDS . 236 Table 13.2 Knowledge of HIV prevention methods . 237 Table 13.3 Comprehensive knowledge about HIV . 238 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 239 Table 13.5 Discriminatory attitudes towards people living with HIV . 240 Table 13.6.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Women . 241 Table 13.6.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men . 242 Table 13.7 Payment for sexual intercourse and condom use at last paid sexual intercourse . 243 Table 13.8.1 Coverage of prior HIV testing: Women . 244 Table 13.8.2 Coverage of prior HIV testing: Men . 245 Table 13.9 Pregnant women counseled and tested for HIV . 246 Table 13.10 Male circumcision . 247 xii • Tables and Figures Table 13.11 Self-reported prevalence of sexually-transmitted infections (STIs) and STIs symptoms . 248 Table 13.12 Women and men seeking treatment for STIs . 248 Table 13.13 Comprehensive knowledge about HIV among young people . 249 Table 13.14 Age at first sexual intercourse among young people . 249 Table 13.15 Premarital sexual intercourse among young people. 250 Table 13.16.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months among young people: Women. 250 Table 13.16.2 Multiple sexual partners and higher-risk sexual behavior in the past 12 months among young people: Men . 251 Table 13.17 Recent HIV tests among young people . 251 Figure 13.1 Knowledge of mother-to-child transmission (MTCT) . 229 Figure 13.2 Discriminatory attitudes towards people living with HIV by household wealth . 230 Figure 13.3 HIV testing . 231 Figure 13.4 Recent HIV testing . 235 14 WOMEN’S EMPOWERMENT. 253 Table 14.1 Employment and cash earnings of currently married women and men . 262 Table 14.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings . 263 Table 14.2.2 Control over men’s cash earnings . 264 Table 14.3 Women’s control over their own earnings and over those of their husbands . 265 Table 14.4.1 Ownership of assets: Women . 265 Table 14.4.2 Ownership of assets: Men . 266 Table 14.5.1 Ownership of title or deed for house: Women . 267 Table 14.5.2 Ownership of title or deed for house: Men . 268 Table 14.6.1 Ownership of title or deed for land: Women . 269 Table 14.6.2 Ownership of title or deed for land: Men . 270 Table 14.7.1 Ownership and use of bank accounts and mobile phones: Women . 271 Table 14.7.2 Ownership and use of bank accounts and mobile phones: Men . 272 Table 14.8 Participation in decision making . 272 Table 14.9.1 Women’s participation in decision making by background characteristics . 273 Table 14.9.2 Men’s participation in decision making by background characteristics . 274 Table 14.10.1 Attitude toward wife beating: Women . 275 Table 14.10.2 Attitude toward wife beating: Men . 276 Table 14.11 Experience of intimate partner violence . 277 Table 14.12 Attitudes toward negotiating safer sexual relations with husband . 278 Table 14.13 Ability to negotiate sexual relations with husband . 279 Table 14.14 Indicators of women’s empowerment . 280 Table 14.15 Ideal number of children and unmet need for family planning by women’s empowerment . 280 Table 14.16 Reproductive health care by women’s empowerment . 281 Figure 14.1 Employment and cash earnings . 254 Figure 14.2 Employment by age . 255 Figure 14.3 Control over women’s earnings . 255 Figure 14.4 Control over women’s cash earning trends . 255 Figure 14.5 Ownership of assets . 257 Figure 14.6 Women’s participation in decision making . 259 Figure 14.7 Attitudes towards wife beating . 260 APPENDIX A SAMPLE DESIGN . 285 Table A.1 Distribution of residential households by prefectures and type of residence . 286 Table A.2 Distribution of Census EAs and their average size in number of households . 286 Tables and Figures • xiii Table A.3 The 2017-18 ADHS sample allocation of clusters by prefectures and type of residence . 287 Table A.4 The 2017-18 ADHS sample allocation of expected completed interviews with women and men by prefectures and type of residence . 287 Table A.5 Sample implementation: Women . 290 Table A.6 Sample implementation: Men . 291 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 293 Table B.1 List of selected variables for sampling errors, Albania 2017-18 . 295 Table B.2 Sampling errors: Total sample, Albania DHS 2017-18 . 296 Table B.3 Sampling errors: Urban sample, Albania DHS 2017-18 . 297 Table B.4 Sampling errors: Rural sample, Albania DHS 2017-18 . 298 Table B.5 Sampling errors: Berat sample, Albania DHS 2017-18 . 299 Table B.6 Sampling errors: Diber sample, Albania DHS 2017-18 . 300 Table B.7 Sampling errors: Durres sample, Albania DHS 2017-18 . 301 Table B.8 Sampling errors: Elbasan sample, Albania DHS 2017-18 . 302 Table B.9 Sampling errors: Fier sample, Albania DHS 2017-18 . 303 Table B.10 Sampling errors: Gjirokaster sample, Albania DHS 2017-18 . 304 Table B.11 Sampling errors: Korce sample, Albania DHS 2017-18 . 305 Table B.12 Sampling errors: Kukes sample, Albania DHS 2017-18 . 306 Table B.13 Sampling errors: Lezhe sample, Albania DHS 2017-18 . 307 Table B.14 Sampling errors: Shkoder sample, Albania DHS 2017-18 . 308 Table B.15 Sampling errors: Tirane sample, Albania DHS 2017-18 . 309 Table B.16 Sampling errors: Vlore sample, Albania DHS 2017-18 . 310 APPENDIX C DATA QUALITY TABLES . 311 Table C.1 Household age distribution . 311 Table C.2.1 Age distribution of eligible and interviewed women . 312 Table C.2.2 Age distribution of eligible and interviewed men . 312 Table C.3 Completeness of reporting . 313 Table C.4 Births by calendar years . 313 Table C.5 Reporting of age at death in days . 314 Table C.6 Reporting of age at death in months . 314 Preface • xv PREFACE he 2017-18 Albania Demographic and Health Survey (ADHS) is a nationally representative sample survey designed to provide information on population and health issues in Albania. The ADHS was conducted by the Institute of Public Health (IPH) and the National Institute of Statistics (INSTAT) under the lead of the Ministry of Health and Social Protection of the Republic of Albania. The ADHS received major funding support from the following international agencies: the Swiss Agency for Development and Cooperation (SDC), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), and the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women). Technical assistance to ensure survey quality and to build local capacity was provided by ICF. The 2017-18 ADHS provides recent estimates on a wide range of demographic and health characteristics of the Albanian population. The objectives of the ADHS were to collect national- and regional-level data on fertility levels and contraceptive use; maternal and child health; adult health; HIV, AIDS, and other sexually transmitted infections (STIs); as well as adult health. The survey obtained detailed information on these topics from women of reproductive age (age 15-49) and also age 49-59 and, for certain topics, from men age 15-59 as well. Overall, the survey provides estimates for a variety of demographic and health indicators. The 2017-19 ADHS results contribute to the growing national and international database of demographic and health indicators. Delina Ibrahimaj, PhD Albana Fico, PhD Director General Director National Institute of Statistics (INSTAT) Institute of Public Health (IPH) T Acknowledgments • xvii ACKNOWLEDGMENTS he Ministry of Health and Social Protection (MHSS) of the Republic of Albania, the Institute of Public Health (IPH), and the National Institute of Statistics (INSTAT) wish to express their appreciation to those involved in the implementation of the 2017-18 Albania Demographic and Health Survey (ADHS) and the preparation of this report. Particular thanks go to:  MHSS for its chairmanship of the Steering Committee of the ADHS  INSTAT for providing its expertise on sampling procedures, cartography, and GIS, and for participating in questionnaire adaptation, data analysis, and final report writing  IPH for participating in questionnaire adaptation, in data analysis and final report writing, and for providing health technicians with medical background for fieldwork and training of the field staff  Swiss Agency for Development and Cooperation (SDC) through the Health for All project (HAP), for providing the funding for organizing and conducting the 2017-18 ADHS  The United Nations Population Fund (UNFPA), Albania; the United Nations Children’s Fund (UNICEF); and Albania and the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) for providing funding and technical support in planning, fieldwork, preparation of the survey report, report writing, and coordinating ADHS donor support  ICF, for providing technical support during the survey design, fieldwork training, data processing, analysis of the data collected, and dissemination of results  The technical staff of the ADHS, including the field work personnel and data quality teams, and the valuable contributions of all experts and organizations whose joint efforts ensured the effective implementation of the survey, and also, to the households whose participation made it possible to obtain the reliable information collected in the survey  NESMARK Foundation for carrying out the financial and administrative procedures T Foreword • xix FOREWORD n the past decade, Albania entered a new phase of major social and health reforms in line with the changes in various demographic and health characteristics of the Albanian society. The 2017-18 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 used to 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 policymakers when drafting new policies and strategies related to the health sector and health services in Albania. The information collected in the 2017-18 ADHS will be used not only by local decision-makers and program managers, but also by partners and foreign donors involved in various development areas in Albania, and by academic institutions to do further analysis with the collected data. The 2017-18 ADHS is the result of quality work of many Albanian institutions as well as national and international organizations that have shown a high level of professionalism and dedication to collection of quality data in the field of health and demographics in Albania. I Contributors to the Report • xxi CONTRIBUTORS TO THE REPORT Specialists who contributed to the ADHS final report Albanian Staff: Albana Fico Institute of Public Health Delina Ibrahimaj Institute of Statistics Genc Burazeri Institute of Public Health Ledia Thomo Institute of Statistics Gentiana Qirjako Institute of Public Health Ruzhdie Bici Institute of Statistics Alban Ylli Institute of Public Health Eduard Kakarriqi Institute of Public Health Enver Roshi Institute of Public Health Ervin Toçi Institute of Public Health Mariana Bukli UNICEF Dorina Toçaj UNFPA Elda Hallkaj UNICEF Jolanda Hyska Institute of Public Health Roland Bani Institute of Public Health Helda Mitre Institute of Statistics Liljana Boci Institute of Statistics Alma Kondi Institute of Statistics Rudina Çumashi Institute of Public Health Alketa Hoxha University of Medicine, Tirana Erida Nelaj Institute of Public Health Dorina Toçi Institute of Public Health Ervisa Demollari Institute of Public Health Bajram Dedja Institute of Public Health Alba Merdani Institute of Public Health Andia Meksi Institute of Public Health Majlinda Nesturi Institute of Statistics Teranda Jahja Institute of Statistics Edlira Subashi Institute of Statistics Eriona Dhamo Institute of Statistics Herion Muja Institute of Public Health Lumturi Mërkuri Institute of Public Health Miranda Hajdini Institute of Public Health Olta Caca Institute of Statistics ICF staff: Juan Schoemaker Consultant/ICF Natalie Shattuck ICF Nancy Johnson ICF Tom Fish ICF Particular thanks to the following experts who provided extensive guidance, which helped improve the content and structure of this report: Manuela Bello UNFPA Debora Kern SDC/Swiss Embassy Besim Nuri Health for All Project Jawad Aslam UNICEF Gazmend Bejtja WHO Abbreviations • xxiii ABBREVIATIONS ANC antenatal care ADHS Albania Demographic and Health Survey APHC Albania Population and Housing Census ASFR age-specific fertility rates BMI body mass index CAPI computer-assisted personal interviewing CPR contraceptive prevalence rate C-section caesarean section DEFT design effect EA enumeration areas EUROSTAT Statistical Office of the European Communities FP family planning GAR gross attendance ratios GDP gross domestic product GPI gender parity indices HAP Health for All Project HLE health life expectancy INSTAT National Institute of Statistics IPH Institute of Public Health IUD intrauterine device IYCF infant and young child feeding MHSP Ministry of Health and Social Protection NAR net attendance ratios NCDs noncommunicable diseases NUTS Territorial Units for Statistics PSU primary sampling unit SD standard deviation SDC Swiss Agency for Development and Cooperation SE standard error STI sexually transmitted infection TFR total fertility rate UNDP The United Nations Development Program UNFPA The United Nations Population Fund UNICEF The United Nations Children’s Fund UN Women The United Nations Entity for Gender Equality and the Empowerment of Women WHO World Health Organization Reading and Understanding Tables from the 2017-18 ADHS • xxv READING AND UNDERSTANDING TABLES FROM THE 2017-18 ADHS The new format of the 2017-18 ADHS final report is based on approximately 200 tables of data. They are located for quick reference through links in the text (electronic version) and at the end of each chapter. Additionally, this more reader- friendly version features about 90 figures that clearly highlight trends, subnational patterns, and background characteristics. Large colorful maps display breakdowns by prefecture, which represents the subnational administrative division as well as one of the sampling domains. The text has been simplified to highlight key points in bullets and to clearly identify indicator definitions in boxes. While the text and figures featured in each chapter highlight some of the most important findings from the tables, not every finding is discussed or displayed graphically. For this reason, ADHS data users should be comfortable reading and interpreting tables. The following pages provide an introduction to the organization of ADHS tables, the presentation of background characteristics, and a brief summary of sampling and understanding denominators. In addition, this section provides some exercises for users as they practice their new skills in interpreting ADHS tables. xxvi • Reading and Understanding Tables from the 2017-18 ADHS Example 1: Exposure to media: Women Question asked to all women 15-49 years old Table 3.6.1 Exposure to mass media: Women Percentage of women age 15-59 who are exposed to specific media on a weekly basis, according to background characteristics, Albania 2017-18 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 19.0 93.2 16.1 8.5 5.7 1,684 20-24 15.9 90.8 16.0 7.9 8.9 1,548 25-29 16.6 88.8 16.0 8.4 9.8 1,514 30-34 15.8 89.2 14.9 7.6 9.6 1,442 35-39 16.1 91.0 15.9 7.6 7.4 1,388 40-44 17.6 93.2 12.9 7.6 5.8 1,601 45-49 16.7 92.2 11.4 5.5 6.9 1,794 Residence Urban 19.9 90.2 16.4 9.1 8.4 6,578 Rural 12.3 92.9 12.0 5.2 6.5 4,392 Prefecture Berat 12.1 96.3 3.1 1.2 3.1 439 Dibër 13.9 90.3 3.8 1.5 9.3 510 Durrës 6.4 96.0 6.6 2.0 3.2 1,017 Elbasan 19.4 97.7 14.5 6.7 2.0 1,100 Education No education/primary 4-year 2.6 70.8 9.5 2.1 28.8 243 Primary 8-year 8.6 92.1 9.9 3.7 7.2 4,123 Secondary/professional/technical 17.3 92.8 14.0 7.3 6.5 3,708 University and post graduate 29.2 89.9 22.7 13.7 7.9 2,897 Wealth quintile Lowest 9.5 90.3 9.5 3.7 9.2 2,145 Second 11.8 93.7 10.2 4.6 5.7 2,161 Middle 15.8 94.8 12.6 6.2 4.6 2,130 Fourth 22.3 90.5 18.8 11.2 8.3 2,279 Highest 24.2 87.4 21.5 11.5 10.2 2,255 Total 15-49 16.9 91.3 14.7 7.5 7.6 10,970 50-59 18.4 90.9 12.7 8.3 8.5 4,030 Total 15-59 17.3 91.2 14.1 7.7 7.9 15,000 1 2 3 5 4 Reading and Understanding Tables from the 2017-18 ADHS • xxvii Step 1: Read the title and subtitle. They tell you the topic and the specific population group being described. In this case, the table is about weekly exposure to various mass media. All eligible female respondents age 15-49 were asked these questions. Step 2: Scan the column headings—highlighted in green in Example 1.They describe how the information is categorized. In this table, the first three columns of data show the percentage of women who read newspapers, who watch television and who listen to the radio. The fourth column shows the percentage of those who access all of the three media, while the fifth column shows the percentage that does not access any of the three media. The last column lists the number of respondents to whom the question was asked. In this case, this question on media exposure was asked to all women 15-59 years old. Step 3: Scan the row headings—the first vertical column highlighted in blue in Example 1. These show the different ways the data are divided into categories based on population characteristics. In this case, the table presents media exposure by age, urban-rural residence, prefecture, education and wealth quintile. Most of the tables in the ADHS report will be divided into these same categories. Step 4: Look at the row at the bottom of the table, highlighted in pink. In this table three rows with totals are presented: the first for women age 15-49, the second for women age 50-59 and the third for women age 15-59. In the first row the percentages, represent the totals for all women 15-49 years old. In this case, 16.9 percent of respondents read a newspaper at least once a week, 91.3 percent watches television at least once a week and 14.7 percent listens to the radio at least once a week. Step 5: To find out what percentage of women with a university or post graduate education have weekly access to all three types of media, draw two imaginary lines, as shown on the table. This shows that 13.7 percent of these women have access to newspapers, TV and radio. Step 6: In this example, examining patterns by background characteristics, one can see how access to mass media varies across the Albanian population. Mass media are often used to disseminate health messages. Knowing how mass media exposure varies among different groups help program managers and policy makers determine how to most effectively reach their target populations. Note that in this explanation the numbers described in the text represent exactly the numbers in the table, including the decimal value. This is done for the sake of clarity. For the remaining of the text in the report the decimal values will be rounded to simplify. xxviii • Reading and Understanding Tables from the 2017-18 ADHS Example 2: Child’s size and weight at birth Question asked to a subgroup of respondents Table 10.1 Child’s size and weight at birth Percent distribution of live births in the 5 years preceding the survey by mother's estimate of baby's size at birth, percentage of live births in the 5 years preceding the survey that have a reported birth weight, and among live births in the 5 years preceding the survey with a reported birth weight, percentage less than 2.5 kg, according to background characteristics, Albania 2017-18 Background characteristic Percent distribution of births by size of baby at birth Percentage of births that have a reported birth weight1 Number of births Among births with a reported birth weight1 Very small Smaller than average Average or larger Don't know/ missing Total Percentage less than 2.5 kg Number of births Mother’s age at birth <20 1.4 11.1 87.3 0.2 100.0 89.5 186 4.4 167 20-34 1.5 9.0 88.9 0.6 100.0 97.8 2,157 5.3 2,108 35-49 1.0 13.8 84.9 0.3 100.0 97.1 218 11.8 212 Birth order 1 1.1 12.0 86.7 0.2 100.0 97.0 1,099 7.1 1,065 2-3 1.7 7.6 90.0 0.8 100.0 97.3 1,348 4.4 1,311 4+ 3.3 8.4 87.6 0.7 100.0 96.5 111 10.5 110 Mother’s smoking status Smokes cigarettes/ tobacco 2.8 8.1 87.9 1.2 100.0 84.0 118 9.5 99 Does not smoke 1.4 9.6 88.5 0.5 100.0 97.7 2,443 5.6 2,388 Residence Urban 1.8 9.7 88.3 0.2 100.0 96.8 1,436 6.7 1,389 Rural 1.1 9.3 88.7 0.9 100.0 97.5 1,125 4.6 1,098 Mother’s education No education/primary 4-year 0.0 15.2 79.1 5.7 100.0 86.2 81 0.8 69 Primary 8-year 1.8 9.6 87.9 0.7 100.0 96.5 1,188 6.8 1,147 Secondary/professional/ technical 1.1 9.7 89.2 0.0 100.0 98.1 634 5.2 622 University and post graduate 1.4 8.6 90.0 0.0 100.0 98.5 658 5.0 649 Wealth quintile Lowest 1.2 11.2 85.6 2.0 100.0 94.8 579 4.8 549 Second 0.3 9.9 89.4 0.3 100.0 95.9 551 6.2 529 Middle 2.3 5.0 92.7 0.0 100.0 97.5 497 4.3 484 Fourth 2.7 12.6 84.7 0.0 100.0 98.5 495 7.4 488 Highest 1.0 8.5 90.5 0.0 100.0 99.6 438 6.2 436 Total 1.5 9.5 88.5 0.5 100.0 97.1 2,561 5.8 2,487 1 Based on either a written record or the mother’s recall 1 a b 2 3 4 Reading and Understanding Tables from the 2017-18 ADHS • xxix Step 1: Read the title and subtitle. In this case, the table presents live births occurred to respondents in the five years preceding the survey in two separate panels: one showing all live births and the other one showing the percentage that weighed less than 2.5 kilograms. Step 2: Identify the two panels. First, identify the columns that refer to all live births, which in this case are presented according to size at birth (a), and then identify the columns that refer only to births for which the birth weight was reported (b). Step 3: The second panel (b) is a subset of the first (a): 97.1% of the 2,561 live births occurred in the five years preceding the survey have a reported birth weight, so the number of cases for the second panel (b) is based in only 2,487 cases Step 4: As an example, among the births to mothers with a university or post graduate education and have a reported birth weight, 5% of the live births were less than 2.5 kilograms. Note that this percentage does not refer to all birth but only to births with a reported birth weight. Some tables show numbers that are based on few cases when the results are desegregated by background characteristics, such as age, education, residence and other characteristics. When the numbers are based on only 25 to 49 unweighted cases, they are shown in parenthesis to indicate that the results have to be interpreted with caution. Numbers based in fewer than 25 unweighted are not considered valid and are not shown and an asterisk (*) is shown instead. When parentheses or asterisks are used in a table, the explanation will be noted under the table. If there are no parentheses or asterisks in a table, you can proceed with confidence that enough cases were included in all categories that the data are reliable. xxx • Reading and Understanding Tables from the 2017-18 ADHS Example 3: Understanding Sampling Weights in ADHS Tables A sample is made of a number of people who have been selected for a survey. In the 2017-18 ADHS, the sample was designed to represent the male and female population age 15-59 at the national level and at the prefecture level. To generate statistics that are representative of the entire country and of each of the 12 prefectures, the number of respondents surveyed in each prefecture and within every sampling cluster in the prefecture has to be proportional to the total population. On the other hand, it is necessary that the number of cases collected in each prefecture be sufficient in quantity and be sufficiently geographically distributed across the prefectures to produce reliable statistics. Having a number of cases that is large enough would pose a problem in a simple proportional sample because such a sample would mean that prefectures with a small population would not yield a sufficient number of cases to produce reliable statistics, whereas prefectures with large population would yield much larger numbers than what is needed for statistical analysis. This problem is solved by assigning different probabilities of selection to the population depending on the size of the prefecture. In prefectures with small populations the probability of selection is higher than in prefectures with large populations. Another way of expressing this is that sample respondents in areas with a relatively large population represent fewer people and respondents in areas with small populations represent more people. When producing results such as percentages, means, medians or other statistics, sampling weights are used to offset the fact that some respondents have higher representation than others. The blue column 1 in Table 3.1 shows the actual number of women interviewed in each prefecture. The number of women interviewed ranges from 630 in Gjirokastër to 1,201 in Tirana. These numbers are sufficient to get reliable results in each prefecture for most variables. Given that, as explained above, women in some prefectures had a higher probability of selection than in others, respondents are overrepresented in some prefectures and underrepresented in others, so the unweighted distribution of women does not accurately represent the distribution of the actual Albanian population. The numbers in the purple column 2 represent number of respondents adjusted by weights, showing the distribution of respondents by prefecture as it would be if the probabilities of selection in the sample had been identical in all prefectures. This distribution of women reflects the actual distribution of women across prefectures. Note that there can be large differences between unweighted and weighted values. Weighted numbers can be smaller or larger than the unweighted numbers. For example, in Tirana 1,201 women represent 3,558 weighted women in column 2, whereas 1,092 unweighted women in Dibër represent only 510 women. The percent distribution in green column 3 shows the weighted percentages and if one compare these values to those in the actual population of Albania, one would see that the percent distribution by prefecture are the same. Now we can be confident that the weighted number of women in the survey accurately represents the proportion of women who live in these prefectures. Note that the number of cases as well as the statistics presented in this report always represent weighted values. Table 3.1 Background characteristics of respondents Percent distribution of women age 15-49 by selected background characteristics, Albania 2017-18 Background characteristic Weighted percent Weighted number Unweighted number Prefecture Berat 4.0 439 776 Dibër 4.6 510 1,092 Durrës 9.3 1,017 866 Elbasan 10.0 1,100 957 Fier 9.9 1,083 920 Gjirokastër 1.9 204 630 Korçë 7.8 859 980 Kukës 3.1 338 1,116 Lezhe 4.4 482 766 Shkodër 7.2 795 862 Tirana 32.4 3,558 1,201 Vlorë 5.3 586 694 Total 15-49 100.0 10,970 10,860 1 2 3 xxxii • Map of Albania Introduction and Survey Methodology • 1 INTRODUCTION AND SURVEY METHODOLOGY 1 he 2017-18 Albania Demographic and Health Survey (ADHS) was implemented by two institutions: the National Institute of Statistics (INSTAT) and the Institute of Public Health (IPH). Other agencies and organizations that facilitated the successful implementation of the survey through technical or financial support were HAP, the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), United Nations Development Program (UNDP), and the Ministry of Health and Social Protection (MHSP). The process was supported by the expertise of the licensed agency in this field: ICF. Data collection took place from 11 September 2017 to 20 February 2018. ICF provided technical assistance for questionnaire design, sampling design, training, and data processing through The DHS Program. The results of the ADHS are intended to provide all information needed to evaluate the existing programs in the country and to provide Albanian decision-makers with the information needed to develop new policies and strategies related to health and health services provided to the Albanian population. The information collected by the Albanian Demography and Health Survey will be used not only by Albanian decision-makers, but also by the leaders of health intervention planning programs, foreign partners, and donors that provide their assistance in various fields, and by academic institutions to carry out in-depth analysis of the data. The 2017-18 ADHS was carried under a Cooperation Agreement between the Albanian Ministry of Health (MoH) and several international donor agencies, namely the Swiss Agency for Development and Cooperation (SDC), the United Nations Population Fund (UNFPA), and the United Nations Children’s Fund (UNICEF). The National Institute of Statistics (INSTAT) and Institute of Public Health (IPH) worked jointly as implementing agencies. 1.1 HISTORY, GEOGRAPHY, AND POPULATION Albania occupies the southwestern portion of the Balkan. The country is located in Southeastern and Southern Europe, with Montenegro bordering to the northwest, Kosovo to the northeast, Macedonia to the east, and Greece to the south. The Mediterranean Sea makes up the entire western border of Albania. The country spans 28,748 square km (11,100 square miles) and has a total population of 2.9 million inhabitants, according to the most recent estimates. Administratively, the country is subdivided into 12 prefectures: Berat, Diber, Durres, Elbasan, Fier, Gjirokaster, Korce, Kukes, Lezhe, Shkoder, Tirana and Vlorë. This subdivision corresponds to the NUTS 3 subdivision applied by EUROSTAT. The capital of the country is Tirana, the country’s most populous city and the main economic and commercial center. According to the World Bank’s assessment, Albania has transformed itself from one of the poorest countries in Europe to an upper-middle-income country, with an estimated GDP per capita of US$4,297 (World Bank 2018), with an overall unemployment rate of 14%, slightly higher for males than females (INSTAT 2018). The Albanian currency is the lek. In the past 2 years, the country has maintained positive growth rates and financial sustainability despite the inherited situation, the impacts of global economic crisis, and the challenges from the economies of neighboring countries. The country has experienced widespread social and political transformations over the years. The changes are reflected also in the economic situation and other aspects of life. The flows of out-migration have influenced the population structure, education, employment, and other sociodemographic variables. T 2 • Introduction and Survey Methodology 1.2 HEALTH CARE The Albanian health system is mainly public. The state provides the majority of services in the promotion, prevention, diagnosis, and treatment. The private sector covers mostly pharmaceutical and dental services, and some specialized diagnostic services. This sector is mainly concentrated in Tirana. The vision for health care in Albania encompasses many aspects of health and wellbeing, including the reduction of inequalities in health, further infrastructure development, modernization of medical technology, human resources, and institutional capacities, improvement of safety and quality, equal access for all, and protection from the financial burden of disease. The principles upon which the strategy is founded are the recognition of health as a human right, which is ensured through an effective, efficient, and well-governed health care system guaranteeing equal access grounded in the principles of solidarity, integrity, transparency, and accountability. The Albanian welfare system consists of several pillars, attained through social protection programs such as pension schemes, employment promotion programs, and economic aid. In recent decades, there has been a steady increase in life expectancy for both sexes in Albania. Currently, the Albanian life expectancy is estimated at 77 years for men and 80 years for women (INSTAT 2018). The gender-related differences in life expectancy may be influenced by differences in risks associated with smoking, alcohol consumption, and road accidents. Recent estimates on healthy life expectancy (HLE) indicate that the number of years expected to be lived in optimal health is 63 for men and 67 for women. Healthy Life Expectancy is the average equivalent number of years of full health that a newborn could expect to live, if he or she were to pass through life subject to the age- specific death rates and morbidity rates of a given reference period. Currently the basic public health services are provided by 12 Regional Directorates of Health and 24 Directorates of Public Health, coordinated by MHSP. In recent years, more attention has been given to the control and prevention of noncommunicable diseases, especially prevention, screening, and detection of cancers, such as breast cancer and colorectal cancer, and cardiovascular diseases. 1.3 SURVEY OBJECTIVES The primary objective of the 2017-2018 ADHS was to provide estimates of basic sociodemographic and health indicators for the country as a whole and the twelve prefectures. Specifically, the survey collected information on basic characteristics of the respondents, fertility, family planning, nutrition, maternal and child health, knowledge of HIV behaviors, health-related lifestyle, and noncommunicable diseases (NCDs). The information collected in the ADHS will assist policymakers and program managers in evaluating and designing programs and in developing strategies for improving the health of the country’s population. 1.4 SAMPLE DESIGN AND SAMPLE UPDATING The ADHS surveys were done on a nationally representative sample that was representative at the prefecture level as well by rural and urban areas. A total of 715 enumeration areas (EAs) were selected as sample clusters, with probability proportional to each prefecture’s population size. The sample design called for 24 households to be randomly selected in every sampling cluster, regardless of its size, but some of the EAs contained fewer than 24 households. In these EAs, all households were included in the survey. The EAs are considered the sample’s primary sampling unit (PSU). The team of interviewers updated and listed the households in the selected EAs. Upon arriving in the selected clusters, interviewers spent the first day of fieldwork carrying out an exhaustive enumeration of households, recording the name of each head of household and the location of the dwelling. The listing was done with tablet PCs, using a digital listing application. When interviewers completed their respective sections of the EA, they transferred their files into the supervisor’s tablet PC, where the information was automatically compiled into a single file in which all households in the EA were entered. The software and field procedures were designed to ensure Introduction and Survey Methodology • 3 there were no duplications or omissions during the household listing process. The supervisor used the software in his tablet to randomly select 24 households for the survey from the complete list of households. All women age 15-49 who were usual residents of the selected households or who slept in the households the night before the survey were eligible for individual interviews with the full Woman’s Questionnaire. Women age 50-59 were also interviewed, but with an abbreviated questionnaire that left out all questions related to reproductive health and mother and child health. A 50% subsample was selected for the survey of men. Every man age 15-59 who was a usual resident of or had slept in the household the night before the survey was eligible for an individual interview in these households. 1.5 QUESTIONNAIRES AND FORMS Four questionnaires were used in the ADHS, one for the household and others for women age 15-49, for women age 50-59, and for men age 15-59. In addition to these four questionnaires, a form was used to record the vaccination information for children born in the 5 years preceding the survey whose mothers had been successfully interviewed. The content of these questionnaires and the form is shown in Appendix E. The questionnaires were applied in computer-assisted personal interviewing (CAPI) mode. This is an interviewing technique in which the interviewer uses a computer to read and ask the questions, as well as to record the responses given by the interviewee.  Household questionnaire The household questionnaire contains the list of household members and their basic socioeconomic characteristics, such as age, education, and marital status. It also has questions on migration during the year preceding the survey, child discipline, anemia testing, and anthropometric measurements for children under age 5 and for men and women age 15-59.  Questionnaire for women age 15-49 This questionnaire has the standard DHS questions on respondents’ background characteristics, fertility, and birth history, reproductive health, mother and child care, knowledge, attitudes and behaviors related to HIV/AIDS, and women’s work and empowerment. The questionnaire also includes a number of questions to capture the prevalence of noncommunicable diseases and lifestyle behaviors correlated with such diseases, namely smoking, drinking, and exercising.  Registry-based immunization form The collection of data on vaccination for the ADHS was a significant departure from standard DHS procedures. Instead of obtaining the dates of vaccinations from the cards or from the mothers, the information was obtained from the health centers’ registries. Team supervisors visited the health facilities servicing the selected EAs with the identifying information and the exact date of birth of every child born between 2014 and 2017 whose mother had been successfully interviewed. Using the health center registries and the data obtained from the mothers, supervisors matched the children on the registry with the ones identified during the interview. When the matches were confirmed, supervisors copied the information using the registry-based immunization form, which linked to their corresponding womens’ questionnaires.  Questionnaire for women age 50-59 Interviewing women age 50-59 was also a departure from standard DHS procedures. This questionnaire had questions on background characteristics, marital status, and work as well as the questions pertaining to noncommunicable diseases and lifestyle. Questions on fertility, fertility regulation, mother and child health, and nutrition were left out.  Questionnaire for men age 15-59 Every man age 15-59 who was a usual household member or who had spent the preceding night in the household was eligible for individual interview in a 50% subsample of households. The mens’ 4 • Introduction and Survey Methodology questionnaire was modelled after the standard DHS questionnaire with modifications to include questions related to lifestyle and noncommunicable disease. 1.6 ANTHROPOMETRY, ANEMIA TESTING, AND BLOOD PRESSURE MEASUREMENT In addition to carrying out oral interviews, interviewers were responsible for the collection of capillary blood samples for anemia testing, for the measurement of height of children less than age 5, and for the measurement of blood pressure of men and women age 15-59. The Institute of Public Health (IPH) led the effort to collect measurements and biomarkers, and its staff were responsible for training and monitoring field personnel during fieldwork.  Measurement of height and weight In every visited household, interviewers measured the height and took the weight of all children 0 to 59 months and all women age 15-59. The height and weight of men was measured only in the 50% subsample selected for interviews. Adults and children were measured with a three-panel Shorr board, especially designed to measure children and adults in the field. The weight of both children and adults was taken with Seca scales that had a mother/child function.  Anemia testing In every visited household, children age 6 to 59 months and women age 15-59 were eligible for anemia testing. The testing for men was done only in households selected for male interviews. The test was done using Hemocue® hemoglobinometers, which require small amount of capillary blood to be used in a simple procedure that produces results within a few minutes. Interviewers were instructed to inform the respondents of test results and to advise them to seek medical assistance in cases of severe anemia.  Measurement of blood pressure Interviewers took blood pressure of respondents during the course of the individual interview, using manual sphygmomanometers and stethoscopes. The measurement was done three times, at the beginning, at the approximate middle, and at the end of the interview. The average of the two final measurements was used as the indicator of blood pressure at the time of the interview. Blood pressure was only measured for men and women who were successfully interviewed with their respective individual questionnaires, not as a part of the household interview. 1.7 PRETEST A pretest was conducted in Tirana and surrounding areas to evaluate questionnaires and survey protocols. The classroom sessions were conducted from June 19 through July 7 at IPH facilities. Interviewers were trained in interviewing techniques and use of questionnaires in both the printed and CAPI version. The digital version of the questionnaires was used in a touch-screen tablet PC that also had a small detachable keyboard. IPH senior staff trained interviewers to measure height and weight; hemoglobin, using a Hemocue hemoglobinometer; and blood pressure, with manual blood pressure monitors and stethoscopes. Because the interviewers were also responsible for updating the lists of households in the EA, INSTAT’s cartography specialist trained them to to read and interpret census maps and use proper procedures for covering the households. The actual pretest took place the week of July 10-14. The pretest field personnel were organized in five teams, each made up of two female interviewers, one male interviewer, and one team supervisor, the same configuration that the teams were expected to have during fieldwork. No major issues were identified during the pretest, but in some cases the application needed adjusting to correct skip patterns and glitches that occurred when transferring data between the team supervisor’s tablet and the interviewers’ tablets. Introduction and Survey Methodology • 5 1.8 TRAINING OF FIELD STAFF FOR THE MAIN FIELDWORK The training session started August 7, 2017, in Tirana. Seventy-two women, 42 men and 17 senior staff from INSTAT and IPH, participated. The INSTAT and IPH staff were trained to be part of the quality control teams during fieldwork, so they needed to be familiar with the questionnaires and measurement procedures. During the first 2 weeks of training, interviewers were instructed on household listing procedures, using the printed version of household and individual questionnaires with explanations on the purpose and relevance of the questions and their logical flow through the questionnaires. After the interviewers were familiar with the content and use of printed questionnaires, they started the training on the use of questionnaires in digital CAPI format on August 21. Various specialists participated in the training. Thus, INSTAT’s cartography specialist trained interviewers on map interpretation, location of EAs, and identification of their boundaries; IPH’s coordinator of the vaccination program covered the section on vaccination and described the vaccination registration forms that the team supervisor had to obtain to record data. The training on anthropometry and collection of biomarkers also was carried out by senior IPH staff. As for the pretest, interviewers were also trained in measurement of height and weight, measurement of hemoglobin levels using a Hemocue hemoglobinometer, and use of sphygmomanometers and stethoscopes to manually measure blood pressure. 1.9 FIELDWORK Fieldwork lasted approximately 6 months, from September 11, 2017, to February 20, 2018. Upon completion of training, 27 teams were formed, each team consisting of two female interviewers, one male interviewer, and one supervisor. Several layers of supervision were used to ensure data quality. First, team supervisors were required to closely monitor interviewers in the field and make sure their performance complied with expectations. Second, quality control teams, composed of IPH and INSTAT senior staff, visited teams in the field on a regular basis to observe their performance and offer guidance when needed. In addition, field check tables were produced every few weeks to assess the quality of the data being gathered. 1.10 DATA PROCESSING The interviewees’ answers, the results of anthropometry and biometric measurements, and the vaccination registration form were entered digitally. One of the advantages of questionnaires in CAPI format is that much of the primary data editing is done instantly, as the interviewer enters the data into his or her tablet PC. For instance, if the interviewer enters the age of the respondent, and this age is inconsistent with the respondent’s date of birth, the application will make the interviewer aware of this error, and he or she will have to correct the error before proceeding with the interview. Once the team supervisor had a representative sample of households in the EA, as explained in Section 1.4, he or she assigned the interviewers to the households they were expected to visit for the survey. This was done by transmitting the household information – location and name of head of household – to the interviewer’s tablet PC via Bluetooth. When interviewers completed their assigned household and individual questionnaires, they transmitted the data back to their supervisor’s tablet PC, where the file for that particular EA was gradually being completed with the input from all interviewers. An EA was considered complete and “closed” when every selected household was accounted for, when there was a record for every person eligible for all individual interviews, and when there were records for all the anthropometric and biometric measurements for all individuals eligible for such measurements. To close one EA, it was also necessary to obtain the vaccination data for eligible children from the vaccination registry in neighboring health facilities. Team supervisors sent the accumulated fieldwork data to INSTAT’s central office via internet every day, unless for some reason the teams did not have access to the internet at the time. The data received from the various teams were combined into a single file, which was used to produce quality control tables, known as 6 • Introduction and Survey Methodology field check tables. These tables reveal systematic errors in the data such as omission of potential respondents, age displacement, inaccurate recording of date of birth and age at death, inaccurate measurement of height and weight, and other key indicators of data quality. These tables were reviewed and evaluated by ADHS senior staff, which in turn provided feedback and advice to the teams in the field. 1.11 RESPONSE RATES Survey response rates indicate what proportion of the people eligible for a survey is successfully interviewed, and it is obtained by of dividing the number of people who were successfully interviewed by the total number of people identified in the sample. These response rates indicate the fieldwork efficiency. It is generally assumed that larger response rates mean one can have more confidence in the results. Table 1.1 shows response rates for the ADHS 2017-18. A total of 16,955 households were selected for the sample, of which 16,634 were occupied. Of the occupied households, 15,823 were successfully interviewed, which represents a response rate of 95%. In the interviewed households, 11,680 women age 15-49 were identified for individual interviews. Interviews were completed for 10,860 of these women, yielding a response rate of 93%. In the same households, 4,289 women age 50-59 were identified, of which 4,140 were successfully interviewed, yielding a 97% response rate. In the 50% subsample of households selected for the male survey, 7,103 eligible men age 15-59 were identified, of which 6,142 were successfully interviewed, yielding a response rate of 87%. Response rates were higher in rural than in urban areas, which is a pattern commonly found in household surveys because in urban areas more people work and carry out activities outside the home. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Albania 2017-18 Residence Total Result Urban Rural Household interviews Households selected 8,680 8,275 16,955 Households occupied 8,506 8,128 16,634 Households interviewed 7,927 7,896 15,823 Household response rate1 93.2 97.1 95.1 Interviews with women age 15-49 Number of eligible women 5,475 6,205 11,680 Number of eligible women interviewed 4,960 5,900 10,860 Eligible women response rate2 90.6 95.1 93.0 Interviews with women age 50-59 Number of eligible women 2,083 2,206 4,289 Number of eligible women interviewed 1,979 2,161 4,140 Eligible women response rate2 95.0 98.0 96.5 Interviews with men age 15-59 Number of eligible men 3,349 3,754 7,103 Number of eligible men interviewed 2,772 3,370 6,142 Eligible men response rate2 82.8 89.8 86.5 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Housing Characteristics and Household Population • 7 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 Key Findings  Drinking water: Eighty-three percent of households in Albania have access to an improved source of drinking water.  Sanitation: Almost all households (96%) in Albania use improved toilet facilities.  Electricity: Twenty-one percent of the households in Albania use electricity for cooking, while 28% of urban households and 10% of rural households use it for cooking.  Children: Seventeen percent of the population is young (age 0-14) compared with 23% in the 2008-09 ADHS.  Household headship: Men head the vast majority of households (83%).  Child registration: Ninety-eight percent of all children under age 5 had their births registered with the civil authorities. nformation on the socioeconomic characteristics of the household population in the 2017-18 ADHS provides context to interpret demographic and health indicators and can furnish an approximate indication of the representativeness of the survey. In addition, this information sheds light on the living conditions of the population. This chapter presents information on source of drinking water, sanitation, exposure to smoke inside the home, wealth, hand washing, household population composition, educational attainment, school attendance, birth registration, and family living arrangements. 2.1 DRINKING WATER SOURCES AND TREATMENT Improved sources of drinking water Include piped water, public taps, standpipes, tube wells, boreholes, protected dug wells and springs, and rainwater. Households that use bottled water for drinking are classified as using an improved source only if their water source for cooking and hand washing comes from an improved source. Sample: Households I 8 • Housing Characteristics and Household Population Use of unimproved water sources increases the prevalence of waterborne disease and the burden of service delivery through an increased demand for health care. Overall, 17% of households have unimproved sources of drinking water, while 87% use improved sources. These percentages are very similar for urban and rural households (Figure 2.1). Five percent of households use an appropriate treatment method to make water safe for drinking. The most commonly used method is bleach or chlorine added (2%) and boiling (1%) (Table 2.1). Trends: The proportion of households with access to improved sources of water increased from 62% to 83% between 2008-09 and 2017-18. This development occurred equally in urban and in rural areas. 2.2 SANITATION Improved toilet facilities Include any non-shared toilet of the following types: flush/pour flush toilets to piped sewer systems, septic tanks, and pit latrines; ventilated improved pit (VIP) latrines; pit latrines with slabs; and composting toilets Sample: Households A household’s toilet or latrine facility is classified as hygienic if only household members use it, if it is not shared with other households, and if the facility separates human waste from human contact effectively. The types of facilities most likely to accomplish this are 1) toilets that flush or pour flush into a piped sewer system, septic tank, or somewhere else, 2) ventilated, improved pit (VIP) latrines, or 3) pit latrines with a slab. Ninety six percent of households use improved sanitation facilities that are not shared with another household; 73% of the households use flush toilets connected to a piped sewer system, 5% use flush toilets that pour into a pit latrine, and 17% use flush toilets that pour into a septic tank. Only 4% of households use a non-improved toilet, and less than 1% share facilities with another household (Table 2.2). Trends: The proportion of households using a flush toilet piped into a sewer and not shared with other households increased from 27% in 2008-09 to 47% in 2017-18 in rural areas, but in urban areas usage remained practically unchanged (90% in 2008-09 and 91% in 2017-18, respectively). 2.3 HOUSEHOLD WEALTH Household Characteristics Household characteristics are a tool to estimate the household’s non-monetary assets. Also, the conditions under which the household members live are an indicator of the exposure to health risks faced by the Figure 2.1 Household drinking water by residence 54 52 57 2 1 51 1 3 26 30 18 17 16 17 Total Urban Rural Percent distribution of households by source of drinking water Unimproved source Protected well or spring/bottled Tube well or borehole Public tap/ standpipe Piped water into dwelling/yard/plot/ neighbor’s yard Housing Characteristics and Household Population • 9 members, especially the children. To assess the socioeconomic conditions under which the population lived, respondents were asked to give specific information about their household setting. Characteristics for which information was collected included source of drinking water, type of sanitation facilities, flooring material of dwelling, and assets possessed by household members. The majority of households live in dwellings with floor covered with ceramic tiles (78%) or cement (17%) and 2% have parquet or polished wood floors. In the vast majority of households (92%) the cooking is done inside the house, using gas (59%), electricity (21%), or wood (19%) as a main cooking fuel. More urban households use gas or electricity compared with rural households, whereas a larger proportion of rural households use wood as cooking fuel (38%, compared with 8% in urban households. Secondhand tobacco smoke has the same harmful chemicals that smokers inhale, and there is no safe level of exposure for secondhand smoke. Household members are exposed to this health risk in 27% of the households daily, and in 3% of the households, they are exposed to it weekly. The exposure is slightly more in rural areas, where smoking occurs daily in 30% of the households, compared with 24% of the households in urban areas (Table 2.3). Trends: The proportion of households living in dwellings with ceramic tiles increased from 79% to 86% in urban areas and from 40% to 64% in rural areas between 2008-09 and 2017-18. During the same period, the proportion using electricity for cooking increased from 20% to 28% in urban areas and from 5% to 21% in rural areas. Household Durable Goods The availability of durable goods is a proximate measure of household socioeconomic conditions and, as explained earlier, an indicator of the availability of nonmonetary assets. Practically all households have television sets (98%), armoires (97%), mobile phones (97%), refrigerators (96%), sofas (95%), and washing machines (94%). Fifty-four percent of households in urban areas and 28% in rural areas have computers. Two-thirds of households in urban areas have a satellite dish or cable television, compared with 58% of households in rural areas. Regarding ownership of means of transportation, 37% of households have a car or truck, 26% have a bicycle, and 10% have a motorcycle or a scooter (Table 2.4). Trends: Between 2008-09 and 2017-18, the proportion of households with a satellite dish or cable remained practically unchanged in urban areas (69% and 66%, respectively), but increased from 39% to 58% in rural areas. The proportion of households with a computer increased from 30% to 54% in urban areas and from 5% to 28% in rural areas. Wealth Index Wealth index Households are given scores based on the number and kinds of consumer goods they own, ranging from a television to a bicycle or car, and housing characteristics such as source of drinking water, toilet facilities, and flooring materials. These scores are derived using principal component analysis. National wealth quintiles are compiled by assigning the household score to each usual (de jure) household member, ranking each person in the household population by their score, and then dividing the distribution into five equal categories, each with 20% of the population. Sample: Households 10 • Housing Characteristics and Household Population The wealth index is a recently developed measure tested in some countries in relation to inequities in household income, use of health services, and health outcomes (Rutstein et al. 2000). The wealth index is constructed by assigning a weight or score factor to each household asset through principal components analysis. These scores are summed by household, and individuals are ranked according to the total score of the household in which they reside. The sample is then divided into population quintiles— five groups with the same number of individuals in each. At the national level, approximately 20% of the population is in each wealth quintile. Because wealth, resources, and economic opportunities tend to concentrate in urban areas, 30% of households in urban areas are in the highest wealth quintile, compared with only 5% of households in rural areas. Inversely, only 5% of households in urban areas are in the lowest quintile, compared with 42% of households in rural areas (Table 2.5, Figure 2.2). The Gini is a coefficient of measuring inequality in wealth distribution. The value varies from “0.0” if wealth is evenly distributed to “1.0” if wealth is completely unequal or concentrated. The Gini coefficient is 0.11. Wealth is more evenly distributed in urban areas (0.05) than in rural areas (0.15) (Table 2.5). Trends: The Gini coefficient decreased from 0.26 to 0.11 between 2008-09 and 2017-18. This could be explained by a redistribution of wealth or the fact that more households in the lower social strata have been able to acquire more assets over the past decade. Patterns by background characteristics  The uneven distribution of wealth, as indicated by Gini coefficient, varies markedly across prefectures, from 0.06 in Durrës and 0.11 in Vlorë to 0.19 in Elbasan and 0.26 in Dibër (Table 2.5). 2.4 HOUSEHOLD POPULATION AND COMPOSITION Household A person or group of related or unrelated persons who live together in the same dwelling unit(s), who acknowledge one adult male or female as the head of the household, who share the same housekeeping arrangements, and who are considered a single unit. De facto population All persons who stayed in the selected households the night before the interview (whether usual residents or visitors). De jure population All persons who are usual residents of the selected households, whether or not they stayed in the household the night before the interview. How data are calculated All tables are based on the de facto population, unless specified otherwise. Figure 2.2 Household toilet facilities by residence 96 98 94 <1 <1 <1 3 1 6 Total Urban Rural Percent distribution of households by type of toilet facilities Unimproved facility Shared facility Improved facility Housing Characteristics and Household Population • 11 The population pyramid in Figure 2.3 shows the de facto household population by 5-year age groups and sex. The pyramid shows that a large proportion of Albania’s population is in the 15-64 age range and constitutes two-thirds of the total population; 17% of the population is in the 0-14 age dependency group and 16% is in the 65 and older dependency group (Table 2.6). The large majority of households (83%) are headed by men, while 17% are headed by women. The mean household size is 3.3, with only slight differences between urban and rural areas (3.1 and 3.5, respectively). Only 2% of households have orphans or foster children. Trends: The mean household size decreased between 2008-09 and 2017-18, from 3.8 to 3.3. This decline was especially noticeable in rural areas, where mean household size declined from 4.1 to 3.5. 2.5 CHILDREN’S LIVING ARRANGEMENTS AND PARENTAL SURVIVAL Orphan A child with one or both parents who are dead Sample: Children under age 18 Children not living with their biological parents are more likely to be disadvantaged compared with those who reside with their parents. When living without parents, children may be at increased risk of impoverishment, deprived of property and other rights, and at increased risk of abuse, neglect, and exploitation. The majority of children under 18 (84%) live with both parents, and only 2% do not live with one of the biological parents; 11% live with the mother only, even though the father is alive, and 1% live with the father only, even though the mother is alive (Table 2.8). Trends: The proportion of children less than age 18 living with both parents remained practically unchanged between 2008-09 and 2017-18 (86% and 84%, respectively). Patterns by background characteristics  There is a slight decrease in the proportion of children living with both parents that occurs as the age of the child increases, from 86% of children under age 5 to 83% of children age 15-17.  There are significant variations in children’s living arrangements across prefectures. This varies from Berat, where 76% of children live with both parents and 19% live with the mother only even though the father is alive, to Kukës, where 90% of the children live with both parents and only 5% live with the mother only even though the father is alive.  The proportion of children living with both parents increases with household wealth, from 81% in the lowest quintile to 91% in the highest. Inversely, the proportion of children living without their fathers even though they are alive declines from 14% in the lowest wealth quintile to 5% in the highest. Figure 2.3 Household wealth by residence 5 28 13 26 24 14 28 8 30 5 Urban Rural Percent distribution of de jure population by wealth quintiles Wealthiest Fourth Middle Second Poorest 12 • Housing Characteristics and Household Population 2.6 BIRTH REGISTRATION Registered birth Child has a birth certificate or child does not have a birth certificate, but his/her birth is registered with the civil authorities. Sample: De jure children under age 5 Birth registration in Albania is governed by legislation “On Civil Status”, which asserts two key elements for the process: a valid document certifying the birth and an individual making the declaration of birth. Parents bear primary responsibility for the registration of their child, and when this is not possible, other adults from the family, the custodians, the legal representatives, and others who can prove the right, could declare for the registration.1 Birth registration is free, and the process happens in the civil registration offices, where a birth certificate is issued after registration. The law does not provide any time limits for registration, but it encourages early registrations. The law provides for financial incentives (of approximately USD $50) for mothers who register their children within 60 days when born in Albania and within 90 days when born abroad. The 2017-18 ADHS provides an estimate of the coverage of birth registration of children less than age 5. Respondents to the Household Questionnaire were asked whether children in the household had birth certificates or whether they had been registered with the civil authority. Birth registration is almost universal in Albania, where 98% of children born in the 5 years preceding the survey were registered, and 84% of them had birth certificates, while 14% did not have a birth certificate but had been registered (Table 2.9). Trends: The proportion of children registered with the civil authorities remained unchanged between 2008-09 and 2017-18 (99% and 98%, respectively) but the proportion of children that had a birth certificate increased from 78% to 85% during this period. Patterns by background characteristics  Given that birth registration is practically universal in Albania, 98% of children less than age 5 are registered, regardless of the place of residence or socioeconomic characteristics. Shkodër and Durrës are the only exceptions, with proportions of registered children of 93% and 97%, respectively.  The proportion of children with birth certificates increases with household wealth, from 82% in the lowest quintile to 90% in the highest. 2.7 EDUCATION 2.7.1 Educational Attainment of Women Median educational attainment Half of the population has completed fewer than the median number of years of schooling, and half of the population has completed more than the median number of years of schooling. Sample: De facto household population age 6 and older Among women and girls age 6 and older, only 4% did not attend school, 21% attended but did not complete primary school, 31% completed primary level, 17% completed secondary level, and 17% went beyond secondary level (Table 2.10.1). 1 Law “On Civil Status” 2009 no 10129; article 4, amended. Housing Characteristics and Household Population • 13 Trends: The proportion of women that completed the secondary level increased slightly, from 13% to 17% between 2008-09 and 2017-18, and the proportion who went beyond secondary school almost doubled during that period, from 9% to 17%. Patterns by background characteristics  Women age 20-24 and age 25-29 have larger proportions that have achieved an education beyond the secondary level, respectively), demonstrating that younger generations have had easier access to advanced education.  There is an important gap in educational attainment between urban and rural female populations, with median years completed of 14.4 and 7.5, respectively.  The proportion of women who have obtained an education beyond secondary level varies widely across prefectures, from 8% in Dibër and Berat to 17% in Durrës and 27% in Tirana.  The proportion of women who have obtained an education beyond secondary level is strongly associated with household wealth: only 4% of women in the lowest quintile achieved this level, compared with 39% of women in the highest quintile (Table 2.10.1). 2.7.2 Educational Attainment of Men Among men age 6 and older, 3% did not attend school, 19% attended but did not complete primary school, 26% completed primary school, 21% completed secondary school, and 16% went beyond secondary school (Table 2.10.2). Trends: There was an increase from 10% to 16% in the proportion of men who went beyond secondary between 2008-09 and 2017-18, and the median number of years of education increased from 7.7 to 12.8. Patterns by background characteristics  Among urban men, the median number of years of education is almost double, 15.1 years compared with 7.8 years for men in rural areas; 21% of men in urban areas achieved an education beyond primary school, compared with 7% of men in rural areas.  As with women, the proportion of men who have obtained an education beyond secondary varies widely across prefectures, from 7% in Dibër and 8% in Berat to 16% in Durrës and 26% in Tirana.  There is a strong association between household wealth and education: 4% of men in the lowest quintile obtained an education beyond secondary, compared with 38% of men in the highest quintile (Table 2.10.2). 2.7.3 School Attendance Net attendance ratios (NAR) Percentage of the school-age population that attends primary or secondary school. Sample: Children age 6-14 for primary school NAR and children age 15-17 for secondary school NAR 14 • Housing Characteristics and Household Population Gross attendance ratios (GAR) The total number of children attending primary school divided by the official primary school age population and the total number of children attending secondary school divided by the official secondary school age population. Sample: Children age 6-14 for primary school GAR and children age 15-17 for secondary school GAR Net attendance ratio (NAR) is defined as the ratio of the number of persons in the official age group attending any educational institution in a particular class-group to the total number persons in the age group. It indicates participation in primary school for the population age 6-14 and secondary school for the population age 15-17. The gross attendance ratio (GAR), measures the number of students enrolled in a given level of education, regardless of age, expressed as a percentage of the official school-age population corresponding to the same level of education. A NAR of 100 would indicate that all children in the official age range for the level are attending school at that level. The GAR can exceed 100 if there is substantial over age or under age participation at a given level of schooling. Gender Parity Indices (GPI) The ratio of female to male students attending primary school and the ratio of female to male students attending secondary school. The index reflects the magnitude of the gender gap. Sample: Primary school students and secondary school students In Albania, school attendance by school-age household members is high. The overall NAR for primary school education is 95, and the GAR is about 99. The difference between the NAR and GAR indicates that some students are either under age or over age for the class in which they are enrolled. The NAR and GAR for primary school do not vary much by residence or wealth. The overall NAR for secondary school education is 79, much lower than for primary school (Table 2.11). Trend: Between 2008-09 and 2017-18, NAR and GAR for primary school remained almost unchanged but had a slight decrease from 95 to 93 in NAR and from 98 to 96 in GAR. For secondary school, on the other hand, NAR increased markedly from 56 to 79 and GAR increased from 62 to 104. Patterns by background characteristics  The NAR in urban areas is 83, compared with 78 in rural areas.  The secondary school NAR varies significantly across prefectures, from 64 in Dibër and 66 in Kukës, to 85 in Tirana and 86 in Korçë. The gender parity index (GPI) is the quotient of the proportion of females divided by the proportion of males enrolled in a given stage of education, indicating the gender gap in attendance ratios. If there is no gender difference, the GPI will be 1; it will be less than 1 if the disparity is in favor of males, and it will exceed 1 if the gap favors females. The overall GPI in primary school is 1.00 for NAR and 0.99 for GAR, and in secondary school is 1.04 for NAR and 0.95 for GAR, indicating that there are no significant differences in school attendance between males and females (Table 2.11). Housing Characteristics and Household Population • 15  The secondary school NAR is closely associated with household wealth, increasing from 66 in the lowest quintile to 88 in the highest one (Figure 2.4).  The secondary school gender parity index fluctuates between 0.93 and 1.16, but it varies more or less evenly regardless of the household characteristics. LIST OF TABLES For more information on household population and housing characteristics, see the following tables:  Table 2.1 Household drinking water  Table 2.2 Household sanitation facilities  Table 2.3 Household characteristics  Table 2.4 Household possessions  Table 2.5 Wealth quintiles  Table 2.6 Household population by age, sex, and residence  Table 2.7 Household composition  Table 2.8 Children's living arrangements and orphanhood  Table 2.9 Birth registration of children under age 5  Table 2.10.1 Educational attainment of the female household population  Table 2.10.2 Educational attainment of the male household population  Table 2.11 School attendance ratios Figure 2.4 Population pyramid 5 3 1 1 3 5 <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age Percent distribution of the household population Male Female 135 16 • Housing Characteristics and Household Population Table 2.1 Household drinking water Percent distribution of households and de jure population by source of drinking water, and by time to obtain drinking water; percentage of households and de jure population using various methods to treat drinking water, and percentage using an appropriate treatment method, according to residence, Albania 2017-18 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 83.6 82.8 83.3 82.2 83.0 82.5 Piped into dwelling/yard plot 52.3 56.9 54.0 52.2 57.2 54.2 Public tap/standpipe 0.8 5.0 2.4 0.9 5.3 2.7 Tube well or borehole 0.6 2.7 1.4 0.8 2.9 1.7 Protected dug well 1.0 9.2 4.1 1.0 9.4 4.4 Protected spring 1.7 3.8 2.5 2.0 3.5 2.6 Bottled water, improved source for cooking/handwashing1 27.2 5.2 18.9 25.3 4.7 17.0 Unimproved source 16.3 17.2 16.6 17.7 17.0 17.4 Unprotected dug well 0.2 1.7 0.8 0.2 1.7 0.8 Unprotected spring 0.5 1.3 0.8 0.5 1.4 0.8 Tanker truck/cart with small tank 14.7 13.6 14.3 16.1 13.5 15.0 Bottled water, unimproved source for cooking/handwashing1 0.9 0.5 0.7 0.9 0.4 0.7 Other 0.1 0.0 0.1 0.1 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises2 78.8 72.8 76.6 77.2 73.0 75.5 Less than 30 minutes 19.3 23.7 21.0 20.8 23.4 21.8 30 minutes or longer 1.3 3.2 2.0 1.5 3.4 2.3 Don’t know/missing 0.5 0.3 0.4 0.5 0.2 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking3 Boiled 1.2 1.6 1.4 1.2 1.7 1.4 Bleach/chlorine added 0.5 4.6 2.0 0.6 4.6 2.2 Strained through cloth 0.2 0.5 0.3 0.1 0.6 0.3 Ceramic, sand or other filter 1.8 1.2 1.6 1.7 1.3 1.5 Solar disinfection 0.0 0.0 0.0 0.0 0.0 0.0 Let it stand and settle 0.3 0.2 0.3 0.3 0.2 0.2 Other 0.0 0.0 0.0 0.0 0.0 0.0 No treatment 95.6 91.9 94.2 95.7 91.8 94.1 Percentage using an appropriate treatment method4 3.4 7.1 4.8 3.3 7.2 4.9 Number 9,864 5,959 15,823 31,058 21,069 52,128 1 Households using bottled water for drinking are classified as using an improved or unimproved source according to their water source for cooking and handwashing. 2 Includes water piped to a neighbor 3 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 4 Appropriate water treatment methods include boiling, bleaching, filtering, and solar disinfecting. Housing Characteristics and Household Population • 17 Table 2.2 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities and percent distribution of households and de jure population with a toilet/latrine facility by location of the facility, according to residence, Albania 2017-18 Type and location of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved sanitation 98.0 93.8 96.4 97.8 93.8 96.2 Flush/pour flush to piped sewer system 91.4 46.9 74.6 90.5 47.6 73.2 Flush/pour flush to septic tank 1.3 9.7 4.5 1.4 9.7 4.8 Flush/pour flush to pit latrine 5.0 36.5 16.8 5.6 35.8 17.8 Ventilated improved pit (VIP) latrine 0.0 0.1 0.1 0.1 0.1 0.1 Pit latrine with slab 0.1 0.2 0.1 0.0 0.2 0.1 Composting toilet 0.2 0.4 0.3 0.2 0.5 0.3 Unimproved sanitation 2.0 6.2 3.6 2.2 6.2 3.8 Shared facility1 0.6 0.6 0.6 0.6 0.6 0.6 Flush/pour flush to piped sewer system 0.5 0.2 0.4 0.6 0.2 0.4 Flush/pour flush to septic tank 0.0 0.0 0.0 0.0 0.0 0.0 Flush/pour flush to pit latrine 0.0 0.3 0.2 0.0 0.3 0.2 Unimproved facility Unimproved facility 1.4 5.6 3.0 1.5 5.6 3.2 Flush/pour flush not to sewer/septic tank/pit latrine 1.2 4.7 2.5 1.4 4.7 2.7 Pit latrine without slab/open pit 0.1 0.6 0.3 0.1 0.7 0.3 Other 0.0 0.2 0.1 0.0 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/population 9,864 5,959 15,823 31,058 21,069 52,128 1 Facilities that would be considered improved if they were not shared by two or more households. 18 • Housing Characteristics and Household Population Table 2.3 Household characteristics Percent distribution of households and de jure population by housing characteristics, percentage using solid fuel for cooking, percentage using clean fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Albania 2017-18 Households Population Housing characteristic Urban Rural Total Urban Rural Total Flooring material Earth, sand 0.3 0.6 0.4 0.2 0.7 0.4 Wood/planks 1.1 2.0 1.4 1.1 1.9 1.4 Parquet or polished wood 2.0 2.6 2.2 1.8 2.7 2.2 Vinyl or asphalt strips 0.2 0.1 0.2 0.2 0.1 0.2 Ceramic tiles 86.4 64.2 78.0 87.0 63.6 77.6 Cement 9.1 28.2 16.3 8.8 28.5 16.8 Carpet 0.8 2.3 1.4 0.8 2.5 1.5 Other 0.0 0.1 0.1 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 28.0 20.9 25.3 19.3 13.2 16.8 Two 54.9 53.6 54.4 57.6 54.2 56.2 Three or more 17.1 25.5 20.3 23.1 32.6 26.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 95.9 86.3 92.3 95.8 86.0 91.8 In a separate building 2.1 9.5 4.9 2.2 9.6 5.2 Outdoors 1.5 4.0 2.5 1.7 4.3 2.8 No food cooked in household 0.5 0.1 0.4 0.3 0.0 0.2 Other 0.0 0.1 0.1 0.0 0.1 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 27.7 10.3 21.2 25.8 8.9 19.0 LPG/natural gas/biogas 63.4 51.2 58.8 64.9 50.8 59.2 Charcoal 0.1 0.3 0.2 0.1 0.3 0.1 Wood 8.1 37.8 19.3 8.9 39.6 21.3 Agricultural crop 0.1 0.2 0.1 0.1 0.3 0.1 No food cooked in household 0.5 0.1 0.4 0.3 0.0 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 8.3 38.4 19.6 9.0 40.2 21.6 Percentage using clean fuel for cooking2 91.1 61.5 80.0 90.7 59.7 78.2 Frequency of smoking in the home Daily 24.3 30.2 26.5 27.3 32.9 29.5 Weekly 2.4 2.7 2.5 2.5 2.7 2.6 Monthly 0.5 0.3 0.4 0.5 0.3 0.4 Less than once a month 1.6 1.8 1.6 1.5 1.8 1.6 Never 71.3 65.0 68.9 68.2 62.2 65.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/population 9,864 5,959 15,823 31,058 21,069 52,128 LPG = Liquefied petroleum gas 1 Includes charcoal, wood and agricultural crops. 2 Includes electricity and LPG/natural gas/biogas. Housing Characteristics and Household Population • 19 Table 2.4 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land and livestock/farm animals by residence, Albania 2017-18 Residence Total Possession Urban Rural Household effects Radio 32.5 28.3 30.9 Television 98.2 98.6 98.4 Mobile phone 97.4 96.2 96.9 Non-mobile telephone 28.8 7.3 20.7 Video/DVD player 39.1 29.3 35.4 Tape/CD player 28.8 21.9 26.2 Refrigerator 97.2 95.1 96.4 Freezer 16.3 14.5 15.6 Washing machine 95.9 90.2 93.7 Dishwasher 17.0 6.8 13.1 Microwave oven 55.4 24.9 43.9 Sofa 96.5 92.1 94.8 Armoire 97.8 96.2 97.2 Electric radiator 63.3 30.6 51.0 Generator 4.5 5.8 5.0 Sewing or knitting machine 16.5 13.4 15.3 Air conditioner 37.4 10.3 27.2 Water boiler 86.1 72.0 80.8 Computer 54.4 27.8 44.4 Satellite dish or cable 65.9 57.9 62.9 Means of transport Bicycle 26.9 25.6 26.4 Animal drawn cart 0.8 7.3 3.2 Motorcycle/scooter 5.6 16.3 9.6 Car/truck 39.6 32.8 37.0 Tractor 0.6 5.9 2.6 Boat with a motor 0.6 1.0 0.7 Ownership of agricultural land 11.8 74.3 35.3 Ownership of farm animals1 5.4 59.6 25.8 Number 9,864 5,959 15,823 1 Cows, bulls, other cattle, horses, donkeys, goats, sheep, chickens or other poultry Table 2.5 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and the Gini coefficient, according to residence and region, Albania 2017-18 Wealth quintile Total Number of persons Gini coefficient Residence/region Lowest Second Middle Fourth Highest Residence Urban 5.0 12.5 24.0 28.4 30.1 100.0 31,058 0.05 Rural 42.2 31.0 14.1 7.6 5.1 100.0 21,069 0.15 Prefecture Berat 25.8 23.1 22.1 20.3 8.7 100.0 2,321 0.13 Dibër 58.3 19.8 12.0 7.9 2.0 100.0 2,264 0.26 Durrës 6.0 22.5 34.9 24.1 12.5 100.0 5,170 0.06 Elbasan 41.2 26.1 16.4 12.1 4.2 100.0 5,069 0.19 Fier 22.7 28.9 19.9 16.8 11.7 100.0 5,339 0.16 Gjirokastër 26.9 16.5 17.7 23.7 15.1 100.0 1,182 0.15 Korçë 29.0 28.9 20.7 17.3 4.1 100.0 4,336 0.16 Kukës 47.0 26.4 17.2 7.6 1.8 100.0 1,422 0.16 Lezhe 29.1 25.9 19.8 14.2 11.1 100.0 2,266 0.16 Shkodër 22.9 22.7 23.1 20.7 10.6 100.0 3,653 0.14 Tirana 5.1 9.7 16.2 24.6 44.4 100.0 15,899 0.12 Vlorë 11.0 19.8 22.4 27.8 19.0 100.0 3,206 0.11 Total 20.0 20.0 20.0 20.0 20.0 100.0 52,128 0.11 20 • Housing Characteristics and Household Population Table 2.6 Household population by age, sex, and residence Percent distribution of the de facto household population by age groups, according to sex and residence, Albania 2017-18 Urban Rural Male Female Total Age Male Female Total Male Female Total <5 4.7 4.6 4.7 5.8 5.2 5.5 5.2 4.9 5.0 5-9 5.4 5.1 5.2 6.1 6.3 6.2 5.7 5.6 5.6 ON10-14 6.6 5.7 6.1 7.6 7.1 7.4 7.0 6.2 6.6 15-19 6.6 6.6 6.6 7.0 7.1 7.1 6.8 6.8 6.8 20-24 7.5 6.6 7.1 7.1 6.0 6.6 7.4 6.4 6.9 25-29 7.2 6.2 6.7 7.0 6.0 6.5 7.1 6.1 6.6 30-34 5.7 6.1 5.9 5.7 5.4 5.5 5.7 5.8 5.7 35-39 5.5 5.3 5.4 5.0 6.0 5.5 5.3 5.6 5.4 40-44 5.1 6.3 5.7 4.9 6.3 5.6 5.0 6.3 5.7 45-49 6.0 6.7 6.3 6.3 7.4 6.8 6.1 6.9 6.5 50-54 6.8 7.4 7.1 6.9 7.8 7.4 6.9 7.6 7.2 55-59 7.1 7.7 7.4 7.8 8.1 8.0 7.4 7.9 7.6 60-64 8.5 8.3 8.4 6.7 6.6 6.6 7.8 7.6 7.7 65-69 6.1 6.1 6.1 5.6 4.9 5.3 5.9 5.7 5.8 70-74 4.1 4.3 4.3 4.1 3.7 3.9 4.1 4.1 4.1 75-79 3.8 3.5 3.7 3.4 2.9 3.1 3.6 3.2 3.4 80 + 2.9 3.2 3.0 2.7 2.9 2.8 2.8 3.1 3.0 Don’t know/missing 0.3 0.3 0.3 0.1 0.3 0.2 0.2 0.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Dependency age groups 0-14 16.7 15.4 16.0 19.6 18.6 19.1 17.9 16.7 17.3 15-64 66.1 67.2 66.7 64.5 66.7 65.6 65.4 67.0 66.2 65+ 17.0 17.1 17.1 15.8 14.3 15.1 16.5 16.0 16.3 Don’t know/missing 0.3 0.3 0.3 0.1 0.3 0.2 0.2 0.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Child and adult populations 0-17 20.6 19.1 19.8 24.0 23.1 23.5 22.0 20.7 21.3 18+ 79.1 80.6 79.9 75.9 76.6 76.2 77.8 79.0 78.4 Don’t know/missing 0.3 0.3 0.3 0.1 0.3 0.2 0.2 0.3 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Adolescents 10-19 13.2 12.3 12.8 14.7 14.2 14.4 13.8 13.1 13.4 Number of persons 15,067 15,901 30,968 10,434 10,484 20,918 25,502 26,385 51,887 Housing Characteristics and Household Population • 21 Table 2.7 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18 years of age, according to residence, Albania 2017-18 Residence Total Characteristic Urban Rural Household headship Male 79.7 87.6 82.7 Female 20.3 12.4 17.3 Total 100.0 100.0 100.0 Number of usual members 0 0.1 0.2 0.2 1 11.7 7.0 9.9 2 29.1 26.4 28.1 3 20.2 19.4 19.9 4 20.2 19.9 20.1 5 11.3 14.1 12.4 6 5.4 8.4 6.6 7 1.3 3.1 2.0 8 0.3 0.8 0.4 9+ 0.3 0.7 0.5 Total 100.0 100.0 100.0 Mean size of households 3.1 3.5 3.3 Percentage of households with orphans and foster children under 18 years of age Double orphans 0.2 0.2 0.2 Single orphans1 1.2 0.9 1.0 Foster children2 1.0 1.3 1.1 Foster and/or orphan children 2.0 2.1 2.0 Number of households 9,864 5,959 15,823 Note: Table is based on de jure household members, i.e., usual residents. 1 Includes children with one dead parent and an unknown survival status of the other parent 2 Foster children are those under age 18 living in households with neither their mother nor their father present, and the mother and/or the father are alive. 22 • Housing Characteristics and Household Population Table 2.8 Children’s living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, percentage of children not living with a biological parent, and percentage of children with one or both parents dead, according to background characteristics, Albania 2017-18 Living with both parents Living with mother but not with father Living with father but not with mother Not living with either parent Total Percent- age not living with a biolo- gical parent Percent- age with one or both parents dead1 Number of children Background characteristic Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Missing informa- tion on father/ mother Age 0-4 85.6 12.4 0.7 0.5 0.0 0.5 0.0 0.0 0.0 0.2 100.0 0.5 0.8 2,585 <2 85.8 12.8 0.5 0.5 0.1 0.2 0.0 0.0 0.1 0.1 100.0 0.3 0.6 1,043 2-4 85.4 12.1 0.9 0.5 0.0 0.7 0.0 0.0 0.0 0.2 100.0 0.7 1.0 1,542 5-9 82.9 12.9 1.4 1.3 0.1 1.3 0.1 0.0 0.1 0.0 100.0 1.5 1.7 2,924 10-14 84.6 10.3 1.7 1.3 0.4 1.2 0.0 0.4 0.1 0.0 100.0 1.7 2.6 3,439 15-17 83.2 7.7 3.0 1.3 0.6 2.8 0.0 0.2 1.3 0.0 100.0 4.3 5.1 2,113 Sex Male 84.6 10.9 1.3 1.1 0.3 1.2 0.0 0.1 0.4 0.1 100.0 1.7 2.1 5,616 Female 83.6 11.1 2.0 1.0 0.2 1.5 0.0 0.2 0.3 0.0 100.0 2.0 2.7 5,444 Residence Urban 84.6 10.2 2.0 1.1 0.2 1.3 0.0 0.2 0.4 0.0 100.0 1.9 2.8 6,138 Rural 83.5 12.0 1.3 1.1 0.3 1.5 0.0 0.0 0.3 0.1 100.0 1.8 1.9 4,922 Prefecture Berat 76.2 19.0 1.3 0.9 0.1 2.0 0.1 0.0 0.3 0.1 100.0 2.4 1.9 480 Dibër 82.9 12.4 1.7 1.1 0.5 0.6 0.0 0.1 0.4 0.3 100.0 1.1 2.7 636 Durrës 84.6 11.5 0.9 0.7 0.3 1.5 0.0 0.0 0.5 0.0 100.0 2.0 1.7 1,002 Elbasan 79.3 14.9 2.5 1.0 0.1 2.1 0.0 0.0 0.0 0.1 100.0 2.1 2.5 1,147 Fier 79.5 16.0 1.0 1.1 0.1 1.9 0.1 0.1 0.2 0.1 100.0 2.3 1.5 1,189 Gjirokastër 90.4 4.7 1.4 1.2 0.6 1.5 0.0 0.0 0.2 0.0 100.0 1.6 2.2 230 Korçë 83.5 10.8 1.9 1.9 0.0 1.4 0.0 0.1 0.4 0.0 100.0 1.8 2.4 865 Kukës 90.4 5.0 2.4 1.1 0.5 0.2 0.0 0.1 0.2 0.2 100.0 0.4 3.1 430 Lezhe 85.4 10.0 3.2 0.3 0.2 0.9 0.0 0.0 0.0 0.0 100.0 0.9 3.4 543 Shkodër 90.2 4.3 2.5 0.7 0.2 0.2 0.0 0.0 1.8 0.1 100.0 2.0 4.5 702 Tirana 86.4 9.1 1.3 0.9 0.4 1.4 0.0 0.3 0.2 0.0 100.0 1.9 2.2 3,233 Vlorë 82.3 10.4 1.5 3.4 0.3 1.4 0.1 0.3 0.3 0.0 100.0 2.0 2.5 604 Wealth quintile Lowest 81.3 13.7 1.5 1.2 0.2 1.6 0.1 0.0 0.2 0.1 100.0 1.9 2.1 2,520 Second 82.4 12.6 1.6 1.1 0.4 1.3 0.0 0.1 0.4 0.0 100.0 1.9 2.5 2,299 Middle 83.6 11.6 1.7 0.8 0.2 1.5 0.0 0.1 0.5 0.0 100.0 2.1 2.5 2,153 Fourth 83.7 10.9 2.5 1.5 0.1 0.9 0.0 0.1 0.3 0.1 100.0 1.3 3.0 2,062 Highest 90.5 5.2 0.9 0.8 0.4 1.4 0.0 0.4 0.3 0.0 100.0 2.1 2.0 2,027 Total <15 84.3 11.8 1.3 1.1 0.2 1.0 0.0 0.1 0.1 0.1 100.0 1.3 1.8 8,948 Total <18 84.1 11.0 1.6 1.1 0.3 1.3 0.0 0.1 0.3 0.1 100.0 1.9 2.4 11,060 Note: Table is based on de jure members, i.e., usual residents. 1 Includes children with father dead, mother dead, both dead, and one parent dead but missing information on survival status of the other parent Housing Characteristics and Household Population • 23 Table 2.9 Birth registration of children under age 5 Percentage of de jure children under age 5 whose births are registered with the civil authorities, according to background characteristics, Albania 2017-18 Percentage of children whose births are registered and who: Total percentage of children whose births are registered Number of children Background characteristic Had a birth certificate Did not have birth certificate Age <2 86.0 12.3 98.3 1,043 2-4 83.6 14.9 98.5 1,542 Sex Male 84.3 14.5 98.9 1,317 Female 84.8 13.2 98.0 1,268 Residence Urban 86.3 12.2 98.5 1,433 Rural 82.4 16.0 98.4 1,152 Prefecture Berat 98.7 0.9 99.6 122 Dibër 79.8 19.6 99.3 152 Durrës 79.9 16.8 96.7 275 Elbasan 84.2 14.0 98.2 274 Fier 89.7 8.6 98.3 274 Gjirokastër 72.2 27.2 99.4 55 Korçë 77.8 21.6 99.4 201 Kukës 48.6 49.3 97.9 102 Lezhe 87.5 12.5 100.0 136 Shkodër 88.9 3.7 92.6 158 Tirana 88.2 11.1 99.4 695 Vlorë 91.9 7.7 99.7 143 Wealth quintile Lowest 81.4 16.8 98.1 570 Second 81.9 16.8 98.7 551 Middle 84.5 12.1 96.6 497 Fourth 86.6 12.7 99.2 488 Highest 89.5 10.1 99.6 478 Total 84.6 13.9 98.4 2,585 24 • Housing Characteristics and Household Population Table 2.10.1 Educational attainment of the female household population Percent distribution of the de facto female household population age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Albania 2017-18 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 24.4 75.5 0.1 0.0 0.0 0.0 0.0 100.0 1,176 1.0 10-14 2.0 72.3 24.7 1.0 0.0 0.0 0.0 100.0 1,646 5.5 15-19 0.7 2.9 24.0 58.1 1.4 12.8 0.0 100.0 1,800 13.2 20-24 1.2 2.0 16.2 17.6 10.4 52.5 0.1 100.0 1,681 16.3 25-29 2.1 3.6 32.0 3.8 15.6 43.0 0.0 100.0 1,622 15.6 30-34 2.3 5.5 38.6 2.9 16.4 34.2 0.1 100.0 1,532 15.1 35-39 2.5 5.0 49.3 3.6 19.3 20.2 0.0 100.0 1,476 7.9 40-44 1.6 3.0 44.5 6.8 28.5 15.7 0.1 100.0 1,658 12.9 45-49 0.9 2.6 40.8 7.7 31.1 16.9 0.0 100.0 1,834 15.1 50-54 1.1 4.1 44.3 9.4 28.3 12.7 0.1 100.0 1,994 12.2 55-59 0.9 6.4 44.0 14.1 27.0 7.7 0.0 100.0 2,073 8.0 60-64 0.9 14.7 33.4 13.9 26.1 10.7 0.2 100.0 2,009 12.7 65+ 6.6 51.1 16.9 7.4 10.7 7.0 0.3 100.0 4,229 6.4 Don’t know/missing 25.3 17.4 18.2 4.1 18.9 14.5 1.6 100.0 78 7.3 Residence Urban 3.0 17.9 23.2 12.1 20.7 23.0 0.1 100.0 14,994 14.4 Rural 4.1 25.4 42.3 10.5 10.6 7.0 0.1 100.0 9,815 7.5 Prefecture Berat 3.5 23.7 35.9 14.4 14.3 8.0 0.1 100.0 1,100 7.7 Dibër 4.5 24.9 39.9 11.9 11.2 7.5 0.1 100.0 1,054 7.6 Durrës 2.6 24.4 27.2 9.9 18.6 17.2 0.1 100.0 2,464 7.9 Elbasan 6.4 19.8 42.6 9.0 11.6 10.4 0.2 100.0 2,384 7.6 Fier 3.9 22.3 37.1 13.1 13.5 9.8 0.3 100.0 2,557 7.7 Gjirokastër 3.8 22.4 30.6 8.5 20.9 13.8 0.1 100.0 550 7.8 Korçë 3.0 21.0 38.5 10.2 15.7 11.6 0.1 100.0 2,009 7.7 Kukës 2.3 19.8 40.2 12.9 13.2 11.6 0.0 100.0 656 7.8 Lezhe 2.9 23.9 35.2 13.8 14.0 10.2 0.1 100.0 1,058 7.7 Shkodër 3.3 24.3 28.9 13.1 14.9 15.5 0.0 100.0 1,752 7.8 Tirana 2.9 16.6 21.8 11.8 20.1 26.8 0.1 100.0 7,656 15.0 Vlorë 3.1 24.1 27.0 9.7 21.0 15.0 0.1 100.0 1,569 7.9 Wealth quintile Lowest 6.0 28.1 46.7 8.6 6.9 3.6 0.1 100.0 4,866 7.4 Second 4.4 25.6 40.1 10.3 12.7 6.8 0.1 100.0 4,961 7.5 Middle 2.9 22.4 32.4 12.7 17.0 12.5 0.1 100.0 5,002 7.8 Fourth 2.5 16.6 22.7 13.6 22.9 21.7 0.1 100.0 5,050 14.9 Highest 1.6 11.6 12.2 12.1 23.7 38.7 0.1 100.0 4,930 15.6 Total 3.5 20.8 30.8 11.5 16.7 16.7 0.1 100.0 24,809 7.9 1 Completed 8 years at the primary level 2 Completed 4 years at the secondary level Housing Characteristics and Household Population • 25 Table 2.10.2 Educational attainment of the male household population Percent distribution of the de facto male household population age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Albania 2017-18 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 23.2 76.6 0.0 0.0 0.0 0.0 0.1 100.0 1,199 0.9 10-14 1.2 76.8 21.3 0.4 0.1 0.1 0.1 100.0 1,786 5.5 15-19 1.1 2.3 27.5 61.6 2.7 4.8 0.0 100.0 1,734 12.9 20-24 1.0 1.6 17.7 31.9 13.9 33.8 0.0 100.0 1,878 15.2 25-29 1.6 3.7 22.4 12.6 25.8 33.8 0.1 100.0 1,814 15.5 30-34 1.9 4.2 31.8 8.9 26.5 26.5 0.2 100.0 1,443 15.2 35-39 2.5 5.8 42.8 5.9 25.6 17.5 0.0 100.0 1,351 8.0 40-44 0.9 4.5 38.0 11.4 30.7 14.2 0.3 100.0 1,284 14.9 45-49 0.7 3.2 36.9 11.2 33.6 14.3 0.1 100.0 1,557 15.1 50-54 0.9 3.8 33.7 15.6 34.5 11.6 0.1 100.0 1,748 15.1 55-59 0.6 5.2 34.9 15.6 32.9 10.8 0.1 100.0 1,888 15.1 60-64 2.0 8.6 28.7 16.5 28.2 15.8 0.1 100.0 1,980 15.1 65+ 1.9 35.6 19.1 10.6 17.9 14.7 0.2 100.0 4,205 7.7 Don’t know/missing (22.5) (16.3) (18.4) (4.1) (21.0) (16.0) (1.7) 100.0 56 (7.5) Residence Urban 2.5 15.9 20.3 15.9 24.0 21.2 0.1 100.0 14,220 15.1 Rural 2.6 23.3 35.4 15.6 16.0 7.0 0.1 100.0 9,706 7.8 Prefecture Berat 2.1 20.7 29.1 22.4 17.9 7.6 0.2 100.0 1,051 8.3 Dibër 2.8 24.6 33.8 15.2 16.9 6.7 0.0 100.0 1,005 7.7 Durrës 1.6 22.0 23.6 15.6 21.3 15.7 0.1 100.0 2,367 13.3 Elbasan 4.9 20.4 37.8 13.0 16.0 7.8 0.2 100.0 2,297 7.8 Fier 3.4 18.1 31.8 20.3 16.2 9.9 0.3 100.0 2,438 8.0 Gjirokastër 2.5 17.9 25.0 11.8 25.5 16.9 0.4 100.0 574 13.7 Korçë 2.5 16.9 34.0 16.2 20.6 9.9 0.0 100.0 2,028 8.0 Kukës 1.7 20.0 31.5 17.7 19.1 10.0 0.0 100.0 650 8.2 Lezhe 2.7 21.5 30.6 17.5 17.2 10.4 0.2 100.0 1,003 7.9 Shkodër 2.2 23.7 25.5 16.0 20.2 12.4 0.0 100.0 1,726 8.1 Tirana 2.2 15.3 18.3 14.3 23.9 25.9 0.1 100.0 7,312 15.2 Vlorë 1.3 20.7 24.0 14.8 26.3 12.9 0.0 100.0 1,474 13.2 Wealth quintile Lowest 4.2 26.7 40.2 13.0 12.2 3.6 0.1 100.0 4,781 7.5 Second 2.6 23.9 35.0 15.2 17.2 6.1 0.1 100.0 4,719 7.7 Middle 2.5 18.5 28.2 17.3 22.4 11.0 0.1 100.0 4,803 12.2 Fourth 1.9 14.8 18.5 18.9 27.3 18.5 0.1 100.0 4,722 15.1 Highest 1.4 10.8 10.8 14.5 24.7 37.6 0.1 100.0 4,901 15.6 Total 2.5 18.9 26.4 15.8 20.8 15.5 0.1 100.0 23,926 12.8 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 Completed 8 years at the primary level 2 Completed 4 years at the secondary level 26 • Housing Characteristics and Household Population Table 2.11 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Albania 2017-18 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 93.9 92.9 93.4 0.99 97.6 96.4 97.1 0.99 Rural 90.9 91.9 91.4 1.01 95.0 94.7 94.9 1.00 Prefecture Berat 96.9 93.0 95.0 0.96 102.2 96.6 99.5 0.95 Dibër 91.5 92.5 92.0 1.01 96.3 95.5 96.0 0.99 Durrës 92.7 95.0 93.7 1.02 96.8 97.3 97.0 1.01 Elbasan 95.6 93.7 94.7 0.98 104.2 100.5 102.5 0.96 Fier 91.2 90.7 91.0 0.99 94.4 93.5 94.0 0.99 Gjirokastër 94.8 91.8 93.3 0.97 96.4 96.5 96.5 1.00 Korçë 95.7 96.8 96.2 1.01 100.3 99.4 99.8 0.99 Kukës 72.9 79.8 75.9 1.09 76.7 82.9 79.4 1.08 Lezhe 87.4 88.7 88.0 1.02 90.9 92.4 91.6 1.02 Shkodër 92.2 95.2 93.7 1.03 97.9 101.2 99.5 1.03 Tirana 93.7 92.0 92.9 0.98 95.4 93.9 94.6 0.98 Vlorë 96.7 93.4 95.0 0.97 100.4 96.7 98.5 0.96 Wealth quintile Lowest 91.0 89.5 90.3 0.98 94.8 93.0 93.9 0.98 Second 93.4 93.9 93.7 1.00 98.2 97.6 97.9 0.99 Middle 91.9 91.3 91.6 0.99 97.4 94.9 96.2 0.97 Fourth 93.2 94.2 93.7 1.01 96.3 97.1 96.7 1.01 Highest 93.7 93.9 93.8 1.00 96.0 96.0 96.0 1.00 Total 92.6 92.4 92.5 1.00 96.5 95.6 96.1 0.99 SECONDARY SCHOOL Residence Urban 80.6 83.4 82.0 1.03 109.8 107.5 108.7 0.98 Rural 74.3 77.7 76.0 1.04 102.4 93.7 98.0 0.91 Prefecture Berat 81.4 75.6 78.4 0.93 118.0 101.3 109.3 0.86 Dibër 58.6 68.1 63.8 1.16 84.3 81.4 82.7 0.97 Durrës 76.8 78.7 77.6 1.02 107.4 111.9 109.3 1.04 Elbasan 66.3 75.1 70.8 1.13 114.6 96.2 105.3 0.84 Fier 75.8 80.6 78.3 1.06 109.5 91.1 100.0 0.83 Gjirokastër 81.3 76.5 78.8 0.94 97.8 91.4 94.4 0.93 Korçë 86.9 84.6 85.8 0.97 113.8 105.8 109.8 0.93 Kukës 64.9 66.8 65.9 1.03 75.9 77.2 76.6 1.02 Lezhe 83.5 85.4 84.5 1.02 112.0 110.4 111.1 0.99 Shkodër 78.2 79.3 78.7 1.01 98.9 103.2 100.9 1.04 Tirana 83.2 87.1 85.2 1.05 109.6 107.8 108.7 0.98 Vlorë 81.4 82.0 81.6 1.01 98.5 112.0 104.2 1.14 Wealth quintile Lowest 64.8 67.4 66.2 1.04 88.0 81.7 84.7 0.93 Second 76.9 77.7 77.3 1.01 113.3 101.9 107.5 0.90 Middle 79.1 84.3 81.4 1.07 102.5 112.2 106.9 1.09 Fourth 83.7 89.7 86.8 1.07 120.8 109.8 115.0 0.91 Highest 86.8 88.1 87.5 1.02 112.2 106.0 109.1 0.94 Total 77.9 80.9 79.4 1.04 106.6 101.4 104.0 0.95 1 The NAR for primary school is the percentage of the primary-school age (A-B years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (C-D years) population that is attending secondary school. By definition the NAR cannot exceed 100.0 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary- school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR(GAR) for females to the NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR(GAR) for males. Characteristics of Respondents • 27 CHARACTERISTICS OF RESPONDENTS 3 Key Findings  Education: More than 20% of the population age 15-49 (26% of women and 21% of men), have education beyond secondary school.  Early education: Three-quarters of children age 36-59 months (73%) attend an organized early childhood education program.  Exposure to mass media: Overall 91% of women age 15-49 and 88% of men in the same age group watch television at least once per week.  Internet use: Overall, 73% of women and 84% of men age 15-49 use the internet. his chapter presents information on the demographic and socioeconomic characteristics of the survey respondents—age, education, place of residence, marital status, employment, and wealth. This information is useful for understanding the factors that affect use of reproductive health services, contraceptive use, and other health behaviors. 3.1 BASIC CHARACTERISTICS OF SURVEY RESPONDENTS As described in Chapter 1, the 2017-18 ADHS produced complete interviews for 10,860 women age 15-49, 4,140 women age 50-59, and 6,142 men age 15-59. In the age 15-49 age range, 29% of women and 34% of men are adolescents or young adults (age 15-24), while 71% of women and 67% of men are age 25 or older. About three-quarters of respondents are Muslim (79% of women and 78% of men). The other religions are Catholic (11%), Orthodox (7% of women and 8% of men), and Bektashi (2%). Atheists represent about 1% of respondents. Regarding ethnicity, the vast majority of respondents age 15-49 are ethnic Albanians (97%); two important ethnic minorities are the Egyptians (Gypsies) and Roma, representing 2% and 1% of respondents, respectively. Because men tend get married later in life, 51% of them are single, compared with 29% of women; 48% of men are in a union (either married or in consensual union), compared with two-thirds of women (68%). The majority of women and men (60%) live in urban areas. One-third of the population is in Tirana, the country’s capital and economic hub. Other prefectures with relatively large concentrations of population are Elbasan (10%), Fier (10%), and Durres (around 9%). T 28 • Characteristics of Respondents 3.2 EDUCATION AND LITERACY Literacy Respondents who have attended a higher level than primary school (4 years) are assumed to be literate. All other respondents, when shown a typed sentence to read aloud, are considered literate if they can read all or part of the sentence. Sample: Women and men age 15-49 The Albanian population is well educated. The median years of education completed is practically identical for women and men age 15-49, 14.4 years and 14.6 years, respectively. Among people age 15- 49, 18% of women and 22% of men completed secondary school, while 26% of women and 21% of men went beyond secondary school. Only 1% of women and men have no education (Tables 3.2.1 and 3.2.2, Figure 3.1). Literacy is practically universal in Albania: 99% of men and women age 15-49 can read, and this proportion is high regardless of the background characteristics or gender of the respondent. The only exception is among people without schooling or with only a primary 4-year education: 55% of women and 69% of men in this category are considered literate (Table 3.3.1 and Table 3.3.2). Trends: A comparison of median years of schooling between the previous ADHS and 2017-18 ADHS indicates that educational attainment has increased markedly among women and men alike. The median number of years of schooling completed in 2008-09 was 8.0 among women age 15-49 and 9.6 among men the same age, compared with 14.4 and 14.6, respectively, in 2017-18. During the same period, the proportion of people who had more than a secondary education increased from 13% to 26% among women and from 12% to 21% among men. Patterns by background characteristics  Only 1% of the population age 15-49 received no education.  More than 36% of urban women age 15-49 have more than secondary education, compared with 13% of rural women; among men, these proportions are respectively 27% and 10%.  There is considerable regional variation in educational attainment. The largest proportions of women and men with more than secondary education are in Tirana (38% of women and 31% of men) and the lowest proportions are in Dibër (12% of women and 9% of men) (Figure 3.2). Figure 3.1 Education of survey respondents Figure 3.2 More than secondary education 1 14 3 35 31 16 23 18 22 26 21 Women Men Percent distribution of women and men age 15-49 by highest level of schooling attended or completed More than secondary Completed secondary Some secondary Completed primary Some primary No education 6 13 21 35 55 6 10 14 27 43 Lowest Second Middle Fourth Highest Percentage of women and men age 15-49 with more than secondary education Women Men WealthiestPoorest Characteristics of Respondents • 29  Access to education correlates highly with wealth. The proportion of respondents who have more than a secondary education increases markedly with wealth, from 6% in the lowest quintile to 55% in the highest quintile among women, and from 6% in the lowest quintile to 43% in the highest quintile among men (Tables 3.2.1 and 3.2.2, Figure 3.3). 3.3 EARLY EDUCATION AND SUPPORT IN LEARNING Early education Respondents were asked if children age 3 or 4 living in their households were attending an organized early childhood education program. Sample: Children age 3-4 Readiness of children for primary school can be improved through attendance at early childhood education programs or through pre-school attendance. Early childhood education programs in Albania provide organized education up to preschool for children age 3 to 4 or pre-primary programming within the compulsory schools as a preparatory year for children age 5. Research has consistently shown that investing in quality early learning programs is one of the most effective ways to achieve universal primary education, improve children’s success in school in later years, and promote gender equality. The gains tend to be highest when early childhood investments target the youngest children and the most disadvantaged groups. Three-quarters of children age 36-59 months (73%) attend an organized early childhood education program, and the level of participation is the same for male and female children. Trends: The proportion of Albanian children age 3 or 4 attending organized early preschool education has increased over the last 10 years from 55% to 73%. Patterns by background characteristics  Participation of boys in these programs is higher in urban areas (77%) than rural areas (68%).  The age of the child is a determinant factor for both boys and girls: 65% of children age 3 were participating in early education programs compared with 80% of children age 4. Figure 3.3 More than secondary education by prefecture Percentage of women and men age 15-49 with more than secondary education 30 • Characteristics of Respondents  The gender of the head of household influences the participation of young children: 73% of children in households headed by men participate in early education programs compared with 66% of children in households headed by women. Boys in households headed by women are the least likely to participate in early education: only 59% take part.  The education of the head of household is also an important determining factor: 63% of children living in households in which the head has a primary-4 year education or less participate in early learning programs compared with 86% of those in households in which the head has a university or post- graduate degree.  Socioeconomic status also influences the level of participation: 62% of children in the lowest quintile participate in early learning programs compared with 88% of children in the highest quintile. Support in learning Female respondents age 15-49 who had a living child age 3 or 4 were asked if in the 3 days preceding the survey any adult engaged in activities that support learning with the child. Specifically, the activities mentioned were reading or looking at pictures in books, telling stories, singing songs, or going outside. Sample: Children age 3-4 whose mothers were successfully interviewed A substantial body of evidence indicates that the nurturing experiences a child receives in early years serve as the foundation for subsequent learning, as well as for his or her social adjustment and intellectual development. To assess the level of early-stimulation activities among young children, mothers of children age 3 or 4 were asked if in the 3 days preceding the survey any person age 15 or older engaged her child in activities such as reading books, telling stories, singing songs, playing, drawing or going for a stroll. If the answer was affirmative, mothers were asked who had engaged in such activity with the child. A sizeable majority of children are exposed to stimulating activities, 92% with their mothers, 58% with their fathers and 57% with someone other than the parents. Exposure to these activities is basically the same for boys and girls. Patterns by background characteristics  Children in urban areas are more likely to have been exposed to stimulating activities in the 3 days preceding the survey, 96% with their mothers, 62% with their fathers, and 61% with another person. In rural areas, these percentages are 87%, 52%, and 52%.  Similarly, children in the highest wealth quintile are more likely to be exposed to stimulating activities, 96% with their mothers, 74% with their fathers, and 65% with a person other than the parents. In the lowest wealth quintile, these percentages are 85%, 45%, and 54% (Table 3.5). Characteristics of Respondents • 31 3.4 MASS MEDIA EXPOSURE Exposure to mass media Respondents were asked how often they read a newspaper, listened to the radio, or watched television. Those who responded at least once a week are considered regularly exposed to that form of media. Sample: Women and men age 15-59 Access to information is essential in increasing people’s knowledge and awareness of the events in their communities and in increasing general knowledge. Data on women’s and men’s exposure to mass media are especially important in the development of educational programs and the dissemination of information, particularly information on health, family planning, nutrition, HIV/AIDS, and other important health topics. Nine out of ten Albanians are exposed to mass media, television being the dominant medium: 91% of women and 88% of men watch television at least once a week. Other sources of information are newspapers (17% of women and 25% of men read newspapers at least once a week) and the radio (15% of women and 30% of men listen to the radio at least once a week). Only 8% of women and 10% of men are not exposed to any of the three media (Tables 3.6.1 and 3.6.2, Figure 3.4). The internet is also a widely-used medium through which people access and share information. This use includes browsing web pages, email, or social media. About two-thirds of women and men age 15-49 use the internet at least once a week (Tables 3.7.1 and 3.7.2). Trends: Between the 2008-09 and the 2017-18 ADHS surveys there was a substantial decrease in weekly exposure to all three media. Among women age 15-49, the proportion reading newspapers declined from 34% to 17%, the proportion watching television declined from 98% to 91%, and the proportion listening to the radio declined from 36% to 15%. Only 2% were not exposed to any of the three media in 2008-09 compared with 10% in 2017-18. A similar pattern is observed among men. A possible explanation for this downward trend is that now more people rely on the internet as a source of information and entertainment and as a result they spend less time accessing other forms of media. Patterns by background characteristics  Urban men are more likely than their rural counterparts to have weekly exposure to newspapers, television, and radio (9% versus 5%), but the pattern is reversed among women: 14% of urban women are exposed to all three media compared with 16% of women in rural areas.  Exposure to the three forms of mass media increases with education. The proportion of women with exposure to all three forms of media rises from 2% among those with less than a primary 4-year education to 14% among those with a university or postgraduate education. Among men, the corresponding increase is from 1% to 19%. Figure 3.4 Exposure to mass media 17 91 15 8 8 25 88 30 15 10 Reads news- paper Watches television Listens to radio All three media None of these media Percentage of women and men age 15-49 who are exposed to media on a weekly basis Women Men 32 • Characteristics of Respondents  A similar pattern is observed by socioeconomic status: 4% of women in the lowest quintile are exposed to all three media on a weekly basis, compared with 12% of those in the highest quintile. Among men, the pattern is less clear (Tables 3.6.1 and 3.6.2). Internet usage Respondents were asked if they used the internet at least once a week, less than once a week, or not at all. Sample: Women and men age 15-59 The use of the internet is quite widespread, and men are more likely to use the internet then women (84% compared with 73%). Among women age 15-49, 64% use it at least once a week, 9% use it less than once a week, and 27% do not use it at all. Among men this age, these proportions are 67%, 17% and 16%, respectively. Patterns by background characteristics  As a new medium, the internet is used much more by young people: 82% of women and 80% of men age 15-19 report use at least once a week compared with 30% of women and 25% of men age 50-59.  Education is directly associated with internet use among women and men alike: 17% of women with a primary 4-year education or less use the internet at least once a week, compared with 93% of women with a university or postgraduate education. Among men, these proportions are, respectively, 29% and 84%.  Wealth also influences access to the internet. One-third of the women in the lowest quintile use the internet weekly compared with 86% of those in the highest quintile. Similarly, 54% of men in the lowest quintile use the internet weekly compared with 80% of those in the highest quintile (Tables 3.7.1 and 3.7.2). 3.5 EMPLOYMENT Currently employed Respondents who reported being employed in the 7 days before the survey Sample: Women and men age 15-59 In the 2017-18 ADHS, respondents were asked about their employment status at the time of the survey and, if they were not currently employed, about any work they may have done in the 12 months prior to the survey. Respondents that reported being employed at the time of the survey, were asked additional questions about their occupation: whether they were paid in cash, in kind, or not at all, and for whom they worked. Among women age 15-49, 37% report being currently employed, 5% are not employed but were employed at some point in the 12 months preceding the survey, and 58% are not employed and were never employed in the 12 months preceding the survey (Table 3.8.1). Among men the same age, 56% report being currently employed, 5% are not currently employed but were employed in the 12 months preceding the survey, and 39% are not employed and were never employed in the 12 months preceding the survey (Table 3.8.2).1 1 The definition of employment based on reported status of economic activity at the time of the survey differs from the definitions used in the Labor Force Surveys (LFS), which follow the methodology recommended by Eurostat and the International Labor Organization (ILO). According to LFS 2017, the employment rate in 2017 was 57%, and the unemployment rate was 14% for the population age15-64. Characteristics of Respondents • 33 Trends: The proportion of women age 15-49 currently employed increased from 30% in 2008-09 to 37% in 2017-18, while for men the same age there was a decrease from 66% to 56%. Patterns by background characteristics  Among women age 15-49, the proportion currently employed is higher among those formerly married (divorced, separated, or widowed) than among those currently married or in consensual union (53% versus 42%). Among men the pattern is reversed: 73% of married men are employed compared with 54% of those formerly married.  Area of residence is a determining factor in employment for women. In urban areas, 43% of them are employed compared with only 28% in rural areas. For men, however, there is no substantial difference by type of residence: 55% are employed in urban areas compared with 58% in rural areas.  The higher the level of education a woman has, the more likely it is she is employed; 26% of those with a primary 4-year education or less are employed compared with 57% of those with university or postgraduate education. The pattern is less clear among men, but 39% of those with a primary 4-year education or less are employed compared with 62% of those with university or postgraduate education (Tables 3.81 and 3.8.2, Figure 3.5). 3.6 OCCUPATION Occupation Categorized as professional/technical/managerial, clerical, sales and services, skilled manual, unskilled manual, agriculture, and unclassified or unspecified Sample: Women and men age 15-59 who were currently employed or had worked in the 12 months before the survey Figure 3.5 Employment status by education 26 29 32 57 39 57 54 62 No education/ primary 4-year Primary 8-year Secondary/ professional/ technical University and postgraduate Percentage of women and men age 15-49 who are currently employed Women Men 34 • Characteristics of Respondents Employment is an important source of income and influence on several aspects of the household and individual life. Information on women’s occupations not only allows an evaluation of their source of income but also has implications for their empowerment. Respondents who indicated that they were currently working or had worked in the 12 months preceding the survey were asked about the kind of work they did. Around one fourth of employed women age 15-49 (26%) work in professional, technical, or managerial positions, and 19% are in skilled manual occupations, 17% are in sales and services, and about 7% work in unskilled manual jobs. Agriculture occupies only 13% of employed women. Men tend to be more often occupied in activities that require physical labor, such as unskilled manual occupations (30%) and agriculture (16%), but sales and services also occupies a sizeable proportion of them (18%). There were a number of occupations recorded in the field that could not be properly specified or classified during data processing. This inaccuracy affected 12% of employed women and 15% of employed men (Tables 3.9.1 and 3.9.2, Figure 3.6). Trends: Between 2008-09 and 2017-18, the proportion of persons age 15-49 employed in professional, technical, and managerial occupations remained practically unchanged for women but decreased slightly for men. During this period, the proportion of women paid only in cash increased from 60% to 82%, while the proportion not remunerated decreased from 31% to 10% (Figure 3.7). Patterns by background characteristics  Urban women are more likely to work in professional, technical, and managerial occupations, and in skilled manual labor (31% and 22%, respectively), while urban men are more likely to be engaged in skilled manual labor (30%) and agriculture (34%).  Among women with a university or postgraduate education, 61% work in professional, technical, and managerial occupations compared with less than 6% of those with secondary, professional, or technical education. A similar pattern is observed with men: 45% of those with a university or postgraduate education work in professional, technical, and managerial occupations, and less than 6% of those with secondary, professional, or technical education do (Tables 3.9.1 and 3.9.2).  Among women who do non-agricultural work, 93% receive payment in cash only, 68% work for a non-family member, and 17% are self-employed. Among those that work in agriculture, only 23% are paid only in cash, and 61% are self-employed. Figure 3.6 Occupation Figure 3.7 Type of employment: Women 26 5 17 19 7 13 12 13 4 18 30 5 16 15 Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Unspecified Percentage of women and men age 15-49 employed in the 12 months before the survey by occupation Women Men 1 1 Refers to occupation that were not recorded clearly during fieldwork 60 3 7 31 82 4 4 10 Cash only Cash and in-kind In-kind only Not paid Percent distribution of women age 15-49 employed in the 12 months before the survey 2008-09 ADHS 2017-18 ADHS Characteristics of Respondents • 35 3.6 HEALTH INSURANCE COVERAGE The health care system in Albania is mainly public, and private practice is limited. The Albanian law guarantees equal access to health care for all citizens. Public health care in Albania is the major provider of health services, health promotion, prevention, diagnosis and treatment. Primarily, the Government of Albania funds the State health care system. Other sources of funding include contributions from some employers, employees, and the self-employed, which involves deducting a percentage of wages or income to contribute to the insurance scheme. Among women 15-49, 32% are covered by the state health insurance, 14% are covered under the social security program, and 62% report not having any form of insurance. Among men the same age the coverage is slightly less: 29% are covered by the state health insurance, 9% are covered under the social security program, and 64% report not having any insurance (Tables 3.11.1 and 3.11.2). Trends: Between 2008-09 and 2017-18, there was an increase in the proportion of persons covered by insurance. The proportion of women protected by state insurance or social security increased significantly, from 26% to 46%, while for men the increase was only modest, from 34% to 37%. Patterns by background characteristics  There are large geographic variations in health insurance coverage among men and women alike: Only 13% of men and women in Kukës prefecture are covered by state health insurance or social security while in Tirana 68% of women and 50% of men enjoy such health coverage.  Having state-sponsored health insurance is strongly determined by education and wealth. Only 17% of women and an equal percentage of men with primary 4-year education or less have either state health insurance or social security, compared with 84% of women and 69% of men with a university or postgraduate education.  Similarly, only 15% of women and 17% of men in the lowest wealth quintile have either state health insurance or social security, compared to 81% of women and 62% of men with a university or postgraduate education. LIST OF TABLES For more information on the characteristics of survey respondents, see the following tables:  Table 3.1 Background characteristics of respondents  Table 3.2.1 Educational attainment: Women  Table 3.2.2 Educational attainment: Men  Table 3.3.1 Literacy: Women  Table 3.3.2 Literacy: Men  Table 3.4 Early education  Table 3.5 Support in learning  Table 3.6.1 Exposure to mass media: Women  Table 3.6.2 Exposure to mass media: Men  Table 3.7.1 Internet usage: Women  Table 3.7.2 Internet usage: Men  Table 3.8.1 Employment status: Women  Table 3.8.2 Employment status: Men  Table 3.9.1 Occupation: Women  Table 3.9.2 Occupation: Men  Table 3.10 Type of employment  Table 3.11.1 Health insurance coverage: Women  Table 3.11.2 Health insurance coverage: Men 36 • Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Albania 2017-18 Women Men Background characteristic Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 15.3 1,684 1,698 16.3 743 749 20-24 14.1 1,548 1,460 17.2 786 699 25-29 13.8 1,514 1,473 15.4 704 661 30-34 13.1 1,442 1,411 12.1 551 588 35-39 12.7 1,388 1,415 12.3 563 545 40-44 14.6 1,601 1,594 11.8 539 573 45-49 16.4 1,794 1,809 14.9 678 714 Religion Muslim 79.4 8,712 8,678 78.0 3,562 3,542 Orthodox 6.5 717 620 7.9 361 320 Cathlic 11.3 1,239 1,329 10.7 490 551 Bektashi 1.6 171 145 1.5 68 68 Atheist 0.7 73 51 1.2 55 31 Other 0.5 58 37 0.6 29 17 Ethnic group Albanian 96.7 10,611 10,523 96.5 4,407 4,411 Egyptian 1.6 173 176 2.0 93 71 Greek 0.1 16 19 0.1 5 6 Macedonian 0.1 9 7 0.0 0 0 Roma 1.2 137 119 1.1 49 33 Vlach 0.1 8 4 0.1 4 5 Other 0.1 15 12 0.2 7 3 Marital status Never married 29.1 3,191 2,964 51.0 2,328 2,209 Married 65.0 7,125 7,342 45.9 2,093 2,194 Living together 2.5 277 212 2.0 89 75 Divorced/separated 2.2 245 211 1.1 50 46 Widowed 1.2 131 131 0.1 4 5 Residence Urban 60.0 6,578 4,960 59.6 2,721 2,037 Rural 40.0 4,392 5,900 40.4 1,844 2,492 Prefecture Berat 4.0 439 776 3.6 163 262 Dibër 4.6 510 1,092 4.4 202 451 Durrës 9.3 1,017 866 8.9 405 355 Elbasan 10.0 1,100 957 9.6 440 374 Fier 9.9 1,083 920 10.0 454 380 Gjirokastër 1.9 204 630 2.4 109 326 Korçë 7.8 859 980 8.9 404 475 Kukës 3.1 338 1,116 3.0 136 493 Lezhe 4.4 482 766 4.1 187 303 Shkodër 7.2 795 862 7.2 328 368 Tirana 32.4 3,558 1,201 32.8 1,500 471 Vlorë 5.3 586 694 5.2 236 271 Education No education/primary 4-year 2.2 243 209 1.9 87 94 Primary 8-year 37.6 4,123 4,744 32.9 1,502 1,634 Secondary/professional/technical 33.8 3,708 3,710 44.7 2,039 2,099 University and postgraduate 26.4 2,897 2,197 20.5 936 702 Wealth quintile Lowest 19.5 2,145 3,062 18.8 856 1,267 Second 19.7 2,161 2,606 19.9 910 1,126 Middle 19.4 2,130 2,095 19.5 889 866 Fourth 20.8 2,279 1,833 20.0 912 729 Highest 20.6 2,255 1,264 21.8 997 541 Total 15-49 100.0 10,970 10,860 100.0 4,565 4,529 50-59 na 4,030 4,140 na 1,577 1,613 Total 15-59 na 15,000 15,000 na 6,142 6,142 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable Characteristics of Respondents • 37 Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Albania 2017-18 Highest level of schooling Total Median years completed Number of women Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 0.4 2.4 19.5 41.2 5.3 31.2 100.0 14.3 3,231 15-19 0.3 2.2 21.8 61.4 1.5 12.8 100.0 13.3 1,684 20-24 0.5 2.6 16.9 19.2 9.5 51.3 100.0 16.1 1,548 25-29 1.6 4.0 33.8 3.7 16.5 40.4 100.0 15.5 1,514 30-34 1.6 6.7 39.0 3.0 17.7 31.9 100.0 15.0 1,442 35-39 1.4 5.2 50.7 3.9 19.3 19.6 100.0 7.9 1,388 40-44 0.7 2.5 45.6 7.3 28.7 15.2 100.0 13.1 1,601 45-49 0.3 2.5 41.4 7.8 31.2 16.7 100.0 15.1 1,794 Residence Urban 1.1 3.3 24.4 15.1 20.4 35.7 100.0 15.4 6,578 Rural 0.6 3.9 51.7 17.1 14.1 12.5 100.0 8.0 4,392 Prefecture Berat 0.5 1.5 47.7 18.0 17.9 14.4 100.0 12.1 439 Dibër 0.8 4.3 52.0 17.5 13.2 12.3 100.0 8.0 510 Durrës 0.2 8.2 32.3 11.4 21.5 26.4 100.0 14.8 1,017 Elbasan 1.8 4.4 53.0 11.1 13.4 16.1 100.0 8.1 1,100 Fier 1.9 2.3 46.0 17.1 15.5 17.1 100.0 8.9 1,083 Gjirokastër 0.7 2.7 30.7 12.1 24.8 28.9 100.0 15.2 204 Korçë 0.1 2.8 41.7 15.2 18.7 21.5 100.0 13.3 859 Kukës 0.3 2.8 41.5 19.8 17.9 17.7 100.0 13.3 338 Lezhe 0.7 3.0 40.3 19.1 18.7 18.2 100.0 13.1 482 Shkodër 0.4 3.9 30.8 23.5 15.6 25.8 100.0 14.4 795 Tirana 1.0 3.0 23.2 15.9 18.8 38.2 100.0 15.4 3,558 Vlorë 0.5 2.5 28.6 14.4 22.4 31.6 100.0 15.2 586 Wealth quintile Lowest 2.3 6.4 60.1 14.9 10.0 6.3 100.0 7.8 2,145 Second 1.2 5.3 49.5 15.9 15.6 12.5 100.0 8.0 2,161 Middle 1.0 3.7 35.6 18.3 20.2 21.2 100.0 14.2 2,130 Fourth 0.0 1.8 22.9 17.6 22.2 35.4 100.0 15.4 2,279 Highest 0.0 0.7 10.6 12.9 21.2 54.6 100.0 16.9 2,255 Total 15-49 0.9 3.6 35.4 15.9 17.9 26.4 100.0 14.4 10,970 50-59 0.9 5.5 44.5 12.7 27.3 9.1 100.0 8.0 4,030 Total 15-59 0.9 4.1 37.8 15.0 20.4 21.7 100.0 14.1 15,000 1 Completed 8 grade at the primary level 2 Completed 4 grade at the secondary level 38 • Characteristics of Respondents Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Albania 2017-18 Highest level of schooling Total Median years completed Number of men Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 0.7 1.8 20.6 48.7 6.9 21.2 100.0 14.3 1,529 15-19 0.3 2.0 26.6 64.2 1.8 5.1 100.0 13.1 743 20-24 1.1 1.7 14.8 34.1 11.8 36.5 100.0 15.3 786 25-29 2.1 2.6 21.0 13.4 27.3 33.6 100.0 15.5 704 30-34 1.4 2.7 34.3 8.6 28.1 24.9 100.0 15.2 551 35-39 1.0 4.7 46.1 6.9 26.1 15.1 100.0 8.0 563 40-44 0.7 3.4 41.8 10.7 28.0 15.4 100.0 13.7 539 45-49 0.7 3.8 40.4 10.3 34.5 10.3 100.0 14.4 678 Residence Urban 1.1 2.3 24.5 21.3 23.6 27.3 100.0 15.2 2,721 Rural 1.0 3.8 40.3 25.7 18.6 10.5 100.0 12.8 1,844 Prefecture Berat 0.3 3.7 37.4 26.3 22.0 10.3 100.0 13.2 163 Dibër 2.5 4.2 42.0 21.2 21.2 9.0 100.0 12.1 202 Durrës 1.1 5.9 31.5 18.7 22.9 20.0 100.0 14.6 405 Elbasan 1.8 2.3 45.0 21.0 16.4 13.5 100.0 11.6 440 Fier 1.5 2.7 33.8 30.6 19.0 12.3 100.0 13.8 454 Gjirokastër 0.8 4.2 22.1 18.2 31.6 23.0 100.0 15.2 109 Korçë 1.1 1.1 33.2 25.4 26.8 12.3 100.0 14.7 404 Kukës 0.0 2.6 34.2 26.8 23.8 12.6 100.0 14.2 136 Lezhe 0.3 2.4 37.5 23.3 21.6 14.8 100.0 14.0 187 Shkodër 0.7 3.5 28.8 27.3 20.7 19.1 100.0 14.5 328 Tirana 0.9 2.5 23.1 21.8 20.3 31.4 100.0 15.2 1,500 Vlorë 0.4 1.8 28.8 17.9 28.7 22.4 100.0 15.1 236 Wealth quintile Lowest 2.8 4.5 47.6 24.2 15.0 5.9 100.0 8.4 856 Second 0.9 5.4 41.8 21.9 19.7 10.2 100.0 12.3 910 Middle 1.5 2.7 37.0 20.0 25.1 13.7 100.0 13.8 889 Fourth 0.1 1.7 18.0 26.3 27.4 26.5 100.0 15.3 912 Highest 0.2 0.3 12.9 23.0 20.6 43.1 100.0 15.7 997 Total 15-49 1.1 2.9 30.9 23.1 21.6 20.5 100.0 14.6 4,565 50-59 0.3 3.7 36.0 14.7 36.3 9.0 100.0 15.1 1,577 Total 15-59 0.9 3.1 32.2 20.9 25.4 17.6 100.0 14.7 6,142 1 Completed 8 grade at the primary level 2 Completed 4 grade at the secondary level Characteristics of Respondents • 39 Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Albania 2017-18 Higher than primary (4 year) schooling No schooling or primary (4 year) Total Percent- age literate1 Number of women Background characteristic Can read a whole sentence Can read part of a sentence Cannot read at all Blind/ visually impaired Age 15-24 98.7 0.5 0.3 0.5 0.0 100.0 99.5 3,231 15-19 98.4 0.6 0.6 0.5 0.0 100.0 99.5 1,684 20-24 99.1 0.4 0.0 0.5 0.0 100.0 99.5 1,548 25-29 96.8 0.9 0.4 1.8 0.1 100.0 98.1 1,514 30-34 95.7 1.7 0.7 1.8 0.0 100.0 98.2 1,442 35-39 96.6 1.5 0.4 1.5 0.0 100.0 98.5 1,388 40-44 98.4 0.8 0.1 0.7 0.0 100.0 99.3 1,601 45-49 98.9 0.4 0.2 0.4 0.0 100.0 99.6 1,794 Residence Urban 97.4 1.1 0.3 1.1 0.0 100.0 98.9 6,578 Rural 98.3 0.5 0.4 0.8 0.0 100.0 99.2 4,392 Prefecture Berat 98.7 0.1 0.1 1.1 0.0 100.0 98.9 439 Dibër 98.4 0.7 0.4 0.4 0.0 100.0 99.6 510 Durrës 99.3 0.0 0.4 0.2 0.0 100.0 99.8 1,017 Elbasan 94.7 2.1 0.5 2.7 0.0 100.0 97.3 1,100 Fier 97.2 0.3 0.0 2.4 0.1 100.0 97.5 1,083 Gjirokastër 98.4 0.4 0.4 0.8 0.0 100.0 99.2 204 Korçë 99.3 0.2 0.1 0.3 0.0 100.0 99.7 859 Kukës 98.5 0.7 0.5 0.2 0.0 100.0 99.8 338 Lezhe 98.7 0.7 0.2 0.3 0.0 100.0 99.7 482 Shkodër 98.3 0.7 0.7 0.2 0.0 100.0 99.8 795 Tirana 97.4 1.3 0.4 0.9 0.0 100.0 99.1 3,558 Vlorë 98.3 1.0 0.2 0.4 0.0 100.0 99.6 586 Education No education/primary 4-year 0.0 39.4 15.6 44.6 0.5 100.0 55.0 243 Primary 8-year 100.0 0.0 0.0 0.0 0.0 100.0 100.0 4,123 Secondary/professional/ technical 100.0 0.0 0.0 0.0 0.0 100.0 100.0 3,708 University and postgraduate 100.0 0.0 0.0 0.0 0.0 100.0 100.0 2,897 Wealth quintile Lowest 95.1 1.7 0.4 2.8 0.0 100.0 97.2 2,145 Second 96.9 1.0 0.7 1.4 0.1 100.0 98.5 2,161 Middle 98.2 1.0 0.2 0.6 0.0 100.0 99.4 2,130 Fourth 98.8 0.5 0.5 0.1 0.0 100.0 99.9 2,279 Highest 99.8 0.2 0.0 0.0 0.0 100.0 100.0 2,255 Total 15-49 97.8 0.9 0.3 1.0 0.0 100.0 99.0 10,970 50-59 97.2 1.1 0.7 0.9 0.1 100.0 99.1 4,030 Total 15-59 97.6 0.9 0.4 1.0 0.0 100.0 99.0 15,000 1 Refers to women who attended schooling higher than the secondary level and women who can read a whole sentence or part of a sentence 40 • Characteristics of Respondents Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Albania 2017-18 Higher than primary (4-year) schooling No schooling or primary (4 year) Total Percentage literate1 Number of men Background characteristic Can read a whole sentence Can read part of a sentence Cannot read at all Age 15-24 82.5 15.9 0.9 0.7 100.0 99.3 1,529 15-19 75.0 22.3 1.9 0.8 100.0 99.2 743 20-24 89.6 9.8 0.0 0.5 100.0 99.5 786 25-29 94.7 3.5 0.5 1.3 100.0 98.7 704 30-34 95.0 3.8 0.1 1.1 100.0 98.9 551 35-39 96.7 2.2 1.0 0.1 100.0 99.9 563 40-44 95.9 3.6 0.1 0.4 100.0 99.6 539 45-49 97.8 1.5 0.2 0.5 100.0 99.5 678 Residence Urban 91.7 6.7 0.7 0.9 100.0 99.1 2,721 Rural 91.3 8.0 0.3 0.3 100.0 99.7 1,844 Prefecture Berat 90.9 8.8 0.0 0.3 100.0 99.7 163 Dibër 86.4 12.4 0.7 0.5 100.0 99.5 202 Durrës 90.3 8.5 1.1 0.1 100.0 99.9 405 Elbasan 89.7 8.2 0.0 2.1 100.0 97.9 440 Fier 89.0 9.8 0.6 0.6 100.0 99.4 454 Gjirokastër 91.1 7.9 0.4 0.7 100.0 99.3 109 Korçë 95.3 4.2 0.5 0.0 100.0 100.0 404 Kukës 93.4 6.4 0.2 0.0 100.0 100.0 136 Lezhe 93.5 6.2 0.0 0.3 100.0 99.7 187 Shkodër 91.4 8.1 0.2 0.3 100.0 99.7 328 Tirana 92.6 5.5 0.9 1.0 100.0 99.0 1,500 Vlorë 91.3 8.2 0.4 0.0 100.0 100.0 236 Education No education/primary 4-year 42.5 16.6 9.8 31.1 100.0 68.9 87 Primary 8-year 98.7 1.0 0.2 0.0 100.0 100.0 1,502 Secondary/professional/ technical 90.1 9.0 0.7 0.2 100.0 99.8 2,039 University and postgraduate 87.6 12.4 0.0 0.0 100.0 100.0 936 Wealth quintile Lowest 90.4 7.4 0.7 1.5 100.0 98.5 856 Second 91.6 7.5 0.3 0.6 100.0 99.4 910 Middle 91.0 7.3 1.0 0.8 100.0 99.2 889 Fourth 91.7 7.8 0.4 0.0 100.0 100.0 912 Highest 92.7 6.2 0.5 0.6 100.0 99.4 997 Total 15-49 91.5 7.2 0.6 0.7 100.0 99.3 4,565 50-59 97.7 2.0 0.1 0.2 100.0 99.8 1,577 Total 15-59 93.1 5.9 0.5 0.6 100.0 99.4 6,142 1 Refers to men who attended schooling higher than the secondary level and men who can read a whole sentence or part of a sentence Characteristics of Respondents • 41 Table 3.4 Early education Percentage of children age 3 or 4 who attend an organized early childhood education program by sex, according to background characteristics, Albania 2017-2018 Male Female Total Background characteristic Percentage Number Percentage Number Percentage Number Residence Urban 77.0 264 73.5 288 75.1 552 Rural 67.6 237 71.4 235 69.5 473 Prefecture Berat (87.7) 22 87.1 31 87.4 53 Dibër 64.8 31 55.8 31 60.3 62 Durrës (82.3) 46 53.4 59 66.0 104 Elbasan 71.5 65 (65.4) 49 68.9 113 Fier (77.7) 53 81.4 58 79.6 111 Gjirokastër (81.5) 12 (68.2) 14 74.3 25 Korçë (83.8) 44 (93.8) 40 88.5 84 Kukës 50.9 23 41.8 22 46.4 45 Lezhe (66.3) 30 (79.8) 26 72.6 56 Shkodër (72.4) 30 (69.2) 30 70.8 60 Tirana (65.3) 110 77.1 137 71.8 247 Vlorë (75.8) 36 (80.6) 26 77.8 62 Age of child 3 years 65.9 242 64.4 267 65.1 509 4 years 78.7 259 81.0 256 79.8 516 Sex of head of household Male 74.6 435 72.3 461 73.4 896 Female 58.9 66 74.4 62 66.4 128 Age of head of household 15-24 * 9 * 7 * 15 25-29 (54.0) 21 * 34 62.0 55 30-39 74.9 143 75.8 148 75.3 291 40-49 86.1 74 65.5 85 75.1 160 50+ 70.8 254 74.9 249 72.8 503 Education of head of household No education/primary 4-year 70.2 48 57.3 54 63.4 102 Primary 8-year 67.3 228 69.4 242 68.4 470 Secondary/professional/ technical 75.9 159 82.4 159 79.2 318 University and postgraduate (91.5) 54 81.1 56 86.2 110 Don’t know/missing * 12 * 12 (43.6) 25 Wealth quintile Lowest 60.3 120 63.6 121 62.0 241 Second 68.0 114 66.6 120 67.3 234 Middle 74.9 100 79.1 114 77.1 214 Fourth 75.2 80 71.3 79 73.2 160 Highest 90.1 87 85.8 88 87.9 175 Total 72.5 501 72.5 523 72.5 1,024 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 42 • Characteristics of Respondents Table 3.5 Support in learning Percentage of children age 3 or 4 with whom an adult engaged in activities that promote learning and school readiness in the 3 days preceding the interview, by person who engaged in the activities and number of activities, according to background characteristics, Albania 2017-2018 Mother Father Other Number Background characteristic 3 or less 4 or more Any activity 3 or less 4 or more Any activity 3 or less 4 or more Any activity Residence Urban 39.2 60.8 95.7 81.7 18.3 62.1 74.3 25.7 61.4 532 Rural 48.2 51.8 86.9 91.3 8.7 52.0 83.3 16.7 52.0 451 Prefecture Berat 32.3 67.7 95.2 95.0 5.0 51.9 79.3 20.7 69.6 50 Dibër 68.9 31.1 67.1 98.3 1.7 25.8 90.7 9.3 25.4 58 Durrës 28.8 71.2 90.9 85.2 14.8 47.8 72.5 27.5 53.2 103 Elbasan 49.2 50.8 94.1 94.1 5.9 38.7 79.8 20.2 56.5 105 Fier 22.3 77.7 98.1 83.1 16.9 62.4 86.5 13.5 45.7 105 Gjirokastër 27.8 72.2 97.1 80.6 19.4 85.3 68.4 31.6 70.7 24 Korçë 40.9 59.1 92.8 92.3 7.7 68.4 71.8 28.2 62.4 82 Kukës 50.8 49.2 91.1 87.7 12.3 60.1 85.1 14.9 62.7 45 Lezhe 56.4 43.6 78.5 94.4 5.6 37.0 95.9 4.1 42.2 57 Shkodër 40.7 59.3 92.6 81.7 18.3 63.3 95.3 4.7 34.4 54 Tirana 52.8 47.2 94.0 78.5 21.5 68.4 68.0 32.0 72.1 241 Vlorë 35.0 65.0 97.5 78.9 21.1 76.7 78.0 22.0 63.3 58 Age of child 3 years 47.0 53.0 91.1 84.9 15.1 57.1 78.5 21.5 57.7 460 4 years 40.1 59.9 92.1 87.2 12.8 57.8 78.4 21.6 56.6 523 Child’s sex Male 45.0 55.0 90.6 86.0 14.0 60.6 78.1 21.9 57.3 495 Female 41.6 58.4 92.7 86.3 13.7 54.3 78.8 21.2 56.9 487 Wealth quintile Lowest 61.7 38.3 85.4 95.4 4.6 45.4 87.2 12.8 53.8 246 Second 41.5 58.5 91.3 91.8 8.2 55.3 82.7 17.3 53.6 222 Middle 33.4 66.6 90.9 80.2 19.8 61.3 70.7 29.3 55.1 196 Fourth 33.1 66.9 98.5 84.7 15.3 58.3 76.0 24.0 61.9 160 Highest 40.0 60.0 96.0 72.5 27.5 73.7 71.0 29.0 64.9 159 Total 43.3 56.7 91.7 86.1 13.9 57.5 78.5 21.5 57.1 983 Characteristics of Respondents • 43 Table 3.6.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, according to background characteristics, Albania 2017-18 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 19.0 93.2 16.1 8.5 5.7 1,684 20-24 15.9 90.8 16.0 7.9 8.9 1,548 25-29 16.6 88.8 16.0 8.4 9.8 1,514 30-34 15.8 89.2 14.9 7.6 9.6 1,442 35-39 16.1 91.0 15.9 7.6 7.4 1,388 40-44 17.6 93.2 12.9 7.6 5.8 1,601 45-49 16.7 92.2 11.4 5.5 6.9 1,794 Residence Urban 19.9 90.2 16.4 9.1 8.4 6,578 Rural 12.3 92.9 12.0 5.2 6.5 4,392 Prefecture Berat 12.1 96.3 3.1 1.2 3.1 439 Dibër 13.9 90.3 3.8 1.5 9.3 510 Durrës 6.4 96.0 6.6 2.0 3.2 1,017 Elbasan 19.4 97.7 14.5 6.7 2.0 1,100 Fier 18.6 94.4 15.4 6.9 4.8 1,083 Gjirokastër 13.2 94.6 15.7 6.5 4.5 204 Korçë 10.1 96.1 14.7 6.5 3.6 859 Kukës 11.2 90.1 7.0 5.8 9.4 338 Lezhe 26.4 84.4 12.3 9.4 13.1 482 Shkodër 18.6 90.1 14.9 10.6 7.4 795 Tirana 19.3 85.4 19.9 10.0 13.1 3,558 Vlorë 22.9 97.7 19.4 11.8 2.2 586 Education No education/primary 4-year 2.6 70.8 9.5 2.1 28.8 243 Primary 8-year 8.6 92.1 9.9 3.7 7.2 4,123 Secondary/professional/ technical 17.3 92.8 14.0 7.3 6.5 3,708 University and postgraduate 29.2 89.9 22.7 13.7 7.9 2,897 Wealth quintile Lowest 9.5 90.3 9.5 3.7 9.2 2,145 Second 11.8 93.7 10.2 4.6 5.7 2,161 Middle 15.8 94.8 12.6 6.2 4.6 2,130 Fourth 22.3 90.5 18.8 11.2 8.3 2,279 Highest 24.2 87.4 21.5 11.5 10.2 2,255 Total 15-49 16.9 91.3 14.7 7.5 7.6 10,970 50-59 18.4 90.9 12.7 8.3 8.5 4,030 Total 15-59 17.3 91.2 14.1 7.7 7.9 15,000 44 • Characteristics of Respondents Table 3.6.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, according to background characteristics, Albania 2017-18 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of men Age 15-19 21.3 84.6 20.9 11.8 13.6 743 20-24 26.4 85.5 26.5 14.3 12.2 786 25-29 24.3 89.0 35.0 15.3 9.4 704 30-34 28.6 92.2 34.1 17.4 7.2 551 35-39 22.7 89.6 33.5 13.9 7.9 563 40-44 25.4 87.5 30.1 15.4 10.0 539 45-49 27.7 90.3 30.1 17.1 9.1 678 Residence Urban 26.5 86.0 27.1 13.9 11.8 2,721 Rural 23.1 91.4 33.4 16.4 7.7 1,844 Prefecture Berat 30.2 97.6 36.9 18.0 1.7 163 Dibër 27.7 85.1 28.1 22.0 12.7 202 Durrës 11.0 82.9 2.8 1.2 17.1 405 Elbasan 26.4 91.9 28.2 18.5 7.8 440 Fier 50.5 97.3 45.2 31.6 1.5 454 Gjirokastër 35.7 96.1 66.7 21.7 1.8 109 Korçë 12.1 91.1 15.5 7.2 7.9 404 Kukës 8.6 92.6 9.5 4.7 6.8 136 Lezhe 10.6 92.9 7.0 3.2 6.4 187 Shkodër 18.0 95.8 33.7 9.0 3.7 328 Tirana 26.7 81.3 37.4 16.9 15.8 1,500 Vlorë 31.2 86.5 26.8 12.3 8.2 236 Education No education/primary 4-year 6.1 75.7 8.2 1.2 23.9 87 Primary 8-year 16.6 87.4 27.4 10.6 10.5 1,502 Secondary/professional/ technical 28.0 90.6 30.2 16.7 8.0 2,039 University and postgraduate 34.4 85.3 34.1 19.2 12.9 936 Wealth quintile Lowest 19.3 89.5 27.8 13.8 9.1 856 Second 21.0 90.4 26.6 13.3 9.0 910 Middle 23.4 89.3 24.5 11.7 9.0 889 Fourth 27.7 87.1 30.3 13.8 10.4 912 Highest 33.1 84.9 38.0 21.2 12.7 997 Total 15-49 25.1 88.2 29.7 14.9 10.1 4,565 50-59 29.6 87.5 29.1 18.4 11.7 1,577 Total 15-59 26.3 88.0 29.5 15.8 10.5 6,142 Characteristics of Respondents • 45 Table 3.7.1 Internet usage: Women Percent distribution of women age 15-59 by internet usage and among women who report not to use the internet, percent that report to have used it some time in the 12 months preceding the survey, according to background characteristics, Albania 2017-2018 Percent distribution by reported use of the internet Number of women Background characteristic At least once a week Less than once a week Not at all Total Age 15-19 82.0 7.5 10.5 100.0 1,684 20-24 87.7 3.7 8.6 100.0 1,548 25-29 74.7 8.9 16.3 100.0 1,514 30-34 65.7 9.8 24.5 100.0 1,442 35-39 53.0 12.2 34.8 100.0 1,388 40-44 45.3 11.9 42.8 100.0 1,601 45-49 40.1 11.0 48.9 100.0 1,794 Residence Urban 72.8 9.7 17.5 100.0 6,578 Rural 50.3 8.6 41.1 100.0 4,392 Prefecture Berat 53.6 8.8 37.7 100.0 439 Dibër 46.1 5.8 48.1 100.0 510 Durrës 69.8 6.7 23.5 100.0 1,017 Elbasan 53.6 4.9 41.5 100.0 1,100 Fier 55.0 4.1 40.9 100.0 1,083 Gjirokastër 60.8 8.4 30.9 100.0 204 Korçë 59.9 9.1 31.0 100.0 859 Kukës 49.7 9.0 41.2 100.0 338 Lezhe 54.2 22.9 22.9 100.0 482 Shkodër 67.5 13.1 19.4 100.0 795 Tirana 73.0 11.0 16.0 100.0 3,558 Vlorë 73.5 8.5 18.0 100.0 586 Education No education/primary 4-year 17.2 11.2 71.6 100.0 243 Primary 8-year 40.0 11.3 48.7 100.0 4,123 Secondary/professional/technical 70.3 10.7 19.0 100.0 3,708 University and postgraduate 93.1 4.4 2.5 100.0 2,897 Wealth quintile Lowest 32.9 10.0 57.2 100.0 2,145 Second 52.6 9.9 37.6 100.0 2,161 Middle 66.8 8.4 24.8 100.0 2,130 Fourth 78.7 9.4 11.9 100.0 2,279 Highest 85.9 8.8 5.3 100.0 2,255 Total 15-49 63.8 9.3 27.0 100.0 10,970 50-59 29.8 13.7 56.5 100.0 4,030 Total 15-59 54.6 10.5 34.9 100.0 15,000 46 • Characteristics of Respondents Table 3.7.2 Internet usage: Men Percent distribution of men age 15-59 by internet usage and among women who report not to use the internet, percent that report to have used it some time in the 12 months preceding the survey, according to background characteristics, Albania 2017-2018 Percent distribution by reported use of the internet Number of men Background characteristic At least once a week Less than once a week Not at all Total Age 15-19 79.6 14.8 5.6 100.0 743 20-24 81.2 14.7 4.1 100.0 786 25-29 82.0 11.3 6.7 100.0 704 30-34 73.2 13.9 12.9 100.0 551 35-39 62.2 21.5 16.4 100.0 563 40-44 50.1 21.2 28.7 100.0 539 45-49 36.4 21.3 42.3 100.0 678 Residence Urban 69.3 18.9 11.8 100.0 2,721 Rural 64.7 13.4 21.9 100.0 1,844 Prefecture Berat 69.9 9.3 20.8 100.0 163 Dibër 56.6 21.3 22.2 100.0 202 Durrës 54.6 34.2 11.2 100.0 405 Elbasan 60.7 17.1 22.3 100.0 440 Fier 75.3 7.5 17.2 100.0 454 Gjirokastër 64.7 5.0 30.4 100.0 109 Korçë 66.8 13.4 19.8 100.0 404 Kukës 68.6 6.9 24.5 100.0 136 Lezhe 63.4 16.4 20.2 100.0 187 Shkodër 73.3 15.2 11.6 100.0 328 Tirana 70.2 18.7 11.0 100.0 1,500 Vlorë 73.3 11.0 15.7 100.0 236 Education No education/primary 4-year 29.4 17.0 53.5 100.0 87 Primary 8-year 48.7 22.9 28.3 100.0 1,502 Secondary/professional/technical 75.4 13.2 11.4 100.0 2,039 University and postgraduate 83.5 14.3 2.3 100.0 936 Wealth quintile Lowest 53.6 14.7 31.7 100.0 856 Second 61.8 19.1 19.1 100.0 910 Middle 65.6 18.7 15.7 100.0 889 Fourth 73.8 15.6 10.6 100.0 912 Highest 80.3 15.5 4.3 100.0 997 Total 15-49 67.4 16.7 15.9 100.0 4,565 50-59 25.4 24.3 50.3 100.0 1,577 Total 15-59 56.6 18.6 24.7 100.0 6,142 Characteristics of Respondents • 47 Table 3.8.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Albania 2017-18 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Background characteristic Currently employed1 Not currently employed Age 15-19 4.8 3.6 91.6 100.0 1,684 20-24 28.7 8.3 62.9 100.0 1,548 25-29 39.1 5.6 55.4 100.0 1,514 30-34 44.9 5.1 50.1 100.0 1,442 35-39 47.1 3.0 50.0 100.0 1,388 40-44 48.3 4.2 47.5 100.0 1,601 45-49 48.8 2.5 48.7 100.0 1,794 Marital status Never married 23.2 4.7 72.1 100.0 3,191 Married or living together 42.2 4.2 53.6 100.0 7,403 Divorced/separated/widowed 53.3 11.6 35.1 100.0 376 Number of living children 0 25.7 5.4 68.8 100.0 3,904 1-2 46.0 4.9 49.1 100.0 5,024 3-4 37.6 2.1 60.2 100.0 1,967 5+ 13.8 1.5 84.7 100.0 75 Residence Urban 43.4 4.6 52.0 100.0 6,578 Rural 27.6 4.5 67.9 100.0 4,392 Prefecture Berat 43.7 4.0 52.3 100.0 439 Dibër 11.0 0.2 88.7 100.0 510 Durrës 37.0 5.2 57.8 100.0 1,017 Elbasan 25.8 9.0 65.3 100.0 1,100 Fier 42.0 2.6 55.4 100.0 1,083 Gjirokastër 36.9 3.7 59.4 100.0 204 Korçë 42.0 8.0 49.9 100.0 859 Kukës 12.6 3.0 84.4 100.0 338 Lezhe 19.6 1.9 78.5 100.0 482 Shkodër 20.2 1.7 78.2 100.0 795 Tirana 50.1 4.5 45.4 100.0 3,558 Vlorë 32.0 5.6 62.5 100.0 586 Education No education/primary 4-year 25.8 10.6 63.7 100.0 243 Primary 8-year 28.9 3.9 67.2 100.0 4,123 Secondary/professional/technical 31.6 4.4 64.0 100.0 3,708 University and postgraduate 56.6 5.3 38.1 100.0 2,897 Wealth quintile Lowest 21.2 4.3 74.5 100.0 2,145 Second 27.8 4.2 67.9 100.0 2,161 Middle 35.6 5.1 59.4 100.0 2,130 Fourth 42.4 5.6 52.1 100.0 2,279 Highest 57.0 3.6 39.3 100.0 2,255 Total 15-49 37.1 4.6 58.4 100.0 10,970 50-59 37.0 3.1 59.9 100.0 4,030 Total 15-59 37.0 4.2 58.8 100.0 15,000 1 “Currently employed” is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 48 • Characteristics of Respondents Table 3.8.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Albania 2017-18 Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Background characteristic Currently employed1 Not currently employed Age 15-19 15.0 4.7 80.3 100.0 743 20-24 40.6 7.3 52.1 100.0 786 25-29 65.9 4.3 29.8 100.0 704 30-34 72.6 5.5 21.9 100.0 551 35-39 77.6 4.1 18.3 100.0 563 40-44 68.8 4.3 27.0 100.0 539 45-49 68.6 4.6 26.8 100.0 678 Marital status Never married 40.5 5.6 53.9 100.0 2,328 Married or living together 73.1 4.3 22.6 100.0 2,183 Divorced/separated/widowed 53.9 9.9 36.2 100.0 54 Number of living children 0 44.5 5.4 50.2 100.0 2,671 1-2 74.6 4.6 20.9 100.0 1,382 3-4 67.9 4.7 27.4 100.0 492 5+ (72.9) (3.7) (23.3) 100.0 20 Residence Urban 55.3 4.3 40.4 100.0 2,721 Rural 57.6 6.2 36.2 100.0 1,844 Prefecture Berat 69.8 7.3 23.0 100.0 163 Dibër 41.0 4.3 54.7 100.0 202 Durrës 61.9 1.8 36.3 100.0 405 Elbasan 41.6 6.8 51.6 100.0 440 Fier 74.2 7.2 18.5 100.0 454 Gjirokastër 48.2 3.0 48.8 100.0 109 Korçë 62.4 4.3 33.3 100.0 404 Kukës 36.2 3.2 60.7 100.0 136 Lezhe 44.8 4.7 50.5 100.0 187 Shkodër 47.2 3.0 49.9 100.0 328 Tirana 57.8 5.3 36.9 100.0 1,500 Vlorë 59.4 7.0 33.6 100.0 236 Education No education/primary 4-year 38.5 4.4 57.0 100.0 87 Primary 8-year 57.2 6.4 36.5 100.0 1,502 Secondary/professional/technical 53.5 4.8 41.8 100.0 2,039 University and postgraduate 62.4 3.6 34.0 100.0 936 Wealth quintile Lowest 50.9 6.0 43.1 100.0 856 Second 55.5 4.8 39.7 100.0 910 Middle 55.7 5.7 38.6 100.0 889 Fourth 57.7 4.4 37.9 100.0 912 Highest 60.6 4.4 35.0 100.0 997 Total 15-49 56.2 5.0 38.7 100.0 4,565 50-59 61.6 4.2 34.2 100.0 1,577 Total 15-59 57.6 4.8 37.6 100.0 6,142 Note: Figures in parentheses are based on 25-49 unweighted cases. 1 “Currently employed” is defined as having done work in the past 7 days. Includes persons who did not work in the past 7 days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 2 Twenty cases for which the number of living children is missing are excluded. Characteristics of Respondents • 49 Table 3.9.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Albania 2017-18 Background characteristic Profes- sional/tech- nical/mana- gerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Non- classified1 Total Number of women Age 15-19 1.9 11.3 34.8 17.0 6.9 14.2 14.0 100.0 142 20-24 17.8 8.9 31.5 19.9 6.5 5.8 9.6 100.0 574 25-29 34.7 9.2 17.0 19.4 3.1 6.5 10.0 100.0 676 30-34 35.9 6.1 14.9 20.4 1.9 9.3 11.6 100.0 720 35-39 27.3 2.4 11.3 21.4 7.6 16.1 13.9 100.0 695 40-44 20.6 3.8 14.2 20.4 11.4 17.7 11.9 100.0 841 45-49 24.7 2.9 12.5 15.0 11.7 19.6 13.6 100.0 921 Marital status Never married 32.4 10.9 26.8 12.0 4.0 4.4 9.4 100.0 889 Married or living together 24.7 3.8 13.9 20.4 8.1 15.9 13.2 100.0 3,434 Divorced/separated/widowed 21.3 8.2 19.9 27.0 10.2 8.6 4.8 100.0 244 Number of living children 0 31.3 9.3 25.5 14.9 4.0 5.5 9.5 100.0 1,217 1-2 27.4 4.9 12.6 20.2 8.3 14.5 12.1 100.0 2,556 3-4 13.6 1.2 17.0 22.3 9.5 20.8 15.5 100.0 782 5+ (2.6) (0.0) (16.1) (14.3) (11.3) (44.7) (11.0) 100.0 12 Residence Urban 31.1 6.7 18.9 21.7 7.8 1.6 12.3 100.0 3,157 Rural 14.6 2.7 12.0 13.5 6.6 39.3 11.3 100.0 1,410 Prefecture Berat 13.5 1.6 12.0 15.5 3.4 34.6 19.5 100.0 209 Dibër 49.9 4.4 15.8 13.2 7.4 0.6 8.8 100.0 57 Durrës 24.0 1.8 16.6 40.4 5.6 2.4 9.3 100.0 429 Elbasan 20.6 3.9 17.9 10.5 7.9 30.5 8.8 100.0 382 Fier 18.8 4.1 15.0 13.4 7.7 25.3 15.6 100.0 483 Gjirokastër 29.4 7.3 13.5 17.1 7.1 8.6 17.0 100.0 83 Korçë 18.7 1.8 9.1 13.7 3.3 46.6 6.9 100.0 430 Kukës 43.3 3.4 12.3 1.0 4.8 31.3 3.9 100.0 53 Lezhe 34.7 4.1 23.2 19.5 7.3 2.3 8.9 100.0 104 Shkodër 27.5 6.0 21.6 25.8 3.4 5.6 10.1 100.0 174 Tirana 29.7 8.1 18.3 20.4 9.3 1.5 12.7 100.0 1,943 Vlorë 32.0 5.7 20.9 9.5 8.4 7.8 15.7 100.0 220 Education No education/primary 4-year 3.5 0.0 43.3 11.8 6.4 23.4 11.6 100.0 88 Primary 8-year 1.0 0.1 10.6 31.5 11.1 33.3 12.4 100.0 1,353 Secondary/professional/ technical 5.5 4.3 24.8 27.6 11.4 9.4 17.1 100.0 1,333 University and postgraduate 61.2 10.6 14.2 3.9 1.7 0.5 7.9 100.0 1,793 Wealth quintile Lowest 7.5 1.6 6.3 11.7 5.9 56.2 10.8 100.0 548 Second 10.5 1.7 17.6 23.5 8.5 27.2 11.0 100.0 693 Middle 20.2 2.6 19.8 27.8 9.4 8.4 11.9 100.0 866 Fourth 30.1 7.6 21.4 19.2 7.9 2.3 11.6 100.0 1,092 Highest 41.7 9.0 15.0 14.4 5.7 0.8 13.3 100.0 1,368 Total 15-49 26.0 5.4 16.8 19.1 7.4 13.2 12.0 100.0 4,567 50-59 19.6 2.2 17.4 11.8 12.1 23.3 13.6 100.0 1,614 Total 15-59 24.3 4.6 16.9 17.2 8.6 15.9 12.4 100.0 6,182 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 These are occupations that could not be coded into any precise category because they were not recorded in sufficient detail in the field. 50 • Characteristics of Respondents Table 3.9.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Albania 2017-18 Background characteristic Profes- sional/tech- nical/mana- gerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Non- classified Total Number of men Age 15-19 1.7 0.2 33.7 22.9 3.8 20.8 17.0 100.0 146 20-24 13.7 4.4 27.9 22.4 4.8 14.2 12.7 100.0 376 25-29 14.0 6.7 22.3 28.5 5.4 10.8 12.2 100.0 494 30-34 17.1 1.2 16.5 31.7 3.3 13.2 17.0 100.0 430 35-39 12.2 2.7 13.3 35.4 7.9 13.1 15.5 100.0 460 40-44 11.7 6.3 11.1 29.1 6.7 18.3 16.8 100.0 394 45-49 11.9 2.3 14.1 31.6 4.3 21.7 14.1 100.0 497 Marital status Never married 13.6 4.8 25.1 24.3 4.3 13.3 14.6 100.0 1,072 Married or living together 12.3 3.1 13.8 33.0 6.0 16.9 14.9 100.0 1,691 Divorced/separated/widowed (13.6) (0.0) (22.7) (31.2) (3.6) (16.1) (12.8) 100.0 35 Number of living children 0 13.5 4.3 22.8 27.0 4.8 13.1 14.6 100.0 1,332 1-2 13.7 3.8 14.8 30.1 6.0 15.2 16.4 100.0 1,094 3-4 7.2 1.6 12.2 38.8 4.7 24.6 10.9 100.0 357 5+ * * * * * * * 100.0 15 Residence Urban 16.6 5.3 22.0 29.5 6.2 2.0 18.3 100.0 1,622 Rural 7.5 1.5 13.1 29.9 4.0 34.2 9.8 100.0 1,176 Prefecture Berat 12.8 2.6 9.6 24.5 6.0 35.2 9.4 100.0 126 Dibër 8.8 0.8 13.7 32.4 5.8 25.5 13.1 100.0 92 Durrës 8.9 2.9 18.0 33.5 7.2 0.5 28.8 100.0 258 Elbasan 6.8 0.0 18.6 35.0 7.8 27.2 4.5 100.0 213 Fier 8.9 3.6 19.0 29.4 4.9 28.6 5.7 100.0 370 Gjirokastër 16.4 4.1 7.7 23.2 9.1 14.9 24.5 100.0 56 Korçë 7.7 1.6 10.1 21.1 3.4 43.6 12.5 100.0 270 Kukës 9.0 1.8 17.0 24.3 16.3 4.1 27.4 100.0 53 Lezhe 10.3 5.2 16.2 37.8 10.5 7.7 12.4 100.0 93 Shkodër 15.2 1.8 17.4 25.4 4.7 18.5 17.1 100.0 165 Tirana 17.8 6.7 23.5 29.7 3.5 2.0 16.9 100.0 946 Vlorë 16.5 0.6 14.5 37.3 5.6 11.0 14.4 100.0 157 Education No education/primary 4-year (1.4) (0.0) (25.1) (21.2) (10.5) (22.1) (19.6) 100.0 37 Primary 8-year 1.7 0.6 11.3 38.8 7.5 28.7 11.5 100.0 954 Secondary/professional/ technical 5.5 2.8 24.9 33.2 5.1 12.2 16.3 100.0 1,188 University and postgraduate 44.7 10.6 15.8 9.2 2.0 1.2 16.5 100.0 618 Wealth quintile Lowest 4.9 0.4 10.8 25.5 6.3 44.9 7.2 100.0 487 Second 6.4 1.1 13.3 37.0 6.2 25.7 10.3 100.0 549 Middle 8.1 2.0 19.4 36.5 6.7 9.7 17.6 100.0 546 Fourth 15.4 3.5 26.3 27.8 4.8 3.0 19.1 100.0 567 Highest 25.9 10.1 19.9 22.4 3.1 0.6 18.0 100.0 648 Total 15-49 12.8 3.7 18.2 29.7 5.3 15.5 14.8 100.0 2,798 50-59 11.8 4.1 15.4 28.2 5.1 24.1 11.3 100.0 1,038 Total 15-59 12.5 3.8 17.5 29.3 5.3 17.8 13.8 100.0 3,835 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 These are occupations that could not be coded into any precise category because they were not recorded in sufficient detail in the field. Characteristics of Respondents • 51 Table 3.10 Type of employment Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Albania 2017-18 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 23.0 92.5 81.5 Cash and in-kind 14.5 2.5 4.4 In-kind only 17.5 1.3 3.9 Not paid 45.0 3.7 10.2 Total 100.0 100.0 100.0 Type of employer Employed by family member 32.5 15.7 18.4 Employed by nonfamily member 6.4 67.8 58.1 Self-employed 61.1 16.5 23.6 Total 100.0 100.0 100.0 Continuity of employment All year 39.5 87.9 80.2 Seasonal 54.7 7.8 15.2 Occasional 5.8 4.3 4.5 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 981 5,201 6,182 Note: Total includes women with missing information on type of employment who are not shown separately. 52 • Characteristics of Respondents Table 3.11.1 Health insurance coverage: Women Percentage of women age 15-49 with specific types of health insurance coverage, and percentage with any health insurance, according to background characteristics, Albania 2017-18 Background characteristic State health insurance Social security Voluntary health insurance Privately purchased commercial insurance Other None Any health insurance Number of women Age 15-19 21.2 1.7 0.2 0.4 0.2 77.3 22.7 1,684 20-24 29.9 12.4 0.4 1.9 0.1 65.1 34.9 1,548 25-29 35.9 16.6 1.2 1.9 0.4 58.2 41.8 1,514 30-34 36.0 20.8 1.8 2.2 0.4 56.3 43.7 1,442 35-39 35.8 17.4 2.1 1.5 0.3 57.3 42.7 1,388 40-44 31.1 16.7 2.1 2.7 0.4 60.5 39.5 1,601 45-49 33.1 15.9 3.0 2.5 0.2 58.9 41.1 1,794 Residence Urban 40.2 20.0 1.6 2.6 0.3 52.1 47.9 6,578 Rural 18.8 5.6 1.4 0.8 0.2 77.2 22.8 4,392 Prefecture Berat 17.0 9.4 1.1 1.9 0.0 71.1 28.9 439 Dibër 14.5 1.6 2.1 0.6 0.1 81.4 18.6 510 Durrës 34.3 15.3 0.0 0.2 0.0 65.4 34.6 1,017 Elbasan 24.6 3.2 0.8 0.7 0.1 73.7 26.3 1,100 Fier 17.4 15.8 3.4 1.7 1.8 72.1 27.9 1,083 Gjirokastër 23.1 27.6 5.0 0.2 0.1 62.1 37.9 204 Korçë 44.1 7.8 2.1 0.7 0.0 53.0 47.0 859 Kukës 9.5 3.4 0.6 0.5 0.0 89.3 10.7 338 Lezhe 12.9 7.8 0.2 0.0 0.0 82.2 17.8 482 Shkodër 35.1 5.7 0.1 1.0 0.0 63.4 36.6 795 Tirana 44.3 23.7 1.8 3.2 0.1 46.6 53.4 3,558 Vlorë 23.4 15.8 1.7 6.2 0.2 68.0 32.0 586 Education No education/primary 4-year 11.9 4.9 0.1 0.0 0.4 86.5 13.5 243 Primary 8-year 19.3 6.6 1.3 0.9 0.3 76.4 23.6 4,123 Secondary/professional/ technical 28.7 11.6 2.3 2.7 0.2 63.6 36.4 3,708 University and postgraduate 54.5 29.4 1.0 2.3 0.3 38.1 61.9 2,897 Wealth quintile Lowest 12.9 2.5 0.5 0.4 0.2 85.0 15.0 2,145 Second 20.4 7.6 1.1 0.5 0.2 75.5 24.5 2,161 Middle 31.7 11.6 1.2 1.9 0.1 62.8 37.2 2,130 Fourth 39.7 19.6 1.6 3.2 0.7 51.7 48.3 2,279 Highest 52.0 29.0 3.2 3.1 0.1 37.8 62.2 2,255 Total 15-49 31.6 14.3 1.5 1.9 0.3 62.2 37.8 10,970 50-59 30.0 13.8 3.4 1.2 0.4 62.5 37.5 4,030 Total 15-59 31.2 14.1 2.0 1.7 0.3 62.3 37.7 15,000 Characteristics of Respondents • 53 Table 3.11.2 Health insurance coverage: Men Percentage of men age 15-49 with specific types of health insurance coverage, and percentage with any health insurance, according to background characteristics, Albania 2017-18 Background characteristic State health insurance Social security Voluntary health insurance Privately purchased commercial insurance Other None Any health insurance Number of men Age 15-19 13.2 0.5 0.2 1.0 0.1 85.4 14.6 743 20-24 21.9 4.0 0.7 3.6 0.6 72.8 27.2 786 25-29 36.7 15.6 0.8 5.7 0.1 54.8 45.2 704 30-34 33.6 11.4 1.3 8.7 0.0 54.7 45.3 551 35-39 37.0 13.7 1.2 3.5 0.1 54.3 45.7 563 40-44 27.6 9.6 1.0 6.3 0.3 61.9 38.1 539 45-49 34.3 8.5 1.0 4.3 0.0 59.5 40.5 678 Residence Urban 32.8 11.0 0.8 6.1 0.2 58.2 41.8 2,721 Rural 22.3 5.1 0.8 2.2 0.2 73.3 26.7 1,844 Prefecture Berat 12.9 24.5 0.4 0.0 0.0 68.2 31.8 163 Dibër 18.2 4.1 3.6 4.0 1.2 72.4 27.6 202 Durrës 26.9 4.7 2.4 12.3 1.3 57.5 42.5 405 Elbasan 13.5 1.7 0.7 0.7 0.2 84.3 15.7 440 Fier 27.7 16.3 0.0 4.1 0.0 68.0 32.0 454 Gjirokastër 33.8 1.4 0.4 0.5 0.0 64.1 35.9 109 Korçë 47.7 1.3 0.0 1.6 0.0 49.6 50.4 404 Kukës 8.8 4.3 0.1 0.2 0.0 90.4 9.6 136 Lezhe 18.0 1.6 0.0 1.5 0.0 78.9 21.1 187 Shkodër 18.8 8.9 1.7 3.4 0.0 75.9 24.1 328 Tirana 37.4 12.4 0.2 6.2 0.0 54.4 45.6 1,500 Vlorë 22.9 6.6 3.7 5.5 0.0 67.8 32.2 236 Education No education/primary 4-year 8.6 0.8 2.9 0.6 0.0 87.0 13.0 87 Primary 8-year 16.2 4.3 0.6 2.8 0.2 78.4 21.6 1,502 Secondary/professional/ technical 28.4 7.9 1.0 6.1 0.3 62.6 37.4 2,039 University and postgraduate 50.7 18.0 0.6 4.2 0.0 43.4 56.6 936 Wealth quintile Lowest 14.1 2.8 0.6 1.4 0.4 82.6 17.4 856 Second 19.0 3.2 0.6 3.9 0.0 75.4 24.6 910 Middle 25.0 6.9 0.9 3.6 0.5 68.6 31.4 889 Fourth 37.7 12.2 1.3 7.2 0.1 52.1 47.9 912 Highest 44.6 16.9 0.8 6.0 0.0 45.9 54.1 997 Total 15-49 28.6 8.6 0.8 4.5 0.2 64.3 35.7 4,565 50-59 31.2 8.4 1.9 3.3 1.2 60.4 39.6 1,577 Total 15-59 29.2 8.6 1.1 4.2 0.5 63.3 36.7 6,142 Marriage and Sexual Activity • 55 MARRIAGE AND SEXUAL ACTIVITY 4 Key Findings  Marital status: 68% of women and 48% of men age 15-49 are married or living with a partner.  Age at first marriage: The median age at first marriage for women age 30-49 is 21.9 years, and for men age 30- 59 it is 27.3 years.  Age at first sexual intercourse: Median age at first sexual intercourse among men age 30-59 and women age 30-49 is 21.9 and 20.9 years, respectively.  Sexual activity: Among women and men age 15-49 years, 24% of women and 23% of men have never had sexual intercourse.  Recent sexual activity: Among women and men age 15-49, 59% of women and 54% of men had sexual intercourse in the 4 weeks preceding the survey. arriage and sexual activity help determine the extent to which women are exposed to the risk of pregnancy. Thus, they are important determinants of fertility levels. The timing and circumstances of marriage and sexual activity also have profound consequences for women’s and men’s lives. 4.1 MARITAL STATUS Currently married Women and men who report being married or living with a partner as though married at the time of the survey Sample: Women and men age 15-49 In Albania, 68% of women and 48% of men age 15-49 are married or living with a partner as though married. For the age group 45-49, only 3% of women and men have never been married. Only 1% of men age 15-49 report being separated or divorced, but for women this proportion is higher (Table 4.1, Figure 4.1). M Figure 4.1 Marital status Percent distribution of women and men age 15-49 Never married 29% Married or living together 66% Divorced/ separated 4% Widowed 1% Women Never married 51% Married or living together 48% Divorced/ separated 1% Widowed 0% Men 56  Marriage and Sexual Activity Trends: The percentage of women who were married remained unchanged in the last decade, at 65%. For men the proportion decreased from 57% in 2008-9 to 46% in 2017-18. The proportion of women in consensual union increased from 1% to 3%, but remained practically unchanged for men despite increasing slightly. 4.2 AGE AT FIRST MARRIAGE Median age at first marriage Age by which half of respondents have been married. Sample: Women age 25-49 and 30-49, and men age 25-49, 30-49, 25-59, and 30-59 Thirty percent of women age 25-49 are married compared with only 3% of men in the same age bracket. By age 25, 73% of women and 25% of men were married. (Table 4.2). The median age at first marriage for women age 30-49 years is 21.9 years, whereas in men age 30-59 it is 27.3 years, indicating that on average men get married about five years later than women do (Table 4.3). Trends: In 2008-09 77% of women and 34% of men age 15-49 were married by age 25, compared with 73% and 27%, respectively, in 2017-18. The median age at first marriage for women age 30-49 has remained unchanged: 21.8 in 2008-09 and 21.9 in 2017-18. Patterns according to background characteristics  Among women age 25-49, those living in urban areas marry a bit more than 1year later than those living in rural areas (22.6 and 21.2, respectively). The same pattern is evident in men.  The median age at first marriage among women age 30-49 is fairly uniform across the country, with little difference among prefectures: it varies from 21.0 in Berat to 22.6 in Tirana. The gap by prefecture is wider among men age 30-59, from 25.3 in Elbasan to 29.6 in Gjirokastër.  Bette-educated women and men, as well as those in the higher wealth quintiles marry later than their counterparts in the lower education brackets and lower wealth quintiles. 4.3 EARLY MARRIAGE As seen in Table 4.2, 11% of women age 20-49 and 2% of men marry by age 18. Trends: There was a slight increase, from 9% to 11%, in the proportion of women age 20-49 who married by age 18 between 2008-09 and 2017-18. Among men age 20-49, this proportion increased from 1% to 2% in the same period. The increase is especially noticeable among women with little education: the proportion married by age 18 increased from 22% in 2008-09 to 35% in 2017-18 among women with primary 4-year education or less. Patterns according to background characteristics  For women and men, the median age at first marriage is a little over a year later in urban areas than in rural areas (Figure 4.2). Figure 4.2 Women’s and men’s median age at first marriage and first sexual intercourse by residence 21.9 20.922.4 21.221.2 20.7 Median age at first marriage First sexual intercourse Median age at first marriage/first sexual intercourse among women age 30-49 Total Urban Rural Marriage and Sexual Activity • 57  Noticeable differences exist between prefectures, with the proportion of women married by age 18 being as low as 7% in Kukës and as high as 14% in Dibër.  Education shows a very strong inverse correlation with early marriage: 35% of women with only primary 4-year education or less were married by age 18, compared with only 3% of women with a university or postgraduate education. Among men, these proportions are 7% and 2% respectively.  There is an inverse correlation between socioeconomic status and early marriage as well, but much less pronounced than education: 15% of women age 20-49 in the lowest wealth quintile were married by age 18, compared with 7% of those in the highest quintile. This pattern does not occur among men (Table 4.4). 4.4 AGE AT FIRST SEXUAL INTERCOURSE Median age at first sexual intercourse Age by which half of respondents have had sexual intercourse. Sample: Women age 25-49 and 30-49, and men age 25-49, 30-49, 25-59, and 30-59 The median age at first sexual intercourse for women age 25-49 is 20.9, indicating that by this age half of them have experienced their first sexual intercourse. Only 1% of women age 25-49 report having their first sexual intercourse by age 15, and by age 20 more than one-third (37%) had initiated sexual activity. The median age at first sexual intercourse for men age 25-49 is 20.8, practically identical to that of women. More men than women have their first sexual intercourse in early adolescence—by age 15 or 18—but at later ages the proportion of people initiating sexual activities tends to be slightly greater among women (Table 4.5). Trends: The median age of first sexual intercourse has not changed much for women in the decade preceding the survey (20.9 years in 2008-9 and 2017-18 ADHS surveys). For men, there was a decline in this median age, from 22.3 years in 2008-9 to 20.8 years in 2017-18. This is because men seem to be initiating their sexual activity when younger. Among men 25 and older, the proportion reporting to have had sexual intercourse by age 15 increased from less than 1% in 2008-9 to 3% in 2017-18, and the proportion who report having had sex by age 18 increased from 8% in 2008-9 to 15% in 2017-18. Patterns according to background characteristics  Among women age 25-49, the median age at first sexual intercourse is about the same in urban and rural areas (21.1 and 20.7, respectively); for men age 25-59 the difference is 1 year (21.0 and 22.0, respectively).  There are no significant differences by prefecture in the median age of first sexual intercourse among women. Among men 25-59, on the other hand, age at first sexual intercourse ranges from 19.6 years in Vlorë prefecture to 24.5 years in Lezhe.  Better educated women tend to initiate sexual activity later. Among women age 30-49, there is a 4- year difference in the median age at first sexual intercourse between those who have reached a university or post-graduate level compared with those who have no education or only primary education.  A similar trend is observed for the median age of the first sexual intercourse across wealth quintiles for women: women in higher wealth quintiles tend to initiate sexual activity at a later age. The pattern is the opposite among men, as men in the higher wealth quintiles tend to initiate sexual activity younger than men in the lower wealth quintiles (Table 4.6). 58  Marriage and Sexual Activity For some respondents marriage represents the initiation of sexual activity, but a significant proportion of respondents initiate sexual activity before marriage. The gap between the age of first sexual activity and age of first marriage indicates duration of premarital sex. Because men tend to marry at a later age, they tend to spend more years being sexually active outside of marriage. Thus, for men age 30-59, the median age at first sexual intercourse is 21.9 but median age at first marriage is 27.3, which means on average they spend 5.4 years having premarital sex. For women, the difference between median age at first sex and median age at first marriage is 1 year, so their exposure to premarital sex is significantly shorter. Figure 4.2 also shows that for men and women alike, exposure to premarital sex is shorter in rural areas, mainly because they marry younger than in urban areas (Figure 4.2). Among men, the median age at first marriage tends to increase with wealth, while the age of initiation of sexual activity decreases with wealth. This means that the average number of years of premarital sexual activity increases from 3.7 years among men in the lowest wealth quintile to 7.6 years in highest quintile. This pattern is not noticeable among women (Figure 4.3). 4.5 RECENT SEXUAL ACTIVITY In this survey women and men were asked how long ago their last sexual intercourse occurred. Among women and men age 15-49, 24% of women and 23% of men have never had sexual intercourse. Seven percent of women and 5% of men reported that their last sexual intercourse occurred more than a year preceding the survey. Among women and men age 15-49, 59% of women and 54% of men had sexual intercourse in the 4 weeks preceding the survey. For more information on recent sexual activity, see Table 4.7.1 and Table 4.7.2. LIST OF TABLES For more information on marriage and sexual activity, see the following tables:  Table 4.1 Current marital status  Table 4.2 Age at first marriage  Table 4.3 Median age at first marriage by background characteristics  Table 4.4 Early marriage by background characteristics  Table 4.5 Age at first sexual intercourse  Table 4.6 Median age at first sexual intercourse by background characteristics  Table 4.7.1 Recent sexual activity: Women  Table 4.7.2 Recent sexual activity: Men Figure 4.3 Women’s and men’s median age at first marriage and first sexual intercourse by wealth 21.4 21.2 21.8 22.0 22.820.9 20.6 20.9 21.0 21.3 Lowest Second Middle Fourth Highest Median age at first marriage and first sexual intercourse among women age 30-49 Median age at first marriage First sexual intercourse Poorest Wealthiest Marriage and Sexual Activity • 59 Table 4.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Albania 2017-18 Marital status Total Percentage of respondents currently in union Number of respondents Age Never married Married Living together Divorced Separated Widowed WOMEN 15-19 93.0 4.8 1.9 0.3 0.0 0.0 100.0 6.7 1,684 20-24 57.6 34.0 6.4 0.9 0.8 0.2 100.0 40.5 1,548 25-29 26.2 67.4 3.5 1.8 0.6 0.5 100.0 70.9 1,514 30-34 10.2 82.7 3.1 2.6 0.8 0.4 100.0 85.9 1,442 35-39 6.8 88.0 1.0 2.7 0.4 1.0 100.0 89.0 1,388 40-44 2.6 90.3 1.3 2.4 0.4 3.0 100.0 91.7 1,601 45-49 3.0 91.2 0.7 1.8 0.3 3.0 100.0 91.9 1,794 Total 15-49 29.1 65.0 2.5 1.8 0.5 1.2 100.0 67.5 10,970 MEN 15-19 99.8 0.1 0.0 0.0 0.0 0.1 100.0 0.1 743 20-24 92.7 5.5 1.8 0.0 0.0 0.0 100.0 7.3 786 25-29 72.8 21.7 5.3 0.0 0.2 0.0 100.0 27.0 704 30-34 34.7 60.7 2.6 1.3 0.5 0.1 100.0 63.3 551 35-39 17.8 79.0 1.3 1.3 0.6 0.0 100.0 80.3 563 40-44 6.6 90.0 1.1 1.2 0.9 0.2 100.0 91.1 539 45-49 2.7 93.2 1.5 1.8 0.6 0.2 100.0 94.7 678 Total 15-49 51.0 45.9 2.0 0.7 0.4 0.1 100.0 47.8 4,565 50-59 2.5 94.3 0.7 1.4 0.1 1.0 100.0 95.0 1,577 Total 15-59 38.5 58.3 1.6 0.9 0.3 0.3 100.0 59.9 6,142 Table 4.2 Age at first marriage Percentage of women and men age 15-49 who were first married by specific exact ages and median age at first marriage, according to current age, Albania 2017-18 Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage Current age 15 18 20 22 25 WOMEN 15-19 1.0 na na na na 93.0 1,684 a 20-24 1.4 11.8 26.2 na na 57.6 1,548 a 25-29 1.9 11.3 28.8 46.2 64.4 26.2 1,514 22.5 30-34 2.9 14.2 29.4 47.5 68.1 10.2 1,442 22.5 35-39 2.2 13.3 32.5 51.0 71.7 6.8 1,388 21.9 40-44 1.7 11.5 33.9 56.2 79.6 2.6 1,601 21.4 45-49 1.4 7.5 25.0 51.3 77.2 3.0 1,794 21.9 20-49 1.9 11.4 29.2 na na 17.5 9,286 a 25-49 2.0 11.3 29.8 50.5 72.5 9.5 7,739 22.0 MEN 15-19 0.1 na na na na 99.8 743 a 20-24 1.0 1.2 2.1 na na 92.7 786 a 25-29 0.8 1.5 2.9 5.3 14.4 72.8 704 a 30-34 1.0 1.2 3.2 6.2 20.4 34.7 551 28.9 35-39 0.4 1.7 4.0 11.8 25.3 17.8 563 28.9 40-44 0.7 1.6 3.4 14.3 31.4 6.6 539 27.1 45-49 0.1 1.5 3.1 9.0 33.0 2.7 678 26.6 20-49 0.7 1.5 3.0 na na 41.5 3,822 a 25-49 0.6 1.5 3.3 9.1 24.7 28.2 3,036 a 20-59 0.5 1.4 3.0 na na 30.1 5,399 a 25-59 0.4 1.4 3.2 8.3 27.0 19.4 4,613 a Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. na = Not applicable due to censoring a = Omitted because less than 50% of the women or men began living with their spouse or partner for the first time before reaching the beginning of the age group. 60  Marriage and Sexual Activity Table 4.3 Median age at first marriage by background characteristics Median age at first marriage among women age 25-49 and age 30-49, and median age at first marriage among men age 30-59, according to background characteristics, Albania 2017-18 Women age Men age Background characteristic 25-49 30-49 30-59 Residence Urban 22.6 22.4 27.8 Rural 21.2 21.2 26.5 Prefecture Berat 21.0 21.0 26.5 Dibër 21.3 21.3 26.5 Durrës 22.0 22.0 27.6 Elbasan 21.3 21.3 25.3 Fier 21.5 21.5 27.3 Gjirokastër 21.8 21.9 29.6 Korçë 21.7 21.6 27.9 Kukës 22.6 22.5 26.5 Lezhe 22.5 22.5 28.1 Shkodër 22.0 21.3 28.4 Tirana 22.8 22.6 27.3 Vlorë 21.8 21.8 28.1 Education No education/primary 4-year 20.1 19.5 24.6 Primary 8-year 20.7 20.9 26.5 Secondary/professional/technical 21.8 21.9 27.6 University and post-graduate a 24.6 29.6 Wealth quintile Lowest 21.4 21.4 26.9 Second 21.2 21.2 26.8 Middle 21.7 21.8 27.6 Fourth 22.4 22.0 27.4 Highest 23.2 22.8 28.0 Total 22.0 21.9 27.3 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. a = Omitted because less than 50% of the respondents began living with their spouse/partners for the first time before reaching the beginning of the age group. Men age 25-59 are omitted because less than 50% of them had started living with a wife or a partner before age 25 in all of the background categories. Marriage and Sexual Activity • 61 Table 4.4 Early marriage by background characteristics Percentage of women and men age 20-49 who were married or in union before age 18, and the percentage of women and men age 15-19 currently married or in union, by background characteristics, Albania 2017-2018 Women Men Current age Percentage married by age 18 Number of women age 20-49 Percentage of women 15-19 currently in union Number of women age 15-19 Percentage married by age 18 Number of men age 20-49 Percentage of men 15-19 currently in union Number of men age 15-19 Residence Urban 10.6 5,589 4.6 990 1.6 2,294 0.0 427 Rural 12.8 3,698 9.7 694 1.2 1,528 0.2 316 Prefecture Berat 13.5 382 11.0 57 0.4 139 (0.0) 25 Dibër 14.4 423 7.4 87 1.6 167 0.0 35 Durrës 9.0 872 4.1 145 1.4 340 0.0 64 Elbasan 12.4 931 12.2 169 4.1 360 0.0 80 Fier 11.9 931 15.9 152 0.7 384 0.0 70 Gjirokastër 12.8 178 5.5 26 0.9 94 (0.0) 15 Korçë 13.2 720 7.9 139 0.4 339 0.0 65 Kukës 7.2 275 2.8 63 0.8 113 0.0 23 Lezhe 8.1 406 2.5 77 0.3 157 0.0 30 Shkodër 10.7 665 4.8 130 1.5 266 1.0 62 Tirana 11.1 2,995 3.5 562 1.4 1,258 0.0 241 Vlonë 14.2 509 9.3 77 2.6 204 (0.0) 32 Education No education/primary 4-year 35.2 216 * 27 7.4 83 * 4 Primary 8-year 17.6 3,741 15.1 382 2.0 1,291 0.0 211 Secondary/professional/ technical 9.3 2,648 4.0 1,059 0.7 1,549 0.1 491 University and post-graduate 3.0 2,682 0.9 215 1.5 899 * 38 Wealth quintile Lowest 14.5 1,772 12.3 372 1.5 696 0.0 160 Second 13.4 1,838 6.6 324 1.6 768 0.4 142 Middle 12.4 1,806 7.7 324 0.9 747 0.0 142 Fourth 10.0 1,940 3.5 339 0.8 778 0.0 135 Highest 7.2 1,930 2.6 324 2.4 832 0.0 165 Total 11.4 9,286 6.7 1,684 1.5 3,822 0.1 743 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 62  Marriage and Sexual Activity Table 4.5 Age at first sexual intercourse Percentage of women age 15-49 and men age 15-59 who had first sexual intercourse by specific exact ages, percentage who never had sexual intercourse, and median age at first sexual intercourse, according to current age, Albania 2017-18 Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourse Current age 15 18 20 22 25 WOMEN 15-19 0.7 na na na na 89.5 1,684 a 20-24 1.9 16.0 38.3 na na 40.9 1,548 a 25-29 1.4 14.9 38.3 60.4 77.4 16.1 1,514 20.9 30-34 1.9 16.5 38.2 58.1 79.6 5.5 1,442 20.9 35-39 1.1 14.3 38.6 60.9 80.5 4.0 1,388 20.8 40-44 0.7 11.8 37.9 62.8 84.2 2.2 1,601 20.8 45-49 0.7 7.9 31.0 58.6 83.1 2.3 1,794 21.2 25-49 1.2 12.8 36.6 60.2 81.1 5.9 7,739 20.9 15-24 1.2 na na na na 66.2 3,231 a MEN 15-19 1.3 na na na na 84.1 743 a 20-24 5.1 24.0 47.5 na na 36.0 786 a 25-29 4.7 24.4 45.3 67.8 79.0 13.7 704 20.3 30-34 4.2 20.9 44.9 60.2 77.3 3.9 551 20.5 35-39 2.4 14.2 35.5 56.9 74.5 2.0 563 21.0 40-44 5.6 16.3 35.6 57.1 76.3 1.1 539 21.0 45-49 1.7 11.1 29.5 50.3 74.9 0.1 678 21.9 20-49 4.0 18.8 40.1 na na 11.0 3,822 a 25-49 3.7 17.5 38.2 58.6 76.5 4.5 3,036 20.8 15-24 3.2 na na na na 59.3 1,529 a 20-59 3.6 16.6 35.6 na na 8.1 5,399 a 25-59 3.4 15.4 33.6 53.1 73.2 3.3 4,613 21.5 na = Not applicable due to censoring a = Omitted because less than 50% of the respondents had sexual intercourse for the first time before reaching the beginning of the age group Marriage and Sexual Activity • 63 Table 4.6 Median age at first sexual intercourse by background characteristics Median age at first sexual intercourse among women age 25-49 and age 30-49, and median age at first sexual intercourse among men age 25-59 and age 30-59, according to background characteristics, Albania 2017-18 Women age Men age Background characteristic 25-49 30-49 25-59 30-59 Residence Urban 21.1 21.2 21.0 21.4 Rural 20.7 20.7 22.0 22.4 Prefecture Berat 20.2 20.4 23.1 23.6 Dibër 20.8 20.7 a 25.6 Durrës 20.7 20.8 a 25.7 Elbasan 20.9 20.9 21.4 21.6 Fier 20.5 20.7 20.1 20.2 Gjirokastër 20.7 20.8 20.6 20.8 Korçë 21.1 21.1 22.8 23.2 Kukës 22.2 22.1 23.4 23.2 Lezhe 21.7 21.8 24.5 24.7 Shkodër 21.1 20.7 21.1 22.2 Tirana 21.2 21.1 20.3 20.5 Vlorë 20.6 20.8 19.6 19.8 Education No education/primary 4-year 19.0 18.6 20.6 21.1 Primary 8-year 20.3 20.4 21.9 22.0 Secondary/professional/technical 20.9 21.0 22.1 22.3 University and post-graduate 22.9 22.9 20.1 20.4 Wealth quintile Lowest 20.9 20.9 23.1 23.2 Second 20.6 20.6 21.9 22.4 Middle 20.8 20.9 22.1 22.4 Fourth 21.1 21.0 21.3 21.7 Highest 21.4 21.3 20.1 20.4 Total 20.9 20.9 21.5 21.9 a = Omitted because less than 50% of the respondents had intercourse for the first time before reaching the beginning of the age group 64  Marriage and Sexual Activity Table 4.7.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Albania 2017-18 Timing of last sexual intercourse Never had sexual intercourse Total Number of women Background characteristic Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 6.5 2.9 1.1 0.0 89.5 100.0 1,684 20-24 43.0 10.6 4.9 0.6 40.9 100.0 1,548 25-29 63.7 11.3 8.3 0.5 16.1 100.0 1,514 30-34 74.3 12.4 6.5 1.3 5.5 100.0 1,442 35-39 76.6 11.7 7.4 0.2 4.0 100.0 1,388 40-44 77.5 11.6 8.3 0.5 2.2 100.0 1,601 45-49 75.6 12.1 9.5 0.5 2.3 100.0 1,794 Marital status Never married 8.8 4.2 5.1 0.8 81.1 100.0 3,191 Married or living together 83.1 13.0 3.6 0.3 0.1 100.0 7,403 Divorced/separated/widowed 10.3 9.6 77.5 2.3 0.3 100.0 376 Marital duration2 0-4 years 82.0 15.0 2.8 0.0 0.3 100.0 1,121 5-9 years 84.6 11.7 3.4 0.3 0.1 100.0 1,220 10-14 years 83.8 13.5 2.3 0.4 0.0 100.0 1,075 15-19 years 85.8 10.9 2.9 0.4 0.0 100.0 1,312 20-24 years 82.0 13.3 4.3 0.4 0.0 100.0 1,356 25+ years 80.1 13.9 5.5 0.3 0.1 100.0 1,209 Married more than once 83.3 12.1 3.7 0.0 0.9 100.0 110 Residence Urban 58.8 9.6 7.0 0.5 24.1 100.0 6,578 Rural 59.3 11.3 5.9 0.5 23.0 100.0 4,392 Prefecture Berat 63.0 13.9 5.2 1.5 16.3 100.0 439 Dibër 57.4 11.4 4.5 0.0 26.7 100.0 510 Durrës 56.6 10.0 9.1 0.0 24.3 100.0 1,017 Elbasan 58.8 16.7 4.4 0.0 20.0 100.0 1,100 F

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